Jan 29, 2015Triple Trouble
How do you treat an athlete who suffers not just one, not two, but three injuries in a season?
By Maria Hutsick
Maria Hutsick, MS, LAT, ATC, CSCS, is Head Athletic Trainer at Medfield (Mass.) High School and former Director of Sports Medicine at Boston University. She is a past president of the College Athletic Trainers’ Society and was honored with an NATA Athletic Trainer Service Award in 2010. She can be reached at: [email protected].
Rehabbing one injury is tough enough, but when an athlete suffers multiple injuries at once, the challenges are multiplied. Last fall, I learned how difficult–and ultimately rewarding–it can be to work with an athlete in this unfortunate position.
Justin Williams, a member of the football and track and field teams here at Medfield (Mass.) High School, began the football preseason by tearing the flexor tendon in his finger, then suffered a partially torn plantar fascia in his foot several weeks later. To top it all off, he suffered the same injury to his other foot with only a few weeks left in the season.
A senior, Justin was a starting running back and linebacker, and a team captain. He arrived at school in August in shape and ready to have a great year. Needless to say, what followed was a tough pill to swallow.
Justin’s injuries were serious, but not season ending, and he was adamant about spending as little time on the sideline as possible. So I had the challenge of getting–and keeping–Justin healthy enough to continue competing. During the months that we worked together, my creativity was tested, I learned a new modality, and we both marveled at what the human body is capable of.
As the first few preseason football practices flew by, Justin felt great and his coaches were very pleased with his performance. But just before the team transitioned to wearing full pads in practice, he caught the fourth (ring) finger on his right hand in a teammate’s jersey and tore the flexor tendon.
The flexor muscles, which control the fingers and thumb, are located in the forearm above the wrist. Long tendons extend from these muscles through the wrist and attach to the small bones in the fingers. A tear anywhere along one of these tendons can make it impossible to bend one or more fingers.
The main concern with a flexor tendon rupture is that depending on where the tear is, the tendon can actually detach from the bone and be pulled back into the palm of the hand. This sort of tear would require major surgery to reattach it.
In Justin’s case, the tear was caused by a sudden pull against a strong grip. This is a fairly common injury in football and basketball, and necessitated a visit to a physician and subsequent x-rays.
Right away, we encountered our first bump in the road. Justin’s parents were out of town and couldn’t be reached. He was only 17 years old at the time and although his parents had signed the high school’s preseason participation waiver, initially, the hospital refused to treat him without direct parental permission. Eventually, after I talked to the receptionist and gave the hospital a copy of the waiver signed by his parents, he was called to radiology for x-rays.
The orthopedic surgeon who looked at Justin’s hand referred him to a hand specialist that same day. The specialist told Justin that although he didn’t need surgery, he would need to take six to eight weeks off for the finger to properly heal. However, knowing Justin’s desire to continue playing, I assured him that he would not need to be out that long and that we would find a way to protect his hand to allow him to continue playing.
I realized I would be going against what the specialist said, but he was a young physician and did not have much experience in sports medicine. I had treated several flexor tendon injuries and felt confident that I could devise a protective device and get Justin back on the field. I would not recommend a novice athletic trainer or one who hasn’t dealt with this type of injury before do this, but I talked about my idea with Justin and his parents, and they had faith in my skills.
The solution I came up with was to buddy tape his injured finger to his middle finger, and cover the hand with a protective pad. I constructed one out of Aquaplast that looked like a small claw.
For the next two weeks of practice, Justin only participated in non-contact situations while his whole hand was encased in the padding. He also missed one game. Then, with his fingers taped and the size of the padding reduced so that it only enclosed the two fingers, he resumed full activity and spent the next two weeks as a major contributor on the field.
In his first game back, Justin’s coach had him play mostly defense, but he soon returned at running back. Handling a football was challenging at first, but he quickly adapted to carrying the ball effectively despite the somewhat bulky padding and didn’t fumble all season. He wore the padding up until the final two games of the year, at which point he was able to play with only tape.
FROM FINGER TO FOOT
During a game almost half way through the season, Justin felt a pop in his right foot. After examining him, I delivered the bad news: He had partially torn his plantar fascia.
This injury occurs when the long fibrous ligament along the bottom of the foot develops multiple tiny tears in the tissue, resulting in pain and inflammation. The discomfort associated with plantar fasciitis is usually located close to where the fascia attaches to the calcaneous, also known as the heel bone, and the most common complaint of the injury is burning, stabbing, or aching in the heel.
During my physical examination, I found that Justin’s posterior leg muscles were very tight and his feet had very little arch. Both of these conditions are often contributors to the development of plantar fasciitis.
Because Justin was so intent on not missing any more games, I tried to formulate a plan that would get him back on the field as soon as possible. I treated him with an icing regime and massaged the area every day.
I also gave him a quarter-inch rubber pad for arch support and showed him how to tape it to the bottom of his foot for daily wear. Before practice, I performed soft tissue work on his calf and affected foot, then reapplied the quarter-inch padding.
With his foot taped and an added layer of soft rubber padding in his cleat, Justin was able to play after missing just one week. Initially, I was using pre-wrap and regular athletic tape for “X” arch taping, but switched to Power Tape, which doesn’t need pre-wrap because it adheres to itself. I found that the Power Tape gripped the soft tissue better and allowed for more strapping strength, which allowed me to remove the padding and allow Justin’s foot to fit more comfortably in his shoe.
Justin was happy to get back on the field, but he wasn’t able to play completely pain-free. Though he performed well in his first game back, he was extremely sore and swollen for the next several days and couldn’t engage in even a light practice until the following Wednesday. This became a cycle as Justin continued to play well during the team’s Friday night game, take time off to recover before engaging in light practices Wednesday and Thursday, and then play again the following Friday night.
After two weeks, Justin’s foot remained tender, but actually got better thanks to the arch support, icing regime, massage, and rest between games. His finger stayed swollen and sore, but intact.
It was at this time that I embarked on an educational journey that would affect my treatment of Justin. I enrolled in a Graston Technique course in which I learned how to use the six different Graston tools to find tissue defects and help resolve them via palpation.
I have always been a strong believer in soft tissue treatment, joint mobilization, and hands-on treatments. Graston is based on the theory that soft tissue treatment with the stainless steel instruments will cause a cascade effect of fibroblasts that flood the injury site and promote healing. The soft tissue manipulation also helps get nutrition to the injury site, loosen any muscle fibers that are stuck together, and align new cells.
I believed this would help Justin immensely. However, I didn’t have the specific Graston Technique tools I needed right away, so I wrote a grant to the school asking for permission to purchase them. In the meantime, I used the handle of a butter knife to treat Justin’s plantar fascia until they arrived toward the end of the season.
The side of the butter knife handle was certainly a bit more of a crude instrument than the Graston tools, but it got the job done. I used coca butter with beeswax in it as a lubricant, applying a thin coating on his foot.
The soft tissue treatment I performed was valuable in returning length to Justin’s plantar fascia. In addition to treating the plantar surface of his foot, I also treated the smaller muscles in his foot, calves, and Achilles tendon.
I elected to treat the entire lower extremity because of basic anatomy and the kinetic chain: The plantar fascia connects to the Achilles, which attaches to the calf muscles. Thus, by treating the posterior chain of the lower extremities I was able to relieve pain and allow his foot to begin functional work.
Justin was getting a little healthier each week, and it was looking like he would finish his senior season. But during a game a few weeks prior to the end of the season, he came off the field and told me he felt something let go and pop. He had sustained another partially torn plantar fascia–this time in his left foot. I was able to tape and pad his left foot just as I had the right, and he finished the game and eventually the season–though it was no easy task.
The major complicating factor throughout Justin’s rehab was managing the injury while trying to keep him playing. It was his senior year and he was willing to do whatever it took to stay on the field, even if it meant playing through pain.
In addition to worrying about keeping Justin healthy enough to finish football, I was also thinking about the upcoming indoor track and field season. I didn’t want him to suffer any sort of long-term or permanent damage by playing through injuries that weren’t yet fully healed.
I felt confident based on my experience that I was not harming Justin by allowing him to play sooner than the physician had recommended. If Justin weren’t a senior, I would not have been as aggressive with his treatment. I would never recommend that an inexperienced athletic trainer follow the same course of action I did unless it was with the close supervision of a physician.
I also spoke with Justin’s parents frequently, answering their questions and addressing their concerns. And since we were keeping Justin on the field, his coaches were very supportive of my plan. With only 30 players on the team, Justin was an extremely important part of the squad’s success.
Due to the soreness in both of his feet at the end of the football season, Justin spent the first two weeks of indoor track and field on the sideline before returning to compete in the 300-meter and 50-meter sprints. During those two weeks, I continued to use the Graston Technique treatment on both of his plantar fascia, gastrocnemius, and Achilles tendons. I also did some light Graston work on his finger. Although Justin’s finger is slightly deformed and still stiff (which is common with this type of injury), he has full range of motion and strength and can type on a computer without any problems.
As Justin gradually returned to the track, he performed light workouts and within 10 days progressed to sprinting drills. He continued to receive treatment for his plantar fascia, and followed up with a colleague of mine who is a lower extremity expert and prescribed a pair of orthotics. He’s able to run without any tape or extra padding, though his right plantar fascia is still very taut. I’m hoping orthotics will help with this issue, and I continue to perform Graston treatment daily on his feet and calves.
Justin did well in indoor track and is also competing outdoors this spring. He’ll be attending an NCAA Division I school in the fall and hopes to walk on to the track team.
He is a tough kid who wanted to compete and was very compliant in his treatment and rehabilitation routines. With his persistence and the support of his coaches and parents, we were able to overcome all the challenges thrown at us and end up with a success story.