This was another home game which I was able to go too. I got told by the club that they tend to have games a week with one being a weekday evening and the other being on a Saturday. It was important for me to try to get to most games as possible so I can learn and help with players that have ongoing injuries. I also got to meet some more of the team who were not there last week. Not many of the players asked for treatment today apart from an ankle taping but that was about it. It was explained to me that sometimes the therapists are needed more than other times depending on how soon previous games have been and if there were any problems or knocks in these games. For this game on Tuesday, they had all played in a big game on the previous Saturday and therefore quite lot of them felt tired and were a bit sore but there were no injuries as such. One of the players has been having problems with tight hamstrings which has been ongoing. They said that they had felt fine in the warmup and that they were happy to go on the pitch. However, once he got into it, he found that it was starting to become more and more of a problem and therefore had to be subbed off the pitch. When he came off, I was able to watch whilst they did some stretches with him and to try loosening the muscles. He explained to us that he feels like it is just a problem due to not stretching enough and therefore it would be good to work with him to find a way of sorting this problem out for him. This session made me feel more relaxed as I was able to chat to some more of the players today and talk to the coaches about what they feel is beneficial to their players.

Introduction:
The patient we are assessing is a 21-year old boxer with a history of an eating disorder. They have been complaining of wrist pain however we are unknown of the location site. Due to this a full wrist assessment will be carried out. To our knowledge, and due to their age we would expect this individual to be training a considerable amount a week, as well as perhaps studying alongside this. Due to these factors, contraindications/Red flags and yellow flags need to be taken under consideration before treating this specific client.

Red Flags can be seen as signs and symptoms that may occur and may indicate a serious underlying pathology, and therefore may need further medical treatment or assessment. If these are detected these patients should not be treated and should immediately be referred to their GP or doctor.

THREADS stands for Thyroid, Heart problems, Rheumatoid Arthritis, Epilepsy, Asthma Diabete and steroids. These are the clinical indicators, on whether massage and other treatments can be performed. If a client is present with any red flags, further medical assistance will be required.

Pins and needles is a pricking, tingling, or numbness of the skin. This happens due to blood flow being stopped or blocked from nerves. If this does happen, this can suggest a nerve problem, or a circulatory issue, and therefore physiological effects (including increased blood flow from soft tissue therapy) should not be performed and the patient therefore should not be treated.

A fracture within the wrist can be described and seen as a small chip or crack in the distal radius. If a client is suspected with a wrist fracture they should be referred to A and E immediately, to ensure they can get the full treatment they need. Especially with fractures of a part of the body like the wrist, fractures may not show up in the acute stage of the injury. It can take as long as up to 7 to 10 weeks for fractures to show. If a therapist still suspects a fracture after a negative X-Ray, clients should be sent for another one for safety purposes.

Yellow flags
These can be seen as the Psychological barriers in treating patients
Due to this individual being the age that they are, they may have many different psychological factors affecting their mental health and emotions. These factors can be suggested as University or work as well as family and beliefs. Some individuals attend University as well as having a part time job. This can put a lot of stress on individuals and therefore affect an individual’s mental health.

Through our knowledge of our patient being the age that they are, they may in fact be on the contraceptive pill and as therapists we must take in consideration the effects of this. Individuals that are on the contraceptive pill are more at risk from not recovering as effectively due to the pill causing soft tissue structures to become more pliable and have a higher laxity, therefore affecting the recovery process and effectiveness of performance after healing.

When assessing hand and wrist injuries, as a therapist, we have to make sure that a lot attention is paid into the subjective assessment. This is due to the lack of special tests in the objective assessment. When dealing with our clients, understanding the onset and duration of pain is important in order for a successful diagnostic and to be able to provide adequate rehabilitation. Knowing that our client struggles with eating means that both their mental and skeletal health may not be up to their performance standard. Quite often amongst female athletes with eating disorders comes the “female athlete triad”. This includes low energy availability, menstrual dysfunctions and low bone mineral density. Issues which then may become complicated with these conditions can include both the mechanism of injury and the rehabilitation process. Low bone density means that the structure of the wrist may become weak which could potentially increase the severity of the injury. Along with these issues comes the added pressure of having to be in a weight category which determines your opponents for boxing matches. Studies have found that athletes participating in sports which emphasize being a certain body weight are more at risk of having eating disorders.Low energy availability causes problems such as dehydration, loss of fat and lean body mass etc which can have a negative impact on sports performance whilst increasing the risk of injury.

Wrist sprains
One of the most common injuries in the wrist amongst boxers is a wrist sprain. A wrist sprain will occur when the hand is bent with great force causing the ligaments to either stretch or tear.This can also include falling on an outstretched hand. In Boxing, if an opponent makes good contact with the wrist, it could force the wrist backwards with the ligaments to become easily distressed. To diagnose a wrist sprain or an acute trauma a physical examination will need to be undertaken. Common signs of a wrist sprain includes swelling, Pain on palpation, pain on both active and passive range of motion, pain on grip and localized tenderness. With the wrist, some of these signs are indicators of red flags so in this case we may feel it is necessary to send them off for a radiograph, which will be an X-ray. This radiography will identify the majority of fractures and dislocations, but provides very little information about injuries to soft tissues, such as tendons, intercarpal ligaments and the triangular fibrocartilage complex. Once the X-ray has come back, it is important for the next stage of the rehabilitation programme to be effective so that our client can get back into training. A study shown by Loosemore et al., (2017) presents hand and wrist injuries in training and competition in Great Britain amateur boxing squad between 2005 and 2012. This study found that of the 172 hand wrist injuries occurred 13.5% of these injuries were diagnosed as wrist sprains.

Scaphoid Fracture (DDX)
Approximately, 3% to 9% of all sporting injuries originate from the hand and wrist. The scaphoid is the most common carpal bone to get broken and accounts for 60% of all carpal fractures. Fracture of the scaphoid in a boxer is a devastating injury, and has the potential of ending an athlete’s career. Scaphoid fractures tend to occur in young adult men between the ages of 15 to 40 years and is rare under the age of 10. The mechanism of injury from a scaphoid fracture can tend to be either a direct blow or if an athlete falls on an outstretched hand. With a scaphoid fracture it is important for an early diagnosis due to the separate blood supply which goes to this bone in the hand. If not treated, problems such as vascular necrosis can occur. When dealing with our patients we need to make sure we are confident that the problem is a fracture and therefore may need to seek further medical attention. As therapists, if we decided this might be the case, our patient would need to be sent off for an X-Ray. However, an X-Ray may not necessarily pick up any fractures in the acute stage of an injury and therefore we need to take this into consideration which may take up to 7 to 10 weeks to be shown as a fracture.

Treatment
When treating our client, we need to make sure we are aware of everything that we need to know in order to give the best and suitable treatment. Our client struggles with an eating disorder and therefore we need to take this into consideration. Boxing is a sport which actually focuses on weight categories and therefore this may be a good indication as to why our client is struggling. Psychologically they may believe that if they eat too much, they may exceed the category they are. Therefore with our treatment, as a therapist, we need to make sure they have adequate nutrition to help the healing process. Ligaments are composed of a protein substance known as collagen. The collagen that makes up ligaments (and tendons) is also known as dense connective tissue. It is arranged in bundles. Between these long parallel bundles are fibroblast cells. If an injury occurs, fibroblast form collagenous. For the first few days following an injury, there is an synthesis-lysis balance and this occurs in injured sites to create new tissue. However this synthesis-lysis balance can only occur and treat traumered areas if the body has sufficient nutrients and ingredients.

With a wrist sprain, the best option at the acute stage of healing is to use our P.O.L.I.C.E theory by Bleakley in 2012. This stands for protect, optimal loading, ice, compression and elevation. When protecting the wrist , as a therapist we need to decide whether to put it in a splint to prevent further damage and immobilise the hand and wrist. In this case we will splint it for a few days for a faster recovery time before then moving onto the sub acute stage. For the first few days, the wrist will be completely rested and ice, compression and elevation will all be applied. Ice will help with decreasing any oedema, inflammation and muscle spasm. Making sure that the wrist is elevated above the heart as often as possible will help to limit vasoconstriction. Once my client has completed this for 48 hours we will bring them back in to start going through the subacute stage

The subacute stage is important for remobilizing and helping to decrease any stiffness or pain after immobilizing the wrist completely. The most effective type of treatment we believe for our boxer will be joint mobilization. The aim of this is to use non contractile movements to increase range of movement, decrease pain, increase strength and proprioception as well as help with joint nutrition. Being one of the smaller joints of the body, as therapists we decided this would be the most adequate and effective treatment for our patients. This type of treatment will be applied for around 30-60 seconds for 3 times depending on the pain level of our client. With this type of treatment it is important to understand what the client is presenting with: this will be whether it is pain or stiffness. This will then help to decide what grade of oscillations we go into with the client. At the acute, it is most likely that they will be in pain and therefore will only be taking the wrist into grade 1 or maybe 2 depending on the severity of the pain. Once the ROM starts to improve, we can then use grade 3 and 4 trying to get to the end feel which will provide full range of movement in our client.

In conclusion, With the wrist especially, we need to make sure as therapists that our subjective assessment is thorough. Knowing what they do in their everyday lives can have an impact on specific injuries. Once we have gathered this sort of information it will then be the process of being able to find the adequate time and type of rehabilitation to get our patients back into their usual training and competing routine. Ligamentous injuries can differ from mild to severe and understanding the different grading can also depend on the treatment we then use.

Reference List

Andersen, G. D. Nutritional Support For Ligamentous Injuries, 2014
Bergh, T. H., Lindau, T., Bernardshaw, S. V., Behzadi, M., Soldal, L. A., Steen, K., & Brudvik, C. (2012). A new definition of wrist sprain necessary after findings in a prospective MRI study. Injury, 43(10), 1732-1742.
Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE?.
Geissler, W. B. (2006). Management of scaphoid fractures in the athlete. Operative Techniques in Sports Medicine, 14(2), 101-107.
Hackney, L. A., & Dodds, S. D. (2011). Assessment of scaphoid fracture healing. Current reviews in musculoskeletal medicine, 4(1), 16-22.
Joy, E., Kussman, A., & Nattiv, A. (2016). 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management. Br J Sports Med, 50(3), 154-162.
Kawamura, K., & Chung, K. C. (2008). Treatment of scaphoid fractures and nonunions. The Journal of hand surgery, 33(6), 988-997.
Loosemore, M., Lightfoot, J., Gatt, I., Hayton, M., & Beardsley, C. (2017). Hand and wrist injuries in elite boxing: a longitudinal prospective study (2005-2012) of the Great Britain Olympic Boxing Squad. Hand, 12(2), 181-187.
Muramatsu, K., Doi, K., Kuwata, N., Kawakami, F., Ihara, K., & Kawai, S. (2002). Scaphoid fracture in the young athlete–therapeutic outcome of internal fixation using the Herbert screw. Archives of orthopaedic and trauma surgery, 122(9-10), 510-513.
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