Sports medicine is at one end of the spectrum of musculoskeletal disorders in that it relates to individuals who have very high expectations of their bodies, and who also have high motivation to get better as quickly as possible. Luckily, most of the patients are young so the potential for natural healing is also high.

As usual, a good history can be very helpful. Careful listening to the athlete at the start of a consultation may reveal unexpected expectations. The injury may also be serving a purpose for changing training or as an honourable way out of sport altogether. It also allows classification of the injury into clear categories which simplify diagnosis.

Classification by presentation

In terms of diagnosis there are three types of presentation.

Sport specificity

Injuries tend to be associated with certain sports. The human body is not always well adapted to the loads applied. A few examples are given below.

Examination

This will often include watching the athlete performing their sport live. The purpose is to try to work out exactly what is happening to their body during performance of their sport. The examination will then follow the ‘look, feel, move’ system described in Chapters 3 and 21.

Imaging

Dynamic imaging of the soft tissues is more likely to yield useful information than static imaging of the skeleton, so ultrasound may prove especially useful.

RICE (rest, ice, compression, elevation)

Rest is not a meaningful concept for athletes. If one part of the body needs to be rested to allow healing to take place, then an equally strenuous programme of exercise which does not involve that part needs to be part of the prescription. Swimming and gym work can be very useful for runners with injured legs. Cycling can also be very good for unloading injured areas.

Ice applied to injured areas (especially acute extrinsic injuries) appears to reduce inflammation and therefore speed recovery. Ice applied directly to the skin can cause a burn. Bags of frozen peas conform to the contours of a limb nicely.

Compression used carefully can also reduce swelling and so speed recovery.

Elevation speeds the recovery of swelling and inflammation.

Physiotherapy

This is the cornerstone of rapid and safe rehabilitation. Its role is to restore strength and mobility as fast as possible without allowing excessive exercise to cause further damage.

Injections

Injections of steroid into painful ligaments and joints can be used to try to reduce inflammation. The effect is usually short term and if more than two or three injections are given the steroid can weaken the tendon itself and cause a rupture. If local anaesthetic is given the injection can be used to try to diagnose the exact source of the pain or tenderness.

Athletes are fit to return to their sport when they are fit enough and confident enough to do so. For lower limb injuries the ‘figure of eight’ test is valuable (see p. 44).

Partial tears can be allowed to heal without surgical intervention. Early movement with minimal loading stimulates healing while minimising pain and stiffness. Controlled exercises, hinged braces and removable splints may all have a role to play. Complete ligament tears may be best treated by surgical repair as this may speed up healing and return to full function.

The blood supply to tendons is not good, so healing tends to be slow. However surgical repair is also not easy. This is especially true of the ruptured Achilles tendon which blights the career of so many middle-aged squash players.

Bones can be broken by direct trauma, or following repeated loading (stress fractures). Each stress fracture is associated with a certain sport. Running tends to produce fractures of the tibia (one cause of shin splints) or of the second metatarsal (the ‘march’ fracture). Weightlifting can cause a fracture of the spine leading to a slip of the vertebral bodies on each other (spondylolisthesis). Stress fractures can be hard to see on X-ray and so may be difficult to diagnose. The gradual onset of symptoms can be confused with a simple strain or very rarely the onset of symptoms in a primary bone tumour.