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.
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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