Dealing with Training Injuries

We are going to be training hard and so it is very important that we learn to distinguish between the sort of injuries that will heal themselves with rest and those that require medical supervision.

The Army training programme will often take us to the limits of our endurance and so it is also important that we learn to recognise and deal with acute medical problems such as hypothermia, hyperthermia and exhaustion. Of course, the risk of incurring any of these problems can be minimised. We should always warm up and warm down before and after exercise. We should push ourselves towards our physical and mental limits only by gradually building on the exercises.

Accidents and injuries often occur when we ignore the ‘danger signals’ of extreme fatigue. Every fit man and woman can successfully complete the exercises here but you must move at your own pace. Set your own personal standards for runs, exercises, weights and endurance work.

Feet and Legs

We are going to be putting a lot of stress on our feet and legs during this training programme so, in our short tour of common injuries, the lower limbs are a good place to start. First, let us start with the advice that sports doctors give to teams of professional runners:

Most foot injuries can be avoided by extensive warming-up exercises and purchasing good running shoes. Good sports shops measure the width and length of their client’s feet to ensure that they purchase close-fitting running shoes. The sole of the shoe should be flexible and the heel cushioned.

Running shoes should fit snugly and the heel design should prevent the ankle from moving from side to side.

There should be about 1 cm Qain) clearance between the big toe and the front of the shoe with no rough edges inside.

Twisted Ankle: This is the most common type of injury in both sports and everyday life. It has been estimated that every day some 5,000 people go to their local doctor or casualty department with ‘twisted ankle’. What has happened is that a sharp, sideways twist of the ankle has stretched, or torn, one or more of the small ligaments which connect the bones of the lower leg to the bones of the upper foot. The ankle is often very swollen and tender and there may be bruising around the site of the injury. Your doctor will need to examine the ankle to determine the severity of the injury and may ask for X-rays and special investigations of the joints and tendons to exclude fractures and more serious complications. In most instances, the injuries soon heal and treatment is directed at relieving the pain and swelling. Anti-inflammatory drugs alone may have the younger person back on their feet in only a couple of days.

In contrast, badly torn ligaments or joint injury may require a lower leg plaster cast and rehabilitation exercises. In these cases, further training involving the legs and feet will have to be suspended for up to 10 weeks or possibly longer.

Policeman’s Heel: This is a common complaint of runners, especially longdistance runners. It is more common in older people. The major symptom of policeman’s heel is a sharp, crippling pain under the heel, which is worse after getting out of bed and placing weight on the foot. Rest can appear to heal the injury but the pain will often return after a long run. What has happened is that the plantar muscles and ligaments, which run underneath the foot from the heel-bone to the toes, have become strained, often because tight calf muscles in the lower leg prevent the ankle from flexing fully.

See your doctor. He or she may recommend physiotherapy or twice-daily exercises to stretch the gastrocnemius muscle and the Achilles tendon. In the interim, much of the pain can be relieved by a course of anti-inflammatory drugs and a Sorborthane heel pad to cushion the heel. In many cases, this complaint can be avoided by ensuring that the leg muscles are fully exercised and stretched during the warm-up period.

If the symptoms persist, injections of steroids or a local anaesthetic underneath the heel usually cure this condition.

Stress Fractures: These occur most frequently in the calcaneus or heel bone. The ankle may be swollen and there is quite severe pain on walking. Although easily detected by X-ray, medical advice as to the treatment often varies. Some doctors recommend iced water to reduce the swelling, followed by exercises to flex the ankle. Later, when the swelling is reduced, the patient is advised to walk as long and as far as the pain permits.

Small stress fractures result from the pounding we give our feet when running on hard surfaces. Consequently, we can reduce the risk of this quite serious injury by choosing well-fitting running shoes with heavily cushioned soles and by avoiding running on roads and other hard surfaces.

The most extreme form of this injury is seen in parachutists who have suffered a bad landing, but it can also result from jumping on to a hard surface and landing on the heel. In these cases, the heel bone can be completely broken, resulting in three to six months recuperation. It can be avoided by heeding the advice given to all parachutists:

Before you jump prepare to land with knees and feet together. Your knees should be bent such that you can just see your toes. Your feet should be horizontal in order to absorb the initial shock of landing across the whole underside of the feet. & As you hit the ground, much of the shock of landing will be further absorbed by your bent legs. The shock is further dissipated by the parachute roll: keeping your knees together and your elbows tucked in close to the body, flex the knees to the side. As you hit the ground, roll, absorbing the now greatly reduced landing shock across your back.

Inflammation of the Joints and Tendons of the Mid Foot: These complaints result from the tendons, ligaments and joints in the feet undergoing a lot of additional strain during intensive training.

Pain is usually experienced only during running or when the affected part is stretched or flexed. Minor injuries are treated with anti-inflammatory drugs. In more severe injuries, the foot is strapped to prevent movement of the inflamed tissue or joint. Most of these injuries will heal quickly. Runner’s Toe: The appearance of ‘blood blisters’ under the toenails of long distance runners is very common. Unfortunately, this bleeding into the soft tissue underneath the nail often produces a painful swelling. The treatment requires more than a little courage and perhaps should be left to the doctor. The immediate treatment involves puncturing the nail above the blood-blister with a sterile needle. In the long term, the complaint can be prevented by buying more appropriate footwear.

Blisters: Doctors correctly associate blisters with new or badly-fitting shoes. However, blisters are also an inevitable consequence of long-distance walking and running. The immediate treatment simply involves bursting the blister with a sterile needle and covering the affected area with a dry dressing, firmly secured with adhesive plaster. Blisters result from the foot being rubbed by the inside of the shoe or boot. In the short term, the way to prevent this is to grease your feet with baby oil or petroleum jelly and to wear two pairs of socks – all of which helps the feet to move within the shoes with the minimum of friction.

In the long term, the friction which results from continuous exercise will induce a hard, leathery layer of skin on the sides and underside of the feet. There is no way to accelerate this process. Bathing the feet in chemicals such as methylated spirits does produce a thin, horny layer of skin but it is quickly sloughed off.

Inflammation of the Achilles Tendon: This is a common complaint in those playing football, volley ball or tennis and in sprinters, middle and longdistance runners and even ballet dancers. Usually, only the sheath surrounding the Achilles tendon is affected, but in more severe cases the tendon itself becomes inflamed. This is a very painful condition. The affected individual becomes aware of mild pain in the back of the leg during exercise and this may disappear only to become much more severe after training. In the morning, the affected individual experiences stiffness and pain which gradually disappears during the day.

Achilles tendonitis is the crippling complaint suffered by soldiers wearing high combat boots. Shoes which hold the feet in such a way as to shorten the Achilles tendon can also cause this condition. It has also been associated with intensive running up hills, rigid training shoes and training on hard surfaces. People with abnormally tight hamstrings or gastrocnemius muscles are also predisposed to inflammation of the Achilles tendon. The simple treatment of this condition consists of oral anti-inflammatory medication and ice-baths.

Medical investigations will generally try to identify the cause by examining the leg muscles and by looking at the patient’s gait – an abnormal gait is often apparent from the unusual pattern of wear on the patient’s training shoes. Some unfortunate patients will need surgery. The patient’s normal training programme is suspended throughout the course of the investigations and treatment in favour of regular sessions of cycling and swimming.

Only about half of the patients with this condition will be able to return to full training; the rest are able to train less intensively and may be troubled by occasional recurrences of pain. A very few will be unable to resume physical training or sports.

Rupture of the Achilles Tendon: This condition rarely occurs in healthy tendons. In some people, the part of the tendon closest to the heel is not well supplied with blood vessels and it begins to degenerate. The weakened tissue then breaks as a result of undue strain on the tendon or a sudden contraction of the calf muscles.

Perhaps not surprisingly, this injury tends to be associated with sports such as badminton, squash and the martial arts. As the tendon severs, the individual often hears a cracking sound or claims that he was hit or kicked behind the heel. There is often very little pain and no difficulty in walking and the person concerned believes that they have only experienced some minor injury. It is only two hours later, as swelling and bruising develops on the leg immediately above the heel, that the person becomes aware of the injury. If the patient intends returning to full activity, this condition must be treated as a medical emergency. The sooner it is diagnosed, the easier it is to treat. It may be possible to treat those cases identified within the first 48 hours by plaster cast immobilisation (eight weeks). Other patients face surgical repair and plaster cast immobilisation for six weeks.

Shoulders and Upper Limbs

Dislocated Shoulder: Displacement of the upper bone of the arm (the humerus) from the shoulder joint often results from a fall on an outstretched hand. This is an anterior dislocation. The other type of dislocation, posterior dislocation, is rarely seen as a sporting injury, although it can result from a fall onto the elbow.

A dislocated shoulder is easy to diagnose. The patient finds that the least painful position involves supporting the affected arm across his or her chest. The normal curvature of the shoulder is lost and there may be a very obvious hollow underneath the deltoid muscle. Under general anaesthetic, the humerus can be pulled and rotated back into position. The arm is then supported by a sling, which prevents rotation or abduction of the shoulder joint, for two to three weeks. At three weeks, the patient is encouraged to undertake increasingly demanding exercises to increase joint mobility, but a return to full training may be delayed for another two to three months.

Tendonitis of the Shoulder: This can start as an extreme and sudden pain in the shoulder which may become worse on movement. The condition results from inflammation of the tendons within the shoulder, usually from the movements involved during intensive training. If left untreated, the inflammation may result in deposition of calcium and some restriction of movement. This condition responds well to injections of anti-inflammatory drugs, such as corticosteroids, and local anaesthetic to ease the worst of the pain. The healing process may also be helped by immobilising the patient’s arm in a sling. During the period of rehabilitation, isometric exercises and free isotonic exercises with weights are recommended. These exercises strengthen the affected muscles and tendons.

Frozen Shoulder: This is a very poorly understood condition. It results in quite severe pain which is often worse at night. Remedial exercises and steroid injections play a role in treatment but the most important factor is time because, although the symptoms may persist for a year or more, the condition is self-limiting and the shoulder will eventually return to normal. Tricipital Tendonitis: This causes quite severe pain when the elbow is flexed or rotated. Once again, the condition can result from over-use of the tendons and muscles associated with the elbow. Patients will be advised to rest, while anti-inflammatory drugs and light exercises will restore the elbow to its normal state.

Tennis Elbow: This very common complaint is characterised by soreness over the inner bony protuberance of the elbow (lateral epicondyle of the humerus). This is the point of insertion of the ulnar extensor muscle of the wrist which is very important in wrist extension. Continual flexing of the wrist, as occurs in racquet games, may result in inflammation of the muscle and tendon where it attaches to the humerus. The condition responds well to rest, steroid injections and local anaesthetic injections to ease the soreness in the elbow.

Golfer’s Elbow: This results from stress placed on ligaments in the area of the outer bony protuberance of the elbow or the medial epicondyle. The strain occurs during wrist-flexing in golf and weight-lifting (particularly snatch lifts). The tenderness, which is localised in the area of the medial epicondyle, quickly responds to rest and anti-inflammatory drugs. In severe cases, injections of local anaesthetic are used to control the pain. Frictional Tenosynovitis of the Wrist and Hand: This also results from unusual stress being placed on the wrist during sports or exercises. The pain is localised at the back of the wrist and thumb, and results from inflammation of the sheaths of the extensor tendons of the wrist.

The affected hand is usually splinted for seven to ten days, to minimise movement of the tendons within the inflamed sheath. Splinting combined with a short course of anti-inflammatory drugs usually results in a cure.

Medical Emergencies

In most sports and activities, the risk of serious injury and unconsciousness is confined to rare and unusual accidents. However, in the martial arts and in ‘risk activities’ such as parachuting, rock climbing, hill-walking and canoeing, to mention just a few, the risk is more immediate. Once a serious accident has occurred, the immediate care which can be provided by anyone with a little knowledge may make a huge difference to the outcome. That care is covered by the simple mnemonic, ABC. But first, the rescuer should perform several other vital tasks:

Check that the path to the casualty is safe. If it is not, take the necessary steps to ensure that you can reach the casualty safely. Make sure that someone else contacts the emergency services. You can only provide immediate aid. Ask a third person to make short, simple notes on when and how the accident happened. These notes will be invaluable for the medical staff at the hospital, who will otherwise have to use their imaginations. Move to the casualty and ascertain his or her level of consciousness.

Is he/she alert and obviously breathing?

Does he/she respond to your voice?

Does he/she respond to pain?

Is the casualty totally unresponsive?

A is for Airway: If the casualty is unresponsive or only partly responsive, check that their airway is clear. Open the casualty’s mouth and use two fingers to check for obstructions such as blood, vomit and broken teeth in the mouth and throat. Clear these obstructions.

B is for Breathing: Place your face close to the casualty’s body and see if his or her chest is rising and falling. Put your hand close to the casualty’s mouth and nose and feel for the exhalation of air. Listen for sounds of breathing or obstruction.

C is for Circulation: Check the carotid pulse on the side of the casualty’s neck to ensure that his/her heart is still beating. If the casualty is not breathing, or if his/her heart has stopped beating, Cardiac-Pulmonary Resuscitation (CPR) must be started immediately. This is not the place to teach CPR, which is a very practical skill complicated by special considerations in, say, cases of drowning or possible spinal injury. CPR should be taught by your local St John’s Ambulance instructor or by first-aid instructors in your sports club or gym. As part of the instruction, you will be taught how to stabilise the casualty and place them in a recovery position.

Hypothermia

This life-threatening condition is usually associated in people’s minds with severe winter conditions on the mountains. In fact, there are different types of hypothermia and it is possible to become hypothermic on a reasonably hot day. In hypothermia, the body’s core temperature, the temperature deep within the body, undergoes a dangerous decline. All of the bodily functions associated with life are dependent on a stable core temperature of around 37°C (98.6°F). Hypothermia is classified into three main types: Rapid or ‘Immersion’ Hypothermia: The affected individual’s core body temperature is reduced by severe cold stress, as happens when a person falls into very cold water. Because it is the environment which is reducing the core temperature, these casualties can still produce body heat and usually respond well to treatment. Exhaustion’ Hypothermia: This is seen in marathon runners and may have been responsible for at least one death on Military Selection. The person runs out of energy and is unable to maintain his or her body core temperature, even though the ambient temperature may not be cold. These casualties are more difficult to treat. An effort must be made to prevent their core temperature falling any further by blocking every possible type of heat loss, because they are no longer producing their own heat. Exhaustion hypothermia may be complicated by blood and body fluids being shunted into the tissues, thus decreasing blood pressure and blood circulation.

Slow Hypothermia: This often occurs in elderly people after an accident. Losing mobility, their energy levels and consequently their body’s core temperature may decline over weeks as they drift into hypothermia. The signs and symptoms are variable and depend on the severity of the condition.

The treatment of hypothermia can be complicated and is best taught by a qualified first-aider or doctor, not least because the patient can collapse during re-warming. The complications associated with hypothermia, both before and after re-warming, are many and various. The majority are life-threatening. Here I will just outline some general advice.

Warm, sweet drinks can be administered if the patient is suffering from the first stages of hypothermia and is alert and conscious.

Allowing the casualty to re-warm spontaneously may save his/her life while doing the least harm. As soon as he/she is discovered, wrap them totally in insulating material – a ‘space blanket’ or a polythene bag will do. If their outer clothes are wet, quickly change them into dry clothes. Additional warmth can be provided by one of the rescuers sharing a sleeping bag with the casualty. Further protection should be provided from the elements by placing the patient and his companion inside a tent or bivi-bag. Hopefully, these protective layers will prevent any further loss of body heat, stabilising the patient until the emergency services arrive.

Treatment of the casualty should always have priority! If the ‘rescue party’ is sufficiently large, one member can be sent to summon help. Otherwise, wait for help to come. Never leave the casualty alone.

If the casualty can be carried to habitation, some text-books advise re-warming the patient in a bath of warm water. Do not attempt this unless you have had training in managing hypothermic patients. The patient can experience circulatory collapse during re-warming and, if there is very little blood circulation to conduct the heat away from the surface of the patient’s body, even quite mild temperatures can result in burns.

Hyperthermia

Heat collapse and hyperthermia are associated with strenuous activity on hot days, marathon and long-distance running and endurance activities. It can also be experienced on cold days if a person has engaged in physical activity wearing full wet-weather kit or an immersion suit. Hyperthermia occurs when the core temperature rises above 37°C (98.6°F). A marathon runner produces 13 times as much heat as he/she would while resting. This might be expected to raise the body’s core temperature by 1°C (2.6°F) every eight minutes. It says much about the body’s cooling abilities that this does not happen. Well-conditioned athletes can withstand moderate hyperthermia without any ill-effects.

The problem arises when the mechanisms which limit further increases in core temperature fail. The core temperature does not have to rise much above 41-42.5°C (105.8-108.5°F) before the person dies within minutes! The early symptoms of heat stroke resemble those of hypothermia: the pace slows and the person stumbles; he or she may be aggressive and irritable, with a glassy-eyed stare. However, these are also the symptoms of dehydration which, in itself, can also lead to heat stroke since little or no fluid is available to produce sweat. The traditional test for heat stroke is to feel the upper chest which is dry and warm. This test is not infallible. If the person feels unwell or presents with any of the above symptoms, treat as follows:

Prevent the person from engaging in further exercise.

Administer water or an isotonic fluid in spaced, moderate amounts. Lie the person flat on the ground and elevate his or her legs.

Sponge the person’s body with tepid water (cold water closes down the small blood vessels in the skin and delays further heat loss).

Seek medical advice. If the casualty suddenly collapses, they will need intravenous fluids and specialist medical support.

Heat stroke, with or without dehydration, is much easier to prevent than treat. The basic rules for avoiding the condition are as follows:

Wear light, loose clothing during strenuous activity. Even if the weather is cold and wet, the heat produced by your body will keep you warm. Moving across country with a heavy bergen, most Marines and Navy Seals wear only a windproof smock over their upper body.

Drink plenty of fluids before and during the activity. Fluid is quickly lost in sweat and sweating has a remarkable ability to cool the body.

On hot days, soak your T-shirt and headband in water.

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