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Approach to Sports Injuries

by Paul L. Liebert, MD

Sports participation always has a risk of injury.

Generally, sports injury can be divided into

Many injuries (eg, fractures, dislocations, soft-tissue contusions, blunt trauma, sprains, strains) are not unique to sports participation and can result from activities that are not athletic or from accidents. Such injuries are described elsewhere in T he M anual (see Fractures, Dislocations, and Sprains). However, athletes may need to learn how to modify faulty techniques that predispose to injuries or may resist taking an adequate period of rest to recover from a sports injury (working through the pain).

Overuse

Overuse is one of the most common causes of athletic injury and is the cumulative effect of excessive, repetitive stress on anatomic structures. It results in trauma to muscles, tendons, cartilage, ligaments, bursae, fascia, and bone in any combination. Risk of overuse injury depends on complex interactions between individual and extrinsic factors.

Individual factors include

  • Muscle weakness and inflexibility

  • Joint laxity

  • Previous injury

  • Bone malalignment

  • Limb asymmetries

Extrinsic factors include

  • Training errors (eg, exercise without sufficient recovery time, excess load, building one group of muscles without training the opposing group, and extensive use of the same movement patterns)

  • Environmental conditions (eg, excessive running on banked tracks or crowned roads—which stresses the limbs asymmetrically)

  • Training equipment characteristics (eg, unusual or unaccustomed motions, such as those made while on an elliptical trainer)

Runners most often sustain injury after too rapidly increasing their intensity or length of workouts. Swimmers may be least prone to overuse injuries because buoyancy has protective effects, although they still are at risk, particularly in the shoulders, from which most movement occurs.

Blunt trauma

Blunt athletic trauma can result in injuries such as soft-tissue contusions, concussions, and fractures. The mechanism of injury usually involves high-impact collisions with other athletes or objects (eg, being tackled in football or checked into the sideboards in hockey), falls, and direct blows (eg, in boxing or the martial arts).

Sprains and strains

Sprains are injuries to ligaments, and strains are injuries to muscles. They typically occur with sudden, forceful exertion, most commonly during running, particularly with sudden changes of direction (eg, dodging and avoiding competitors in football). Such injuries also are common in strength training, when a person quickly drops or yanks at the load rather than moving slowly and smoothly with constant controlled tension.

Symptoms and Signs

Injury always results in pain, which ranges from mild to severe. Physical signs may be absent or may include any combination of soft-tissue edema, erythema, warmth, point tenderness, ecchymosis, instability, and loss of mobility.

Diagnosis

Diagnosis should include a thorough history and physical examination. History should focus on the mechanism of injury, physical stresses of the activity, past injuries, timing of pain onset, and extent and duration of pain before, during, and after activity. Patients should be asked about exposure to quinolone antibiotics, which can predispose to tendon rupture. Diagnostic testing (eg, x-rays, ultrasonography, CT, MRI, bone scans, electromyography) and referral to a specialist may be required.

Treatment

  • Rest, ice, compression, elevation (RICE)

  • Analgesics

  • Cross training

  • Gradual return to activity

RICE

Immediate treatment of most acute sports injuries is RICE.

Rest prevents further injury and helps to reduce swelling.

Ice (or a commercial cold pack) causes vasoconstriction and reduces soft-tissue swelling, inflammation, and pain. Ice and cold packs should not be applied directly to the skin. They should be enclosed in plastic or a towel. They should be left in place for no more than 20 min at a time. An elastic bandage can be wrapped around a tightly closed plastic bag containing ice to keep it in place.

Wrapping an injured extremity with an elastic bandage for compression reduces edema and pain. The bandage should not be wrapped too firmly because doing so may cause swelling in the distal extremity.

The injured area should be elevated above heart level so that gravity can facilitate drainage of fluid, which reduces swelling and thus pain. Ideally, fluid should drain on an entirely downhill path from the injured area to the heart (eg, for a hand injury, the elbow, as well as the hand, should be elevated). Ice and elevation should be used periodically throughout the initial 24 h after an acute injury.


Pain control

Pain control usually involves use of analgesics, typically acetaminophen or NSAIDs. NSAIDs should be avoided in patients with renal insufficiency or a history of gastritis or peptic ulcer disease. However, if pain persists for > 72 h after a seemingly minor injury, referral to a specialist is recommended. For persistent pain, evaluation for additional or more severe injuries is indicated. These injuries are treated as appropriate (eg, with immobilization, sometimes with oral or injectable corticosteroids). Corticosteroids should be given only by a specialist and when necessary because corticosteroids can delay soft-tissue healing and sometimes weaken injured tendons and muscles. The frequency of corticosteroid injections should be monitored by a specialist because too-frequent injections may increase the risk of tissue degeneration and ligament or tendon rupture.


Activity

In general, injured athletes should avoid the specific activity that caused the injury until after healing occurs. To minimize deconditioning, athletes can cross-train (ie, do different or related exercises that do not cause reinjury or pain). Injury may also necessitate reducing exercise range-of-motion if there is intolerable pain at certain points of movement. Initially, exercise of previously injured areas should be low in intensity to gradually strengthen weak muscles, tendons, and ligaments without risking reinjury. It is more important to maintain a good range-of-motion, which helps direct blood to the injured area to accelerate healing, than to rapidly resume full intensity training for fear of losing conditioning. Resumption of full activity should be gradual once pain subsides. Competitive athletes should consider consultation with a professional (eg, physical therapist, athletic trainer).

Athletes should be placed in a graduated program of exercises and physical therapy to restore flexibility, strength, and endurance. They also need to feel psychologically ready before re-engaging in an activity at full capacity. Competitive athletes may benefit from motivational counseling.


Prevention

Exercise itself helps prevent injuries because tissues become more resilient and tolerant of the forces they experience during vigorous activities. In general, flexibility and generalized conditioning are important for all athletes as a means to avoid injury.

General warming up raises muscle temperature and makes muscles more pliable, stronger, and more resistant to injury; it also improves workout performance by enhancing mental and physical preparedness. However, stretching before exercise has not been shown to prevent injury. Cooling down (ie, a brief period of lower-level exertion immediately after a workout) is sometimes thought to prevent dizziness and syncope after aerobic exercise and help remove metabolic byproducts of exercise, such as lactic acid, from muscles and the bloodstream. However, studies fail to show that cooling down decreases post-exercise stiffness and soreness. Removing lactic acid may help decrease muscle soreness. Cooling down also helps decrease heart rate slowly and gradually to near-resting levels.

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