Thigh strains and ankle sprains: a rower with thigh strain and a cricketer with ankle sprain

Two injured athletes who asked the familiar question: can you get me right for next weekend?

If you're an athlete, you can picture it now: you've been training all off-season for the first game and everything is going so well - you've made the top squad - when suddenly you turn too quickly to catch a ball and feel your ankle give way beneath you. It happens so suddenly you can't stop it; a slight clunk, a sharp searing pain in your ankle you wouldn't believe possible, and you're in a heap on the ground screaming for the ice.
Or similarly, you've just finished a hard session on the water with your crew, your legs are completely shot and that awesome endorphin rush is flooding your body. As the boat is being lifted out of the water, you're starting to dream about the feeling of flying past the flags next weekend, when all of a sudden your foot slips on the wet concrete as you take the weight of the boat on your shoulders. Your foot slides backwards beneath you and you instinctively resist by trying to pull it forward so the boat won't be damaged. Suddenly a tug on your thigh, and a sharp burning pain forces you to cry out. The boat is okay but your leg is not.
You spend the rest of the weekend on pain killers, icing every few hours, elevating your leg, keeping it bandaged tightly and cursing your false move that led to this. You ring up and book in with a sports medicine professional for Monday first thing. And the question that burns incessantly night and day in your head is:
will I be right for next weekend?

The two case studies we are looking at here describe a very common situation in the world of sport: countless injuries do not recover in time for a final game or the beginning of a season selection. This is simply because every injury has a minimum time frame required for complete healing. When damage is done to the body, certain time parameters are required by most injuries in order to heal successfully. Usually, though, you may have to miss the first couple of games but it's not too many weeks before things are improving and you can start training again.

Speeding up the process
Every now and then, however, situations present themselves such that even though a small tear of soft tissue has taken place, the progress can be so speeded up that playing at close to full strength becomes possible the following weekend. Only an experienced sports medicine professional will be able to tell whether it is realistic to hope for return to sport in such a short time, and whether or not further damage will occur if you do play. It is termed a 'Grade II' injury of ligament or muscle when the load placed upon the tissue was great enough to stretch it beyond its normal elasticity until separation of fibres takes place (a muscle or ligament 'tear').
Bear in mind, however, that complete healing will still take another four to six weeks, and that what we are doing by rushing it for the weekend may slow down or stall the healing process for a few days. Minimising the pain (for maximal performance) and minimising further damage (for maximal healing) are the primary goals of treatment in the first week.
Let's now take a snap-shot look at that first week for two injured competitors who were fortunate enough to play again the following weekend.

Case study 1:
the young female rower
with a thigh tear
Kristina is a final-year high-school student, first VIII rower preparing for her first regatta of her last season; she slightly tore her rectus femoris muscle (long, thin quad muscle extending from front of pelvis to kneecap) helping lift the boat out of the water after training.
Physiotherapy assessment revealed bruising and swelling at the top of her thigh, and a slight indentation giving sharp pain when the muscle was felt for irregularities. No hip or knee joint pathology was found, and her thigh movement was very limited because the muscle was in spasm to prevent any stress being placed on the site of the tear. She could not lift her leg off the bed without significant pain.
Keep in mind that the most important action for Kristina to be able to perform was the equivalent of a squat, ie, the rowing motion. She did not need to be able to run or swim - she would not be able to do these for about 4-5 weeks, until much more complete healing and rehabilitation had taken place. But because she only needed to row, we made it our goal to get her to the point of being able to do repeated squats with full strength and speed in five days' time.

How did it happen?
Heaps of 15 minute ice sessions, gradually firmer massage to surrounding muscle and then very gently to the scar tissue being laid down. Ultrasound and other electrotherapy treatments were used to maximise the rate of healing. By Wednesday she could manage a half-squat pain-free with rigid and compressional taping firmly supporting the injury site. By Thursday she was on a stationary bike, and on Friday she was able to do four sets of ten full squats with only body weight and two sets of ten standing straight leg lifts with minimum pain. That afternoon she did a gentle pain-free ten minute rowing ergonometer session and iced after.
She was hoping to race twice on the Saturday. With the more important race in the afternoon, we negotiated and decided not to row in the morning and give it everything she had in the afternoon. She ended up racing well that afternoon, though was a little more sore on Sunday. Full training sessions during the following week became painless and she went on to full strength for the next weekend's races (though still used tape on her quad for the whole of the week).
The keys to her speedy progress were tape, massage and the nature of the rowing movement preventing the rectus femoris muscle from being further strained.

Case study 2:
the college cricketer with an ankle sprain
Matthew is a university student, first grade cricketer (batsman) who sustained a small tear to his (L) calcaneo-fibular ligament - the classic, very painful ankle sprain that makes you feel as if you've fractured it but instead often begins to recover faster than you might expect!
Physiotherapy assessment revealed a slight laxity (looseness) on a medial stress test to his ligament compared to his good ankle, but no laxity on the very important anterior drawer test. There were moderate amounts of swelling around the outside area of his ankle but none obvious on the inside ankle area, while his range of motion all round was up to full - a very encouraging sign. He had no pain in the back of the ankle joint, being able to point his foot into almost full plantar flexion. This indicated a good chance that there was minimal bruising of the inside of the ankle joint ('osteo-chondral' damage) which would really slow down the chance of being able to run within four weeks. X-rays showed nothing abnormal.
We knew therefore that if we could get that swelling down by the end of the week and maximise his dorsiflexion (knee forward over the foot) range of motion to enable him to run between the wickets, we would win the battle against time. Heavy taping would do the rest in terms of preventing strain through the fragile scar tissue and the healing process would not be unduly set back.

Treatment
A rigorous regime of ice treatment with active motion exercises (cryotherapy) was carried out religiously all week; ultrasound and electrotherapy were applied to the damaged ligament, and some non-steroidal medication was further used towards the latter part of the week - all in a desperate attempt to reduce the swelling, (research has shown unequivocally that swelling slows the rate of healing).
Joint mobilisation, stationary bike riding, gentle strength exercises, and a very light training session on Thursday night were sufficient to prevent weakness setting in. Disciplined taping method ensured good adhesion and therefore good support right through to the team's successful first round game where Matt achieved the second highest score of 45 runs. Boy, was he chuffed!
Matt continued to battle swelling over the healing ligament until the third week, due in part to his full training and game participation, but it did not stop him playing as long as he was strapped. In the third week the balance and proprioception (brain- ankle connection) component of rehab was stepped up, in an effort to prevent a repeat sprain of the ligament once he was weaned off the tape.

Final points
For both Kristina and Matthew, their respective injuries were to continue needing rehabilitation for another three to four weeks each until full range of motion and strength had returned. This required on-going commitment, physiotherapy treatment and exercises, constant taping to prevent re-injury, and restrained approach to training drills as well as being wary of doing too much.
These two studies show that, every now and then, when the factors are right and the damage is very specific to only the soft tissues, miracles can happen that mean your physiotherapist can help you be back in action as soon as the next weekend!

Ulrik Larsen