Hypothesis

Injury classification may happen as a direct or indirect result from an abrasion to muscle, or of ligament damage as a result in strain of varying categories. The site of which my patient presents his injury is at the shoulder as a result of occupational work incorporated by leisure activities at the gym.  The anatomy of the shoulder structure which consist of the ball and socket and scapula, including the acromion, which is within the acromioclavicular joint and coriacoid process. The patient’s exact present site of injury is at the point of the acromion where pain was located and aggravated by the passive movement of abduction. The patient had sustained a grade two injury to the supraspinatus tendon, this has a partial tear which was confirmed by x-ray from the GP’s referral, this had gradually developed from repetitive heavy lifting at work and aggravated by movements of abduction elevation sustained by overhead activity.

The anatomy of the supraspinatus is from a group of four muscles; the supraspinatus, infraspinatus, teres minor, and subscapularis which make up the rotator cuff. Together they stabilise the glenohumeral joint, including the tendons which attach muscle to the periosteum at the head of the humerus. The supraspinatus has a special function, as it provides the first 30 degrees of abduction in the arm, continued by the action of the deltoid muscle. The supraspinatus muscle is a thin triangular shaped muscle that runs from the medial aspect of the superior scapula and runs laterally, narrowing as it passes under the acromion process, and crosses the glenohumeral joint to attach onto the greater tubercle of the humerus. The tendon of the suprspinatus blends into the joint capsule, as with the infrspinatus tendon. The tendon of the supraspinatus muscle passes under the acromion of the acromioclavicular joint. Inflammation on this area can lead to injury of the supraspinatus tendon. The clinical presentation of this injury is supraspinatus tendonitis, which is a result of increased subacromial loading causing an impingement within the rotator cuff. The tendonitis is where structurally the critical tissue is weakened by repetitiveness.

Over use injury can be common in overhead activity and inflammation can occur at the insertion of Supraspinatus which then progressively developed in tendonitis. This can develop from anterior instability causing a posterior tightness. The inflammation has caused a decreased range of movement, strength and functional activity. Inflammation follows an injury in different stages where repair begins. It is normal and necessary to allow inflammation to take place. Up to 48 hours rest from the point of injury is required immediately to allow the complexity of events to happen within the injury process. The patients shoulder was examined for symmetry, localised swelling and muscle atrophy, on palpation of the shoulder there was tenderness below the acromion and over the greater tuberosity.

Prevention and management of injury

The goal of the acute phase is to relieve pain and inflammation, and to prevent muscle atrophy and gain a non painful range of motion. By applying sports massage methods to prevent and manage the injury it can have a physiological effect over the muscles, encouraging a relief from soreness, tension, and stiffness, and to improve muscle tone. To increase the range of movement by using techniques of relaxation effects on the propriocepetive neuromuscular facilitation PNF stretching techniques and muscle energy techniques, MET also to improve stretch and contraction of the muscles surrounding the affected area. These techniques target the nerve receptors in the muscle to extend the muscle length, allowing a pain free movement.

Sports massage techniques have a variation and modification of effleurage which involves a gliding movement to stimulate the parasympathetic nervous system and to evoke the relaxation of endorphins; this also applies to the end of a session giving a relaxing finish to the treatment. Petrissage is applied to help strengthen the structure of the tissue and to increase the blood supply. Tapotement, is a faster massage movement, using cupped hands to promote new blood and to strengthen the muscle tissue. Vibration, compression, and frictions are also applied with the thumbs to particular sites of muscle where there is tension or muscle spasm. Massage techniques increases the nerves sympathetic system, increase the circulation of the blood to the muscles and to allow the muscle to be flushed and oxygenated. To reduce the change of the injury, stretchers fibres reduce pain ‘pain-gate’ relief of chronic inflammation.

The general indications for massage is to relax, have a anxiety reduction, stimulation, to increase the range of movement, increases tissue flexibility, increase or to decrease muscle tone, increase local circulation, remove waste products, enhance the immune system function and exercise recovery. It is important to keep communicating with the patient during the treatment, by checking to ensure that you are staying within their limits of the pain tolerance and to build a rapport in a professional approach, this builds the confidence of the patient.

Advice for the patient is relevant to the Healing process, by avoiding repetitive overhead movements that may aggravate pain during work; this also involves reaching and lifting. Part of the general conditioning programme is that of injury prevention a period of rest from the gym by reducing the use of shoulder strengthening equipment. The education of gentle movement of activity that can help to increase the range of motion which can be then  performed to prevent the development of adhesive capsulitis, and to improve the  muscle function.

The pathology in a sports management plan

The impact of pathology in a sports massage treatment plan can be effective by addressing the strength and condition of the injured area. Massage will address pain, spasm, and range of motion. Lymphatic drainage may be used to reduce swelling where necessary. Trigger point compression may also be used to reduce muscle tightness. Methods of pain free passive joint movements are used to maintain the range of motion. After a few weeks, friction techniques can be worked as a more direct therapy which can be used to reduce adhesions and scar tissue to muscle and tendons at the remodelling phase.

The relevance of nutrition and hydration

It is most important to hydrate the body with water to help lubricate and to cushion the joints. Water is essential to protect the spinal cord and other sensory tissue. It provides valuable transportation of wastes, beneficial through the stages of tissue repair. Water helps to maintain blood volume, and to regulate the body’s temperature and to allow the muscle to contract. During exercise, water is necessary to replace the loss of fluids which are lost in sweat. There is an importance to maintain muscle function by keeping the body hydrated.

An effective diet is required after any injury to aids patients recovery. Muscle, blood and bone need water and nutritional replacements in order to repair. Sufficient vitamin C is recommended for a speeder recovery, it is known to be a strong antioxidant with amino acid which is necessary for collagen synthesis. The body benefits from vitamins and minerals, as they form a natural anti-inflammatory compound. Minerals are required for the normal call functions that are involved in the synthesis of connective tissue. Calcium, phosphates, and vitamin D are said to regulate both joint and bone health, playing a role in the normal turnover of articular cartilage. Vitamin B12 is said to decrease inflammation and promote repair of musculoskeletal injuries and the maintenance of joints, ligaments, muscle and tendons. B12 is also helpful to reduce tiredness and fatigue of muscle, having a neurological effect.

Neurological effects

The effects of massage neurologically to the body are as follows: the nervous system, central nervous system that is the brain and the spinal cord. The peripheral nervous system, that is the autonomic, somatic, enteric, and pain gate theory.

Psychology of injury

The psychological effect of injury on a patient with regards to their response to an injury, the recovery time, their mood, and possible end of occupation or career, can have a detrimental effect. Coming to terms with a traumatic injury that has an impact on occupational work and hobbies can be frustrating. This is often accompanied by related thoughts of distress. This can lead to distorted and irrational thinking, cognitive beliefs. During the initial injury stage the patient felt different emotional experiences; this may be more of low self esteem from not been able to be as active in everyday activities, which if in sports performance  can be addressed by a sports psychologist, if necessary.

A frame work is set in place for a  recovery period of the nature of  injury, which in effect  can be a help with pain management, adherence to rehabilitation plan, to rebuild personal confidence in the injury site, motivation issues discussed, relaxation techniques, help to deal with setbacks in rehabilitation, restore confidence, use of imagery to speed the recovery. This is recorded by Taylor and Taylor which examined the five phases of post-injury, and the key cause of psychological distress which relates to the rehabilitation for athletes. When the athlete came to accept the injury, and to recognise the inevitability to the future, with social support recovery then the focus is improved.

Article By

Susan Whitney MSc  BRCP Acupuncture Council, a member of the Complementary Practitioners Association and the SMA Sports Care Association