Download Common Sports-Related Injuries and Illnesses: Generic Conditions

and Illnesses: Generic Conditions^
D ouglas B. McKeag
The philosophies o f care given here are meant to serve
as "ground rules." We will refer to these protocols in
discussing specific injuries. The general conditions covered
are as follows:
Acute injury
Chronic injury (with emphasis on overuse syndromes)
Allergy
ACUTE INJURY
Acute injury is the most com m on sports medicine con­
dition; unfortunately, it is also the one most likely to be
ignored. Injuries that require attention on the playing field
are rare in comparison to the number o f acute injuries
incurred in less formal contests. Beyond the initial invol­
untary rest (usually temporary, whether symptoms have
disappeared or not), the only other attention that might
be given to an acute injury is the application o f a pressure
dressing (elastic bandage) and/or hot/cold therapy. Little
else is done, and rarely is medical attention sought. Most
athletic injuries do not occur in competition but in practice
or unobserved, unsupervised surroundings. Granted that
most acute injuries are not true medical emergencies, but
they can be treated easily if proper diagnosis is made. The
untoward effects o f any athletic injury can be minimized
by proper care, especially in the first 24-hour postinjury
period.
Coverage o f athletic competition and/or practice is
discussed in Chapter 9; however, the following guidelines
apply to the care o f any acute injury.
Become familiar with the frequency level o f common
injuries in the sport you are covering and in the community
you live in. O f the multiple factors that determine injury
frequency, the two with the greatest effect are the local
community environment and the specific position played
by an athlete. Sports and exercise produce more than a fair
share o f "zebras," but for the most part we still see and care
mostly for the "horses": expea them, and learn to take care
o f them.
There is no single true philosophy in primary care
sports medicine, only guidelines. Those guidelines should
reflea individual community situations. The following
mind-set for covering a sports event works well in any
community regardless o f the situation, geography, or
personnel involved:
before competition, prevention;
during competition: triage;
after competition: rehabilitation.
Someone who understands and accepts this philoso­
phy is the best person to be responsible for the care o f
competitors in a sports event in your community. Contrary
to what some may think, this does not require comprom is­
ing any principles of medicine. Athletes are no different
from nonathletes where health care is concerned. Where
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the groups diverge is with respect to exercise-induced in­
jury. Athletes are in an environment that exposes them to
acute macrotrauma as well as chronic microtrauma. In that
environment the athletes will suffer more injur)' than the
nonathletes.
SITUATIONS PRECLUDING RETURN TO
PARTICIPATION IN COMPETITIVE SPORTS
FOLLOWING AN INJURY
See
Before Competition
Active intervention in the precompetitive aspects o f any
community sports system offers the greatest opportunity
for significant injury prevention. The preparticipation
screening and assessment o f the sports environment are
two major areas o f preventive impact.
During Competition
One o f the most uncomfortable and disquieting moments
a team physician can have is when he must make sideline
decisions while under the close scrutiny o f many spectators.
However, 67% o f all injuries occur during practices or
training, a time when the physician is unlikely to be present.
The situations are different, but these are the norms in
covering athletic teams and it underlines the need to have
established protocols for triage in place. Coaches, trainers,
and other responsible parties need to learn appropriate
triage techniques for the more common injuries. Even
when the physician is present, his/her major responsibility
is the triage o f the acutely injured athlete.
A decision on whether to allow the participant to resume
play should be made only when (a) a definite diagnosis has
been made, (b) the injury will not worsen with continued
play so that the athlete is at no greater risk o f further
injury, and (c) the athlete can still compete fairly and is
not incapable o f protecting him/her because o f the injury.
See Table 23.1 for a list o f injuries that preclude further
participation. This table may seem conservative at first;
please reread it. It is less conservative than most lists and
can be helpful in assessing the most com m on athletic
injuries in youngsters. With college-aged or professional
athletes, this apparent conservatism can be addressed on
an individual basis if the physician finds it necessary to
move outside these vaguely defined boundaries. The best
philosophy for evaluating acute athletic injuries on-site
should be neither excessively conservative nor dangerously
liberal. The final decision on return to competition should
always be that o f the physician.
Generally speaking, the evaluation o f all acute injuries
that occur in competition should follow the same steps
(see Figure 23.1). Immediate initial assessment is manda­
tory and will help elicit signs and symptoms before the
inevitable secondary reactions (pain, swelling, inflamma­
tion, spasm, decreased range o f motion, and guarding).
First, obseive the position of the athlete and the injured part
in relation to the rest o f the body. Begin the history' with the
patient's account o f how the injury occurred and amplify
it with the physician's assessment of the biomechanics
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o f the situation, as well as that o f others who may have
witnessed the injury occur (trainer, coach, teammate, or
official). Determine any positive past medical history from
available records if they exist. Next should be a focused
clinical appraisal o f the injury'; that is, an examination em­
phasizing function, range of motion, and the neurological
and vascular integrity of the injured area.
With serious injuries, a protocol is implemented that
addresses whether to treat the injured player at the site
or take him/her to a medical facility. If he/she is unable
to walk safely, then a decision must be made on how to
transport the athlete.
With less serious injuries, the first decision is whether to
allow the athlete to continue to participate. Even if the deci­
sion is affirmative, he/she should be periodically rechecked.
The interval between checks will depend on the severity and
rapidity o f evolving symptoms. Any athlete with an evolv­
ing injury in which signs and symptoms are changing
must be watched and not left alone. If an athlete leaves
the sideline, he/she should be accompanied by someone
who is aware o f the significance o f the changing symptoms
of the injury. Subsequent assessment on the sidelines or
in the locker room should include the same components:
observation, history, and re-examination. Clothing and
equipment should be removed whenever possible. A later
examination should focus not only on the injured area, but
also above and below the area surrounding the injury. An
Chapter 23: Common Sports-Related Injuries and Illnesses: Generic Conditions
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appraisal of how the signs and symptoms have progressed
since the first examination should also be made.
If an athlete is allowed to return to play and sustains
a recurrence or exacerbation o f the injury, he/she must be
withdrawn from play for the remainder o f the contest. If
the athlete is not allowed to return, periodic assessments
should continue and initial treatment and/or transporta­
tion begun.
After Competition
After a diagnosis is established and appropriate treatment
given, rehabilitation can be considered and a multidis­
ciplinary team approach involving the team physician,
athlete's personal physician, other consultants (if neces­
sary), trainer, and coach should be initiated. In reality,
such a coordinated effort rarely happens. Statistics in West
Virginia (2) revealed that a physician saw only 13.5% o f
acute injuries from a system at the high school level within
24 hours, which is the period when evaluation and treat­
ment are the most productive. Although this low figure has
hopefully increased over the past 30 years, the problems o f
physician accessibility remain significant. Even so, proper
rehabilitation is the most important factor in the rapid
return o f an injured athlete to participation sports (see
Chapter 35).
Common Acute injuries by Type
One o f the best and most useful surveys on sports injuries
was conducted by Garrick and Requa (3). Although it dealt
only with the high school level, it broke down sports
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injuries by type and provided a guideline on what to
expect for the com m on acute sports injury. The numbers
in parenthesis in the following text are from this study.
1. Sprains and strains (60.5%)—There are two ways that
most sprains and strains develop. The common etiology
is a sudden, abrupt, violent extension or contraction on
an overloaded, unprepared, or undeveloped ligament or
musculotendinous unit. There can be varying degrees of
severity, from the overstretching o f a few myofibrils to
complete unit rupture. A second, less common, mechanism
involves chronic stress placed upon the unit over time, in
association with poor technique, overuse, or deformity.
Strains are stretch injuries to the musculotendinous unit;
sprains involve similar injury to ligamentous structures. A
grading system is used to assess these injuries.
First degiee/grade 1. There is little tissue injury and no
increase in laxity. There usually is little immediate
swelling because the tissues have not been stretched
enough to produce instantaneous hemorrhage. With
strains, there is usually no significant damage to the
muscle or tendon and only a brief period o f pain and
disability if it is properly treated. Secondary tissue
edema and inflammation develop within hours,
restricting range o f motion and resulting in minimal
loss o f function. Pathologically, less than 25% o f the
tendinous or ligamentous fibers are involved in a
first-degree sprain or strain.
Second degree/grade 2. These injuries are the result
o f tears and disruptions o f ligament or tendons.
The partial tearing ranges from 25% to 75% of
the fibers and there is demonstrable laxity and
loss o f function. There is immediate swelling and
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function is significantly reduced. Signs and symptoms
increase until bleeding is controlled and the injury
immobilized.
Third degreejgrade 3. Complete disruption o f the liga­
ment or tendon usually exists with immediate pain,
disability, and loss of function. However, some thirddegree sprains may actually be less painful than
second-degree sprains. Once a ligament is torn,
there is no further stretch to cause pain sensation.
Third-degree strains usually have diffuse bleeding
and continuous pain.
The treatment o f a third-degree injury (ligament or ten­
don rupture) continues to undergo change. With proper
immediate care, including immobilization, these injuries
can be treated conservatively without surgical intervention.
Common examples of this type o f injury include the me­
dial collateral ligament in the knee, the lateral supporting
structures o f the ankle, and clavicular ligaments of the
shoulder. Ligaments or tendons that normally are under a
high amount o f natural stress (Achilles tendon, biceps ten­
don, and the patellar ligament), as well as tendons that have
retracted or ruptured, require prompt surgical intervention.
Occasionally, when the tear is at the musculotendinous
junction (such as an Achilles ligament rupture), the pre­
ferred treatment is immobilization. Bear in mind that severe
strains and sprains may cause fewer symptoms and signs
than the more moderate ones. Many young athletes have
natural ligamentous laxity. Always examine and compare
the injured and uninjured sides to help resolve those cases
in which the findings appear equivocal.
Frequent sites o f sprain are ankles (anterior talofibular
ligament), knee (medial collateral ligament), and fingers
(intrinsic collateral and interphalangeal ligaments). Fre­
quent sites o f strains are upper leg (hamstring muscles and
adductors), back (paraspinal muscles), and the shoulder
(rotator cuff tendons).
The following modalities (RICE regimen) are useful in
treating strains and sprains:
; —rest the injured part to allow healing to begin and
prevent further injury.
1—apply ice to the injured part to reduce swelling and
extravasation o f blood into the tissue (the ice should
be applied directly to the skin as a massage unit at
frequent intervals, but not to exceed 10 to 15 minutes
per session).
C—compression with an elastic bandage, air splint, and
so on, to prevent movement and further swelling.
E—elevate the injured area whenever possible to prevent
pooling o f blood and to control swelling.
When you know that an athlete cannot return to practice
or competition, it is often beneficial to start nonsteroidal
anti-inflammatory drugs (NSAlDs) to combat the inevitable
soft tissue inflammatory response. Do not use these medi­
cations if the injury is minor. Some physicians now caution
against early initial use o f aspirin and related compounds
(including NSAIDs) because they may possibly promote
bleeding secondary to the inhibition o f platelet function.
Cyclooxygenase-2 (COX-2) NSAIDs have not been found
to alter bleeding patterns. Additionally, there is evidence to
suggest that NSAIDs, as a medication group, slow the heal­
ing o f bone and soft tissue. Therefore, the sports medicine
physician will have to balance the need for pain control
and patient comfort with the need to speedup healing in
the athlete.
2. Contusions (13.7%)—A contusion is the bruising of
the skin and/or the underlying dermal tissues caused by
direct trauma. Capillaries and other small vessels rupture
causing extravasation o f blood and effusion, followed
by swelling and inflammation o f the soft tissues of
the surrounding areas. The secondary' swelling is usually
superficial and local, but occasionally may be deep if
something like a hockey puck strikes an unprotected thigh.
Because extravasation o f blood into the soft tissue can cause
extreme inflammation, a marked decrease in function may
occur. Use the RICE regimen for treatment. It is important to
immobilize a contusion because more bleeding may occur
if the injured area is moved. An individual should not
return to play until there is painless full range o f motion.
Complications o f contusions include deep vein thrombosis
and thrombophlebitis within the injured muscle mass. A
more com m on long-term sequela o f repeated contusions
in the same area is myositis ossificans, a condition in which
there is deposition o f bone substance into the soft tissue
areas. Thorough treatment and rehabilitation should be
initiated promptly and full rehabilitation accomplished
before the athlete returns to activity. The injured area
should be protected from repeated trauma. The most
com m on etiology o f contusions is blunt trauma caused
by an object hitting a muscle group in an extremity (a
helmet against the anterior thigh o f a player, or a field
hockey stick hitting an opponent's forearm). The most
frequent sites o f contusions are the lateral upper arm and
anterior thigh.
3. Inflammation (5.9%)—Inflammation is almost a uni­
versal sequela o f acute injury and can be controlled with the
RICE regimen and appropriate use o f NSAIDs. Inflamma­
tion (in this situation) usually is not the result o f infection,
but a sign o f minor injury.
4. Fractures (5.5%)—A fracture is a break in the conti­
nuity o f bone. The major mechanism for sports injuries is
a direct blow, and it is reasonable to expect a significant
number o f fractures in any epidemiological survey o f sports
injuries. The on-site care o f all suspected fractures is the
same. Immobilize the injured area, including the proximal
and distal joint, and then transport the person to a hospital
or office to obtain x-rays and definitive care. Fractures can
happen at any site, and range from relatively insignificant
breaks o f the distal phalanx o f the toe to life-threatening
skull or neck fractures. Because o f the possibility o f further
injury to the neurovascular bundle, manipulation o f a frac­
ture before radiographic examination is contraindicated.
However, if the blood supply appears to be compromised,
manipulation to re-establish vascularity may be necessary
Chapter 23: Common Sports-Related Injuries and Illnesses: Generic Conditions
in this rare orthopedic emergency. Under ordinary circum­
stances, immobilize the fracture, place ice and slight com ­
pression around it, and transport the patient immediately.
5. lacerations (1.8%)—Lacerations are no different in
sports than in any other area o f medicine. Most are su­
perficial, caused by trauma to an unprotected portion of
skin. Occasionally, equipment used in the game, such as
basketball hoops or high jump standards, or those worn by
the athletes (braces) have been responsible. Rapid disinfec­
tion and debridement, followed by primary closure (where
appropriate), produces an uneventful recovery. Neuromus­
cular function and vascular status of the underlying tissues
should be tested before anesthesia is given. If there is any
possibility o f a foreign body in the wound, an x-ray should
be taken to identify its location before extraction. X-rays
may help when there is a non-radio-opaque foreign body
by showing the pockets o f subcutaneous air caused by the
path o f the object. Most athletes will want to play with
repaired lacerations, so the wound must be protected and
thoroughly disinfected before and after each participation.
It is wise to cover and protect a wound longer than would
be done for a nonathlete because the skin o f an athlete
is continually exposed to trauma and there is a signifi­
cant possibility o f wound dehiscence. A check o f medical
records from the preparticipation screening will indicate
whether the athlete needs a tetanus toxoid injection.
6. Other injuries (12.7%)—Although the musculoskele­
tal and skin systems account for most o f the acute injuries
to athletes, other systems (internal organ trauma, thermal
injury) also are involved. This highlights the need for the
physician to have a primary care perspective.
CHRONIC INJURY
Less dramatic but only slightly less prevalent are chronic
injuries, most o f them are overuse syndromes. Significant
medical intervention is often lacking with these injuries,
perhaps because of the lack o f intensity o f the symptoms
or signs. Many athletes self-treat these injuries and take
the advice o f fellow athletes, partly because o f the
inconsistencies o f the medical treatment regimens that
maybe given. The frequency and prevalence o f chronic and
overuse injuries should not be understated; they parallel the
increase o f exercise participation more than acute injuries
do. About 71% o f the patients seen in our primary care
oriented sports medicine clinic present with complaints
of overuse, overtraining, or overconditioning (4). In a
survey of over 16,000 recreational runners, more than
1,800 overuse injuries were identified in a 2-year span (5).
From the primary care perspective, the overuse syndrome,
regardless o f how it is defined, will account for many o f
the problems seen by the physician in the recreational,
nonorganized athletic population.
The individual most likely to suffer from overuse is the
regular daily exerciser. The sporadic "weekend" athlete is
prone to acute injuries as described earlier. Overuse is a
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process, not an event. It is directly related to the amount,
intensity, and frequency o f exercise. The biomechanics o f
the sport or activity involved dictate the geographic body
area affected. The overuse process causes breakdown and
fatigue o f body structures, usuallyresultingin inflammation
followed by swelling. Tenosynovitis, tendonitis, fasciitis,
compartment syndromes, and stress fractures are common
examples o f overuse syndromes. Most o f these terms imply
inflammation o f specific types o f structures, with most of
them classified as soft tissues. These structures are the first
to show the impact o f exertional overindulgence. If exercise
continues and warning signals (in the form o f perceived
pain) are ignored, the process continues and begins to
involve the hard tissues, such as bones. In these cases,
abnormal stress will result in damage to the normal tissue.
The concept o f normal tissue being injured by abnormal
stress is entirely consistent with the opinion held by
most pathophysiologists that mechanical stress is the most
important cause o f overuse syndromes. We occasionally
see an athlete suffering the result o f another phenomenon,
normal stress on abnormal tissue. Congenital defects and
abnormalities, postinjury weakness or imbalance, and
other types o f structural malalignment may cause a
predisposition to overuse problems.
Because overtraining and overconditioning happen so
often and are becoming so prevalent in primary care prac­
tices, the entire concept o f overuse has caused a great deal
o f frustration for physicians who are attempting to learn
all the various treatment regimens advocated for specific
areas and parts of the body. It has been contended (6)
that most overuse injuries could, and should, be treated in
one com m on "generic" way. The practical guidelines (see
Table 23.2) o f overuse as a spectrum o f injury is a concept
that assures the athlete o f receiving consistent treatment
regardless o f the specific physician seen or the malady suf­
fered. This protocol is based on clinical experience, taking
into consideration the history, physical examination, an
understanding o f the pathophysiology behind a specific
overuse syndrome, and the appropriateness o f various di­
agnostic aids. Others (7,8) have advocated using similar
guidelines to treat more specific injuries. These clinical
guidelines cover all the musculoskeletal injuries caused by
ovemse, with the understanding that incorrect biomechan­
ics and the athlete's lack o f knowledge must be corrected at
the same time if the condition is to be treated successfully.
The protocol is designed to cover most overuse injuries
encountered in the primary care settings. Overuse injuries
are divided into four grades across an injury continuum. A
word o f caution, the clinical protocol is not intended to be
used in a dogmatic way, Individual injuries may overlap
grades and inconsistencies will exist. However, most injuries
will approximate one o f the clinical pictures outlined here.
Continuum of Injuries
The following is a general description o f the four grades o f
chronic injuries used in Table 23.2:
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MUSCULOSKELETAL OVERUSE INJURIES: A CLINICAL GUIDE
Grade
1
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Pathophysiology
Diagnostic Aids
Treatment
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Grade 1 injuries. Patients presenting with Grade 1
injuries give a vague history o f transient pain,
usually occurring many hours after injury. It may
be perceived as soreness, is commonly present in
beginner athletes attempting to "get into shape," and
is accompanied by generalized tenderness. The cause
o f postexercise muscle soreness has been studied by
various researchers (9,10). Increased levels o f lactic
acid, muscle breakdown, or minor inflammation
have been advanced as possible explanations. There
are no diagnostic aids for the physician and the only
treatment is reassurance and occasional use of ice.
However, the physician has an excellent opportunity
to intercede in the prevention o f further injury at this
point by appropriate athlete education and advocacy
of established exercise guidelines.
Grade 2 injuries. Grade 2 injuries describe pain o f ap­
proximately 2 to 3 weeks duration that typically
occurs late in activity or immediately following it.
Physical examination reveals more localized pain but
no true point tenderness. The signs and symptoms
may suggest mild musculoskeletal inflammation, but
useful diagnostic aids are absent. Treatment consists
o f repeated applications o f ice directly to the affected
area for 10 to 15 minutes at a time. In addition, rela­
tive rest is achieved by decreasingthe training regimen
by 10% to 25%. The physician should look at such
environmental factors as use o f improper or wornout equipment, or at poor techniques or intrinsic
biomechanical abnormalities. A Grade 2 injury is the
most common presenting clinical picture o f overuse.
Grade 3 injuries. Pain usually occurs in the middle
o f an activity and, over time, moves nearer to the
commencement o f the activity. Physical examination
demonstrates point tenderness and other signs. A
bone scan at this point may be positive, but the find­
ing adds little to the clinical diagnosis or treatment
plan. Treatment includes using ice and decreasing the
exercise regimen by 25% to 75%. In addition, we have
found that a 5 to 7 day period o f complete rest with
Chapter 23: Common Sports-Related Injuries and Illnesses: Generic Conditions
concurrent NSAIDs medication is helpful in arresting
the initial inflammation and allow the individual to
return to higher levels o f activity quicker.
Grade 4 injuries. Grade 4 is the most serious type o f in­
jury in the continuum and has a pain pattern similar
to Grade 3. Pain prevents further activity and affects
performance. If swelling is a major finding, espe­
cially in the lower extremity, compartment syndrome
should be considered. A positive bone scan indicat­
ing the extent o f a stress fracture(s) may be helpful
in obtaining better patient compliance. Treatment
o f Grade 4 injury consists of ice, complete rest, and
treatment with NSAIDs. Some physicians believe that
stress fractures in certain areas o f the body, such as the
proximal tibia, require immobilization with a cast or
brace. However, this is not generally recognized as
the current standard o f care.
Important points to be emphasized in treating overuse
syndromes are as follows:
Decreasing the training regimen (relative rest) should be
based not only on the grade of injury but also on factors
known to the physician about the individual (lifestyle,
motivation, and ability to comply).
I.ong-term complete rest is not well accepted by most
athletes as a legitimate treatment, but they will comply
with 5 to 7 days o f complete rest and treatment with
NSAIDs. In Grade 3 injuries, this is very effective in
initially controlling the inflammation and allowing a
better pharmacological effect. The rest period should be
followed by light intensity training (LIT).
The application o f ice should come after exercise in
Grade 2 to Grade 4 injuries. Ice should be applied
frequently, directly on the skin whenever possible, for
10 to 15 minutes at a time. An ice allergy may develop,
but this is rare and can be controlled by stopping the ice
therapy. An easy way to prepare ice for therapy is to fill
small paper cups with water and freeze it for use in ice
massage.
NSAIDs should not be used if the history reveals any
previous allergies or hypersensitivity reactions to these
drugs.
The following points about Table 23.2 should be kept
in mind:
The onset o f pain as a symptom will occur closer to
the start o f exercise as the severity o f the grade increases.
Figure 23.2 illustrates the interrelation between the injury
(pain) continuum and the physiological continuum.
Tenderness changes from vague to specific as the process
increases in severity.
The duration and intensity o f signs and symptoms
increases with each grade.
The findings on physical examination involves increas­
ingly more functions as one moves through the contin­
uum.
The underlying pathophysiology can be subdivided:
Grades 1 and 2 affect only soft tissue, and Grades 3
and 4 affect both soft and hard tissues.
By using this table a costly lest, such as a bone scan, can
sometimes be avoided. A bone scan should be ordered
to confirm an already suspected stress fracture, rule out
multiple sites, and improve treatment compliance.
Return to Activity
After rest, ice, and medications have been used, return
to activity is the next consideration. Using the following
protocol for LIT allows the patient to dictate his/her own
pace o f return to activity, and thus maintain some control
over the process. LIT involves the following principles:
Training should restart only when the individual is able
to cany out functions o f daily activity without pain. Once
this is achieved, exercise can begin at a very low level of
intensity and duration (half mile jog, 100 yd swim, 1 mi
low gear biking).
At the conclusion o f this daily activity, the athlete then
has the following three options:
(a) If the athlete experiences pain and/or swelling
during the exercise, stop the exercise immediately
and decrease duration by 25% the next day.
Consistency in the treatment o f overuse injuries is a de­
sired result of the widespread use of a clinical protocol such
as this. A major factor contributing to patient compliance
is faith in the regimen. If the regimen is consistent and the
patient can be assured that the physician has not unduly
restricted exercise, compliance usually will follow.
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(b) If the athlete experiences pain after exercise, ice the
area and continue at this level o f exercise the next
day.
(c) If the individual experiences neither pain nor
swelling during or after exercise, the program may
be increased by up to 25%.
Five major points that need to be examined during
the treatment o f overuse injuries to try and prevent
recurrence include the following:
The athlete's philosophy about exercise should be
considered.
A brief but knowledgeable look at the training regimen
may show the possibility o f beneficial alterations.
A systematic appraisal o f the exercise environment o f
the athlete should be made, with an idea o f making
the needed changes.
Congenital or injury-induced biomechanical prob­
lems, including muscle imbalance (inherent or the
result of previous injury), leg length discrepancy, or
self-treatment with orthntics, should be addressed.
The athlete should be educated in the concept o f pain
so that he/she knows when to stop exercising and
when to resume.
Treatment Modalities
Five basic modalities are used to treat most chronic injuries.
Three are used in combination, occasionally with som e
form o f electrical impulse therapy (the fourth modality),
before resorting to surgery, which is the fifth modality.
Ice. Ice is the foundation treatment for all overuse
injuries. It is the most effective intervention currently
available.
Rest. Absolute rest from exercise has advantages and dis­
advantages. The ability to allow healing to progress
unimpeded is one advantage. Minor reinjury, caused
by using an injured part, will slow the healing process.
Rest combined with medication enhances the effect o f
the medication. The disadvantages include noncom ­
pliance and dissatisfaction on the part o f the athlete.
Also, rest can cause muscle atrophy, deconditioning,
and loss o f fine motor skills, which may then predis­
pose an individual to further injury once activity is
resumed. Relative rest is a reasonable compromise.
Anti-inflammatory medications. Anti-inflammatory med­
ications that are applied topically, taken orally, or
injected can be used to treat overuse injuries. Top­
ical medications have yet to come into widespread
use. Dimethyl sulfoxide (DMSO), although not a
federally approved medication, may be used in the
self-treatment o f some overuse injuries.
Oral NSAIDs are used frequently to treat overuse
syndromes, and there are many different NSAIDs. All
have a dual action: anti-inflammation and analgesia.
They do tend to mask pain, an
important consideration in caring for an athlete with
a serious overuse injury. Do not prescribe any
NSAIDs initially unless the patient is willing to
rest completely and allow the medication to work.
The use o f corticosteroid medication, either alone
or in combination with an anesthetic, should be re­
served for such conditions as bursitis or tenosynovitis.
Injections into the tendons or ligamentous structures
can significantly weaken these structures for up to
14 days following the procedure (11,12). Repeated
injections can cause biomechanical disruption o f soft
tissue and lead directly to collagen necrosis. The possi­
bility o f tendon or ligamentous rupture is a significant
side effect o f such therapy and should be avoided.
Electrical impulse therapy. The use o f low-grade electrical
circuits set up over an injured muscle or ligamentous
unit have successfully aided healing. Transcutaneous
nerve stimulation not only eliminates pain feedback
to the brain through the "gate theory" (13), but also
stimulates the healing process peripherally and al­
lows the soft tissue unit to relax. Similar types of
therapy include galvanic stimulation, electromyos­
timulation, and the use o f surface electrodes for
serious injuries such as slow-healing stress fractures.
The latter treatment usually is reserved for the most
serious o f overuse injuries.
Surgery. The use of surgery to treat overuse injuries,
including supraspinatus tendonitis, plantar fasciitis,
Achilles tendonitis, and compartment syndromes is
appropriate, but only after medical measures have
proven ineffective. Most clinicians argue that surgery,
especially where an athlete is attempting to function
at high performance levels, should be avoided at all
costs.
ALLERGIES
Allergies can cause everything from chronic symptoms
o f the upper respiratory tract to decreased performance
secondary to respiratory inefficiency. Following is a list o f
allergies that can be factors in athletic performance:
1. Ice: Ice allergies are relatively rare, affecting no more
than 1% to 2%. This allergy is generally seen after
ice treatment for soft tissue injury. Symptoms include
the development o f wheals and urticaria in the area
surrounding the skin where ice was applied. Treatment
is removal of the ice. Rarely, an antihistamine such as
Benadryl may be necessary.
2. Equipment: Equipment that has been washed and
cleaned in certain types o f detergent can result in al­
lergic dermatitis. Consider this in an individual with an
unexplained skin rash.
3. Medications: Always a possible problem. This can be
avoided by obtaining a history o f allergies before placing
an athlete on any medication.
4. Airborne dust and molds: Competing indoors in large
arenas, athletes may be susceptible to problems caused
Chapter 23: Common Sports-Related Injuries and Illnesses: Generic Conditions
by dust and molds that collect in the rafters or are
circulated by ventilation systems.
5. Chlorine: Some swimmers have an unfortunate allergy
to the chlorine or bromide used to disinfect pools. This
results in a contact dermatitis and should be treated as
such.
6. Personal contact: On occasion, participants will spray or
apply substances on their skin, which may be allergic
to them or their opponents. During contact, an allergic
reaction to the substance develops. Examples o f such
substances include tape, rubber, and Vaseline.
IMMUNOLOGY________________
____
The issue o f immunology o f exercise has been addressed
by Simon (1984) (14). Habitual exercise may protect
the athletes against infection. A transient increase in
various host-defense factors is thought to be caused by
exercise hyperthermia. Other evidence regarding immune
function suggests exactly the opposite.The rigorous training
programs o f some aerobic sports (swimming, long distance
running, bicycling) can result in anorexia and poor
nutrition. While not proven, many team physicians believe
that such training regimens actually decrease an athlete's
resistance to endemic intections. Practices like losing a
large amount o f weight (wrestling, gymnastics) may put
the body in a state o f vulnerability. Also, many athletes,
especially at the collegiate level, live in close proximity,
a setting that lends itself to the spread o f minor illness
among team members.
It seems unlikely that exercise produces substantial
functional changes in immunoglobins or complement. A
number o f studies have found that an increased level of
habitual physical activity in a young, normal population
313
does not result in fewer upper respiratory symptoms or
shorter duration. In addition, maximal aerobic power as
a measure o f cardiovascular fitness is not related to the
incidence or duration o f upper respiratory symptoms. We
can conclude that there is no clinical evidence that exercise
alters the frequency or severity of human infections.
As primary care team physicians, the authors bias is that
high intensity training done in the winter months or in close
proximity to large groups does constitute at least a minor
risk factor for developing acute contagious infections.
Whenever possible, the team physician should try to aid
athletes by pre-outbreak immunization or emphasizing
good eating and sleeping habits.
REFERENCES
1. Garrick JG. Sports medicine. Pediatr Clin North Am 1977;24(4):737-747.
2. Bowers KD. Disposition o f high school athletic injuries. W V Med I
/,%
;, !
:- - -
-/
.
3. Garrick (G, Requa R. Medical care and injury surveillance in a high school
setting. Phys Sportsmed 1981;9(2): 116-120.
4. McKeag DB. Overuse injuries: the concept in 1992. Prim Care 1991,
18(4):851-865.
5. Clement DB, Taunton IE, Smart GW, el al. A survey o f overuse running
injuries. Phys Sportsmed 1981;9(5):47-58
6. McKeag DB. The concept o f overuse: the primary care aspects o f overuse
syndromes in sports. Prim Care 1984; 11(1)43-59
7. Blazina DE. Fox IS, Caron SI. Basketball injuries Med Aspects of Sports 1974:
15:15-19
8. lackson DW. Shinsplints: an update, Phys Sportsmed 1978;6(10):51-62.
9. Schwane JA, Williams IS, Sloan |H. Effects o f training on delayed muscle
soreness and serum creatine kinase activity after running. Med Sci Sports
Exerc 1987;19:584-690.
10. Tiidus PM, lanuzzo CD. Effects o f intensity and duration o f muscular
exercise on delayed soreness and serum enzyme activities Med Sci Sports
Exerc 1983;15:461-465.
11. Gottlieb N[, Riskin WG. Complications o f local corticosteroid injections.
JAMA 1980;243( 15): 1547-1548.
12. Kennedy JC, Willis RB The effects o f local steroid injections on tendons:
a biomechanical and m icroscopic correlative study. Am I Sports Med 1976;
4(1):11-21.
13. Ersek RA Transcutaneous electrical neurostimulation: a new therapeutic
modality for controlling pain. Clin Orthop 1978;128:314-324.
14. Simon HB The immunology o f exercise. JAMA 1984;252(19):27352738.