Sports Injuries - Basic Principles

The potential scope of this topic is vast and no attempt will be made here to cover all the ground. The aim is to help the generalist who does not have special expertise in sports-related injuries in the approach to diagnosis and management. The term "sportsman" here includes all who partake in physical activity, both male and female, as a hobby or as a career.

• Find out exactly how the injury occurred. This is essential to understand the mechanism of injury.
  • Was there direct trauma?
  • If so, where, how and in what direction?
  • Try to assess the force of the impact.
  • Was a rotating action involved?
  • What was the position of the joints when it happened?
  • Especially if you are not familiar with the sport, ask the athlete to explain exactly what was happening.
• Was there a sound? One study found that 30% of patients with an anterior cruciate ligament injury noticed a cracking or popping sound.¹
• Was the athlete able to continue the game?
• How long ago was the injury?
• What has happened since? This may include marked improvement, little improvement or even deterioration. They may have attended A&E and been dismissed after an X-ray revealed no fracture.
• Has there been a similar injury before?

The next part of the history may be completed before examination or between diagnosis and discussing management:

• How often does the athlete compete?
• At what level does the athlete compete?
• How often does the athlete train? This may include number of times a week and number of hours a week.

This will give an indication of how seriously the athlete takes their sport. It may also indicate over-training, a strain or an overuse injury related to the sport.

• How long has it been a problem?
• Has it been progressive?
• What brings it on?
• Exactly where is the pain?
• Ask about training regimes.
• Has the athlete discussed it with their coach?

Poor technique predisposes to overuse or other injuries, or poor equipment may be at fault.

Apart from the usual examination specific to the area in question (e.g. a joint), assessment of sports injuries should include a functional examination and a biomechanical assessment.

Functional examination will be specific to the sports activity undertaken and may include agility, co-ordination, power and flexibility. The patient should be assessed through the full range of movements involved in participation of the sport.²

The knee is very often injured and ability to examine the knee must include the ability to detect instability of ligaments, and effusion. Shortly after an injury, especially if there is effusion or spasm of muscles due to pain, it may not be possible to detect instability. The general principles of examining a joint are as follows:

• Look at the area. Is there bruising or swelling? Is there any distortion?
• Put the joint through its full range of passive movements in all directions. Some joints have a great variety of movements; for example, the shoulder can flex, extend, abduct, adduct and internally and externally rotate.
• Ask the patient to perform that range of movement actively.
• Test active movement against resistance.
• Stress the joint to detect instability of ligaments.
• Palpate the joint and also around it for local tenderness, swelling or effusion and muscle spasm.

If cause for the pain has not been found, look elsewhere. For example, trouble in the hip can cause pain in the knee and, less often, vice versa. Pain from the back may be referred to the lower limb. Look at stance and gait. A problem lower down may cause trouble higher up. Flat feet will cause hyperpronation and this may strain the ankle. It can also put a valgus strain on the knee and present as pain and effusion after running. Inequalities of legs may cause back pain. Thus, correcting flat feet may solve many problems higher up.

• Look at the patient standing with both feet bare. Does the stance look normal?
• Is it possible to get a finger under the medial longitudinal arch of the foot?
• Look at the heels from behind. Is the line of the Achilles tendon straight? With hyperpronation it will curve out laterally as it descends.
• With the patient seated, inspect the soles of the feet. There should be callus over the 1st and 5th metatarsal heads and the heel. Callus over other metatarsal heads or elsewhere on the sole suggests flat feet.

If the patient is complaining of pain associated with running, it is helpful, if possible, to inspect the trainers that are used. If not, at least look at the current pair of shoes. The sole of the shoes may show uneven wear with perhaps excessive wear on the lateral side of the shoe. Trainers may have a high heel tab that rubs on the Achilles tendon. The trainers may be worn out and have lost their spring and resilience. They may need to be changed.

• X-rays are mandatory if a fracture or dislocation is suspected but they are of little value otherwise, as they do not show soft tissue well. It is important to get the balance right between excessive requests for X-rays and missing fractures. It should be possible to reduce the number of ankle X-rays whilst not missing fractures by application of the Ottawa rules, as described in ankle injuries, and Pott's fracture.
• A biomechanical assessment involves applying mechanical principles to living beings. In the context of sports medicine, various techniques are used to assess forces and deformations applied to various tissue during movement. A common technique is three-dimensional cinematography or videography. The findings from this type of assessment can lead to the use of orthoses, the avoidance of certain movements which might aggravate the condition or the adaptation or replacement of sports equipment.³
• If a knee is swollen, aspiration of the joint, using a wide-bore needle after appropriate infiltration of local anaesthetic, is a useful diagnostic and therapeutic exercise. The fluid may be straw-coloured with an inflammatory exudate. It may be blood stained or frank blood. If there is blood in the fluid or frank blood, something is torn. This may be a tendon or cartilage. If the fluid is left to stand and a layer of fat globules appears on the surface, this is bone marrow and there is a fracture at the joint. Removal of fluid helps pain and aids recovery, even if it reforms. Muscle wasting around the knee is accelerated by effusion. Blood is very irritating and damages joints, as shown by the joints of those with haemophilia. If the fluid seems purely inflammatory, there may be some benefit from injecting steroid into the joint.
• Imaging for soft tissue injury usually requires MRI scan or ultrasound and it may be necessary to refer to secondary care to get access to this. CT scanning may also be contributory but all imaging modalities should be considered in terms of the cost-effectiveness of the information they can provide.⁴
• The arthroscope is a useful, minimally invasive tool to inspect the inside of joints and perhaps to undertake some repair. It is often used on the knee but some surgeons use arthroscopy of the shoulder and ankle joint too. The hip is too deep for ready access.

Sportsmen may also suffer disease, as may anyone else, and so other investigations may be indicated.

Drugs

The list of banned substances in sport is such that, for the serious sportsman, prescription needs some consideration. This is discussed in the separate article Drugs and Sport. There should not be any problem with paracetamol or the non-steroidal anti-inflammatory drugs (NSAIDs) but avoid any codeine based substances. Topical NSAIDs may be a valid alternative.⁵

Acute injury

If a part is injured it will need to be rested; however, simply telling a sportsman to rest it until it gets better will lead to lack of compliance and risk of further injury. A discussion is needed about a programme of rehabilitation back to full activity again. Active rehabilitation is applicable not just to sports-related injuries but should be part of any programme of rehabilitation.
Acute soft tissue injuries need management, as described in the separate article First Aid for Soft Tissue Injuries. The mnemonic RICE is well known and stands for:

• Rest
• Ice
• Compression
• Elevation

It is often extended to PRICER, in which the P stands for protection, which may mean immobilising the joint, and the last R stands for rehabilitation. Another variation of the mnemonic is PRICEMMM in which the last three letters stand for:

• Medication requires NSAIDs or paracetamol for pain relief.
• Mobilisation early on when pain-free to expedite return to play. Mobility should be graded.
• Modalities are exercise and proprioception training⁶ to prevent re-injury.

Active rehabilitation

The basic objectives of rehabilitation are as follows:⁷

• Resolution of pain and inflammation
• Restoration of range of motion
• Restoration of strength
• Proprioceptive training
• Sports specific activities

Advice needs to be adjusted to the person and the injury but, as an example, specific advice to an athlete with an injured knee may go like this:

• For the next four or five days you need to keep off that knee as much as possible. Keep it elevated when you can. Take the anti-inflammatory painkillers. If you need to train, then just do upper body work. (Similarly, if the upper body is injured, the sportsman may do lower body training and cardio-respiratory fitness whilst resting the upper body.) Static quadriceps exercises can be done at an early stage. Extend the knee to the horizontal position. Pull tightly with the quadriceps. Now invert the foot and feel how the tension moves to the lower vastus medialis. Keep any weights on the ankle light at an early stage.
• After that, it is possible to do some gentle lower body work but start with low intensity and short duration. Avoid running. Cycling or a step machine, cross-trainer or rowing machine in a gym may be satisfactory.
• About 10 to 14 days from the injury there will be some muscle wasting around the knee and this needs to be built up again. When exercising the muscles, keep movements slow and controlled. Build up the quadriceps but also, when building one group of muscles (agonists), work on the opposing group (antagonists) too. In this case it is the hamstrings.
• If the knee gets painful or starts to swell, ease back on training again and then gradually build it up.
• Fitness training can be started again using cycling, step machine or cross trainer. Swimming may be possible but see how it goes and avoid breaststroke.
• You can start some gentle jogging about three weeks after the injury. Keep it slow and in a straight line.
• As you get more confident, build up speed. When you can sprint at full speed in a straight line you are about half way through rehabilitation.
• Then start zig-zagging. Work on rapid changes in direction and twisting around. This builds up strength and position sense (proprioception - see below).
• Only when you can do all of this with great confidence is it safe to go back to active competition.

Proprioceptive exercises have been shown to improve function after ankle and knee damage and reduce the risk of future injury.⁸ Proprioception is defined as the ability to establish a sense of position in space and proprioceptive exercises are designed to restore this function in a joint.⁹

Children often get injured in the fun and games of everyday playing and life and usually they heal very fast and without problem. For some children, sport is more than just some fun and they train very hard and long to a very high standard. This is particularly true of swimming, gymnastics and dancing. Children are still growing and the epiphyses of their bones have not yet fused. This makes them very vulnerable to overuse injury¹⁰ and to injuries of those parts, including avulsion.¹¹ Weight training before puberty should be with the utmost caution, if at all. Beware of the coach who is pushing the child too hard. This is especially a problem if the coach is a parent. Some people try to live their own frustrated ambitions through their children. The child may be under enormous pressure and, whereas they can usually go home and moan about the coach, if the coach is a parent this outlet is closed.

Some children, especially boys, get very awkward and accident-prone at the growth spurt of puberty. This is because their bodies are growing so fast and muscles and proprioception have not yet caught up. Reassurance is required whilst the body catches up with its growth.

Proper rehabilitation is essential to enable the injury to heal and to reduce the risk of recurrence.

Sportsmen will work very hard to recover as quickly as possible but their impatience must be tempered by the need to achieve full recovery, especially before returning to competition. Different people recover at different rates but, generally, healing is slower with older age.

As we encourage people to take more exercise, we can expect to see more sports-related injuries. The rules of sport are often designed or amended to help reduce the risk of injury.¹² There is a widely accepted dictum that warm up before exercise and, to lesser extent, warm down and stretching after exercise, reduce the risk of injury. The level of evidence for this is very poor but the dictum has not been shown to be untrue.^13,14 One study found that stretching reduced the risk of some but not all injuries; it may, however, reduce soreness.

Before engaging in sport it is important to have adequate training to assure fitness, especially if sport is being taken up after a period of abstention. Equipment must be suitable and adequate. This does not apply simply to protective equipment.

All too often, sports-related injuries are poorly managed in primary care; however, the British Association of Sports and Exercise Medicine provides some excellent courses at basic, intermediate and advanced levels. This will include sports physiology and nutrition, correct orthopaedic examination and management. It is an excellent example of a multi-disciplinary organisation and speakers and delegates will include GPs, orthopaedic surgeons, A&E specialists, physiotherapists, podiatrists, dieticians and physiologists. It is very informative and very enjoyable but do get reasonably fit before attending, as you will be expected to partake in some physical exercise too.

Although the standard tomes are listed at the end, there are many other good works on the subject - shorter, cheaper and less detailed.

1. McNair PJ, Marshall RN, Matheson JA; Important features associated with acute anterior cruciate ligament injury. N Z Med J. 1990 Nov 14;103(901):537-9. [abstract]
2. Shultz SJ, Houglum PA, Perrin DH. Champaign; Examination of Musculoskeletal Injuries, Edition 2, 2005.
3. Birrer,R O'Connor F; Sports medicine for the primary care physician 2004.
4. Coris EE, Zwygart K, Fletcher M, et al; Imaging in sports medicine: an overview. Sports Med Arthrosc. 2009 Mar;17(1):2-12. [abstract]
5. Vaile JH, Davis P; Topical NSAIDs for musculoskeletal conditions. A review of the literature. Drugs. 1998 Nov;56(5):783-99. [abstract]
6. McGuine TA, Keene JS; The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006 Jul;34(7):1103-11. Epub 2006 Feb 13. [abstract]
7. DeLisa, J Gans, B Walsh N; Physical medicine and rehabilitation: principles and practice, Volume 1
8. Zech A, Hubscher M, Vogt L, et al; Neuromuscular Training for Rehabilitation of Sports Injuries: A Systematic Review. Med Sci Sports Exerc. 2009 Sep 2. [abstract]
9. Proprioceptive exercises balance ankle stability and activity; Biomech.com 2006.
10. Cassas KJ, Cassettari-Wayhs A; Childhood and adolescent sports-related overuse injuries. Am Fam Physician. 2006 Mar 15;73(6):1014-22. [abstract]
11. Adirim TA, Cheng TL; Overview of injuries in the young athlete. Sports Med. 2003;33(1):75-81. [abstract]
12. Arriaza R, Leyes M, Zaeimkohan H, et al; The injury profile of Karate World Championships: new rules, less injuries. Knee Surg Sports Traumatol Arthrosc. 2009 Jul 8. [abstract]
13. Pope RP, Herbert RD, Kirwan JD, et al; A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc. 2000 Feb;32(2):271-7. [abstract]
14. Hart L; Effect of stretching on sport injury risk: a review. Clin J Sport Med. 2005 Mar;15(2):113. [abstract]

• British Association of Sport and Exercise Medicine.; Organisation for doctors, physiotherapists and others involved in treating sportsmen and women.
• Oxford Textbook of Sports Medicine OUP. 2nd edition Ed Mark Harries. 1998
• Oxford Handbook of Sports and Exercise Medicine. OUP ed Domhnall MacAuley. 2006