CHCA Blog

The Fan’s Guide to Sports Injuries

Clavicle Fractures

Clavicle (also known as collarbone) fractures are common injuries that occur in contact sports and in motor vehicle accidents.  The clavicle extends from the sternum to the shoulder in an “S” shape, acting as a strut to keep the shoulder and arm away from the sternum and thoracic cage, helping to stabilize the shoulder girdle, and allowing the arm a full range of movement.  In addition to the multiple muscle attachments on the clavicle, it also provides protection to vital neurovascular structures.  When the clavicle is fractured, it is necessary to make sure the broken ends of the bone are not compromising the neurovascular structures it protects.  There are three areas where a break occurs: the medial portion (closer to the sternum), the distal portion (closer to the shoulder), and the middle portion (in between the medial and distal zones).

Injury often occurs when there is a direct force applied to the shoulder or from falling on an outstretched arm.  With contact sports like football, it is most commonly found when the athlete is tackled and lands on their side, primarily on the shoulder. (Interesting side note: clavicle fractures were the most common fractures that occurred on RAGBRAI from data collected 2004-2008. Most likely due to falling off the bike onto the shoulder.) The force of the tackle is transmitted through the collarbone, the “S” shape makes the forces overload the middle section of the bone.  This is likely why 70-80% of clavicle fractures occur in the middle portion. Once the bone is fractured, it is easily visualized with a lump and swelling over the involved area.  The clavicle is a superficial structure, so any bump or alteration to the bone is very identifiable.  When the athlete explains to the sports medicine staff what happened you commonly see them palpate along the clavicle to feel for any disruption in the normal contour of the bone.  In football players this means the athletic trainer will go under the shoulder pads to feel along the bone.  After the fracture occurs, other signs and symptoms present include pain, often severe sagging of the shoulder in a down and forward position, and an inability to lift the arm due to pain.  After the initial injury, the arm of the affected clavicle is placed in a sling and immobilized.  Healing times depend on age; in adults, healing could take up to eight weeks, in younger individuals it may take six.

The major objectives of rehabilitating a clavicle fracture are to:

- increase flexibility in the shoulder

- establish pain-free range of motion in shoulder  

- strengthen the muscles of the shoulders, upper back, chest, and upper arms.  

Maximum Protection Phase

Initially the shoulder will be immobilized with the arm in a sling.  Ice is used to help reduce pain and inflammation.  When the arm is out of the sling without pain, the athlete can progress into more activity.  Exercises in this phase focus on keeping movement.  Pendulum-type exercises called Codman’s exercises are utilized.  This very simply is the athlete bent at the waist, allowing the arm to hang freely while small movements back and forth and in clockwise/counterclockwise movements are performed.

Moderate Protection

As healing progresses and no pain is present with movement, more involved exercises can occur.  Arm movements that help to strengthen the muscles of the chest and back (like bicep curls, arm raises, tricep extensions, and shrugs) are initiated without the use of weights.  These movements are gradually increased in demand; incorporating underwater resistance, thera-bands, and ultimately weights.

Return to Play

Return to full participation should be avoided until the fracture is healed – as evident on x-ray – and movements of the shoulder are equally strong compared to the other side.  When performing the skills specific to the sport, no pain should be present.  If an athlete returns before strength is back or the fracture is healed, there is a higher incidence of re-injury.  This is especially true when the sport involves heavy contact, such as with a running back that could be tackled on a previously injured shoulder.

Generally, the athlete who wishes to return to a contact sport should expect to be out of action for 6 to 12 weeks.  The time to return to full activity depends on the severity of the injury, dedication of the athlete to remain in a rehabilitation program, position the athlete plays, and strength of the athlete.  It is important to evaluate each athlete on an individual basis.

Michael Tunning D.C., ATC

Dr. Tunning is a faculty member at Palmer College of Chiropractic in the Diagnosis and Radiology Department.  He also is an Associate at Chiropractic Healthcare Associates in Cedar Rapids, IA focusing in all musculoskeletal injuries as well as athletic injuries.  Dr. Tunning is a member of the Iowa Athletic Trainer’s Society, the Iowa Chiropractic Society and is a member of the American Chiropractic Association’s Sports Council working as the liaison to the National Athletic Trainer’s Association.

For more information please visit www.chiroassoc.com

Injury to the Hamstring

Hamstring injuries can occur at the most inopportune times.  Strain to this muscle is most likely to occur during high speed activities, specifically during running just prior to the foot hitting the ground.  Sprinters most commonly experience hamstring strains in the final straightaway, as evidenced by “pulling up” with the leg locked while grabbing the back of the thigh.  The same presentation occurs with football players on a breakaway play: with one opponent left to beat, the player will pull up and grab the back of the leg.  The similarity between these two events is that the athlete pushes for greater speed.  There are many theories as to why this injury occurs: inadequate flexibility, inadequate strength, an imbalance in the ratio of strength between the quad (muscles on the front of the thigh) and hamstrings (muscles on the back of the thigh), leg length inequalities, electrolyte depletion, and an improper warm-up.

In a study of one NFL team from 1998-2007, the occurrence of hamstring injuries accounted for 85 injuries, second only to knee sprains, which accounted for 120 injuries (1).  This injury tends to give athletes continuous problems, giving the illusion that the initial injury never healed.  The recurring problems could actually be from re-injury rather than a single persistent injury.  The scar tissue that may take over is weaker than normal muscle tissue, increasing the risk of injury with even less intense activity.  Statistics show that re-injury to the hamstring occurs in about one-third of athletes, most commonly within the first two weeks upon return to play.  This places extreme importance upon evaluation of the severity of the injury and the resultant rehabilitation program to ensure that the athlete is strong enough to return to competition without the threat of re-injury.  Rehabilitation for this injury could take anywhere from 2-6 weeks or longer depending on severity.  Much like in the previous article on ACL injuries, we will break down the evaluation of the injury and the phases of rehabilitation in order to return to play.

On-field injury

When an athlete injures the hamstring, as in the examples previously described, the certified athletic trainer and sports medicine staff already know it is injured by the characteristic pulling up and grabbing the back of the thigh.  When the ATC or other staff come onto the field and work with the athlete, they are not assessing the presence of the injury as much as they are starting to evaluate the location (whether the strain is closer to the knee or the buttock), and the severity (visible tear or substantial pain).  The sports medicine staff already knows the structure that is injured; they are now narrowing the focus to determine the prognosis.  They are attempting to determine if surgery will be needed and the approximate time the athlete may miss.  In the worse cases of the muscle tearing, the muscle fibers will ball up giving the illusion of a Titleist or racquetball under the skin.  The hamstring is a complex muscle.  At the typical time the hamstring is injured during running, one end of the muscle is shortening while the other end of the muscle is lengthening; the muscle is in effect trying to stabilize at one end and produce substantial force at the other.  The difference in pull is a main reason why this muscle has to have the flexibility to overcome these forces.  Without flexibility, the incidence of injury increases.

When determining the severity of the injury, the sports medicine team will categorize the strain into one of three grades based on strength, range of motion, and palpation (feeling the consistency of the muscle tissue).  These criteria for grading the injury are based upon comparison to the uninjured leg.  With a grade 1 strain there will be some pain, minimal loss of motion and minimal loss of strength.  With a grade 2 strain there will be a larger area of pain, increased swelling, moderate loss of strength and motion.  With a grade 3 strain there is a definite rupture of the muscle (think back to the Titleist/racquetball image) with no strength and very little motion.

Maximum Protection Phase

Initially, the emphasis of treatment is on restoring and keeping the range of motion.  However too much stretching and movement could result in more dense scar formation, limiting the muscle healing.  The athlete is instructed to move the leg in a motion that does not cause pain, this will represent the motion that the athlete can move without stressing the injured muscle tissue.  Walking may initially be painful, in which case the athlete will use crutches or shorten the stride length.  The goals of this phase focus on protecting the injured muscle and minimizing muscle atrophy or decreased strength.  Exercises are only to be performed if they do not increase or cause pain.  These include riding a stationary bike, side stepping, running in place, core exercises (abdominals and low back), and easy isometric activation (contracting the muscle without moving the leg).  In order for the athlete to progress into the next phase, he/she must have a normal, pain-free walking stride length; must be able to jog at low speed without pain; and should have improved strength to 50-70% against resistance without pain.

Moderate Protection Phase

Activities begin to incorporate more complex movements and sport-specific tasks during this stage.  If an activity starts to cause even minimal pain it is stopped.  Goals during this phase include regaining full pain-free strength in the hamstring both in a shortened state and when the leg is straight.  The hamstring is most likely injured when the leg is fully extended, just before the foot hits the ground.  In this position the hamstring is at its longest; it is therefore important to evaluate for adequate strength while mimicking the injurious action before moving to the next phase.  As with any injury, moving on to more complex tasks before the athlete is ready can result in re-injury and even longer time away from competition.  Exercises during this phase will still include all the exercises from the previous phase and start to bring in a few more complex activities such as lunges and single leg balance movements.  In order to progress to the next phase, there should be normal strength and no pain, and the athlete should have the capability of jogging pain-free forward and backward at a moderate intensity.

Minimal Protection and Return to Play

It may seem during this last stage that the hamstring simply will not loosen up.  Therapies such as Active Release Technique and soft tissue mobilization are performed to help the muscle regain elasticity and strength.  These techniques work to break up and release the weakened scar tissue allowing the muscle to function better.  Important goals for this phase include improving running coordination of the trunk and pelvis (neuromuscular control), sport-specific activities such as quick starts and stops, and improving strength.  Exercises will continue to be used from the previous phases, but their intensity and focus on quality of movement is increased.  Some movements that have been shown to help strengthen and reduce re-injury include high-knee marching, quick running drills, forward-falling running drills, explosive start drills, and eccentric muscle actions (muscle is lengthened while it is activated).

More research is being performed each day to identify the causes of hamstring injuries and develop strategies to prevent occurrence and reduce prevalence.  A recent study involving an Australian Rules football club even showed a link between chiropractic adjusting/manipulation to the pelvis and decreases in hamstring injury incidence (3).  No matter the sport or the intervention, this injury is one that causes a multitude of problems and time away from competition.  More knowledge on prevention and rehabilitation of hamstring injuries is a focus of many sports medicine practitioners.

Michael Tunning D.C., ATC
Dr. Tunning is a faculty member at Palmer College of Chiropractic in the Diagnosis and Radiology Department. He also is an Associate at Chiropractic Healthcare Associates in Cedar Rapids, IA focusing in all musculoskeletal injuries as well as athletic injuries. Dr. Tunning is a member of the Iowa Athletic Trainer’s Society, the Iowa Chiropractic Society and is a member of the American Chiropractic Association’s Sports Council working as the liaison to the National Athletic Trainer’s Association.

For more information please visit www.chiroassoc.com

References

(1.) Heiderscheit B, et al. Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitation and Injury Prevention.  J Orthop Sports Phys Ther. 2010 February; 40(2):67-81

(2.) Hammer, Warren. Functional Soft-Tissue Examination and Treatment by Manual Methods. Sudbury, MA: Jones and Bartlett, 2007

(3.) Hoskins W, Pollard H. The Effect of a Sports Chiropractic Manual Therapy Intervention on the Prevention of Back Pain, Hamstring and Lower Limb Injuries in Semi-Elite Australian Rules Footballers: A Randomized Controlled Trial. BMC Musculoskeletal Disord. 2010 April 8;11:64

(4.) Kisner, Carolyn; Lynn Allen Colby. Therapeutic Exercise Foundations and Techniques. Philadelphia:FA Davis Company, 2007.