Martial Arts Trauma:
Dealing With Bone Bruises
By Bruce Everett Miller, PA-C
Editor's note: This
is the third in a series of articles on Martial Arts
Trauma. See the first article by Miller entitled,
Stretching
As An Important Tool and the second,
The
Post Exercise Stretch.
 One
of the more frequent encounters we have all had while
sparring is striking our opponent and instead of finding
the nice soft place we intended to strike, hitting
bone. Sometimes we try for a kick, never even intending
to strike our opponent, but get blocked part way there
with a bony surface.
If we get struck on muscle or soft tissue during
these unexpected encounters, we understand the bruising,
discoloration and swelling which occurs and treat
ourselves accordingly. However, when we are struck
on a bony surface, there doesn't seem to be any discoloration
or swelling, and it is hard to understand why the
area hurts and continues to hurt for so long. In fact,
it is not uncommon for such injuries to hurt for 8
to 12 weeks.
To understand the why of it all is this: when we
strike a bone against another hard surface, we cause
small fractures in the outer layers of the bone which
are called the cortex. The layman's term for this
condition is a bone bruise.
The cortex of bone is comprised of small fibers which
the body lays down in a kind of cross hatch pattern.
It is this cross hatch pattern of fibers which then
fills in with calcium to produce the strength inherent
in a bone. When we strike the bone hard enough, we
actually break some of these fibers. If we break enough
of these fibers, the bone can separate and it is then
called a fracture. Such a separation can be seen on
x-ray, but when only a few fibers are broken, it is
impossible to see the damage on an x-ray film (the
sensitivity just isn't good enough).
Even though the injury can't be seen on x-ray, the
body has to treat the injured area like any other
fracture. First it must remove the calcium and damaged
fibers from the area, called remodeling, and then
it can begin to rebuild new fibers and lay down new
calcium to the area. This whole process can take up
to 8 to 12 weeks, depending on the size of the injury.
One thing is important, though, and that is: if you
strike the area again after it is partially healed,
you will be damaging new, poorly protected fibers
that the body has just laid down. Thus, the body will
have to stop its rebuilding process in the re-damaged
area and remove these fibers and the associated calcium
before it can resume rebuilding. Now let me state
for clarity that the body can tear down the fibers
on one spot at the same time it is building up a spot
just next to it, but in general re-injuries will significantly
increase the healing time. To help improve healing
time, use heat (as described later in this article)
and to use anti-inflammatory medication to minimize
swelling, as swelling delays the healing process.
What to do after you have had an injury is a hard
question to answer, mostly because there is such a
varied response depending on the type of injury and
the severity.
I will not try to diagnose or teach you how to diagnose
your injuries. Obviously I cannot. I can only (morally
and legally) tell you that you should seek competent
medical opinions when ever there is a doubt. You should
remember, however, that many injuries which could
be minor can turn into chronic problems if not treated
correctly.
Danger signs:
If ANY of these signs are present then I recommend
you seek a competent medical opinion. NOTE: The absence
of any of these signs does not rule out a significant
injury.
- The injury doesn't not improve in a reasonable
time.
- There is excessive motion of the joint.
- There is excessive swelling of the injured area.
- The level of pain is dramatically above what should
be present for the swelling and discoloration seen.
(This may indicate a broken bone which frequently
does not cause very much swelling.)
- There is deformity of the joint.
- There is a limitation of range of motion (especially
if the decrease in range of motion is not being
caused by pain).
- There is significant discoloration of the affected
area (bruising).
If you have determined through your own means or
competent professional advice that you do not have
a serious injury, then here is some general advice
you might consider.
Muscle injuries are the most common cause of mild
pain. When you tear a muscle several things happen.
First of all there is bleeding into the injured area.
This bleeding is what causes the discoloration you
see, although that may not show up on the skin's surface
for several days.
Secondly there is swelling which occurs in the immediate
area of the injury. This swelling is due to the fact
that damaged cell tissue (torn muscle or other cells)
release a substance called prostaglandin. There are
different types of prostaglandins, but the types which
are released at an injury site cause both swelling
of the area around the injury and an increase in pain
in the same area. The purpose of the pain is to tell
you something is wrong and to keep you from causing
further damage to the area. That understanding, however,
does not make it any more fun to bear.
If you are treating a minor injury, the best thing
you can do for it is, of course, to rest the area.
The second thing to decrease the amount of swelling.
The reason for this is that swelling seems to increase
the amount of time it takes for an injury to heal.
The best way to decrease swelling of an area is to
elevate the area. DO NOT put an Ace wrap or other
constrictive bandages over an injury to prevent the
area from swelling. The area probably will swell anyway.
It just won't expand outward and will thus compress
the injured area including the blood vessels. When
that happens you risk cutting off the blood supply
to the area which could result in severe complications.
 The
second thing you can do is to apply ice. Because ice
causes your body to contract the blood vessels in
a cooled off area (but not close them off completely),
ice is a valuable tool. There are a few important
things to know about ice: First, make sure the ice
is wrapped in something. NEVER put ice directly against
the skin surface for any length of time. You may cause
frost bite. Second, ice will initially make the pain
of an injured area slightly worse because of shivering.
This effect last only for about one to three minutes
. Then the area will lose sensation and the pain feeling
(of both the ice caused sensation and the original
pain) will dramatically lessen. Ice and elevation
should be used exclusively for the first 24 to 36
hours after an injury.
After the initial period of the first 24 to 36 hours
after the injury, heat can be used. There are, however,
some important rules about the use of heat which most
people and even some medical professionals are not
aware of. If you do not pay attention to these rules
then heat will cause you more harm than good. The
important thing to remember is that heat does not
always help an injury even if it makes the area feel
good. When you apply heat to an area, you cause the
body to dilate the blood vessels in the area that
is being heated. This is both good and bad.
Dilation is good because when the blood vessels are
dilated they can bring in more oxygen and healing
materials to rebuild the damaged area and remove waste
products which have built up. However, blood vessels
are like pipes made out of a porous material. When
they are small there are very small holes in the walls
of the blood vessels. When you expand the pipes the
holes also get larger. The longer that you apply heat
to an area, the larger the blood vessels become, up
to the point where they can't expand any more. When
they are fully expanded blood vessels leak like a
sieve (forgive the pun). They let small amounts of
red blood cells and a significant amount of protein
leak into the tissue surrounding the blood vessels.
These red blood cells and the proteins break down
within a short period of time into substances which
cause irritation and thus release more prostaglandins,
causing swelling and more pain.
What we have is a situation where a little heat can
help but heat for prolonged periods can actually harm.
Perfect examples of this are patients I have treated
for acute muscular back pain. A significant number
of these patients have used a hot water bottle at
night for their back injuries. It makes their back
feel good they all tell me. But when I ask them what
their back feels like in the morning they always admit
they feel worse but usually blame it on the fact that
the water got cold during the night.
The real problem is not that the water got cold,
it's that it stayed hot for too long. The optimal
period for applying heat is for about 15 to 20 minutes.
During this period the amount of benefits from the
increased oxygen and removal of waste products from
the area outweigh the small amount of swelling which
is produced. After this period the amount of swelling
outweighs the benefits.
Don't misunderstand me, I do prescribe heat treatments
for my patients when that is indicated. I just make
sure that they know how to use heat correctly!
Once you have used a heat treatment you must wait
for the blood vessels to return back to their normal
size before applying heat again. The present belief
is that the body takes approximately two hours to
return to the base line. If you wait for a period
of time which is at least this long, then you can
and probably will benefit from the next application
of heat.
The proper way to apply heat is to use as hot as
you can bear it, but only for a 15 to 20 minute time
limit. Moist heat is better than dry heat. A hot water
shower with a massage is probably the best possible
way that you can accomplish that at home. The next
best way is to soak the area. Medical facilities may
use ultrasound to ally heat to an area because it
penetrates the tissue much better and actually causes
less swelling than surface applied heat, but these
machines are expensive and thus not likely to be found
at home.
In summary, the best thing you can do for an injury
is to rest it. Use ice and elevation for the indicated
periods of time, then use heat in short periods of
time with sufficient intervals of time between treatments
for your body to return to its vascular baseline.
Watch for the next article on martial arts trauma
which will discuss various medications.
Let
Us Know Your Comments & Opinions On This Article
About The Author
Bruce Everett Miller, PA-C, is a 6th degree black
belt in the style of Quan Li K'an and a teacher of
Tai Chi which he combines with his Western medical
training as a Physician's Assistant to provide his
own unique perspective on the martial arts. He is
a well known teacher, seminar leader and author who
has produced thirteen books and four videos on various
karate related subjects including freefighting, pressure
points, the principles of kata, Acupuncture, and light
force knockouts. For more information on his books,
videos and seminars see: www.cloudnet.com/~bemiller/
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