Injury by Area

The previous chapters have prepared the reader to assess the indication (or contraindication) for massage therapy in cases of injury, illness, and disorders, and to provide appropriate intervention. Typically, the client will come to the massage therapist with an injury diagnosis. A massage treatment plan is then developed as part of a multidisciplinary care approach. This chapter enables the massage therapist to understand the physician’s diagnosis, provides guidance for effective treatment, and discusses the injury in relation to its body region.

If massage therapy is appropriate as treatment or as an adjunct to treatment, the reader is referred to a section in a previous chapter outlining appropriate procedures. Occasionally, a more expansive discussion is presented here, along with specific strategies for the particular injury.

It is the responsibility of the massage therapist who is treating a client with an injury to thoroughly research the specific injury, understand the treatments being used by the medical team, and provide appropriate supportive care during the healing and rehabilitation process. How injuries cluster in relation to common sports is found in Table 20-1.

TABLE 20-1

Common Injuries by Sport

Athletic Sport	Definition	Common Injuries
Baseball/Softball	Bat and ball game: A game played with a bat and ball by two teams of nine players on a field with four bases marking the course the batters must take to score runs.	Shoulder tendinopathy (tendonitis, tendonosis), bursitis, impingement syndrome, muscle sprains and strains, rotator cuff, frozen shoulder, wrist sprains, tennis elbow, anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries, medial collateral ligament (MCL) and lateral collateral ligament injuries.
Basketball	Ball game played on a court: A game played by two teams of five players, who score points by throwing a ball through a basket mounted at the opponent’s end of a rectangular court.	ACL and PCL injuries, ankle sprain, Achilles tendinopathy (tendonitis, tendonosis), rotator cuff tendinopathy (tendonitis, tendonosis), injuries to the meniscus, wrist sprain, finger fractures, Achilles tendon rupture, hamstring pull or tear, muscle sprains and strains.
Bicycling	The act or sport of riding or traveling by bicycle or motorcycle.	Neck pain, neck strain, knee pain, patellofemoral pain, chondromalacia, osteoarthritis of the knee, Achilles tendinopathy (tendonitis, tendonosis), plantar fasciitis.
Boxing	Sport of fighting with fists: The sport of fighting with the fists with the objective of knocking out the opposing boxer, or inflicting enough punishment to cause the other boxer to quit or be judged defeated.	Facial lesions, rotator cuff injury, inflammation, impingement syndrome.
Canoe/Kayaking	Sports canoe: A lightweight plastic- or fiberglass-covered canoe propelled by a double-bladed paddle, used for leisure and in competitive sport.	Shoulder strain, wrist/hand and elbow/forearm sprains.
Football	Game played with an oval ball: A game in which two teams of 11 players score points by carrying an oval ball across their opponents’ goal line, or by kicking the ball through the opponents’ goal posts.	Anterior and posterior cruciate ligament injuries, meniscus injury, groin pull; hamstring pull, tear, sprain, or strain; iliotibial band syndrome, shin splints, concussion, shoulder fracture, torn rotator cuff, shoulder separation, shoulder dislocation, whiplash, neck strain, Achilles tendinopathy (tendonitis, tendonosis), turf toe, back muscle strains, low back pain, herniated disks.
Gymnastics	A competitive sport in which individuals perform optional and prescribed acrobatic feats mostly on special apparatuses to demonstrate strength, balance, and body control.	Muscle back strain, spondylolysis, bruises, contusions, muscle soreness, overtraining syndrome, ankle sprains.
Hockey	Team sport played on ice: A game played on ice between two teams of six, using long sticks with curved ends. The objective is to hit a small hard rubber disk into the opposing goal.	Lacerations, knee sprains, medial collateral and capsular ligaments, acromioclavicular joint separation, shoulder dislocation, gamekeeper’s thumb, fracture of the hand and wrist, bruises and contusions, muscle cramps, lumbosacral pain.
Golf	Game with ball and clubs: An outdoor game in which an array of special clubs with long shafts are used to hit a small ball from a prescribed starting point into a series of holes.	Muscle back strain, low back pain, herniated disks, shouder tendinopathy (tendonitis, tendonosis), bursitis, impingement syndrome, torn rotator cuff, frozen shoulder, rotator cuff tendonitis, shoulder instability, golfer’s elbow, bursitis of the elbow, tennis elbow.
Ice skating	Skating on ice as a sport or pastime.	Sprained wrist, plantar fasciitis, MCL injury, low back injury.
Running	The exercise or sport of someone who runs.	Shin splints, runner’s knee, ankle sprain, foot arch pain and strain, Achilles tendinopathy (tendonitis, tendonosis), blisters, delayed-onset muscle soreness, groin pull, heel spur; hamstring pull, tear, or strain; iliotibial band syndrome, muscle cramps.
Snow skiing/Snowboarding	Activity of gliding over snow using skis or a flat board (originally wooden planks, now usually made from fiberglass or related composites) strapped to the feet.	Anterior and posterior cruciate ligament injuries, meniscus injury, concussion, knee pain, low back pain, skier’s thumb, wrist arthritis pain, shoulder fracture, torn rotator cuff, shoulder separation or dislocation, neck strain, shoulder fracture.
Soccer	Ball game using no hands: A game in which two teams of 11 players try to score by kicking or butting a round ball into the net goals on either end of a rectangular field.	Hamstring pull, ankle sprain, Achilles tendinopathy (tendonitis, tendonosis), cruciate ligament tears, concussion, groin pull, iliotibial band syndrome, ACL and MCL injuries, meniscus injuries.
Swimming	Moving through water: The action or activity of making progress unsupported through water using the arms and legs, whether for pleasure, exercise, or sport.	Swimmer’s shoulder (shoulder joint pain), inflammation, impingement, rotator cuff pain, eye irritation.
Tennis	Game with ball, racquets, and net: A game played on a rectangular court by two players or two pairs of players, who use racquets to hit a ball back and forth over a net stretched across a marked-out court.	Tennis elbow, bursitis of the elbow, rotator cuff tendonitis, shoulder tendinopathy (tendonitis, tendonosis), frozen shoulder, shoulder joint pain, inflammation, ankle sprain, torn rotator cuff, wrist tendinopathy (tendonitis, tendonosis), Achilles tendinopathy (tendonitis, tendonosis), iliotibial band syndrome, osteoarthritis.
Triathlon	Athletic contest with three events: An athletic competition in which the contestants compete in three different events and are awarded points for each to find the best all-around athlete.	Shin splints, runner’s knee, shoulder inflammation and pain, Achilles tendinopathy (tendonitis, tendonosis), plantar fasciitis.
Volleyball	A sport in which two teams hit a large ball over a high net using their hands, played on a rectangular court.	Shoulder joint pain, inflammation, impingement syndrome, rotator cuff pain, tendinopathy (tendonitis, tendonosis), tennis elbow, bursitis of the elbow, glenohumeral arthritis, wrist tendinopathy (tendonitis, tendonosis), Achilles tendinopathy (tendonitis, tendonosis), osteoarthritis of the knee, low back pain, ankle sprain.
Weight training	Training using weights: Physical training using weights to strengthen the muscles.	Strained lower back injury, shoulder joint inflammation, tendinopathy (tendonitis, tendonosis).

Massage applications recommended for a specific condition can be incorporated into the general massage session protocol.

The Head

Objectives

1. Identify specific injuries based on location.

2. Develop and implement appropriate treatment plans for massage application for a specific injury.

Because the head houses all of the body’s vital control centers, any injury to the head other than a mild bump or scrape should be seen by a physician. Head injuries should be monitored for at least 2 weeks because some conditions worsen slowly. Consider ALL head injuries to be serious until proven otherwise because they can be life-threatening.

Concussion

A concussion is any disorientation or loss of consciousness, even for a moment, after a blow to the head. The brain floats within the skull surrounded by cerebrospinal fluid, which cushions it from the light bounces of everyday movement. However, the fluid is not able to absorb the force of a sudden blow or a quick stop, and the brain slides forcefully against the inner wall of the skull and becomes bruised. This can result in bleeding in or around the brain and tearing of nerve fibers. It is common for a person who suffered a concussion to not remember events just before, during, and immediately after the injury. Memory of these events may return. After recovery, cognitive function almost always returns to normal, although repeated concussions (even if mild) can result in minimal brain damage.

A serious aftermath of a concussion is a condition known as second impact syndrome. This can occur when a person who is still recovering from a concussion returns to a contact sport or activity or has recurrent head trauma. A seemingly minor trauma or bump on the head in these individuals can lead to devastating swelling of the brain, which may prove fatal.

Head trauma can result in various types of closed head injuries. Impaired functions depend on the area of brain injury. Any change in typical behavior or ability in a person who has suffered head trauma should be closely monitored.

More than 300,000 athletes suffer concussions each year. There is no way to predict which athletes are likely to suffer concussions. The severity of a concussion depends on how much force is applied to the head and whether the blow is head-on or glancing.

People who wear helmets, which absorb shock, probably will have milder concussions than those who do not. Advances in the design of protective headgear are helping to prevent head trauma and reduce the severity of a concussion. Although protective equipment continues to improve in quality, many athletes participate in high-impact sports activities, such as soccer, or sports in which head trauma can result from falling, such as gymnastics, or the many other sports in which head protection is not required. Therefore, concussions are an ongoing concern, and repeated head trauma can have cumulative effects. Previous head trauma seems to make a person more predisposed to future problems.

Signs and symptoms of concussions can be subtle and may not appear immediately. Once present, symptoms can last for days, weeks, or longer. The severity and side effects of a head injury depend greatly on which area of the brain was most affected.

Immediate signs and symptoms of a concussion may include the following:

• Confusion

• Amnesia

• Headache

• Loss of consciousness after injury

• Ringing in the ears (tinnitus)

• Unusual eye movements

• Convulsions

• Slurred speech

Delayed signs and symptoms may include those listed here:

• Personality changes

• Poor concentration

• Trouble with memory

• Getting lost or becoming easily confused

• Increased sensitivity to sounds, lights, and distractions

• Loss of sense of taste or smell

• Difficulty with gait or in coordination of the limbs

When diagnosing a concussion, the doctor may ask questions about the accident and may conduct a neurologic examination to assess memory, concentration, vision, hearing, balance, coordination, and reflexes. Depending on the results of the neurologic examination, the doctor may request a computed tomography (CT) scan or a magnetic resonance imaging (MRI) scan.

Rest is the best recovery technique. Some over-the-counter and prescription drugs may be taken for headache pain. Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) usually are not recommended because they could contribute to bleeding. The healing process takes time—sometimes several months—and includes the following:

• Plenty of sleep at night, and rest during the day

• Gradual return to normal activities

• Avoiding activities that could result in a second head injury

After a concussion, some symptoms may persist, including headache, dizziness, loss of memory of the event, fatigue, and general weakness. This is called postconcussion syndrome. In some people, these symptoms clear up and they feel fine, but the symptoms recur when they become active again. If these symptoms persist, the athlete should be reevaluated by the physician. No athlete should return to heavy physical activity until the symptoms clear completely.

Returning to athletic activity depends on the cumulative effects of the concussions. The following time frames are typical:

First concussion—7 days or until all postconcussion symptoms clear, whichever is longer.

Second concussion—3 weeks or until symptoms cease.

Third concussion—up to 6 months.

The effect of multiple concussions can result in long-term neurologic and functional deficits, including changes in emotional behavior.

Massage Strategies

Massage, if approved by the physician, should be general and nonspecific. Avoid any abrupt movements of the head. The focus of the massage should be sleep support and recovery (parasympathetic dominance). Once the athlete is allowed to practice, gait patterns and ocular reflexes need to be reset. The massage therapist should maintain vigilant observation for any postconcussion symptoms and should urge the athlete to see the physician for even minor symptoms.

A hard blow to the head can fracture the bones of the skull (Figure 20-1). Although not common, skull fractures occur, and a severe blow to the head can cause a fracture. Blood or clear fluid leaking from the ear or nose may be a sign of a skull fracture. This is a medical emergency—refer the client to a physician immediately.