The Role of Recovery in Injury Prevention

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(Author's note: The following sections on the role of recovery in injury prevention are presented by Dianna Linden, MT. Dianna is an experienced and highly-credentialed soft-tissue therapist who treats athletes in the Los Angeles Area. Her contribution to this book reflects years of "in the trenches" experience with a wide variety of injuries that occur in a variety of disciplines including jujitsu, weightlifting, cycling, and recreational weight trainers. Dianna believes that athletes can prevent the vast majority of potential injuries through smart training, awareness, personal discipline, and knowing a handful of simple techniques to employ when injuries do occur.)

Awareness of the need for active recovery techniques and methods is possibly the most critical aspect of injury prevention. Above and beyond scheduling recovery cycles in Periodization phases and ensuring optimal nutritional support for cellular repair and regeneration, there are several other tools available to accelerate recovery. Charlie Francis, author of The Charlie Francis Speed Training System asserts that "an athlete who is receiving regular regeneration methods and treatments is able to increase the volume of high quality, high intensity work by as much as 40% . . . this process involves massage, saunas, whirlpools, showers, baths, and electronic muscle stimulation (EMS)."56

These, combined with well-planned workout schedules, help accomplish recovery and regeneration of the athlete and thus prevent injuries. Think of recovery efforts in three phases: pre-training, during training, and post-training:

Phase One: Pre-Training Recovery

The application of pre-training recuperative techniques will ensure not only a better training performance, but more effective post-training recovery as well. The following two suggestions enhance recuperative abilities.

1) Pre-training salicylate (aspirin). Aspirin is perhaps the most powerful anabolic drug available (legally). This effective substance operates on a variety of levels. First, Aspirin improves blood flow by reducing the body's output of thromboxane, a natural chemical which causes blood platelets to become "stickier." Even as little as 30 mgs (about one-tenth of a normal tablet) of aspirin prior to training can thin the blood to the point where muscle tissue is exposed to greater amounts of nutrient carrying blood, thus speeding up recovery between training intervals.

Additionally, lactic acid and other waste products (the result of heavy training efforts), will be flushed from muscle cells with greater speed and efficiency. Aspirin also reduces edema (swelling), another result of hard training. Local tissue swelling and inflammation (usually not visible) is universally regarded by experts as the enemy of healing. Recovery simply does not begin until edema has subsided.

Aspirin also reduces pain associated with training. While there is no benefit in masking pain resulting from injury, aspirin can often make the difference between a "ho-hum" workout and a really supercharged effort, which when coupled with an effective recovery regimen, will lead to increased progress.

Experiment with dosages. In many cases low dosages of aspirin work just as well as large doses with less possibility of stomach irritation. Instead of assuming that "more is better," it is a wiser practice to seek the smallest possible dose that enhances recuperative efforts. To protect the stomach lining even further, try crushing the aspirin tablets between two spoons and mixing them into a glass of milk. Since the body eventually develops a tolerance to it, use aspirin judiciously—perhaps prior to the most difficult training sessions. Finally, check with a physician before implementing a regular schedule of aspirin therapy, no matter how small the dose.

2) Leg Elevation. Many people either sit or stand while at work for eight or more hours before going to the gym or dojo. During this time, the legs can often become edematous and swollen. Training with legs in this condition impedes training efforts right from the start. To help remedy this condition, spend between twenty and thirty minutes (both during the work day and prior to the training session) lying face-up on the floor, legs up against the wall or up against the side of a couch. Positioning the legs in this way allows gravity to assist the body in returning blood back to the heart, restoring optimum circulation. Additionally, use this opportunity to listen to some relaxing music or take a light nap. This promotes an important physical and psychological transition between work and training.

Phase Two; Recovery During Training

The recovery process starts each time training ends. This means between the positive and negative portion of each repetition, between repetitions, between exercises, and between workouts. In the larger sense, recovery is needed between heavy training cycles, which sometimes last months! The following aspects of recovery during the training session must be addressed.

1) Time between intervals (i.e., sets or rounds). Time is the most elemental unit of recovery. The amount of time spent between training intervals has a significant effect on performance in succeeding intervals, and on future training sessions. In fact, one can raise the overall difficulty of the workout simply by decreasing the time between intervals. One can employ either objective or subjective methods of monitoring time between intervals. Objectively, the pulse rate is commonly used to determine when to begin the next interval. Usually, the athlete waits until heart rate has fallen to below 60% of maximum (maximum heart rate is estimated as 220 minus current age). The downside of this method is that the pulse only measures metabolic fatigue, and is not a reliable assessment of neural fatigue. The more intense the training, the less reliable the pulse is in determining recovery.

Another objective method is to use the clock. For example, performing a set every three minutes. The limitation with this method is that the body's functioning varies from workout to workout, depending on recovery from previous training efforts. Therefore, using a standard time unit can be a hit or miss proposition at best.

Most people use a subjective assessment to determine time between intervals. Many resume the next interval when they "feel ready." While there is merit in trusting and listening to the body, athletes are best served by pre-planned time increments, perhaps tempered with subjective assessment, to determine time between intervals.

2) Move between intervals. Many individuals mistakenly sit down and move as little as possible between intervals. WTiile this feels like the thing to do from an intuitive perspective, faster recovery can be realized by moving around a bit between intervals. WTiy? Consider the importance of the warm-up and cool-down in the context of a workout and then think of moving between intervals as both a cool-down for the previous set and a warm-up for the next interval. Movement serves as a "transition" between all-out efforts during the interval and relative inactivity between intervals. This practice aids circulation and helps reduce swelling of muscular tissues.

3) Peripheral Heart Action Training (PHA). PHA is the practice of structuring workouts so that upper and lower body exercises are alternated with one another, instead of first training legs, then back, and so on. The effectiveness of PHA is that it keeps the blood moving between major areas of the body, which accelerates recovery per body part.

4) The uLight Day." Instead of performing each and every workout at gut-busting intensity, incorporate planned, easier workouts about every third or fourth session. An example of such a session would be four sets of fifteen repetitions at 50-55% of maximum. This type of moderate intensity training is quite effective in "feeding" sore muscles with fresh blood, reducing scar formation on the micro-level, and flushing waste products from affected tissues. Planning light days into the training schedule not only accelerates recovery times, it also provides variety for athletes, which in itself assists in the recovery process.

Phase Three; Post-Training Recovery

Post-training recovery methods complete the integrated recuperation format. These methods are designed to assist the body in rapidly accelerating the recovery process when it is needed most, directly after training. Two techniques in particular give the most "bangs for the buck" in terms of immediate results:

1) Contrast Showers. Done immediately after training (use the gyms shower if possible) expose the lumbar area to alternating bursts of hot and cold water as hot as one can reasonably stand for two minutes, followed by two minutes of progressively colder water up to the point of discomfort. This procedure is then repeated for four to six cycles. Since hot water is a vaso-dilator, and cold water a vaso-cons trie tor, the net effect of contrast showers is vastly improved circulation to the affected areas.

The effectiveness of contrast showers is markedly increased when combined with trunk stretching. Facing away from the shower nozzle, slowly bend forward at the waist while rounding the spine (forward flexion). Then return to an upright position and extend slightly backwards to extend the spine. Finally, flex the spine laterally by bending to each side at the waist. Use a handrail and non-slip rubber "skids" for safety! All four stretches are repeated for each contrasting cycle.

2) Cryo-kinetics. Immediately after leaving the shower, construct an ice pack by placing crushed ice in a "zip-lock" bag. Laying down on the floor with feet propped over a bed or couch, place the ice pack under the lumbar spine. To increase the effect of this procedure, try stretching the spine while on the ice. Gently perform lateral (side to side) flexions, alternated with pulling the knees into the chest.

Mobilizing the spine in this way will counteract the stiffening effect possibly experienced while icing ones back in the past. Cryo-kinetic therapy is very beneficial in reducing contracted, tightened muscle tissue as well as pumping these tissues free of accumulated training-induced waste products. Spend at least five, but no longer than twenty minutes on the ice.

Any athlete who feels that a body part is overworked and detects signs of micro- or macro-trauma can mitigate what would otherwise become a chronic problem right as it is about to occur by using ice treatments for just five minutes immediately after trauma signs are detected. The signs include excessive soreness, stiffness, and/or pain at the site of an old or recovering injury.

This "fast five" enables athletes to continue training uninterrupted by an injury caught and deterred in time. Micro-trauma is often present after tough workouts without symptoms until it builds to macro-trauma and has some pain, inflammation or swelling associated with it. Individuals who tune into their bodies and detect and treat these things when they are almost imperceptible are way ahead of the game in prevention and remaining symptom free. The value of such a simple resource as ice cannot be overemphasized.

Ongoing Professional Assistance

Many forms of therapy, including various types of "bodywork" are available to athletes at moderate cost, and are highly recommended. Chiropractic adjustments, massage, whirlpool, sauna, acupuncture and acupressure are among the most readily available and effective of these therapeutic modalities.

Massage speeds up recovery and improves flexibility as well as offering feedback in a more in-depth way to the coach and athlete regarding the texture, tone and state of muscles, tendons, and the athletes psycho-emotional-physical state. Well applied, it can relieve stiffness, soreness and muscle spasms, thus making the muscles more receptive to the training stimuli. If muscles remain too stiff, they are susceptible to injury.

The type of massage applied before and after a competition will be different from work of a more clinical nature, intended to relieve deep adhesions or spasms which should be done more than 72 hours before an event. This is because the deep work lowers the tone of the muscle too much and could negatively affect its strength and an individuals performance at the event.

The light work before the event is usually performed without oil, using compression strokes, slapping and jostling on muscle bellies and light friction massage on tendons and their attachments. These methods are designed to stimulate blood flow through the muscles, warm-up the tendons, and to help the athlete feel alert, awake, primed and ready for the competition. After the event, the massage is best performed after the cool down and after eating. It is given to flush the remaining by-products from the muscles, restore proper tonus, remove areas of localized tightness, and relax the athlete.

This after-event massage can be really helpful, not only to restore the muscles to be able to train again, but also to alleviate post-event depression which sometimes occurs after an extreme effort has been made. Anecdotal reports by marathon runners indicate that the post-event rubs received by volunteers at the event (which have to be very short due to the huge numbers of runners in line for them) are enough to circumvent the usual depression experienced without the massage after this event.

In Sports Restoration and Massage> Secrets of the World's Greatest Superstars,57 edited by M.C. Siff and M.Yessis, a study by V. Dubrovsky concluded that:

1) When using restorative massage such techniques as stroking, rubbing and kneading should be used.

2) In restorative massage it is not advisable to use techniques (chopping, tapping, etc.) that stimulate the CNS, raise venous pressure, worsen the microcirculation and so on.

3) Restorative massage should be done within thirty minutes to four hours after training or competitions, with regard to physiological changes in the body.

4) Clinical studies of the cardiorespiratory system provide a basis for taking a new view of the methodology of restorative massage, its physiological features, and the changes that occur in the athlete s body.

5) Restorative massage should be sparing, excluding stimulating techniques and lasting no more than 35 minutes (with regard for the athletes gender, age, weight and functional state).

6) Massage promotes redistribution of blood, its removal from the depot, and increased microcirculation.

7) Massage leads to blood redistribution and to a more uniform blood supply for all lung regions.

8) After massage, muscular blood flow remains accelerated for more than three hours.

9) Special significance should be given to massage of the back and paravertebral region since the region of the back is a vast reflexogenic zone. By influencing this zone a response can be obtained from the internal organs according to the viscero-sensory reflex type. Another interesting study from the Siff and Yessis text mentioned earlier, titled Methods of Warm-up Massage for Wrestlers,58 authored by Birukov, Kafarov, and Lukyanov, used 32 sambo wrestlers aged 18-21 years as subjects. They concluded that "massage employed after the warm-up markedly increases the wrestlers' special work capacity (the number and quality of throws, the effectiveness of actions in a bout), and betters the neuromuscular system's functional state (muscle tonus). Also, there was a speedier restoration of the muscular system's functional capabilities following a physical work load (a bout) as produced by warm-up and massage."59

Dianna headed a massage team for Rickson Gracie and offers this compelling personal account of her experience.

At the First International Rickson Gracie American Jujitsu Association Tournament at UCLA in August, 1997, I headed the team of sports massage therapists which Rickson requested as support for the athletes in competition. We were there for the pre-event, between event massages, stayed and gave some short post-event sessions to the contestants. The association also provided a triage team of chiropractors for the athletes. We used one of the racquet ball courts near the main gym for the massage center and also provided fruit, balance bars, water, ice, and minor first aid supplies.

The athletes came in repeatedly to partake of the support services but also to hang out and talk to each other and to us about their events. The atmosphere there was an inspiring example of camaraderie, friendship, and sportsmanship among competitors. Athletes were graciously deferring to others whose needs were more immediate, for whatever reason. Among the joking around there was an atmosphere of honor, friendly respect, and true support for each other in the efforts made there that day. I saw not one hostile act between competitors.

We stretched some athletes, used acupressure and shiatsu on others, revved some up, calmed some down, helped them recover their enthusiasm and energy after a tough round, and got them back out on the mats ready for another bout. There were surprisingly few injuries to be addressed. Rickson wanted his association members to have that support as part of what their entry fee provided for them in the experience of competition.

It was a long, very rewarding day for the team. The competitors came back again and again for massage between their events and there were no restrictions placed on them as to how best to utilize the services we provided. For many of these athletes, this kind of support provided for them was a novel and highly appreciated experience. Thanks to Rickson's insight, we all learned a lot from the experience.

In a transition from the preceding sections illustrative emphasis on both the preventive and recuperative abilities of massage and it's role in recovery, the following sections now turn to more acute instances of injury management. Several sections have been adapted by permission from the Penn State Sports Medicine Newsletter.

Common Martial Art Injuries

Eye INJURIES (R£i>rinted with permission from the penn state sports medicine newsletter)

If struck forcefully in the eye while training or competing (whether by a finger, fist, elbow, or foot), seek an immediate examination by an ophthalmologist. "Assume that any trauma severe enough to cause blurred vision or bleeding around the eye is sufficient to cause injury to the eye itself," says Paul Vinger, M.D., associate professor of ophthalmology at Tufts University Medical School and a consultant to the U.S. Olympic Committee.

According to Vinger, immediate medical attention is warranted when an injury to the eye results in blurred vision that doesn't clear, double vision, significant pain or bleeding in and around the eye.

A "blowout"fracture is another eye injury that requires immediate attention. When the thin bone that serves as the floor and wall of the orbit of the eye is fractured by an opponent or an object (such as a weapon or piece of equipment), the eyelid droops as the eye sinks and goes back into it's socket. Experiencing double vision is another common symptom of the injury. "Approximately 10% of all patients with blowout fractures also have significant injury inside the eye," says Vinger.

Immediate Treatment. After suffering a blow to the eye, the only effective self-care is to close the eye and apply an ice pack directly over it. The cold temperature keeps swelling to a minimum. Without ice, a cold soda can soda will do. By immediately combating the swelling, this also reduces the level of subcutaneous bleeding, which causes the black and blue discoloration of the eye. If there is no obvious bleeding in the eye, aspirin may be taken for pain relief. If there is bleeding, however, acetaminophen (not aspirin) should be taken to decrease the chance of further bleeding.

The Eye Exam. A complete eye examination after an injury will include a careful vision test, a check to rule out a blowout fracture, and a complete opthalmologic examination. In addition, the physician will examine the surface and the anterior portion of the eye. The lens of the eye will also be examined to make sure there are no abnormal movements signifying dislocation.

In the opthalmologic examination, the physician will check the back of the eye for any trouble with the retina, the light-sensitive layer that lines that portion of the eye. WTien a retinal tear is discovered immediately after it occurs, it usually requires minimal treatment, and the procedure has a very high success rate.

Prevention. Eye injuries shouldn't be considered an inevitable part of sports participation, even for fighters. "Protection is virtually assured," says Vinger, "when the athlete wears protective eyewear during practice and competition." (Of course, such eyewear may not be allowed or even feasible during the training and/or competitive phases of some combat sports, but in most cases, protective headwear along with proper gloves and/or boots will go a long way in preventing eye injuries in sports such as boxing and kick-boxing).

Eyeguard lenses should be made of polycarbonate (a plastic that is ten times stronger than glass) or a plastic called CR-39. This material resists shattering and also softens any impact. Make sure the frame is 3mm thick and that it meets the racquet-sports frame standard F803 of the American Society of Testing and Materials (ASTM).

nosebleeds (r£printen with permission from the penn state sports medicine newsletter)

The cause of nosebleeds is usually an impact to the nose from an opponent s foot or fist, but sometimes the nose bleeds because of a seasonal nasal allergy, a sinus infection, or a winter cold that irritates and weakens the delicate nasal lining.

To stop a common nosebleed that occurs during a workout or competition, Michael J. Lynch, M.D., team physicians at Penn State and a member of the Newsletters Board of Advisors, recommends the following measures:

1) Stuff a soft material such as a piece of tissue or cotton in the affected nostril. Sit or stand upright with the head tilted forward to lower blood pressure to the head. This will also prevent the escaping blood from flowing down into the throat, which can lead to fits of coughing, gagging, and in some instances, vomiting.

2) Apply pressure to the dividing wall between the nostrils by squeezing the nostrils between the thumb and forefinger. Breath through the mouth and continue to apply this pressure for at least one minute, timing this with a watch. Remove the tissue before resuming activity.

3) If the nose continues to bleed, apply pressure for five additional minutes. Again, time this with a watch. To assist in controlling the bleeding, squeeze the bridge of the nose. If the bleeding continues unabated after fifteen minutes of steady pressure, contact a physician so the nosebleed can be evaluated and treated.

4) Once the bleeding has stopped, avoid nose-blowing for several hours or it may bleed again. Apply an antibiotic ointment (Bacitracin) to a cotton-tipped applicator and gently rub it on the inside of the nose. The antibiotic will help kill any bacteria, while the ointment keeps the nasal lining moist. Reapply the ointment for several days, especially before going to bed at night.

concussions (repwnted with permission from the penn state sports medicine newsletter)

During the final playoff game to win a Super Bowl berth, Dallas Cowboys quarterback Troy Aikman rammed his helmet into the knee of a defensive lineman while attempting to avoid a sack. One play later, he was on the sidelines. When he began talking gibberish to a teammate and failed to answer a series of questions posed by a team physician, it was obvious he had sustained a cerebral concussion. Aikman was kept out of the game and spent that night in a hospital for observation. The next day, Aikman said he was all right, but he remembered very little about the previous days game.

It has been reported that during the week preceding the Super Bowl, Aikman still had lingering effects from his concussion. Although he led Dallas to their second straight Super Bowl victory, he quickly bowed out of the follow-up Pro Bowl, claiming he was still feeling the effects of his head injury.

"Allowing Aikman to play in the Super Bowl sends a very bad message," says Robert C. Cantu, M.D., a neurologist and medical director of the National Center for Catastrophic Sports Injury Research. "He was allowed to play because of the magnitude of that particular game, but I don't think he understood the risk he was taking."

Many athletes and coaches consider concussions minor injuries that shouldn't preclude further competition. But, as leading neurologists warn, misguided thinking like this can lead to further injury caused by the impaired coordination and judgement that often follow concussions. In addition (although this is rare), athletes who sustain a second minor head injury before fully recovering from a concussion may suffer Sudden Impact Syndrome, a catastrophic swelling that may be difficult, if not impossible, to control.

No one is certain of the long-term effects of concussion. While some athletes claim to have had twenty or more concussions in the course of their careers, its thought that the effect of repeated blows to the head may be cumulative, leading in some cases to the "punch drunk" sy n dro m e.

Therefore, in an effort to protect athletes from either overzealous coaches or from their own drive to continue competing, Hugh H. Greer, M.D., consulting neurologist at the Santa Barbara Medical Foundation Clinic, recommends that athletes who suffer a second concussion during the competitive season not be allowed to practice or compete for the remainder of that season.

What Happens and to Whom. A cerebral concussion is a traumatically induced injury to the head that brings alteration in mental states, sometimes (but not necessarily) with loss of consciousness. A concussion requires a blow that rapidly accelerates the brain inside the cranium in a rotational pattern. This movement torques the brain, exerting shear forces, and its forces like these that the brain tolerates least. This movement of the brain within the skull may cause microscopic damage. "The brain is fairly soft and malleable and can absorb a fair amount of energy," says Greer. "But if the forces are strong, nerve fibers and cells can be damaged." Confusion, along with amnesia (either instantaneous or delayed several minutes) are classic symptoms after such a head injury.

More severe concussions cause unconsciousness lasting five minutes or longer, with a post-traumatic amnesia that could last for days. "The likelihood is high that you are losing brain cells during this period of time," says Cantu. "Even though you will recover, chances are you will not be 100% as you were before the injury."

The athletes most prone to concussions are those involved in collision sports. "Anybody who may collide with another player, the ground, or an object faces the risk of concussion," says James P. Kelly, M.D., Director of the Brain Injury program at the Rehabilitation Institute of Chicago. Its estimated that 20% of high school football players suffer concussions each year, some more than once.

Kelly notes that, in addition to football, athletes participating in martial arts, wrestling, horseback riding, swimming, diving, ice hockey, basketball, and gymnastics are also at risk. Even a seemingly safe activity such as running is not without danger. Three years ago, a runner in the Twin Cities Marathon in Minneapolis sustained a concussion from a fall and had to be treated.

Leading Symptoms. Its important to note that an athlete can suffer a mild concussion without losing consciousness. Concussion symptoms vary, depending on the degree of severity, which is assessed on a scale of one to three that was developed by Dr. Kelly and members of the Sports Medicine Committee of the Colorado Medical Society. These symptoms may include dizziness and impaired orientation, concentration, and memory. Headache is the most common complaint of concussed athletes, but is not present in all cases.

Often athletes who are concussed, but not rendered unconscious, wont report the concussion and will attempt to finish a workout or competition as if nothing happened. However, there are often physical signs that can tip off alert observers. "There may be a diminished frequency of blinking" says Kelly, "or the athlete may have a glassy-eyed, bewildered look. The athlete may also look worried and concerned and may ask the same questions over and over. On rare occasions, athletes will cry because they are extremely confused and nothing makes sense to them."

When to Resume. Most authorities agree that when an athlete has sustained a mild concussion during training or competition (typified by mild confusion but with total recall of the incident) the athlete can return to action within 20 to 30 minutes if there are no symptoms whatsoever.

Cantu notes that it goes against most athletes' competitive nature to remain on the sidelines, so they'll often cover up their condition. A short memory test and exertion exercise should clear up any doubts that a physician or coach may have.

"Every five minutes, name a color, someone's name, and two common objects," says Cantu, "and have the athlete repeat this listing a minute later. If they're having trouble processing new information, which is a typical symptom of amnesia, they won't be able to repeat your list and shouldn't be allowed to play."

If the athlete passes the mental exams, he or she should then perform five repetitions each of push-ups, sit-ups, and knee-bends. The athlete should be kept on the sidelines if there is any nausea, dizziness, headache, or blurred or double vision.

Kelly urges all athletes who sustain a concussion and develop amnesia, post-traumatic headache, or have any other lingering symptoms to seek expert advice, either from their team or family physician or neurologist. After symptoms subside, they should be kept from practice or competition for a minimum of seven days. Athletes who require hospitalization can resume practice and competition one month after they have been symptom free for two weeks. In all cases, once the athlete returns to action, the coach and trainer should be on the alert for any gait problems, headache, or other abnormal symptoms.

Strengthening Neck Muscles. Concussions can happen to any athlete, but some people may be more susceptible than others. "In general," says Cantu, "you are at greatest risk for head or neck injury when you don't have sufficient neck musculature to overcome whatever it is that's imparting acceleration forces to your head."

The following exercises, in which athletes contract their neck muscles and push against a fixed resistance, help build overall neck muscle strength. Perform the exercises slowly and steadily throughout the full range of motion.

1) Forehead Push. While sitting, place one palm on the forehead. Tense the neck muscles and try to push forward. Resist with the palm so the head moves slowly forward. Repeat five times.

2) Head Push-Up. While sitting, tilt the head slightly forward and place one palm on the back of the head. Push against the resistance, gradually tilting the face upward. Repeat five times.

3) Side-to-Side Push: While sitting and looking forward, place the right hand to the side of the head and gradually move against the resistance until moving the head to the right as far as possible. Repeat five times and then perform the exercise on the left side.

4) Side-Bends. While sitting, place the right hand to the side of the head and gradually tilt the head against the resistance until the hand touches the right shoulder. Repeat five times and then perform the exercise on the left side.

Cuts, Scrapes, and Abrasions (reprinted with permission from the penn state sports medicine newsletter)

Cuts, scrapes, and abrasions are the most common type of athletic injury. These injuries, commonly known as open wounds, should be treated promptly and properly to avoid infection.

Before any wound is treated, the individual providing care must protect himself. Attention to proper hygiene and the use of personal protective equipment is essential. Always wash one's hands thoroughly before and after any contact. Disposable gloves should also be worn, and then properly disposed of after any contact with blood or body fluids.

If a wound is bleeding heavily, stopping the flow of blood should be the first priority. Once the bleeding has been brought under control, properly bandage the wound to prevent infection. Following is a simple, step-by-step approach to bandaging the majority of open wounds.

1) Wash hands thoroughly and put on a new pair of disposable gloves.

2) If the wound is bleeding, apply direct pressure with a sterile gauze pad. Small wounds with minimal blood flow can be cleaned while they are still bleeding.

3) Apply a liberal amount of aerosol soap or warm, soapy water. Wash with a new, sterile gauze pad. Start from the inside of the wound and work out. Wash at least two inches around the wound site to kill any germs near the wound.

4) Once the wound is washed, dry the area with a new, sterile gauze pad.

5) Saturate another sterile gauze pad with a small amount of antiseptic germ killer (hydrogen peroxide) and clean the wound.

6) Apply an antiseptic ointment to the wound, being careful not to touch the tube to the wound.

7) Apply a new, sterile gauze pad and secure with a gauze roller bandage and elastic wrap or some form of underwrapping.

8) Apply adhesive tape to keep bandage in place.

9) Do not attempt to remove debris that remains in a wound after washing. Removing debris is a physicians role.

Puncture wounds, which are caused by pointed objects penetrating deep into the skin, should not be washed with soap and water. Puncture wounds are too deep to allow contact with anything not sterile, but they should be disinfected and bandaged.

Proper wound treatment and disposal of blood-contaminated wastes are important elements in an athletic health care program. The procedures outlined above are a good starting place, but seek immediate medical treatment with questions or concerns about an injury.

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