Hands-on treatments on pain in athletes

Injuries in sports are common, and the resulting pain limits the athletes’ activity. But pain has a weak connection to the degree of injury but a strong connection to the perception and body image. The main goal of treatment for sportspersons is pain relief and return to play as quickly as possible. Therapies in sports should also focus on conservative rather than on invasive approaches (surgery), and drugs should also be avoided.

A review published in Science and Sports journal assesses the current evidence with a focus on recreational and elite athletes on conservative hands-on treatment for reducing pain.

Based on the current body of evidence, the review recommends the following

Grade A: nerve blocks and injection techniques, ultrasound and laser therapy, manipulation mobilization, massage and traction

Grade B: acupuncture and dry needling.

Non-drug therapies in pain seem to do more good than harm in patients, as far as reported. Still, the overall quality of retrieved data is poor.

In particular the review found that the field of massage and related techniques is variable; they usually apply biomechanical pressure, which decreases muscle stiffness, as well as mediating vagal relaxation. The authors found several extensive studies and reviews:

• A Cochrane review identified two trials with 122 participants (all but one being male athletes) who had experienced adductor-related groin pain. Besides limited evidence, passive techniques, like massage, seemed to be inferior to active modalities (e.g., exercise therapy), improving short term outcomes, but also return to sports in athletes.
• Clinical data suggest Chinese massage combined with and without herbal ointment improved nonspecific low back pain in an RCT with 110 athletes. Herbal ointment improves the effects of massage, but a clinically meaningful difference is small.
• Massage also has been shown to reduce pain intensity in 25 ultra-marathon runners. This was further confirmed by a large randomized controlled trial involving 75 Ironman triathlon athletes. Massage decreases pain and perceived fatigue.
• A 2011 literature review identified 4 studies comparing the effects of manual therapy with stabilization exercises in athletes with chronic low back pain, showing both treatments to be effective.
• A study in 59 elite Australian rules footballer showed small effects of a sports chiropractic manual therapy on the incidence of lower limb muscle strains, this reducing perceived low back pain when compared to conventional medical practice.
• A case series of 30 athletes with chronic adductor-related groin pain report a return-to-sport ratio of 90% and pain reduction from 8.7 cm to 2.2 cm on a visual analogue scale when treated with manual therapy.
• Several case reports suggest the use of chiropractic in the management of musculoskeletal pain in a junior hockey player, shoulder pain in a softball athlete, pain due to a sudden, non-traumatic, ballistic movement of the cervical spine during a Taekwondo competition, or thoracic pain in a collegiate runner.
• A systematic review showed the efficacy of manual joint mobilization on pain relief and functional improvement of acute lateral ankle sprains, without explicitly referring to sports-related sprains.

As a summary, there is a considerable body of evidence justifying the use of manipulation mobilization, massage, and traction in sports-related pain conditions. Trained and experienced therapists should be considered to reduce harm.