As with many occupations involving intense physical labor and repetitive motion, construction workers develop a wide variety of musculoskeletal disorders. There is a 75 percent probability that a construction worker will suffer a disabling injury during an average 45-year career.¹ Low-back pain due to heavy lifting is the most frequent problem. Lower-extremity overuse disorders, such as plantar fasciitis, are also common, as are cumulative trauma disorders from repetitive motion tasks. 

Occupational injury statistics also cite a high frequency of serious acute injuries that occur in this worker population, the large majority involving sprains and strains. Although relatively common, sprains and strains can lead to time off work, chronic pain that interferes with work, and more serious and disabling conditions. Nailing down the specific tissues involved in a client’s particular presentation will ultimately predict how successful your treatment will be. 

Understanding the physiological aspects of what occurs during ligament sprains and muscle strains is important, and will also help you accurately evaluate the injury so that your treatments specifically target the affected tissues. Particular massage treatment techniques are quite successful in reducing pain and encouraging healing in these common conditions.

Ligament Sprains

The primary function of ligaments is to connect adjacent bones. While the bones provide the rigid support for our body, we are reliant on the ligaments to efficiently tie each of these rigid segments together. Ligaments must allow certain motions, but prevent others.

Within each ligament, the fibers predominantly go in one direction. This gives the ligament its greatest strength in that direction, and the greatest capability to resist forces that come from that direction (Image 1). However, ligaments also contain fibers that run crosswise, allowing for additional strength and pliability when tensile forces are applied from other directions. This helps the joint withstand large force loads without causing more significant tissue injury.

A sprain is an injury in which the ligament is torn or stretched beyond its capacity. Most ligament sprains arise from acute injuries that occur when a short-duration, high-intensity load is placed on the tissues (e.g., twisting an ankle). 

Image 2 shows the relationship between increased load on a ligament and the length change, or degree of tissue damage. When a moderately small load is placed on the ligament, the ligament slightly stretches. When the load is removed, the ligament regains its normal resting length. This ability to recoil from stretching is known as elastic deformation, shown in the “elastic region” in Image 2. 

If the force load during a short-duration injury is significantly higher, the ligament will overstretch but not return to its normal resting length. This is known as plastic deformation, meaning that when the length of the ligament is changed, some of that change is permanent. This region of change is represented on the graph as the “plastic region.”

In a more severe injury, the force load is enough to cause a complete rupture of the ligament fibers. These three segments of the ligament-stress curve correspond pretty closely to the three categories of ligament sprain: mild or first degree (elastic damage), moderate or second degree (plastic damage), and severe or third degree (complete rupture). 

Second- and third-degree ligament sprains often include complications in which fibrous adhesions develop, adhering the healing ligament to adjacent tissues. For example, in a lateral ankle sprain, the anterior talofibular ligament will often attach to the underlying joint capsule or adjacent tissues, and further complicate and lengthen the rehabilitation process (Image 3). 

Ligament sprains can happen at virtually any joint. However, they are most common where joints are exposed to high velocity and high load, such as the knee and ankle. Sprains may also happen to the small ligaments of the spine, which play a major role in maintaining stability during heavy-lifting activities. 

Managing Ligament Sprains

In ligament sprains, swelling from the injury accumulates around the joint. Ligaments are not highly vascularized, and therefore bruising is usually not as significant as it is in a muscle injury where highly vascularized tissue has been damaged or disrupted. Ligament injuries are also routinely painful; any active or passive motion, even if it is well within the joint’s normal range, may cause pain.

Because ligaments are located around joints where thick muscle tissue is minimal, they are easy to access and ligament damage can often be detected with palpation. Consequently, the practitioner’s knowledge of anatomy is key for identifying which specific ligament may have been damaged. Special orthopedic tests also exist that identify joint hypermobility that may result from a ligament sprain. These tests are highly valuable in determining the level of severity of a ligament injury and can help the practitioner make an appropriate decision about treatment or referral to another health-care professional.

A primary role of massage in treating ligament sprains is to encourage fibroblast proliferation in the ligament so tissues heal faster. In addition, deep transverse friction also encourages mobility between the ligament and adjacent tissues. In many instances, massage treatment reduces tightness in the adjacent muscles that become hypertonic as a result of a sprain. 

In some cases, however, reducing tightness in surrounding muscles is not the best strategy. With moderate or severe ligament sprains, joint stability is compromised. Muscles then play an important role in helping to maintain joint stability in a hypermobile joint by becoming tighter around that joint. In this case, it is more valuable to work on the ligament itself to encourage lymphatic drainage to reduce swelling and work on opposing muscles, but not address the muscles in question. 

Muscle Strains

A strain is a tensile stress injury to the muscle tendon unit that occurs when it is pulled beyond its capacity to withstand the tensile load. Strains occur in either the muscle or tendon fiber; however, tendon fiber is far more resistant to high tensile loads, so more often the injury occurs in the muscle belly. It is also common at the musculotendinous junction where the two tissues interface with each other.

Strains occur both as a result of chronic, repetitive loads, as well as sudden, high-force loads in an acute injury. Keep in mind that muscles are under high loads when they are shortening in a concentric contraction as well as when they are lengthening in an eccentric contraction. In many cases, strains are more likely to result from eccentric overload. Consequently, it is valuable to identify if injury factors involved concentric contraction, eccentric contraction, or passive lengthening of a muscle.  

A chronic strain can result from lower-level forces repeatedly applied to a muscle over time until the muscle finally reaches fatigue and tears. In acute strains, the muscle injury results from a sudden, overwhelming force load that is more than the muscle fibers can withstand. Similar to ligament sprains, muscle strains are classified into three grades of severity: first degree (mild), second degree (moderate), and third degree (severe). 

Strains can happen to any muscle, but certain muscles are more susceptible than others because they are biomechanically more vulnerable. For example, multiarticulate muscles, such as the hamstring group, are those that cross more than one joint (Image 4). These muscles can be put under severe compromised tensile loads if both joints are in a position to stretch the muscle at the same time. If an individual is forced into a position with hip flexion and knee extension occurring simultaneously, as in a fall, there is far greater tensile load on the hamstrings than if that person is forced into hip flexion or knee extension alone.

Muscle strains produce greater bruising because of damage to the highly vascularized muscle tissue. However, if the injury is at or near the musculotendinous junction, bruising may be limited, as that area has less blood supply. 

The pain of a muscle strain will be reproduced with active contraction of the muscle tendon unit during a manual resistive test (Image 5). Ligament sprains, on the other hand, are not painful during a manual resistive test because there is no significant stress placed on the joint during the movement. Muscle strains are also painful during palpation, and if the muscle tendon unit is stretched.

Managing Strains

Numerous factors place an individual at risk for developing muscle strains, and many of these factors are present in routine construction work: repetitive movements, heavy lifting, sustained awkward postures, and fatigue from the chronic contraction of holding power tools. 

Educating the client about precipitating factors is a valuable way to reduce the likelihood of a strain injury developing. If a strain injury has already occurred, a detailed history will reveal some or all of these factors and will help to understand what initially caused the injury.

Massage treatment strategies for muscle strains should focus primarily on managing the tissue-tear site and the scar tissue that the body uses to repair the damaged muscle fibers. Deep transverse friction massage applied directly to the site of the tissue injury can reduce any fibrous adhesion from the scar tissue that may adversely adhere adjacent fibers during the injury repair process (Image 6).

An injured muscle, along with surrounding muscles, may become hypertonic in a protective spasm. While muscle tightness can protect the region in the initial stages of injury, it can very quickly set up a pattern of dysfunctional hypertonicity that can remain long after the injury has healed. 

Massage treatment is highly valuable at this point to reduce the muscle tightness and restore normal functional mechanics. Massage techniques that will be most advantageous are those that encourage tissue lengthening, such as longitudinal stripping techniques. Stretching is also highly valuable to maintain tissue elasticity.

A crucial part of the rehabilitation process is rest from offending activities, yet many workers simply cannot take time off. Work modifications are important, as are splints or braces to support tissues as they heal. Due to the nature of these injuries, and the nature of the tissue-repair process, massage is an outstanding approach that will help reduce long-term tissue dysfunction and get the individual back to healthy activity as soon as possible. 

Note

1. X.S. Dong et al., “Lifetime Risk of Occupational Injuries & Illnesses Among Construction Workers,” American Public Health Association, accessed December 2012, www.cpwr.com/pdfs/Dong_APHA_Lifetime risk_103111.pdf.