First Aid For Musculoskeletal Injuries

Posted on 19 Dec 2008 15:28

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The first part will focus on the soft tissue injuries that a bodybuilder or strength athlete may incur and the important first steps one should take to ensure a speedy recovery. It will not go into specific exercise and sports injuries and is not meant as a comprehensive guide or a replacement for professional medical advice.

Click on images for further info.

Please keep in mind that asking “some dudes I know at the gym” does not constitute medical advice!

Also, it is important to note that injuries to the head, neck, face, or spinal cord; bone fractures, breaks, or injuries with excessive bleeding, are beyond the scope of this article and may require immediate medical attention.


First, some definitions:

Muscle: OK, so you know what a muscle is.

Tendon: Fibrous connective tissue serving for the attachment of muscles to bones and other parts.

Ligament: (Joint Ligament) A band or sheet of strong fibrous connective tissue connecting the articular ends of bones, binding them together and facilitating or limiting motion. It is important to note that ligaments have little if any flexibility. There are other parts of a joint that can be injured, such as the meniscus, but you don’t really want this article to be that long…

Strains and Sprains

The two basic soft tissue injuries are strains and sprains.

Strain: A trauma, tear, or rupture to the muscle or musculotendinous unit from violent contraction or excessive forcible stretch. Can also be caused by a sudden blow. It can be difficult to know when you have strained a muscle or tendon. Bodybuilders and strength athletes are so used to pain and chronic injuries they find it easy to ignore discomfort in a muscle. You may feel something pulling loose or feel a ripping sensation. Or, you may just feel a mild pain in a muscle or tendon. It is best to take any unusual pain or discomfort seriously.

Strains are Sprains are classified into one of three categories:

Grade I: overstretching of a few muscle fibers with less than 10 percent actual fibers tearing. The fascia is intact. No palpable defect in the muscle. These low grade strains may go unnoticed, with no pain.

Grade II: a partial tear of the muscle fibers usually between 10 and 50 percent of the fibers (some clinicians consider only 10 to 30%). A definite palpable defect in the muscle belly but fascia may be intact. Pain is present with palpation.

Grade III: an extensive tear or complete rupture of the muscle fibers. From 50 to 100 percent destruction. Very large palpable depression in the muscle. The muscle may be torn away completely. There is no possibility of normal contraction. The fascia is torn. There is pain with movement and palpation.

Some clinicians consider that there are 4 grades, with a grade 3 strain being a severe tear but not a complete rupture of the muscle and fascia, and a grade four stain is a complete tear, with no possibility of healing without surgical intervention.

Sprain: A trauma, tear, or rupture to a ligament or joint capsule. Many of us have suffered a sprain at some point and it is usually fairly obvious when you have sustained and Grade II or III. Sometimes even a “pop” is heard. A mild sprain can sometimes be easily overlooked so it is important to take even a mild sudden discomfort in a joint seriously.


They are classified similarly:

Grade I: mild injury caused by an overstretching or slight tear of the ligament with minimal pain, swelling and little or no loss of function. Weight can usually be put of the affected joint.

Grade II: a moderate injury that causes partial tearing of the ligament with bruising, moderate pain and swelling. There is some difficulty putting weight on the affected joint and there is some loss of function.

Grade III: a severe injury with complete tearing or rupture of the ligament. Pain, swelling and bruising are usually severe and the patient is unable to put weight on the joint.

Immediate First Aid

What you do during the first few minutes after an exercise injury or sports injury will greatly determine how well you recover. If you experience this type of injury or even suspect you have there are some important first steps you can take to lessen damage and speed recovery. What you do in the period immediately following an injury is the most important part of your recovery. It can make or break you. I cannot stress this enough.

Step 1: Stop! Stop training. Stop moving around as soon as you can and try to asses the inury. Just don’t damage it further. If you hurt yourself somewhere in your upper body that doesn’t mean you should ignore it and switch to legs. The sooner you begin treatment, the better.

Step 2: R.I.C.E. This is still the most common and most effective treatment for strains and sprains. It has been shown to significantly reduce recovery time.

It will help alleviate the bleeding around the injury site and the resultant swelling and pain. It will help prevent further tissue damage and aid in the healing process.

Rest: This goes back to step one. A soon as possible begin keeping the injured area as still. Even moving it around while working other body parts can speed up the blood flow to the area and cause further damage. If it hurts even a little don’t do it. Use some kind of sling or brace to support the injured area if necessary.

ICE: This is the most important of all. Apply ice ASAP using crushed ice in a plastic bag, commercial cold packs or even frozen vegetables such as peas.Chemical ice packs are ok but some can be too cold or not cold enough. Real ice melting in water is best.

Use some kind of buffer between the skin and ice. A damp towel is best. It’s going to be slightly uncomfortable but not painful. You don’t want to get ice burns so only apply it for as long as is tolerable. Go for around 10 minutes but if this is too long then apply it for shorter times more often. Rotate it on and off every 30 minutes, several times a day for the first 24 to 48 hours. Avoid prolonged use of ice on the extremities such as hands and feet/toes and face.

Compression: Wrap snugly, but not to tight, with an elastic bandage. Begin wrapping area farthest from heart. You should be able to slip a finger underneath but even so make sure that it doesn't start to tingle or become numb. I have not been able to find consistent recommendations on whether strained muscles or tendons should always be wrapped. It should help with the bleeding and swelling and in some instances it may help to stabilize the injured area. In general I would say to use a bandage if it helps to reduce the pain. With joint injuries, especially those of the ankle, knee, or wrist it is generally recommended. It is best not to wrap the joint in a circle but to wrap over the joint in a zig-zag or figure eight pattern, anchoring below and above. I would recommend that you have your medical professional tell you whether this step is necessary or warranted based on your injury and have him or her instruct you in the correct method. They may provide you with a special wrap. Included below is specific instructions on wrapping an ankle.

Elevation: Raise the injured area above the level of the heart whenever possible. This will help further reduce the bleeding, swelling, and pain.

A commercial first-aid kit specifically made for athletics can be purchased at a reasonable price for the individual. You do not need to by a professional athletic trainer's kit or coaches kit, which can cost upward of 100 dollars. A 15 to 20 dollar kit will include most of what you need to have on hand including instant ice packs, which, although not as good as cold ice water bags, can be very good to have on hand if you work out alone. Kit's small enough to be carried in gym bags are readily available.

The First 24 to 72 hours

For the first 24 to 72 hours avoid any type of heat to the inured area. It would be best to even take lukewarm or cold showers. Avoid any massage or movement. There sould be NO STRETCHING AT ALL during this period.

The following is a cut and paste from The Stretching Handbook

After the First 48 to 72 Hours

Lets move on. What happens after the first 48 to 72 hours? Lets take a quick look at how your soft tissue (muscle, tendon, ligament, etc.) repairs itself.

When any sort of damage occurs to the soft tissues, like a strain or sprain, the body immediately goes into a process of repair. Where the individual fibers have been ruptures, or torn, the body begins to bind the damaged fibres together using a fibrous protein called collagen. Or, as it's more commonly known, scar tissue!

You see, when a muscle is torn, you would expect that the body would repair that tear with new muscle. In reality, this doesn't happen. The tear, or rupture, is repaired with scar tissue.

Now this might not sound like a big deal, but if you have ever suffered a soft tissue injury, you'll know how annoying it is to keep re-injuring that same old injury, over and over again. Untreated scar tissue is the major cause to re-injury, usually months after you thought that injury had fully healed.

Scar tissue is made from a very brittle, inflexible fibrous material. This fibrous material binds itself to the damaged soft tissue fibres in an effort to draw the damaged fibres back together. What results is a bulky mass of fibrous scar tissue completely surrounding the injury site. In some cases it's even possible to see and feel this bulky mass under the skin.

When scar tissue forms around an injury site, it is never as strong as the tissue it replaces. It also has a tendency to contract and deform the surrounding tissues, so not only is the strength of the tissue diminished, but flexibility of the tissue is also compromised.

So what does this mean for the athlete? Firstly, it means a shortening of the soft tissues which results in a loss of flexibility. Secondly, it means a weak spot has formed within the soft tissues, which could easily result in further damage.

Last, the formation of scar tissue will result in a loss of strength and power. For a muscle to attain full power it must be fully stretched before contraction. Both the shortening effect and weakening of the tissues means that a full stretch and optimum contraction is not possible.

If you've used the R.I.C.E.R. regime to treat the initial reaction to a soft tissue injury, you're well on your way to a complete recovery. If however, you didn't use the R.I.C.E.R. regime, you're behind the eight-ball, so to speak.

When an injury occurs the body responds by sending large amounts of blood to the injury site. If this isn't controlled, with the R.I.C.E.R. regime, it will result in massive bleeding, swelling and pain. More importantly, it will also result in a large formation of bulky, painful scar tissue.

The R.I.C.E.R. regime will help to control the bleeding, swelling and pain, but more importantly, it will also control the formation of scar tissue. When the R.I.C.E.R. regime is used correctly, there will only be a minimal formation of scar tissue, which allows for optimal return of flexibility and strength.

(The last R here means Referral to a qualified medical specialist.)

The Next 10 to 14 Days

So, how do we put the finishing touches on your recovery? How do we get rid of that annoying formation of scar tissue?

After the first 72 hours most of the initial swelling will have subsided and you can start with some gentle active rehabilitation techniques.


The most effective treatment at this stage is the use of heat and massage, but including light, gentle static and passive stretching exercises after your heat and massage treatment will help to dramatically speed up the recovery process.

First, you must keep active! Don't listen to anyone who tells you to do nothing. Now is the time to start active rehabilitation. Most of the swelling will have subsided after the first 48 to 72 hours and you are now ready to start light activity.

Light activity will not only promotes blood circulation, but it will also activates the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products, which can accumulate in the body following a sports injury. Activity is the only way to activate the lymphatic system.

Before we move on, a quick word of warning. Never, Never, Never do any activity that hurts the injured area. Of course you may feel some discomfort, but NEVER, NEVER push yourself to the point where you're feeling pain. Listen to your body. Don't over do it at this stage of the recovery, you've come too far to blow it now.

To complete your recovery and remove most of the unwanted scar tissue, you now need to start two vital treatments. The first is commonly used by physical therapists (or physiotherapists), and it primarily involves increasing the blood supply to the injured area. The aim is to increase the amount of oxygen and nutrients to the damaged tissues.
Physical Therapists accomplish this aim by using a number of activities to stimulate the injured area. The most common methods used are ultrasound and heat.

Ultrasound, or TENS (Transcutaneous Electrical Nerve Stimulation) simply uses a light electrical pulse to stimulate the affected area. While heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating blood flow to the damaged tissues.

Secondly, to remove the unwanted scar tissue it is vital that you start a course of deep tissue sports massage. While ultrasound and heat will help the injured area, they will not remove the scar tissue. Only massage will be able to do that.

Either find someone who can massage the effected area for you, or if the injury is accessible, massage the damaged tissues yourself. Doing this yourself has the advantage of knowing just how hard and deep you need to massage.

I guarantee that right now most of us are walking around with soft-tissue adhesions, scar tissue, trigger points, etc. Foam Rolling and other self-myofascial release techniques are the BEST thing you yourself can do to improve soft tissue quality and therefore function. This is BETTER than stretching and in some cases stretching can do more harm than good. The only thing that is better is some type of deep tissue, such as ART®, by a professional. I am NOT suggesting, however, that you foam roll a recently injured area!

To start with, the area will be quite tender. Start with a light stroke and gradually increase the pressure until you're able to use deep, firm strokes. The more you massage the effected area the harder and deeper you will be able to push.

Use deep, firm strokes, moving in the direction of the muscle fibres. Concentrate your effort at the direct point of injury, and use your thumbs to get in as deep as possible to break down the scar tissue

I've heard of R.I.C.E but what about M.I.C.E. that new thing?

The RICE regimen is still the standard reaction to acute sports injuries like strains and sprains. But lately M.I.C.E has gotten a lot of discussion. In this model, "movement" replaces the "rest".

Appropriate movement and even stretching during the chronic phase of an injury can shorten healing time and reduce scar tissue formations. This knowledge has been acted on for some time now during the chronic later phases of injuries. For instance..we use appropriate movement to rehabilitate ankle sprains whereas in the "old days" we immobilize the ankle in casts or wraps.

But during the acute phase even more than the later healing stages movements and stretching can potentially aggravate the injury if you don't know what you are doing. Unless a professional is prescribing a M.I.C.E regimen to you then JUST USE it.

So What is Static and Passive stretching?

Static stretching is performed by placing the body into a position whereby the muscle (or group of muscles) to be stretched is under tension. Both the opposing muscle group and the muscles to be stretched are relaxed. Then slowly and cautiously the body is moved to increase the tension of the stretched muscle group. At this point the position is held or maintained to allow the muscles to lengthen.

Passive stretching is very similar to static stretching; however another person or apparatus is used to help further stretch the muscles. Due to the greater force applied to the muscles, this form of stretching is slightly more hazardous. Therefore it is very important that any apparatus used is both solid and stable. When using a partner it is imperative that no jerky or bouncing force is applied to the stretched muscle. So, choose your partner carefully, they must be responsible for your safety while stretching.

The important point to remember during this phase of the rehabilitation process is light, gentle stretching. Never, never, never do any activity that hurts injured area. Of course you may feel some discomfort, but never push yourself to the point where you're feeling pain. Be very careful with any activity you do. Pain is the warning sign; don't ignore it.

The Next 2 to 5 Weeks

The aim of this phase of your rehabilitation will be to regain all the fitness components that were lost as a result of the injury. Regaining your flexibility, strength, power, muscular endurance, balance, and co-ordination will be the primary focus.

Without this phase of the rehabilitation, there is no hope of completely and permanently making a full recovery from your injury. A quote from a great book called "Sporting injuries" by Peter Dornan & Richard Dunn will help to reinforce the value of this phase of the rehabilitation process.

"The injury symptoms will permanently disappear only after the patient has undergone a very specific exercise program, deliberately designed to stretch and strengthen and regain all parameters of fitness of the damaged structure or structures. Further, it is suggested that when a specific stretching program is followed, thus more permanently reorganizing the scar fibers and allowing the circulation to become normal, the painful symptoms will disappear permanently."

So what type of stretching is best to use during this phase? Stick with the static and passive stretching exercises described above, but also include PNF Stretching.

PNF stretching, or Proprioceptive Neuromuscular Facilitation, is a more advanced form of flexibility training that involves both the stretching and contraction of the muscle group being targeted. PNF stretching was originally developed as a form of rehabilitation and to that effect it is very effective. It is also excellent for targeting specific muscle groups, and as well as increasing flexibility, (and range of movement) it also improves muscular strength.

Looking Long Term

Once you're over your injury and have started to regain the fitness components that were lost during the injury process, it's time to focus on making the injured area stronger and more flexible that it was before the injury occurred. To do this, the best types of stretches to use are dynamic and active stretching exercises.

Dynamic stretching uses a controlled, soft bounce or swinging motion to move a particular body part to the limit of its range of movement. The force of the bounce or swing is gradually increased but should never become radical or uncontrolled.

Active stretching is performed without any aid or assistance from an external force. This form of stretching involves using only the strength of your opposing muscles to generate a stretch within the targeted muscle group. The contraction of the opposing muscles helps to relax the stretched muscles. A classic example of an active stretch is one where an individual raises one leg straight out in front as high as possible and then maintains that position with out any assistance from a partner or object.

Just a few final points before we finish up. Be sure to drink plenty of fluid during your injury rehabilitation. The extra fluid will help to flush a lot of the waste products from your body.

How do you know when you’re injured?

There are some common tip-offs you should recognize as warning signs that you have an injury that needs your attention. While some sports injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop. The following list of six injury tip-offs comes from Anybody's Sports Medicine Book, written by James Garrick, M.D. and Peter Radetsky, Ph.D.

1. Joint Pain: particularly in the joints of the knee, ankle, elbow and wrist, should never be ignored. Because these joints are not covered by muscle, there is rarely a muscular origin. Joint pain that lasts more than 48 hours requires a physician diagnosis.

2. Tenderness At A Specific Point: If you can elicit pain at a specific point in a bone, muscle or joint, by pressing your finger into it, you may have a significant injury. If the same spot on the other side of the body does not produce the same pain, you should probably see a physician.

3. Swelling: This is usually quite obvious, and can be seen, but occasionally you may feel swollen without outward signs. Swelling is always a sign of a sports injury and should never be ignored. Often, swelling within a joint will cause pain, stiffness, or may produce a clicking sound as the tendons snap over one another because they have been pushed into a new position due to swelling.

4. Reduced Range Of Motion: If swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion; the limb will only go so far in each direction. Again, compare one side of the body with the other to identify major differences. If there are any, you have an injury that needs attention.

5. Comparative Weakness: Comparing one side to the other for weakness is often hard to do, but can be a good clue to identify significant injury. One way to tell is to left the same weight with the right and left side and look at the result. Often therapists will test comparative weakness manually or with special equipment.

6. Numbness and Tingling: Never ignore numbness or tingling. Often related to nerve compression, these warning signs may indicate serious injury and should always be seen by a physician.

Giving Injuries the Cold Treatment

Bryant Stamford, PhD

When you sprain your ankle or have a similar injury, tissue is stretched and torn, and swelling occurs. Swelling interferes with healing, so anything that will prevent or reduce swelling should help you recover from a minor injury more quickly.

The sooner you attend to swelling after an injury the better, and the best approach is to apply cold directly to the injured area right away. (See "A Time for Cold, a Time for Heat") Cold shrinks the blood vessels, which reduces bleeding in the area and helps to prevent swelling. It also helps prevent the muscles from going into spasm (involuntary contractions) and relieves pain.

The use of cold as a treatment is as old as the practice of medicine, dating back to Hippocrates. Today, methods of applying cold are more advanced than they were in 400 BC, but the principles and the need for precautions are the same. When you apply cold, the skin will initially feel cold, often followed by relief of pain from the injury. As icing progresses, you will feel a burning sensation, then pain in the skin, and finally numbness.

To avoid skin damage, stop when the skin begins to feel numb. (This is different, though, from the "numbness" you feel early on as the cold relieves injury pain. Keep icing after this pain subsides.) Applying too much cold for too long can cause frostbite or even nerve damage. Also, cold treatment is not for everyone (see "When to Avoid Cold Therapy").

The length of time you apply cold will vary depending on the method and location of the injury (see specifics below). Areas with little body fat (like the knee, ankle, and elbow) do not tolerate cold as well as fatty areas (like the thigh and buttocks). So, for bonier areas, keep to the low end of the recommended application ranges listed below.

For best results, apply cold at regular intervals throughout the waking hours of the day, allowing a few hours between treatments. Time off will keep cooling effects from accumulating and will allow the skin to return to normal temperature. An ice bag remains—for good reason—the cool treatment of choice for most people, but several options exist:

Ice Bags
Strengths: Ice bags are the old standby for applying deep, penetrating cold. Fill a bag made of thick plastic, rubber, or moisture-proof fabric with ice and apply it directly to the skin. The cooling effect of ice bags lasts long and is more effective than some of the superficial methods like ice massage. If you use a regular plastic food bag, place a thin towel (like a dish towel) between the bag and your skin.

Weaknesses: A shortcoming is getting the bag to contour to the curves of the body for maximum application. The bag will mold better if you don't fill it completely with ice or if you use crushed ice. An alternative is to use a bag of frozen peas or corn. The bag will conform nicely to the injured part of the body. Place a thin towel between the bag and the skin.

Application time: 10 to 30 minutes, depending on the body part and comfort.

Gel Packs
Strengths: Cold gel packs contain a special gel that can be frozen and refrozen. Just store the packs in the freezer until needed. The gel remains flexible when frozen, allowing it to contour to the injured body part.

Weaknesses: Cold gel packs will cool the skin faster than ice bags and so deserve greater caution. Never apply them directly to the skin—always wrap them in a towel.

Application time: No more than 10 minutes at a time.

Chemical Cold Bags

Strengths: Chemical cold bags stay at air temperature until squeezing the bag and mixing the chemicals produces cold. They work well on the field or in the wilderness.
Weaknesses: The degree of cold produced by the chemical reaction is not great. Even so, the bags provide a good first-aid approach.

Application time: Because the temperature is not that low, a 30-minute application should not be a problem, and the bag can be applied directly to the skin.

Strengths: Immersion entails placing the foot, hand, or elbow in icy water filled with crushed ice or ice cubes. This technique provides very complete and concentrated cold exposure to the entire injured area.

Weaknesses: Body parts besides the foot, hand, and elbow do not lend themselves to immersion, because too much of the uninjured area is exposed to the cold.

Application time: 10 to 20 minutes. Let comfort be your guide.

Ice Massage
Strengths: Ice massage involves rubbing ice on the skin with a circular motion. It is easy to apply and focuses the cold on the injured area. A useful approach is to fill a paper or foam cup with water and freeze it until needed. Then peel away the top to reveal the ice and hold the bottom of the cup to apply. Ice cubes or chunks can also be used.

Weaknesses: The cold tends not to penetrate as deeply nor last as long as the methods listed above.

Application time: When applying to bony areas such as the ankle, apply for only 7 to 10 minutes. Double the time when applying to fatty areas such as the thigh or buttocks.

Combination Treatment
To maximize the benefits of cold therapy, think RICE: rest, ice, compression, and elevation. So in addition to cold therapy, rest your injury, apply elastic wrap snugly, and keep the injured area raised. New technologies combine RICE aspects. Cold tape, for example, compresses and-because of a chemical reaction-applies cold to an injured part.

Putting Injuries on Ice
Whichever method you choose, remember to ice early, ice often. But not too often. To avoid harmful effects like frostbite, let your skin recover between cold applications, and listen to your body.

A Time for Cold, a Time for Heat

There has been controversy over the years as to when to apply cold and when to apply heat. Because heat stimulates blood flow, it promotes healing just as cold does. It can also relax muscles and ease pain.

But heat can make swelling worse. That's why cold is best right after an injury and heat is recommended for later, when swelling abates. As a rule of thumb, use ice for at least 48 hours after injury. Then, when the swelling is gone, you can apply heat.

When to Avoid Cold Therapy

Using cold therapy may not be a good idea for some people. Those who are very sensitive to cold will not be able to tolerate icing long enough to do any good. Conversely, those who have a high tolerance to cold-or who pride themselves on being "tough"-open themselves to injury by applying cold therapy too long.

People with problems in the blood vessels near the skin should avoid cold therapy, especially those with Raynaud's phenomenon (a condition in which the blood vessels in the fingers, toes, ears, and nose constrict dramatically when exposed to cold and other stimuli). If you suspect you may be at risk because of diabetes or another condition that can diminish blood flow, check with your doctor before applying cold to an injury.


Wrapping an Ankle Sprain

Here is how to wrap a typical ankle sprain caused by inversion (ankle turned inwards):

1. Position the foot straight (in dorsiflexion), not pointed. You want the injury to heal in an unstretched position.

2. Wrap the elastic bandage around the foot several times for an anchor.

3. Coming from outside, bring the wrap over the ankle and around the back of leg just above the ankle, pulling the outer edge of the foot slightly upward (eversion, twisting outward, opposite of the injury), to counteract the inversion injury.

4. Complete several figure-8 wrapping patterns, again coming from the outside up and around the back of the leg, keeping the foot in dorsiflexion and slight eversion.Don't wrap too tightly. You want to slow the circulation, not stop it. Frequently check feeling, colour and temperature of areas beyond the injured portion; if they become numb, blue or cold, loosen the wrap.

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This page created 19 Dec 2008 15:28
Last updated 29 Jan 2017 00:29

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