Bruises and hematomas

Bruises, especially deep-tissue bruises, can be a serious and disabling affliction for both the recreational and the professional athlete. For example, combining the massive thighs of a fullback with the onrushing helmet of a linebacker offers the potential for an impact that can send a running back to the sidelines with a deep thigh bruise. "A key component of bruises is kinetic energy, with the factors of mass and velocity," says Dr. Bert Mandelbaum, team physician for the U.S. World Cup soccer team and a member of the Association of Professional Team Physicians (PTP). "If a large mass meets a high velocity on an exposed area, conditions favor a deep bruise."

We asked Dr. Mandelbaum to explain the basics of bruises and hematomas and to provide a few details on the treatment of this painful condition.

What exactly causes a bruise?

Dr. Mandelbaum: Bruises are caused by an impact between an object, whether it be a racquetball or a football helmet, and a body part. All connective tissue structure -- muscle, tendons, bones and organs -- can be bruised, and there is a direct relationship between the energy of the object and the severity of the bruise. Specifically, we are talking about the energy of motion where one-half the mass of an object multiplied by the velocity squared equals the kinetic energy, a very important concept where bruises are concerned. So you can see how a bigger, faster-moving object -- say, a 250-pound fullback who runs the 40-yard dash in 4.6 seconds -- runs a greater risk of encountering a severe, bruise-like injury.

In terms of the bodies' response to the trauma, there is increased blood flow to the area, swelling in the layer of the tissue, loss of range of motion, stiffness and obviously pain.

How does a bruise affect an athlete's performance?

Dr. Mandelbaum: Well, in a bad circumstance, such as a deep muscle bruise to the quadriceps, you'll have a hematoma in the muscle plane -- a space-occupying mass of blood and concurrent jelly-type of material. As a consequence, the muscle gets stiff, prohibiting it from working the way we would like it to work. The athlete is unable to run, and walking can be very difficult. One of the standard treatments for a high-energy impact to the quad area is to occasionally tape the knee in a hyperflexion state so as to keep the muscle flexed and not lose muscle tension. In rare circumstances, the pools of blood between the layers of tissue are so significant as to warrant a sort of vacuuming in the injured area.

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Q: How can high or low blood sugar levels affect an athlete's performance? -- Chris Holland, Okeechobee, Fla. A: From Dr. William E. Straw (www.straws.com), PTP member physician and team physician for the San Francisco Giants: "Chris, the condition most likely to affect blood sugar levels is the disease diabetes mellitus. If uncontrolled, diabetes can cause elevated blood sugar levels (hyperglycemia). This results in increased thirst, frequent urination and weight fluctuations. The treatment of diabetes with insulin shots can result in hypoglycemia or low blood sugar. If mild, hypoglycemia produces weakness, confusion and headache. Severe hypoglycemia can produce coma. Diabetics are taught to recognize the warning signs of both hypoglycemia and hyperglycemia, Portable blood glucose measuring devices allow diabetics to closely monitor their blood sugar levels to adjust the amount of insulin required. Diabetics often alter their insulin doses to adjust for exercise and sports. Some non-diabetics suffer from reactive hypoglycemia. This condition is usually mild and can often be prevented by eating smaller, more frequent meals." Do you have a question for a team physician? Click here to ask. And check out more "Ask the Pro Doc" answers to users' questions.

How do you treat a bruise?

Dr. Mandelbaum: The first issue in dealing with the problem and management of bruises is making an accurate diagnosis. Part of that is understanding the principles of the injury -- what happened, how it happened, the nature of the bruise -- essentially making sure it is a bruise. In terms of the physical examination, we palpate the area of injury and look at the anatomy, feeling for discontinuity in key sections of the muscle to make sure the muscle is continuous. This is our primary concern.

Treatment in most cases is the standard RICE -- rest, ice, compression and elevation in conjunction with anti-inflammatories to control the swelling. If there are any questions as to the nature of the injury, we take x-rays and secondary image studies, including MRI tests. MRI tests are extremely helpful in understanding the situation. They can detect the exact nature of the hematoma, how big the size of the injury is and its precise location.

Regardless of the tissue affected, the healing process can basically be divided into three phases:
The infiltration of the cell with blood
The laying down of new collagen in the tissue plane
The maturation of the bruise to completion
The whole process can take six weeks or more, depending on the severity of the injury.

Can bruises present any danger to an athlete?

Dr. Mandelbaum: Sometimes a high-energy bruise to a lower extremity can result in what we call "compartment syndrome." This condition occurs when the pressure in the tissue rises to the point well above normal, causing potential damage to muscle and nerves and all of the soft tissue. For instance, a basketball player can get kicked in the calf and develop compartment syndrome a few hours later. Pressure rises to a danger zone and actually begins to knock out the function of nerves and muscles. This is a very serious and disabling problem. This is definitely one thing that needs to be watched for, so if there is any numbness or tingling that cannot be controlled through normal treatment, this syndrome could be a culprit. It must be treated very aggressively. One needs to reduce the pressure by opening up the "compartment" and allowing the area to breathe.

What are hematomas?

Dr. Mandelbaum: A hematoma, by definition, is a collection of blood, meaning that the tissue has to be injured enough to cause a significant bleeding response. Hematomas are static and are not clots of blood and they cannot move to another area of the body via the bloodstream. A hematoma is just a reservoir of blood anywhere. The consequence of a bruise is a hematoma, and the higher the kinetic energy of an impact, the bigger the hematoma.

Dr. Bert Mandelbaum, a member of the Association of Professional Team Physicians (PTP), was medical director for the U.S. World Cup soccer team and is currently team physician at Pepperdine University. He has a private orthopedic practice at the Santa Monica Orthopedic and Sports Medicine Group, Inc. in Santa Monica, Calif. Dr. Mandelbaum received his undergraduate degree from the State University of New York at Cortland and his medical degree from Washington University in St. Louis. He also completed his internship in General Surgery and his residency in Orthopedic Surgery at The Johns Hopkins Hospital.

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