Proprioception and injury

Proprioception, Performance and Injury

Terms proprioception and proprioceptive reflexes are often used when discussing muscle performance and injury prevention. The term proprioception is broadly defined as the awareness of posture and movement. Movements of joint systems are constantly monitored by various sensors called proprioceptors. The reflexes that arise from these proprioceptors can initiate, inhibit or fine tune joint movements by actions on the muscle motor neurons. By influencing muscle activation and contraction, these reflexes play an important role in stabilizing joints and preventing injury.

What is Proprioception?

Information about joint movement, muscle length and force are all provided by proprioceptors, small structures that are found in muscle, ligaments and tendons that are connected to the spinal cord by neurons. Well known proprioceptors include the muscle spindle which monitors muscle length, tendon organs that monitor that amount of force applied to the tendon, and joint receptors that monitor joint position, movement and acceleration. Proprioception operates under the concept of feedback. When a proprioceptor identifies an unwanted movement, it sends a signal from the joint, muscle or ligament to the spinal cord. Within the spinal cord, the signal can either initiate or inhibit the motor neuron responsible for muscle contraction. That is, proprioceptors can cause a muscle to contract or relax. These reflexes are very fast, occurring within 20-50 thousandths of a second (millisecond) and are designed to protect the joint from unwanted movements.

The best example of a proprioceptive reflex is the knee jerk. The knee jerk begins when the patellar ligament is tapped (this is the thick band that attaches the patella or knee cap to the tibia or shin bone). This causes rapid knee extension or a “jerk”. The reflex happens as a result of the tap causing a small but rapid stretch of the quadriceps muscles. The rapid stretch activates the muscle spindle that lies within the muscle. This stretch causes the muscle spindle to send a signal to the spinal cord. There, the motor neurons controlling the quadriceps are activated, causing the muscle to contract and shorten, counteracting the stretch. An important concept is that this reflex does not involve information processing by the brain. It is far too rapid. The muscle spindle is stretched, a signal is sent to the spinal cord, the muscle contracts and shortens. The brain is aware of what has happened but the movement is initiated within the spinal cord.

Many feel that the stretch reflex is very important in stabilizing joints and preventing ligament injury. For example, a player cuts by planting her left foot and accelerating to the right. As force is applied to the foot, the ankle begins to turn inward (inversion). This, in turn causes a small, but rapid stretch of the muscles that turn the ankle outward (eversion). The stretch activates the muscle spindles of the stretched muscles (the muscles on the lateral side of the lower leg) and causes them to contract. The force exerted by these muscles counteracts to inward movement. In this case, the stretch reflex aids in preventing the athlete from “rolling” her ankle and injuring the ankle ligaments.

Ligaments also have proprioceptors that exert protective reflexes. A number of researchers feel that proprioceptors within the anterior cruciate ligament (ACL) are sensitive to tension placed on the ligament. One function of the ACL is preventing the tibia from sliding forward with respect to the femur (the bone of the upper leg). When the tibia moves forward and the ACL is stretched, these proprioceptors trigger the hamstring muscles to contract. The hamstring force pulls the tibia backwards. This stabilizes the knee, reduces ACL tension and reduces the risk of being damaged. This reflex is thought to play a role in protecting against ACL injuries. Its importance is seen in athletes who have undergone ACL reconstruction. In these athletes, the reflex is greatly diminished and may even be absent and may contribute to the high rate re-injury.

Not all proprioceptive reflexes activate muscle. Some are inhibitory. The Golgi tendon organ (GTO) is located in the tendons of most major muscles. This proprioceptor is sensitive to the amount of force exerted by the muscle. If, during muscle contraction, excessive force is placed on the tendon, the GTO sends a signal to the spinal cord. This signal inhibits the motor neuron and causes the muscle to relax. This inhibitory reflex is designed to protect the tendon from being damaged by excessive muscle force. Better to relax the muscle than to have it ruptured or torn away from the bone.

Force production by muscles during dynamic activities such as landing, cutting and running is a complex interaction of activating signals originating from the brain (voluntary control) and modulating signals arising from proprioception (reflex control). The brain activates specific muscles for a specific task and the proprioceptive reflexes modify contractions to accommodate unexpected changes in movement.

Can We Train the Proprioceptive System?

When an untrained individual lands a jump, there is a brief period of muscle relaxation (around 50 msec) that is quickly followed by contraction. As the person lands, the knees and ankles flex stretching the quadriceps and calf muscles. This should trigger the stretch reflex and cause a rapid contraction. However, the excessive force of lengthening (or eccentric) contractions seems to trigger the GTO and cause a brief period of relaxation, about 50 msec. Shortly after the relaxation period, the brain initiates contraction of the hip, knee and ankle extensor muscles so that the athlete can land the jump without collapsing.

Several research studies also show that trained athletes have enhanced proprioceptive reflexes. In the example above, that brief period of relaxation when landing a jump is replaced by a period of enhanced muscle activation. Training seems to either improve the stretch reflex or diminish the GTO reflex. Either way, the proprioceptive reflex is enhanced following training. This results in greater and more rapid force production at landing as well as improved height of a subsequent rebound jump.

Proprioceptive training involves exercises such as jumps, cutting maneuvers and balancing activities. They are designed to evoke rapid changes in movement of the knee and ankle. The idea is to place stress on the joint by simulating “unwanted” joint movements very controlled conditions. These movements are thought to “Train” the proprioceptive reflexes as well as build strength of the musculature. Research has shown that programs targeting proprioception, balance and strength training do indeed result in reduced injury risk.

Summary

Proprioception or the awareness of body position and joint movement is an important aspect of normal neuromuscular function. The reflexes that arise as a part of the proprioceptive system are critically important for peak performance and reducing the risk of joint injury. Coaches and athletes should remember that a part of any comprehensive training program should include exercises designed to enhance proprioceptive reflexes.

Further Reading

Ergen E, Ulkar B (2008) Proprioception and ankle injuries in soccer. Clinics in Sports Medicine, 27:195-217.

Hewett TE, Paterno MV, Meyer GD (20020) Strategies for enhancing proprioception and neuromuscular control of the knee. Clinical Orthopaedics and Related Research, 402:76-94.

Silvers HJ, Mandelbaum BR (2007) Prevention of anterior cruciate ligament injury in the female athlete. British Journal of Sports Medicine, Supplement 1:i52-i59..

Nosebleed injury

Description Of The Injury: Nosebleeds are one of the most common minor injuries. They usually occur due to an excess drying of the nasal membrane which most often occur during dry winter months. Additionally, certain factors such as infection, allergies, hypertension and the use of blood clotting or aspirin medication may predispose a person to nosebleeds. In nearly all cases, nosebleeds can be treated quickly and easily. 

Injury Symptoms: The only sign is minor or profuse bleeding from the nostril. Usually it is only from one nostril, and not from both. In addition, typical time durations of the nose bleed can range from 5 minutes to as long as 30 minutes.

Treatment: Nosebleeds can be treated with conventional conservative treatment. The nose should be pinched together firmly with pressure applied toward the face. The head should be leaned forward to prevent blood from running down the throat. The blood should be cleaned and the nose pinch should be maintained for five minutes or until the bleeding subsides. A cold towel can be applied on the nose to help matters. Nasal packs may be advised to compress the vessels.

How to decrease the chance of nosebleeds: Prevention of nosebleeds do not involve exercise techniques. Prevention is largely through keeping the mucous membrane in a more humid environment as opposed to a cold dry environment. Those who are prone to nosebleeds should limit the use of blood thinners such as garlic, ginger, ginseng and aspirin.

Blisters and soccer

Blisters often are a problem in soccer, particularly on the feet. Tight-fitting shoes and aggressive running styles over long periods sometimes encourage blisters to form. Understanding how to treat and prevent blisters will keep you in the game longer.

Cause

Excessive irritation on the skin causes blisters. Stiff, narrow soccer shoes rub on the sides of the feet as soccer players run, causing friction and irritation. Abrasive socks can cause blisters, too, especially if the shoe is too large and allows the foot to slide around. Blisters are more likely to occur in moist environments. Sweat and wet field conditions frequently create moisture in a soccer cleat.

Symptoms

When a blister begins to form, it appears as a red, slightly tender area. Rubbing may produce a burning sensation. As the blister gets worse, a bubble filled with fluid develops -- your body's attempt to cushion the area. If the fluid-filled area is left untreated and you continue to play, the fluid will increase and the bubble will rupture and drain. You may feel slight relief after the blister ruptures.

Treatment

If you catch a blister before it has filled with fluid, treat it with a cushioning bandage or moleskin product and continue to play. You should not attempt to puncture the blister in field conditions because that might lead to infection. If the blister is already filled with fluid, continuing to play will only make the problem worse. If the blister has ruptured, clean the area as you would a normal wound and apply a clean bandage and antibacterial cream.

Prevention

The first step in blister prevention in soccer is choosing a proper shoe. Soccer shoes should fit your foot's length, width and most importantly, volume. When you try on soccer shoes at the store, wear the socks in which you play to achieve a better fit. If you wear shin guards that have ankle guards, bring them. Always break in new cleats slowly to avoid blisters from a stiff new pair. Wear comfortable socks and change them during halftime to help keep your feet dry and comfortable.

References

http://www.usyouthsoccer.org/news/all_there_is_to_know_about_blisters/?story_id=3978

“Handbook of Sports Medicine and Science - Football(Soccer)”, Björn Ekblom

Immediate injury treatment

What to do first few days after an injury occurred?

Rest?

• Rest from painful exercise or a movement is essential in the early injury stage. We call this active rest. "No pain. No gain." does not apply in most cases.  The rule of thumb is - don't do anything that reproduces your pain for the initial two or three days.  After that, you need to get it moving or other problems will develop.

• If you are unsure what to do, please contact your doctor.

Ice or Heat?

Ice

• Ice is preferred for the initial two or three days post-injury.
• Apply ice for 20 minutes each two to three hours for the first few days until the "heat" comes out of the injury.
• Ice should also help to reduce your pain and swelling in traumatic soft tissue injuries, such as ligament sprains, muscle tears or bruising.

Heat

• It is preferable to avoid heat (and heat rubs) in the first 48 hours of injury. The heat encourages bleeding, which could be detrimental if used too early.
• Once the "heat" has come out of your injury, heat packs can be used to stimulate blood flow. We recommend 20 minute applications a few times a day to increase the blood flow and hasten your healing rate. Heat will also help your muscles relax and ease your pain.

• Heat Wheat Packs are an excellent home solution for a multitude of conditions.

Not Sure?

• If you're not sure what to do, please contact your doctor.

Bandage / Support?

• Yes. If it is possible to apply a compressive bandage or elastic support to the injury, it will help to control swelling and bleeding in the first few days.  In most cases, the bandage/support will also help to support the injury as the new scar tissue is laid down. This should help to reduce your pain.

• Some injuries will benefit from more support such as a brace or rigid strapping tape.

• Please contact your doctor if you are unsure what to do.

Elevation?

• Elevation of an injury in the first few days is very helpful.

• Think where your injury is and where your heart is. Gravity will encourage swelling to settle at the lowest point.  Try to rest your injury above your heart.

• Obviously some injuries are impossible or it would be detrimental to elevate, so please use your common sense and be guided by your pain.

Treatment - When? 

In most cases, "the early bird gets the worm".  Researchers have found that intervention of physiotherapy treatment for acute soft tissue injuries within a few days has many benefits. 

Prompt Treatment Benefits include:

• Relieving your pain quicker via joint mobility techniques, soft tissue massage, electrotherapy etc

• Improving your scar tissue quality using techniques to guide the direction it forms

• Getting you back to sport or work quicker through faster healing rates

• Loosening or strengthening of your injured region with individually prescribed exercises and techniques

• Improving your performance when you do return to sport, work or simply daily life

• Correct any biomechanical faults that may be affecting your movement, technique or predisposing you to injury

What If You Do Nothing?

Research tells us that injuries left untreated do take longer to heal and have lingering pain. 

They are also more likely to recur and leave you with:

• abnormal scar tissue formation
• joint stiffness
• muscle weakness

It's important to remember that symptoms lasting longer than three months become habitual and are much harder to solve.  The sooner you get on top of your symptoms the better your outcome.

Recovery ladders

Throwing ladders  

Quadriceps rehabilitation ladder – heart and lungs  

Quadriceps strength rehabilitation ladder  

Knee rehabilitation ladder  

Hamstring rehabilitation ladder  

Calf and Achilles rehabilitation ladder  

Rehabilitation ladder - general muscle ladder 

Lower leg injuries

 Lower leg  

Ankle and foot injuries 

Hallux limitus/rigidus  

Metatarsalgia  

March fracture 

Navicular stress fracture  

Calcaneocuboid ligament injury  

Plantar fascitis  

Os trigonum  

Posterior capsule injury  

Retro Achilles bursa  

Ruptures Achilles  

Achilles tendinopathy 

Posterior tibialis tenosynovitis   

Deltoid ligament sprain  

Peroneal subluxation  

Acute lateral ligament sprain 

Sprained ankle 

Anterior meniscoid of the ankle injury 

Extensor digitorum longus  

Tibialis anterior injury  

Footballer’s ankle  

Capsulitis of the talar joint 

Posterior tibialis tendinitis 

 Medial tibial syndrome  

Torn gastrocnemius  

Peroneal nerve entrapment  

Anterior compartment syndrome  

Knee injuries

Patellar tendinitis 

Popliteus muscle strain 

Iliotibial tract injury  

Lateral ligament sprain 

Medial collateral ligament(deep fibres) 

Tibial collateral ligament 

Anterior coronary ligament strain 

Sinding - Larsen – Johansson syndrome  

Maltracking of the patella  

Meniscal tear 

Posterior cruciate ligament tear 

Anterior cruciate ligament tear  

Dislocated patella 

Thigh injuries

Thigh injuries  

Biceps femoris bursa  

Hamstring muscle injury  

Semimembranosus/pes anserine bursa  

Quadriceps expansion  

Anterior thigh injuries  

Tensor fasciae latae strain  

Hamstring syndrome  

Adductor muscle strain 

Hip injuries

 Sacrotuberous ligament injury  

Piriformis muscle injury  

Piriformis syndrome 

Psoas strain/bursitis 

TOPS  

Osteoarthritis of the hips  

Prevention and treatment with upper parts injuries

Treatment and prevention of soccer injuries  

How to treat muscle cramps and spasms 

Injury prevention  

Emergency treatment of soccer injuries  

Training under injury and during rehabilitation 

Soccer injuries according to player positions 

List of tests and manoeuvres P-Y  

List of tests and manoeuvres G-O  

List of tests and manoeuvres A-F 

 Classification of sports injuries  

Prevent injuries during training session 

Abdomen injuries 

Axial skeleton 

Rotator cuff injuries   

Head injuries 

Treatment and prevention of soccer injuries - part II

PART I

Torn muscles

There are all sorts of conceivable situations in which a player can tear a muscle. Usually an uncontrolled movement is the cause. A torn muscle often occurs immediately after the start of a match or a training session. This is usually attributable to insufficient warming-up. At the end of a match or an intensive training session, muscles are often tired and the players feel generally fatiqued. Common actions such as kicking, sprinting and jumping frequently cause a muscle to tear. Unlike muscle bruising, which is always the result of external violence, torn muscles have an internal cause. The symptoms of a torn muscle vary from:

• a relatively slight but often sharp, penetrating pain, especially when the affected muscle is stretched to the utmost;
• minor functional impairment and less strength, so that maximum performance is lower;
• slight swelling(in some cases);
• a certain degree of muscle contraction;
• the muscle feels hard(a sort of muscle cramp);
• the affected part of the muscle is tender to the touch.

to:

• extreme pain, similar to a whiplash;
• a snapping feeling, followed immediately by loss of function;
• extravasation of blood;
• swelling(fluid);
• muscle contractions(spasms).

Torn muscles can vary in severity from a strain to a partial tear or a complete rupture. A torn muscle must first be given the RICE treatment. In more serious cases, a doctor must be consulted and physiotherapy is necessary. Torn muscles can be prevented by planning training sessions properly, by always carrying out warming-up routines, and by performing stretching exercises. Complete recovery is essential, because muscle tears can easily reappear at the same place. Local tenderness to the touch and stretching pains must disappear and the muscle must be restored to its initial strength and size before sporting activities can be carried out again at maximal capacity.

Tendinitis

Tendinitis is an inflammation of the tendon and the surrounding tissue. Fluid associated with the inflammation penetrates between the tendon itself and the sheath around it.Such inflammation usually occurs at a point where the tendon connects to a bone. Tendinitis can be regarded as a typical over-use injury. The major causes of tendinitis in sport are a too rapid increase in workload, repetitive one-sided movement, and repetitive one-sided work. In soccer, the tendons most frequently affected by this complaint are hamstring tendons, the patellar tendon and the Achilles tendon. The commonest cause of this latter injury is a hard or a very heavy pitch. Not only top sportsmen suffer from tendinitis – recreational players are also at risk. The term “over-use” is not very far from tendinitis – recreational players are also at risk. The term “over-use” is not very well understood. Players often do not know when the body’s limit has been reached, or what to do in such a case. A sportsman who finds it difficult to run on the morning after participating in his sport must take a break. Most people underestimate the problem, because the pain disappears after the first few strides. Many sportsmen continue to participate in their sport when they are in this condition. In doing so, they are risking a chronic over-use injury, which is often very difficult to overcome. Any sportsman who is in pain while participating in his sport, or feels pain when at rest, should consult a doctor. A painful tendon can be helped by placing a piece of foam rubber in the heel of the shoe. Thick socks and a soft insole can help, too. It is advisable to wear shoes with a thick insole or a shock-absorbent heel. Sports shoes should be thrown away when they start to wear or lose shape. In addition, training sessions should preferably be held on a soft surface such as grass. The healing process can be stimulated by an ice massage of the affected area. Massaging and stretching the affected muscles also helps. When the discomfort has disappeared, the muscles must be strengthened to prevent any recurrence of the injury. Good physical fitness is, of course, a necessity.

Fractures

A bone may be fractured in one or more places, and may even be splintered at the site of the break. Fractures occur regularly in contact sports such as soccer. Fractures may be closed or open. If the skin at the fracture site is intact, then the fracture is said to be closed(or simple). An open fracture involves not only a broken bone but also an open wound. This means that the site of the fracture is exposed to the air. Sometimes a piece of bone may project from the wound. The most common symptoms of a fracture are:

• extreme pain;
• in many cases the bone or part of the body assumes an abnormal position;
• absolute inability to move or take any strain on the bone;
• swelling due to bleeding(closed fracture), or visible loss of blood(open fracture);
• a feeling that something has broken.

A fracture can resemble a bruise, strain or dislocation in all respects. It is sometimes very difficult to make the right diagnosis. The symptoms may be so slight that a player carries on playing until the end of the game, even though he is later found to have a cracked bone. If there is the slightest suspicion of a fracture, therefore, it must be assumed that there is one. Playing on is out of the question. The injury must be immobilized, and the injured player must remain lying down if he is in great pain. The player must be transported to hospital under expert supervision. An open fracture must be covered with sterile gauze to prevent infection. X-rays must be taken at a hospital to determine whether the player has really suffered a fracture. Fractures can be avoided by general preventive measures such as maintaining a good level of physical fitness, wearing protective equipment such as shinguards, and fair play.

Cartilage injuries

Soccer players regularly have problems with damage to the cartilage in the joints, with zones of irritiation or wear being formed on the cartilage. Such injuries usually occur behind the kneecap. Excessive pressure builds up between the kneecap and the bottom of the femur. This pressure can be caused by unsuitable footwear, excessively strenuous conditioning, or insufficient muscle strength(through lack of fitness or duing the growth phase). A cartilage injury is accompanied by symptoms such as pain around and/or behind the kneecap. This pain becomes more severe during sporting activity. Sitting for long periods with bent knees also gives rise to such complaints. Periods of more or less pain alternate. One way of preventing cartilage injuries is to cut down on the movements that cause the injury. Conditioning programs must be specially adapted for soccer players who have cartilage problems, as should their footwear. Drills that increase the strength of the muscles of the upper leg are crucial to the treatment of these problems.

Meniscus injuries

If the body turns and the lower leg is blocked, the lateral or medial meniscus may be jammed. This often happens in soccer, and fortunately there are usually no ill effects. Sometimes, however, the applied forces are so great that the meniscus tears. Detectable symptoms are:

• acute pain on the medial or lateral side of the knee;
• bending and stretching are only possible to a limited extent(sometimes the whole knee is locked);
• the knee swells rapidly;
• the pain extends to the back of the knee and/or the front of the knee;
• within a few weeks the upper leg becomes thinner.

The meniscus can also suffer chronic damage by being continuously jammed during rapid turns and changes of direction, and again a tear may occur. Here, too, there are also a number of characteristic symptoms:

• slowly worsening complaints;
• pain in the knee;
• slight restriction of bending and stretching;
• pain extends to the back of the knee or to the front, when a full bend or stretch is made;
• slight swelling of the knee.

Such patterns of complaints are indicative of meniscus damage. The player should consult a doctor, to prevent any further damage to ligaments and/or cartilage. An exploratory operation or radiograph enables a diagnosis to be made and, in most cases, the necessary treatment can also be carried out.

Various injuries

A fresh bruise under the nail must be pricked with a drill or the hot end of a paper clip. The blood must then be drawn off, the wound treated with iodine, and a pressure bandage applied with tape or bandaid. Otherwise the nail will be lost due to the extravasation of blood. A blood blister under the skin or under a callous layer must be treated very carefully to avoid any infection. If necessary(for example, if an awkwardly situated blister is causing pain), a blister must be opened, emptied and disinfected. A broken collarbone is almost always clearly visible on an X-ray. Naturally the player must go to hospital for examination and treatment. There is a danger that the top of the lung may be pricked. Players who suffer eye injuries and/or a possible fracture of the orbit or cheekbone must always go to hospital for examination and treatment. It is possible to recover quickly from such injuries. During the preparations for the European Championship in 1988, Marco van Basten arrived from Italy with a fractured cheekbone on the Friday, underwent an operation, and took part in a training session on the following Wednesday. He scored his first goal in practice match on Friday, just two days later.

Treatment and prevention of soccer injuries - part I

The symptoms and emergency treatment of a number of common injuries are described below. Suggestions are also given for avoiding such injuries. A number of serious, but less common, injuries are also described.

Nosebleed

A nosebleed involves bleeding in one or both nostrils. There are many possible causes. The most usual cause is a nose injury. A nosebleed should be treated by pinching the player’s nostrils and keeping them closed for one minute. The head should be inclined slightly forward. The nostrils can then be slowly and carefully allowed to open again. If bleeding resumes, there is a good chance that clotted blood is holding the edges of the wound apart. These clots of blood must be removed from the nose before another attempt is made to stop the flow of blood. This can be done by firmly blowing the nose into a handkerchief. The nostrils should then be pinched together again as described above. If there is still no success, one more attempt can be made. If this fails to help, it is advisable to consult a doctor to go to a hospital first-aid department. The shape and condition of the nose must also be looked at. The nose might be broken. If there is any suspicion of this, the player must be taken to hospital as soon as possible for examination.

Scrapes

Soccer players frequently carry out sliding tackles, in the course of which they may scrape their hips or, to a lesser extent, their knees. The main danger associated with scrapes is that infections may occur through the open wound. This must therefore be immediately and carefully cleaned, removing as much dirt as possible. This can best be done with running water and disinfectant soap. Do not run water directly onto the wound. If necessary, use a clean, soft brush. When this has been done, apply iodine to the wound and the adjacent skin. The blood and pale yellow fluid subsequently dry and form a crust. The wound should never be dried with powders, because this would hinder the healing process. A scrape heals fastest by being exposed to the air. If clothing is worn over a wound, the wound must be covered with a bandaid or sterile gauze to prevent infections. If a wound is very badly soiled, a doctor should be consulted. Players are less likely to sustain scrapes if they wear protective clothing or other material. Coating the most vulnerable areas with a layer of Vaseline also has a preventive effect.

Blisters

Blisters are caused by excessive friction and pressure, especially on the heels, toes and ball of the foot. The surface skin is displaced with regard to the underlying layer, and moisture is therefore formed between the two layers. Friction between the skin and clothing can also cause blisters. This can happen when new boots are worn. An area of inflamed skin appears before a blister forms. It is advisable not to burst a blister. If this is unavoidable, the following procedure must be followed:

1. Apply iodine to the blister and the surrounding skin.
2. Sterilize a needle by, for example, holding it in a frame.
3. Prick the edge of the blister, then prick the opposite edge.
4. Use sterile gauze or absorbent cotton to press the moisture out of the blister, from the center outward.
5. If you have a pipette, drip a little iodine into the blister.
6. Squeeze the blister again until no more fluid emerges.
7. Apply iodine to the blister and the surrounding skin again.
8. Cover the blister with sterile gauze or a bandaid.
9. If necessary, spray a “second skin” over the blister.

If a blister is not a hindrance during a training session or match, it is better to cover it with layers of bandaid, arranged like tiles on a roof. The blister will dry out within a few hours or days, and will then present no more problems. If a blister is formed under a thick layer of horny skin on the foot, it is advisable to consult a doctor or chiropodist. Wearing comfortably fitting boots can prevent the formation of blisters. When new boots are worn, they should be “run in” properly before they are worn during a complete training session or match. Soap or Vaseline can be applied to the inside of the heel to reduce friction. Wetting the socks and smearing them with soap is another good method.

Cuts

A superficial cut only affects the skin. Deeper cuts may damage the underlying structures. The cuts sustained by soccer players are often caused by studs with a ragged edge. Hygiene is a very important aspect of the treatment of cuts. Any infection must be prevented. A small wound must be sterilized with iodine and then covered with gauze or sticking bandaid. Longer and deeper cuts must be treated by a doctor. There are two reasons for this. Firstly, they need to be inspected to determine whether underlying blood vessels, nerves and muscle tendons have been damaged. Secondly, such cuts, and especially facial cuts, have to be stitched carefully.

Bruises

A bruise is an extravasation of blood into the skin or underlying tissues due to tissue damage. Such damage is caused by the violent impact of an object against the body. Examples of such impacts are a knee against the thigh, or a kick against the shin. The symptoms of a superficial bruise are:

• in most cases, brief localized pain;
• loss of function, which, depending on the positon and strength of the violent impact, can range from mild to considerable;
• swelling as a result of extravasation of blood;
• a subsequent black and blue discoloration.

The swelling and the discoloration are only visible if the deeper-lying muscles are bruised. Bruises must be given the RICE treatment. A minor swelling begins to recede after 48 hours. Recovery must then be stimulated with a hot shower, light massage, or gentle exercise below the pain limit. Extensive massage is out of the question during the first 24 to 36 hours, because this would damage the recovering tissues again. A doctor or a physiotherapist is the most suitable person to determine the severity of the bruising of a muscle, and to determine how to handle it. Inexpert treatment of a bruised muscle can result in the deposition of calcium in the muscle tissue, causing permanent functional impairment. Bruises can be avoided in the same way as broken bones, by protecting the vulnerable parts of the body with specific equipment such as shinguards and padding.

Sprains

A sprain involves damage to the tissues in and around a joint, usually the ligaments of the joint and their connections to the bone. Sometimes the surrounding muscles are also damaged and, in serious sprains, joint capsule. Depending on the severity of the sprain, the ligaments may be torn or ruptured. A sprain is a consequence of an abnormal movement. The joint that is most frequently sprained in soccer is the ankle. In addition, goalkeepers often sprain their wrists and fingers. The symptoms of a sprain can vary from:

• mild, short-lived pain;
• no or minimal swelling;
• no or slight impairment of function;
• slight tenderness to the touch;
• extreme, persistant pain;
• major swelling due to extravasation of blood in and around the joint immediately after the injury is sustained;
• complete loss of function;
• a cracking noise or sensation.

A mild sprain should be treated by cooling it and applying a pressure bandage. Sporting activity can then be resumed. Sport must not be carried out if:

• the joint becomes more painful;
• swelling occurs;
• the player’s movements clearly indicate a functional impairment.

A player who suffers a serious sprain must be immediately withdrawn from the training session or match. It is advisable to consult a doctor or visit a hospital within 24 hours. Knee and ankle sprains, which are very prevalent in soccer, can be avoided to some extent by providing the joints with more support. Research has shown that 75% of soccer ankle sprains are sustained by players who have previously had such a sprain. Soccer players who have “slack” ankle ligaments also have a higher risk of suffering sprains. This group of players should have their ankles taped during training sessions and games. It takes 6 to 9 months to recover completely from a serious sprain. During this period, it is advisable to tape the ankle. It is also good idea to strengthen the muscles. This must be done by means of specific exercises for the muscles that have a supporting function in the injured joint.

Dislocations

A dislocation is the most serious type of sprain. When a dislocation occurs, there is no longer any contact between the articulating bones that form the joint. This results in serious damage to the joint capsule and ligaments. Soccer players often dislocate a shoulder when they fall awkwardly. Goalkeepers regularly suffer longer dislocations when they catch the ball incorrectly. Ankle, knee and hip dislocations also occur. The symptoms of a dislocation are:

• extreme pain when at rest and in motion;
• swelling due to extravasation of blood;
• abnormal shape and position of the joint(this can be seen by comparing the right and left sides);
• loss of function due to complete inability to move the injured joint.

The joint must be returned to its correct position as soon as possible. A doctor should therefore be called in immediately. Unqualified persons should never try to put a dislocated joint back into place themselves. The only thing that an unqualified bystander can do is immobilize the joint. It is also advisable to cool the joint, so that the swelling will decrease. Under no circumstances should anyone with a dislocated joint continue playing. Dislocations are caused, in particular, by the considerable range of movement and the less efficient development of the ligament system and the corset of muscles around the joint. Good recuperation is vital after a dislocation. Incomplete recovery can result in reccurence of the dislocation. For this reason, players who suffer sprains must concentrate on strengthening and coordination exercises. If the muscles attached to the affected joint are strengthened, they can help to prevent a subsequent recurrence of the dislocation. Joints that have already been dislocated in the past should also be protected by a supporting brace, bandage or tape during training sessions and matches.

Bursal damage

Bursae can be compared to cushions filled with fluid. These small cushions are located between skin and bone and between tendon and bone. Bursae are found at sites where there is a lot of friction, or where a lot of pressure is exerted. The most familiar bursae are above the kneecap and behind the lowest part of the Achilles tendon or the knee tendon. Bursae have a protective function. They protect the underlying tissues against violent impacts, such as those that regularly occur when a goalkeeper lands on his hip or elbow. Acute bursal damage is associated with the presence of blood in the bursa. The blood can cause inflammation. Long-term irritation can also result in inflammation in and around a bursa. Acute damage is characterized by symptoms such as:

• rapid swelling;
• pain, together with reddening of, or damage to, the skin.

Persistent irritation is usually associated with the following symptoms:

• gradual swelling;
• local heat and reddening;
• painful movement, which becomes worse during sporting activity.

Bursal damage should initially be treated by rest, avoidance of any painful movements, keeping the site cool for 48 hours, and application of a pressure bandage. A doctor should then be consulted. A doctor can prick the bursa, remove blood and fluid and, if necessary, prescribe inflammation-inhibiting drugs. A physiotherapist can treat the bursal damage so that the inflammation process is brought to a stop more quickly. Sometimes the inflammation recurs, even if protective material is worn. The doctor in charge must decide whether an operation is necessary.

Muscle cramp

Every soccer player has suffered a muscle cramp at some time or other. When muscle cramp occurs, the muscle tenses and contracts of its own accord, which results in a very unpleasant feeling. Muscle cramp is usually experienced at the end of a very tiring match or training session. Soccer players suffer most from cramp in the calf muscles. It is treated by active stretching(pointing the toes towards the nose as far as possible, and stretching the calf muscles). Passive stretching by a teammate or a bystander must be carried out very carefully, to ensure that no tearing of the muscle fibers occurs. Another possibility is to grab hold of the muscle with one or both hands, and to stretch it diagonally while gently squeezing. Sporting activity must be resumed carefully, and must be stopped immediately if the cramp returns. Although this phenomenon is far from fully understood, there are a number of possible causes of muscle cramp:

• a slight muscle tear;
• excessive loss of fluid and salt;
• sudden cooling;
• disturbances of the blood circulation;
• lack of muscle fitness or general physical fitness.

Muscle cramp can best be treated by tensing the group of muscles whose action opposes that of the affected muscles. This causes a movement in the opposite direction(biceps/triceps, hamstring/quadriceps). Muscle cramp can be avoided by:

• maintaining a good level of physical fitness;
• wearing the correct(non-pinching) clothing;
• checking bandages, etc. during warming-up, to ensure that they do not pinch;
• drinking regularly if the weather is hot.