Sports Injuries

Individuals that experience nerve pain in the foot could be caused by a number of different conditions, can recognizing the most common causes help in developing an effective treatment plan?

Nerve Pain In The Foot

These sensations can feel like a burning, shooting, electrical, or stabbing pain and can happen while in motion or at rest. It can occur on the top of the foot or through the arch. The area closest to the nerve may be sensitive to the touch. A number of different conditions can cause nerve pain in the foot, including:

• Morton's neuroma
• Pinched nerve
• Tarsal tunnel syndrome
• Diabetic peripheral neuropathy
• Herniated disc

Morton's Neuroma

Morton's neuroma involves the nerve that runs between the third and fourth toes, but can sometimes occur between the second and third toes becoming thicker. Typical symptoms include a burning or shooting pain in the area, usually while walking. (Nikolaos Gougoulias, et al., 2019) Another common symptom is the sensation of pressure beneath the toes like the sock is bunched up underneath. Treatments can include:

• Arch supports
• Cortisone injections to decrease swelling
• Footwear modifications - can include lifts, orthotics combined with metatarsal pads, and rocker soles, to provide cushion where needed.

Things that increase the risk of developing the condition include:

• Regularly wearing high-heels - the condition occurs more frequently in women.
• Shoes that are too tight.
• Participating in high-impact sports like running.
• Having flat feet, high arches, bunions, or hammertoes.

Pinched Nerve

A pinched nerve can feel like shooting or burning pain. Nerve entrapment can occur in various regions of the foot or the area on top of the foot may feel sensitive. Causes can be caused by: (Basavaraj Chari, Eugene McNally. 2018)

• Trauma that causes swelling.
• Blunt impact.
• Tight shoes. 

Treatment can include:

• Massage
• Physical therapy
• Rest
• Footwear modifications
• Anti-inflammatories.

Things that increase the risk of developing a pinched nerve in the foot include:

• Poor-fitting footwear.
• Repetitive stress injury.
• Trauma to the foot.
• Obesity.
• Rheumatoid arthritis.

Tarsal Tunnel Syndrome

Another type of nerve entrapment is tarsal tunnel syndrome. Tarsal tunnel syndrome is "anything that produces compression on the posterior tibial nerve." (American College of Foot and Ankle Surgeons. 2019) The tibial nerve is located near the heel. Symptoms include numbness and foot cramps, burning, tingling, or shooting sensations that often radiate from the instep/arch. Both can worsen while the foot is at rest, like when sitting or sleeping. Treatment can consist of:

• Placing padding in the shoe where the foot is being compressed to relieve the pain.
• Custom foot orthotics.
• Cortisone shots or other anti-inflammatory treatments.
• Surgery may be necessary to release the nerve.

Conditions that compress the tibial nerve and can lead to tarsal tunnel syndrome include:

• Flat feet
• Fallen arches
• Ankle sprain
• Diabetes
• Arthritis
• Varicose veins
• Bone spurs

Diabetic Peripheral Neuropathy

Long-term high blood sugar/glucose associated with diabetes can lead to a form of nerve damage known as peripheral neuropathy. (Centers for Disease Control and Prevention. 2022) Neuropathy pain feels like burning or shooting pain, or the sensation of walking on bubble wrap that usually shows up overnight. The pain can come and go as well as a gradual loss of feeling in the feet that begins in the toes and moves up the foot. It's estimated that around half of individuals with diabetes will eventually develop neuropathy. (Eva L. Feldman, et al., 2019) Treatments can include:

• Physical therapy massage to increase circulation.
• Topical treatments with capsaicin.
• Vitamin B.
• Blood sugar management.
• Alpha lipoic acid.
• Medication.

Individuals with diabetes have an increased risk of developing peripheral neuropathy if:

• Blood sugar is not well-controlled.
• Diabetes has been present for many years.
• Kidney disease.
• Smoke.
• Overweight or obese.

Herniated Disc

Nerve pain in the foot can be caused by spinal issues. A herniated disc in the lower back can irritate and compress the nerves, causing pain that radiates down the leg and foot. Additional symptoms usually include muscle weakness in the legs and/or numbness and tingling. Most herniated discs don't require surgery and get better with conservative treatment. (Wai Weng Yoon, Jonathan Koch. 2021) If symptoms don't improve or worsen, a healthcare provider may recommend surgery. Herniated discs are most common in young and middle-aged adults. Increased chances of developing a herniated disc can come from:

• Degenerative changes in the spine from normal age wear and tear.
• Physically demanding job.
• Lifting incorrectly.
• Overweight or obese.
• Genetic predisposition - family history of herniated discs.

Spinal Stenosis

Spinal stenosis occurs when the spaces in the spine begin to narrow, creating pressure on the spinal cord and nerve roots. It is usually caused by wear and tear on the spine as the body ages. Stenosis in the lower back can cause burning pain in the buttocks and leg. As it progresses pain can radiate into the feet along with numbness and tingling. Conservative treatment consists of physical therapy exercises and non-steroidal anti-inflammatory medications/NSAIDs. (Jon Lurie, Christy Tomkins-Lane. 2016) Cortisone injections can be beneficial and if the condition worsens, surgery may be an option. Risk factors include:

• Age 50 or older.
• A narrow spinal canal.
• Previous injury.
• Previous spinal surgery.
• Osteoarthritis that is affecting the back.

Other Possible Causes

Other conditions can result in nerve damage and pain symptoms and sensations. Examples include: (Nathan P. Staff, Anthony J. Windebank. 2014)

• Vitamin deficiencies (Nathan P. Staff, Anthony J. Windebank. 2014)
• Physical trauma - after surgery or an automobile or sports accident.
• Certain cancer, antiviral medications, or antibiotics.
• Complex regional pain syndrome.
• Tumors that irritate and/or compress a nerve.
• Liver or kidney disease.
• Infectious diseases - Lyme disease complications or viral infections.

Nerve pain in the foot is definitely a reason to see a healthcare provider. Early diagnosis can help prevent symptom progression and future problems. Once the cause of the pain has been identified, the healthcare team can work together to develop a personalized treatment plan to release compressed nerves and restore mobility and function. See a healthcare provider right away if the pain and symptoms worsen, or if there are difficulties standing or walking.

Chiropractic After Accidents and Injuries

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please contact Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Gougoulias, N., Lampridis, V., & Sakellariou, A. (2019). Morton's interdigital neuroma: instructional review. EFORT open reviews, 4(1), 14–24. https://doi.org/10.1302/2058-5241.4.180025

Chari, B., & McNally, E. (2018). Nerve Entrapment in Ankle and Foot: Ultrasound Imaging. Seminars in musculoskeletal radiology, 22(3), 354–363. https://doi.org/10.1055/s-0038-1648252

American College of Foot and Ankle Surgeons. Tarsal tunnel syndrome.

Centers for Disease Control and Prevention. Diabetes and nerve damage.

Feldman, E. L., Callaghan, B. C., Pop-Busui, R., Zochodne, D. W., Wright, D. E., Bennett, D. L., Bril, V., Russell, J. W., & Viswanathan, V. (2019). Diabetic neuropathy. Nature reviews. Disease primers, 5(1), 42. https://doi.org/10.1038/s41572-019-0097-9

Yoon, W. W., & Koch, J. (2021). Herniated discs: when is surgery necessary?. EFORT open reviews, 6(6), 526–530. https://doi.org/10.1302/2058-5241.6.210020

Lurie, J., & Tomkins-Lane, C. (2016). Management of lumbar spinal stenosis. BMJ (Clinical research ed.), 352, h6234. https://doi.org/10.1136/bmj.h6234

Staff, N. P., & Windebank, A. J. (2014). Peripheral neuropathy due to vitamin deficiency, toxins, and medications. Continuum (Minneapolis, Minn.), 20(5 Peripheral Nervous System Disorders), 1293–1306. https://doi.org/10.1212/01.CON.0000455880.06675.5a

Triathlon training involves running, biking, and swimming. This much fitness training takes a toll on the body. Pulled hamstrings, twisted ankles, and sore heels are common, but triathlon training can also cause or worsen back pain. Because the back muscles are connected to many other muscles, certain types of movement after a tough training session can present with back pain. There was an Ironman triathlete study that found that 90% of the athletes suffered some form of soft-tissue injury during training, with 70% reporting low back pain and/or sciatica. A 2020 study in BMC Musculoskeletal Disorders found that 14% of recreational half-marathon runners presented with low-back pain.

Triathlon Training Hard on the Back

High-impact activities/exercises, constant repetitive motion, places a heavy pounding on the body that impacts the joints and spine. Using improper techniques will aggravate any issues. The stresses applied from repetitive motions, and poor form can lead to the joints breaking down. If new to intense training the muscles might not be strong enough yet, which could also cause back pain and injury. The back stabilizer muscles tend to get neglected in the training, but these muscles support the structures in the midline, spine, and joints. Strengthening the:

• Base muscles
• Glutes
• Back muscles
• Core
• Ensures stability of the spine and joints from all the wear and tear.

Training and Overtraining Errors

Even veteran athletes can make mistakes during their training that can lead to sore backs. The biggest mistake individuals make during triathlon training is that they only swim, bike, and run. Training for the specific sport/s is important; but weight lifting, core strengthening, and flexibility training are just as important. Proper rest can become neglected as the individual wants to get in as much training as possible that often gets overlooked, leading to overuse injuries. However, rest is a vital part of training to allow the body to fully recover and operate at full and optimal potential.

Preventing and Avoiding Back Pain When Training

How to sidestep back pain altogether during training includes:

Sleep

A healthy lifestyle includes proper sleep cycles and is even more important during training. The mental aspects a triathlon competition can create require proper rest. Fatigue can also lead to poor technique/form, placing excess stress on the joints and the spine, leading to injury.

Flexibility

Muscles need to maintain flexibility to preserve function and recovery ability. After a training session stretching and working on flexibility will help with overall performance. Stretching should be done after activity when the muscles are warm, and the fibers can be stretched/elongated for optimal recovery.

Proper nutrition

The body needs high-performance fuel to support high-calorie deficits that are associated with intense training and competition.

Strengthening the body

Having a solid body foundation is the objective. Everything is balanced with strong muscles supporting healthy bones. Specific exercises that target the multifidus muscles. These are the body's back brace. Strengthening these muscles will help prevent spinal injury/s. Back-strengthening exercises include:

• Cat-cow stretch
• Glute bridges
• Bird dog
• Planks
• Mobility stretches

Rest days no matter what

Plan rest days no matter what. Pushing through will not make the body stronger or able to perform better, and could cause performance to decrease leading to injury. This does not mean sleeping all day, but engaging in active recovery where the body gets the rest it needs while still maintaining fitness. Active recovery includes:

• Moving
• Stretching
• Foam rolling
• Sports chiropractic massage
• Body rejuvenation
• Body and mind exercises
• Allows for a thorough recovery and enhances training.

Technique Improvement

Proper form and technique can really make the difference between staying injury-free and injury/s. Using the right form promotes healthy function. It could help to have gait, swim stroke, and bike techniques evaluated by a professional to ensure that proper form is being utilized.

Body awareness

Stop if the body signals one to stop. This is why the body feels pain. It is the internal mechanism that tells the individual something is wrong. It is not recommended to follow the phrases train through the pain, and no pain, no gain. Individuals are recommended to:

• Always pay attention if pain presents and does not go away after exercising or warming up.
• Pain that limits function.
• Pain that interferes with daily activities.
• These could significantly exacerbate a spinal injury and should be checked by a doctor.

Body Composition

Rest and Recovery

During rest and recovery, the body goes back to normal or homeostasis. This is the body’s resting rate or normal phase. The body is always trying to go back to homeostasis. This is done by:

• Maintaining core temperature regulated
• Blood pressure stable
• Muscles refreshed

When exercising/training, the homeostasis phase is disturbed, meaning the body needs a period of rest to return to normal. The process of homeostasis uses a lot of energy, which results in an abundant amount of calories burned. After exercise, there is an increase in excess post-exercise oxygen consumption or EPOC. The body uses up more oxygen during recovery than it does before or during exercise. This increase results in burned calories and strong muscles. The most important part of recovery is the rebuilding of muscle. When working out, especially resistance training, tiny tears are made in the muscle fibers. For the tiny tears to turn into growing muscles, they need to repair themselves. This happens during rest. Apart from the physiological benefits, rest helps prevent injury caused by overuse and assists in healing when injuries do occur. Time off helps with mental health as well to refocus, reassess, and apply what has been learned. What rest and recovery can do for the body includes:

• Burn massive calories
• Build muscle
• Refuels the muscles
• Prevents injury
• Improves mental health and motivation

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

American journal of physical medicine & rehabilitation/Association of Academic Physiatrists. (October 2014) “Efficacy of Aerobic Exercise for Treatment of Chronic Low Back Pain: A Meta-Analysis” https://www.researchgate.net/publication/266682158_Efficacy_of_Aerobic_Exercise_for_Treatment_of_Chronic_Low_Back_Pain_A_Meta-Analysis

Scientific Reports. (April 2017) “Running exercise strengthens the intervertebral disc” https://www.researchgate.net/publication/316262547_Running_exercise_strengthens_the_intervertebral_disc

Stretch Before and After Journal of Chiropractic Medicine. (Winter 2003) “Changes in low back pain in a long-distance runner after stretching the iliotibial band” https://www.sciencedirect.com/science/article/pii/S0899346707600718

Individuals can become overly passionate about exercising. However, constantly training the body without taking enough time to rest and recover can impact athletes and fitness enthusiasts physically and mentally and lead to overtraining syndrome. Excessive training can cause decreases in athletic physical performance that can be long-lasting, sometimes taking several weeks or months to recover. Individuals who don't learn to manage overtraining can have injuries and more frequent illnesses and infections. And the psychological effects can also lead to negative mood changes. Learn the signs and how to cut back to prevent injury and/or burnout.

Overtraining Syndrome

Athletes and fitness lovers often exercise longer and harder than average to reach peak performance. Even individuals just getting started with exercise can push their limits as they try to figure out what works for them. This means taking into consideration the following:

• The mental side of training.
• How to get and stay motivated.
• How to set up a safe and effective program with balanced cardio and strength training.
• How to avoid skipping workouts when things get in the way.
• Exercising too much is a mistake many beginners make, putting themselves at risk for injury.

Overtraining syndrome is when the body goes through and feels:

• Extreme fatigue.
• Physical performance problems.
• Mood changes.
• Sleep disturbances.
• Other issues due to working out or training too much and/or too hard without giving the body enough time to rest.

Overtraining is common among athletes who train beyond their body's ability to recover, usually when preparing for a competition or event. Conditioning for athletes and enthusiasts requires a balance between work and recovery.

Signs and Symptoms

There are several signs to look for, with the more common symptoms being:

• Mild muscle or joint soreness, general aches, and pains.
• Decreased training capacity, intensity, or performance.
• Lack of energy, constantly tired, and/or drained.
• Brain fog.
• Insomnia.
• Decreased appetite or weight loss.
• Loss of enthusiasm for the sport or exercise.
• Irregular heart rate or heart rhythm.
• Increased injuries.
• Increased headaches.
• Feeling depressed, anxious, or irritable.
• Sexual dysfunction or decreased sex drive.
• Lower immunity with an increase in colds and sore throats.

Prevent Overtraining

• Predicting whether there is a risk of overtraining can be tricky because every person responds differently to various training routines.
• Individuals have to vary their training throughout and schedule adequate time for rest.
• Individuals who believe they may be training too hard should try the following strategies to prevent overtraining syndrome.

Take Note of Mental and Mood Changes

Methods exist to test for overtraining objectively.

• One is taking note of psychological signs and symptoms associated with changes in an individual's mental state can be an indicator.
• Decreased positive feelings for exercise, physical activities, and sports.
• Increased negative emotions, like depression, anger, fatigue, and irritability, can appear after a few days of intense training.
• If these feelings and emotions begin to present, it is time to rest or dial the intensity down.

Training Log

• A training log that notes how the body feels daily.
• It can help individuals notice downward trends and decreased enthusiasm.
• This can help individuals learn to listen to their body's signals and rest when necessary.

Monitor Heart Rate

• Another option is to track changes in heart rate over time.
• Monitor heart rate at rest and specific exercise intensities while training, and record it.
• If the heart rate increases at rest or a given intensity, this could be a risk indicator, especially if symptoms develop.
• Track resting heart rate each morning.
• Individuals can manually take a pulse for 60 seconds immediately after waking up.
• Individuals can also use a heart rate monitor or fitness band.
• Any marked increase from the norm may indicate that the body has not fully recovered.

Treatment

Rest and Recovery

• Reduce or stop the exercise and allow the mind and body a few rest days.
• Research on overtraining shows that complete rest is the primary treatment.

Take Extra Rest Days

• Starting anything new will usually make the body sore.
• Be prepared for the aches and take extra rest days when needed.
• The body won't have the same energy levels from day to day or even from week to week.

Consult A Trainer

• Not sure where to start or how to approach working out safely.
• This is the time to meet with a professional who can look at physical and medical history, fitness level, and goals.
• They can develop a customized program to meet specific needs.

Nutrition and Hydration

• Maintain optimal body hydration with plenty of H2O/water and rehydrating drinks, vegetables, and fruits.
• Staying properly hydrated is key to both recovery and prevention.
• Getting enough protein and carbohydrates supports muscle recovery.
• Carbs are important for endurance, and protein is important for muscular strength and power.

Sports Chiropractic Massage

• Research shows that sports massage benefits muscle recovery and can improve delayed onset muscle soreness/DOMS.
• Massage keeps muscles loose and flexible and increases blood circulation for expedited recovery.

Relaxation Techniques

• Stress-reduction techniques such as deep breathing and progressive muscle relaxation exercises can improve rest and recovery.

Total recovery from overtraining syndrome can take a few weeks or longer, depending on the individual's health status and how long the excessive training has gone on. A physician can refer individuals to a physical therapist or sports chiropractor, who can develop a personalized recovery plan to get the body back to top form.

Military Training and Chiropractic

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, don't hesitate to get in touch with Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Bell, G W. "Aquatic sports massage therapy." Clinics in sports medicine vol. 18,2 (1999): 427-35, ix. doi:10.1016/s0278-5919(05)70156-3

Carrard, Justin, et al. "Diagnosing Overtraining Syndrome: A Scoping Review." Sports Health vol. 14,5 (2022): 665-673. doi:10.1177/19417381211044739

Davis, Holly Louisa, et al. "Effect of sports massage on performance and recovery: a systematic review and meta-analysis." BMJ open sport & exercise medicine vol. 6,1 e000614. 7 May. 2020, doi:10.1136/bmjsem-2019-000614

Grandou, Clementine, et al. "Symptoms of Overtraining in Resistance Exercise: International Cross-Sectional Survey." International Journal of sports physiology and Performance vol. 16,1 (2021): 80-89. doi:10.1123/ijspp.2019-0825

Meeusen, Romain, et al. "Brain neurotransmitters in fatigue and overtraining." Applied physiology, nutrition, and metabolism = Physiologie applique, nutrition et metabolisme vol. 32,5 (2007): 857-64. doi:10.1139/H07-080

Peluso, Marco Aurélio Monteiro, and Laura Helena Silveira Guerra de Andrade. "Physical activity and mental health: the association between exercise and mood." Clinics (Sao Paulo, Brazil) vol. 60,1 (2005): 61-70. doi:10.1590/s1807-59322005000100012

Weerapong, Pornratshanee, et al. "The mechanisms of massage and effects on performance, muscle recovery, and injury prevention." Sports medicine (Auckland, N.Z.) vol. 35,3 (2005): 235-56. doi:10.2165/00007256-200535030-00004

How frequently have patients said something like, "I've been resting my leg since the injury so it doesn't get worse"? Injury expert, Dr. Alexander Jimenez looks at the use of 'rest' in acute injury management.

Introduction

History Of Rest Vs Activity

Differences of opinion relating to activity compared to rest date back to the early 1700s(3). Several high profile researchers and doctors in the 1700s and 1800s encouraged the benefits of motion and loading . Julius Wolff published his research to what we now refer to as Wolff's law of bone loading to invigorate the adaption of bone remodeling and recognized. Lucas- Championniere went farther in the 1800s to say that the healing response time accelerated with rest inhibiting muscle, cartilage and ligament regeneration and remodeling.

In contrast, their contemporaries John Hilton and John Hunter widely recognized rest as an important treatment modality, suggesting that early motion was a cause of increased bleeding which eased adhesion formation(3). Researchers during the 1800s had scientific evidence available pertaining to tissue recovery to support their claims of movement. Consequently, rest became the favored safe strategy, especially for patients with acute back pain and mattress rest undoubtedly became a frequent feature of lumbar spine rehabilitation(4). Bed rest became a precursor to the disablement of the human motor system amongst patients with musculoskeletal injury, which predisposed the patient to additional health complications(3). Current evidence now relates to that of the initial findings of Championnaire, which gives rise to a movement and tissue loading approach.

Suggested Acronym Alternatives

Other acronyms which were suggested within the literature and clinical practice include MICE(5) (movement, ice, compression and elevation) and PRICE, with 'rest' being replaced with 'restricted activity and controlled mobility'(6). An acronym recently published in the British Journal of Sports Medicine is the POLICE guidelines (Box 1) that changes rest for optimal loading(1). However, it is essential to protect the injured body part during the inflammatory stage in the first 3-6 days to prevent bleeding.

It's essential to protect the tissue from damage and to handle pain. To provide protection, braces crutches and strappings are often used as treatment tools. It is important not to just think about loading from a standing perspective from a standing standpoint but also to include moves in sitting, supine or side lying too with gravity assisted or removed (1). It's the expertise of the clinician that ought to determine the amount of loading appropriate for severity and the character of the tissue. The ice, compression and elevation (ICE) components of POLICE continue to be essential as part of the initial stages of the management of an acute injury to handle the inflammatory response. In certain situations, it's critical to keep an structure motionless to allow for repair, but movement is advised to promote the formation of collagen networks.

Consequences Of The Term 'Rest'

An individual will be advised that rest (combined with ice, compression and elevation) is the appropriate treatment and they'll perceive that as when they were told to do 'nothing'. For the novice exerciser, being advised to rest may mean that they have a return to activity or perhaps don't return at all which could have a significant impact on their health to game. For the elite athlete, being told to rest may have impacts that are emotional during the rehab process that they cannot do some kind of conditioning. Although one body part may be injured, with loading this is an fantastic opportunity for the individual to maintain their physical state and to work on areas that are poorer. This is where the therapist's skills come to prevent excessive or undesirable loading to the part. For instance, a grade 1 muscle strain requires 'rest' from the field of play but not break from activity and demands controlled loading. The diagram in Box 2 illustrates the patient should be encouraged by a therapist to perceive an injury, which is a fantastic opportunity to develop skills and conditioning rather than to rest, which the RICE protocol encourages.

The remodeling of scar tissue is most effectively influenced immediately after the inflammatory phase of repair as scar tissue is more pliable at this point(3). Scientists from the University of Tampere, Finland, stated that after a muscle tear the limb needs to be immobilized initially, to allow for a sufficient scar to form before activity is recommenced within the limits of pain(7). However, restricting movement over a longer period allows for the orientation of the scar tissue to not be put down in the direction of the applied stress (Box 3)(3). As the construction is positioned ultimately, during healing, it is optimal for the tissue fibers to align in the direction of stress. A factor is that re-injury could occur if the collagen fibers are not uniformly aligned in the direction of stress.

Mechanotherapy

Mechanotransduction is a term used for evolving physiological processes evident throughout the human body(2). The skeleton is an example as it lays cells down through a network of bone cells, ie the mentioned Wolff's law. Without physical loading the process of regulation is weak and bone cells are not able to be distributed efficiently and subsequently . Researchers from the University of Queensland, Australia, used a randomized controlled trial design with assessor blinding to measure the effect of an applied pneumatic cuff pressure in patients with a distal radius fracture(8). Twenty-one patients were allocated to either the treatment (with cuff pressure) or control group with both groups performing grip strength exercises for six months whilst immobilized and four weeks post-immobilization. The results yielded increased muscle strength in the treatment group from week one to week 10 as measured by a power grip test. Furthermore, at 10 weeks post-fracture the treatment group had 10-15 percent more range of movement than the control group and was 24-29 % more powerful. It is clear how controlled loading during fracture healing has the capacity although this was a study.

A research carried out by scientists at the University of Ulster, Ireland, found that ancient exercises for grade 1 and 2 ankle sprains started during the first week of rehabilitation significantly accelerated tissue healing(9). The study was a randomized controlled trial design, with assessor blinding, whereby 101 participants were allocated to either a group that is PRICE or a PRICE group with ankle exercises to improve range of strength and movement. There were significant gains in the time spent walking, step count and time being physically active in the therapy group. There were, however, no substantial differences observed during swelling and activity in pain. The re-injury speed was 4% (two participants from either group). This is an example of optimizing and enhancing the integrity of the ankle ligaments can promote scar tissue formation to encourage an early return.

Early passive motion is recommended for joint injuries and post-surgical interventions like cartilage defects undergoing repair(5). Continuous passive motion (CPM) is an example of providing movement using a low-level 'optimal loading' whilst in a non or touch weight bearing position to promote fluid drainage. It's vital to track the forces of surgically-treated cartilage defect with low loads and with use of a CPM machine for 6-8 hours each day for 6-8 weeks allows for enhanced grade of injury(10). It forms an abundance of data pertaining to movement after articular cartilage repair although this research is dated. This reinforces the need for another approach to the 'rest' aspect of the RICE protocol, which the POLICE acronym provides: that opportunity for loading.

Achilles tendinosis is a injury within a clinic and has proved hard to treat. In a Achilles tendon there's a concentration of the neurotransmitter glutamate but not the inflammatory substance prostaglandin E2 in normal tendons. There is no chemical inflammation present in the chronic stage of the injury(11). Researchers from the University Hospital of Emeå, Sweden, analyzed the effect of eccentric loading in 25 patients' tendons (26 tendons in total) using focal tendon thickening, hyperechoic regions and irregular limb structure. All patients were followed up after 3.8 years(12). The patients had symptoms averaging 17 months prior to eccentric loading. At followup, 22 of the 25 were satisfied with the treatment provided and that tendon thickness had decreased on ultrasonography. There were no areas identified at follow- up. This research reaffirms the requirement and the best loading is vital in contrast to the age-old 'rest' approach.

Patellofemoral pain syndrome is a frequent diagnosis in sports injury clinics and is efficiently managed through strengthening exercises for the vastus medialis muscle to give medial control to the patellofemoral joint(13). This study was a randomized controlled trial design, with assessor blinding, which investigated patients with a history of anterior pain during simple exercises(14). The treatment group were supplied with a comprehensive rehabilitation program for six weeks to be completed daily (Box 4). The results indicated significant improvement during stair ascent following the analysis and at eight months follow-up in VMO activation. This advancement in VMO firing had the capacity to reduce symptoms of pain proximal to the joint. This is an excellent example of optimal loading with steps to reduce pain by resting from aggravating activities but not resting from strength exercises.

Summary

The review has highlighted and reemphasized the requirement during the early phases of rehabilitation of loading and movement to increase tissue healing. Although movement is broadly used by therapists and controlled loading in their rehab protocols, it is very important that we look at moving on to an acronym commensurate with movement and loading, which the POLICE acronym acknowledges well from RICE. It is essential to be able to influence the phase of healing, that the therapist explains the value of optimal loading. Patients should be encouraged to use the term POLICE in sports injury practices and they should be educated on what optimal loading is compared to rest. This is where the therapist's skills are powerful and it ought to be recalled that the patient doesn't have the understanding of a trained therapist.

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