Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Principles Of Treatment

Soft tissue injuries include:

– muscle and tendon damage (hematoma and/or rupture);

– joint and ligament damage (dislocation and/or rupture);

– soft tissue injuries associated with fractures.

When muscles, tendons, or ligaments are damaged, blood vessels in the area are also torn, and bleeding spreads rapidly into adjacent tissues. The bleeding causes swelling, placing increased pressure on surrounding tissues, which become tense and tender. The increased pressure causes pain in sensitive tissues, and the combination of bleeding, swelling, and increased pressure can adversely affect and delay the healing process.

Once bleeding has been controlled, some blood remains in the tissues and has to be resorbed. This function is performed mainly by the lymphatic system. A variable amount of scar tissue forms in the area and constitutes a weak spot in the injured muscle, tendon, or ligament. If too early or too heavy a load is applied to this scar tissue, injury is liable to recur. Sports injuries may take so many different forms that it is impossible to create a standard protocol for their management. Certain guidelines for immediate treatment can, however, be drawn up.

Immediate management

– An on-the-spot assessment of the extent of injury should be made by the injured athlete or by the trainer. A more careful examination can follow in a quiet place such as the changing room.
– The injured athlete should be undressed to the extent necessary for a full examination of the injured area. Tapes, strapping, and protective pads are removed.
– The course of events should be analyzed. Listen to the injured athlete’s description of how the injury occurred and what symptoms are present.
– The injury should be examined in the light of the history. Is there any effusion of blood, swelling, an open wound, or any other abnormal sign?
– A simple functional assessment of the injured part should be made. Can the injured athlete carry out normal movements of the part (with or without a load) without pain?
– The area around the injury should be examined. Is there tenderness in soft tissues or bone? Can a defect be felt in any soft tissue?

If there is swelling and tenderness together with pain when movements are made or a load is applied, treatment should be started as follows.

Compression

A compression bandage is intended to provide counterpressure to the bleeding developing within the injured area, so that the body’s own hemostatic functions can take effect more easily. A compression bandage is an elastic bandage applied with careful tension. It should be applied as soon as possible. It is convenient to position an ice pack with the aid of an elastic bandage so that cooling and compression effects are achieved simultaneously. The compression bandage should be kept in position usually for another 2 days after cooling has ceased, provided the location and extent of the injury allow it. Later it may be replaced by a supportive bandage or strapping.

Cryotherapy (cooling)

When soft tissue injuries occur, the first priority is to attempt to stop the bleeding, since this results in swelling, pain, and tenderness. The general rule is that the lighter the bleeding, the faster the effusion of
blood disappears, and the less scar tissue forms in the injured tissue. Therefore, in soft tissue injuries, reduce the extent of the bleeding by compression bandaging, rapid cooling, an elevated position of the injured limb, and rest. This enables the hemostatic functions of the body itself to take effect more easily. Cooling of body tissues brings about:
a local pain-relieving effect which makes the injured athlete feel better and may encourage a return to sporting activity. Here trainers and coaches have a great responsibility: if an injury needs cooling it is probably of such severity that further exertion will only delay healing. Common sense should prevail;
contraction of the blood vessels so that the blood flow is reduced in the injured area. The effect of the treatment is limited and does not really start for 15 minutes. Less swelling may occur and healing proceed more rapidly.

Cryotherapy is usually applied for 15–20 minutes per treatment and may be applied hourly for the first 24– 72 hours after the injury. During each application of cold therapy, four progressive sensations will be
experienced: cold, burning, aching, and numbness.

Cryotherapy is beneficial for sports injuries because:
– the patient quickly feels an improvement in symptoms;
– the treatment is easy to carry out and is well tolerated;
– there are few risks;
– it is inexpensive.

Cryotherapy cooling is mainly a treatment for pain and can be applied in several ways.

Ice massage

Ice massage is most commonly used prior to range-of-motion exercises, for friction massage, and for its localized analgesic effect. Ice is rubbed over the area in small circular movements for 5–10 minutes until numbness is reached.

Ice packs and contoured cryo-cuffs

Ice packs made with ice cubes or ice chips are by far the most popular, effective, and easiest method of application. The ice pack is applied to the area for 15–20 minutes, often wrapped on with an elastic bandage for compression and perhaps a light layer of material between the skin and ice for skin protection. Ice packs may be molded to the body contour and elevated above the heart to minimize swelling.

Contoured cryo-cuffs use ice water flowing into a contoured insulated pack, while a moderate amount of compression is maintained at the same time, thus combining cold and compression. However, they are more expensive.

Ice immersion, cold whirlpools

Ice immersion and cold whirlpools are often used to combine the analgesic effect of the cold and the buoyancy of water to treat the inflammatory phase and allow early range-of-motion exercises. The water should be maintained at a temperature of 10–15 °C (50–60 °F). Treatment lasts 5–15 minutes. As pain is relieved, the body part is removed from the water and functional movements are performed.

Commercial cold gel and chemical packs

Commercially available cold packs are generally made up of a chemical or gelatinous substance enclosed in a strong vinyl case. The packs are activated by squeezing or hitting the pack against a hard area, thereby
setting off a chemical reaction to produce the cold. These packs are convenient to carry, and many are single-use disposable packs. They can be expensive and are usually do not maintain their coldness as well
as real ice. The packs can be molded to the body area and used with elevation just as with ice for treatments.

Cold water

Cold water can be used for cooling injuries when ice packs are not at hand, and also when the injuries involve larger areas which cannot easily be covered with packs of the usual size.

Cooling sprays

A cooling spray may be used when local pain relief is the only objective. This applies to areas where the skin is in close contact with the skeleton such as the shins, knuckles, and ankles. The cold from such a spray penetrates only 3–4 mm (0.12–0.25 in) into the skin and therefore does not affect underlying injured tissue. There may be some contraction of deeper blood vessels triggered by reflex action, but this effect is probably only slight and transitory. Cooling ceases after spraying has stopped, and the blood flow subsequently increases, causing an effect entirely opposite to that desired. Apart from this disadvantage, there is also a risk of inducing cold injuries to the skin when a cooling spray is used.

Rest

It is generally true to say that an injured athlete should rest the injured part for 24–48 hours and that it should not be subjected to loading. It follows, therefore, that the athlete should be assisted from the scene of the injury and taken home or to a doctor, as soon as possible. Crutches are usually very helpful in the acute phase.

Elevation

When an injured part is elevated, its blood flow is reduced, and expelled blood is transported away from the site of injury more easily, thus reducing swelling. An injured leg that is elevated should be supported at an angle of more than 45° when the patient is lying supine. Four or five cushions or a stool placed under the leg
will achieve this effect. In cases of extensive bleeding and swelling the injured part should be kept elevated for 24–48 hours if possible. Subsequently, it should be elevated whenever the opportunity arises.

Pain relief

Cooling, compression, and rest usually provide relief from pain in soft tissue injuries. Pain-relieving medication may be given if the examination is complete but should be avoided in the early stages as it can complicate further treatment if continued analysis and medical examination are required.

Preparation

At sporting venues available equipment should include (as well as the trainers’ and physicians’ kits) crutches, stretchers, and immobilization splints. An emergency plan should be in place to provide adequate
acute treatment and transportation. Staff should be well educated and trained.

Treatment within 24–48 hours

When a soft tissue injury does not require further medical treatment, but effusion, pain, and impaired functioning of the injured part are present, treatment should continue along the following lines:
– compression bandaging replaced after a few hours by a support bandage;
– further cooling if pain relief is the objective;
– rest the injured area if there is persistent pain;
– elevation of the injured part. If walking is necessary, use crutches to unload the injured area if the lower limbs are involved.

Injured athletes should seek a medical opinion within 24–48 hours in cases of:
– persistent symptoms arising from injuries to muscle, tendon, joint, or ligament;
– severe pain.

It is generally true to say that a doctor should be consulted if there is any uncertainty about the diagnosis, and thus the treatment, of any sports injury.

Urgent conditions

For life-threatening injuries, a medical opinion should be sought urgently in any of the following circumstances:
– unconsciousness or persistent headache, nausea, vomiting, or dizziness after a head injury;
– breathing difficulties after blows to the head, neck or chest;
– pains in the neck after impact, whether or not they extend to the arms;
– abdominal pain;
– blood in the urine;
– fracture or suspected fracture;
– severe joint or ligament injury;
– severe muscle or tendon injury;
– dislocation;
– severe eye injury;
– deep wound with bleeding;
– injuries with intense pain;
– any injury in which there is doubt about its severity, diagnosis or treatment.

Treatment after 48 hours

As well as the treatment options described in this section, exercises are an important part of long-term treatment.

Rest

After any injury it is usually necessary to avoid painful activities and to rest the affected part, and occasionally confinement to bed is justified. In cases of overuse injuries and in certain ligamentous injuries accompanied by swelling, adhesive strapping or tape may provide relief. Rest is also recommended after an operation. It is usually continued until pain and swelling are negligible before loading the injured part.
Even if an injured athlete is obliged to wear a cast or a brace, other parts of the body can still be trained and muscle exercises and conditioning carried out. A lower leg in a cast or brace does not prevent physical fitness being maintained by activities such as cycling. The immobilized part should be held in an elevated position and exercised by repeated isometric contractions.

Heat treatment (thermotherapy)

Heat has been used for thousands of years in the treatment of different types of pain. Experience shows that it has a beneficial effect on pain arising from inflammation, which is the body’s defense mechanism in cases of injury due either to accident or to overuse. Injuries caused by trauma or overuse, such as ligament injuries and muscle ruptures, are often treated during the acute stage by cooling and bandaging so that the bleeding in the injured area is limited. After the initial 48 hours, heat treatment can be introduced to help the healing process. Heat may be started once the risk of hemorrhage is over, and aids healing by increasing the blood flow to the injured area.
If an injury is treated by heat applications in its acute stage the blood vessels expand, and the blood clotting procedure may be disrupted. The amount of fluid in the tissue increases. This leads to increased bleeding in the injured area, increased swelling and higher pressure in the surrounding tissues. The result may be more pain and slower healing than would otherwise be the case.
Perhaps the most important effect of heat treatment is its influence on collagen fibers. A tendon is composed of 90% collagen fibers and 10% elastic fibers. Collagen has viscous and elastic properties, which means that the more rapidly a tendon is loaded, the stiffer (less elastic) and less extensible it becomes. Heat increases elasticity and plasticity, so after its application the collagen fibers become more extensible and more capable of rehabilitation exercises. Heat also decreases joint stiffness and relieves muscle spasm. This reduces the risk of injury.
Heat can be used in both the prevention and rehabilitation of overuse injuries and to combat the after-effects of torn muscles and tendons. It can be valuable during warm-up before training sessions and competitions and in cold weather, increasing the mobility of joints.
Heat therapy is used after the acute inflammatory stage to increase blood flow and promote healing to the injured area. It increases circulation and cellular metabolism, decreases muscle spasm, and has an analgesic effect on surrounding tissues. Heat is typically used before activity to increase the extensibility of connective tissues, leading to an increased range of motion. The depth of heat penetration depends on the method of application.

Superficial heat treatment

Superficial modalities transfer heat by conduction, convection, and radiation. The heat penetrates to a depth of less than 1 cm (0.4 in).

Whirlpools

Whirlpools combine warmth with a hydromassaging effect to increase superficial skin temperature, decrease muscle spasm and pain, and facilitate range-of-motion exercises. Treatment times are from 20–30
minutes, with the body part to be treated immersed in water at temperatures of 37–40 °C (100–105 °F).

Hydrocollator packs

Hydrocollator packs provide superficial moist heat to a slightly greater tissue depth than whirlpool treatment. The packs consist of a silicone gel encased in canvas fabric compartments, and are stored in a hot
water unit. The pack is wrapped in terry toweling or a commercially available hot-pack cover and placed over the injured area for 20 minutes.

Contrast baths

Contrast baths combine cryotherapy and thermotherapy to reduce edema and restore range of motion in subacute or chronic injuries. One whirlpool or container is filled with cold water and ice at 10–15 °C (50–60 °F) and the other is filled with hot water at 37–43 °C (98–108 °F). The injured body part is alternated between the two containers at a 3:1, 3:2 or 4:1 ratio of hot to cold for approximately 20 minutes, or 4 or 5 cycles. The treatment should end in the cold water.

Heat Retainer

A heat retainer is a support made of synthetic material which generates and retains heat in the parts of the body which it encloses. It can be effective at rest as well as in training and competition. Heat retainers are made of a fine, porous material with low fluid absorption and good heat retention. They have an elasticity which keeps them in place without hampering movement in the bandaged part of the body. In addition, they give some support and exert counterpressure which may be of value when there is swelling. They are available in versions suitable for most joints and most types of injuries.

Heat retainers have been tested clinically to assess their effect on prevention as well as treatment of sports injuries, and results have been good. By relieving pain, improving tissue elasticity, and maintaining and extending the range of mobility, they assist not only the rehabilitation of ligament injuries in the knees and ankles but also the treatment of pain arising from muscle injuries and osteoarthritis.

Ultrasound

Ultrasound waves are of a higher frequency than those detectable by the human ear. The penetration of ultrasonic waves is inversely related to their frequency. As the ultrasonic beam travels through tissue, the energy is absorbed, producing heat. Ultrasound energy can produce temperature increases in tissue as deep as 10 cm (4 in). The technique is especially suitable for the treatment of pain in tendon attachments.
The indications for ultrasound treatment are pain and inflammatory conditions that are deeply located. Ultrasound can reduce the pain as well as increase the extensibility of the collagen fibers. It has been shown to be effective in combination with stretching. It may have some effect on calcium deposits in various tissues, but this is debatable.

Phonophoresis

Phonophoresis uses the mechanical energy of ultrasound to introduce medications such as cortisone through the skin to deeper tissues. In one study, 68% of those receiving phonophoresis with hydrocortisone
cream obtained relief from pain and improved range of motion, compared with 28% of patients receiving ultrasound alone. This medication has been found 10 cm (4 in) deep within the tissue after 5 minutes of treatment, but it is not known how long it remains. This procedure is used in the postacute stage of inflammatory conditions such as tendinitis, bursitis, contusion, or arthritis. The advantage of this treatment is that the medication is delivered directly to the injury site but it is less invasive than an anti-inflammatory injection, and may be used where an injection is contraindicated.

Electrical stimulation

Electrical stimulation is increasingly widely used. It has three recognized applications for the treatment of soft tissue injuries:

– pain reduction by transcutaneous stimulation of sensory nerves; this is known as transcutaneous electrical nerve stimulation (TENS);

– muscle strengthening; electrotherapy is sometimes used after surgery when hypotrophy is serious;

– enhancement of healing

More research concerning the effects of electrical stimulation is needed. Although electrical stimulation may control pain and be beneficial in muscle strengthening, it should not be used in routine rehabilitation. Treatment should be given by knowledgeable physical therapists only.

Iontophoresis

Iontophoresis uses a direct current to drive charged molecules of medication into damaged tissue. The medication is placed under the electrode with the same polarity and the molecules are pushed away from the electrode into the skin toward the injured site. Anti-inflammatory, analgesic or anesthetic drugs may be used.

TENS

Transcutaneous electrical nerve stimulation enhances the body’s ability to control pain. A weak electric current is applied to the skin in the painful area by means of superficial electrodes. The response to TENS varies, and some, but not all, patients find it very effective in relieving pain. It probably exerts its effect by activating a ‘gate’ mechanism in the spinal cord which prevents painful sensations from reaching the brain.

Acupuncture

Acupuncture is widely used in China where the method was developed and is used increasingly all over the world. Traditional acupuncture is based on the assumption that each half of the body has 12 meridians, representing certain organ systems. Along these meridians are a number of points that are connected with particular organs, and these points can be stimulated by needles of varying shape and length, effecting changes in the organs concerned. The connection between the meridians and anatomical nervous pathways has not yet been explained. The effect of the acupuncture needles is intensified by rotating them or connecting them to a low-voltage power source (electroacupuncture).

Scientific evaluation of acupuncture is as yet incomplete and inconclusive, but it does seem to benefit a significant number of people.

Massage

Massage has been used in the world of sport from time immemorial. It was once thought that it increased the blood flow in muscles and thus relieved pain, stiffness, and tenderness. However, studies have not been able to prove that blood flow is increased, although massage does bring about symptomatic improvement.
Massage should not be too vigorous, and should work inwards from the extremities towards the heart. Carried out by a trained and capable masseur, massage can produce a feeling of general well-being and relaxation.

Water massage

Water massage is usually carried out in hot water. The injured part is immersed for about 20 minutes during which time air is injected under high pressure into the water, providing an effect similar to that of manual massage. Use of a whirlpool or jacuzzi enables the whole body or individual part to be immersed alternately in hot and cold water, which is supposed to stimulate circulation and facilitate healing and rehabilitation.

Support bandages

Different types of support bandage are used depending on the degree of stability required.

An elastic bandage is made of cotton woven together with strands of rubber. It can be used for securing dressings or ice packs over injured areas and also provides compression in acute injuries, such as ankle sprains. The elastic bandage is flexible and stretches after use, which makes it unsuitable for long-term support. It has the advantage of being washable, and can be reused.

An adhesive elastic bandages is firm and flexible and its adhesive properties provide a strong hold. It is particularly useful for injuries of the knee, ankle, and wrist. Adhesive elastic bandages can also be used for taping as a preventive measure. Disadvantages of this type of bandage are that it is bulky and cannot be reused.

Self-adhesive elastic bandages consist of closely packed, unwoven polyester fibers. This type of bandage adheres to itself but not to the skin. It does not interfere with the normal functions of the skin, and is nonallergenie. It remains in place during bathing and dries quickly after getting wet. Self-adhesive elastic bandaging can be used as a preventive measure as well as during rehabilitation after an injury. It provides a stable but flexible dressing which is not bulky and even fits inside a shoe when applied to the foot. If the correct technique is used when applying the dressing and its elasticity is not overstretched, self-adhesive elastic bandage can be used as a semi-permanent support in ligament and other soft tissue injuries.

Braces

Braces are increasingly used in sports. They are mostly used for the ankle and knee, but are increasingly used for the shoulder, elbow, hand, and wrist.

Knee braces

Knee injuries are often serious. The risk of knee injuries is 6–22% each year for a college American football player. Many of these injured players use knee braces of some kind during the treatment phase.
Knee braces can be divided into three types: prophylactic, rehabilitative, and functional.

Prophylactic knee braces

Prophylactic knee braces are designed to distribute applied loads away from the knee joint and, thereby, reduce the load on the medial collateral ligament (MCL) and perhaps also on the anterior cruciate ligament (ACL). Biomechanical studies indicate that there may be a limited protection to the MCL and ACL when they are subjected to valgus loads. Research indicates increased stiffness to valgus loads, with highest efficiency around 20°. The benefits have, however, been documented only for low nonphysiologic loading. The few clinical studies available indicated a trend in the reduction of serious MCL injuries. There has been only one report of a prospective randomized study controlling playing surface, shoe wear and type of brace,
that also included a control group: this study indicated that a prophylactic knee brace can reduce the amount of knee and MCL injuries in defensive players in American football.

Rehabilitative knee braces

Rehabilitative knee braces are at least as effective as a plaster cast in treatment of complete MCL injuries, since they allow controlled early motion. They are valuable during the first weeks of conservative treatment of knee ligament injuries and after knee ligament surgery.

Functional knee braces

Functional braces are valuable in supporting the knee so that the joint can function without ‘giving way’. The brace operates by interacting with ligament, meniscus, and muscle function. The functional knee
brace supports the following:
– varus/valgus (side-to-side) instability with medial and lateral side posts;
– anterior tibial translation (tibia moves forward in relation to femur) by preventing hyperextension;
– rotational control—this is extremely difficult to achieve and at present no brace can really control rotation;
– suspension is the most difficult part to control in these braces as the thigh muscles are very giving and their motions are difficult to control.

Biomechanical studies show that functional knee braces can reduce anterior translation at low physiological loads and during weightbearing. Clinical studies show that the athlete experiences positive effects from the brace, although many may continue to have some instability episodes despite brace wear. The braces have a verified effect on activities of daily living, but during physical activities benefits are not well documented, and vary from individual to individual.

Braces for patellofemoral pain syndrome

Braces for use in patellofemoral pain syndrome have unloading areas designed to fit against the patella. They usually incorporate horseshoe-shaped lateral supports to stabilize the patella and prevent lateral subluxation. Medial straps may give extra stability. Some studies indicate that these braces improve the performance of these patients. Bracing seems to make it possible to include isotonic and isokinetic
exercises in the rehabilitation program and to allow early return to recreational and athletic activities.

Ankle braces

Ankle injuries account for 15% of all athletic injuries. To reduce the incidence, athletic tape and bracing are extensively used to support the ankle joint. Ankle braces do not, as a rule, significantly affect
performance. There may be a slightly decreased performance in vertical jumping.

Biomechanical studies indicate that some support is provided by these braces, especially in the loading situation. Clinical studies show that braces decrease the severity of ankle sprains and also decrease the
recurrence of ankle sprains. Other studies show that the combination of low-top shoes and ankle stabilizers are the most effective means of preventing ankle injuries in college American football players.

Taping and bracing are both effective in rehabilitation after ankle injuries. Taping will, however, lose its biomechanical support over time, and ankle braces seem to be more effective in reducing ankle injuries.
Taping is, however, still popular with athletes who perceive it not to affect performance. The use of ankle braces will increase as the designs become lighter and more effective.

In the treatment of acute first-time ankle sprains research shows that the combination of an ankle brace and an ace wrap seems to be the most effective.

Shoulder braces

Surgery for anterior shoulder instability can be successful, but the use of bracing is controversial. A few shoulder braces are commercially available. The aim of these braces is to limit abduction and external
rotation, and prevent the shoulder from being placed in unstable positions. These braces are large and affect the performance of highly skilled athletes. They can be used by ice hockey players, for example, who do not perform overhead shoulder movements. No clinical or biomechanical studies have evaluated these braces.

Elbow braces

Elbow braces are available for tennis elbow or elbow hyperextension injuries.

Braces for tennis elbow are based on the counterforce principle. An elastic strap placed on the proximal portion of the forearm provides a counterforce to muscle contractions either by constraining full muscular expansion and thereby decreasing the potential force the muscle can generate, or by dispersing pressure from the area of injury, which lessens the stress at the lateral epicondyle. The counterforce brace thereby controls the muscle forces and directs the tension overload to healthy tissue. Studies indicate that the counterforce brace decreases the electromyographic activity in the proximal lower arm muscles. In athletes with tennis elbow, the counterforce brace may produce significant increases in wrist extension and grip strength, although no significant effect on perceived pain has been reported. Although scientific evidence is limited, these braces seem valuable in the management of tennis elbow.

Traumatic hyperextension injuries may occur in contact sports such as American football and wrestling. Braces are available that can prevent elbow hyperextension.

Hand and wrist braces

Functional wrist orthoses for ligament injuries of the wrist can be fabricated to protect the injury and allow return to sports. Even distal radius and scaphoid fractures can be protected this way.
Stener’s lesion, which is an injury to the ulnar collateral ligament, can be treated by protective devices. These often have to be properly padded as the hard and nonyielding materials used are not allowed in many sports. Less severe cases can be well treated by taping.

Taping

Tape was known to be in use in Egypt around 300 BC. Tape is still extensively used, especially for ankle ligament injuries. Taping is mainly used for the protection of uninjured ankle ligaments, but it is also used
after injury to prevent recurrence or worsening of the injury. After a recently healed ankle ligament injury,the ankle needs long-term rehabilitation to regain strength and nerve muscle function. During this time it is valuable for the ankle to be protected in order to prevent recurrence.
The object of taping is to support a weakened part of the body without limiting its function, by preventing movements that would stress the weakened area. However, this goal is difficult to achieve, even when taping is correctly applied.

Indications for taping

The primary purpose of taping is to provide a semirigid or rigid splint around a joint and/or surrounding tissue. Taping has stabilizing effects mainly on structures and joints where there is little soft tissue, and
where the skin can not move too freely around the joint, such as the ankle and wrist joints. Taping soft tissue injuries such as a ruptured thigh muscle may be questioned, since it is doubtful whether tape has a
stabilizing influence in this case. There may, however, be a compression effect which can be beneficial.

Taping and performance

Taping an injured ankle will decrease its range of motion for 2–3 hours of physical activity. Correctly applied tape probably does not affect performance in sports very much. Biomechanically the support of tape
is limited, but clinically it does seem to have an effect. Studies on tiltboards indicate that taping has a proprioceptive effect on unstable ankles.

Applications

Acute injury

It can be risky to use tape on acute injuries, and overtight taping of an area in which swelling and bleeding are occurring may cause serious impairment of circulation.
Before taping an acute injury a detailed medical examination should be carried out, including a careful stability test. If there are any indications of a total rupture, taping should not be used. The taping of an acute injury may unfortunately lull the athlete into a false sense of security, encouraging the resumption of sporting activity which will make the injury considerably worse.

Preventive taping

There has been some suggestion that taping healthy ankles as a preventive measure could, by changing mechanical conditions, increase the occurrence of knee injuries. Research has shown that this is not the case, and has confirmed that preventive taping can decrease the number of ligament injuries to the ankle. It is of particular value in sports in which the ankles are vulnerable to violent impact, e.g. soccer, team handball, and volleyball.
Ligaments such as those around the ankle joint can be subjected to repeated impact and injuries with a result that they become weak and stretched. In such cases taping plays an important part in contributing to the stability of the joint. If, despite precautions, progressive instability of the joint is seen, surgery should be considered.

Taping during rehabilitation

Taping is most useful in rehabilitation after an injury has been treated surgically or has healed spontaneously. It is becoming common for athletes to use taping when they resume sporting activity after an
injury, though the value of this practice has not been proven. Studies have shown that taping the knee joint does not provide stability to any significant degree. In cases of medial instability of the knee, taping gives virtually no support after 5 minutes’ hard physical activity

Types of tape

The tape in general use is inelastic and is available in a range of widths; 38 mm (1.5 in) and 50 mm (2 in) widths are often used.The tape is perforated so that strips can be torn off easily. By stretching the tape before application it is possible to achieve a firm restriction early in the range of movement.

Risks of taping

– In certain situations, for example in acute injuries, taping may restrict circulation.
– The long-term effect of taping is limited. It can never provide a permanent solution, and there are few justifications for using it continuously for as long as a week.
– Skin irritations may occur if tape is in contact with the skin for a long period. This problem is unlikely to occur in less than a week, but as a rule tape should not be used directly on the skin for more than a few
hours at a time. If it is necessary to exceed this limit, a protective material should be worn under the tape.

Tape may cause irritation by mechanical or chemical means or because of allergy, and the effects may be exaggerated by sweating, itching, and bacterial infection. In order to reduce the risk of skin irritation some
tapes are backed with zinc oxide.

Applying the tape

Knowledge of taping is gained first by instruction and thereafter by experience. It is only possible to learn how to tape quickly and safely by constant practice.

– Any body hair in the area to be taped should be shaved. If the skin is damaged or infected it is advisable to wait until it has healed before tape is applied.
– The skin in the area to be taped must be cleaned, as grease or sweat will stop the tape adhering. An adhesive spray may also be used.
– Various types of tape underlay in the form of thin plastic foam, adhesive cream, or plastic dressing can be applied to the skin. One of these underlays should be used if the tape is to be worn for a long time or if skin allergy occurs.
– A tape bandage must never be applied around a swollen joint as it may impede circulation.
– In principle, application of a tape bandage should begin distal to the injured part, be built up over the injury, and be fastened below it.
– Tape adheres better to itself than to skin, so an ‘anchor’ of tape should be applied on each side of the injured joint. The injured ligament which is to be supported should be held in a shortened position during
taping. If, for example, the ligament on the lateral (outer) aspect of the ankle is injured, the lateral (outer) edge of the foot should be directed upwards and the tape stretched over the outer side of the joint.
– Folds and creases in the dressing should be smoothed out, as they may cause blisters and skin irritation. The effect of the bandage is also reduced if the tape is ‘concertinaed’.
– The tape should be removed with care. It is better to try to ‘push’ the skin away from the tape rather than to tear or pull the tape away from the skin. The edges of the wound are often difficult to free, but it can sometimes be effective to hold the skin tight and pull it from the tape. Alternatively, tape bandages can be removed with the help of tape cutters or tape scissors; solvents are also available.
– The athlete should always be listened to, and if the tape is causing any discomfort, it should be adjusted.

Walking boots

Walking boots are particularly useful because they limit motion of the ankle during weightbearing and walking, but can be removed to allow non-weightbearing early motion exercises.

Casts and splint

When there is a need for rigid support (e.g. in fractures and ligament injuries) or complete immobility (e.g. in acute peritendinitis), a plaster cast or splint is the best solution. Depending on the nature of the injury, some activity, such as isometric exercises, can be allowed on the muscles encased in the cast. In principle, a plaster cast or splint should include the injured area and the joints above it, not those below it.

Waterproof cast

Casts can be made of many synthetic materials; some are composed of fiberglass impregnated with a plastic compound which hardens in cold water. The plastic cast becomes pliable 5–7 minutes after it has been
dipped into cold water and can then be wrapped around the injured part of the body or applied as a splint. After 30 minutes it can withstand a certain amount of load. These casts are suitable as a temporary or permanent support for various parts of the body without the need for any restrictions on bathing, showering, or swimming.

During the last few years there has been a rapid development of bandages made from plastic material. Various types with different properties (and colors) are available.

Medication

Medication may be used for soft tissue injuries.

Pain relieving and anti-inflammatory medication

Acetylsalicylic acid (aspirin) is effective on mild and moderate pain, particularly that caused by headache and muscle and joint problems, but is inadequate in controlling serious pain such as is caused by a fracture. Side-effects include gastric irritation. Paracetamol is as effective as aspirin against some forms of pain although its inflammatory activity is not great. It may reduce raised temperature. There are no real side-effects.
Medications with combined pain-relieving and anti-inflammatory effects are widespread in sports medicine. The most commonly used are diclofenac sodium, which is effective against inflammation and has
some pain-relieving effect (there can be gastric irritation) and ketoprofen, naproxen and ibobrufen, which have relatively good pain-relieving and anti-inflammatory effects, which last for a relatively long time (there is some gastric irritation). The COX-2 (cyclooxygenase 2) inhibitors celecoxib and rofecoxib are also useful: they seem to be effective and give possibly less gastric irritation.

Cortisone preparations (corticosteroids) for local injections

These injections can be of great value for overuse injuries but should not be given directly into muscles or tendons or into young joints, since they may cause weakening and consequent tendon injury. They can be given around the muscle or tendon attachment or into the surrounding sheath. Refraining from exercises with loading activities is recommended for 1–2 weeks after injection.

Local injection with pain-relieving drugs can sometimes be valuable to secure a diagnosis.

Ointments and liniments

Ointments may be used for muscle pain, stiffness and medial tibial stress syndrome. These products may increase skin circulation and produce a feeling of local heat without really affecting muscular blood flow. The psychological effects on athletes from the act of rubbing in the ointments and liniments cannot be denied.

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