Water Polo Injuries

Dean M. Brewer

Richard P. Eide III

Michelle E. Szczepanik

INTRODUCTION (3,4,8,10,12)

Water polo is a team aquatic sport played throughout the United States and in many countries around the world, particularly in Europe.
It is a fast-paced, physically demanding game requiring both strength and skill as a swimmer combined with excellent hand-eye coordination to facilitate ball handling, passing, and scoring.
During a typical match, a player will swim short distances with high-energy bursts lasting 10-18 seconds. For some players, these short distances can add up to 1,000 m. These sprints are separated by 30- to 40-second intervals of “eggbeater” leg work.
Statistics from the 2004 Olympic Games demonstrated that an injury occurred once in every two to three matches, with the total incidence being 21 injuries per every 1,000 player matches. All injuries were caused by contact with another player, with the head and upper extremities being the most affected.
Water polo had the highest incidence of injury in the 2009 Fédération Internationale de Natation Amateur (FINA) World Aquatic Championships.

HISTORY

Although the exact origins are unclear, the first documented rules were codified in 1877 by William Wilson, a Scottish aquatics enthusiast. Initially, the game more closely resembled an aquatic form of rugby football.
The game was altered into its modern-day form by the turn of the 20th century, when it was incorporated into the modern Olympic Games in Paris, France in 1900.
Water polo is governed internationally by FINA and within the United States by USA Water Polo, a not-for-profit organization under the aegis of the U.S. Olympic Committee.

REQUIRED EQUIPMENT (8)

Although it could be played in any suitably sized body of water, water polo is most often played in swimming pools. Known as “the field,” the dimensions of the pool will vary depending on the age and gender of the players, ranging from 20-30 m long by 10-20 m wide by 2-4 m deep.
The goals are rectangular, centered at both ends of the field, and 3 m wide by 0.9 m high.
The ball is spherical, weighing approximately 1 lb, roughly equivalent in size to a volleyball, and coated with a high-friction rubber to facilitate grip.
Individual equipment includes a swimsuit and a swim cap with cupped ear protectors.

GAME PLAY (8)

The object is to throw the ball into the opposing team’s goal, thereby scoring 1 point. The ball may be passed around the field in any direction, but a team may not possess the ball for more than 30 seconds without attempting a shot on goal, or else they forfeit the ball. The team that scores the most number of points before regulation time has expired is the winner.
Teams are composed of seven players, six in the field of play and one goalkeeper; teams are designated by the required uniform swim caps, which also serve to protect players’ ears.
All players, with notable exception of the goaltender, may use either hand but must use only one hand at a time to handle, pass, and shoot the ball. Players will use the “eggbeater” kick, which combines the clockwise motion by one leg and a counterclockwise motion of the other leg in order to stay afloat.
The game is divided into four quarters, which are 8 minutes in length for collegiate and professional play; youth leagues through high school have shorter periods, which range from 5-7 minutes.

FOULS (8)

There are three types of fouls: ordinary, penalty, and exclusion.
- Ordinary fouls are minor infractions of game play. They include holding the ball underwater or tucking inside one’s swimsuit, using two hands, pushing off of the pool floor (except shallow-end goalkeeper), striking the ball with a closed fist, swimming within 2 m of the opposing
  goal ahead of the ball, and impeding the free movement of an opposing player who is not holding the ball, including pushing or pushing off. Ordinary fouls result in a change of possession by means of a free throw.
- Penalty fouls are ordinary fouls committed within the 5-m goal area and result in a penalty throw (exclusion fouls in this area also result in a penalty throw).
- Exclusion fouls are more grievous violations and include using two hands to block a pass or shot, exiting the pool without permission, intentionally splashing water in an opponent’s face, or intentionally striking an opponent (elbow, punch, kick). The penalty for exclusion fouls is removal from play for 20 seconds. The official may determine if there was malicious intent to harm another player, in which case the player is removed from the game and the team must play one man down for 4 minutes.
In general, water polo is an intensely physical game, with players swimming at a sprint pace in immediate proximity to one another for control of the ball and for defensive maneuvers. The result of such activity and a limited amount of protective equipment is a propensity for many different types of injuries.
Injuries to the head and face are among the most common (15.5%-53.0%) acute injuries in water polo due to the relative exposure above water.

EYE INJURIES (1,2,4,7,12,13)

Annett et al. found that eye injuries accounted for 6.1% of acute injuries in water polo.
The most common eye complaints in water polo are eye irritation or lacerations from direct trauma. Due to the severity of some uncommon injuries, they are also included in this section.
- Corneal abrasion
  - □ Signs/symptoms: Severe eye pain and photophobia
  - □ Common mechanism: Excoriation from fingernail, toenail, or trapping of debris under contact lens
  - □ Treatment: If you suspect corneal abrasion, you should transfer the patient to a higher center of care to confirm diagnosis with fluorescein dye and slit lamp examination, especially looking for any foreign body remnants. The athlete should be advised to keep eye closed and to avoid rubbing/touching. Topical anesthetic drops may be used initially to relieve pain and facilitate exam; however, long-term use is discouraged because these drops will delay healing of the corneal epithelium and can lead to a pseudo-addiction state by the patient, resulting in corneal ulceration, scarring, and blindness. Treatment ultimately consists of topical antibiotic ointment (e.g., erythromycin) or drops (e.g., Polytrim, ciprofloxacin, ofloxacin) four times a day for 3-5 days. Athlete should not be allowed to return to play until the abrasion has healed.
- Laceration of eyelid, eyebrow, lip, cheek (most common acute injury)
  - □ Signs/symptoms: Bleeding from laceration, pain
  - □ Common mechanism: Direct trauma to skin overlying bone
  - □ Treatment: Cleanse/irrigate wound, assess depth/severity of laceration, and repair via approximation of skin edges. The primary care provider should be skilled in simple laceration repair, although if there is concern about cosmetic result or involvement of eyelid, consultation with plastic surgeon and/or ophthalmologist is warranted. Sterile adhesive bandages (e.g., Steri-strips) and adhesive glue (e.g., Dermabond) may be used for small, superficial repairs with minimal active bleeding.
- Chemical irritation
  - □ Signs/symptoms: Discomfort/burning of eyes, scleral injection
  - □ Common mechanism: Excessive exposure to chlorine or other disinfectant
  - □ Treatment: Saline eye drops, limit exposure to chlorinated water
- Hyphema (hemorrhage into anterior chamber from ruptured trabecular blood vessels)
  - □ Signs/symptoms: Blood pooling in inferior portion of iris
  - □ Common mechanism: Direct trauma to globe from fist, elbow, ball, etc.
  - □ Treatment: EMERGENCY. Protect eye with loose, occlusive dressing (e.g., Fox shield) and seek immediate evaluation by ophthalmology; if untreated, it could result in glaucoma or permanent corneal staining.
- Blowout fracture of orbital floor (orbital floor is weaker relative to surrounding bones)
  - □ Signs/symptoms: Periorbital hematoma, protruding or sunken globe; herniation of inferior contents can cause entrapment, which will manifest as an inability to gaze upward in affected eye, producing diplopia and/or maxillary numbness
  - □ Common mechanism: Direct trauma to globe resulting in fracture of orbital floor
  - □ Treatment: EMERGENCY. Protect eye with loose, occlusive dressing (e.g., Fox shield) and seek immediate evaluation by ophthalmology to rule out intraocular trauma. It is essential to perform a thorough neurologic exam to rule out entrapment of inferior orbital contents.