Objective

A commonly encountered problem in physical conditioning and training is overexertion. A gradual pattern of overloading the body is necessary for training effects; however, many athletes and training personnel still believe that if there is no pain, there is no gain. Overtraining occurs when athletes work too hard to improve performance and train beyond the ability of the body to recover.

Overtraining is reflected in muscle soreness, decreased joint flexibility, and general fatigue 24 hours after activity. Four specific indicators of possible overexertion are acute muscle soreness, delayed-onset muscle soreness, muscle stiffness, and muscle cramping and spasms.

Common warning signs of overtraining include the following:

The massage professional needs to be aware of these warning signs and must refer to a physician for proper management. Proper diagnosis by the physician can rule out potentially serious problems. Interventions include rest, drinking plenty of fluids, alteration of diet if needed, and general nonspecific massage that is even less targeted and intense than the pain management protocol presented in the previous chapter. Massage supports parasympathetic dominance, pain management, fluid movement, and sleep. Do not overmassage someone with overtraining syndrome. Adaptive capacity already is strained, and massaging too much (e.g., too aggressively or by pursuing too many outcomes in a single session) can add strain to the client’s adaptive ability.

Objective

Overexertion during strenuous muscular exercise often results in muscular soreness. Most persons, at one time or another, have experienced muscle soreness, usually resulting from some physical activity to which they are unaccustomed.

Acute-Onset Muscle Soreness

Acute-onset muscle soreness accompanies fatigue. This muscle pain is transient and occurs during and immediately after exercise. The pain is caused by lack of oxygen to the muscles and buildup of metabolic waste from anaerobic functions. The pain dissipates as oxygen is restored and metabolic wastes produced are removed from muscle tissue and are eliminated or converted. Massage is not especially effective in treating acute-onset muscle soreness. If massage is used immediately after exercise, the focus is arterial and venous circulation. Do not attempt to stretch or aggressively treat. Cramping usually will occur.

Delayed-Onset Muscle Soreness

Delayed-onset muscle soreness (DOMS) becomes most intense after 24 to 48 hours and then gradually subsides so that the muscle becomes symptom-free after 3 or 4 days. Delayed-onset muscle soreness leads to increased muscle tension, swelling, stiffness, and resistance to stretching. Delayed-onset muscle soreness is thought to result from several possible causes. It may occur from small tears (microtrauma) in the muscle tissue, which result in an inflammatory process and seem to accompany eccentric or isometric actions. Soreness also may occur because of disruptions in the connective tissue that holds muscle tendon fibers together. Another contribution to delayed-onset muscle soreness is increased interstitial fluid resulting in hydrostatic pressure on pain-sensitive structures.

Muscle soreness can be produced by many types of muscular activities. A common deterrent for ongoing interference with physical activity is post-exercise soreness from movements that produce tension as the involved muscles are forced to lengthen. The muscle actions needed for these movements are known as eccentric or negative actions. These types of movement activities include movements that resist gravity or forward momentum, such as downhill running, lowering of heavy barbells, and the downward phase of push-ups or sit-ups; movements that resist forces exerted by stronger opponents, such as performing a pin or a hold in wrestling and a block in football, are also eccentric. Current explanations for muscle soreness include lactic acid accumulation, muscle spasms, and muscle damage. Lactic acid and muscle spasms have been largely discredited as reasons, but as described in Chapter 3, the muscle damage explanation has a sound scientific basis.

Movements that cause muscle soreness have been shown to produce localized damage to the muscle fiber membranes and contractile elements. Chemical irritants such as histamine are released from damaged muscles and can irritate pain receptors in the muscle. Muscle damage often causes swelling of the muscle tissue, which creates enough fluid pressure to stimulate pain receptors. Swelling has been shown to persist long after muscle soreness has disappeared. Pain receptors gradually adapt to the swelling or to some other factors present that reduce pain perception. Because no effective treatment for muscle soreness has been identified, training programs should be designed to minimize or prevent soreness.

Typical recommendations for treatment of delayed-onset muscle soreness include gentle stretching, topical application of analgesic creams and/or ice, submersion in hot baths, hot and cold contrast exposure, Epsom salt soaks, and sauna. Each of these treatments may provide temporary relief, but none is effective for long. Delayed-onset muscle soreness is common and annoying but not serious. The athlete can do many things to prevent, avoid, and shorten delayed-onset muscle soreness such as:

Soreness will go away in 3 to 7 days with no special treatment, and the athlete should avoid any vigorous activity that increases pain. The individual should allow the soreness to subside thoroughly before performing any vigorous exercise. Easy, low-impact aerobic exercise will increase blood flow to affected muscles, which may help diminish soreness.

Treatment of delayed-onset muscle soreness usually involves general massage with a lymphatic drainage focus. Muscle soreness can be treated with ice applied within the first 48 to 72 hours.

Gentle stretching of the affected area with gentle massage helps. Do not overmassage, work aggressively, or use any methods that would increase swelling or cause tissue damage.

Almost all professional sports teams use various ointments and liniments on sore athletes, but sports medicine doctors may not fully understand how liniments work. The massaging action of rubbing in the liniment and working it into muscles may be what actually relaxes the muscle and may be part of the mechanism of action.

Two basic types of ointments/liniments are available. The first typically contains menthol and an aspirin-like chemical, methyl salicylate. When liniment is massaged on the skin, the skin becomes slightly irritated, which causes an increase in blood flow to the area. This produces heat, which relaxes stiff muscles. Some salicylate may enter the bloodstream. Because salicylate is the active ingredient in aspirin, it also may have some pain-relieving effect. A counterirritant action occurs as well.

The second type of ointment depends on a substance called capsicum, which is the active ingredient in jalapeño and other hot peppers. An extract of this chemical now is being used as a prescription ointment for arthritis pain, which is an indication that these ointments really do have benefit. These hotter ointments have a much stronger irritating effect on the skin to stimulate blood flow and give off enough heat that they can cause a burn, so caution is required. Do not allow these preparations to come into contact with any mucous membranes or with the eyes.

Make sure the client has no skin sensitivity to an ointment that will cause an allergic reaction.

Muscle Stiffness

Muscle stiffness is different from muscle pain. Stiffness occurs when a group of muscles has been worked hard for a long time. Fluids that collect in the muscles during and after exercise are absorbed into the bloodstream at a slow rate. As a result, the muscle becomes swollen, shorter, and thicker and therefore resists stretching. Light exercise, lymphatic drainage types of massage, and passive mobilization assist in reducing stiffness. Stiffness also results in decreased pliability of connective tissue. This occurs when the ground substance thickens as part of an enzyme process during sympathetic dominance.

Massage is effective for muscle stiffness, particularly in the management of fluid retention. See the discussion on lymphatic drainage in Unit Two. All pain management approaches are appropriate. Massage performed to restore connective tissue pliability and hydration helps to reduce stiffness. These conditions are not the result of an increase in muscle tone but rather reflect an issue of fluid dynamics. Do not use aggressive massage.

Muscle Cramps and Spasm

Muscle cramps and spasm can lead to muscle and tendon injuries. A cramp is a painful involuntary contraction of a skeletal muscle or muscle group. Cramps often occur because of lack of water or other electrolytes, from muscle fatigue, and from an interruption of appropriate neurologic interaction between opposing muscles. A spasm is a reflex reaction caused by trauma to the musculoskeletal system.

The two types of cramps or spasms are the clonic type, with alternating involuntary muscular contraction and relaxation in quick succession, and the tonic type, with rigid muscle contraction that lasts for a time. The massage therapist applies compression firmly in the belly of the cramping muscle and gently massages, moves, and stretches surrounding joint areas. If cramps recur, send the client for hydration and electrolytes. Cramps and spasm respond to proper hydration and rest.

Muscle Guarding

After injury, muscles that surround the injured area contract in effect to splint that area, thus minimizing pain by limiting regional movement. Often this splinting is referred to incorrectly as a muscle spasm. Muscle guarding is a more appropriate term for the involuntary muscle contractions that occur in response to pain after musculoskeletal injury. Muscle guarding is appropriate during acute and subacute healing processes. Massage application should not attempt to reduce muscle guarding until later stages of the subacute phase. Use gentle massage to reduce pain sensation.

Objective

A bruise, or contusion, occurs because of a sudden traumatic blow to the body. The severity of a contusion can range from superficial and minor to extremely serious with deep tissue compression and hemorrhage.

The extent to which an athlete may be hampered by this condition depends on the location of the bruise and the force of the blow. This type of injury is common in contact sports. An impact to the muscles can cause more damage than might be expected and should be treated appropriately. The muscle is crushed against the bone, and if the injury is not treated correctly or if it is treated too aggressively, a condition such as myositis ossificans with calcification of the tissues may result. The speed of healing of a contusion, as with all soft tissue injuries, depends on the extent of tissue damage and internal bleeding.

The three types of contusions are intramuscular, intermuscular, and bone bruise.

Intramuscular contusions occur as tearing of the muscle within the sheath that surrounds it. This means that initial bleeding may stop early (within hours) because of increased pressure within the muscle; however, the fluid is unable to escape because the muscle sheath prevents it. The result is considerable loss of function and pain; days or weeks may be needed for recovery. The typical bruise discoloration may not appear with this contusion type, especially in the early stages. Because a bruise is not seen, the severity of the injury may not be recognized. The typical bruise may appear finally in the subacute phase and indicates progressive healing.

Intermuscular contusions consist of tearing of the muscle and part of the sheath surrounding it. The initial bleeding will take longer to stop. Recovery is often faster than with intramuscular contusions because the blood and fluids can flow away from the site of injury through tears in the muscle sheath. Bruising discoloration occurs with this type of contusion.

A bone contusion can penetrate to the skeletal structures, causing a bone bruise. Bone bruises are painful and require a fairly extensive healing time.

Symptoms of contusions include the following:

If after 2 to 3 days the swelling has not gone, an intramuscular injury is likely. If bleeding has spread and has caused bruising away from the site of injury, the injury is likely to be intermuscular. Contusions are classified as grade 1, 2, or 3, depending on severity (Box 17-1).

Caution is necessary when providing massage over contusions. Compressive force and depth of pressure need to be modified to prevent further injury. Lymphatic drainage types of applications are usually appropriate. Once bruising dissipates, in all three grades of contusion, kneading is used to prevent fibrosis. Over the next 3 to 6 months, continue to apply bending and torsion forces of kneading to support the remodeling stage of healing.

Objective

The first concern with any wound is the need to control bleeding. In terms of first aid, this usually means use of a pressure bandage. The next concern is the need to prevent wound contamination by cleaning the wound and applying a sterile bandage and possibly an antibiotic ointment. Last, immobilization of the injured part, along with medical intervention, is needed. Many wounds will have to be sutured or stitched.

The purpose of suturing is to pull the tissues together just enough that no dead spaces will exist below the skin where blood and fluid can accumulate. If space is present, it eventually could serve as a breeding ground for infection. Wounds heal better when the edges are close together.

Generally speaking, the deeper the wound, the more serious the consequences. With minor wounds, the outer layer of skin, the epidermis, is scraped away or opened up to permit bacteria and materials to enter. With a more severe wound, the next layer deeper, the dermis, is injured. This contains connective tissue, sweat glands, hair follicles, nerves, and lymph and blood vessels, and the potential for infection to spread increases.

Wounds can be classified as follows (Figure 17-1):

Depending on how the injury was obtained, dirt or foreign matter usually is ground into it. To treat an abrasion such as a scraped knee, the wound first must be cleaned to remove dirt that could cause an infection and therefore impair healing.

Once cleaned, the wound should be blotted dry with sterile gauze, and pressure should be applied over the injured site for a few minutes for the purpose of controlling bleeding. Application of first aid or antibiotic cream to the abrasion could help to prevent infection and keep the bandage from sticking to the raw wound. For the best protection, the bandage should cover an inch beyond the wound. An ice pack over the final bandage can serve to reduce swelling and ease some of the discomfort.

Therapeutic Massage Application for Wounds

Follow these guidelines when performing therapeutic massage for wounds (Figure 17-2).

Old Scars

Old scars that are adhered to underlying tissue can be softened and stretched. All mechanical forces are used in multiple directions on the scar at each session until the scar tissue and tissues at least 1 inch away from the scar become warm and slightly red. The intensity should be enough that the client experiences a burning stretching sensation (Figure 17-3). A small degree of inflammation is desired, and the area may be a bit tender to the touch after the massage but not painful to movement. Ideally, treatment should occur every other day, allowing the tissue to recover on alternate days. These methods can be taught to the client or family member.

Objective

Note: A specific massage treatment protocol for strain and sprains is provided on p. 299.

A strain is a stretch, tear, or rip in the muscle or in adjacent tissue such as fascia or muscle tendons (Figure 17-4). Strains also are called pulls and tears. The cause of muscle strain is often not clear. Often a strain is produced by an abnormal muscular contraction during reciprocal coordination of agonist and antagonist muscles. This type of injury often occurs when muscles suddenly and powerfully contract. Possible explanations for the muscle imbalance may be related to a mineral imbalance caused by profuse sweating, fatigue, metabolites collected in the muscle itself, or a strength imbalance between agonist and antagonist muscles. A muscle may become strained or pulled—or may even tear—when it stretches unusually far or abruptly. A muscle strain may occur while slipping on the ice, running, jumping, throwing, lifting a heavy object, or lifting in an awkward position.

A strain may range from a tiny separation of connective tissue and muscle fibers to a complete tendinous avulsion (breaking away from the bone) or muscle rupture. The resulting pathologic condition is similar to that of a contusion or sprain, with capillary or blood vessel hemorrhage. Typically, persons with a strain experience pain, muscle guarding, and muscle weakness. They also can have localized swelling, cramping, or inflammation and, with a minor or moderate strain, usually some loss of muscle function. Clients typically have pain in the injured area and general weakness of the muscle when they attempt to move it. Severe strains that partially or completely tear the muscle or tendon are usually very painful and disabling.