Sports Injury
Injury management
The initial management of an acute sporting injury is vital as optimal treatment will shorten the recovery time, protect the athlete from further injury, and enable the athlete to return to training and competition as soon as possible. Delayed or inappropriate treatment has the opposite effect and may adversely affect an athlete’s career.
Good initial management requires on-site recognition of the injury and prompt initiation of treatment. It requires a team approach with experienced medical and physiotherapy staff working with coaches, referees, and administrators.
Sports injuries may be as a result of trauma or overuse and can involve any of the tissues of the body. The most commonly involved are muscles, ligaments, and tendons, (soft tissue injury) or the bony skeleton. Some serious joint injuries may involve a combination of bone and soft tissue.
Injuries to the head and cervical spine or the thoracic and abdominal organs are potentially life threatening.
Acute injury
Bleeding occurs with tissue damage.
Immediate swelling and the resultant pressure on surrounding structures causes secondary effects.
Response follows the classical inflammatory pattern—see ‘Non-steroidal anti-inflammatory drugs’, p. 48 for an explanation.
Local oedema increases tissue pressure, further delays healing, and lengthens rehabilitation.
In immediate treatment of acute injury, the objective is to interrupt this cycle, limit bleeding, and swelling, reduce inflammation, and reduce the size and extent of the injury.
Overuse injuries
This type of injury leads to the same cycle of response, without local bleeding. Continued activity causes repetitive micro-trauma, tissue inflammation, and damage. The treatment of overuse injury follows the same plan.
Soft tissue inflammation
This follows the classic pattern of:
Swelling.
Heat.
Erythema.
Pain and loss of function.
The treatment plan is based on this process and cycle as described above.
General management plan for acute sports injuries
Preparation and planning
The management of sports injury requires preparation and planning. Factors include:
Equipment and facilities.
First aid kit and doctors bag.
Liaison with officials, administrators, and coaches.
Membership of ‘The Medical Team’, which includes a variety of health professionals.
On-site availability
On-site availability allows:
Initiation of the appropriate management immediately.
Direct observation of the mechanism of injury—this aids accurate diagnosis.
This, ideally, includes presence at both training and matches or competition. This helps to build trust with the coaching staff and the athletes. It also allows further input into the athlete’s preparation in areas such as:
Pre-season screening and assessment.
Fitness assessment.
Planning of training schedules.
Monitoring rehabilitation, arranging surgical opinions/operations, etc.
Event management
Medical input may be needed in planning of events, and may include advice on playing surface, equipment, adequate time for warm-up and rest, training facilities, and first aid equipment. Good event management will not only limit injury risk (e.g. by not playing on dangerous surfaces), but will also ensure prompt and appropriate management at the time of the injury.
Observation
This includes:
Observation of training and warm-up, etc., to ensure good technique.
Observation of exact injury mechanism will result in prompt and appropriate treatment.
Observation of the sport so that the doctor is familiar with the rules and likely injuries which will result.
History
An appropriate history is vital to ensure correct diagnosis and treatment. In acute sports injury the athlete may be distressed both by the pain and the implications of serious injury.
The exact nature and location of the pain will give a guide as to the structures injured. In Achilles tendon or anterior cruciate ligament rupture, for example, the athlete may describe an audible ‘pop’.
Clinical examination
Early examination, before swelling and the inflammatory response ensues, may give clues as to the diagnosis, which are more difficult to elicit at a later time. Initial pitch side assessment is usually helpful but at times it may be more appropriate to carry out a clinical examination at a better location, e.g. first aid room. Protective equipment should be removed to allow full examination, unless this will worsen the injury, e.g. fractured tibia. Sporting headgear should not be removed unless to enable Basic Life Support to be performed especially where spinal injury is suspected.
The initial examination should:
Establish a preliminary diagnosis.
Determine whether the athlete can continue.
Determine whether further treatment is required, e.g. at hospital.
Treatment
Emergency care: injuries to the head, cervical spine, and chest, and those to major joints or bones should be considered as an emergency and managed appropriately.
Triage: this includes transport from the field and, if required, onwards to hospital for X-ray, further examination, etc. Good communication with the hospital and the athlete/coach to ensure appropriate after care. Arrangements for review as soon as practical.
Immediate injury care: if standard care is appropriate it should follow the PRICES/POLICE regimen—see Management of acute soft tissue injury, p. 40.
Return to play
Return to training and competition is determined by whether:
Return will not worsen the injury.
Return will not increase the risk of further injury.
The athlete will be able to perform at pre-injury level.
The athlete’s return will not place other competitors at risk.
This decision should take into account factors such as the importance of the event, time left in the event, future schedule, and playing conditions.
The medical team should observe the athlete closely on their return to ensure rehabilitation is complete and no further damage is taking place.
Judgement on return to play should be based solely on the health of the athlete and should take precedence over the wishes of the coach, relatives, club, supporters, and sometimes, the wishes of the athlete him/herself.
Management of acute soft tissue injury
The ‘PRICES’ mnemonic incorporates the various treatment modalities for acute soft tissue injuries:
P = Protect
R = Rest
I = Ice
C = Compression
E = Elevation
S = Support
POLICE substitutes Optimal Loading for Rest.
Protect
This refers to a number of types of protection such as:
Protect the athlete so they do not make the injury worse.
Protect and support surrounding structures.
Protect other competitors.
Protection of the injured part may include crutches, splints, slings, braces, taping, strapping, etc.
Rest
True rest is difficult to enforce—and in practice usually unnecessary.
Absolute rest
Severe soft tissue injuries may require a short period of bed rest or immobilization in plaster or brace to limit movement to a minimum. Absolute rest will also be required initially after an operation.
Relative or active rest
An athlete can often maintain some activity. This will usually be part of the treatment programme and is important psychologically. Relative activity ensures:
Maintenance of muscle strength.
Maintenance of general cardiovascular conditioning and aerobic fitness, e.g. hydrotherapy.
Exercise is a recognized part of the treatment programme for soft tissue injury. Damaged ligaments benefit from the ‘stress’ of weight-bearing and movement. Excessive rest will prolong the inflammatory phase and lengthen the time to return to play.
A recent (2010) UK consensus conference on the PRICES regime recommended that the duration of the unloading (Protection/Rest) and speed of progression of rehabilitation depends on the severity of the injury, the injury mechanism, and the type of soft tissue injured (ligament v tendon v muscle).
More recently, a modification of the acronym substitutes Optimal Loading for Rest and the acronym becomes POLICE. Optimal loading is more appropriate in facilitating early rehabilitation. Available at: http://bjsm.bmj.com/content/early/2011/09/07/bjsports-2011-090297.full.pdf
Ice
The application of cold (cryotherapy) has been advocated since the classical description of inflammation by Celsus in the 1st century AD (redness, swelling, heat, and pain) to which Virchow, in 1858, added loss of function.
Theoretical benefits of cryotherapy
Limitation of bleeding via vasoconstriction. The theory of reflex vasodilatation remains controversial.
Limitation of swelling.
Limitation of inflammation and further tissue damage. This may be due to the effect of histamine on vascular membranes and on neutrophils and leucocytes.
Reduction in metabolism in local tissues. This reduces enzyme function, inhibits pain and decreases swelling and oxygen consumption.
Assists with pain control—however, beware the athlete who becomes ‘pain free’ with ice and wishes to resume playing. Ice inhibits pain in 2 ways:
Relief of surrounding muscle spasm.
Slowing of sensory pain impulses.
How to apply ice
Ice comes in a variety of forms including crushed ice (better than ice cubes as the contact is better), chemical ice packs, reusable gel cold packs, and those combined with compression, e.g. cryocuff. Be careful as only melting iced water is at 0°C. Ice taken directly from a freezer may be at a much lower temperature.
Coolant sprays work by evaporation thus reducing skin temperature. They do not achieve sufficient depth of cooling to be effective in reducing muscle temperature.
Debate continues as to the optimum frequency and time of application. An intermittent protocol is more effective than continued application.
The primary clinical effect of the application of ice is a reduction in pain. Ice, preferably crushed, should be applied for 10-20min every 2h initially. Ice should not be used continuously for longer than 20-30min. There is no agreed scientific consensus re the duration of the use of ice though it would appear to most beneficial in the first 48-72h.
Ice works via conduction. As adipose tissue is an excellent insulator, ice application may have to be extended in those areas with greater body fat.
A thin damp barrier should be used at the cooling interface to avoid reduction of the clinical effectiveness.
Contraindications to using ice
Broken or damaged skin.
Where nerve damage is suspected and sensation altered.
Altered circulation is suspected.
When ice application increases pain.
Compression
The early use of compression will:
Support the injured area.
Decrease swelling.
Ice can be combined with compression. Later, compression can be replaced by a supportive bandage or strapping. Taping is best done by an experienced sports physiotherapist to achieve maximum benefit.
It is recommended that the compressive modality configures to the shape of the body part and provides a gradual compressive force. Compression provides additional benefits in terms of biomechanical support, control of the range of movement and reassurance to the injured athlete. It also corroborates the severity of the injury.
Elevation
Contributes to the reduction in blood flow and as a result, swelling. The lower tissue pressure will contribute to the reduction in pain.
Must be at a significant angle, i.e. greater than 45° for a lower limb.
Should be combined with support of the elevated part, e.g. pillows.
While there is no optimal duration of the elevation it should be maintained at least over the first 24h. Distal body parts will require longer periods of elevation.
Support
Support aims to help to stabilize the injured tissue and prevent further injury. Under controlled conditions it may allow the athlete to return to competition earlier.
Support also allows an early commencement of controlled and monitored activity such as weight bearing, which will shorten the rehabilitation period and facilitate an earlier return to sport.
Care of wounds, cuts, and grazes
A wound is defined as a ‘disruption of the tissues produced by an external mechanical force’. Wounds include:
Contusions.
Abrasions.
Lacerations.
Incised and puncture wounds.
Open wounds are very common in contact sports such as football, rugby, hockey and ice hockey, American football, etc. They are also common in sports where falls often occur such as cycling and riding. Wounds account for 25-30% of the workload in emergency departments.
Prognosis is dependent on the type of trauma and the extent of the damage.
Severe bleeding and clinical shock.
Infection.
Complications secondary to the extent of the damage, e.g. blood vessel, nerve, and tissue damage.
Abrasions
An abrasion (Latin abradere-to scrape) is a superficial injury. Damage is only to the epidermis so it should not actively bleed (though in practice abrasions may extend into the dermis). A scratch is linear, while a graze suggests a broader impact.
The cause is normally a glancing contact with a rough surface. Tangential impact produces a moving abrasion, which indicates direction by the pattern of damage to the epidermis and may leave trace material such as grit. This type is most common in sport on artificial surfaces, such as Astroturf.
Direct impact produces an imprint abrasion with the pattern of the causative object.
All abrasions reflect the site of impact (contrast contusions).
Contusions (bruises)
A contusion involves bleeding into the soft tissue due to the rupture of a small blood vessel resulting from a direct, blunt force, e.g. a punch. A haematoma is a contusion where a larger amount of bleeding results in a pool of blood.
Contusions and strains comprise 60-70% of all sports injuries and are of variable severity from simple skin damage to contusions of internal organs. Most go unreported and untreated. Typically caused by blunt trauma, such as a blow or a fall. Uncomplicated contusions do not breach skin surface and there is no external bleeding.
It is important to exclude other causes of bleeding including abnormalities of the clotting system in diseases such as leukaemia, thrombocytopenia, liver disease, and vitamin deficiencies (Vitamin C).
Pathology
Trauma causes rupture of capillaries and possible venules (arterial damage rare). After impact, bleeding may continue for some time due to circulatory pressure. If the volume of bleeding is sufficient, swelling occurs. If extravastrated blood collects in a pool it is known as a haematoma. Local inflammatory reaction occurs at a site with necrotic tissue, caused by macrophage infiltration.
Site of bruising does not always indicate the exact site of injury, as blood will track through tissues under influence of gravity and body movement. (e.g. bruising along lower border of foot in ankle ligament and thigh bruising in fractured hip)
Deeper bruising will result in a slower appearance of surface skin discolouration. Changes in colour will give an inaccurate estimate of the time of the initial impact.
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