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tendons, hamstring, overuse, achilles tendinitis

Athletes Injury Guide

Injuries to muscles and tendons can be traumatic. Common examples are “pulling” a hamstring while sprinting, or a direct blow to a muscle, or overuse such as in Achilles tendinitis.

A later article will cover specific back and neck injuries, but the common sites of muscle and tendon injuries are:

  • Quadriceps (thigh) – muscle
  • Hamstrings – muscle
  • Gastrocnemius (calf) – muscle
  • Achilles – tendon
  • Rotator cuff – tendons
  • Patella – tendon

Muscle injuries

The most difficult part of dealing with muscle injuries is to assess the severity of the injury. The continuum can run from cramping of the muscle and “spasm” (in both these cases the muscle fibres are not directly injured), to a serious tear of the muscle where some of the muscle fibres are actually torn and separated from each other.

Muscles can also be injured by a direct blow and this type of injury can run from superficial, where no actual muscle fibres are damaged, to deep bruising (bleeding) into the calf muscle itself, which affects the mechanics of muscle contraction. When somebody tells you that they had a similar injury to yours and that it got better within a week, remember that every injury and each individual is different, even though the injury may occur in a similar place.

Tendon injuries

Tendons are the structures that anchor the end of muscles to the bones; for example, the Achilles tendon attaches the calf muscle to the heel bone. Unlike muscles, they are not elastic in nature and have a poor blood supply compared to the muscle belly itself. It is exceptionally rare to pull a tendon off the bone. It is, however, quite possible to rupture a tendon, the most spectacular example being the Achilles tendon that goes off like a gunshot when it ruptures. Any rupture, whether partial or complete, needs either surgery and/or immobilisation for a lengthy period, followed by specialist rehabilitation.

By far the most common form of tendon injury is overuse, which creates tendinitis. This is an inflammation of the tendon. If it is not treated it will, in the acute phase, quickly become chronic and very difficult to treat. Many tendons have their own sheath, which lubricates the tendon while allowing it to move smoothly. Unfortunately the fluid in the sheath can become inflamed and the tendon sticks instead of running smoothly. That in turn causes pain and stiffness, which is an annoying injury as it rarely feels bad enough to stop exercising; in fact exercise temporarily makes it feel better. This, however, does not last and the condition usually worsens. The main areas of tendinitis in contact sports tend to be the Achilles, the patella (knee) and the rotator cuff (shoulder).

Achilles tendinitis

Achilles tendinitis has various causes, the main ones being (a) rubbing of ill-fitting trainers or boots, (b) running on hard ground, (c) increased running/sprinting and uphill work and (d) tight calf muscles. Symptoms include pain and stiffness in the morning, pain on calf stretching and tenderness to palpation (touch), especially if the tendon is squeezed and the pain tends to be in one specific area of the tendon (i.e. the pain is localised). Treatment consists of rest, if possible, icing and heel raises to alter the tension on the tendon; gentle massage of the painful area can also help. It is important for athletes to check their trainers and/or boots in case these are possibly the cause of the initial aggravation. As the symptoms settle, calf stretching with a mixture of bent and straight knee exercises is important. Then there can be a gradual increase in the resumption of a training programme but the tendon must not be overloaded.

Patella tendinitis

Patella tendinitis – jumper’s knee – is caused by increased jumping activities, squatting and running. Pain is felt on a resisted straightening of the knee from a bent position. Squatting also causes pain, which can be felt when pressure is applied to the bottom of the knee cap. As with all tendinitis problems, rest is the answer before a gradual return to activity. Benefit will be gained by stretching the hip flexor and quadriceps muscles. (See the first part of this guide in SIB 19 for general injury principles.)

Rotator cuff tendinitis

There are four muscles that help to stabilise the shoulder in its socket. Most joints rely on the fit of the bones to provide stability; for example, the thigh bone fits into the pelvis as a ball and socket but the arm bone fits into a shoulder like a golf ball on a tee. This allows for a large range of movement but, in order to achieve this movement, help is needed from the muscles for stability. This very function of stability for the rotator cuff muscles can lead to problems because overuse or a fall onto the shoulder can irritate the tendons of one or all the muscles. That in turn leads to catching pains, especially on movements when the arm has to be lifted above the shoulder. Any resisted movements of the shoulder, or lifting heavy objects, will also cause a pinching/catching type of pain.

If the normal treatment regime (RICE and MICE as mentioned in part 1 of this guide) does not work then it is very important to see a specialist therapist as the condition usually gets worse and leads to complications. Suffice to say that the shoulder is a very complex area and the best course of action is probably to visit a local physiotherapist to seek a proper diagnosis and rehabilitation programme (for a more technical discussion of rotator-cuff problems, see page 4 of this issue).

That deals with some of the anchor (i.e. tendon) problems, which leads into injuries to the muscles themselves.

Muscle injuries caused by a blow

Haematomas, bruises and contusions mean the same thing and relate to bleeding in the muscle, brought about by a sudden blow or a loading of the muscle that is too great, leading to torn fibres. The most common muscle injuries in players of contact sports are:

  • Direct blow to the quadriceps (thigh) muscle
  • Strain of the hamstring
  • Strain of the calf muscle.

Although I will be dealing with the thigh muscle, the treatment can be related to any muscle that has taken a blow. The quadriceps is made up of four muscles which all have the same action, that of straightening the knee. It is the most exposed muscle to a direct blow, which can either (a) damage the small blood vessels that supply the muscle, causing a leak of blood to the surrounding area or (b) mechanically tear the individual muscle fibres in the area. Superficial blows will quite often show bruising in the area after a couple of days and this can usually be taken as a good sign that the injury will repair fairly swiftly. However, deeper bruising may not show for several days and, even then, discolouration may be further down the leg; this could be at the knee joint, even though the initial blow was sustained half way up the thigh. This happens because all muscles are surrounded by a white, fibrous sheath that separates one muscle from another. The sheath prevents blood from leaking into the surrounding tissues, so it follows the line of least resistance – that is, downwards with the aid of gravity. One player who suffered a blow to his thigh had no visible bruising, but two weeks later the outside of his ankle turned blue/green. It had taken that long for the blood from the injury site to track down his leg. Treatment and healing times depend upon the severity of the injury. Superficial bruising takes only a few days to heal, but even a slight tear of muscle fibres will take two to three weeks. A large tear may take anything up to three months. Most, though, fall into the category of three to six weeks. Special points about the quadriceps muscle are that one of the muscles (rectus femoris) starts above the hip joint and then joins the other three to attach just below the knee. Besides straightening the knee, the quadriceps muscle also helps to lift the knee to the chest.

Treatment principles were mentioned in first part of this guide. When stretching is started, it is important to take the muscles through their full range of movement. The stretch should never be too hard.

Massage and soft tissue mobilisation

As the tissues start to heal and the bleeding has stopped, stretching begins. At this stage the injured muscle can be massaged, which will aid the healing process and prevent tissues sticking to each other. Another benefit is that the blood supply is stimulated to the area and that helps to get rid of the damaged cells. When massaging, it is better to start a little way from the injury site and move directly to that site as the pain lessens. Start gently and work deeper as the injury gets better, but do remember that “no pain no gain” is NOT the motto when treating soft tissue injuries. One last point must be made about the quadriceps. If the injury does not clear up, or the player is unlucky enough to get another direct blow on the thigh, it is sometimes worth going to a doctor to get an x-ray. Sometimes calcium can be laid down in the muscle (myositis ossificans) and this will prevent the muscle from operating properly.

Hamstring strains

These are one of the most common injuries. Treatment is exactly the same as for the quadriceps. There are a couple of points worth making, as many hamstring injuries can be attributed to a back problem. It is, therefore, important not to sit for too long before a match, so a long journey should be followed by a warm-up and back stretch. Irritation of the sciatic nerve that comes from the back and runs down the middle of the leg can sensitise the muscles and cause increased tension. That tension can in turn stop the muscle from functioning properly and increase the chances of injury. If, when stretching the hamstring, you feel the sensation of pins and needles, tingling or pain in the lower part of the leg from behind the knee or into the foot, this is not a normal sensation for muscle stretching. It is likely that you have tension signs coming from the back and a good manual therapist should carry out treatment.

Calf strains

Treatment is the same as for the others, except that in the early stages the player may need to keep weight off the foot. Each time the foot is placed on the floor, the calf is stretched and, during the early stages of repair, stretching does not help. Using crutches or a heel raise inside the shoe (anything up to an inch in depth), will take the tension off the calf. As healing takes place, gradual reduction of the heel raise will bring about a natural, controlled stretch. There are two calf muscles which both share the Achilles tendon as their anchor on to the heel bone. One of them (gastrocnemius) crosses and attaches just above and at the back of each side of the knee. The other (soleus) attaches below the knee. That is why it is important to stretch the calf in two ways, one with a straight knee and the second with a bent knee.

Rehabilitation for muscles

The most common reason that I see for players not recovering properly from a muscle strain is that their end-stage rehabilitation has been somewhere between poor and non-existent. They do all the right things at the beginning with RICE and MICE; after a couple of weeks they do not feel the pain so go out immediately and play again. The muscle has to be put through a rigorous testing procedure before you can guarantee that it is ready for playing. The calf muscle, for example, needs to be tested explosively by sprinting, hopping and jumping to make sure that it is totally ready for playing again. The best advice? Do not go out and test the muscle by playing!

Chris Stephenson

tendons, hamstring, overuse, achilles tendinitis