Points are scored in boxing by landing punches using the knuckle area of the glove on an opponent’s target area. The target region is the front of the head and the body above the belt. Punches landing on upper limbs will not count. A landing strike has to be directed with plenty of power for the punch to count. To create a closed fist the thumb tucks round the fingers between your knuckles and fingernails, always keeping the fist securely clenched when reaching contact. While starting the punch there’s a drive off the rear foot while rotating the trunk of the body, revolving on the central axis of the body. When making a fist, make sure your thumb is tucked round the fingers.
Straight punches are the initial strike taught to a fighter. The strike is powered from the shoulder complex, snapping towards the targeted region. Closed fist and tricep / bicep tend to be relaxed right up until contact.
With a straight punch the hand turns prior to impact with the palm of the hand facing downwards. An ideal punch is made up of lower leg extension, hip revolving and arm extension. The other hand should remain in protection mode up until the striking hand makes contact and returned to its source, retaining the elbow forwards. The development of pace and power ought to place focus on foot speed and lower leg strength as quicker feet help to make quicker hands.
It must be coached early on in a fighter’s training that each punch thrown doesn’t have to be a knock-out strike. Fighters who use an excessive amount of power behind every punch will quickly exhaust energy. Force is going to be needed with every scoring punch, but exactly how much the fighter implements will be influenced by his challenger. Much more energy will be depleted with punches that have missed the target compared to ones that have landed. In order to connect properly with a striking blow, a punch will require pace and acceleration as it draws near the target. Adequate power behind the blow should be employed and the punch should be precise and well-timed. Fighters need the capability to assess range from the scoring hand and target, keeping the attacking arm relaxed up until the last few inches prior to contact, when the strike will then speed up to its target.
For the punch to possess intense power, it is necessary that proper inhaling and exhaling technique is tutored by the trainer as soon as the very first punch is thrown in the gym. The heavy grunting-type breathing which is frequently observed throughout a competition isn’t used for effect, but offers a significant function.
By breathing out either through the nose or mouth when delivering punches, or even both will add power to the strike. For instance, when tennis players serve the ball or field athletes throw the shot-put or javelin, their intense inhaling and exhaling will help with their explosive strength. Not only will proper breathing enhance the effort of attacking punches, but it will heighten the capability to soak up punches, particularly in the belly area. You have to keep in mind that breathing has to be controlled and should not be too noisy or overstated as this might be seen by the referee as a tactic to frighten or mix up a competitor.
The fighting style that a martial artist or boxer adopts is established by several variables. His or her build, height, temperament and character will be important in the continuing development of their bodily and mental abilities. For example a tall, lean, rangy fighter is not likely to decide on a crouching, brawling technique in his punching. It would be just as strange for a more compact more muscularly developed martial artist to fight at long range behind a rapier-type jab. A great coach should be able to appraise the best approach for his fighter, but the majority of mma fighters will embrace the style easiest for them.
As an example, the smaller fighter will frequently undertake the function of the fighter when matched against a bigger adversary. He will have the inclination to take a position squarer to his foe with his weight towards the front foot when operating behind a two-fisted assault. A bigger martial artist will use his size advantage against a smaller challenger, doing the job at long range behind his jab while using bodyweight on the rear foot.
For a fighter to formulate his ideal stance, he must work from the feet upwards. Placement of the feet is quite crucial, as they will move the fighter in and out of striking range. As soon as an individual’s style has been identified by the trainer, it will be his role to consider a stance and guard best suited to his mma fighter. A coach’s key considerations are that their fighter’s position and defense supply him with with defense all of the time. The golden rule in mixed martial arts is to hit your adversary without being hit yourself. This seems reasonable, but whenever an mma fighter throws a punch he opens up his own defence, leaving areas of the body uncovered. As soon as the fighter has thrown a punch towards an adversary he must be completely protected from the counter-punch. Counter-punching is when the fighter has guarded against an attack and instantly launches a strike of their own. Therefore, it is of the utmost significance that when a punch has been thrown the attacking fighter brings his hand into the guarded placement immediately.
Orthodox Stance and Guard
If the fighter leads by using his left hand it’s called orthodox. The orthodox position is the most widely used by fighters rather than the southpaw, leading with the right. It is almost always accepted that the southpaw is left-handed, however it is not necessarily the case. Some right-handed fighters might embrace this style to give them an edge over an orthodox fighter.
For optimum defense the fighter needs to have a sideways stance with hands kept elevated in a relaxed style. Elbows are tucked into the side of the body with the head set at an angle somewhat downwards while looking up through the brows. The chin area will obtain cover from the left shoulder.
Good sight between the guard is required continually, permitting a precise look at the opposition. Your body is well balanced between your front and rear legs and the fighter will have to develop the ability and mobility make it possible for him to transfer his weight laterally and front to back for evasion and assault. Feet ought to be roughly shoulder-width apart permitting a solid base for movement and balance. His front foot ought to be around 45 degrees from his foe with the sole of his feet staying on the ground and his front knee slightly flexed. The rear foot is turned a little more in an outward direction with the heel raised constantly and knee flexed.
Each and every tactic can be tailored to the southpaw. The same concepts apply but the other way round, just like a mirror image. A lot of southpaws are counter-punches but, just like the orthodox fighter, they come in various different types and styles. To the orthodox fighter a southpaw normally presents an uncomfortable challenger and lots of time and work is required in the gym to prepare yourself to fight against a southpaw.
Since there are a lot more orthodox fighters compared to the southpaw a left-handed fighter will invariably have the advantage of sparring with a larger choice of orthodox fighters, giving him an edge when meeting in tournaments. Having said that, increasingly more southpaw fighters seem to be entering the sport of boxing and mma. In the 2005 World Boxing Championships in Asia a southpaw featured in just about every fight from the semi-finals right through to the finals. It would appear improbable that all these competitors would be naturally left-handed, so it might be that many right-handed fighters are now being urged to embrace a right-hand lead stance. For the amateur sport this is often a significant benefit in the point-scoring system, because they are leading using their normally more powerful arm.
Fundamental Footwork and Stability
Footwork in boxing and often mma is a variety of quick sliding motions permitting a fighter to transfer his body weight ahead or laterally, whilst also allowing him to rapidly alter and move in different directions. The skill of good footwork is having the cabability to shift forwards, backwards, left and right at speed whilst sustaining good stability. Sense of balance is an essential part of mixed martial arts, as inadequate balance could leave a fighter at a significant disadvantage when rolling and slipping punches, producing a fairly easy target for his adversary.
If off balance, punching power will diminish as well as leaving the fighter exposed against counter-punches. Understanding footwork and sychronisation is like learning how to dance, as tempo plays an important part in all movements. When moving forwards the front foot will lead, serving as the range finder, whilst driving off the back foot, which is the fighter’s power driver. With backward actions drive off the front foot, while leading with the back foot. The left foot slides first when moving to the left, rapidly followed by the right to guarantee good stability and a well-guarded stance. Shifting off to the right the identical step will apply, but leading using the right foot with the left foot following. While striking, the punch follows the foot and good form has to be enforced constantly. Foot position should not be too wide or too narrow, neither should the front and back foot be straight in line with one another or the legs cross over each other. Getting the feet away from position would certainly affect natural movements and sense of balance, whilst lowering punching power.
If the fighter’s back is attacked they are at a disadvantage and for that reason ought to break free immediately.
Escaping the turtle position through standing up
A fighter in the turtle position with their adversary implementing an under hook body lock counters the move through coming up on to one and then both feet. When standing up, they wedge their thumbs in to the top of their opponent’s hands and drive the hands towards the floor. Simultaneously, the fighter leans into their opponent, but shoves their hips forwards and steps away. The fighter after that turns in the direction of their opponent and assumes the fighting stance.
- The opponent holds the fighter in a double under hook body lock in the turtle position.
- The fighter swiftly will get up on to one foot.
- The fighter is back on both feet and begins to wedge their thumbs into the top of their opponent’s hands.
- The fighter steps forwards using their front leg, leaning their torso back and pressing their hips ahead whilst pressing their opponent’s hands down.
- The fighter breaks their opponent’s grip and continues to turn away from them.
- The rivals face each other in the fighting stance.
Choke defence from back control
If the fighter is actually being locked in the back control position their challenger will probably use a choke hold. To guard against this, the fighter ought to stop access to their neck by utilizing, for instance, the figure four defence position.
- The fighter is being held in the back control position with their opponent’s feet about their hips.
- The fighter raises their hands to guard their neck.
- The fighter places one of their arms around their neck and coils the other arm around it.
Bottom turtle into guard
The fighter implements a forward roll in the direction of their opponent to remove them from their back and to get the much more useful guard position. The strategy is best when the opponent has not established hooks and for that reason hasn’t got complete power over the fighter’s back.
- The opponent has their arms wrapped across the fighter’s lower back whilst they’re in the turtle position.
- Just before the challenger secures leg hooks, the fighter responds by rolling forwards on to their shoulder nearest to their opponent. This has the impact of shifting their hips away from their opponent’s body.
- The mma fighter continues to roll forwards, which makes it hard for their opponent to keep their grip.
- The fighter secures his leg around the opponent’s neck, draws the arm across and wraps the other knee around his knees together, raising his hips and pulling the head down.
- The fighter applies the triangle choke by pulling the other foot.
Properly implementing the back position results in probably the most dominating situations in Mixed martial arts because there is very little the adversary can carry out in defence. The opponent will consequently attempt everything never to be trapped in this manner.
Turtle to back position
The mma fighter initially secures the turtle position by lowering their bodyweight on to their opponent’s back and hooking one arm about their body. The fighter’s inside knee is positioned extremely near and parallel to the opponent’s body whilst standing on their other leg to give additional balance.
The opponent has their elbows near to their knees in a protective posture to stop the fighter from attaining a leg hook. To maneuver the opponent’s elbows, the fighter attacks their head using a punch. As the opponent defends themselves using their arm, the fighter implements their initial leg hook, spins the opponent onto their back and employs a choke.
- The fighter secures the turtle position by lowering their bodyweight on to their opponent’s lower back and hooking their arm about them. The fighter’s inside knee is positioned parallel to the opponent’s body and additional balance is obtained with the outside foot on the floor. The fighter’s free arm is retracted in readiness to try a strike.
- The fighter implements a punch to the opponent’s facial area whilst retaining their elbows in a leg hook defence placement near to their knees.
- The opponent brings their arm in the direction of their head to guard against an additional hit towards the face.
- The fighter takes the opportunity created in order to slip their outside foot inside of and round the opponent’s hip to risk-free the initial hook.
- Then repeats and obtains their second leg hook. The fighter implements a choke hold by positioning one arm around their opponent’s neck, another on their head, and contracting their arms together.
Stopping an opponent from countering the back position
With the opponent in the turtle position, and the fighter in the established back placement using their legs hooked round the inside of their opponent’s hip and legs, the opponent must stand up and shake them off before they are able to utilize some other strategies. To stop this, the fighter wraps their arm round the leg the opponent is attempting to stand upon.
- The fighter obtains the turtle position by disseminating their bodyweight over the opponent’s lower back and wrapping one arm about their body.
- The fighter attacks their opponent’s head, requiring them to shield. By getting their elbow forwards, the opponent generates an area that the fighter makes use of to implement their initial leg hook.
- The next hook is employed by the fighter getting their other leg above their opponent’s body.
- The opponent attempts to stand up to get rid of the fighter off their back by pressing on to their palms and one leg.
- As soon as the opponent pops up on to one foot, the mma fighter grabs their leg by wrapping their arm around it, efficiently. Stopping them from standing up any more.
Flattening the opponent in the turtle position
With the opponent in the turtle situation and the fighter in the back control position, the fighter forces their opponent’s entire body level to the floor. This is accomplished through the fighter having to wrap his or her legs around their opponent’s sides, driving back using their thighs and towards the floor using their hips. When the opponent is flat, the fighter can either apply punches or a choke hold.
- The fighter secures the back control position by wrapping both their legs around their opponent’s hips and their arms around the opponent’s chest.
- The fighter pushes their legs back and their hips towards the ground.
- While the opponent is flat on the mat, the fighter straightens as they continue to push their hips towards the ground.
- The fighter applies punches to the side of their opponent’s head.
Arm bar from back control position
When sitting down, the mma fighter has their adversary within the back position with both feet positioned on their inner thigh. By turning themselves in the direction of where the arm bar is going to be utilized, the fighter positions their leg from the same side on their opponent’s hip. The other leg is positioned over the opponent’s head and the arm bar employed with the opponent’s thumb directed to the ceiling. The fighter sits behind their opponent with their feet on their opponent’s inner thigh.
The mma fighter rotates into the side where the arm bar will be applied and also places their foot on their opponent’s outer hip to assist with the movement. The fighter holds the arm to which the arm bar will be applied. While continuing to rotate, the fighter slips their other arm over the opponent’s head.
In the side control position the mma fighter sets their body on top of their opponent’s whilst securing their arms about their neck. To work, the fighter should press their body weight down on to their adversary while lowering their hips to the ground.
It is a transition position since to implement effective punches the fighter needs to free their hands and gain elevation.
Punching and elbowing from standard side control
To carry out a powerful strike, the mma fighter needs to gain height by getting out of the opponent’s arm lock, whilst controlling their arms. In this instance, the fighter makes use of their knee on the opponent’s bicep, which also leaves their opponent’s head unprotected. Key points:
- The fighter is in the standard side control position
- The fighter frees their arm from the opponent’s with one arm around the opponent’s neck and the other hooked beneath their arm.
- To defend themselves, the opponent closes the space in between by locking their arms round the fighter’s back.
- The fighter drives their wrist down on to their opponent’s jaw, forcing their head to the side and their hands apart.
- The released fighter spins their upper body in the direction of their opponent’s head and comes upwards on to their front foot.
- The fighter traps the bicep of their opponent’s free bicep, that is pinned to the mat with the fighter’s shin.
- The fighter’s knee is placed over the opponent’s arm with their hand, and brings their front knee forwards.
- Both of the opponent’s arms are controlled, one behind the fighter’s neck and the other pinned to the floor by the fighter’s shin. The fighter now has a choice of strikes.
- The fighter punches the opponent’s face with their free arm.
- The opponent is extremely vulnerable and prone to tap out or be knocked out. The fighter prepares to get a second hit to their facial area.
- The fighter delivers an elbow strike to the opponent’s unprotected face.
Americana from side control
To improve the usefulness of submission methods, you should include distracting attacks in the set-up. In the Americana the mma fighter traps one arm so the opponent needs to guard their face using the other. However, the weeknesses produced by the movement to shield is employed by the fighter while they catch the shielding arm and implement the submission.
- The fighter is in the side control position.
- The fighter proceeds to face their adversary by rotating their upper body toward them.
- The fighter’s arm on the mat is securely positioned close to their opponent’s hip whilst securing their elbow.
- The other hand is positioned on the inside of their opponent’s other arm, which they start to drive in between their thighs.
- The opponent’s arm is caught by the fighter squeezing their legs together.
- Out of this situation, the fighter may either use an elbow or hammer fist to their opponent’s face.
- The opponent defends with their free arm.
- The fighter catches the wrist of the defending arm using their striking hand. The fighter’s other hand is positioned close to the opponent’s shoulder.
- The fighter places almost all their weight on to the opponent by rotating and lowering their hips. The opponent’s arm is held and pressed towards the ground between the fighter’s arms.
- The fighter catches and secures the opponent’s wrist nearest to the floor.
- The mma fighter creates additional leverage by yanking both their elbows towards the opponent’s body.
- The opponent’s arm is twisted by pulling their elbow up and pushing their wrist down. The twist is applied until they submit.
Side control to mount
Since the mount position offers excellent possibilities for striking, the opponent attempts to stop the fighter from attaining it by crossing their legs. The fighter handles this by pressing their opponent’s top knee towards ground using their hand to generate room for their leg to maneuver over.
- The fighter is in the side control position.
- The fighter changes their base by turning their torso towards their opponent’s legs.
- The fighter takes hold of their opponent’s far knee.
- The opponent’s knee is pushed towards the ground to create space for the fighter’s leg to go over the opponent’s body.
- The fighter places their knees on the ground, level with the opponent’s hips. To secure the position, the fighter brings their heels together underneath the opponent’s legs.
- The fighter straightens up and prepares to punch.
Side control to knee on stomach
When it will not be feasible to attain the mount position, the mma fighter has the option of positioning their knee on the opponent’s abdomen to achieve elevation and thus a lot more striking possibilities.
- The fighter is in the side control position.
- The fighter extends his right arm and puts his forehead on the floor.
- The fighter makes use of the head as well as the extended arm for control so as to position the knee on the abdomen.
- The fighter arises on his knee to draw back his striking arm.
- The fighter attacks their opponent using a punch.
Side control to standing
- The fighter slides away from their challenger on to their belly, knees and lastly their feet.
- The fighter is locked in the side control situation.
- The fighter turns into their opponent and pushes their hips using their hands to maneuver themselves apart.
- The fighter proceeds to move their body till they are facing down on the mat.
- The fighter quickly moves onto their knees to stop the opponent getting their back.
- The fighter comes up on to one leg.
- The fighter is now back on his feet.
A half guard (or half mount) is when two rivals are on the floor yet only one of the fighter’s legs is in between their opponent’s legs. The competitor that is not on their back is referred to as being in the top position and has several choices, though their primary goal is to attain the mount or side control position.
While in the half guard top position you should keep charge of the adversary, for instance making use of the under hook around the rear of their head. Continuing to keep the opponent pinned flat to the floor is also valuable since it stops them from performing a sweep.
By transferring from the half guard to the mount, the fighter puts themselves in a much more useful placement for attacks. Throughout the changeover the fighter controls their opponent’s head and one of their arms because this minimises their capability to strike. The mma fighter also has to have their head low as well as their hips high to avoid their opponent’s leg hold. As soon as their foot is free, they might opt for the mount position. Technique tips:
- The mma fighter in the opponent’s half guard is controlling the opponent’s head and one of their arms.
- The fighter lifts their hips by pressing off the leg which is between the opponent’s. Their other foot is positioned on their opponent’s knee.
- The fighter continues to raise their hips and begins pressing their shoulder into their opponent’s face
- The fighter pushes their opponent’s knee to the floor using their foot.
- The fighter’s legs pin one of the opponent’s legs to the floor and begin to wedge the other leg by putting one knee on the opponent’s thigh.
- The fighter straddles the opponent’s hips and flattens their entire body onto their opponent’s.
- The fighter secures the mount by wrapping their legs beneath their opponent’s and putting their heels together.
- The mma fighter throws a punch in the mount position.
Any time both competitors are on the floor with the fighter on top in between their opponent’s legs, this can be referred to as being in the guard top position. Using this position, the fighter can hit with both their hands or elbows.
The opponent in the guard bottom position will either make an effort to sweep the fighter or control their head and hands to minimise the amount of weight they can put behind their strikes.
Posture up guard
The mma fighter places one hand on the opponent’s upper body to stop them from sitting upright and taking hold of the head. With this particular control set up, the fighter can use strikes using the complete power of their body weight. The fighter keeps good posture and a strong base by sitting upright. Key Points:
- The fighter forces the opponent’s chest straight down with one hand while keeping good posture.
- The fighter’s other hand stays back to give you the choice of strikes or to push the opponent’s legs apart.
The bicep control stops the opponent from sitting upright. When utilized, the fighter’s arms are straight and the hands are put around the biceps with the thumbs on top. With their arms pinned to the mat, the opponent’s choices for counter strategies are decreased.
- The fighter controls the biceps by pinning the opponent down with their hands, with the thumbs on top.
- The fighter’s arms are straight and their body is leaning forwards.
The opponent on the floor strives to reduce the effect from strikes and elbows by manipulating the fighter’s hands and head. The fighter counteracts this by swiping away or manipulating the opponent’s hands. Both are able to use strikes to pass through each other’s defences.
- The fighter frees one hand in anticipation of punching.
- The fighter controls the opponent.
- The non-punching hand can be used to pin the opponent’s hand to their upper body, successfully stopping them from protecting themselves.
- The fighter throws an overhand by dropping their weight forwards.
- The opponent controls the fighter’s head and wrist to stop the fighter from hurling straight punches.
- The side of the opponent’s arm holding the fighter’s head is unprotected, therefore the fighter draws back their hand in preparation to toss a hammer fist.
- The fighter has a clear route for the hammer fist.
- The hammer fist lands in the opponent’s face.
- The opponent controls the fighter’s head to stop them from throwing straight punches. The fighter has one hand about the opponent’s bicep to pin it to the mat.
- The fighter brings their other hand underneath the arm controlling their head.
- The fighter holds back for the adversary to look up.
- Any time they do, the fighter throws an uppercut to their chin.
- The opponent controls the fighters hands
- The fighter leans their body to the opposite side holding their wrists.
- The striking arm rotates upwards and forwards.
- The elbow clears the opponent’s arm and continues to rotate with the fighter’s body weight behind it until striking the opponent in the face.
- The opponent controls the fighter’s head and one arm.
- By controlling the fighter’s head, the opponent leaves one side of their body exposed. The fighter plans to take advantage of this and pulls their striking arm back in preparation.
Striking Combinations from Guard Top Position
Striking combinations in ground and pound are essential as they generate openings for strikes. The body-body-head punching combination is used to make the opponent protect the side of their body and, once they do, to punch their unprotected face. However, the non-striking arm should remain active to prevent the opponent’s hips from rising or an
BODY-BODY-HEAD COMBINATION FROM GUARD TOP
- The fighter strikes the opponent’s ribs with a body Hook.
- The fighter strikes again.
- To defend against another strike, the opponent lowers their arm to protect their side.
- The fighter takes advantage of the space create: and applies a hook to the opponent’s face.
Passing the guard
The fighter is in the full guard of an opponent on the ground when the opponent has their legs locked around them. (this position the opponent has the advantage as they are able to create distance, defend against strikes and attempted submissions.)
To get past this, the fighter distracts the opponent with combinations of strikes and then mixes and matches striking and specific passing-the-guard techniques. Here is how it plays out:
The fighter is in the opponent’s full guard.
The fighter simulating a pass-the-guard attempt by pushing down on to the opponent’s leg.
The opponent focuses their attention on their leg and the fighter uses the moment to come in with a strong overhand.
The impact of the overhand forces the opponent’s leg lock to break. The fighter pushes their knee and elbow against the opponent’s inner thigh to prevent the leg lock from being reapplied.
A good defence against takedowns is essential for fighters who are more vulnerable on the ground, for example grapplers and strikers.
Takedown defence principle
The basic defence principle is the same for all takedowns: step aside and avoid contact by deflecting the opponent with a push. This also puts them off balance and provides the opportunity to apply a punch, strike or takedown. This is often how takedowns are set up and defended against:
- The opponent attempts a jab to distract the fighter, who parries.
- Following the jab, the fighter drops down and shoots in for a takedown.
- The opponent responds by placing their forearm around the fighter’s neck and moving their legs out of the fighter’s reach.
- The fighter steps backwards and the opponent’s momentum takes them forwards into the space created.
- The fighter continues to pivot their body around their opponent’s to keep out of their reach.
- While pivoting, the fighter is pushing their opponent off base, creating the perfect moment for a strike or takedown.
- The fighter chambers their knee in preparation for a devastating knee to the head
- The fighter pushes their opponents head down in
- The fighter strikes with a cross to the head.
Guillotine choke to defend against a leg takedown
The guillotine choke can be used by the fighter as a defence move if their opponent is shooting in for a takedown. As the opponent comes in, it is too late to defend against them with other techniques, but because the opponent is likely to have their head down, it provides a good position for the guillotine choke to be applied.
- The opponent shoots in for a double-leg takedown. As the opponent’s hands are low their neck is exposed, providing a good opportunity for the fighter to apply the guillotine choke.
- The fighter places their feet outside their opponent’s and wraps their arm around the opponent’s neck.
- The opponent drives the fighter to the ground. The fighter attempts to keep their legs away from their opponent’s body so that they can later be wrapped around them.
- The fighter applies the guillotine choke by tightening their arms around the neck. The legs are wrapped around the opponent’s body and interlocked. By pushing the opponent away with the legs and applying the choke, the opponent is likely to be forced to tap out.
The sprawl can be used as a last resort when an opponent penetrates too far with a takedown. To prevent the opponent grasping the back of the fighter’s legs, they step and push back with their legs until their legs and hips are flat to the ground. The feet are also flattened to help keep the hips down and to prevent the body from involuntarily rising if pushed. This can also help trap the opponent under their weight. From this position the fighter can slide backwards, again to prevent the opponent reaching their legs.
- The opponent shoots forwards for a double-leg takedown. The fighter reacts by lowering to a crouched stance.
- The fighter’s elbow is bent on their leading side and catches the opponent’s shoulder in the crook.
- The leg on the preventing the opponent from grabbing them.
- Same side as the crooked arm is pushed backwards so all their weight is on the opponent.
- Defence against a single-leg takedown
Balance is very important when defending against a single-leg takedown as techniques are applied while being pushed about on one leg. In this technique the opponent’s head is pushed away to the side, and then down from the fighter’s body in order to roll them to the ground.
- The opponent goes in for a single-leg takedown.
- The opponent holds on to the lead leg.
- The fighter pushes their opponent’s head away and to the side with their hands.
- The opponent’s head is pushed from the fighter’s side towards the ground while the fighter’s other arm wraps around the opponent’s leg.
- The opponent’s head is pushed down and their leg pulled upwards, forcing them into a forward roll.
- The opponent is followed to the ground and held in the side control position.
For the single or double-leg takedown to be effective, it is important to be within arm’s length of the opponent and with a correct set-up. The success rate also increases when the move is combined with strikes. When going in for the move, the hands remain up until the head has made contact with the opponent’s body. With the hands high, the fighter is less vulnerable to strikes, kicks and knees. This is particularly important when the fighter’s body is moving forwards as this increases the impact of blows received.
A single-leg takedown is normally executed when the opponent has one leg forward and the other back. In this situation a double-leg takedown would be inappropriate: the fighter would become vulnerable when travelling the further distance required to capture both legs, during which time the opponent would react and counter. Application as follows:
- The opponent in the normal stance, one leg in front and one behind.
- When the opponent’s legs ‘mirror’ those of the fighter, the ideal opportunity for a single-leg take down is created.
- The fighter drops their body and steps to the outside of the opponent’s lead foot.
- The fighter grabs the opponent’s front leg, placing their head in the centre of the opponent’s chest and pushing off their back leg.
- The fighter pulls the opponent’s leg to their chest and brings their elbows together. The fighter’s legs are now bent.
- The fighter’s head continues to push into the opponent’s chest as they rotate their body, and the opponent falls backwards over the fighter’s leg.
- The fighter continues to push their head into the opponent’s body and rotates them to the floor.
- When both competitors are on the floor, the fighter tries to get on to their knees.
- Once the fighter is on their knees, they secure the situation by using the top position.
A double-leg takedown is normally executed when both competitors have the same stance and therefore the same lead leg. When going in for the shoot, it is important to keep the forward momentum while securing both legs with the arms. If possible, the opponent should be pushed sideways to keep away from counter-strikes, known as guards. Once on the ground, the opponent should be secured by using the side control position. How it’s done:
- Both competitors lead with the same leg in the normal fighting stance.
- The fighter moves into a crouched stance.
- Pushing off with their back leg, the fighter explodes forwards while keeping their hands up to protect against strikes.
- The front leg steps forwards and is placed between arms are wrapped around the back of the opponent’s knees.
- The fighter’s head is placed on the side of the opponent’s body, on the same side as their leading leg.
- To keep away from potential strikes from the opponent’s guard, the fighter stays to the side.
- The fighter establishes the side control position.
Body lock takedown
A body lock takedown follows a successful double under hook where a tight grip around the opponent’s body has been achieved: This is a very effective takedown that can seriously injure the opponent when they land. Pointers:
- The fighter achieves the double Under hook with a firm grip of their wrist.
- The fighter steps behind the establish a double under hook.
- The opponent is rotated and tripped backwards by the fighter, who maintains a strong grip.
- Once the opponent is on their back, the fighter secures the side control position.
Takedown from the Muay Thai clinch
- If the fighter has been unable to bring their opponent’s head down to apply strikes, they can use their resistance against them by releasing their grip and shooting in for a takedown.
- The fighter holds their opponent in a Muay Thai clinch.
- The opponent successfully prevents their head from being pulled forwards, so the fighter releases their hold.
- Released from the hold, the opponent’s body moves backwards and the fighter shoots in for a double-leg takedown.
Body lock takedown from the back
An opponent held from the back in a body lock becomes very vulnerable to a takedown. This is a simple manoeuvre for the fighter, involving wrapping their leg around their opponent’s and applying their body weight until they collapse to the ground. Once on the ground, the fighter can apply a rear naked choke (as GSP demonstrates at the end of the fight in the above video).
- The fighter applies a back body lock with one arm of the opponent secured
- On the same side as the arm, the fighter wraps their leg around their opponent’s.
- Keeping in close contact with the opponent, the fighter applies their weight while pushing forwards, thereby forcing the opponent to the ground.
- Once on the ground, the fighter rolls on to their back, taking their opponent with them and securing their legs by hooking them with their own.
- The fighter applies a rear naked choke hold.
Throws are integral to MMA and are used in a variety of ways. Simplicity is the key as the opponent may strike, clinch or perform a takedown at any time.
UNDER HOOK THROW
With this throw the fighter applies an under hook with one hand and holds the opponent’s wrist with the other. The fighter then steps in close with their back and both heels turned towards the opponent. Forward movement of the opponent’s body is then created by pulling on their wrist and maintaining the under hook. The fighter also kicks backwards with their leg just below the hip of the opponent, who then falls over it. Key points:
- The fighter applies the one-arm under hook and wrist hold.
- The fighter turns their back and both heels towards the opponent to make the throw easier.
- The fighter’s kicked-back leg provides the pivot for the opponent to fall forwards, while the under hook and Wrist hold provide the force.
- The throw can be followed by other moves including the side mount position.
UPPER BODY THROW
The throw starts in a neutral position with one arm in the under hook and the other over the opponent’s arm. The opponent could also be in the same position. The leg of the fighter, on the side the throw will be executed, steps past the opponent’s feet. The fighter’s body is turned at the same time and the opponent is thrown over the fighter’s hip.
- Often starts with both competitors in a single under hook where neither has the advantage.
- The fighter moves their leg past their opponent’s feet turning their hips.
- The fighter is fully turned, with both feet fairly close together and the knees bent in preparation to lift and pivot the opponent over the hip
- The opponent is lilted on to the fighter’s hip by the fighter straightening their legs, pulling the opponent over.
- The opponent is thrown to the floor.
What Type of Fight?
There are some key points to consider when learning how to throw a knockout punch.
Firstly – what is the situation? Is it a street fight? A boxing match. A mixed martial arts (MMA) fight?
All of these have to be taken into consideration separately. Also, a knockout punch is different to punches that are thrown without the aim of a knockout, such as jabs and body shots. Although jabs can in theory knock someone unconscious, they are used as set ups for following punches, and to keep an opponent at a safe distance.
Body punches do not normally knock an opponent out, although they can end a fight via injury to kidneys, liver and ribs. They can do this with one blow (rare) but usually by a sustained onslaught over several rounds. Of course, blows like this delivered to an untrained adversary (e.g. in a self defense situation) can result in sudden incapacitation.
So what punches can potentially result in a KO? And where should they be aimed?
Where to Target Punches
A punch landed anywhere on the head with sufficient force can work. But depending on whether it is a street fight, boxing match or MMA fight, there are limitations in place.
In a street fight, it is not a good idea to land a clenched fist on to any part of the head as it often results in the one striking breaking bones in the hand. People often don’t believe me when I tell them this. But to illustrate the point, imagine hanging a sheep’s head from the ceiling with string. Go ahead and punch it as hard as you can. Well, you would think twice.
It is a solid object for a start. You wouldn’t slam your bare fist into a wall with full force and not expect an injury would you? The bone in the sheep skull is harder than brick believe it or not. And so is the bone in the human skull and surrounding bones of the cheeks and jaw.
For this reason, palm strikes are the method taught in military unarmed combat when attempting to knock an opponent out. These are not punches though and that is the subject of this discussion. So if you find yourself in such a situation, think twice before your knuckles connect with the person’s head! You could come off worse. I’ve seen it happen many a time when I worked as a doorman on the London club scene.
Ok. That deals with the limitations in a street fight. What about boxing and mixed martial arts?
Punching in Competition
In an organised contest, your hands are protected with gloves and wrapping. So hand trauma is not so much an issue – unless you are carrying a pre-existing injury or have a weakness of some kind. The limitations here are down to the rules of competition.
So this means you can’t land your punches on the back of the head, throat, or neck. Anywhere else to the head is fine. The best place is the chin as it is a leverage point. If you throw a punch that causes the head to turn fast you stand a good chance of flooring your opponent. The chin is the obvious choice as it sticks out from the rest of the head. You could go for the temples or cheeks but you won’t get as much leverage. But beggars can’t be choosers, so take whatever chance you get.
Types of Punches
If you want to turn the chin in the horizontal plane i.e. left to right or right to left, then some kind of hook will do the business. To turn the head up, then an uppercut should be used.
But the chin is not the only area that will give you results. Knocking the head back with straight punches works well if they have enough power. As stated above, you can do this with jabs but its not seen often. The Klitschko brothers are the jab experts and have finished many fights with just the left hand. Being 6 foot 8 inches tall with an 80 inch reach is a huge advantage.
But a more devastating punch would be the straight right (or left if you are a southpaw). For most fighters, this is the most powerful weapon in the arsenal. Yes I know hooks can have more speed in their delivery, but body weight transfer is greatest in a straight line.
Compare the weight you could move with a dumbbell bench press (straight path) and the weight you could move with a dumbell flye (arc movement). You can generate more power in the straight path movement. The same principle applies with punches. More on that later.
The straight right can be delivered in a number of ways, ranging from a full body power movement beginning with the feet, and channeling power from the ground through to the hands – down to the classic 1 inch punch popularized by Bruce Lee.
Whichever version is used, the aim is to force the opponent’s head back as fast and as far as possible. Therefore, the punch is delivered with a follow through in mind. This is unlike the jab, which is retracted as quickly as it was extended to get back into guard. With the straight, you want to aim to punch through your adversary and then bring it back.
If you want to land a blow with some real force behind it, you need to incorporate rotational power into the movement. Force emanating from the arm alone will not have the power to do much damage. If you don’t realize how important this principle is, I suggest the following gym experiment:
1. You will need some kind of cable pulley positioned with the handle at shoulder height.
2. Load enough weight to enable you to feel it pulling you back when you grab the handle and perform a punching out to the front movement. Not too much weight though. Enough to handle about 8-12 repetitions.
3. Brace yourself and keep your hips static and push the handle out in front a few times. You will feel your shoulders and triceps doing most of the work. Do 8-12 reps and take a minutes rest.
4. Now I want you to do the same thing but this time swivel your hips first and then as your shoulders start coming forward, release and punch out. Do about 8-12 reps. Then rest a minute.
5. What you will notice is that you can move the handle forward faster and easier. Why? Because involving your hips gives your arms and shoulders a head start. They are not working from a dead start.
6. Next, I want you to involve your feet in the movement. So instead of just rotating your hips, begin by pushing off with the ball of your right foot (if you are throwing a straight right). So now what you should find is that your hips rotate even faster than before, because they get a head start too . The transference to your shoulders and arms is even greater as well.
I hope this explains the importance of rotational power in delivering a knockout punch. You can build this exercise into your training program. Obviously do it for the left and the right sides. Make a note of the weight you use and number of reps.
At the next training session, try and increase either the reps, weight, speed of movement, or a combination of all three. Just keep trying to progress somewhere. Do about 3-5 sets each side. Rest anywhere from 30 seconds to 2 minutes between sets.
If you want to add a conditioning aspect to this exercise, have no more than 15 seconds rest between sets as you swap from left to right. This will increase not only absolute punching power, but your cardio-vascular capacity and muscle endurace too. You need all three to become a well rounded fighter.
You should be able to punch with full force at any point in the fight. If you have not got the muscle endurance and conditioning you will weaken as the fight progresses. This type of training will ensure you have enough gas in the tank.
Heavy Bag Drills
Punch bag training is essential in developing knockout technique. It allows you to simulate landing on a human, and practice combinations of punches. It will increase speed of delivery, muscle endurance and cardio-vascular capacity. Punch bags alone though will not do much to increase your force of delivery. Here’s a quick physics lesson to explain why.
1. Force = mass x acceleration. Heavy bag drills will go some way to increase the acceleration aspect of the equation, but mass, my friend, is down to the meat you got on your bones!
2. Let me illustrate in another way. Imagine you are a linebacker and want to improve your game. Problem is you only weigh 150 lbs.
3. You can practice running into pads all day long, but unless you put some weight on, you’re not going to get far. Running into the pads will only increase your speed.
Weight Training and Diet
So how does this relate to the combat athlete learning how to throw a knockout punch? Well, you have to increase your mass, via resistance training and diet if your goal is to punch with more force. The best resistance exercises to perform would be those that increase strength and size, but also are specific to the movements in a real fight. So the cable exercise above is ideal. But there are plenty of other MMA weight training exercises that you should use.
Reflexes and Accuracy
Its all very well having a powerful punch, but unless you can hit the target, it is useless. Hitting a punch bag is no big deal. But hitting a human being’s head is not so simple. Especially when blows are coming your way at the same time. So what can we do to in terms of fight training to make sure we have a good chance of connecting?
The obvious choice. As close to a real fight as you can get the better- without injury. Save that for competition. How close sparing comes to a real fight scenario depends on several factors. How good is your sparring partner? How hard do you want to spar? Mexican boxers are renowned for sparring hard. So no wonder they produce some the most successful and toughest fighters in the world. You need the right equipment such as headguards, gloves (the bigger the better if you don’t want injuries– 16oz is ideal). If its an overall MMA session then shin guards too. Sparring will help hone the reflexes and should be a foundation of your training. Spar for the same length of time the rounds are in your sport. Usually 3 or 5 minutes.
Double End Bag
This favourite of professional boxers will go a long way in teaching you how to throw a knockout punch. Its a soccer sized ball with 2 ropes that hold it tight to the floor and ceiling. When you hit it, it pings around wildly and fast. This teaches you to hit a rapidly moving target and dodge incoming blows at the same time.
At first you will find yourself missing and being hit. But after a few sessions your brain will start adapting and your reflexes will improve. Its a good cardio workout and will also condition your legs, hips, abs and lower back as it forces you to dodge and weave.
You’ll find that you can see punches coming at you in sparring sessions and a real fight a lot earlier once you’ve gotten to grips with the double end bag. Also, instead of missing the ball as you did in your first few sessions, you will connect accurately because the double end bag improves your co-ordination and anticipation.
Uppercut Training for a Knockout
Knockout by uppercut is a good way to end a match during in-fighting. You might prefer to fight up close or your opponent may be forcing the issue against your will. If you are a rangy tall fighter, then you probably want to maintain distance, use your jab a lot and wait for the right moment to deliver a straight right or hook. But if you are up against a pressure fighter who continually closes down the distance between the two of you, then a good uppercut is key to a KO.
Uppercut bags are the tool you need. The classic one is about 2 times the size of a basketball and hangs from the ceiling. They allow you to get under the target, which you can’t do with a normal heavy bag. There are several types, including hybrids, which are a cross between a conventional heavy bag and an uppercut bag. But to seriously train the uppercut it is best to use the ball shaped bag.
The key to a powerful uppercut is to keep your body tight and to transfer as much of your entire body weight vertically into the movement. A good uppercut should also act as a guard with the forearm coming up in front of you. Beginners tend to throw the punch too far up and away from their bodies. This produces independence of movement between the arm and torso.
This is wrong. It will throw you off balance and there is little transference of power from the rest of the body. So keep things tight and whip the fist up maintaining a chain of control from feet to hands. If you do this you will maintain good defense, a protected face, and guarded ribs. You only have to get as high as the chin for it to work. So depending on the height of your opponent, do not think that the hand has to go much higher than your own chin.
Because of the arc of movement in an uppercut, it is easy to strengthen the musculature involved via cable and dumbbell exercises. To build mass and strength, one arm dumbbell shoulder presses performed with palms facing you, while seated on an incline bench are good. Go as heavy as you can for 3 sets of 5-8 reps. Rest 2 -5 days and try and up the weight and / or reps the next training session. It is not a full range of movement exercise. Keep the shoulders and torso tight to mimic a real uppercut.
To increase speed and endurance, do the same exercise but with a weight you can lift 12-20 times, and do it standing. Again, mimic the uppercut even more now, as you will be on your feet. Power up the dumbbells starting from the feet. Remember to engage the torso, this time trying to transfer your rotational power into upward force.
Overhand Right or Haymaker
For some reason, this punch seems popular among drunk brawlers! I used to see them being thrown every weekend, when I worked on the doors. Wild swinging un-focused lunges. But for the serious combat athlete the Haymaker (usually called the Overhand in MMA) is a legitimate punch and cannot be ignored if you want to find out how to throw a knockout punch from all angles.
This punch enables you to go over your opponents guard and land straight on his head. With skill and timing it can even land on his chin. It is a chambered movement, a bit like a tennis serve. It requires a strong chain of supporting muscles and connective tissue to maintain any effective force on the connection. Care should be taken when launching one as your own guard is opened up to a degree.
I’ve left the best til last, in some respects. Most people when thinking of how to throw a knockout punch will have some kind of hook in mind. Most people can throw a hook pretty fast. A hook can get round the guard of an opponent which is why it is devastating in the right hands.
The problem is, when they connect with the target, there is a loss of transfer of force due to weaknesses in the body. Out of all the punches, hooks rely the most on the power generated via rotation of the torso. If you have not trained specifically to strengthen the chain of connecting ligaments, tendons, and muscles used in this rotational movement, you put yourself at a severe disadvantage.
You can test how weak or strong you are in this area, by attempting a one arm push up. To do this, you need to get into a normal push up position, but spread your feet apart a lot wider and support yourself on one hand or fist. So you should now be spread out like a tripod.
Attempt ONE. A lot of people cannot do one! If you complete one easily it is an indicator of reasonable core strength. But you need to be at a level where you can bang out sets of 20 reps. The one arm push up is a good guide in revealing weaknesses that you have in your torso, shoulder rotator cuffs, and back.
You might be able bench press 405lbs, but if you have weaknesses in your core and supporting ligaments, tendons, etc. you won’t be able to transfer much of your strength into a hook. Throwing hooks to a heavy bag is a start. But it will only go so far in strengthening your weak points because as your arm moves through the air, prior to contact, there is little resistance.
What you need to do is exercise the same plane of movement with cables, weights, and bands. And get this straight – you need to train unilaterally. In other words one arm at a time. Another little experiment for you here.
1. Get a dumbbell that you would normally use to perform a dumbbell chest flye.
2. Lay on a bench or the floor, and do it with just one arm. Notice the pull in your abs and obliques? These are the exact same muscles that are used in rotating the hips.
The major muscles used are:
1. Rectus Abdominis
2. Transverse Abdominus
4. Quadratus Lumborum
5. Erector Spinae
6. Gluteus Maximus
9. Deep External Rotators
These can be most effectively targeted by training one side at a time. When you train with both arms at once, you are equally balanced so it does not put much stress on the the parts of the body used in a rotational movement. Think about it. You don’t throw a hook (or any punch) two hands at once! So be creative and alter your weight training so that it is fight movement specific.
I hope this article has really helped you to understand how to throw a knockout punch and the type of exercises you should incorporate in your mixed martial arts training program.
What is 52 Blocks?
There is a lot of mystery surrounding the term “52 Blocks”, (a.k.a. 52 Hand Blocks, Jailhouse Rock (JHR), Jailhouse Boxing and the Bumrush) and for good reason. Its origins are not exactly mainstream and it still resides primarily in a sub-culture within a sub-culture. Ever heard of Mother Dear, Fat Cat, Glass Man or True-God? The plot thickens. Read on.
It’s a contentious issue but probably correct to state that 52 is a type of Jail House Rock. JHR as a term has been employed decades longer than 52 Blocks. Is there a difference? Again – another contentious issue, but most people that were inside the penal system during the 1970′s when the term 52 Blocks started being used, have a definite take on it. They claim that 52 is an all over body beat up. From toes to your head. JHR was more conventional boxing with some dirty moves thrown in. Not so many elbows though.
You won’t find many books with the title “52 Blocks” on Amazon. It has but a passing mention in wikipedia and there are vague scatterings of information on it in the blogosphere. But when it is associated with MMA champions such as Rashad Evans of the UFC, people start to take notice and want to find out more.
America’s Only Indigenous Martial Art?
52 Blocks has been called the Capoeira of North America. It is a fighting style that uses the upper body (mainly forearms and elbows) to block strikes, mainly punches. There are various modern demonstrators of 52 Blocks, some displaying more practical applications, and some more fanciful versions that would have little application to a real fight. The more practical versions resemble what is commonly referred to as dirty boxing, but in reality, it is part boxing and part martial art.
Its taught as a valid system of self defence as well as a practical method for use in MMA.
Famous Fighters Endorse 52
Rashad Evans – a UFC Light Heavyweight Champion – said this about 52 Blocks: “The thing about 52 is that its not really known about for one, in the mass public. But what it is, is dirty boxing taken to the next level. A lot of people see Randy Couture and what he does and say man, Randy Couture, he has the best inside game and the best dirty boxing out there. But 52 is, in my opinion, the best dirty boxing, the best inside game fighting out there. Its good. It’s everything that happens in the UFC.”
He’s not the only fighter to have praised the style. Mike Tyson is said to have been well versed in it and used aspects of 52 blocks when he took the WBC Heavyweight title off James Bonecrusher Smith in 1987. Zab Judah, the southpaw welterweight, acknowledges its effectiveness. MMA brawler, Kimbo Slice fights in a very “52″ way, employing a lot of elbow blocking. And Bernard Hopkins, who reigned supreme in the middle weight division for ten years, has referred to 52.
It’s worth noting that if anyone was ever going to be exposed to the style it would be Hopkins. He was already a career criminal at the age of 13, been in numerous knife fights (having been stabbed 3 times himself), and served 5 years in Graterford Penitentiary where he saw murders, rapes, and all sorts of fights. It was in prison that he took up boxing.
For the mixed martial artist, it is well worth looking at considering its origins. Any form of fighting that has been put to the test for decades in what is the most violent section of society – the penal system – has to be taken notice of. At last the wider fighting community has accepted the validity of 52 Blocks and it is being taught in more and more Martial Arts schools.
History of 52 Blocks
As mentioned before, information is patchy. And extremely contentious! Unlike Chinese and Japanese martial arts, it has no authoritative texts, grading systems, or established schools. The main authorities on the subject are its current practitioners and ex-inmates. It is to them we must go to glean something of the origins of 52 Blocks.
The main point of issue is whether it came from Africa. I’m not going one way or the other on this. But I think its worth just looking at some of the facts concerning slavery and African Martial Arts. If we do this, then it is foolish to rule out the possibility at least, that there was a transmission of knowledge that spanned the 1500,s to the present era – an Africa to America theory.
This fighting style existed among the first African American inmates in the prisons of the United States. But the history might go deeper than this. It is certain that the first Africans to be enslaved and brought to the Americas were well versed in martial arts. There is widespread ignorance of African culture as it stands today, let alone its historical record. However, martial arts play a huge role in contemporary African society, and have done for centuries. Fighting competitions were (and still are) integral to their cultures, forming rites of passage to adult status for young men. In most West African cultures, a man could not truly be a man unless he competed.
The West African fighting arts that exist today such as Dambe – in the photo above – (Nigeria), Laamb wrestling (Senegal, Gambia) and Evala wrestling (Togo), have well documented histories pre-dating trans-Atlantic slavery. Competitions among practitioners draw crowds in their thousands. A fighter can earn up to 2 years average workers pay in a single tournament. Events are taken seriously and training camps exist, run by ex-champions, who work as full time coaches. Check out the CNN report in this video.
The styles themselves have evolved over the centuries, but nearly all West African martial arts involve grappling, and varying degrees of striking. There are also weapons events using sticks and spears.
Despite urbanization and migration from villages to cities, traditional martial arts still form an important part of the culture and entertainment in West Africa. So we can say without doubt that the knowledge of these styles came to the Americas with the enslaved Africans.
White slave owners saw these talents as a threat to their own security. Along with their original African languages and religions, the fighting skills were forbidden to be practiced. The fighting arts were practiced back in Africa to develop militancy, confidence and strength. However, slaves continued to pursue training in secret. Slave owners feared that if they allowed this form of recreation to continue, rebellions among slaves would be inevitable.
Rebellions took place in many areas of the Americas and Caribbean, most notably Jamaica, Colombia, and Florida. Those who escaped the tyranny of slavery were known as Maroons (pictured above). They set up villages and small towns, defended their territories and lived as free men. The ex-slaves in Florida joined forces with the Seminole Indians and became the biggest Maroon community in North America.
With abolition of slavery and the migration of African Americans from the southern states to the industrial north east, the ancient knowledge of these African fighting styles would have moved into the ghettos and prisons. They were brought into the spotlight by several black boxers such as the first black heavyweight champion Jack Johnson.
Johnson didn’t just compete under Marquess of Queensberry rules. He was a working prize fighter and took part in bouts which were essentially no holds barred events. To the modern eye, those matches would have had more in common with mixed martial arts than modern boxing. Johnson employed what he had learned from ex-inmates and applied this system of blocks in his contests, with great success. He could get in close, and because he knew how to use his forearms and elbows defensively, lay on heavy hits at the same time.
Some of these contests were sickening and degrading, perverse almost. Sometimes as many as ten men were pitted against each other, blind folded, and left to to their own devices. Whoever remained conscious was declared the winner. Johnson is reported to have employed the JHR / 52 Blocks system in situations like these. As sick as these contests were, they proved a point and have some carry over to MMA today.
Fighting close quarters in dark prison cells, corridors, and alleys, would have given a deadly advantage to competitors in extreme no hold barred contests. The techniques would have been harnessed in situations where men were fighting for their very lives.
The psychological edge would have made a huge difference too. Knowing you were most likely going to live through the fight and possibly pick up a payment, is a lot less frightening than fighting for your life in jail, possibly against multiple, and, often armed attackers.
This explains how some of the black prisoners at the turn of the century, adapted these honed reflexes to boxing on release. They elevated the level of finesse of the sport to a great extent and introduced a method of boxing that was unknown to white fighters.
Some of the sports journalists back in the early 1900′s were taken aback by this. Some even claimed that the black boxers fought in a cowardly manner! They had not seen this level of defensive skill prior to this. We wouldn’t call it cowardly today of course. Its now appreciated as part of the craft. But it does show a definite separation between the white American / European school of boxing, and that which emanated from the ancestors of African slaves. Coincidence? Judge for yourself.
As the name implies, 52 Blocks has been described as a defense based countering fighting style. That’s a little misleading though because as it’s taught and displayed today, I would say its 50/50 defense / offense in application. The blocks themselves are intended not only to defend but to inflict injury at the same time. To any of you who had ever punched an elbow, you’ll appreciate the gravity of a fist landing on hard bone.
This often results in fractures to the metacarpels. This can also occur to punches landing on the head, which is why palm strikes are the preferred method of striking to the head in hand to hand combat. Slaps are used in 52 Blocks street fighting moves. Its an ever advancing method involving dynamic torso twisting, tight footwork, shifting stances, and a natural flowing pressure-fighting feel. Some of the “blocks” or moves are:
- Skull and Crossbones
- Close Door Open Door
- Triangle Train
- Black Man Rising
- Kiss and Catch
- Scoop against shank
- The pants leg flip
- Shaolin blocks
- Secret g=mc lock
- Defense against an uppercut
- Circle hands trap
- Hook and take down.
- Open gates (buttefly) and take down.
- Choke out
- The shank
- Gun disarming
- Slap hands etc.
Prominent New York trainer, Lyte Burly maintains that 52 Blocks “is 90% elbows”. Unlike the stiffer approach though used in Muay Thai, 52 requires fluidity of the shoulder joints and rotator cuffs. This is achieved by daily mobility exercises that increase and maintain that suppleness of the joints.
Footwork and body Movements
Although developed in close quarters situations, such as crowded and cramped cells, it does have footwork and evasive moves of the head. It is common to hone reflexes and condition the defensive movements through highly repetitious fear drills and dodging moves.
Elbow and Forearm Blocks
These are the predominant guard techniques employed. This gives an interesting insight into the origins of the style, as it is thought that shackled slaves employed this form of protection when beaten. With the hands tied – elbows and forearms were all that was left to defend with.
Jab Catch and Elbow Block Combos
These techniques really highlight 52′s defense emphasis. The one pictured above is a counter to a jab / straight right combo. The jab is caught and then the elbow presented to spoil the incoming straight right.
Punches and Arm Movements
When you see a display of 52 Blocks, there sometimes appears to be an unnecessary amount of arm motion. These movements are not always employed in actual fights, but are often just drills that aid the student in becoming at ease with his body’s natural movement patterns.
It is not a “hard” fighting method, despite the ferocity of its blocks. There is no “kata” employed as such, as in traditional karate, but an improvisational form of blocking patterns is used as a form of shadow boxing.
Haymaker punch (more often called the Overhand Right in MMA) is often used in 52. Why? Consider a situation where a man is waving a knife in your face. Your back’s up against a wall. At some point though, you get the chance to throw something at him. You want to go over his hands, rather than take a path that could land your knuckles on his blade. So the Haymaker is the obvious choice. Rashad Evans used the Haymaker in his UFC match against Chuck Liddell. This punch is Liddell’s favourite, his trademark almost. But Evans beat him at his own game, throwing one at the same time Liddell did. Evans landed a fraction of a second earlier, and knocked Liddell out.
52 employs a lot of techniques that involve a sort of hybrid of blocks and holds. These are designed to simultaneously defend, immobilize, and set up counter attacks. They are useful in real life self defense, and in mixed martial arts competition.
Practitioners sometimes refer to these techniques as catching punches. There are several techniques but the most famous is the “kiss and catch” which made Mother Dear famous. The move involves catching a haymaker or wild overhand throw. The opponents arm is then locked and a counter to either the head or body is dealt as the locked arm is maneuvered to open the opponent up. It can be used against jabs too, but requires speed and accuracy. Its a dangerous one for the novice as the back is exposed to a degree.
The New York Jiu-Jitsu Connection
If you have ever learnt Jiu-Jitsu (the original Japanese style, not Brazilian/Gracie Jiu-Jitsu), you might have noticed a lot of similarities with the blocking-holding moves in 52 Blocks. This is an odd “relationship” because Jiu-jitsu has almost became extinct in Japan. It is a lost art and no longer passed from generation to generation. A lot of you reading this won’t know too much about the original Jiu-Jitsu as its been overshadowed by BJJ. When you mention Jiu-Jitsu people think of the ground game they see in MMA. However, original Jiu-Jitsu was primarily a stand-up fighting art.
So where is the New York connection? Enter Professor Kiyose Nakae. Back in the 1940′s and 50′s he was considered the foremost instructor of authentic Jiu-Jitsu in the world. Seeing that the art was dying out in his native Japan, he moved to America and set up in New York City circa 1908. There he taught thousands of private students, and also the armed services and police department. He was like the original Bruce Lee, in that he shared a previously secret fighting art to a western audience. Its not surprising then that his influence on the New York martial arts scene has permeated 52 Blocks. My father was a student of a student of Nakae’s,the author of the book Jiu-Jitsu Complete. Below is a photo of me with the original hardcover published in 1958.
Rhythm, Synergy and Spatial Awareness
Coaches of the art maintain that paying attention to your own rhythm is vital. Without this, the essential “synergy” needed can’t be developed. The aim of this is to fight with natural, rather than contrived body movements.
At its core, 52 is an up close infighting system. Among coaches, the analogy of the ‘phone booth’ is used. This is to make students aware of the space they need to focus on in order to judge their opponents angles and movements. To this end, sparing often takes place in corners, stair wells, and roped off areas of not more than a few square feet.
Although the style is often slated as dirty boxing, it isn’t if looked at from an MMA perspective. Most trainers deny its dirty boxing but instead an effective form of self defence. They insist that it is as valid a style of martial art as boxing, Brazilian Jiu-Jitsu or Muay Thai etc.
Capoeira, and 52 Blocks
Some people have said there are organic connections between Capoeira and 52. However, there are big differences in the techniques employed. For example, there are no roundhouse kicks, amadas (spinning back circular kick) or 45 degeree kicks in 52 Blocks.
There may have been a point in history where the two were similar due to the trafficking of slaves from Africa to Brazil and the Southern States of America. But as the two styles stand now, they are miles apart.
The Migration of 52 Blocks from the Prison System to the Gym
Some say this style has died and is no longer being passed down. The reason stated is that disputes in prison are seldom sorted by fist fights nowadays. I’ve asked ex-inmates about this and been told its generally true.. Most disputes are settled by merchandise (money, drugs, phones etc, all being exchanged to cool things off). Or a straight shank in the back of the neck.
The Death of Fist Fights
Up until the late 80′s though, it was still common to sort out a problem with your hands. Straight fights between two inmates, with a nod from a prison guard, were an accepted way of resolving issues. There was a code of conduct and the acceptance of defeat and victory that put an end to the matter. But Gangs and their ever growing use of weaponry on the outside ended all that. Nowadays, weapons are improvised from a variety of objects, including tuna cans, plastic chair legs, bone etc., in order to fashion tools that draw blood. And that is the bottom line.
Fist fights, if they do occur, are usually started by first timers who don’t have too much of an understanding about prison politics. Wanting to make a rep for themselves, they lash out when provoked. The consequences are usually dire. As the gang system controls most aspects of prison life, what takes place on the street, is merely transferred inside, but with a change of weaponry. So instead of a drive-by shooting, someone just walks up behind their target and an improvised knife does the business. It’s an unemotional solution to a problem. Nothing but business.
So if the days of “honour among thieves” are dead and buried, has 52 Blocks, aka Jailhouse Rock, ceased to exist? Well, thanks to the current popularity of mixed martial arts, it has found a way back from near extinction. It’s thriving in the boxing gyms and public parks of New York City.
Lyte Burly and 52 AOD
One of the most prominent trainers on the scene isLyte Burly. Burly (who teaches in and around Tompkins Square Park, Manhattan) is pushing 52 into a broader MMA technique. His new take on the style - 52 AOD (Art of Defense) – fuses it with the kicking aspects of Muay Thai, tae-kwon-do and wing-chun, and the ground fighting of Brazilian Jiu-Jitsu.
The logic behind this appraoch Burly takes is that nowadays men do not usually call each other out, and fight with fists like they used to. Things are more sneaky and vicious. If you went to ground in an “honour” match years ago, your opponent would do the decent thing and let you get back to your feet. Not so today! You’re more likely to get a kicking while you lay on the ground at best, and a knife in the back of the neck at worst. Or even shot.
So Burly looks at things holistically. He takes the Bruce Lee approach in using what works and discards the rest – even some of the more traditional 52 moves. The core elemental values of 52 Blocks are still there. Especially the rhythmical body movements. To this end he employs tai-chi, so his students can learn energy flow and leverage.
Marks is a scholar in the truest sense of the word. An accomplished fighter and trainer himself, he is on a mission to preserve 52 Blocks as an integral part of African American culture. He has been researching it and piecing together the bigger picture since he
first learnt of the style during his military service. He teaches the style, its history and cultural significance in New York and beyond. He compares it to Jazz, believing it is just as integral to Black American culture as the music form. He has lectured at Black History conferences to this effect.
Daniel Marks runs the 52 Blocks Preservation Program which helps helps ex-offenders re-integrate into society. It does this by an education program which helps them set themselves up as 52 Blocks instructors. Marks employs his professional social work experience to aid them in avoiding the too often easy path back into crime.
Born Justus (BJ)
BJ is is a fight trainer. He spent 33 years of his life “behind the wall” as he puts it. So he is well acquainted with the prison fighting styles that predominated back in the 60′s and 70′s. His take on 52 Blocks is that it is boxing taken to another level. He claims that a lot of the methods seen now, were created by boxing enthusiasts during the 1960′s and 70′s. These fighters worked off boxing as a foundation, and a lot of the techniques they created were a fusion of western boxing and eastern martial arts such as Karate, King Fu, Stato etc. It was a quest to find the perfect defense, and to break the accepted methodologies and “rules” employed by boxing trainers of the time to take fighting to another level.
BJ saw that boxers were trapped into fixed ways of fighting and training. His take on 52 is that you should be able to throw a hook or a jab from anywhere and still maintain guard, by the use of elbows and forearms. His philosophy is based on mentor-ship and brotherhood. He believes in passing on the art form free of charge, and encouraging his disciples to do the same.
Check back for more on 52 Blocks. I’m going to keep researching because I feel its well worth the effort. Every time I start turning over rocks, I find some real gems. I’m going to get down into the nitty grity of the actual moves next. See you soon!
PRINCIPLES OF REHABILITATION
The principle aim of rehabilitation is to restore full function after an injury or a disease. The differences between rehabilitation of the average patient and a sportsman are of degree and specificity. While rehabilitation of the average patient ceases when he can walk without a limp and manage stairs, the rehabilitation of the sportsman must continue not only to a much more advanced level of activity, but it must also be designed to meet the specific demands of his sport. It is for this reason that physiotherapists working in the field of sports medicine must be knowledgeable about the sports with which they are involved, not only about individual techniques such as the different types of strokes in racket games, but also about the tactics of the games. Ideally, the physiotherapist should have participated in the sport in order to more fully appreciate it from a player’s point of view. There should be a close liaison between physiotherapist and coach, in order to have a direct and logical continuation from treatment to early training. Similarly, the coach should know something about the principles of physical treatment so that communication will not be complicated by misinterpretation of jargon.
Rehabilitation should start at the moment of injury, although perhaps the most important thing at that stage is knowing what not to do. Early treatment is dependent upon the nature and severity of the injury and not initially on the type of sport. The essentials of such first aid are simply to ease pain, limit swelling and encourage early movement without over-stressing the injured part. However, when the acute reaction to the injury is diminishing and early repair has started, the rehabilitation programme becomes more specific to the sport. This programme must have the optimum balance of exercises to promote strength, endurance, flexibility, speed and coordination. This balance should not only fit the sport, but in team games should fit each position on the field. Obviously, forwards in soccer or hockey will need running speed and endurance, while a goalkeeper will need more general bodily speed and agility. Similarly, weightlifters will aim mainly to develop power, sprinters will aim for speed, and marathon runners will want to develop endurance.
Whatever programme is designed for an injured sportsman, he must be absolutely clear about what to do, how to do it, when to do it and how many repetitions to do. The programme must be carefully progressed from day to day, always responding to the ‘feedback’ from the previous day’s work, so that the injured part is allowed to take a little more strain at each stage without ever being suddenly overloaded. This type of regime not only builds up muscle, but actively stimulates the repair process, much in the same way as more callus formation is stimulated if the opposing fragments of a fracture are allowed a little movement rather than complete immobility.
Treating the actual injury is only a part of rehabilitation in sport for it is essential to give exercises to all the unaffected parts of the body, so long as the exercises do not jeopardise the injured pan. Such collateral exercises should be strenuous enough to make the patient breathless in order to maintain cardiovascular fitness. With a fairly severe knee injury, for example, exercises to the unaffected parts of the body could include bench press, sit-ups, chinning, curls, press-ups, step-ups with the good leg, etc. The ultimate example of this principle is seen in the Paraplegic Olympic Games.
Although active exercises are the essence of rehabilitation, the physiotherapist in sports medicine requires also the use of other techniques, including electrotherapy and massage. The choice of such supplementary techniques is usually determined not so much by the sport as by the local problems associated with the injury of which the most common are pain, swelling and restricted movement.
It must not be forgotten that while, initially, pain is nature’s warning that damage is occurring, after an injury the pain is often out of proportion to the force producing it. Its effect then is to over-protect an injured part and so prevent the movements which are vital to normal physiological function.
This does not justify the total ablation of pain by local anaesthesia, but it does mean that pain should be reduced sufficiently to allow the player to move the injured part more easily. In most cases, the degree of pain relief afforded by such physical agents as locally applied ice packs and ultrasound is sufficient, although sometimes analgesic medication is necessary. In such cases soluble aspirin is useful because of its additional anti-inflammatory effect, but equally it must be remembered that aspirin is not a trivial drug and it should always be used with great care. Supportive strapping is also useful in the early stages to protect injuries from unnecessary pain or damage.
Ideally, swelling should be prevented by early ice cold compression, elevation and temporary local rest. One of the great skills of the physiotherapist in sports medicine is the recognition on the field or track side of those injuries which are severe enough to develop a swelling. In this context it is helpful to know the individual players, for some players make a fuss over the most minor injuries while others are loathe to admit injury. Similarly, it is useful to feel the ‘pulse of the game’, for an extended interval created by an injury can allow a losing team to sort out its mistakes. When joint injuries are involved it is important to distinguish between a haemarthrosis, which is usually quite severe and swells within minutes, and a synovitis, which may appear initially as a very trivial injury but takes many hours to swell so that the full extent of this injury is evident only the following morning. Clearly there is little or no real structural damage in many so-called injuries which stop football matches, especially in the professional game. It would be pointless to treat every one of these, especially if it meant taking each player off the field, either temporarily or even for the rest of the game.
When swelling has occurred, its dispersal may be aided mechanically by the following methods: 1. The pumping action of isometric exercises. 2. Ultrasound to the periphery of the swelling. 3. Positioning of a limb so that gravity will assist the drainage of swelling away from the distal parts of the body. 4. At a later stage by effleurage massage and heat, especially if an injury has passed into the chronic stage.
The resolution of large swellings may also be aided by the use of proteolytic enzymes, e.g. trypsin and chymotrypsin (Chymoral Forte). It is advisable not to use any form of heat until after about 48 hours, since the reflex vasodilatation may cause further haemor- rhage as blood clots are dislodged. It is safer, therefore, not to prescribe the useful home treatment of contrast bathing until at least the third day.
This problem may be caused by various types of internal joint derangement, but the main causes affecting rehabilitation are protective muscle spasm and joint swelling. Protective muscle spasm is not always accompanied by pain, although it is the patient’s conscious or unconscious attempt to avoid pain. If the patient is helped to move the joint without producing too much discomfort, he will start to get his confidence back. This is obviously achieved by pain relieving methods, particularly cryotherapy, and carefully graded movements. Sometimes this means moving in only a limited part of the joint’s range, or moving in only one plane, in order to get the patient started.
Intra-articular swelling is a special category of swelling, for most cases of synovitis diminish only with rest, and cannot be dispersed with electrotherapy. The classical treatment for a grossly swollen knee is a Robert Jones bandage, the main effect of which is probably simply to splint the joint, although the pressure may help to prevent further swelling of the joint. With such cases the only definitive rehabilitation is a programme of isometric exercises to maintain the tone in those muscles which pass over the affected joint.
Chronic extra-articular swelling can be a stubborn problem, particularly following a fracture of the lower end of the tibia. While this can be dispersed with elevation, massage and electrotherapy, the swelling can sometimes recur over five or six months. It is important in such cases to support the skin with firm bandaging, otherwise the foot and ankle simulates an elastic bag which readily fills up with fluid. The Coban bandage has been found to be ideal for this purpose, and patients may be instructed to wear it whenever the leg cannot be raised, but not to wear it all the time. Usually the problem is overcome when the calf muscles reach their normal strength and there is a full range of ankle movement.
Not all rehabilitation problems begin with an acute injury. Sometimes a sportsman has had an illness and seeks professional advice about early training, or, perhaps, during a tournament, a player develops a mild febrile condition. While always keeping in mind the fact that strenuous activity can be dangerous following acute febrile conditions, especially those of viral origin, the two main parameters to guide rehabilitation are the pulse and temperature. It is advisable also to check respiratory ventilation and blood pressure. Rehabilitation should not begin until the heart rate and body temperature have both returned to their normal resting levels. The resting heart rate of a top athlete is rarely anywhere as high as the average 72 beats per minute. Once it has returned to normal, the player is tested with a little light activity, aimed at not increasing the pulse rate to more than double its resting level. If the heart rate does not return to normal during a period of rest within the two minutes immediately following the activity, or if there is a resultant increase in body temperature within two hours, the patient is not tested again until the next day, and then with proportionately less activity. If the patient passes these tests, he may be tested two or even three times more the same day, with an increase in activity each time, and then even more the following day. It should be emphasised that this system is very much a ‘rule of thumb’ and there is a case for not exercising athletes so soon after febrile conditions because of the danger of myocarditis. Ideally, such athletes should be given an electrocardiograph (ECG) before commencing training. Obviously, if the patient feels worse after such exercise, or does not feel ready to begin rehabilitation, it is probably safer to wait a day or so longer. Patients undergoing this regime are advised to drink large quantities of fluid and to rest in well aerated rooms between exercise sessions, at least during the early stages of the programme.
Another type of problem with no history of injury, is the athlete who develops pain only at high levels of performance, for example during a 100m sprint, or after 10 miles (16km) of cross-country running. It is very difficult to locate any abnormality with the usual repertoire of clinical examination and therefore it may be necessary to accompany the athlete to the gymnasium, track or field in order to let him properly demonstrate the problem. Sometimes electrotherapy is indicated but the really critical treatment is to prescribe the optimum ratio between rest and activity. Basically, the principle is to work the athlete hard at the level just below that which evokes pain, occasionally almost producing the pain for a few seconds. Ice packs may be applied immediately after the work-out in order to diminish any inflammatory response which may occur.
A special category of injury, which fortunately is rare, is that which befalls the sportsman who suffers damage to the skull, brain or spinal cord . Initially these patients require emergency medical and surgical treatment which is almost always followed by time in hospital. Such cases may not reach the sports physiotherapist until several weeks or even months after the injury; even then there is much to be done.
One of the main effects of a serious head injury is the extra-dural haemorrhage which can cause pressure on the brain and result in a hemiplegia . The introduction of computerised axial tomography has enabled surgeons to localise cerebral haematomata and thus aid the speed and accuracy of decompression surgery. Even then some patients are left with a hemiparesis and varying degrees of spasticity. Treatment is initially by proprioceptive neuromuscular facilitation techniques (PNF), although patients will be started in the gymnasium as soon as possible. It is surprising how soon they can manage simple manoeuvres from sports activities such as stopping, then hitting a hockey ball, or hitting a shuttlecock. This is usually the most enjoyable part of their treatment and often makes demands on the skills of the physiotherapist who should try to extend the patient further every day, while keeping good control. Injuries to the spinal cord may result in bilateral paralysis with segmental loss of sensation below the level of the injury. Cervical spine lesions result in tetraplegia while cord lesions at lower levels may result in paraplegia of varying severity. The ultimate achievement by patients with spinal cord injuries will depend on the level of the injury, but like most injuries the personal motivation and the design of the rehabilitation programme will play important roles. The basic principle of the rehabilitation is to make those parts of the body above the lesion as strong as possible and often this will be stronger than a healthy person. The latis-simus dorsi muscles with their high level nerve supply and attachment on the iliac crests, are very important and require much attention. This is particularly so with those patients who can be taught to walk with the use of crutches and bracing with calipers. Many paraplegics have achieved world class status in sports such as archery and swimming, as well as becoming competitive in wheelchair basketball and table tennis. Every four years, paraplegics from all over the world meet to take part in the Paralympic Games, which include athletics, lawn bowling, weightlifting, fencing and shooting as well as those sports already mentioned. Many people do not realise that these games are also open to those with cerebral palsy, amputations and who are blind.
Whatever the onset of the problem, whether a sudden acute injury or gradual overuse, or some infectious condition, at some point after treatment and rehabilitation has begun, the fitness of the patient will have to be tested. This is usually done at two levels: 1. between treatment and early training, and 2. between advanced training and competitive play.
The first level
In order to make this first step and commence early training, the injured limb should fulfil the following criteria: 1. It must have at least 50 per cent of its normal power measured with 10RM (according to De Lorme, 1945). 2. It must have at least 80 per cent of its full range of movement. 3. It must have less than 20 per cent of its full potential swelling. 4. It must have virtually normal stability, although this may be supported slightly by strapping at this stage. 5. There should be no pain at rest, nor gradual increase in pain as the work-load increases, although slight pain during or immediately after exercise is acceptable.
The patient continues to have physiotherapy during the period of training, so it is at this point that there must be close liaison between the therapist and the trainer; in addition the therapist must understand what the coach or trainer is trying to achieve and what is demanded not only from the sport but also from the level at which the player will ultimately compete.
The second level
This second stage of fitness testing has to be very demanding, otherwise the player returning to the game will be vulnerable to further injury. The more advanced general criteria are: 1. Absence of pain. 2. No swelling. 3. Full power. 4. Full range of joint movement. 5. Full extensibility of muscles, particularly those which pass over two joints, e.g. the hamstrings. 6. Endurance, e.g. minimum jog of 20 minutes or 2km. 7. Speed, e.g. 100m sprint and shuttle runs.
In addition to these general criteria, there are specific tests depending on the types of skills and situations demanded by the sport. These include, for example, block tackle in soccer, two leg jump in hockey, scrummaging in rugby and lunging in badminton. It is only when a player has passed all these tests that the aim of rehabilitation has been achieved, that is, the attainment of match fitness.
The objectives and methods of rehabilitation in sport have been discussed. What must be emphasised is that the physiotherapist working in this field must have total commitment. His effort should equal that of the sportsman as he fights to achieve physical and mental perfection. Each stage of rehabilitation must be carefully observed and analysed, always making sure that there is a sound reason for every variation in treatment and advice. It is only then that sportsmen can achieve the necessary fitness to overcome the apparent limitations imposed by time, space and gravity. It is only then that physiotherapists may claim a small part in the establishing of new world records or the winning of gold medals.
De Lorme, T. L. (1945). Restoration of muscle power by heavy resistance exercises. Journal of Bone and Joint Surgery, 27, 645-667.
This article is concerned with the problems of fitness following injury in order to prevent or reduce the danger of recurrence when participation is resumed.
The essence of sports injury management is bound up with the problems of ‘fitness to participate’, whether this refers to a resumption in training or to a return to competition. The greater the degree of involvement whether it be with the athlete, the team, the club, or a sport generally, the more difficult it becomes to be completely objective and the greater the tendency to become empirical in reaching decisions. As one’s interest develops the more danger there is of being influenced by the athlete’s changing moods or the team’s needs and demands.
Keen observation and experience will always have a place in the satisfactory outcome of any fitness assessment but these qualities must be integrated with an objective and scientific approach which embodies fundamental anatomical, physiological, pathological and psychological considerations. Experience provides an approximate time schedule for the recovery from any injury, but it also creates sufficient opportunity to realise the individuality of each one and to understand the folly of forecasting the outcome.
The ideal programme of recovery in any injury is one of steady, uneventful progress. Minor deviations from the ideal are frequently encountered and in the field of sports injury these still remain within the limits of normality. Serious set-backs, as presented by recurrence or complete breakdown, represents either a lack of organisation, a lack of patience or a lack of discipline.
GENERAL CONSIDERATIONS IN TESTING FOR FITNESS The nature of the injury
This means that the site, the tissues involved, and the severity of injury will obviously determine the overall time schedule of recovery and will determine the need for more careful testing at every stage.
The stage of pathological improvement
Sight must never be lost of the fact that, following injury, the body’s natural reaction is to attempt to repair the damage. Consequently it is of paramount importance that we are familiar with the subtle changes which occur as recovery progresses through its acute, subacute and chronic stages of inflammation. Failure to observe these stages leads to a singular lack of success.
The sport involved
This factor will determine the emphasis of the tests employed. Tests used will to an extent mirror the specificity of the sport.
The playing position or role of the participant in the sport must be considered. The skills demanded frequently vary within the same team. This applies particularly in field invasive games.
The level of involvement
Generally speaking, the need for higher standards of fitness run parallel with higher levels of involvement, even though motivation, dedication and experience can often disguise the fact.
The validity of the result of any fitness test depends on many factors. Generally speaking we are only concerned with physical fitness because significant mental involvement tends to be confined to the higher levels of sport.
Physical fitness is a relative quality and the standard of this quality can vary from the once-a-week squash player to the Olympic Games decathlete. Regardless of the standard, there are certain basic components of fitness which contribute to the whole. These are mobility, endurance, strength (power) and coordination. In any test of physical ability whether it be general or local, it is these components which should be assessed. It may well be that only one, or perhaps a combination of them, is of particular interest at any one stage in the recovery programme. However, in the final analysis all these individual qualities must be tested before the verdict of ‘fit to play’ can be issued. It must be remembered that to the professional athlete ‘fit to play’ means ‘fit to work’ and the thoroughness of the tests employed must be correspondingly searching. This is not to say that the sprained ankle joint is any different in a member of the ‘Extra B’ team to that sustained by the international team player. One often has to be realistic and accept that the opportunities to avoid potentially dangerous situations are available far more frequently in the ‘Extra B’ game and that the consequences of failing to avoid them are not quite so devastating in their implications.
Fitness testing must be an on-going routine throughout the recovery period in order to detect improvement and chart progress. The psychological effect of being able to demonstrate a measure of improvement by tangible recording is of inestimable value to all concerned. Progress which is seen to be made has a strong motivating effect.
The testing for fitness, or the lack of it, generally takes place in three main areas: 1. the treatment room 2. the gymnasium 3. the field of play.
The significance of an immediate post-injury assessment is minimised by many considerations, not the least of which is the athlete’s own acceptance of pain. Pain is a complex phenomenon and the measurement of it, along with that of pain tolerance, remains the greatest obstacle to the evaluation of treatment methods. It is the difficulty in measuring these factors which prevents the treatment of sports injuries from becoming truly scientific.
As a quality of physical fitness mobility deserves the greatest consideration. Recovery of mobility is the most important yardstick of improvement while a lack of it remains the biggest obstacle to full recovery. A failure to achieve the normal range of movement is the most common cause of injury recurrence because of the limitation in full function which it inevitably creates. The ideal situation for which we should aim is one where active mobility, accomplished by the athlete’s own effort, equals passive mobility (the range achieved by an external force during relaxation of the part), whether we are referring to the stretch of a muscle or the movement of a joint.
It would be irresponsible to produce mobility without the support and protection of muscle strength. In any re-education programme mobility and strength should progress in unison. An important stabilising factor in most of the freely moveable joints of the body is the strength of the approximating effect on opposing articular surfaces by muscle contraction.
The product of time and distance gives a measure of power and is the characteristic of complete fitness to be finally restored in a rehabilitation programme following injury. Power is exhibited in propulsive actions involving either propulsion of the body itself or of sporting implements. Apart from the fact that it is measurable by virtue of performance, power also bestows a certain quality to movement.
If there is normal mobility and strength it is highly probable that coordination is reasonably efficient. Coordination in sport is tied up with the skills of a particular sport, and the level of involvement will determine the standard of these skills. Skills have to be practised in order to establish neuromuscular patterns. In considering the long-term injury, it is vital that we should consider the effects which immobilisation and disuse have on these important mechanisms. In some sports, e.g. weightlifting, slight lapses in coordination often result in serious injury.
The principles advocated in the text are illustrated by referring to the tests which can be employed in assessing the fitness of three common sites of injury in three different major sports. These include a hamstring injury in a sprinter, a shoulder injury in a rugby football player and a knee injury in a soccer player.
HAMSTRING INJURY IN A SPRINTER
A typical injury of this kind tends to follow a time schedule of three to four weeks before full activity is resumed. Full participation should not be allowed until the muscle is pain free on: 1. deep digital pressure on the specific site of injury 2. full stretch application 3. strong contraction against heavy resistance 4. performing all the skills of the sport.
EARLY STRETCH TESTS FOR INJURED HAMSTRINGS 1. This involves sitting with one leg extended out in front and the other fully flexed . An attempt is made to touch the toes of the extended leg with both hands. The distance from the finger-tips to the toes is measured and the result compared with that recorded when the leg positions are reversed. 2. This test involves lying on the floor and raising a straight leg while the other leg remains perfecdy flat . The angle between the raised leg and the horizontal is measured at the point where either the knee begins to flex or the position of the other leg is unable to be maintained. 3. This method is to lie on the unaffected side and flex the knee and hip of the injured leg to 90° while the trunk and the other leg remain in the same alignment . While the thigh is retained in the same position, the lower leg is passively stretched and the degree of movement measured.
LATE STRETCH TESTS FOR INJURED HAMSTRINGS 1. With the heel of one foot resting on a chair seat, an attempt is made to touch the toes with both hands while retaining a fully extended knee. The distance from finger-tips to toes is recorded and compared with the other leg when their positions are reversed . 2. A slightly more exacting test is that of repeating (1) but with the leg raised to a higher level as on a table top . 3. A very demanding test of the hamstring group of muscles to withstand stretch is that of crossing the legs and retaining the feet close together while stooping forwards and downwards in an attempt to touch the toes of the rear leg . Measure from fingertips to toes and compare both legs. The leg which crosses behind is the leg under stress.
STRENGTH TESTS FOR INJURED HAMSTRINGS 1. The simplest test and one which allows safe progression to be made is that of lying face downwards and with an initial weight of 2kg fixed to the ankle or foot of the injured leg. Bend the knee to 90° and then slowly lower it back to the starting position. Progress is made by increasing the weight by 1kg and repeating the exercise . 2. Another specific test of hamstring integrity is that of assuming a kneel-standing position with the feet anchored firmly under a wallbar, or even held manually. The athlete leans forwards from the knees beyond the vertical and then pulls back to recover his position .
FUNCTIONAL TESTING FOR INJURED HAMSTRINGS 1. Stand sideways to a support which can be grasped. Swing the injured leg forwards and backwards progressing to a gradually increasing level. In this initial test bend the knee on the forward swing . 2. This is a variation on (1), but is a much more demanding test. The injured leg in this test is maintained in a fully extended position throughout the swing. To avoid recurrence of injury the height of the swing forwards must be increased gradually. The trunk must be kept in an upright posture throughout . 3. The athlete performs a high-kicking action by stepping forwards for two paces and on the third step swings the leg forwards and upwards to successively higher levels .
Running on the spot should initially be at a slow pace with a low knee action, progressing to a quicker pace with a high knee action. It is essential in practice to acquire even timing by virtue of symmetrical leg action.
The actual running stage is a vital one because it is now that recurrence most frequently occurs. There should be a progressive schedule over a period of at least one week which should be discounted if there is any semblance of pain. A sharp stabbing sensation is an untoward sign of recurrence, while a dull heavy feeling suggests that progress should be halted at that stage and previous tests of mobility repeated and compared with earlier recordings. Efficient running entails considerable reflex coordination. This is shown by the innate ability to take perfectly even strides with each leg. Consequently, uneven pacing suggests an interruption of this ability by virtue of pain resulting from the demands made when full bilateral mobility is lacking. Uneven pacing can develop into a running habit which, if established, becomes difficult to eradicate.
The re-education of running begins with jogging and finishes with all out sprinting. In this gradual process three variables need to be considered – speed, footwear and surface. Initially, the athlete jogs at a slow pace in flat ridged-soled training shoes on a dry yielding surface and builds up by increasing the pace until he is running in spiked shoes on a firm surface. This is the only safe way of reaching maximum sprinting ability. The only other factor to be considered is the ability to make an explosive start; hitherto the speed running being executed from a gradual build up of speed in a ‘rolling-start’.
A conclusive test to convince one of the ability to withstand the stretch involved in the push-off and the strong contraction in the pick-up action is to attempt some progressively faster shuttle-runs. Starting from blocks in an explosive start would be an important final test to convince one of the injury’s full recovery.
To give the injury, as well as the athlete, every consideration, each running session should be preceded by a sensible preparatory warm-up period of progressive mobility and strengthening exercises.
SHOULDER INJURY IN A RUGBY PLAYER
EARLY MOBILITY TESTS FOR SHOULDER INJURY 1. Grasp a pole or brush handle with the arm stretched sideways. While the elbow is maintained in a fully extended position, the stick is rotated forwards and backwards . 2. A second test is similar to (1) but with the arm stretched upwards above the head . 3. A third test is another variation of (1) but with the arm stretched forwards .
These three exercises with a pole can also be used as early strengthening activities, particularly if the hand is moved towards one end of the pole, or if the pole is replaced by a brush so that one end is weighted.
A useful test of progress in the early stages of recovery is to attempt to touch the finger-tips of both hands behind the shoulder blades using the injured arm alternately above and below . The distance between the finger-tips is measured.
LATER MOBILITY TESTS FOR SHOULDER INJURY 1. Hold a light barbell (Skg) at arm’s length above the head then lower it behind the neck . 2. Grasp the ends of a rope which pass over a pulley, hook, or bar and move each arm alternately up and down to full stretch . 3. Hold a light barbell at arm’s length overhead while lying astride a bench. Lower the barbell beyond the head while retaining straight arms .
EARLY STRENGTH TESTS FOR SHOULDER INJURY Any progressive system of dumb-bell or barbell exercises for the arm beginning with light weights would be a satisfactory measurable test.
LATER STRENGTH TESTS FOR SHOULDER INJURY 1. A useful test is that of raising bodyweight in a modification of the press-up exercise. The feet are placed at a higher level than the arms on the seat of a chair. The shoulders are raised to full arm’s length . 2. A more strenuous modification is that of dipping between two benches. The feet and the arms are placed on each bench and the body is lowered between them . 3. Another test using bodyweight as resistance is by sitting between two benches with legs outstretched and the hands flat on each bench. The buttocks are then raised from the floor by extending the elbows . 4. A similar exercise test is that of raising the buttocks and pulling backwards to sit on a stool or chair .
In all these examples of strength tests, it should be realised that either the starting position or the eventual finishing position are also making demands on mobility.
FUNCTIONAL TESTING FOR SHOULDER INJURY Progressive weight transference to the arms is a necessary inclusion, not only because of the demands on mobility and strength but also as a test of the athlete’s confidence. 1. Initially the hands are retained in contact with the floor while the legs are simply kicked upwards into the air . 2. As a progression the player is asked to drop on to the hands and kicks into the air simultaneously from a crouched position . 3. The natural sequence from this is a straightforward handstand from the standing position . 4. Wheel-barrow walking in various directions is a searching test to employ . 5. In a similar manner, crab-walking in all directions is also a severe test of shoulder integrity . 6. A gymnastic forward roll is a necessary functional skill to be tested both from a standing and a running start.
The basic skills of the sport itself must now be practised. Rugby skills consist of passing and catching a ball, tackling, being tackled and avoiding tackles, scrummaging and scoring points by kicking goals and scoring tries. These skills are performed by players in all positions. However, there are certain positional skills which make particular demands. An example of this is the hooking position which has relevant demands so far as the shoulders are concerned. Therefore, the hooker with a doubt about his recovery from shoulder injury must be tested thoroughly in his particular skills, no less than his ability to suspend his body mass from the adjacent supporting prop forward.
KNEE INJURY IN A SOCCER PLAYER
Injuries affecting the knee joint require application of a deeper knowledge of anatomy than most others. The testing of knee joint integrity centres on both its mobility and stability under varying conditions.
EARLY MOBILITY TESTS FOLLOWING A KNEE INJURY 1. In a prone lying position, attempt to bend the affected knee . Either the angle between upper and lower legs is measured or the distance between the heel and the buttock. 2. In a high sitting position on a table, bend the knee and simply measure the angle attained . 3. A third test is employed to assess the ability to fully extend the knee by either relaxation or active contraction of the quadriceps muscles. The gap between the back of the knee and the table is measured . 4. Sit on the front edge of a stool with the toes of both feet against a wall. Raise the buttocks and thrust the knees forward towards the wall. The heels must be maintained in contact with the floor . The distance between the knees and the wall is measured.
LATER MOBILITY TESTS FOLLOWING KNEE INJURY 1. While kneeling on a firm surface attempt to sit on the heels . Measure progress by recording the distance between buttock and the heel of the affected leg. 2. Place the foot of the injured leg on the seat of a dining chair. The heel should be level with the front edge of the seat and must be retained in contact with the seat. The knee is now thrust forwards towards the back of the chair . The distance between the knee and the back of the chair is measured. This should be compared with the other leg and progress charted. 3. The simple squat position and its variations are the ultimate in knee mobility tests. The ability to progress forwards while squatting, either by moving alternate legs or by hopping on both feet together is a severe test of full flexion . 4. Stand alongside a bench with the foot of the injured leg flat on top of the bench. While this foot remains stationary step to the opposite side of the bench with the other foot and then return . 5. Stand alongside a bench as before, but while extending the injured knee twist around quickly to finish facing the opposite direction and with the sound leg on the opposite side of the bench . Then reverse the procedure.
EARLY STABILITY TESTS FOLLOWING KNEE INJURY Any sensation of instability or the actual evidence of it by locking or giving way is the warning sign that further testing should be halted. 1. Long sitting on the floor with the knee fully extended. Initially a plastic ball is kicked with the inside of the foot and ankle . Progress using a football and then a medicine ball. The routine is repeated with the outside of the foot. 2. The previous test is repeated but with the knee flexed to varying degrees . 3. These two tests should be repeated in the more functional position of standing but still progressing from straight leg to flexed, and from plastic ball to medicine ball . confidence. The three variables to be considered in making the test progressive are the height, the landing surface and the method of landing. Initially, a gymnasium bench may be of sufficient height and the landing made on a rubber mat. The ultimate requirement would be to jump from a height of 3 feet (lm) on to a firm surface and in a crouched position. The important aspect of jumping tests is to ensure that the landing is made with equal weight on both feet. An understandable reluctance and apprehension can be overcome by reducing the height to a minimum and by making the landing surface as reasonably soft as possible to encourage the taking of body weight on the affected leg only. 2. An invaluable test of lower limb fitness is that of ‘bounding’ over a series of benches. If the benches are so placed as to allow only one footstep between them, there is no escape from using the affected leg . The test is a modified hurdling exercise and can 4. Hopping exercises are particularly useful in testing knee stability because of the strain placed upon the joint by making it support the weight of the body. Hop in a circular direction around an object. The specificity of the test is increased by reducing the diameter of the circle or by reversing the direction. 5. A variation on (4) is hopping around a square but making sure that the foot is pointing forwards throughout and that the direction is changed at 90°. Another variation is by describing a figure-of-eight around two objects. Progression is made by decreasing the distance between the objects.
LATER STABILITY TESTS FOLLOWING KNEE INJURY 1. Jumping from heights is another excellent method of testing stability as well as restoring be performed at an increasing speed. Power and coordination are essential qualities in executing a flowing rhythm.
The essential skills of soccer are passing, dribbling, trapping, shooting and tackling. These are useful individual tests in themselves and form a necessary preliminary before progression into the training modifications of the game itself.
Reaction to these tests may be a recurrence of pain, swelling and an increased temperature of the joint area; these are indications of negligence either in observation during the tests or in too rapid a progression.
Testing for fitness is a fascinating challenge which requires careful organisation. Athletes should be made to feel that, in the physiotherapist, they have an ally who is concerned only for their interests and welfare. They must not be made to feel that every test is a personal battle where every deficiency is to be used as evidence to support a pre-determined decision to prevent them from participating. Varying degrees of elation and disappointment are the inevitable companions of fitness testing. Experience is the only tutor in learning to recognise whether a situation demands support and encouragement or guarded optimism and a restraining influence.
The attitude towards injury of athletes varies considerably. The acceptance of pain and physical defi- ciency with the consequent limitations on skill and ability is often exhibited to remarkable levels. However, experience will also teach one to realise that the decision on fitness which will benefit the athlete in the long-term will be the best decision to make for the short-term.
AIMS OF TREATMENT
Physiotherapists involved in the treatment of sports injuries require a clear picture of the aims of treatment. These may be summarised as follows: 1. To enable the injured athlete to return to his or her sport quickly and safely. 2. To regain the strength, mobility and coordination of the muscles of the affected area so that the healing or healed tissues are sufficiently protected. 3. To maintain and if necessary increase the general strength and cardiovascular endurance of the patient. 4. To influence any biomechanical abnormalities such as muscle imbalance, limb imbalance and inflexibility. 5. To gain the cooperation, not only of the athlete, but of the coach or any other influential person to ensure that the patient is discouraged from returning to sport too soon and that the faulty technique precipitating tissue damage is corrected. 6. To make a positive contribution towards the prevention of another injury by advising on further rehabilitation exercises. 7. To provide a psychological ‘prop’. 8. To try to prevent the subsequent development of degenerative disease due to the unavailability of treatment. 9. To provide a prophylactic service.
The injured sportsman should only return to sport when the doctor and physiotherapist are satisfied that adequate strength and mobility in the affected area have been regained. He should persevere with rehabilitation, even if it is lengthy for some conditions. In top class competition, particularly, a minimal loss of function is not only the difference between winning and losing, it can lead to re-injury or tissue breakdown in a previously uninvolved area of the body because of compensation and resultant unnatural movement.
Exercises to maintain general body strength and cardiovascular fitness should be included in the treatment because they will keep the person as fit as possible until he is ready to resume training. Too many athletes sustain further injury in attempting to regain general fitness too quickly following an enforced lay off. An active physiotherapy approach should enable the person to be concerned with more specific fitness when training is resumed.
Bender et al (1964) investigated strength levels in relation to injuries in new military cadets. They found that athletes with average or above normal strength levels were less susceptible to injury than those with below average strength or with imbalance in excess of 10 per cent between the lower limbs. This must be considered during rehabilitation.
Balance between the agonists and antagonists is also thought to be important both in the prevention and treatment of sports injuries, although more work needs to be done to advise on the pre-requisite strength values for different sports. It is believed that the strength value of the hamstrings should be 60 to 70 per cent of the quadriceps for most running sports.
It appears that weakness in one area of the body can lead to involvement elsewhere. Nicholas et al (1976) have shown a strong correlation between ankle and foot injuries on the one hand and ipsilateral weakness of the hip abductors and adductors. This type of relationship must be accounted for during rehabilitation.
Inflexibility is a prevalent problem among many athletes. Poor flexibility appears to lead to a high incidence of muscle injuries, joint lesions and non-specific aches and pains. The naturally inflexible are helped by carefully performed stretching exercises and they should be encouraged to persevere with these throughout their competitive careers.
Some athletes are excessively prone to injury because of musculoskeletal abnormalities which render them inappropriately equipped for withstanding the demands of certain sports. The physiotherapist should be aware of this: the following two examples may help to explain this. 1. A boy with marked hyperextension of his knees has naturally lax ligaments and therefore contact sports expose him to an unacceptably high risk of serious injury to these joints. 2. A child with several degrees of hyperextension of the elbow is more prone to elbow dislocation than his ‘normal’ contemporaries. He should be discouraged from participating in such sports as rugby, judo and wrestling.
Ideally, a child with an unsuitable physique for safe involvement in a particular sport should be recognised early in school life so that he can be encouraged to adopt a more suitable sport.
The physiotherapist should have a basic understanding of sport so that the mechanics of injury and the stresses to which the performer is subjected can be understood. Coaches have a far greater knowledge of the finer points of technique and the physiotherapist can gain much by liaising with them. If the physiotherapist suspects that an injury was caused by poor technique or biomechanical abnormality, this should be discussed with the coach so that the style can be altered.
Prophylaxis will probably play an increasingly important role in the field of sports medicine as further research is carried out and it is shown that adequate training can prepare the tissues more effectively for the demands of sport. Physiotherapists are ideally trained for this type of work which should enable future generations of sportsmen to avoid many of the lesions that are commonly seen in sport today.
INITIAL EXAMINATION AND ASSESSMENT
When the doctor has examined the patient and, hopefully, been able to make a definitive diagnosis, the physiotherapist should carry out an examination and assessment. This must be done meticulously so that the most suitable treatment can be given. Each injured person should be treated according to individual needs; the physiotherapist should adapt the treatment to the person, not vice versa.
The physiotherapist must acquire information from the patient before carrying out a physical examination; this should include what is his sport, the actual event and level of competition. The mechanics of the injury should be clearly understood as this aids the rehabilitation as well as the diagnosis. The physiotherapist should enquire about past injuries; if a similar injury has occurred previously, it is helpful to discover the patient’s opinion of the value of previous treatment because this may point towards a particular course of treatment.
The equipment used by the player/athlete merits attention because ill-fitting or unsuitable footwear, for example, may be a contributory factor which, if ignored, will precipitate further problems.
A thorough physical examination can then take place. The damaged structure should be carefully investigated; where there is a limb injury the opposite side should be used for comparison. The joints proximal and distal to the injury should be examined, particularly if the injury is a chronic or an overuse lesion because adaptive changes may have taken place; failure to include this aspect can mean that the player returns to sport ill-prepared and further breakdown almost inevitably ensues. The spine should always be included in the examination because poor strength and/or mobility in the trunk seem to contribute to some sports injuries.
The general strength and flexibility of the patient should be assessed; exercises may be required to influence either or both of these. Cardiovascular fitness should also be tested, provided that in so doing the patient does not impose stress on the lesion.
Continual assessment enables the physiotherapist to provide effective treatment. Sophisticated electrical equipment can be used but more than adequate treatment can be provided by a competent physiotherapist used to handling soft tissue injuries.
Full range of efficient muscular and joint motion, including accessory movements, must be regained before the patient can be considered to be rehabilitated for sport. Controlled exercises are introduced 24 to 48 hours post-injury for most conditions. In the first instance, the activities are selected so that the damaged tissues are not subjected to any pressure which could lead to further inflammation, increased scar tissue and adhesions. Initially, the movements are performed to enhance drainage and gently mobilise the tissues. The severity of the exercise is increased as healing advances and this enhances resolution provided that the player avoids excessive stress by never pushing the movement through pain. Pain is a warning signal that must not be ignored.
The physiotherapist must adapt the treatment to the stresses of the patient’s sport. A prop forward and a full back will require subtly different exercises if both sustain similar ankle sprains, because of their dissimilar roles on the rugby pitch; a female gymnast with a similar lesion would require the emphasis to be placed much more on fine balance and coordination.
The physiotherapist may employ many techniques. Familiarity with the feel of injured tissues is essential as this guides the treatment. Massage and transverse frictions certainly have a place; vertebral and peripheral mobilisation and manipulation techniques as described by Maitland (1977a, and b) and Cyriax (1977; 1978) are useful methods of treatment. Connective tissue massage (Ebner, 1977) is also useful in the manage- ment of many of the soft tissue lesions seen in sport. Proprioceptive neuromuscular facilitation techniques (Knott and Voss, 1968) and other means of applying manual resistance have a major part to play because they enable the therapist to guide the movement and adjust the resistance according to the ‘feel’ of the tissues.
Muscular atrophy occurs quickly as a result of injury; the resulting weakness means that the patient cannot safely participate in sport. During rehabilitation, a wide variety of exercises are used aimed at improving (a) strength, (b) endurance, (c) power and, (d) flexibility.
Modified circuit training should be used whenever possible to maintain a degree of cardiovascular endurance. The exercises must be selected carefully to ensure that they do not affect the damaged structures, for example, an arm and trunk circuit may be given to a patient with a leg injury. Work on a static bicycle may be possible when the pounding effect of running is contra-indicated. There are many injuries that benefit from work in a swimming pool – an athlete may even be able to run in water when it would be injurious to do so on dry land.
A suitable warm-up should be performed at every level of rehabilitation to ensure that the muscles are ready for work.
The physiotherapist should be familiar with the injuries where exercise may be contra-indicated. The list includes Achilles tendinitis, patellar tendinitis, intramuscular haematoma of the quadriceps femoris and tenosynovitis.
The use of ice for the initial management of injuries has already been mentioned in 4. It must be stressed that the following methods of treatment are used usually in conjunction with exercises or some other form of therapy, and not as a treatment on their own.
Contrast bathing is an effective method of reducing swelling and it may be introduced 24 to 48 hours post-injury. Heat, in the form of a hot pack or hot water bottle, is applied to the tissues for one minute to cause vasodilatation and so increase the circulation; this is followed by an ice-pack towel or iced water bath for two to five minutes to induce vasoconstriction and thus encourage drainage. The process is repeated five times. The advantage of contrast bathing over more sophisticated electrical treatments is that it is both effective and cheap, as well as being something which the patient can easily do at home several times during the day.
This is a popular piece of equipment for treating soft tissue injuries, whether they are acute, due to overuse or chronic. The mechanical effect of the sound waves is thought to encourage re-absorption of extravasation at cellular level and to reduce sensory stimulation, consequently affording pain relief.
The two frequencies of sound that are commonly available in Great Britain are three and one megacycles, penetration being greater with the lower frequency. The choice of frequency and intensity is very much according to the preference of the physiotherapist. The ultrasound may be given as a continuous or pulsed beam. The pulsed beam is favoured by some operators because it ensures the dissipation of any heat which is desirable in the presence of acute inflammation.
This medium frequency electrical equipment has been used for some time in Europe to manage many soft tissue lesions and is now becoming popular in Great Britain. It is used in the treatment of acute injuries to produce an analgesic effect. The patient must be warned that it may only afford temporary relief which will permit natural movement; it must not be used to allow immediate participation in sport.
The currents can be adjusted to cause an increase in circulation which is valuable for sub-acute and chronic lesions. Interferential can also be used to stimulate muscle and this is useful for the management of chronic muscle injuries such as groin strains which sometimes prove resistant to other forms of therapy.
Hot pack and infra-red
The main effect of these modes is to raise the temperature in the superficial structures; the thermal effect in the deeper tissues is minimal. An infra-red lamp or hot pack can be used as a prelude to exercise to ease the pain, relieve muscle spasm and increase the superficial circulation. From the psychological aspect, the patient may benefit from heat because most people associate warmth with a feeling of well-being.
Short wave diathermy and microwave
Physiologists have shown that the most effective way to elevate joint temperature is to exercise the area. Both short wave diathermy and microwave cause an increase in temperature of those body tissues that are positioned within their electric fields. The heating effect is produced in the deep as well as the superficial structures and this can be made use of for treating some sub-acute and chronic lesions, particularly in circumstances where full range exercise is temporarily undesirable, for example, chondromalacia patellae.
This machine, which emits pulsed electro-magnetic waves, is said to shorten the time taken for tissue to heal. It was developed in the United States of America and now European firms have introduced equipment following similar principles. Healing is said to be enhanced by the pulsed electro-magnetic waves which can be used immediately after injury because a thermal effect, which is undesirable in the early stages of inflammation, is not produced.
Faradism may have an occasional place in the treatment of sports injuries. It can be used to overcome muscle inhibition which is sometimes present following an injury or operation. For example, it can be applied to the quadriceps femoris if adequate contraction cannot be gained actively. Some physiotherapists also use faradism during the early treatment of muscle strains; the affected muscle is supported in a shortened position and the current used to produce alternate contraction and relaxation so that the formation of adhesions is discouraged and the drainage of exudate encouraged.
It is not practicable to mention the specific physiotherapy for many sports injuries, but four injuries involving different structures will be discussed.
Klein and Allman (1969) have shown that ligamentous weakness in the knee leads to joint instability. This applies to other joints as well and it is therefore important that ligamentous injuries are diagnosed and treated early so that chronic disability is avoided. Adequate muscle function must be ensured to protect the damaged ligament and encourage resolution; proprioception must be re-educated as it is so vital in the avoidance of further sprains.
Sprain of the lateral collateral ligament of the ankle (inversion sprain) is one of the most common sports injuries. Minor sprains involve one or more bands of the lateral ligament. More serious sprains can be associated with capsular damage, interference with the inferior tibio-fibular syndesmosis, the calcaneo-cuboid joint or the base of the fifth metatarsal. Intracapsular injuries inevitably require more treatment than extracapsular injuries. The muscles traversing the joint may be implicated in ankle sprains. The physiotherapist must examine all the joints of the foot to eliminate the presence of any unrecognised lesion elsewhere which could have contributed to the injury and may adversely affect rehabilitation. The strength of the muscles of the hip and knee should be assessed and suitable exercises prescribed if weakness is proven.
Contrast bathing is used 24 to 48 hours after injury; ultrasound, diapulse or interferential may be chosen by the physiotherapist to encourage re-absorption of inflammatory exudate and relieve pain. Foot and ankle movements are then carried out with the leg supported in elevation to further encourage drainage; inversion and eversion must be performed gently within the limit of pain. Intrinsic foot exercises must be included because the integrity of the arches is essential for the normal functioning of the foot. A strapping, holding the ligament is a shortened position, may be indicated between treatments.
As the swelling and discomfort subside, weight-bearing exercises are performed within the limit of pain. A correct walking pattern must be encouraged from the first because bad habits become established rapidly and are difficult to correct. When the patient can perform a good range of active inversion and eversion, resistance is applied to the invertors and evertors; particular emphasis is placed on the peronei which are inevitably involved in the injury and must be strengthened to protect the healing ligament. Repeated balance and coordination exercises are essential to re-educate effective proprioception; without these activities, a sprain could re-occur at the slightest provocation. A Jonas board or other balance boards are useful pieces of apparatus for retraining balance. Running, jumping and hopping activities are only introduced when the patient can demonstrate controlled balance during single leg exercises; poor landings due to insufficient muscle control will otherwise lead to further injury and ligamentous laxity. Rotational and side-stepping activities are included in final rehabilitation.
A small or large number of muscle fibres may be damaged in the injury and the number will dictate the speed of recovery. Rest is inadvisable because the inevitable muscular atrophy as a result of injury is further enhanced by total inactivity. The muscle should be gently encouraged to work as soon as pain permits.
The injury may involve the upper or lower attachments or the mid-belly; the latter usually resolves more rapidly because of the greater blood supply. The physiotherapist is asked to treat acute and chronic lesions. Chronic lesions are often long established -they may be due to repeated minor pulls which the athlete has considered too trivial to warrant attention. By the time that help is sought the muscle has shortened, and adhesions, excessive scarring and fibrosis may be present. These lesions are inevitably difficult to treat and progress is often slow; graduated stretching and strengthening exercises must be done until maximal function is regained.
With an acute injury, after the first 48 hours contrast bathing, ultrasound, interferential or faradism may be used for the reasons mentioned previously. Ice may be required to relieve associated muscle spasm.
Management is dictated by the physiotherapist’s assessment of the severity of the lesion. Early treatment is directed towards the re-absorption of inflammatory exudate, relieving pain and muscle spasm and encouraging pain-free muscular activity, albeit in a limited range. It may be desirable to carry out active assisted exercises to ensure that the damaged muscle is not subjected to excessive stress.
Resistance techniques – designed to encourage relaxation by working the antagonists then contracting the affected muscle – are valuable because they help to relieve muscle spasm, overcome inhibition and regain extensibility. The severity of the exercises is gradually intensified but again it must be stressed to the patient that the activities must be done properly and they should not be painful. Manual techniques are very useful because the operator can regulate the effort demanded of the muscles, while a weak arc of movement can be appreciated and rectified. Stretching and resistance exercises which provide for all the needs of the muscle, endurance, strength and power, must be performed. The movements must be accomplished slowly at first, but later increased speed of motion and rapid alteration of pace are included in the rehabilitation programme.
Exercises can usefully be carried out in water a few days after incurring a muscle strain but the athlete may need to avoid certain movements. For example, it is undesirable for a patient suffering from a groin strain to attempt breaststroke for the first two to three weeks.
Exercise is often contra-indicated in the initial management of these lesions be they acute, chronic or through overuse. They can be slow to resolve because of the inherent poor blood supply of the tendon.
Injury to the Achilles tendon or the paratenon is common in sport. A definitive diagnosis is required but ultrasound is often the treatment of choice: when swelling exists, contrast bathing is also useful. The tendon should be maintained in a shortened position because repeated stretching will lead to further irritation. A heel pad should therefore be incorporated into the patient’s shoes or one inch (2.5cm) heels may be worn. A strapping is occasionally necessary. As healing progresses and the pain and swelling diminish, the tendon can be subjected to manual stretches which should not elicit pain. Later, a strengthening and flexibility programme is introduced. Balance and coordination exercises for the ankle and foot are included in the regime.
Chronic lesions often require transverse frictions and firm mobilisation techniques as well as electrical treatment to soften the scar tissue and enhance the circulation.
Recurrent lesions of the Achilles tendon and surrounding structures are common and it is important that the physiotherapist ensures that the patient has adequate strength, flexibility and muscle balance in the region to reduce the chances of re-injury. All the joints of the foot must be checked, as should the more proximal joints, to ensure that possible contributory factors are not overlooked. The patient’s footwear, both sports and every-day shoes, should be inspected for signs of excessive or uneven wear. Training and competition surfaces must be considered and the patient should be encouraged to do a large proportion of his training on grass rather than road or composition flooring. The physiotherapist should watch the patient’s running to ensure that a fault in style has not precipitated the lesion.
Many athletes who require a meniscectomy do not present with symptoms and signs that necessitate an immediate operation, although the indications are such that the surgeon can make a definitive diagnosis. A pre-operative strengthening regime is advisable for these athletes, firstly because many have experienced repeated insult to the knee with ensuing muscle weakness and second, because adequate strength before the operation should reduce to a minimum the resultant muscular atrophy. This means that in normal circumstances, rehabilitation can progress more rapidly. All the muscles surrounding the knee should be considered by the physiotherapist when preparing an exercise programme. The quadriceps, hamstrings, gastrocnemius, ilio-tibial tract, gracilis and sartorius require special attention as all play a part in stabilising the joint.
POSTOPERATIVE TREATMENT Adequate rehabilitation is important following any surgical procedure if a patient is to return to sport without exposure to an unacceptably high risk of further injury.
Most surgeons advocate immediate postoperative isometric quadriceps contractions for their meniscectomy patients. There is a variance of orthopaedic opinion regarding the duration of the patient’s stay in hospital, the type of support used, the time at which weight-bearing is introduced and so on. However, the patient usually commences outpatient physiotherapy following removal of the stitches.
Ideally, outpatient physiotherapy should be provided daily. After a careful examination of the knee and associated structures, the early treatment in the department is aimed at reduction of any swelling and contrast bathing can be useful. Effective quadriceps contractions must be achieved with particular attention being paid to the vastus medialis for it is most important that final extension of the knee is gained at this stage. General hip and foot exercises are also performed, both legs being worked. The knee should be bandaged between treatments, and between home contrast bathing and exercise sessions, until the effusion has cleared. The patient should be instructed to keep weight-bearing to a minimum as it can increase the swelling and retard progress.
Knee flexion and weight-bearing exercises begin as soon as the swelling has subsided but the knee must be carefully observed for any signs of irritability. Resistance exercises may be given either manually or by using weights, pulleys or springs. These exercises must be performed correctly.
The strength of the uninvolved leg must be considered when assessing the weight requirements for the operated knee; if a footballer can straight leg raise 301b (13.5kg) with his unaffected leg, then ultimately, he should be expected to perform similarly with the involved knee. Obviously, a 120kg rugby forward needs to use far greater resistance to adequately rebuild his quadriceps as compared with a marathon runner or a young footballer.
Table 1 shows the rough guide which is used in the Sports Clinic at St James’ Hospital at Leeds, to assess whether a patient’s quadriceps are considered strong enough to attempt running.
These values are adjusted according to each patient’s physique. At all times the lifts are performed slowly and extension is held for three to five seconds. Lighter weights with higher repetitions are used to build up endurance.
Exercises must also be carried out to strengthen the hamstrings, gastrocnemius and the hip muscles. Klein and Allman (1969) described hip adductor exercises which appear to favourably influence the medial ligament of the knee and these would seem advisable following a medial meniscectomy. Similarly, hip abductor exercises seem to be of some benefit to the lateral ligament and should be included following a lateral meniscectomy.
Before the patient returns to sport, the physiotherapist must ensure that his muscles have been reeducated to cope with twisting and turning, as well as sprinting or jumping. Further injury seems very likely if this vital stage is omitted because the various structures need training to work efficiently; this appears to be the phase that is often forgotten, yet it is a vital stage to rehabilitation.
The physiotherapist, working in conjunction with a doctor, has much to offer the field of sports injuries. There is much to be gained from meeting the coaches, trainers and athletes to discuss certain aspects of sport and a great deal can be learned from their opinions. A considerable amount is yet to be discovered about the management of many of the lesions that are commonly seen. This is a challenging field of physiotherapy because, generally, the patients are very well motivated and are willing to cooperate in endeavours to find a more scientific and effective approach to treatment. This should be to the benefit, not only of the sporting fraternity, but of all patients with a similar injury.
Bender, J. A., Pierson, J. K., Kaplan, H. N. and Johnson, A. J. (1964). Factors affecting the occurrence of knee injuries. Journal of the Association of Physical and Mental Rehabilitation, 18, 130-134.
Cyriax, J. (1978). Textbook of orthopaedic medicine, Volume 1, 7th edition. Bailliere Tindall, London.
Cyriax, J. and Russell, G. (1977). Textbook of orthopaedic medicine, Volume 2,9th edition. Bailliere Tindall, London.
Ebner, M. (1975). Connective tissue massage. Robert E. Krieger, Huntingdon, New York.
Klein, K. K. and Allman, F. (1969). The knee in sports. Pemberton Press, New York.
Knott, M. and Voss, D. E. (1968). Proprioceptive neuromuscular facilitation patterns and techniques. Harper and Row, New York.
Maitland, G. D. (1977a). Vertebral manipulation, 4th edition. Butterworths, London.
Maitland, G. D. (1977b).Peripheral manipulation, 2nd edition. Butterworths, London.
Nicholas, J. A., Strizak, A. M. and Veras, G. (1976). A study of thigh muscle weakness in different pathological states of the lower extremity. American Journal of Sports Medicine, 4, 241-248.
First aid, immediately following injury, is the start of rehabilitation. Much of the advice offered is not new; it is the first treatment in a continuing plan, rather than first aid. The more severe type of injury is dealt with because many of the knocks or damage sustained during sporting activity are of a minor nature and, though causing excruciating pain for a short while, can be treated effectively by ‘cold sponge, reassurance and a rub’.
The importance of fitness in preventing sports injuries is well documented and many authors have shown that consideration must also be given to clothing and equipment (Williams, 1965; O’Donoghue, 1970).
PRINCIPLES OF TREATMENT
Pitfalls are many and can best be avoided by experience; basically one must not be over-enthusiastic or too timid in approach. Often a rigorous attitude will achieve results but so also can a more conservative approach. A tremendous responsibility is placed upon the first person to treat an injury. The pressures can be enormous in assessing when to allow a player to restart; what are the economics and the match importance; what to do at the moment which will bring about a perfect result later; and there are many others. In gaining experience what does one consider? The following recommendations are offered as guidance and not intended to be absolute.
Functional anatomy and kinesiology
It is a distinct advantage to have a sound basis of functional anatomy and the study of movement in injury and in health. Study of movement is reinforced largely by experience and one needs to understand the movement that will cause injury (Browning, 1976).
This is the province of the doctor but those who are seeing the injury first should be able to diagnose the average sports injury. Many of the treatments recommended are only first aid, subsequent treatment has to be carried out under the supervision of a doctor who will make his own diagnosis.
Correct diagnosis is important, otherwise essential immediate treatment is directed towards the wrong aims and valuable time is lost. The work of Cyriax (1978) is a valuable aid.
Speed of treatment
Action must be taken at once and the injured person must be made to do something in return. In most sports injuries the length of the disability period depends upon the speed with which the initial treatment is made. This refers only to acute recent trauma which has a more pressing need for instant response. Stress injuries usually have a chronic cause but often they have an acute end or result which may require first aid treatment. Overuse injuries of ligaments or tendons are usually chronic conditions unless the overuse produces attenuation and then rupture.
Prevention of further injury
The steps taken during the first aid period should always consider prevention of further injury. For this reason, returning to competition supported by strapping or bandage is not favoured unless the latter is to cover a mild or moderate graze. Application of strapping or bandaging may mask a worsening situation or may serve to shift stress to some other area and cause injury.
No one who has had a local anaesthetic injection into a lower limb ligament or joint should be allowed to restart match play (Williams, 1965). A tennis or table tennis player may get away with it if it is the arm not being used to hold the bat or racket.
Know when to call a doctor
Recognise when you are out of your depth. The list provided by Williams (1965) gives some precise advice in this area. It includes, for example, all cases of head injury involving unconsciousness for more than ten seconds; all cases of minor injury where there is no marked improvement after 48 hours; and any or all cases of doubt.
The majority of sports injuries are slight, but severe and very severe injuries can be sustained and the first aider should be prepared for them. Here are some rules to follow.
Send for an ambulance without delay. Procrastination is pointless.
Bleeding should not be stopped by applying a tourniquet. If a tourniquet is forgotten or left on for too long, gangrene can follow devitalisation of tissue. The bleeding can usually be controlled by either digital pressure over a pressure point, or by dressings over the site of the injury. The technique is to soak up the blood by applying sufficient pads. A shell dressing of the type issued to HM Forces is ideal.
The unconscious person should not be moved until fully recovered. Concussion is an ever present danger. Loosen tight clothing and cover the person with a coat or blanket if conditions warrant it. Immobilise the injured person. If consciousness is regained quickly, allow the person to stay until his mental faculties are recovered. An escort must be provided to the dressing room or car where a period of rest should be encouraged.
In no circumstances should the injured person be allowed to resume play after prolonged unconsciousness.
In unconsciousness, steps must be taken to prevent the tongue falling back and the airway being blocked. This is achieved by: (a) Turning the head to one side with the person lying semi-prone. The tongue can be fixed by inserting an airway (if one is available). (b) Removing dentures. (c) Allowing ample fresh air. (d) Allowing nothing to be given by mouth while semi-conscious. This is particularly important after recovery of consciousness if there is any likelihood of an operation being necessary. Food or liquid contents of the stomach may delay anaesthesia because of the danger of vomiting. (e) It may be necessary to commence artificial resuscitation; ‘mouth-to-mouth’ or ‘mouth-to-nose’ breathing is the method of choice unless there are facial injuries (Figs. 34/1 and 34/2). External cardiac massage may be required if it is thought that breathing has ceased . Anoxia will lead to cardiac arrest. (f) If the person is pale, the head should be lowered if possible; and if the person is flushed, the head should be raised. The former indicates a drop in blood pressure and the latter a rise.
This is a disorder of the nervous system causing sudden complete loss of consciousness often with convulsions and coma. Some sufferers may have warning of an attack and can take the necessary steps to be in a position of safety.
First aid is relatively simple if the condition is recognised. There must be protection from injury at the two crucial periods – onset and convulsions. If possible, a gag consisting of a folded handkerchief should be inserted between the teeth to prevent the tongue being bitten. In the absence of a proper mouth gag, a well-padded dessertspoon is an asset in a first aid kit. It is not always possible to put in a gag as the rigidity is almost immediate.
All tight clothing must be loosened to prevent constriction and when recovery is effected the patient should be encouraged to sleep.
Most epilepsy sufferers are aware of their condition except in the case of the initial attack due to an injury. It is wise to remain nearby until medical assistance is obtained. With increasingly better treatment more epilepsy sufferers will participate in sport and thus present a possible risk to themselves and others.
This may occur for a variety of reasons – a car or bicycle crash, a rugby tackle, or an awkward fall on rough ground. The person should not be moved unless absolutely necessary and, unless removal is from a burning vehicle or a similar awkward situation, the following technique is adopted.
At least three or four persons are needed. One person should time or control the lift and should be stationed at the head. The head should be in the neutral position with slight traction in the long axis.
Two or three persons are then deployed both sides of the body and legs so that the lift can occur evenly and just sufficiently to put a stretcher underneath. Body alignment must be maintained during the lift and the stretcher padded to maintain alignment. Flexion must be prevented.
If a fracture is suspected, the part should be immobilised with no other interference except to control any bleeding. To immobilise the part, a sling, the other limb, or any rigid object such as a tree branch- or a broom handle may be used. Await medical assistance and arrange transfer to hospital.
At the time of the injury keep the treatment to a minimum, help the patient to bear the pain, offer reassurance and give no drinks. Do not offer a cigarette unless asked for one.
COMMON INJURIES AND TREATMENT
Skill in treatment comes by experience. All persons, medically and non-medically trained, who are responsible for sports teams or individual athletes, should enrol on first aid courses. The local branch of the St John Ambulance Brigade is always very willing to help in this respect.
Contusions or bruises
These are usually caused by direct blunt violence or crush or direct contact with another performer and/or playing surface. Often the skin is unbroken although there may be extravasation because of damage to blood vessels. There may be some occlusion of capillaries and normal nutrition is impeded. The affected part stiffens because of pain, swelling and muscle spasm.
The aim of first aid is to limit bleeding by the application of a dispersant such as a solution of heparinoid and hyaluronidase (Lasonil) or a heparinoid gel (Hirudoid) (Quiles, 1965; Bass, 1969), cold compresses and pressure bandaging. If the haematoma is not too severe, or the sport is non-contact or the bruise is in a part of the body not vitally important to the performance, then the player may be allowed to continue. If strapping or bandaging is necessary then it is preferable not to allow the individual to restart.
Judgement needs to be exercised in restricting, for example, soccer and basketball players with upper limb injury, or racket/bat players with opposite arm injury.
Cuts and abrasions
These may be trivial superficial cuts, grazes or scratches, or may be deeper. They can be caused by sharp or blunt pressure on the body acting obliquely or tangentially.
A superficial bruise is red with excoriation of the skin. Scratches may be patterned if left by finger nails, studs or spikes. An abrasion may present with streaking or directional markings if the person is dragged along the playing surface. It is helpful to remember these markings in cases of inquiry into violence or breaking of the rules.
Superficial cuts are best cleaned with an antiseptic such as chlorhexidine (Hibitane) or chlorhexidine and cetrimide (Savlon) and collodion, or a dry dressing may be applied after using an iodine spray. An alternative is to apply sterile paraffin gauze underneath the dry dressing. To allow a player to continue to play it may only be necessary to spray the area with iodine or collodion or allow sterile talcum powder to ‘cake’ on the area.
Deeper cuts may require suturing. A gaping wound can be overcome by using thin strips of Elastoplast and placing them under tension at right angles to the wound and then bandaging over them. A puncture wound may hide a deeper more serious damage with internal bleeding.
The skull is a closed box and if knocked, the brain and blood vessels will absorb the shock. If the force is great enough a skull fracture or ruptured blood vessels may result; this can lead to pressure and brain damage. Any blow will also directly damage brain cells.
Loss of consciousness must be regarded seriously and anyone knocked out for more than ten seconds should not be allowed to restart and should be kept under observation for 48 hours, preferably in hospital.
This is a sustained painful spasm of muscle. One cause is the disturbance of electrolyte and fluid balance which affects the level of excitability of motor units. As yet, the phenomenon has not been completely explained.
To overcome cramp it is best to put the muscles on physiological stretch by working the antagonist strongly, e.g. if the calf muscles cramp, then extension by flexion of the knee and dorsiflexion of the foot is needed (De Vries, 1961; 1962). A passive stretch may be added to supplement the action of the non-affected muscle group. A frequent sufferer from cramp should be clinically investigated or at least advised as to the maintenance of a good fluid intake (Norris et al, 1957; Denny-Brown, 1953). Massage and heat are helpful in alleviating the condition.
This term is used to describe damage to muscle tissue. There are two types (chronic and acute) and four categories of strain (Ryan, 1969).
Chronic strain describes the overuse syndrome leading to fatigue and muscle spasm; specialist treatment is required. Acute strain is the result of a single violent force, usually to those muscles passing over two joints, and occurs by forcing contracting muscle to lengthen, for example by a blow.
In Grade I strains, damage is to very few fibres and the sheath is intact. They are treated by immediate application of ice lasting 10 to 15 minutes (Wooton-
Whitling, 1977), then compression bandage for 30 minutes to one hour, followed by gentle active stretching. Normal weight-bearing is allowed. Ultrasound may be given immediately.
In Grade 2 strains, more cells are crushed or torn, the sheath is still intact but bleeding is considerable. They are treated immediately with ice for 10 to 20 minutes and a pressure bandage is then applied. No active movement, stretching or weight-bearing is allowed for 24 hours but rhythmic static contractions may be possible if the pain is tolerable.
In Grade 3 strains a very large area of muscle is involved and the sheath is at least partially torn. Damage may be found in more than one area. Bleeding is considerable but it is more diffuse because of the torn fascia. The treatment is as for Grade 2 strains but arrangements are made for admission to hospital.
A Grade 4 strain involves a complete rupture of the muscle with an obvious gap between the ends of the muscle. Hospital treatment is required but immobilisation, ice and compression are needed immediately.
A sprain is an overstretch injury of a ligament at the extremes of range. It can be chronic or acute with three categories, Grade 1, 2 or 3, I.e. minor strain, severe strain and total rupture (Colson and Armour, 1961; Featherstone, 1957). In all these injuries there is pain, swelling, tenderness at the site and some loss of function.
Movement will cause pain and thus the site may be either muscle or ligament, I.e. a contractile or non-contractile structure. To differentiate, the muscle is contracted strongly isometrically (static). If this causes no pain it is non-contractile tissue which is affected; conversely, if pain results contractile tissue is involved (Cyriax, 1978).
If damage is negligible, an aerosol refrigerant (Coolspray) may be applied and the player allowed to continue when the pain subsides.
If the injury is minor (Grade 1) although a few fibres are damaged then apply ice for 10 to 15 minutes, with cold compresses and a pressure bandage to the affected joint in the neutral position. If the injury is to the lower limb the patient is allowed to walk but is not allowed to do anything else for 24 hours. Rhythmic isometric contractions of the major muscle groups should be encouraged at once.
A Grade 2 sprain requires a greater force for the injury to occur and unless the therapist is experienced then the patient should see a doctor. Again, ice and a cold compress under a pressure bandage are essential, with the joint placed in the neutral or shortened position. Rest and elevation are required for at least hours, and no weight-bearing is allowed. If the subject is well-motivated then isometric rhythmic contractions should be encouraged. The doctor may give a local anaesthetic but on no account should the patient be allowed to continue or restart playing, as a relatively minor injury may become a more serious one.
In Grade 3 sprains or a complete tear there may be rapid effusion with exquisite pain and tenderness; there is instability and complete loss of function. The injury must be seen by a doctor. The first aid treatment is splinting and rest in an elevated position to allow for reduction of swelling by gravity. The part can be treated with ice, or cold compresses; a pressure bandage should be applied with the ligament in the shortened position.
If rib fractures are suspected then the patient should not restart unless in a non-contact sport and even this may be a doubtful procedure. At the very least the exertion will cause more pain and at most, further damage to the rib cage may puncture the pleura and lead to a pneumothorax developing.
It is essential that the patient sees a doctor but the immediate treatment is rest in a sitting position. Strapping, though providing some relief by splinting the ribs, is not recommended as it tends to restrict breathing even more. It is prudent to restrict any strapping to the area overlapping the fracture but not all round the chest, and this only in respect of the lower more mobile ribs. The patient can usually be taught to fix the affected area with muscular effort and use the unaffected parts. If there is bruising only, the decision to allow a restart will depend upon the distress felt by the patient-when breathing and upon the importance of the event.
Injuries to the testes and scrotum
Bruising of the testes and scrotum occurs by direct body contact or a blow from apparatus or sports equipment. The injury is extremely painful and incapacitating for a short while though at times it may be more prolonged. In the latter instances the player is removed from the playing area and a sponge or towel soaked in hot water is applied to the scrotum. When the pain subsides the patient is encouraged to micturate. If the urine contains any blood, the patient must see a doctor.
Locking of the knee
Locking of a joint can be caused by extreme pain due to muscle spasm or by the interposition of a foreign body or torn cartilage. The knee joint is particularly prone and care must be exercised as this joint may become locked either by spasm of the biceps femoris due to injury at its lower insertion to the head of the fibula, or it may be caused by a tear in the lateral meniscus (Williams, 1971).
The patient with a locked knee due to a meniscus tear should not be allowed to restart. If it is caused by muscle spasm, this may be relieved by the use of an aerosol refrigerant (Coolspray) but otherwise the treatment outlined previously applies. ‘Winded’ players
A blow to the solar plexus produces a momentary paralysis of the diaphragm with spasm of the abdominal muscles. Consequently, respiration is impaired and the player may feel nauseated; he is said to be ‘winded’. Treatment consists of reassurance and allowing the person to adopt a comfortable position. Recovery is usually rapid and a cold sponge at the nape of the neck can help. If recovery is slow with signs of shock and restlessness, the player should be taken out of play and medical advice sought.
The most usual joints to dislocate are the shoulder and the fingers, especially in rugby players. Fingers are also commonly dislocated in basketball and volleyball. Reduction of the shoulder should not be attempted by the inexperienced because of the possibility of damage to the axillary nerve; very often reduction can be effected by the person himself with a little help. More precise information may be found in textbooks on fractures or orthopaedics, e.g. Colson and Armour, 1961; Featherstone, 1957; Adams, 1978. It is not advisable to allow the player to restart play and there should be at least two to three days rest of the arm in a sling if it is the first dislocation, and longer if the condition occurs frequently.
With finger dislocations or partial dislocations it is possible, after using Coolspray, to apply force along the axis and so reduce the joint. The affected finger is then immobilised by strapping it to adjoining fingers. The player may be allowed to restart but must seek medical help later.
First aid is the start of rehabilitation and is the first treatment in a continuing plan. Everyone dealing with sports people should have some knowledge of first aid and the principles of treatment will assume knowledge of anatomy, movement, simple diagnosis, speed in treatment and prevention of further injury. It is essential that personal limitations be recognised so that more specialist treatment can be instituted. Finally, it is important that therapists involved with sports people should gain skill in treatment which can only come by experience gained in the ‘park’.
Adams, J. O. (1978). Outline of fractures including joint injuries. 7th edition, Churchill Livingstone, Edinburgh.
Bass, A. L. (1969). Treatment of muscle, tendon and minor joint injuries in sport. Proceedings of the Royal Society of Medicine. 62, 925-928.
Browning, G. G. (1976). Sports medicine and the physiotherapist. Physiotherapy, 621, 246-250.
Colson, J. H. C. and Armour, W. J. (1961). Sports injuries and their treatment, Stanley Paul, London.
Cyriax, J. (1978). Textbook of orthopaedic medicine. Volume I. Diagnosis of soft tissue lesions. 7th edition, Bailliere Tindall, London.
Denny-Brown, D. (1953). Clinical problems in neuromuscular physiology. American Journal of Physiology, 15, 368.
De Vries, H. A. (1961). Electromyographic observations of the effects of static stretching upon muscular distress. Research Quarterly, 32, 468-479.
De Vries, H. A. (1962). Evaluation of static stretching procedures for improvement of flexibility. Research Quarterly, 33, 222-229.
Featherstone, D. F. (1957). Sports injuries: their prevention and treatment. John Wright, Bristol.
Norris, F. H. Jr., Gastiger, E. L. and Chatfield, P. O. (1957). An electromyographic study of induced and spontaneous muscle cramps. Electroencephalography and Clinical Neurophysiology, 9, 139-147.
O’Donoghue, D. H. (1970). Treatment of injuries to athletes. W. B. Saunders Co., Philadelphia.
Quiles, J. (1965). Enzymes in the treatment of acute sports injuries. Proceedings of the 5th Latin Congress Physical and Sports Medicine.
Ryan, A. J. (1969). Quadriceps strains, rupture and charley-horse. Medicine and Science in Sports, 1, 106-111.
Williams, J. G. P. (1965). Medical aspects of sport and physical fitness. Pergamon Press, Oxford.
Williams, J. G. P. (1971). Diagnostic pitfalls in the sportsman’s knee. Proceedings of the Royal Society of ^Medicine, 64, 640-641.
Wooton-Whitling, Y. (1977). Ice in the treatment of sports injuries. British Journal of Sports Medicine ,11, 146.
All mobile collision sports have a quota of injuries. Specific injuries are not confined to any particular sport, but regular injury patterns do occur among players in their chosen pastime.
The circumstances, diagnostic assay, treatment and management of injuries both on the field of play and immediately afterwards vary considerably, particularly in personnel and facilities available. Ideally, a team is covered by a doctor and physiotherapist, both skilled in medicine in sport, and an enlightened coach; the playing area is regularly inspected while first aid facilities at hand include a stretcher, inflatable splints and a treatment room, easily accessible from the field of play, which is equipped with good lighting, running water, couch, steriliser and ice, and so on. In practice, facilities at most matches seldom extend beyond the proverbial bucket and sponge and an elementary first aid box, possibly locked with the key unavailable! This happens despite encouragement and prompting from the concerned sporting organisation.
At all times medicine in sport should be advisory rather than authoritative, similar to its role in the community, and it is as well for the attendant to remember this. He should, ideally, have a working knowledge of the prevailing laws of the sport, be situated close to the field, undisturbed and able to watch the game closely, so allowing maximum opportunity to recognise cause and site of injury.
When summoned on to the field of play (solely by the referee) it is most important to remember what not to do and as far as possible no treatment should occur before a shrewd idea of the diagnosis has emerged. It should be appreciated that the attendant has arrived at a situation which every casualty officer envies – within a minute of the incident and before effects such as exudate, swelling, bruising, painful muscle spasm can cloud the diagnosis.
Well before the player is touched important aspects can be elicited such as; Who saw the incident? What happened? Where is the site of the injury? Observation and inspection are paramount necessities by which the presence of vital normal function such as consciousness, breathing, limb movements, source of haemorrhage is established without necessarily touching the injured player. Removal of a mouthguard, if worn, reassurance in approach to the casualty, and quiet authoritativeness to the other participants are fundamental.
Palpation and establishment of movement range must be with the player’s cooperation rather than despite him. Passive movements may rarely be employed as a primary diagnostic or therapeutic aid. Fortunately, the human anatomy, with one or two notable areas of exception, has been duplicated thus allowing comparative examination of the uninjured side. The attendant should be ever mindful of the possible pitfalls, such as the artificial eye, the slight long-standing squint, the ‘normally’ deformed nose of an earlier injury, long-standing calcification and hard swelling of an old quadriceps muscle injury, the permanent lump over an old costal cartilage injury or deformity of the acromio-clavicular joint from former damage.
The attendant is there to give advice and assistance and must have control of the situation. No one should attempt to drag the injured player to his feet without the agreement of the attendant, or medical or paramedical supervision.
Within one minute or thereabouts basic decisions of likely diagnosis and playability should be made or, if not possible in such a short time, decided off the pitch after unhurried removal of the player. Where the particular sport permits replacements or substitutes, the casualty should be taken directly to the main facilities.
Always before the match, the attendant must be acquainted with the location of a stretcher and the address, location and telephone number of the ground. In major injury an unnecessarily long delay can occur with the ambulance careering around the countryside vainly following inadequate instructions as to the whereabouts of, say, the Tolpuddle Martyrs fifth eleven pitch. The appropriate official should also be notified of the hospital to which the injured player has been taken.
Specific areas of injury may be considered from surface anatomical situations, being ever mindful that there are areas of increased vulnerability in particular sports.
Head, neck and face
Difficult diagnostic and management decisions arise with these areas. Applied forces causing injury to the head and neck are mechanically similar to those applied to a heavy ball on the end of a chain. The forces are sudden acceleration and deceleration, hyperextension, flexion, rotation and compression – the last mentioned commonly with the vertex of the skull fixed as in a rugby front row player when the scrum collapses, or in a badly executed tackle with the head anterior to the hip or thigh or an acute frontal approach to the tackle. These forces can result in the rare but terrible injury of fracture-dislocation of the cervical spine with consequent paralysis.
Tangential blows can produce serious brain damage, apart from lacerations and facial bone fractures, by shock waves passing through the skull into the loosely suspended brain covered by three membranous layers or meninges. These are namely the tough outer fibrous tissue or dura mater (the inner lining of the skull), the middle layer or arachnoid and the inner membrane closely applied to the surface of the brain, the pia mater . The resultant spaces are traversed by blood vessels and the space between the inner two mem- branes contains the cerebrospinal fluid. Hence the importance of the awareness of the possibility of structural damage to the brain which can be fatal in a matter of hours. There were eight fatal accidents in rugby in England from October 1971 to November 1978, a fatality in soccer in 1978 and a fractured skull in hockey in the same year.
Momentary insensibility, confusion, unsteadiness, incoordination and retrograde amnesia, are all symptoms which make the removal of the injured player from the field of play mandatory.
An unconscious player represents an emergency and immediate attention should be given to fundamental principles – if he is not breathing, then resuscitation is vital whether or not there is a suggested broken neck. Remove the mouthguard if present, check deeply with a probing index finger that there are no loose avulsed teeth, dentures, chewing gum or anything else in the mouth and throat preventing maintenance of a good airway. Concurrently, start emergency resuscitation with the neck extended and chin well forward. After establishment of normal respiration and if there is no suspected neck injury, the injured player should be placed on his side with the knee of the uppermost leg bent at a right angle.
If mouth-to-mouth resuscitation is not causing movement of the chest, or lividity, foaming at the mouth and extreme restlessness are occurring, the player may be asphyxiating because of airway obstruction from a foreign body. Sit him up and at the same time apply sharp pressure with the heel of one hand from behind placed over the spine just below the ribs to attempt expulsion of the foreign body. This can be carried out very quickly; if unsuccessful, while inverting the player, give sharp blows between the shoulder blades; there are enough strong men around to make this a rapid manoeuvre which in practice has proved life-saving. In every case the player must be taken to hospital without delay.
The classical example of only transient alteration in brain function without any structural damage, is concussion. On the field, diagnosis and decision can be difficult and misleading in the two following phases of concussion and symptoms.
Firstly, the mildest degree of concussion occurs with doubtful loss of consciousness, very transient memory loss and the player appearing mentally alert at the time of examination. If he is able to rise promptly to his feet without assistance, to stand firmly with eyes closed, to perform heel-toe and ‘tandem’ walking, followed by a shuttle run to a mark then he may continue to compete but he should be watched carefully for the rest of the game for any further signs developing. His fellow players should also be told to watch him.
Secondly, difficulty arises with moderate degrees of concussion where the player may not necessarily go down but be ‘out on his feet’ – a situation analogous to the boxer stopped on a ‘technical knock-out’: he is dazed, amnesic, unsteady, possibly aggressive and unreasonable, and repeating the same phrases. For example, to the question ‘What is the score?’ he may reply ‘Has the game begun yet?’ In all sports, such casualties must be withdrawn from the game with firmness, and the captain and referee must assist if necessary. Remember, there is no sophisticated method on the field of play or, for that matter, in a neurosurgical unit to determine whether or not a player at the moment of injury has suffered a simple concussion or is going to develop secondary brain damage necessitating urgent surgical interference.
Neck injuries can vary from a simple muscle sprain with the neck held in flexion, or an acute wry neck caused by subluxation of one of the pars articularis facets with the chin rotated to the opposite side and pointing upwards, to fracture-dislocation and resultant paralysis. The utmost vigilance is required.
The player may, on questioning while down on the ground, be able to manage full limb movements, but, for example, if he complains of a sensation of numbness or tingling, heat running into the arms or hands, no matter how transient, he must be removed on a stretcher and referred to hospital. Persistent high interscapular pain requires similar firm management and the game suspended until ambulance facilities have been arranged. These signs indicate suspicion of cervi- cal nerve root damage or developing cord involvement at C7 level and require strict immobilisation before removal. At Twickenham Rugby Football Union ground a Ferney-Washington ‘scoop’ stretcher is always present for such an eventuality. In the period October 1973 to April 1978, there were ten reported cases of neck injuries involving paralysis (quadriplegia) in rugby in England, estimated by the writer from insurance claim reports.
Cuts and lacerations predominate in this area in rugby and to a much lesser extent in soccer and hockey. Seventy-five per cent of lacerations occur in the front five forwards in rugby with usually over half requiring suture. All lacerations should be adequately cleaned: a dilute solution of cetrimide and chlorhexidine is preferred for this purpose, though in the absence of anything else, soap and water is excellent for debridement. A protective dressing should be applied before returning to play. If there are facilities available to suture a wound this should be carried out forthwith; if not, the casualty should be referred for suturing within four hours. (The numbing effect of the injury makes local infiltrative anaesthesia unnecessary for immediate suture: there is no swelling of the tissues, there is more accurate alignment of the skin edges and as a result a more acceptable scar. In preparation, never shave any segment of the eyebrows before suture – re-growth is uncertain in timing and the resultant appearance might result in litigation.) Prevention of such injuries or at least reduction of their incidence would be assisted considerably by firmer application and review of existing laws, increased club and player cooperative responsibility and equipment modification.
A plastic/rubber composite stud is feasible for those sports. There is no room for complacency: the incidence of disfiguring lacerations is not falling and the elimination of the nylon stud and sharp-edged sole is not the answer. Sports authorities must maintain regular contact with the Shoe and Allied Trades Research Association. Finally, it is a foolhardy player who has not had a full course of tetanus immunisation plus regular booster injections.
In any collision sport eye injuries can be disastrous. In the middle of the furious scrambles of forwards and centres for the ball rebounding at eye level in basket–ball, the eyes are very vulnerable. Eye injuries may also arise from fingers, thumb, or collision of heads in any sport. Mistiness of more than a brief duration or partial loss of vision require examination off the pitch; where there is contusion the application of ice and prompt hospital referral is advised. Apart from the pain of a corneal abrasion which resolves fairly rapidly after 48 hours or so depending on dimension, discomfort may not always be a prominent symptom of eye injury despite obvious haemorrhage into the interior or posterior chamber of the eye. (Proxymetacaine hydrochloride (Ophthaine) drops plus an eye pad will relieve the abrasion pain: the possession of an ophthalmoscope is invaluable to eliminate more serious injury and avoid hospital referral.)
Dislocation and fracture of the teeth occur in the unguarded mouth. If this occurs, retrieve the tooth, wash it gently in normal saline or under the tap and apply sustained gentle pressure until the blood and tissue fluids are expelled. Gentle pressure will maintain position until specialist dental advice is sought. Latex mouthguards, dentally moulded and fitted, drastically reduce facial and dental injuries, and concussion. The type available ‘off the peg’ in sports shops should be avoided as it is loose, ill-fitting, and can and has caused asphyxia. Examination for a fracture of the lower jaw includes a full inspection and palpation via the mouth: a swab plus probing finger may reveal bleeding from a tooth at the gum margin; biting on a folded handkerchief can produce localised pain even as posteriorly as the tempero-mandibular joint. With such signs present, a fracture is likely. The player who is tackling is usually the victim, frequently through incorrect technique or the faulty coaching of smother tackling in rugby.
Injuries to the nose primarily require arrest of haemorrhage. This is best effected on the field of play by firm pressure on the distal one inch (2.5cm) of the nose using ice, adrenaline gauze or ribbon gauze packing. Any displacement of the nasal septum can often be corrected painlessly on the spot by pressure with the handle of a scalpel or straight forceps inserted into the nasal vestibule. No further investigation or treatment is rewarding for approximately four days due to oedema, and bruising.
The shoulder and arm
Any injury to the shoulder joint and girdle is not adequately examined until comparison with the surface anatomy of the normal side has been made. The angular ‘step down’ of the acromio-clavicular joint injury, the absence of the normal gentle rounded curve of the shoulder in gleno-humeral dislocation, especially when viewed from behind, the forward displacement of the humerus in dislocation of the elbow joint (no rarity in schoolboys) will all be readily established.
Fractures, particularly of the ulna or head of radius, may not be accompanied by a complaint of pain. Quite frequently only loss of power is apparent until later, when exudate and haematoma formation promote discomfort. Fractures of the metacarpal bones can result from a misguided punch providing a salutary lesson to the offender. Whether or not reduction of dislocation of the phalangeal joints is promptly attempted by skilled attendants, a subsequent x-ray is essential. A Bradford support or Kirschner malleable padded metal splint should be applied to injured fingers post-match.
Thorax and abdomen
Direct forces as in tackling, kicking and crushing, cause injuries to the thorax in team games, though surprisingly, rib fractures are not so common as those of other bones. A reasonable opinion should be possible ‘on site’ as to whether or not the ribs are broken . Naturally, the exertional dyspnoea caused by the game will increase the pain. Sudden but slight pressure with the heel of one hand over the lower end of the sternum and the heel of the other hand over the back bone will produce confirmatory pain at the site of the fracture. If the diagnosis is still uncertain and discomfort persists, further decision should be taken on the touch line; a hasty, ill-advised return to competition may produce the alarming sign of blood stained spit on the pitch thus showing there is lung involvement. An x-ray is essential.
At the costal margin, in the lower part of the front of the chest, the ribs join the costal cartilages and this is the area of maximum chest movement. Costal cartilage injuries are generally due to a crush injury: they are characterised by a sore area, possibly a palpable click on inspiration and the development within half an hour or so of a hard swelling which to some extent will be permanent. An x-ray frequently reveals no fracture. Strapping is inadvisable and the player is match fit when totally pain free. This usually takes five to six weeks.
Serious abdominal injuries are fortunately rare: this is surprising when one considers the blunt trauma to which the area is exposed, e.g. a high velocity boot over the ball, a football weighing approximately 450g and reaching speeds of up to 100km per hour, or a 200g hockey ball at approximately the same speed, from 10 to 15 metres in a penalty corner. A winded player left alone will recover completely after a minute or two. Intelligent awareness and suspicion on the part of the attendant on the field of play are important; if the winded player shows delayed recovery, vomits, looks pale or shocked, prompt hospital referral is required. Unfortunately, the three main internal organs – the spleen, liver and intestines – do not show early bleeding externally; internal bleeding can be rapid and catastrophic.
Be advised: get the player to the hospital in time. Similarly, blunt trauma in the loin may fracture one or more transverse processes or damage the kidney. If a player is injured in this way, even apparently slightly, a routine urine test for the presence of blood, using Haemostix, should be performed after the match; if the test is positive, hospital referral is necessary.
The pelvis and lower limbs
Success in team sports basically depends on running ability. In consequence, more ill-advised decisions to continue playing in the match are made for injuries to this vulnerable region than anywhere else. Objective examination is essential: try to decide whether it is a direct or indirect injury: question the possibility of previous injury at the site, e.g. wasting of the vastus medialis in a former knee injury and look for signs of deformity by comparison with the other limb.
Again, initial pain may be misleading; whereas a superficial type of soft tissue lesion or ligamentous stretch may produce intense transient discomfort which rapidly disappears with an equally rapid recovery, a condition such as an oblique fracture of the fibula just above the lateral malleolus may initially produce a complaint of loss of power and inability to support the body, even though there is a palpable click at the fracture site.
Injury to the quadriceps muscle mass whether due to strain, boot, ball, stick or knee drastically reduces in-match mobility. The ‘charley-horse’ of a central trauma, or the ‘dead-leg’ of the laterally placed lesion need to be treated properly; such injury should be treated early and off the field of play, rather than rubbing with liniment and attempting to ‘run it off with reckless endeavour. The injury site should be first covered with olive oil or Vaseline petroleum jelly to reduce ice burn risk, then crushed ice applied for at least twenty minutes with compression and elevation. A hot bath should not be taken, only a quick shower, followed by replacement of the compression dressing and elevation; ice application should be repeated three times daily for the 48 hour ‘treatment vacuum period’ until review. A player who cannot flex his knee to a right angle 48 hours after the quadriceps injury is most likely suffering from an intramuscular haematoma. This will necessitate careful management, patience, rest, ice contrast treatments, ultrasound, and static quadriceps contractions, otherwise calcification at the site or myositis ossificans may appear insidiously within six weeks.
The sudden jumping when in full stride, or the slide tackling manoeuvre of soccer, may produce avulsion injuries of muscular attachments to the pelvic rami and chronic adductor muscle strain in the thigh, with instability of the symphysis pubis. These injuries also occur in other sports but are much less common. Hamstring injuries, including partial tears, will also drastically reduce coordination and mobility. Avulsion of the biceps femoris tendon of origin has been known to occur. Examination should be full and include the prone position to accurately define the lesion. Frequently it is a recurrence of an injury due to inadequate preparation after the previous one. It should be emphasised that recurrent thigh and adductor lesions require orthopaedic and radiological investigation rather than expectantly persisting with physiotherapy.
The knee, probably the most publicised joint with reference to injuries in sport, is examined initially with the player sitting, not standing. Gently locate the site of pain or tenderness; encourage the player to carry out a few static quadriceps contractions for promoting confidence thus facilitating assessment of the range of active movements; locate the joint line – at the inferior end of the patella with the knee extended. The degree of any injury to the collateral ligaments can be assessed roughly by the range of abduction or adduction, and the presence of ability to draw the tibia forwards in relation to the femur indicates damage to the anterior cruciate ligament. Any suspicion of the presence of these abnormal signs in a previously normal knee joint demands that weight-bearing be avoided and the player carried off for an early orthopaedic opinion: ice should be applied. An effusion into the knee joint may only appear by the time the player has reached hospital. If in doubt, any player with a full movement range who cannot hop on the afflicted leg should come off. (Note: in the case of a minor collateral ligament tear, ice followed by four-hourly treatments with ice and ultrasound preferably for 48 hours often rapidly assist recovery.) With such precautions much recurrent knee joint pathology could be considerably reduced.
Ankle injuries may well beby the type of sports footwear which gives no support to the ankle joint and increases forefoot running instability. A stirrup of extension plaster or the Louisiana Wrap technique are useful measures to augment support.
The traction force of extreme plantar flexion from the prolonged kicking of a soccer ball with the strain of the blow borne by the dorsal capsule of the ankle joint, has long been suspected of exacting a toll on the kicker’s foot with periosteal roughening and bony outgrowths developing laterally. Basketball perhaps shares the running with abrupt changes of direction as in soccer with resultant chronic troublesome stresses. On the field, the decision simply demands absence of full painless movement for the player to be advised to leave the field of play. Likewise, competitors with acute inversion sprains, or injury to the inferior tibiofibular joint should leave the field. The ice technique already mentioned should be used routinely. To some, it would seem reasonable that, after injury, immobilisation of the ankle joint with plaster of Paris, for up to a week as an initial measure, would reduce the incidence of recurrence.
Although the team attendant’s main preoccupation is with primary treatment, he should envisage other responsibilities. He should feel that he has a moral duty to bring to the notice of club officials and the referee after the match any injuries caused in his opinion by dangerous or violent play or improper playing equipment. Furthermore, he should be prepared to discuss with them any player who is predisposed to repetitive injuries particularly concussional incidents. Where injuries are concerned on the field of play, there is no place for heroes!
Injury to the ankle joint is the most common sports injury, comprising about 12 per cent of the total number of injuries. Eighty-five per cent of the ankle injuries are sprains, that is ligamentous, and four out of every five of these involve the lateral ligament. The problem with these injuries is that they are so common, familiarity breeds contempt, and the result is frequently unsatisfactory treatment. In the general public, one-third of patients with ankle sprains still have symptoms after 12 months.
The true ankle joint is of the hinge type with movements limited to dorsiflexion and plantar flexion; many of the movements we associate with the ankle joint actually occur at the subtalar and other joints of the mid-foot.
The ankle joint is formed superiorly by the concave articular surface of the tibia, a downward projection of the tibia to form the medial malleolus, and a downward projection of the fibula to form the lateral malleolus; the convex articular surface of the talus is partially held in their grip . At the ankle joint, the tibia and fibula provide a narrower mortice posteriorly and the talus itself is broader anteriorly so that in plantar flexion the joint is at its most unstable and in dorsiflexion at its most stable.
The medial and lateral ligaments of the ankle run downwards and backwards from the malleoli and prevent forward displacement of the leg in relation to the foot. The medial ligament is triangular in shape with its apex attached to the medial malleolus, its base attached to the posterior part of the talus, the calcaneus, the neck of the talus and slightly to the navicular. The lateral ligament is in three parts and is attached above to the lateral malleolus; the anterior band runs downwards and forwards to be attached to the talus and is taut in plantar flexion; the middle cord-like part is attached to the calcaneus and is taut in dorsiflexion and inversion; the posterior band is attached to the posterior tubercle of the talus and is taut on dorsiflexion. There is also a ligament between the tibia and fibula; although not in the ankle joint itself, it is often involved in injuries to the ankle .
The immediate assessment of an ankle injury on the playing area or in the dressing room is an appropriate starting point. The immediate decision to be made is whether there is likely to be a fracture and this is most easily decided immediately after injury. At this time, it is possible to examine an unswollen ankle which is ideal for inspection and palpation on all but its posterior aspect. An hour later this advantage may be lost through swelling, and examination becomes difficult. A history of an acute tearing or snapping sensation with severe pain and disability requires that the athlete should be seen by a doctor as this is likely to be a fracture or a complete tear of the ligament. In other cases, the injured joint should have all bones palpated as far as possible, at first very gently but then with increasing pressure, to be certain there is no tenderness of the bone itself which could be an undisplaced fracture. Ligamentous tenderness is usually anterior and/ or inferior to the prominence of the malleolus on either side of the joint.
The athlete should then be encouraged to move the ankle joint through a full range of movement, initially while sitting on the floor, then with partial weight-bearing and finally with full weight-bearing. The athlete should be asked to stand on tip-toe, jog, run, turn and if he manages this, he may then continue with the activity. If the athlete is unable to complete this procedure he should be removed from the activity area to a more suitable place for examination.
At this time, the areas of maximal tenderness should be reassessed and the initial area of swelling noted. Some injuries of the ankle develop considerable swelling within a very short time – this is often unrelated to the severity of injury but does itself cause considerable tenderness and disability. Swelling must be prevented as far as possible and the ice, compression and elevation routine started immediately. All the swelling has to be removed during the recovery phase and the more there is to remove, the more delayed will be the return to sport.
The most common injury is to the lateral ligament and is caused by a plantar flexion and inversion strain. There is tenderness below and usually in front of the lateral malleolus. There may also be some tenderness on the opposite side of the joint because the stretch to the lateral side of the ankle is associated with compression on the medial side of the joint and the capsule or ligament may be nipped between the bones.
A complete tear of the ligament must be excluded. This may be checked by assessing talar tilt, that is, considerably increased inversion of the heel in relation to the lower leg when the heel is manually inverted or everted. Care must be taken to compare this finding with that in the uninjured ankle because there is considerable individual variation. The test may be difficult to perform owing to pain and if there is serious doubt about the possibility of a rupture then examination under anaesthetic may be required.
A further test for stability is the anterior ‘drawer’ test which is carried out by having the foot in 20° of plantar flexion, applying the flat of one hand against the anterior surface of the tibia to push backwards and the cupped ringers of the other hand behind the talus gently pulling forwards. Significant forward movement of the talus in relation to the tibia indicates a rupture and when this is a possibility, the ankle must be assessed by an orthopaedic surgeon.
Injury to the lateral ligament is the most common but damage to the medial ligament does occur and is caused by eversion of the foot. There is also the possibility of damage to the tibio-fibular ligament due to a forced dorsiflexion strain and this injury heals extremely slowly. On examination there would be general tenderness and swelling on both sides of the joint with pain made worse by dorsiflexion of the foot.
Treatment of all these ligamentous injuries is basically the same. The first object must be the control of bleeding and swelling. The usual routine of ice, compression and elevation should be applied from the moment the injury is reported. There must be some form of strapping for 24 to 36 hours and then a re-evaluation.
An active process of rehabilitation is favoured but there are some cases which do better with a short period in plaster of Paris. Infilling of the two hollows at the back of the ankle joint, on either side of the Achilles tendon, usually implies an effusion within the joint and this should be treated in plaster for one week. There are also some players who cannot be guaranteed to follow advice and therefore require effective immobilisation in plaster for two or three days to prevent them causing further damage to the joint. There are considerable problems with the long-term use of plaster in an athletic situation; microscopically it has been possible to show that the ligamentous attachment to bone remains abnormal for 24 weeks after six weeks in plaster, consequently prolonged periods in plaster for an athlete require a considerable period of rehabilitation.
Thirty-six hours after the initial injury the stage of definitive treatment and rehabilitation begins. Initially, this may only consist of attempting to regain the full range of movement non-weight-bearing, gradually progressing to weight-bearing, strengthening and rotation exercises with particular emphasis on all those activities requiring coordination. This active programme must not be forced too quickly and any evidence of increased swelling or pain requires an immediate re-adjustment of the exercise. Care must be taken to correct abnormal gait as soon as possible because false patterns of movement rapidly become habit. The exercises are time consuming and laborious but appear to produce satisfactory results. Strapping is no substitute for strength and coordination around the joint; for in order to be effective in reducing the force of bodyweight and providing stability to the joint, strapping has to be so strong that normal movement is abolished.
The ankle injury which persists for several weeks also requires great care to be taken in re-establishing the strength of inversion and eversion of the foot. It must also be remembered that there will be some wasting of the involved calf and thigh musculature which has to be corrected.
There has to be a check on the extensibility of the gastrocnemius and soleus muscle group, because limited dorsiflexion appears to be an important factor in the causation of a sprained ankle. This is thought to be due to the tightness of the Achilles tendon which tends to naturally invert the foot thereby making further inversion and sprain likely.
Full functional testing must be carried out before the player or athlete resumes activity. Attention to these apparendy minor injuries is important to ensure that the individual does not develop a chronic or recurrent ankle problem.
OTHER SOFT TISSUE INJURIES
An ankle complaint which is not always directly related to injury is discomfort around the joint due to tendinitis. Tenderness may be localised along the course of the posterior tibial tendon running behind the medial malleolus or along the peroneal tendons running behind the lateral malleolus. Palpation may reveal a fusiform swelling, acute tenderness and crepitation on movement of the involved tendon. This condition is most often seen in runners and there does not appear to be any local treatment with a significant advantage. Some people favour the use of ultrasound, others apply ice directly to the area, or prescribe anti-inflammatory tablets or an injection of hydrocortisone alongside the tendon.
The most important factor is to restrict markedly the athlete’s activities until symptoms and signs subside after which there has to be a graduated return to activity. Adhesive strapping to limit the movement of the joint is of some value but it must be carefully applied because any direct pressure over the involved tendons will aggravate the condition.
There are various lesions of the Achilles tendon which may be extremely disabling. The most spectacular is a rupture of the tendon which classically occurred in the older, heavier athlete but is now more common in the younger group. There is usually a very definite history of sudden, acute pain over the tendon with remarks from the patient such as ‘I thought I had been shot’. Examination two or three hours later may be confused by the considerable swelling which occurs but there is usually a palpable gap in the Achilles tendon about Scm from its distal attachment. Function of the Achilles tendon must be checked and many doctors or coaches merely ask the patient to plantar flex the foot against slight resistance but the athlete can do this by using the accessory muscles and considerable resistance should be provided to check the functional capacity of the Achilles tendon.
The treatment of an acute rupture is open to argument in terms of the usual conservative versus radical approach. Plaster of Paris with the foot in slight plantar flexion for six weeks produces reasonable results but with a rehabilitation period lasting several months. Surgery with end-to-end suture may produce an excellent result but still involves six weeks in plaster, a long rehabilitation period and the associated risks of anaesthesia, infection and delayed healing in a relatively avascular area. It would appear to me that surgery is the treatment of choice in the younger, athletic patient.
In the runner, particularly, there are various less dramatic Achilles tendon pains which are, none the less, disabling. The common condition is a peritendinitis where the athlete develops swelling, usually along the medial border of the tendon, and associated with considerable tenderness. This typically occurs in runners with a large training mileage and is usually associated with some minor abnormality of gait or flat foot which affects the alignment of the Achilles tendon in relation to the calcaneus. The initial treatment of this condition is to stop training, elevate the heel with a pad of chiropody felt or Plastazote and use ultrasound. Peritendinitis sometimes shows a good response to an injection of hydrocortisone alongside but not into the tendon. Occasionally the condition persists and surgery is required; then there has to be a gradual return to activity in a condition which has a great tendency towards chronicity. It is essential to look for minor biomechanical abnormalities and attempt to correct these during the rehabilitation phase.
There is a superficial bursa over the attachment of the Achilles tendon and this may become an acute problem as the result either of direct blows or by friction from the so-called ‘Achilles protector’. Usually this bursitis settles with control of the footwear and judicious padding. There is also a deep bursa which is less frequently a cause of trouble. Inflammation of both these bursae may be helped by a direct injection of hydrocortisone; sometimes surgery is necessary.
The knee joint is very vulnerable because of its basic structure, which is a hinge with long levers on either side . The knee is really two joints, one between the femur and the tibia, the other between the patella and the anterior surface of the lower femur. The rounded end of the femur contacts the flat upper part of the tibia, and the two menisci or cartilages lie between them. The menisci are deeper around the edge and so provide a slight depression on the flat tibia for the rounded femur but even then the basic stability of the joint is almost nil. Its strength depends upon its capsule and ligaments together with the muscles acting across the joint.
The knee has always been considered a simple joint but over the last decade the whole concept of the functional anatomy of the knee has changed and the exact functions of each ligament are still open to argument. The joint is surrounded by a capsule, the posterior part of which is only taut in full extension of the knee and provides some stability even in medial and lateral directions. The anterior part of the capsule is only taut in full flexion and is extended as a pouch above and behind the patella. The only structures within the capsule are one small tendon and two menisci.
The medial ligament of the knee passes from the femoral condyle to the upper margin of the tibia. It is composed of a superficial layer which is attached to the tibia several inches below the joint line and a deep layer which is attached to the medial meniscus and the upper margin of the tibia. The whole ligament forms a wide fan-like structure.
The lateral ligament of the knee is a narrow band passing from the femoral condyle to the head of the fibula and should not be considered the major support on the lateral aspect; this function is performed by the ilio-tibial tract. There are also thickened areas in the capsule which are sometimes described as ligaments.
There are also two major ligaments which are situated centrally, deep within the joint and because of a fold in the capsule are actually outside the joint capsule. These are (1) the anterior cruciate ligament which runs upwards and backwards from its origin on the anterior lip in the mid-line of the upper tibia to the femur and (2) the posterior cruciate ligament, the key to stability of the joint, which arises just medial to the mid-line of the femur and runs downwards and backwards to the tibia. These ligaments are important in the antero-posterior plane.
A major stabilising factor for the knee joint are the muscles . Anteriorly, the powerful quadriceps muscle is inserted into the patella and then through the patellar tendon into the upper part of the tibia. Posteriorly, there are not only the hamstring muscles from the thigh but also the gastrocnemius muscle from the calf. This stabilising factor is important in sport because we can only strengthen the ligaments in a minor way but we can ensure maximum help from the muscles.
A previously unreported series of 8899 sports injuries seen in the sports medicine clinic of St James’ Hospital, Leeds over a four year period and in an accident and emergency department over a three year period show that ligamentous injuries of the knee comprised nine per cent (803 patients) and of the ankle 11.4 per cent (1014 patients), these being the two most frequent diagnoses.
Injury to the knee may damage skin and subcutaneous tissue, muscle, tendon, ligament, capsule, cartilage or bone. Initial examination of an injured player has to decide only three things. 1. Is there a possibility of a fracture? 2. Is there severe ligamentous injury? 3. Is there a torn cartilage?
These are the three serious problems which have to be considered at first.
It is important to have some idea of what happened to the athlete or player at the time of injury as well as any history of previous trouble with the knee joint before proceeding to an examination. The mechanism of injury is important in diagnosis and this is best recalled immediately. Did the patient have the weight on the leg? Was the leg bent or straight when injured? Was the patient turning and if so, in what direction? When laid on the ground could the patient bend and straighten the leg? If unable to straighten the leg, what position was the best he could manage? Was the patient aware of any snapping or tearing sensation? How soon after injury did any swelling occur? If there was contact with an opponent where was the patient struck and from which direction? In many cases it is a precise history of the mechanics of injury and of the symptoms upon which a diagnosis is made.
Examination should start with observation for the presence of any deformity or swelling. Obvious deformity, severe pain, tenderness over bone and loss of power raise the possibility of fracture and the patient should be moved as carefully as possible to hospital. Can the patient fully flex the knee and, more particularly, can he fully extend the joint? If there is any loss of movement this must be recorded. Carefully palpate the joint for swelling and localised tenderness. It is important to localise accurately any tenderness and in particular to say whether this tenderness was over bone or over the joint line.
Examine the knee for stability, testing in full extension when instability implies damage to the posterior cruciate, the posterior capsule and the medial ligament. Also check for stability in approximately 30° of flexion when the posterior capsule and the posterior cruciate ligament are relaxed; instability in this position implies a possible rupture of the medial or lateral ligament which will not show when the joint is in full extension if the posterior cruciate ligament is intact. Considerable swelling developing within 30 minutes of injury means there has been bleeding into the joint, I.e. haemarthrosis, and this implies serious injury. On some occasions, however, the absence of this sign may be misleading in that if the injury is sufficiently severe then the capsule itself will be torn and the blood will leak into the subcutaneous tissues, particularly at the back of the knee. Similarly, it is important to remember that a complete tear of the ligament may be less painful than a partial tear but this type of injury can almost always be differentiated from the minor injury by the fact that there has been significant violence, the patient is usually aware that something has torn or given way and, in the more serious injury, there is gross instability when the patient attempts to bear weight.
Effusion which is due to damage or irritation of the synovial lining of the capsule will show several hours later. This might be caused by a direct blow or in response to an internal injury of the knee.
When there is a possibility of serious injury to the knee joint then this must be adequately examined in proper surroundings and examination may include x-rays, arthrography (when dye is injected into the joint) or arthroscopy (when a small telescope is placed into the joint for direct vision). All methods of examination have advantages and disadvantages.
Routine x-rays do not show soft tissue such as the menisci so a radio-opaque dye may be injected into the joint in an attempt to show these tissues. However, there is a risk of infection; the x-rays may still not show the area of interest; and the interpretation of the films requires considerable skill. Arthroscopy allows a direct view of the majority, but not all, of the articular surfaces of the knee joint and the menisci but carries the risk of a general anaesthetic and of infection.
PRINCIPLES OF TREATMENT
The basic principles in the treatment of knee injuries are those applicable to other injuries. Initially, check for possible fracture or severe ligament injury both of which should be seen at hospital. Other injuries should be treated by ice followed by compression for 36 hours after which definitive treatment usually begins. Contrast bathing is most helpful in reducing swelling with more complicated forms of electrotherapy being only marginally better.
For the athlete it is essential that exercises be carried out from an early stage but these must be exactly performed and their severity frequently adjusted to the capability of the injured limb. Speed of rehabilitation is important in the athlete but the maximal rate of progress through an exercise routine is very close to that which will exacerbate the condition or cause another injury so great skill is required.
Initially, simply lifting the leg with the knee fully extended may be carried out and then with increasing weight strapped to the ankle or using a lead boot, progressing to at least 201b (9kg) in the adult. When flexion of the knee to 90° is pain-free, extension from this position may be started, using a De Lorme boot for increasing resistance. An adult must be able to fully extend 301b (13.5kg) ten times in 45 seconds before starting to run. This is necessary to provide joint stability. The adult should similarly lift 401b (18kg) before returning to sports other than rugby when the weight should be 451b (20kg). This may appear a lot but it is required to protect the joint against body contact forces.
It is important to ensure that there is muscular balance between the two legs, a difference of greater than five per cent statistically increases the chance of further injury. This balance should be between the strength of the two quadriceps muscle groups and also between the hamstrings and the quadriceps of the same limb when the hamstrings should have at least 60 per cent of the strength of the quadriceps (Klein and All-man, 1969).
In order to protect a joint it is essential to have strength applied very quickly to counteract potentially damaging forces so ‘power’ is required. Power or explosive strength may be improved by activities such as hopping which should only be attempted late in the rehabilitation phase. Hopping may be carried out for distance or height or up a slope, all methods being useful.
Fitness testing should be carried out before the player returns to competition and this must be related to the requirements of the athlete’s own sport. Can he sprint, check, twist, jump, stretch as required? If there is any discomfort it is better to have a further week of rehabilitation rather than have a possible recurrence or endure the remainder of the season performing below par with a minor chronic injury.
Contusions of the knee
Contusion of the knee is common in many sports but particularly football. There is a history of a direct blow and on examination there may be localised swelling, tenderness, possibly bruising and slight limitation of movement. Initial treatment is ice, that is to say, ice, compression and elevation. An ice pack is applied to the injured area and held in place for at least 30 minutes by an elasticated bandage, the leg being elevated. The player has a quick shower, not a leisurely bath, and a compression dressing is applied. This may consist of a layer of cotton wool over which is a crepe or elastic bandage and the compression should extend for a hand’s breadth above and below the joint. This should stay in place for 36 hours after which the patient should be encouraged to move the joint. The player usually returns to full activity within the week.
Ligamentous injury, usually known as a sprain, of the knee is less common than the similar injury to the ankle joint but is often more serious. The injury may range from the trivial to the most severe and could keep the athlete permanently from competition. The severe injuries typically occur when the whole bodyweight of the opponent is against the joint when the leg itself is carrying weight and therefore fixed to the ground, for example, in a rugby tackle.
Minor ligamentous injury with tenderness over the attachment of the ligament to bone, pain on stressing the ligament and without effusion, may be treated as a contusion but with a definite rehabilitation phase in which increasingly severe turning movements are incorporated.
Moderate sprains show considerable pain, swelling which is localised at first but may become generalised, tenderness, pain and some apprehension on movement, pain and possibly some laxity on stressing the ligament. In this injury a variable proportion of the ligament has been torn and the important aspect of treatment is to prevent the patient accidentally stressing the ligament, thereby converting a partial into a complete tear. The initial treatment with ice must be followed by a firm bandage which gives great support to the joint and prevents movement but allows the initial swelling to take place. A Robert Jones bandage, which consists of three alternating layers of cotton wool and domette bandage, is the most usual form of firm bandage. Three or four days later this should be removed for re-examination of the knee in case the initial examination, obscured by pain and muscle spasm, led to the wrong diagnosis. Depending upon the severity of the condition a decision is then made regarding further treatment. This will vary from some support with periodic exercise to immobilisation in a plaster cast.
Complete tear of the ligament constitutes a severe injury. The history is one ofsevere violence, the patient usually being aware of a tearing sensation and instability of the joint. Pain may be variable. Swelling within the joint or in the subcutaneous tissues rapidly appears. Laxity in full extension implies rupture of the posterior cruciate ligament. Laxity of more than 10° greater than in the uninjured knee, when the joint is examined in part flexion, implies damage to the medial or lateral ligament. Antero-posterior instability of the tibia in relation to the femur may be misleading; examination of this with the foot in a neutral position may be positive but in the minor injury this should be abolished when the foot is internally rotated. A posterior sag of the tibia in relation to the femur is always significant.
The presence of a ruptured knee ligament in an athlete requires surgical repair to all the torn structures. This should be carried out within ten days of injury and this is why moderate sprains should be re-assessed after three or four days in case the initial diagnosis is wrong. Care must also be taken in this type of injury to look for the presence of ‘O’Donoghue’s triad’ – tears of the medial ligament, the anterior cruciate ligament and the medial meniscus (O’Donoghue, 1970). This is also called the ‘unhappy triad’ because unhappily the full extent of the injury is often not appreciated.
Cartilage injuries ‘You have a torn cartilage’ are words of impending doom to the athlete which are not inevitable; troubles arise not from surgical technique but through inadequate rehabilitation. There is a covering of articular cartilage over the weight-bearing surfaces of the bones within the joint and there are also two C-shaped menisci – it is these latter structures which the athlete calls cartilages. They are avascular and may develop, within their substance, cysts or tears which do not heal. Once torn, there is the choice of leading an inactive life with possible occasional trouble or having the cartilage removed surgically. After removal, the space occupied by the meniscus is filled by a replacement but not of the same material or quality so the joint is marginally worse than previously. Therefore, the operation should not be undertaken lightly and also, it may be very difficult to decide whether the symptoms are truly from a torn meniscus or from which of the two menisci.
A meniscus usually tears when the knee joint is carrying bodyweight, the foot being fixed as may happen with a studded shoe and the body is rotated in relation to the foot. The patient usually complains of pain on one side of the joint and often of inability to fully extend the knee, so called ‘locking’. This occurs about 30° short of full extension and typically, full extension suddenly returns minutes or days later. Momentary difficulty in extension with the knee more fully flexed is not locking and not due to a torn cartilage. Generalised swelling of the joint may occur later that day or next morning. An athlete with this type of history requires a medical opinion and the initial treatment of simply ice.
Other knee injuries
Less common causes of knee pain include patellar tendinitis known as ‘jumper’s knee’ because it is often associated with sports such as basketball which demand take-off and landing on hard surfaces (Blazina et al, 1973). It is characterised by pain in front of the knee, below the patella and precipitated by forceful knee extension. There is localised tenderness in or around the patellar tendon, usually near its proximal attachment. The condition comes on gradually over several matches and may be very persistent. Treatment is, initially, rest – a dreadful word to the athlete! – for about two weeks. The condition is helped by ultrasound, anti-inflammatory drugs, injection of hydrocortisone and more rarely, operation.
A condition peculiar to the early teenage, enthusiastic athlete is Osgood Schlatter’s disease. This affects the tibial tuberosity- the prominence on the upper part of the anterior surface of the tibia into which is attached the patellar tendon. Comparative overstrain of the quadriceps muscle acting upon a delicate area of growing bone can produce a painful reaction. It usually involves boys aged 12 to 16 years; there is an aching pain over the tuberosity which is worse during or commonly after exercise, and there is local swelling and tenderness. The condition may be diagnosed clinically, although the x-ray has a characteristic appearance of fragmentation. Treatment is very definitely rest until the bone settles down. I merely prohibit organised physical activity for several months but some orthopaedic surgeons place the joint in a full leg plaster for six to eight weeks followed by a gradual return to full activity. Usually the condition settles satisfactorily but may recur during the growth phase of adolescence.
Injury to the knee joint is common and may be very difficult to manage. The most important single factor is to ensure that the athlete does not cause further damage by returning to sport without adequate, balanced strength. It is neglectful to allow an athlete to participate with a weak leg or swollen knee.
Blazina, M. E., Kerlin, R. K., Jobe, F. W., Carter,
V. S. and Carlson, G. J. (1973). Orthopaedic Clinics of North America, 4, 665-678. Klein, K. K. and Allman, F. L. (1969). The knee in sports. Pemberton Press, New York. O’Donoghue, D. H. (1970). Treatment of injuries to athletes. W. B. Saunders, Philadelphia.
The hip bone is formed by the fusion of the ischium, pubis and iliac bones which meet at the acetabulum. Anteriorly, the pubic bones articulate at the symphysis pubis. Posteriorly the iliac bones articulate with the lateral surface of the sacrum. The sacro-iliac joint is a synovial joint of the plane type and its strength depends on the posterior and anterior sacro-iliac ligaments.
The hip joint is a ball and socket type of joint. Its strength is dependent on the deep acetabulum and on muscle action rather than ligaments. The most important is the Y-shaped ligament of Bigalow which lies anteriorly and is the strongest ligament in the body .
The important anatomical landmarks are: 1. The head of the femur which can be felt in the ilium with the femoral artery lying in front of it just below the middle of Poupart’s ligament 2. The greater trochanter 3. The anterior superior iliac spine 4. The tuberosity of the ischium.
Nelaton’s line is drawn from the tuberosity of the ischium to the anterior superior iliac spine. The tip of the greater trochanter just touches this line in the normal limb. Bryant’s triangle is drawn by dropping a perpendicular from the anterior superior iliac spine onto the bed on which the patient rests. The distance from this line to the tip of the greater trochanter is compared with the other side.
An oblique plane passing through the promontory of the sacrum behind, and the arcuate line in front divides the pelvis into true and false parts. The false pelvis is an expanded part of the cavity lying above and in front, the true pelvis lying below and behind the pelvic inlet.
Flexion of the hip joint is limited by the abdominal wall when the knee is flexed. Tension in the hamstring limits flexion of the hip to about 90 to 100° when the knee is extended. Hyperextension of the hip is limited by the strong iliofemoral ligament of Bigalow. Abduction is limited by the pubofemoral ligament and by tension of the adductor muscles. Adduction is limited by contact with the other limb. Tension of the lateral rotator muscles and the ischiofemoral ligament limit medial rotation while lateral rotation is limited by the medial rotators and the iliofemoral ligament.
SOFT TISSUE INJURIES OF PELVIS AND HIP
Bruising in the gluteal region
Superficial bruising occurs with pain and tenderness at the site of the injury and the contusion can be seen.
This consists of ice packs in the initial stage followed by local massage and exercise to promote the absorption of the haematoma. Injection of local anaesthetic (1% plain) plus lignocaine may help the absorption.
Deep bruising may produce a large haematoma which can be seen and felt very quickly due to the looseness of the connective tissue of the buttock.
In minor cases ice, and contrast baths later, may be satisfactory. If the swelling is large it may have to be aspirated either with a needle or through a small incision under a local anaesthetic. This limits the pain and stiffness which often follows such an injury and enables active treatment and exercise to be carried out finally.
There may be a strain or tear of muscle origin from the iliac crest, the ischial tuberosity or the adductor region. A flake of bone may be avulsed from the muscle origin at the time of the injury which can be seen on x-ray examination. Examination of the site shows tenderness and swelling.
In the early stages cold and pressure should be applied to the painful area and later, as the swelling and tenderness subside, heat and graduated exercises. Ultrasound may help the painful area, and injections of hydrocortisone also help relieve pain.
These injuries tend to recur, but they can be prevented by careful ‘limbering up’ exercises before taking part in sporting activity. Some cases can become chronic with calcification in the muscle origin. Treatment with an injection of hydrocortisone and physiotherapy in the form of short wave diathermy and gende stretching exercises, may help the pain and stiffness.
Pain from injury to the hamstring origin at the ischial tuberosity may be similar to the sciatica from a disc lesion of the lower lumbar spine. Examination of the spine and a negative Lasegue’s test with no neurological signs will help in the diagnosis.
FRACTURES OF THE PELVIS
These may occur in rugby football, or from falls at speed from motor cars, cycles or horses.
Fractures of the false pelvis along the pelvic ring
These fractures may be due to a direct injury of the ilium or an indirect injury when the trunk muscles are avulsed from the iliac crest. In the same way the sar-torius may pull off the anterior superior iliac spine and the straight head of rectus may pull off the anterior inferior iliac spine. There may be an avulsion from the ischial tuberosity due to a pull of the hamstring muscles causing ischial apophysitis. This is possible, for example, in the lead leg of high jumpers using the straddle technique.
There is tenderness and swelling at the site of injury which is painful and swollen. Later, bruising will occur. An x-ray will confirm this fracture.
In the early stages cold and pressure with rest will limit the bruising and swelling. Later, heat with gentle exercises as soon as possible should be started. Operative treatment is rarely indicated. Ultrasound and an injection of hydrocortisone may be needed for any local painful area.
Fractures of the true pelvis
There are three main types: 1. Solitary fracture of a pelvic bone 2. Intra-articular fracture 3. Disruption of the pelvic ring.
Solitary fracture of a pelvic bone
This may affect the pubis, ischium, sacrum or coccyx. Symptoms include pain and tenderness at the site of injury; the patient can walk. The injury is characterised by tenderness at the fracture site with some swelling; the limbs are equal in length; shock is minimal. X-rays confirm the fracture.
Bed rest for a few days is advised until the pain has lessened. This is followed by heat and gentle exercises.
Here the posterior wall of the acetabulum may be fractured with a dislocation of the head of the femur as well. There may be a central dislocation of the head of the femur. The patient complains of pain about the hip joint. There may be some stiffness at the joint but no shortening of the leg. The sciatic nerve may be damaged in the posterior wall fractures of the acetabulum with weakness of dorsiflexion of the foot. X-rays confirm the fracture.
Reduction of the dislocation and internal fixation of the posterior fragment of the acetabulum may be necessary. Rest in bed until the fracture is healed will be required, followed by partial weight-bearing with crutches. Fractures of the side wall of the acetabulum require traction for about six weeks; no weight-bearing is allowed for three months and this is followed by gentle weight-bearing for a further three months. Aseptic necrosis of the head of the femur may occur in one year and osteoarthritis may develop in some cases after five years.
Disruption of the pelvic ring
In this type of fracture there may be damage to the urethra, the sciatic nerve or a major blood vessel in the pelvis. There are three types of fracture which have one thing in common, both sides of the pelvic ring being broken causing an unstable pelvis.
The crush injury: The patient complains of pain in the pelvis. He is shocked and cannot stand. There is pain over the front of the pelvis which is tender. The legs show no shortening and there is no excessive rotation in either leg. X-rays show a fracture of the pubic and ischial rami on both sides.
There may be damage to the urethra in this type of fracture and this is suspected if blood is seen at the external urinary meatus.
The urethral damage may have to be repaired. The fracture of the pelvis requires no special treatment except rest in bed till the patient can raise his legs from the bed. This takes about three weeks: he then can get up using sticks and will become more mobile as the pain becomes less.
Hinge separation of the symphysis: This is caused by a rolling type of injury, the force pushing the ilium on one side, downwards and outwards. One sacro-iliac joint is hinged open and the symphysis separates like an oyster. The patient complains of pain in the pelvis and cannot stand up on his feet. The gap can be felt in the symphysis and the leg on the damaged side lies in external rotation with no shortening. X-rays confirm the damaged pelvis.
Complications include severe intra-pelvic bleeding, but damage to the sciatic nerve or urethra is rare.
The disruption of the pelvis is controlled by a firm binder. The patient remains in bed for about six weeks after which walking exercises can begin.
The vertical fracture of the pelvis: This is caused by a fall from a height landing on one leg. This could happen, for example, in rock climbing or in some imperfectly executed gymnastic routines. The patient complains of pain in the pelvis and cannot stand on his feet. There is pain and tenderness on the symphysis and sacro-iliac joint on the same side. The leg on that side is shorter due to the pelvic bone being pushed up on that side. X-rays confirm the injury.
Complications include possible intra-pelvic bleeding and often damage to the sciatic plexus.
Strong skeletal traction on the leg reduces the upward displacement of the ilium, and traction on the leg is maintained for six weeks. Weight-bearing is not allowed for about three months.
FRACTURES OF THE NECK OF THE FEMUR
These are rare in young people, though the possibility must be borne in mind in hip injuries. This fracture can result from cycling falls at high speed. The possibility of a slipped upper femoral epiphysis must be remembered.
DISLOCATIONS OF THE HIP JOINT
This occurs when the leg is forced into abduction and external rotation. The main sign is that the leg Ues in external rotation, flexion and abduction. The head of the femur can be felt in the obturator foramen. X-rays confirm the diagnosis and whether a fracture is present as well.
Complications may include avascular necrosis of the head of the femur. There may be damage to the sciatic nerve and stiffness due to myositis ossificans.
Under a general anaesthetic the hip is manipulated into position. Sometimes the head of the femur may be button-holed in the capsule or caught in the tendon of the psoas muscle and an open operation is required to reduce the dislocation. The leg is then immobilised on traction for six to eight weeks.
This occurs when the femur is forced backwards with internal rotation and adduction. There may be a fracture of the posterior wall of the acetabulum as well. The leg Ues in adduction and internal rotation with flexion of the hip joint.
There is sometimes damage to the sciatic nerve, avascular necrosis of the head of the femur or myositis ossificans.
The hip joint is reduced under a general anaesthetic. If there is a fracture of the posterior wall of the acetabulum, the reduction may be unstable and the bony fragment may have to be replaced and fixed by means of a screw. Traction is applied as for an anterior dislocation.
This is a painful inflammation of the symphysis pubis due to chronic inflammation. It is more common in footballers but may occur in runners and walkers.
The patient complains of pain in the groin which may spread to the adductors, hip or external genitalia. The pain is relieved by rest and made worse by hip movements especially rotation and leg strains on the pelvis by contraction of the rectus abdominus. There may be a history of slight fever. An erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count may sometimes be raised though not always. X-rays may show a widening of the pubic symphysis with calcification in the later stages.
This is symptomatic and consists of limiting physical activity until the symptoms are better. Phenylbutazone (200mg) three times daily with meals may also help and short wave diathermy may relieve pain. When the pain has subsided, gradual resumption of physical exercises will be required or the pain will return.
Chronic rheumatic diseases such as ankylosing spondylitis and Reiters disease must be excluded. Chronic adductor strains may also cause symptoms which are somewhat similar.
SPRAIN OF THE HIP JOINT
This occurs after a twisting injury to the hip. The patient develops a painful limp soon after the injury and complains of pain over the front and inner side of the hip. The pain may be referred to the inner side of the knee and thigh. There is tenderness over the front of the hip joint which is held in flexion and abduction; movements are painful. An aspiration of the joint may be carried out to exclude infection. X-rays are taken to exclude a fracture or other disease such as infection or tuberculosis.
Rest from weight-bearing is essential in the early stages with the patient walking with crutches. A firm supporting spica bandage of crepe will help relieve the pain and non-weight-bearing exercises are begun as soon as possible. As the pain and muscle spasm subside, weight-bearing may then be resumed.
This bursa lies between the deep surface of the fascia lata and the superficial surface of the greater trochanter with the gluteal muscle insertion. It may be inflamed by a direct blow on the trochanter or by the fascia lata slipping over the trochanter in vigorous exercises.
The patient complains of pain over the greater trochanter which has a deep aching character. It is more common in women than men, and the condition is aggravated by a trick movement which can make the tensor fascia lata slip over the trochanter by flexing the hip at the same time as the gluteus maximus is contracting. There is tenderness over the greater trochanter and pain when the fascia lata moves over the trochanter in flexion and extension of the hip. X-rays exclude any underlying bone damage or disease.
Rest from training; short wave diathermy helps resolution of the early acute cases. Hydrocortisone may be given by injection into the bursa. In some cases surgical division of a tight band of fascia lata may be required.
AVULSION FRACTURES OF THE GREATER AND LESSER TROCHANTER Avulsion fractures of the tip of the greater trochanter are caused by a sudden contracture of the gluteus medius. The patient complains of sudden pain over the tip of the greater trochanter, and walks with a limp. Signs include tenderness over the tip of the greater trochanter. There is a loss of power of abduction of the hip which causes a positive Trendelenburg’s test, I.e. when weight is put on the injured leg in standing the opposite hip drops rather than rises. X-rays confirm the fracture.
Mild cases of strain may settle quite quickly but the unstable fractures require internal fixation by figure-of-eight wiring.
Avulsion fractures of the lesser trochanter are caused by a sudden contracture of the psoas muscle. The patient complains of sudden pain while running or kicking; the pain being felt in the adductor region of the thigh. Bruising follows quite soon after the injury. There is painful tenderness over the lesser trochanter region with pain on adducting the leg at the hip joint. X-rays confirm the injury.
As soon as the pain allows, non-weight-bearing with gentle exercises is the best treatment. As the pain diminishes more vigorous exercises are commenced. Surgery is not required.
SOFT TISSUE INJURIES OF THE THIGH
This occurs after a direct injury to the thigh and causes bleeding in and around the thigh muscles .
The patient stops playing and complains of severe pain which is caused by pressure in the muscle due to bleeding. The pain is at the site of the injury and the patient also complains of stiffness in the thigh with difficulty in walking. There may be a superficial abrasion of the overlying skin with swelling and tenderness over the injured muscle.
Immediate application of a cold compression bandage helps to limit the bleeding. In severe cases the patient is put to bed for a day or so, to limit bleeding. Large collections of blood may have to be drained surgically. In less severe cases limitation of activity is immediately enforced with no attempt to help the pain by gentle exercise. In this way the onset of myositis ossificans, I.e. calcification of the haematoma by osteoblasts spreading from the injured periosteum, is less likely. As the condition settles, gentle graduated exercise is begun; short wave diathermy will help to encourage absorption of the haematoma and relieve muscle spasm.
This commonly occurs in the rectus femoris muscle but may also be found in the adductor muscles or in the hamstrings. It is interesting to note that the muscles which develop these injuries, act on two joints, flexing one and extending the other. As the muscle is relaxing a sudden strain is put upon it causing the tear before the muscle has properly relaxed. The strain may be either an indirect injury or the result of a direct blow over the site of the injury when the muscle is contracting.
The patient complains of pain at the site of the injury which is severe at first and later becomes more dull in nature. There is tenderness at the site of the injury where a gap may be felt. Later, swelling occurs which may be quite marked and may cause bruising at a considerable distance from the injury. There is pain when the muscle is tensed which limits activity.
Cold pressure bandaging helps to limit the bleeding; gentle exercises as soon as possible after the injury are advised. Injections of hydrocortisone with local anaesthetic and hyaluronidase (Hyalase) will limit adhesion formation later. Muscle spasm is helped by short wave diathermy. Late cases of adhesion formation and stiffness may require gentle manipulation under a general anaesthetic to relieve the pain and stiffness of the injured hamstring. In some cases the damage to the fascia lata may cause a muscle hernia which, if it becomes a nuisance, may have to be repaired surgically. Hamstring injuries, where the tendon is pulled a little out of the muscle belly, require care in rehabilitation to prevent recurrence. A careful examination of the patient’s running technique is required.
This commonly affects the biceps femoris tendon at its insertion into the head of the fibula rather than the other hamstrings where the injury is where the tendon leaves the muscle belly. In injuries to the biceps tendon the usual symptom is a complaint of pain at the outer side of the knee, which is made worse by running, or felt on getting up from squatting. The medial hamstrings produce pain at the level of the junction of the middle and lower thirds of the thigh along the postero-medial border.
In injuries to the biceps tendon there is tenderness at the insertion of the biceps into the head of the fibula. Flexion of the knee allows the injured biceps tendon to be removed away from the lateral joint line, thus differentiating it from an injury to structures on the outer side of the knee. X-rays show no bone damage. In late cases there may be a little calcification over the head of the fibula where the biceps tendon is attached.
This is on similar lines to a tennis elbow with ultrasound treatment and hydrocortisone injections into the painful muscle .
FRACTURES OF THE SHAFT OF THE FEMUR These occur in the course of various sporting activities and treatment is on the accepted orthopaedic lines for such fractures. It is important to remember that these fractures can cause extensive bleeding which leads to shock. A litre or more of blood may be lost into the soft tissue. The bleeding and shock can be limited considerably by careful handling of the patient and early splinting of the fracture before transporting the patient to hospital.
Careful examination of the pelvis and hip joint will help to localise the site of the injury. Gentle movements which do not put tension on a damaged ligament do not cause pain. Stretching a damaged ligament does cause pain and the movement is restricted. Careful palpation of the site of injury will help in identifying the injury.
Pain due to bruising of the articular cartilage of the joint may not appear for a week or so after the injury due to vascularisation of the injured cartilage. As the vascularisation becomes less with healing, so the pain lessens and exercises can be encouraged. Gentle movements, as the pain becomes less, will help limit the formation of adhesions.
Adhesion formation causing stiffness is treated by manipulation under a general anaesthetic when the pain has resolved. Such a manipulation is carried out firmly and steadily, taking care to break adhesions in all directions. If the manipulation is carried out too early or inefficiently, irritation of the joint and its musculature and more adhesion formation will follow.
The use of the hand in sports is widespread. Whether in direct handling by the protected or unprotected hand its vulnerability to direct or indirect trauma can be estimated by the numbers of injuries which present at specialised sports or hand injuries clinics. Even in those sports in which the hand is protected by the use of gloves, as in cricket or boxing, there still remains a large number of injuries presenting at hospitals.
The hand may be used without protection for ball handling, catching, throwing or through its constant grasping and power function with various forms of bats, rackets and weights or even as an organ of communication in gesturing or signalling to other participants or spectators.
THE ANATOMY OF THE HAND
Connected to a large area of the sensori-motor cortex, the nerve supply to the hand comes mainly through the median, ulnar and radial nerves; the former two deliver both a sensory supply to the skin and a motor supply to the intrinsic muscles. The radial nerve limits itself to a sensory supply only. In addition, a rich complex supply is afforded by all three nerves to the sweat glands and blood vessels making the hand an important regulator of temperature of the body as a whole. On the front of the hand a marginal contribution to grip is made by the sweat gland secretion.
Basically, the bony skeleton of the hand consists of a platform made up of small carpal bones proximally and a radiating quadumvirate of metacarpal bones, the thumb metacarpal being placed laterally and almost in a plane at right angles to the other metacarpals. From the medial four metacarpals the three phalanges to each finger arise and from the thumb the shorter phalangeal chain of two phalanges. The fine movements of the digits are controlled by intrinsic muscles and the grosser movements by extrinsic tendons, I.e. the flexors on the front and the extensors behind.
The basic pattern of power, pinch and hook grips are applied to fingers and thumb. Additionally, the hand may be used in sports in the ‘paddling’ position or as a ‘platform’ with the wrist hyperextended in swimming and floor gymnastics respectively.
LIGAMENTOUS INJURIES OF THE FINGERS AND THUMB Anatomy
The metacarpo-phalangeal joints are of the condyloid variety, each having a palmar and two collateral ligaments . In the fingers, side-to-side movements of the thumb metacarpo-phalangeal joint are much more restricted. The palmar ligaments are of thick, dense fibrocartilage attached on either side to the collateral ligaments, loosely to the metacarpal and firmly to the phalangeal bases. In addition they blend on either side to the deep transverse ligaments of the palm and their sides give attachments to the fibrous flexor tendon sheaths.
Sprain of the collateral ligaments of the metacarpo-phalangeal joints Sprains of the collateral ligaments are common in the thumb, but less common in the finger metacarpal joints. The former lead to continued pain and swelling which constitutes a severe handicap to thumb usage in gripping and untoward sudden sideways strains. Patients should be warned of these continued effects. In the initial stages it is often better to protect the ligaments by a small splint made from three to four sheets of plaster of Paris moulded directly on to the thumb, maintained for two to three weeks; later, continued pain can be lessened by an injection of hydrocortisone around the joint. With metacarpophalangeal joint sprains, again they should be immobilised initially by a metal well-padded splint extending from the butt of the palm up to the distal joints of the finger for two to three weeks. These injuries seem not to have continued pain, as in the thumb collateral ligament joint sprains, and can be protected by immobilising with strapping to adjacent fingers.
Sprains of the proximal interphalangeal joint ligaments The collateral ligaments of the proximal finger joints appear especially vulnerable to sprains sustained mostly during body contact sports. The immediate swelling and pain may be more pronounced unilaterally and the finger joint should be tested for instability and x-rayed. During the painful initial stages it is wise to immobilise the joint for up to ten days, then mobilise the finger by gartering to the adjacent fingers. The patient should be warned of persistent swelling in the joint with some discomfort on movement .
Collateral ligament rupture at metacarpo-phalangeal level With greater violence the collateral ligaments are prone to complete division. They usually rupture at joint line level but may be avulsed with bone fragments at either end; instability ensues and it is detected clinically by stressing laterally the affected joints.
The small and ring fingers would appear to be the most common fingers to be affected. Treatment for certainty should be operative, as conservative treatment cannot guarantee as good a result. In the author’s experience the resultant disability of instability where treatment was expectant weighs heavily towards operative treatment. Repair of the ligaments should be afforded by interrupted white silk and the fingers maintained at 60° flexion for three weeks. In the thumb, similar operative treatment is necessary where the most common injury is to the collateral ligament on the ulnar side. Non-operative treatment often leads to instability, an extremely disabling condition.
In those undetected ruptures and in long-term disability an attempt should be made to construct new collateral ligaments by free fascia lata grafts, although no absolute guarantee can be given to completely cure the instability. The only absolute cure, but which is difficult to obtain, is by metacarpo-phalangeal fusion in a position of function; thumb mobility being ensured by the basal carpo-metacarpal and terminal inter-phalangeal joints.
Operative repair is needed for fresh injuries. It is necessary to maintain the finger in the mid-range position postoperatively at about 45° of flexion for three weeks, with some ‘lively’ splintage following for a further three to four weeks. Long-term results have shown the success of this aggressive treatment with only a minimal loss of flexibility in a few instances.
CLOSEDTENDON INJURIES IN THE HAND
Direct finger-tip injury from ball-game pursuits often results in ‘attritional’ lengthening of the extensor tendon insertion; the flexion deformity resulting at the terminal interphalangeal joint is known colloquially as a ‘mallet’ finger . The deformity is corrected by application of one of the plastic splints of which many are on the market and maintained for five weeks. If the deformity is of the magnitude of 90°, it is considered better to operate and overcome the tendon lengthening by ‘darning’ the tendon over the joint with white silk, afterwards maintaining the joint in extension for three weeks. Slight loss of flexion range may result in the long term.
Occasionally indirect trauma to the extensor tendon ‘middle slip’ insertion over the proximal phalanx occurs again with attritional lengthening of the insertion. The resultant deformity is the ‘boutonniere’ finger where the terminal interphalangeal joint remains in extension and the proximal interphalangeal joint adopts an attitude of flexion . The lateral slips of the extensor mechanism move away from their anatomical axis and cause the deformity. Fresh injuries are treatable by splintage in an attempt to reverse the deformity. The splint should be close fitting and maintain the proximal joint in extension and the terminal joint in flexion. Late deformities should undergo operative treatment whereby the extensor is restored as best as possible to its anatomical position.
FINGER AND THUMB DISLOCATIONS
Most finger joint dislocations occur at the proximal interphalangeal joints with body contact sports. The middle phalanx is displaced backwards and results in the clinical ‘step-off which is so easily recognised: on the spot diagnosis is easy and often the joint is restored by a single sharp traction on the finger. As the joint capsule is not breached this manoeuvre is, in the majority of cases, successful. Simple gartering to adjacent fingers is all that is necessary but it is imperative to check reduction by x-ray. In the thumb, the common displacement is at the terminal joint and re-position is done in the same way. Occasionally both interphalangeal joints can be concomitantly displaced in a ‘stairway’ fashion.
The rare metacarpo-phalangeal dislocation where the proximal phalanx is displaced backwards on the metacarpal head demands care, as the volar capsule often ‘buttonholes’ and renders closed manipulation impossible. It is in such cases that open reduction and re-position is necessary because of the trapping effect on the metacarpal head.
PERI-ARTICULAR AND FRACTURES
Intra-articular fractures without significant joint surface deformation These fractures are treated by gartering the injured digit to the neighbouring digit from which it tends to deviate. Finger movements are encouraged immediately.
Fractures without significant displacement usually only involve one condyle of the proximal phalanx and are treated by gartering. Fractures with displacement are usually unstable, rotation resulting in effacement. Treatment is operative with Kirschner wire fixation. Even after restoration, occasionally the fragment may die but its buttressing effect can have a fair outcome.
This injury commonly occurs in body contact sports and from falls. The outcome is an intra-articular fracture through the base of the thumb metacarpal with a variably sized triangular fragment of bone remaining articulated while the main shaft carrying the larger articular surface is displaced. The resultant pain and swelling at the thumb base is easily detected and the fracture confirmed by x-ray.
Treatment is by operative reduction of the fracture and screw fixation through the fragment which allows anatomical re-position of the metacarpo-carpal relationship. The consequent stability ensures restoration of movement and delays possible later degenerative osteoarthritis.
Chip or flake fractures around joints
Without displacement, chip or flake fractures are commonly seen at the bases of the middle phalanges. If the joint is stable then simple splintage is all that is necessary for three weeks.
Where the fracture occurs with displacement and the joint is unstable then open fixation should be done. However, late diagnosis often leads to a fair result.
Fractures of the head or necks of metacarpals
These fractures are common sporting injuries particularly in boxing. Those through the metacarpal head can be left alone and healed by elevation and early movement. With fractures through the metacarpal neck significant displacement can occur. The head moves into the palm of the hand and the fracture angulates backwards. Moderate angulation can be left alone but significant displacement should be reduced by manipulation: if this is unsuccessful then open operation should be performed.
It is important to realise that hand injuries in sports require adequate first and second treatment. First aid requires the services of an adequately trained first aider, physiotherapist or doctor on site at the time of the injury. Simple immobilisation and, above all, elevation of the hand is all that is necessary. Second aid, which should always follow, should be afforded at a special hand clinic at hospital run by a specialist in hand surgery. Too often hospital care is left to a junior doctor without supervision and poor results follow. Within the same confines physiotherapists and occupational therapists should work within the hand service team, for it is only by team work that the very best results are achieved.
The wrist joint is commonly injured in those sporting activities where falls are numerous on to hard surfaces as in rugby, football, ice-skating and so on. However, repetitive injuries to surrounding tendonous structures may be sustained by high levels of repetitive activity in tennis or badminton: usually the precipitating stresses are chronic and are exacerbated by the relative avascu-larity of the tendon structure which has a low metabolic rate.
The radio-carpal or wrist joint is a condyloid or bi-axial joint. The parts forming it are the distal end of the radius and lower surface of the articular disc which stretches from the ulnar margin of the radius to the notch at the base of the styloid process of the ulna above, and the lunate, scaphoid and triquetral bones below. The former constitute a transverse elliptical concave surface, the ‘receiving cavity’ and the latter form a smooth convex surface received into that cavity.
The line of the joint corresponds to a line convex upwards joining the styloid process of the radius and ulna .
The joint is surrounded by an articular capsule strengthened by anterior and posterior ligaments together with medial and lateral ligaments. The ‘articular disc’ is triangular in shape and binds the lower ends of the radius and ulna together. It is attached, by its apex, to a depression between the ulnar styloid and the inferior surface of the head of the ulna and, by its base, to the proximal edge between the ulnar notch of the radius and its carpal surface . When the hand is adducted, it articulates with the triquetral bone and when the hand is neutral, with the lunate. As hand movements on the forearm are not solely confined to the radio-carpal joint it is necessary to consider the mid-carpal joint in the context of wrist injuries. This consists of the joints between the proximal and distal row of carpal bones and between the carpal bones themselves in the proximal row.
The joints of the proximal row of carpal bones
The joints between the scaphoid, lunate and triquetral bones are of the plane variety and are connected by dorsal, palmar and interosseous ligaments. The dorsal and palmar ligaments are weaker than the dorsal (Chaubal, 1959). The interosseous ligaments are two narrow bundles, one connecting the lunate and scaphoid bones, the other the lunate and triquetral bones.
The joints of the two rows of carpal bones with each other The joint between the .scaphoid, lunate and triquetral bones on the one hand and the second row of carpal bones on the other is named the mid-carpal joint and is made up of two portions: on the medial side is the head of the capitate bone and the hamate bone which articulate with the concavity formed by the scaphoid, lunate and triquetral bones and constitute a modified condyloid joint; on the lateral side the trapezium and trapezoid articulate with the scaphoid and constitute a plane joint. The ligaments are the dorsal, palmar, medial and lateral. The lateral and medial ligaments are short: the one is placed on the radial and the other on the ulnar side of the carpus. The former, the stronger and more distinct, connects the scaphoid and trapezium, the latter the triquetral and hamate.
About 60 to 65 per cent takes place at the mid-carpal joint. The entire proximal surface of the scaphoid is in contact with the radius, the styloid process of which touches the trapezium. The lunate moves under the triangular cartilage.
About 50 per cent of ulnar deviation takes place at the mid-carpal joint. The line of transmission of forces passes through the capitate and the proximal half of the scaphoid and the radial styloid.
The tendons around the wrist
At the level of the lower radius and ulna a transverse section shows the tendons in distinct groupings, flexor tendons anteriorly, extensors dorsally and thumb tendons on the outer side of the radius . Two
Movements of hand and forearm
These movements involve both radio-carpal and mid-carpal joints. They are flexion, extension, radial deviation and ulnar deviation.
About 65 to 75 per cent of flexion occurs at the radiocarpal (wrist) articulation, the rest at the mid-carpal joint. The lunate is almost horizontal, so that most of its proximal articular surface is dorsal instead of being in contact with the articular surface of the radius.
Most movement takes place at the mid-carpal joint. In extension and hyperextension, the lunate turns its distal articular surface dorsally; the capitate turns and becomes vertical with its base orientated dorsally and its neck abuts against the posterior lip of the radius. The proximal end of the scaphoid follows the lunate and the distal part of the scaphoid follows the capitate only partially. A large part of the proximal articular surface of the lunate remains unsupported anteriorly by any bony socket. synovial sheaths envelop the flexors, one for the superficial and deep flexors of the fingers, the other for the flexor pollicis longus. On the back of the wrist, beneath the fibrous extensor retinaculum, lie the six tunnels for the passage of the extensor tendons. One tunnel on the lateral side is for the abductor pollicis longus and extensor brevis; next, behind the styloid process are the tendons of the extensor brevis and the longus of the wrist, on the medial side of the dorsal tubercle of the radius the extensor longus of the thumb, then the extensor digitorum and extensor indices. Between the radius and the ulna is the extensor digiti minimis and lastly, between the head styloid process of the ulna is the extensor carpi ulnaris.
INJURIES TO THE SOFT TISSUES
Sprains of the wrist
It is true that falls on the hand may sometimes cause a synovitis of the synovial membrane (lining the joint) and an effusion into the joint ensues concomitant to sprains of the volar wrist ligament. These injuries are far rarer than bone injuries but nevertheless one does see them without bone damage. The injury may be treated by a simple elastic bandage for ten to fourteen days.
In such sports as tennis, squash, badminton and rowing which require repetitious movement of the wrist tendons and owing to their relative avascularity, the wrist tendons become the site of swelling (tendinitis) or the investing synovium and fibrous sheaths become irritated (peritendinitis). The commonest site is certainly in the thumb extensor pollicis brevis and abductor pollicis longus on the radial side of the wrist. There is aching pain with slight swelling over the lower quarter of the radius and thumb movements are accompanied by ‘wash-leather creaking’. Temporary rest from sport is necessary. It is usually wise to apply a dorsal plaster of Paris slab to include the thumb, wrist and forearm or a local injection of anaesthetic and hyaluronidase prior to this helps relieve symptoms. Similar attacks in the flexor carpi radialis and extensor carpi ulnaris are occasionally seen with acute local tenderness or swelling over the area just prior to the insertions into bone: they are treated in a similar fashion to the thumb tendons.
Pain over the radial side of the wrist associated with thickening of the fibrous sheath (De Quervain’s disease, 1895) is a well-known entity. Careful palpation may reveal a small hard fibrous nodule about the size of half a pea. Pain is produced by adducting the thumb across the palm of the hand. Provided the condition is not chronic, hydrocortisone injections may give relief; however, if it is chrome, then division with removal of a segment cures the condition. Care has to be taken not to injure the filaments of the radial nerve which pass over this area as a divided nerve may leave a painful neuroma, which in itself is vulnerable to repeated trauma.
Acute peritendinitis crepitans
This is an inflammatory condition of acute onset which appears to involve a large area of tendon sheaths; it is commonly seen in athletes in the extensor longus tendon and its muscle. The swelling extends usually from the wrist across the lower forearm, and on thumb movements creaking is felt underneath the examining fingers. A similar condition is mainly seen in the extensor tendons crossing the dorsum of the wrist beneath the extensor retinaculum. The condition is best treated by splintage, resting the part for at least two weeks.
Injuries to the triangular cartilage of the wrist
This rare injury usually occurs on falls on the outstretched hand with an added rotational element. It involves detachment of the apex of the triangular cartilage from the ligamentous attachment to the fossa on the lower ulnar head . On rotation of the forearm, it gives rise to a disturbing ‘click’ which may be painful. If acute and diagnosed early, it is best treated by repair of the ligamentous attachment. If chronic, it is usually treated by excision of the whole cartilaginous structure.
FRACTURES AND DISLOCATIONS AROUND THE WRIST The scaphoid fractures
The scaphoid may be fractured at any of three levels -the distal pole, the waist or the proximal pole. The most common level is the ‘waist’ fracture, the others being comparatively rare. The blood supply variations of the scaphoid may account for the occasional ‘death’ of the proximal segment. One of the most common fractures seen in sports is the ‘waist’ fracture of the scaphoid , caused by falls on the outstretched hand or ‘hand-off injury in rugby. There is swelling of the wrist in the region of the ‘anatomical snuff-box’, with tenderness in the same area; there may initially be a negative x-ray but this should not put one off doing a further x-ray examination between the tenth and fourteenth day, when the fracture line may become evident.
The fracture should be immobilised by plaster which includes the thumb up to the distal joint and the forearm up to below the flexor elbow crease. The position of immobilisation should be in the ball-holding position of the hand with the wrist in dorsiflexion . This fixation should be maintained for six to twelve weeks. If, at the end of this period, healing is not evident on x-ray then the freedom of the hand should be allowed; however, if pain is encountered on activity then internal fixation by screws should be done (Maudsley and Chen, 1972). London (1961) has shown that the majority of fractures given this freedom will unite but the percentage of non-union in the experience of this author has been up to 25 per cent and screw fixation has been so successful that he has adopted this procedure.
Established non-union of the scaphoid
The inevitable result of non-union of the scaphoid is the establishment of degenerative arthritis of the mid-carpal and radio-carpal joints. Although this may be painless it always results in limitation of wrist movement, and in the athlete where wrist trauma is apt to occur injury causes further pain. In these instances the scaphoid should be curetted, packed with bone and internally fixed by screwing, with, perhaps, excision of the radial styloid.
Established painful arthritis
Painful arthritis is probably best treated by excision of the proximal carpus or wrist arthrodesis.
Rupture of the inter-osseous ligaments between scaphoid and lunate This results often and is not recognised; a gap occurs between the scaphoid and the lunate which can be painful. It is diagnosed by x-ray and the gap noted. The injury is best treated by operative re-position and internal fixation.
Dislocation of the lunate
The lunate is a wedge-shaped bone with its broad base forward. A fall on the outstretched wrist may displace it forward by rupture of its dorsal attachment to the capitate . The anterior proximity of the median nerve within the confines of the carpal tunnel often causes numbness or tingling in the thumb and radial three ringers. The diagnosis is confirmed by x-ray examination and in new cases re-position may be afforded by traction and a direct push from in front of the wrist. Old unreduced cases are best treated by operative removal of the lunate as are cases where the lunate dies from loss of blood supply even though successfully reduced.
Injury to the lower radius
Fractures of the lower radius are classified as forearm fractures but it is best to include them in wrist injuries. The usual cause in sports is a fall on the outstretched hand. In the young athlete before growth is complete the injury results in a backward displacement of the lower radial epiphysis . If displaced greater than one third of the way across the radius it is best treated by manipulation and fixation on a dorsal plaster slab.
In the adult, sporting injury may result in a vertical splitting of the lower radius with widening of the breadth of the articular surface of the radius in both planes . Although this often results in broadening of the radial articular surface the late results are good, often with, perhaps, some loss of dorsiflexion movement.
Falls on the wrist with the hand in palmar flexion may result in a fracture of the lower radius with varying degrees of obliquity of the fracture line .
This is known as a Smith fracture. If the fracture extends into the articular surface and displaces, the eponymous name of Barton is applied to it! The usual treatment is by manipulation and immobilisation of the forearm in full supination with plaster including the elbow and wrist.
FIRST AID TREATMENT
It is important in all spheres of sports that facilities be made available for adequate initial care to be afforded to all participants, and to spectators. This means that splints, slings and bandages should be available for mild or severe injuries around the wrist and personnel able to apply them adequately. Comfort by pain relief and elevation to reduce swelling often means that later treatment can be made much more easy.
Chaubal, K. V. (1959). Dislocations of lunate. Dissertation for Mch(Orth) thesis, Liverpool University.
De Quervain, F. (1895). Uber eine form von chronischer tendovaginitis. Korrespondenz-Blatt fur Sweitzer Arzte, 25, 389.
London, P. S. (1961). The broken scaphoid – the case against pessimism .Journal of Bone and Joint Surgery, 43-B, 237-244.
Maudsley R. H. and Chen, S. C. (1972). Screw fixation in the management of the fractured carpal scaphoid. Journal of Bone and Joint Surgery, 54-B, 432-441.