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CHAPTER 4:
First Aid: What to Do Until the Doctor Comes

The first person to treat an injured professional athlete is usually the team physician or trainer. Unfortunately, most amateur athletes are treated by someone with no training and little if any experience in administering first aid to sports injuries. A few areas of the country have trainers available for high school games, but no one is there to manage acute injuries for the recreational athlete.

      The primary goals of immediate first aid are to protect the athlete from further injury and to get the person back in action as soon and safely as possible. To be sure this happens, every recreational athlete needs to follow these basic principles:

  • Take your time.

  • Use the "RICE" formula to reduce swelling.

  • Note how the injury happened.

  • Use the right pain killers.

  • Use first aid for common muscle injuries.

TAKE YOUR TIME

If you become injured, don't allow yourself to be rushed off the floor or field. You may feel that you have to get to the sidelines as quickly as possible to get out of the spotlight. Well-meaning but inexperienced teammates, friends, or officials may rush you in order to get on with the game, particularly if it's a twilight affair with darkness approaching.

      Don't be pressured into moving before you are convinced that it's safe. This is particularly important for neck and spinal cord injuries. I have taken as long as 15 minutes, with national television footing the bill, to move an athlete whom I felt had been seriously injured.

      In the same vein, take care about "walking off the field." Many recreational athletes and coaches believe that once an athlete is on her feet, she will be okay. But I have seen athletes walk off the field only to collapse when they get to the sidelines. Lie still until you are absolutely sure it's safe to move. If you are not sure, wait for a stretcher.

      A broken bone should be splinted before the player is moved. This is a concept basic to all fractures. Any suspicious-looking injury should be treated as a fracture and splinted. The splint can always be removed later; but if you fail to splint and you guess wrong, you may do irreparable damage that leads to permanent disability.

USE THE "RICE" FORMULA TO REDUCE SWELLING

The most basic treatment principle is summed up by the acronym RICE, which stands for rest, ice, compression, and elevation. These four, in combination, reduce swelling, which occurs when blood and fluids leak into the injured body part, often a joint.

      Swelling is the most important factor in delaying your return to activity long after the pain is gone. A swollen joint has severely limited function. If you can keep the swelling down to a minimum at the time of injury, you will have much less pain and aggravation to deal with as you heal. Anything that can prevent swelling will save you days of recovery later on.

  • Resting the injury cuts down the circulation to the area. The less circulation, the less leakage occurs from broken blood vessels. Also, when small blood vessels are torn, any motion in the area prevents them from sealing, so they keep bleeding.

  • Ice constricts blood vessels when first applied. The blood vessels shrink and limit bleeding into the affected area, which reduces swelling.

  • Compressing the swollen area with an elastic bandage limits the area available for fluid to leak into. Compression causes a higher pressure outside of the torn blood vessels than inside, which makes it difficult for fluid to flow out.

  • Elevating the damaged area also decreases blood flow. The heart has to pump harder against gravity if the injured area is raised to a level higher than the heart. At the same time, gravity helps any fluid that has accumulated at the injury site to move back toward the torso.

      RICE also helps prevent further injury. Rest avoids complications caused by moving the injured part. Ice prevents more bleeding, which can cause calcium deposits to form later. Compression helps support the injury. Elevation prevents you from putting any weight on the injured part, which could damage it more.

NOTE HOW THE INJURY HAPPENED

One of the most helpful yet often overlooked ways to lessen the extent of an injury is to note how the injury happened. Swelling and pain often mask the actual injury, and it may be difficult to examine the injury by the time a player has been brought into the emergency room or doctor's office. The player, his teammates, or coach should be able to say where the athlete was hit, which way he fell, and what he was doing at the time of injury. Often, using this information I can make a precise diagnosis when I am unable to do a total physical examination.

USE THE RIGHT PAIN KILLERS

I suggest three types of pain-killing pills for my patients. I find these drugs to be valuable because they allow me to start aggressive, early rehabilitation of injuries.

      Aspirin is the oldest and probably most widely prescribed drug. It not only kills pain but also reduces inflammation. The major side effect of aspirin is stomach upset and even bleeding from the lining of the stomach. If you have problems with regular aspirin, use buffered or enteric coated aspirin intead. Aspirin also interferes with blood clotting and should not be used in large doses during contact sports.

      Acetaminophen pills, such as Tylenol®, have the same pain-killing effects as aspirin in most people but do not have as much of an anti-inflammatory effect. They are less irritating to the stomach and have no anticlotting effect.

      Ibuprofen is the active ingredient in non-steroidal anti-inflammatory agents. The various over-the-counter preparations are half-strength versions of the prescription medication Motrin®. They all have a very strong anti-inflammatory effect and also have pain-relieving properties.

      Anti-inflammatories must be taken carefully. They can have severe gastrointestinal (GI) side effects; they may irritate the stomach and cause bleeding as well as ulcers. They can interfere with the production of the coating that protects the stomach and intestine from stomach acid. Anyone with a history of GI problems should not take anti-inflammatory agents, including those sold in drug stores, except under a doctor's direction. The doctor may prescribe accompanying medication to ameliorate the side effects.

      When I suggest that athletes take a pain killer, I let them choose whichever one they like best. Most people know from previous experience which drug works well for them.

      The only caveat is not to take aspirin along with anti-inflammatory agents. Since these two are chemically similar, adding one to the other could lead to a toxic reaction. So, for example, if you are taking ibuprofen for sore muscles and you get a headache, take acetaminophen instead of aspirin.

USE FIRST AID FOR COMMON MUSCLE INJURIES

How to Treat Muscle Pulls

No matter how diligently you warm up and stretch, or warm down and stretch, you may still pull a muscle from overuse, fatigue, or injury. A muscle pull is probably the most common sports injury next to a bruise, which you can do little if anything to prevent. A muscle pull occurs when a sudden, severe force is applied to the muscle and the fibers are stretched beyond their capacity. If most of the fibers are overstretched and a few are torn, you have a muscle pull. If many of the fibers tear, it becomes a muscle tear.

      The universal treatment for a muscle pull or tear is to apply ice. This relaxes the muscle and helps relieve any spasm. Apply ice to the injured body part and rest it until the pain and swelling subside. You should apply the ice for about 20 minutes at a time for several days to reduce inflammation. Then you can start rehabilitating the body part with a gentle exercise and stretching program.

      It is of the utmost importance to stretch the muscle while it heals. A pulled muscle usually goes into spasm, which is a protective mechanism that causes the stretched muscle fibers to contract. If the fibers are not gradually relengthened, the muscle will pull again once you return to activity because it will have healed in a shortened state. If you stretch the healing muscle gradually, not violently, you'll decrease your chances of reinjuring it.

      In general, you can return to action when you are able to stretch the injured body part without pain as far as you can stretch the healthy one on the other side of the body.

How to Treat Muscle Spasms

If you show up on Monday at your doctor's office complaining of a "pulled muscle" from running over the weekend, you may have a delayed muscle spasm rather than torn muscle fibers. Most muscle injuries result in some degree of spasm or tightness. In fact, many mild muscle "pulls" actually end up to be low-grade spasms. If you are not sure when the muscle began to hurt, you probably have not torn the muscle.

      Some doctors like to give pain killers or anti-inflammatory agents as soon as possible after a muscle spasm starts and then suggest that the athlete rest. Pain killers help prevent truly torn muscles from going into spasm. However, rather than keep my patients out of action with total rest, I prefer to get them involved in a gradual exercise program that uses a combination of icing and stretching.

      First, apply a large cold pack to the muscle to numb it. A good way to do this is to make an ice cone by freezing water in a styrofoam cup and peel down the rim, and then rub the muscle with the ice until it is numb.

      Next, start moving the sore muscle until you begin to feel tightness or pain. When the pain disappears, hold the injured body part in that position for a 20-second static stretch. A few moments later, contract the muscle slowly but fully, and hold for about 5 seconds. This isometric contraction will help relax the muscle more.

      Now move the body part again until you feel tightness or pain. Hold the body part for 10 seconds and then contract the muscle for 5 seconds. Repeat the stretch and contraction again, and then stretch the muscle one last time.

      Let the body part rest naturally for 20 seconds and repeat the entire program. You may need to renumb the muscle between sessions.

      This method of icing and stretching can also be used initially in muscle pulls and tears.

      Within two or three days, the dull ache of the muscle spasm will be partially relieved. Then you can gradually resume full activities.

How to Treat Sore Muscles

Delayed muscle soreness and pain typically occur a day or two after strenuous exercise. The soreness usually subsides by itself within a few days. Mild exercise and liniment may help relieve the soreness.

      Most athletes have used liniment to relieve the aches and pains of exercise. The unmistakable smell of liniment pervades locker rooms. I have found a direct correlation between an athlete's age, the ambient temperature, and the amount of smell--the older the player and lower the temperature, the worse the liniment smells.

      Almost all professional teams use various balms on injured players, but sports doctors don't fully understand how liniments work. It's difficult to say whether liniment is directly responsible for an athlete's quick recovery and return to action. The actual massaging action of rubbing in the liniment, working it into muscles, may relax the muscle.

      There are two basic types of liniment you can buy in a drug store. The first includes products such as Ben-Gay® and Sports Creme®, which typically contain menthol and an aspirinlike chemical, methyl salicylate. When you rub it in, your skin becomes slightly irritated, which causes an increase in blood flow to the area. This also produces heat, which relaxes stiff muscles. These rubs may also allow some salicylate to enter the bloodsteam. Since salicylate is the active ingredient in aspirin, they may also have some painrelieving effect.

      The second type of rub, including Hot-Stuff® and Atomic Balm®, depends on a substance called capsicum, which is the active ingredient in jalapeño peppers. An extract of this chemical is now being used as a prescription ointment for arthritis pain, which is an indication that these rubs really do work. These hotter rubs have a much stronger irritating effect on the skin to stimulate blood flow. They give off so much heat that you can actually burn yourself, especially if you have fair skin. Go slowly when you use them until you can see how your skin reacts.

      In addition to its use as an exercise rub, liniment is touted by some manufacturers as a warmup aid. Liniment can help relax tight muscles and increase circulation. It may shorten your warmup time, particularly in cold weather, and may help increase blood flow after warmdown to reduce the lactic acid residue.

      But don't think that because you have applied liniment you are warmed up. A proper warm-up raises overall body temperature, not just the temperature in one muscle group. Think of liniment as a passive warmup for one body part. Combine it with 10 minutes of light exercise, followed by stretching, to warm up the whole body.

      Aspirin may be helpful in relieving muscle soreness after a tough workout. This soreness dissuades many people new to strength training from going back to the gym for another session. Most weight lifters have sore muscles for a day or two after working out, and then the soreness disappears. Anti-inflammatory drugs such as aspirin may ameliorate this discomfort somewhat. Several studies have found that taking aspirin after exercise reduces muscle soreness and improves the athletes' range of motion a day or two later.




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