Authors: Fred Kahn MD, FRCS (C), R. Liboro, F.Saraga, phD
Source: Meditech International Inc.
Over the past 20 years, our company has treated an extensive number of high level professional and amateur athletes and members of sports organizations. Some of our prominent clients have included the Toronto Maple Leafs Hockey Club, the Toronto Raptors, the Miami Heat and periodically, individual members of the Blue Jays, the Detroit Lions etc. In addition, we have treated an extensive number of golfers from the PGA tour, gymnasts and other high performance athletes. Almost invariably we have been able to successfully rehabilitate players suffering from an extensive number of musculoskeletal problems, which had failed to respond to traditional methods.
Pathophysiology of Sports Injuries
These are generally the result of overuse or acute injuries, sustained while participating in strenuous physical activities. For example, a runner’s knee is a painful condition associated with the impact of running; similarly, tennis elbow is a form of repetitive stress injury affecting the elbow, associated with activities such as tennis or golf. Contusion-type injuries relate to firm contact with a hard object or another player. These can result in fractures or extensive soft tissue injuries involving ligaments, tendons and muscles.
Traumatic injuries are most prevalent in contact sports i.e. football, rugby, soccer – secondary to the dynamics and collision nature of these activities. Concussions may also result from these activities. From the overall perspective, injuries can cause extensive soft tissue damage, fractures or a combination of both. The major response of the organism to trauma is inflammation. This is characterized by pain, edema, erythema, elevated temperatures and in most cases, partial or complete loss of function. It must be understood that the inflammatory stage is the first phase of the healing process and initiates the cascade of cell proliferation and migration involved in healing and tissue regeneration. An excessive inflammatory response in the early stages of the injury may stall the healing process and delay functional recovery. It is important therefore to understand that Laser Therapy mediates and resolves the inflammatory phase of an injury, with subsequent acceleration of the entire healing process.
Muscle and Ligament Injuries
A muscle strain or ligamentous sprain can result from strenuous activity and lead to a tear of the affected structure. This is characterized by pain, tenderness and functional limitations.
- First-degree strains involve stretching muscle or tendon fibers, without tearing
- Second-degree strains involve partial tearing of the muscle-tendon unit
- Third-degree levels result in complete severance of the tissues involved
A severe muscle strain or contusion injury causes secondary damage to the blood vessels resulting in the formation of a hematoma, which may be described as a pooling of blood in the interstitial tissues. This can develop into a firm mass in the subcutaneous area. The associated edema and inflammation can delay the recovery of cellular function by limiting arterial perfusion of the area.
Injuries of the muscles and tendons surrounding the knee are caused by acute hyperflexion, hyperextension or twisting injuries of the knee. Bursitis, or an inflammation of the bursae, can occur secondary to direct trauma or chronic overuse. Acute knee injuries can result in pain and edema accompanied by difficulty in flexing or extending the knee and negatively impacting weight-bearing activities.
Knee Sprain: ligament tears can result from acute hyperflexion, hyperextension or overuse.
The risk for injury to the foot or ankle is higher in sports involving jumping such as basketball, soccer or football, where quick directional changes are required. Aging adults are also at higher risk for injuries and fractures of this nature, as they lose protective muscle mass and bone density (osteopenia) in a progressive manner.
Acute injuries of the soft tissues and bones can result from a sudden misstep in which the weight-bearing extremity is improperly aligned to provide appropriate support to the body. Overuse injuries occur when significant stress is imposed on a joint or other tissues repeatedly, often caused by simple repetitive movements. These injuries include Achilles tendonitis, stress fractures, plantar fasciitis, retrocalcaneal bursitis and metatarsalgia.
Achilles Tendonitis: micro-tears in the connective tissue in or around the Achilles tendon which connects the calf muscles to the calcaneum may weaken the tendon and make it more vulnerable to tear or rupture.
Shoulder and Elbow Injuries
These types of problems occur frequently in the athlete who throws, particularly baseball players, javelin throwers and so forth. Many sports injuries involve the shoulder, elbow and wrist and these include strains, dislocations, separation, rotator cuff injuries, epicondylitis and fractures. Tears of the rotator cuff tendons are classified as partial thickness, full thickness and occasionally with complete detachment from the bone. Shoulder pain may be characterized as variable and does not always correspond to the degree of the injury. Chronic rotator cuff problems are more frequent than acute injuries and most frequently result from repetitive activity of the muscle groups.
Epicondylitis results from inflammation localized to the extensor or flexor origins at the inferior aspect of the lateral and less frequently the medical epicondyle. Lateral epicondylitis is more often related to tennis and medial epicondylitis is associated with golf, however they are quite interchangeable. The primary symptom is pain and tenderness over the epicondyles accentuated by movements including flexion, supination and pronation. Similar movements at the wrist can also enhance the symptoms. These situations restrict the ability to perform the tasks involved in everyday activities. As the disease progresses, it is accompanied by muscle weakness of the extremity and an inability to grasp objects or opening jars etc.
Physiological Effects of Laser Therapy
There have been a number of animal studies and human clinical trials that have evaluated the efficacy of Laser Therapy for a wide range of soft tissue and musculoskeletal problems. The evidence published to date in support of the application of Laser Therapy for sports injuries has been growing over the past decade. With most conditions, therapeutic guidelines have now been delineated to treat specific conditions. In our estimation, Laser Therapy is rapidly assuming a position as the treatment choice in the majority of these problems. In summary, Laser Therapy has been found to be highly effective in the treatment of entities including Achilles tendinopathies1,2, fibulo collat4 Laser Report – Winter 2013 eral sprains of the ankle, rotator cuff injuries and epicondylitis. The American Physical Therapy Association (APTA) recently established evidence-based clinical practice guidelines for the use of Laser Therapy for these conditions, along with eccentric exercises, resulting in the highest level of proof supporting this therapeutic approach. Laser Therapy has also been associated with a biostimulatory effect on the proliferative and regenerative phases of skeletal muscle repair7. Along with increased ATP production, Laser Therapy reduces oxidative stress, increases collagen and fibroblast production and regenerates new muscle fibers to replace those that are damaged as the result of injury. In addition, Laser Therapy has been demonstrated to decrease exercise-induced skeletal muscle fatigue8 and relieve acute pain resulting from soft tissue injuries10.
Diagnosis: Partial tear of the right hamstring muscle origin with an associated extensive hematoma.
History: The patient is a 52 year old male golfer who injured his right hamstring muscles while forcefully rotating in the course of a golf swing. The result – a tear accompanied by hematoma that continued to expand rapidly with accompanying tenderness, edema and complete loss of function of the extremity. The pain was severe even at rest and the patient had difficulty sleeping, along with the inability to engage in any meaningful physical activities.
Physical Examination: A significant degree of tenderness was noted over the hamstring muscle origin (i.e. biceps femoris, semimembranosus and semitendinosus muscles).
Discussion: Following the administration of four Laser Therapy treatments over the course of seven days, there was a dramatic resolution of the hematoma along with the edema, tenderness and pain. The patient was able to walk without difficulty and resume normal weight bearing activities.
Diagnosis: Full thickness tear of the right supraspinatus tendon.
History: The patient injured his right shoulder during a sudden movement utilizing the extremity.
Imaging Results: An ultrasound study prior to the administration of Laser Therapy revealed a full thickness tear of the anterior and midfibres of the supraspinatus muscle at its junction with the tendon. The defect measured 24 x 15 x 9 mm.
Discussion: After the administration of 13 Laser Therapy sessions over the course of two months, a follow-up ultrasound study indicated that the tear had diminished to less than 50% of its original dimension, measuring 10 x 4 mm. The patient received 5 additional treatments and a second ultrasound study subsequently demonstrated that the rotator cuff injury was no longer visible. It should be noted that the patient was asymptomatic and had a normal range of motion of the shoulder at this point despite having continued to perform normal activities throughout the course of treatment.
Diagnosis: Partial tear right hamstring origin.
History: The patient is a 28 year old female heptathlon competitor who sustained a partial tear of the right hamstring origin 9 months earlier. She had suffered from constant pain and significant disability with regard to activities. She had been subjected to a prior course of extensive physiotherapy, ART treatment, ultrasound therapy, along with ice and analgesics to reduce her symptoms without any significant benefit. She was unable to train routinely and compete in any physical events.
Physical Examination: Acute tenderness was noted on palpation over the origin and the proximal portion of the right hamstring muscles. The range of motion of the lumbar Laser Report – Winter 2013 5 spine, hip and knee were within normal limits.
Discussion: Laser Therapy was administered on 3 consecutive days and subsequently 3 times per week over the following 2 weeks, for a total of 9 treatments. At the termination of the course of treatment, no tenderness was noted on palpation and the patient was able to resume training with the objective to compete in upcoming heptathlon events.
Diagnosis: Bilateral synovitis of the knees along with tears in both medial menisci and the right lateral meniscus.
History: The patient is a 16 year old male elite soccer player who presented with pain in both knees. Symptoms had been present in the left knee for approximately 1 year and the right for several months. There was no history of any significant knee injury. The patient was unable to continue playing soccer; moreover symptoms precluded even minimal physical weight bearing activities.
Physical Examination: The circumference of the right knee was 38 cm and the left 37.5 cm. Flexion was noted to be normal in both knees. The left knee lacked 15° extension and the right 10°. Tenderness was noted over the medial and patellar compartments bilaterally. No instability was noted.
Imaging Results: An MRI of the right knee prior to his initial presentation revealed a horizontal tear of the body and anterior horn of the medial meniscus, with an adjacent parameniscal cyst measuring 2.7 cm x 4 mm. In addition, there was a horizontal upper-surface tear at the anterior horn of the lateral meniscus. A joint effusion was also reported. The MRI of the left knee indicated a horizontal lower-surface tear at the anterior horn of the medial meniscus with an adjacent parameniscal cyst measuring 2.5 cm x 5 mm. Similar to the right, a joint effusion was present.
Discussion: The patient was initially treated 5 times over the course of 6 days and reexamination revealed marked improvement characterized by reduced edema, decreased tenderness and a normal range of motion. For geographical reasons the patient was instructed in the use of a Home II BioFlex System to continue treatment on alternate days at home. The patient was able to resume training and competition within 2 months after the initial examination and continued to be asymptomatic. Re-assessment demonstrated a normal range of motion, no existing tenderness or other abnormalities.
A follow-up MRI of both knees 9 months after his initial examination indicated significant reduction in the extent of all meniscal tears and in the size of the associated cysts. This patient had been offered a full soccer scholarship to a major US university and was able to accept this offer, as the knees were normal on clinical examination and he was completely functional.
Conclusion: In the past five years particularly, an increasing number of athletes have acquired BioFlex Laser Therapy Systems for their personal use, in order to be able to treat their injuries immediately after occurrence. All have been educated to understand that the therapy can be utilized with protocol specific guidelines, for most sports injuries. In these situations, rapid and complete recovery is almost invariably assured.
A number of golf professionals have learned “never to leave home without it” (i.e. the BioFlex System), knowing that they can independently treat their injuries on the road as required.
Several baseball pitchers in the Major Leagues have followed suit. Athletes are instructed to use the system for 10- 20 minutes prior to pitching and also subsequently. The benefits resulting from this approach include the immediate reduction of any inflammation and pain, increased proliferation of collagen, cartilage and muscle cells. In essence the result is the rapid repair of injuries, enabling athletes to continue with their activities and to return to the playing field soon after sustaining an injury or in many instances to continue performing.
Both the professional athlete and the weekend warrior can benefit significantly from the early application of Laser Therapy for a wide range of soft tissue and musculoskeletal problems. Increased awareness of the benefits of this emerging, highly effective medical technology will allow more athletes, both professional and amateur, to return to the playing field sooner after suffering an injury and even more importantly prolong their career for many years. In addition, the Systems may be used to prevent future complications and curtail recurrence of previous problems.
References available upon request.