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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 306 ACSM's Primary Care Sports Medicine • www.acsm.org 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 ! "# $ $ $ %& ' ( ) *$ $ + $ $ ,& - " # ($ . / & $$ "# 0 ' $' 1 #2 ($ . # Source:3.435$ /,,6%6,!,7,%,' Pediatr Clin North Am 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 307 9# I I 9$ 8 :7; #<7 = >$ ' : 8 ?:7; #< = @$ ' ; : I N oP ' : Figure ! 5 $ 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 ; 7: 7; #< I 7777 A= i 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 308 ACSM's Primary Care Sports Medicine • www.acsm.org 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 309 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: 310 ACSM's Primary Care Sports Medicine • www.acsm.org B r i l -1C -w MUSCULOSKELETAL OVERUSE INJURIES: A CLINICAL GUIDE Grade 1 History after : Physical Exam Pathophysiology Diagnostic Aids Treatment Comments 3 I* B. B$$ 8 J9 *. #'# D E 5FG( H. * $ 8 3 '* B$ late# $$# # 8 9<;$ $$ : 1 $ 7)K 1 0$ >0 ! > early middle of# '> B $ $$ > L7#J I% K > #$ )7,)K 9)7,# > M$$ # 9<;$ & $$ '#$' ' % > # "3! 85"9 M. '( $GL N%. <;&B $# L7#J I/)K 5 O$$ #$ # $ 9 $; ( 85"9 9$$< # 0 ROM - range of motion; NSAID - nonsteroidal anti-inflammatory drug; Source: McKeag DB. The concept of overuse: the primary care aspects of overuse syndromes in sports. Primary Care /-% D P 6 %! 7 +/ ' 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. Figure ! ; O7 $ #$ 311 > 3% 3! 3 3 O$ 312 ACSM's Primary Care Sports Medicine • www.acsm.org (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. 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