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Orthopaedics

Sports Injuries

Sports injuries are common among athletes and other people who participate in sports. Certain injuries that are traditionally considered sports injuries can also occur in people who do not participate in sports. For example, homemakers and factory workers often develop tennis elbow, although they may never have played tennis.


Sports participation always carries the risk of injury. Sports injuries are more likely when people do not warm up properly. 


Muscles and ligaments are injured when subjected to forces greater than their inherent strength. For example, they may be injured if they are too weak or tight for the exercise being attempted. Joints are more prone to injury when the muscles and ligaments that support them are weak, as they are after a sprain.


Individual differences in body structure can make people susceptible to sports injuries by stressing parts of the body unevenly. For example, when legs are unequal in length, forces on the hips and knees are unequal and place more stress on one side of the body.


Excessive pronation—rolling onto the inside of the foot after it strikes the ground—can cause foot and knee pain. Some degree of pronation is normal and prevents injuries by helping distribute the foot's striking force throughout the foot. In people with excessive pronation, the feet are so flexible that the long arch flattens out, allowing the inner part of the foot to come close to touching the ground during walking or running and giving the appearance of flatfeet. Runners with excessive pronation may develop knee pain when running long distances because the knee caps tend to turn outward when the feet turn inward. This position in turn places excessive pressure across the front of the knee.


The opposite problem—too little pronation—can occur in people who have rigid ankles. In these people, the feet appear to have very high arches and do not absorb shock well, increasing the risk of developing small cracks in the bones (stress fractures) of the feet and legs.


The way in which the legs are aligned can produce pain, particularly in women with wide hips. Such women develop a tendency for the knee caps to be pushed outward from the midline. This force on the knee caps causes pain.


Generally, sports injuries can be divided into four categories:


      • Overuse
      • Blunt trauma (for example, falls and tackles)
      • Fractures and dislocations
      • Sprains (ligament injuries) and strains (muscle injuries)



Overuse


One of the most common causes of sports injuries is overuse (excessive wear and tear). Overuse injuries are often due to faulty technique. An example of an improper technique is running along the same side of a banked road. Repeatedly hitting the slightly higher surface with the same foot results in different forces being applied to the right and left hips and knees. This difference in forces increases the risk of injury on the side striking the higher surface and changes the forces acting on the other leg, risking injury to it as well.


Some athletes increase the speed or intensity of their workouts too quickly, putting stress on the muscles. For example, some runners who increase speed or distance too quickly during training stress the legs, hips, or feet. This extra stress often leads to muscle sprains and stress fractures of the bones.


Some athletes overly train one set of muscles without equally strengthening the opposite group of muscles, resulting in imbalances that can contribute to injury.


Another factor contributing to overuse injuries is inadequate recovery after a workout. Also, some people do not stop exercising when pain develops (working through the pain). Continuing to exercise when pain is present injures more muscle or connective tissue, extending the damage and delaying recovery, whereas rest allows recovery.



Blunt trauma


Blunt athletic trauma can result in bruises, concussions, and fractures. This type of injury usually involves high-impact collisions with other athletes or objects (for example, being tackled in football or checked into the sideboards in hockey), falls, and direct blows (for example, in boxing and the martial arts).



Fractures and dislocations


Fractured bones and dislocations of a joint are serious injuries that require immediate medical attention. People with these injuries often have deformity of a limb, intense pain, and dysfunction of the limb or joint and must be further evaluated with diagnostic tests, such as x-rays. When people suspect that they have a fracture or dislocated joint, they should splint the limb “as it lies” without moving it and go to the emergency department.


Stress fractures are small cracks in bone caused by repetitive stress injury. They are most common in the feet or long bones of the legs. They may cause no visible signs of injury and do not always appear on x-rays. The only symptom is pain when the person tries to put weight on the injured foot.



Sprains and strains


Sprains and strains typically occur with sudden, forceful exertion, most commonly during running, particularly with sudden changes of direction (for example, while dodging and avoiding competitors in football). Such injuries also are common in strength training, when people quickly drop or yank the load rather than moving slowly and smoothly with constant controlled tension.



Symptoms


Injury always causes pain, which can range from mild to severe. Injured tissue may have any combination of the following characteristics:


    • Swelling
    • Warmth
    • Tenderness to touch
    • Bruising
    • Loss of normal range of motion



CHILDREN AND SPORTS INJURIES



About 3.5 million sports-related injuries involving children younger than 14 occur in the United States each year. As more children participate in organized athletic activities and begin participating at younger ages, they are at greater risk of sports injuries, particularly overuse injuries. This risk is particularly high for children who participate in a single sport year-round, move from one sports season to the next with no break between them, or play on elite-level teams. Some children may try to play when they are injured because they fear being dropped from a team.


In general, the same injury prevention guidelines apply to children as to adult athletes, including the need for proper warm-up and stretching techniques. Some experts believe children younger than 10 should participate in a wide range of activities rather than specialize in one sport. Specialization can lead children to overtrain one group of muscles, increasing injury risk.


Use of appropriate equipment that is properly fitted is important. Safety equipment, such as helmets, eye protection, mouth guards, and elbow and knee pads that are approved for the sport, can help prevent injury.


Some sports have specific guidelines about the amount of time that child athletes can practice or play. For example, in baseball, pitch counts based on the pitcher's age have been established.


Pain during an activity or excessive pain after an activity may be clues to an overuse injury. The need for ice and pain-relieving drugs after exercise may also be a clue. If pain or soreness causes changes in gait, body mechanics, or sport technique, overuse may be a problem. Some children do not complain of pain but instead experience diminished success or enjoyment in sports participation and changes in mood or school performance.


In adolescent girls, a history of stress fractures may be a sign of the  female athlete triad of osteoporosis, menstrual irregularities, and an inadequate diet. Although no athlete is immune from the consequences of inadequate nutrition, young women who participate in endurance activities or “appearance” sports, such as figure skating, gymnastics, or dance, are at particular risk.




Diagnosis


    • A doctor's evaluation


To diagnose a sports injury, doctors ask when and how the injury happened, what recreational and occupational activities the person has recently or routinely been engaged in, and whether there has been a change in the intensity of the activity. They may ask whether the person has taken certain antibiotics that increase the risk of tendon injury (for example, ciprofloxacin or levofloxacin). Doctors also examine the injured area.


People may be referred to a specialist for further testing. Diagnostic tests may include x-rays, computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography, bone scanning, dual-energy x-ray absorptiometry (DEXA scanning), and electromyography (EMG).



Prevention


General measures that help increase safety during exercise, including proper warm-up, cool down, and hydration, are discussed elsewhere. Exercise itself helps prevent injuries because tissues become more resilient to the stresses of vigorous activities.


Use of proper equipment can help prevent injuries. For example, wearing helmets and mouth guards can help prevent injuries while playing football. For running athletes, good running shoes are essential. Running shoes should have a rigid heel counter (the back part of the shoe that surrounds the heel) to control movement of the back of the foot, a support across the instep (saddle) to prevent excessive pronation, and a padded opening (collar) to support the ankle.


Shoe inserts (orthotics) can sometimes help correct problems such as excessive pronation. The inserts, which may be flexible, semirigid, or rigid and may vary in length, should be fitted into appropriate running shoes. The shoes must have adequate space for the inserts, which replace the inserts found in the shoes at the time of purchase.


Stopping exercise at the first sign of pain, which precedes most overuse injuries, limits the degree of injury to muscles and tendons.


After sustaining a sports injury, athletes often want to know how quickly they can resume activity. Recovery time depends on the severity of the injury. Initially, exercise of previously injured areas should be of low intensity to strengthen weak muscles, tendons, and ligaments and prevent re-injury. Often, athletes need to adjust their technique to avoid re-injury. For example, a racquet sports player who has tennis elbow may need to alter technique for use of the racquet.


Treatment


    • PRICE
    • Rehabilitation


Treatment of sports injuries is similar to treatment of non-sports injuries.



Initial treatment


Immediate treatment for almost all injuries consists of PRICE:


    • Protection
    • Rest
    • Ice
    • Compression
    • Elevation


Protection involves immediately resting and splinting the injured part to minimize internal bleeding and swelling and to prevent further injury .


The injured part swells because fluid leaks from blood vessels. By causing the blood vessels to constrict, ice reduces their tendency to leak, thus limiting swelling. Ice also helps to reduce pain and muscle spasms and limit tissue damage.


Ice and cold packs should not be applied directly to the skin, because doing so could irritate or damage the skin. They should be enclosed (for example, in plastic) and placed over a towel or facecloth. An elastic bandage can be wrapped around the ice pack to keep it in place while the injured part is elevated. The ice is removed after 20 minutes, left off for 20 minutes or longer, and then reapplied for 20 minutes. This process can be repeated several times during the first 24 hours.


Whether or not ice is in place, wrapping the injured part with an elastic bandage compresses the injured tissue and limits internal bleeding and swelling. The wrap is thus kept on until the injury heals.


The injured area should be elevated above heart level so that gravity can help drain the accumulated fluid that causes swelling and pain. If possible, fluid should drain on an entirely downhill path from the injured area to the heart. For example, for a hand injury, the elbow, as well as the hand, should be elevated.



Ice and Elevation for the Arm




Analgesics can be used to lessen pain. Acetaminophen is usually effective for pain but does not reduce inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can be used for pain and inflammation but have a slightly higher risk of side effects (most often stomach upset) than acetaminophen. If pain is severe or persists for more than 3 days, a medical evaluation is recommended.


Injections of corticosteroids into an injured joint or the surrounding tissues are sometimes used in addition to PRICE to relieve pain and reduce swelling. However, corticosteroid injections can delay healing, increase the risk of tendon and cartilage damage, and enable a person to use an injured joint before it is fully healed, perhaps worsening the injury, and should only be done by a doctor.



Rehabilitation


After the initial injury has healed, the person should rehabilitate the injured area before resuming the activity that led to the injury. Rehabilitation may involve formal regimens carried out under the supervision of a physical therapist or athletic trainer or less formal strengthening and conditioning done without supervision. Sometimes a physical therapist provides instructions for exercises that athletes can do on their own. Physical therapists may incorporate heat, cold, electricity, sound waves, traction, or water exercise into a treatment plan in addition to therapeutic exercises . How long physical therapy is needed depends on the severity and complexity of the injury.


The activity or sport that caused the injury should be avoided or modified until the injury has healed. Complete inactivity causes muscles to lose mass, strength, and endurance. Therefore, substituting activities that do not stress the injured part is preferable to abstaining from all physical activity. Substitute activities include bicycling, swimming, and rowing when the leg or foot is injured. Swimming and bicycling are good substitutes when the lower back is injured.



SPOTLIGHT ON AGING: EXERCISING SAFELY



Most older people can safely exercise. Exercise even helps relieve some disorders, such as high blood pressure and diabetes. However, older people should check with their doctors before they start an exercise program.


Exercise programs for older people should include activities to promote flexibility and agility as well as those for strengthening and aerobic conditioning. Older people are more likely to injure themselves than younger people who are participating in the same sport. Proper footwear and equipment are important.


People need to begin gradually and build up slowly. As with people of all ages, a careful warm-up period is key to reducing the chance of injury. Aging causes a decrease in flexibility because of changes in connective tissue. Older people are also more likely to have arthritis, which further decreases flexibility. Lack of flexibility means that joints bear greater stress during exercise, rather than spreading it to surrounding tissues, such as nearby muscles. This stress can gradually damage the joints. Extra warm-up and flexibility exercises can help prevent injury.


Older runners are subject to the same running-related sports injuries as younger runners. Older runners are also more likely to fall. Often, balance deteriorates in older people, so older athletes may want to consider adding balance exercises to their workouts. Dehydration can lead to episodes of confusion, which could possibly cause falls in older people.