Chapter 15. Sports injuries
Sports medicine is essentially a type of occupational health medicine and this should not be forgotten just because many of the patients are well-known public figures.
No injury is unique to athletes and the conditions described in this chapter could equally well be described elsewhere. The chapter deals with the particular problems of the sporting world and describes lesions that occur more often in sporting activities than everyday life.
Psychology and the athlete
Many sports injuries are treated by orthopaedic surgeons because of their involvement with trauma, but sports medicine is very different from the rest of orthopaedic surgery. For one thing, an athlete who is 100% fit will be unhappy – an athlete needs to be not less than 110% fit, at least in his or her own estimation, and will strive for 120%. This belief, coupled with the athlete’s drive to achieve goals beyond the scope of ordinary people, may loosen their hold on reality and prevent them understanding that their body is made of the same stuff as ordinary mortals.
A further problem is that many athletes have a compulsive–obsessional approach to their sport. A cyclist or a runner who does not put in the allotted number of miles per week will feel uneasy and fear their performance will be permanently impaired. In this regard the behaviour of some athletes is similar to that of other compulsive neuroses such as alcoholism, compulsive gambling and anorexia nervosa. Fortunately, most sportsmen and women have a healthy approach to their sport, but compulsive individuals do exist and must be recognized at an early stage.
For many well-balanced athletes fitness is an integral part of their way of life and self-image. Occasional recreational athletes may feel that their sporting activities distinguish them from their more everyday contemporaries. To find that their sporting prowess has been taken away can make both groups clinically depressed and produce a similar reaction to bereavement or the loss of a limb.
Ageing
Athletes have great difficulty in accepting the ageing process. Ageing athletes – over 30 years of age – may be so convinced of their own eternal youth that they will seek medical advice to find out why they cannot run as fast or jump as high as they did 10 years earlier. The simple explanation that they are ‘growing old’ will not be believed.
Other patients may, unconsciously, be a little more subtle in their approach to advancing age and look to injury as an excuse for graceful retirement or a gradual descent to a lower level of performance. Neither of these conditions can be treated by operation.
The ageing process cannot be denied. However rigorous the training programme and however assiduously it may be pursued, hair still goes grey, skin wrinkles, articular surfaces become less resilient and more fragile, muscles waste, tendons weaken and soft tissue degenerates. These are biological facts that cannot be altered by training or ‘dedication’.
For these reasons the approach to the athlete cannot be based on organic features of the injury alone. Many athletes may have a perfectly straightforward organic injury but to treat that without understanding the feeling of the athlete towards his or her own physical fitness will lead to disillusionment on both sides.
Practical and professional considerations
Sports medicine presents practical and ethical problems. In other specialties doctors are in no doubt that they are the patient’s medical attendant, but in the field of sports medicine there may be more concern for the success of the player’s club than for the long-term future of the player.
The welfare of any patient has to be considered not only from the short-term point of view but also from the long-term. Considerable pressure is sometimes applied to the doctor by the team manager or club, as well as by the player, to achieve a good short-term result without regard for the long-term.
Enabling a player to take part in an important match soon after a serious injury or operation, for example, could have harmful long-term effects. To complicate matters, the players themselves are not always in a position to disagree with their club official and may enthusiastically embrace the prospect of osteoarthritis in middle age if only they can play on Saturday.
The need for rapid results and the fast return to sport after injury also means that athletes demand priority over other patients. If health service resources are in short supply, it is hard to justify treating a recreational athlete in preference to a wage-earner who cannot work. Injured sportsmen are seldom ill or disabled in the common sense of the word, yet their powerful motivation will often find a way through the normal channels to be treated in preference to patients with genuine organic illness. This can lead to ill-feeling when resources are scarce.
To avoid this problem, sports clinics treating athletes only are often set up outside hospitals and orthopaedic departments, but this leads to the paradox that in some places the only way to receive prompt treatment for a musculoskeletal disorder is to declare that it was the result of a sporting injury rather than an accident at work.
These observations do not detract from the need for a specialized service for sportsmen or deny the existence of injuries specific to individual sports. Provided that the doctor can come to terms with the psychological aspects of sportsmen and women and the practical problems of establishing a clinic for sports injuries, sports medicine is a rewarding and fascinating specialty.
The conditions described below are commonly seen in athletes but are not unique to them.
Injuries to muscles
Musculotendinous injuries
• Ruptures of the muscle belly.
• Haematoma in the muscle belly.
• Rupture of the musculotendinous junction.
• Rupture of the tendon.
• Tendinitis.
• Tears at the muscle insertion.
Ruptures of the muscle belly
Clinical features
Rupture of a muscle is felt as a tearing sensation. Swelling and tenderness at the site of the rupture follow within hours, and bruising about 24 h later. The bruising is caused by bleeding from the ends of the ruptured muscle and can be quite dramatic, even alarming.
On examination a defect can be felt in the muscle belly and the belly becomes prominent as the muscle contracts. The swelling can occasionally be mistaken for a soft tissue mass. The rectus femoris and hamstrings are the muscles most often affected.
Haematoma
A haematoma in a muscle is a serious lesion, sometimes called a ‘Charley horse’ for no obvious reason. The lesion usually follows direct trauma or, more rarely, a tear of the central fibres of the muscle. The quadriceps is most commonly affected.
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