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Sports Medicine – Focus Question A How are sports injuries classified and managed? 1K1: Ways to classify sports injuries - Direct and indirect - Soft and hard tissue - Overuse Direct and Indirect injuries Direct injuries are caused by an external blow or force, they can be caused by: A collision with another person e.g. tackling Being struck by an object e.g. broken arm as a result of being hit by a bat Indirect injuries result from internal forces built up by the actions of the performer, such may be caused by: Overstretching e.g. ballistic stretching (putting excessive pressure on the stretch reflex) Poor technique e.g. swinging a bat with the wrong technique Fatigue Lack of fitness Soft and Hard tissue injuries Soft tissue injuries are the most common injuries from participation in sport. These include: Skin injuries – abrasions, lacerations and blister Muscle injuries – tears or strains of muscle fibres and contusions Tendon injuries – tears or strains of muscle fibres and inflammation Ligament injuries – sprains and tears of ligament fibres They may be acute (occurring suddenly, such as a sprain) or chronic (prolonged). Ligaments join bone to bone and tendons join muscle to bone. Hard tissue injuries are those involving damage to bones of the skeleton and teeth. Hard tissue injuries include breaks to bones and dislodged teeth. They are serious, many causing severe pain and discomfort. Secondary injuries are those that occur as a result of a previous injury being poorly treated or not being fully healed. Athletes at risk of recurrence of injures should regain full strength and range of movement before returning to play. Overuse injuries Overuse injuries occur when excessive and repetitive forces are placed on the bones and other connective tissues of the body. Little or no pain might be experienced in the early stages of these injuries and the athlete might continue to place pressure on the injured site. By depriving the overused site of healing time, the damage around the site accumulates and becomes inflamed. Overuse injuries are caused by: Poor technique - poor technique can instigate additional stress on the site Repetitive - low impact exercise e.g. jogging or stepping Poor equipment e.g. shoes with poor support, racquets that are too heavy. Typical overuse injuries include anterior shin splints (irritation of front portion of the shinbone), tendonitis (irritation of the tendons). Overuse often contributes to stress fractures, which are small incomplete bone fractures caused by repeated pounding, usually on hard surfaces. 1K2: Soft tissue injuries - Tears, sprains, contusions - Skin abrasions, lacerations, blisters - Inflammatory response Tears, sprains, contusions A tear is a disruption of the fibres of a muscle or tendon. Tears occur when a muscle or tendon is over stretched or when a muscle contracts too quickly. The severity of the tear can range from the microscopic level (a strain), to a small number of fibres through to a complete rupture of all muscle fibres. A sprain is a tear of the ligament fibres. These are strong rigid and relatively inelastic tissue. Their role is to connect bone to bone, thereby providing joint stability. Sprains occur when ligaments are stretched or torn resulting in pain, swelling and the inability to perform normal joint movements. Healing is a slow process because ligaments have a relatively poor blood supply. Sprains are classified according to the severity, first, second and third degree. A strain is when a muscle or tendon is stretched or torn. Tendons join muscle to bone. They cause considerable pain and bleeding may cause discolouration around the injury. Any movement in the form of stretching and any pressure on or around the injury will result in sharp pain. Strains are also classified according to severity, first, second and third degree. A contusion or bruise is bleeding into the soft tissue. This is usually caused by a collision with external agents. Contusions interrupt blood flow to the surrounding tissue; this can cause a blood clot in the connective tissue. In severe cases, this internal bleeding may occur for a long period of time. Contusions vary in intensity – with some remaining close to the skin while others penetrate deeply causing the bone to bruise. THE RICER METHOD When can you use heat? Heat can be applied to loosen tissues and relax areas recovering from injury after the first 72 hours. Head pads, hot wet towels, spas, heat creams can be applied for 20 minutes at a time. Skin abrasions, lacerations, blisters These are forms of skin trauma; they are caused by the application of force, such as scraping or friction to the outer layer of the skin. Skin abrasions results in the skin being scraped against a hard, dry surface, they usually cause pain and shallow bleeding. Upon the fall, dirt and other foreign material can enter through the skinned area therefore treatment requires gentle cleansing and sterilisation of the wound to prevent infections. The wound should then be covered with a non stick dressing. Lacerations are wounds where the flesh has incurred an irregular tear. Lacerations can occur to the scalp, mouth and particularly to the lips and tongue. Scalp lacerations: the area needs to be thoroughly cleansed with antiseptic soap, dried and a sterile gauze pad applied. Pressure may still need to be applied to prevent excessive bleeding. Lacerations longer than 1cm need to be referred to a doctor. Mouth lacerations: require a thorough inspection to ensure there is no further damage, such as dislodged teeth. The mouth can be rinsed with antiseptic liquid. Sucking on ice assists in the control of bleeding and swelling. Blisters are caused by a collection of fluid below or within the surface layer of skin. Blisters usually occur as a result of friction or rubbing with other objects and surfaces. Injury management requires the area be washed with soap and warm water, liquid antiseptic to be applied. The area should be dried and antibiotic ointment applied. What does immediate management aim to do in skin injuries? The aims of the immediate management of skin injuries include prevention of infection for both the victim and the first aider, minimisation of blood loss and tissue damage, and promotion of healing in order to reduce recovery time. Usually follows these steps: 1. Reduce dangers of infection – wearing gloves 2. Control bleeding with rest, pressure and elevation 3. Assess severity of the wound 4. Clean wound using clean water or saline solution 5. Apply an antiseptic to the wound; ensure person is not allergic 6. Dress wound with sterile pad and bandage. 7. If necessary, refer person to medical attention. When should skin injuries be medically referred? Skin injuries that should be referred to medical attention include wounds that require suturing, wounds that show signs of infection or cannot be properly cleaned of foreign material and wounds to the head. All head wounds usually should be referred to medical attention as even minor injuries to the head may be accompanied with more serious injuries such as concussion. The Inflammatory response When soft tissue is injured, the body activates a self healing process known as the inflammatory response. It may last up to 3-4 days depending on the extent of the damage. Phase 1: The inflammatory stage – just after the injury has taken place, it is characterised by: pain and swelling loss of mobility damage to cells and surrounding tissues an increased blood flow to the area leakage of fluid that causes swelling formation of many blood vessels to promote healing. Phase 2: The repair and regenerative stage – this stage usually lasts from 3-6 days, characterised by: the removal of debris from the area (dead cells etc) formation of new fibres production of scar tissue reduced swelling. Phase 3: The remodelling stage – can last from 6 weeks to many months, characterised by: replacement of scar tissue Replacement tissue that needs to strengthen the area. The type of remodelling depends on the timing and degree of mobilisation of the injury. It also varies on the conditioning and rehabilitation strategies the athlete has implemented. Excessive exercise too early causes further damage. Too little movement allows large quantities of scar tissue to form, the decreases strength and flexibility. Immediate treatment of soft tissue injuries aims to reduce swelling, prevent further damage and ease pain. In the long term the treatment aims to restore flexibility, regain full function, prevent recurrence and return the player to the field as soon as possible. Management of soft tissue injuries requires application of the RICER principle. Properly used, the RICER method ensures that the injury heals correctly and in the shortest period of time. If RICER is not used, or its use is delayed, the injury takes longer to repair, has less strength and flexibility. In a) scar tissue is not properly targeted therefore is not properly removed, this affects the remodelling stage as much scar tissue is still present preventing optimum recovery of the site. The athlete may have problems regaining full strength and pre-injury results. The injury is also more likely to reoccur. In b) the tissue is fully healed, the fibres are more compact and therefore strength can be quickly regained without additional stress or issues. 1K3: Hard tissue injuries - Fractures - Dislocation Fractures A fracture is a hard tissue injury where there is a partial or complete break of a bone. The type of fracture will depend on the severity of the break to the bone. They can be: Complete, where the bone is broken into two parts (i.e. oblique) Incomplete, where the break is only part-way through the bone (i.e. greenstick) Comminuted, where there are more than two breaks in the bone Fractures can also be classified as: Closed, where the broken bones do not pierce through the skin Open, where the bone protrudes through the skin Complicated, where the broken bone damages a major nerve, organ or blood vessel. Causes of a fracture: Fractures can be caused by either direct or indirect forces. Signs and symptoms: swelling, deformity, pain, limited movement. In an open fracture bone will be visible. Management of fractures: Immobilising a fracture is important to lessen the pain, reduce bleeding, treating shock, and prevent further damage. Managing a fracture involves the following steps: 1. Following DRABCD procedures in case player is unconscious. Danger should be checked for under all circumstances. 2. Control bleeding. 3. Identify type of fracture. 4. Immobilise the fracture with broad bandages and a splint, ensuring no circulation is cut off. 5. Immediate medical attention. How to immobilise? Management of hard tissue injuries aims to minimise movement of the injured area. This is achieved by immobilising the joint above and below the injury site. If the injury site is the shaft of a long bone (e.g. femur, humerus) the injury can be supported with a sling or splint. A supporting splint should be long enough to extend beyond the nearest joints of the injured site, e.g. you can use, another limb, another part of the body, a firm, straight object. The correct application of the splint is essential. Should be secured at 6 points: Above the joint of fracture, below the joint of fracture At the joint above the fracture, and at the joint below the fracture. Just above the fracture, and just below the fracture. Why is immobilisation important? Immobilisation is important in the treatment of hard tissue injuries for a number of reasons. By immobilising the area, the first aider prevents further injury to the bone and the surrounding soft tissue structures. This may help to reduce the amount of bleeding and swelling and it reduces the amount of pain to the patient as it stops grating and aggravating the nerve ending between the ends of the fracture. Immobilisation may also reduce the chances of the patient experiencing shock, a life threatening condition. Dislocation Dislocations are when bones are displaced from a joint. A dislocation can also result in damage to the surrounding ligaments and muscles. Causes of dislocations: Caused by excessive force that move joints out of their sockets. Shoulder and finger joints are more susceptible to dislocations, as the surrounding ligaments are less supportive. Signs and symptoms of dislocation: Deformation, pain, swelling, loss of function, bruising. Management of a dislocation: 1. Follow DRABCD procedure. 2. Immobilise 3. Do not attempt to put the joint back in place; this must be done by a sports specialist, as there is a risk of nerve damage if the bone is not put back correctly. 4. Seek medical help. Management of finger dislocation: 1. Secure with a splint to fully immobilise. 2. Ice, elevation and support using a bandage. 3. Medical attention. Finger dislocations can be easily splinted and supported using a straight object. Shoulder dislocations should be immobilised using a sling or by holding the arm in place. What is subluxation? When a bone momentarily “pops out” of the joint and quickly returns to place. Although it stretches the ligaments, it may not cause additional damage at the time. However, the joint will be vulnerable. Managing hard tissue injuries: Because hard tissue injuries can be accompanied with damage to surrounding muscles, blood vessels’, surrounding organs and nerves, immediate treatment is required. For serious hard tissue injuries, the person should not be moved, and medical help should be called immediately. 1K4: Assessment of injuries - TOTAPS (Talk, Observe, Touch, Active and Passive movement, Skills test) TOTAPS procedure is used to assess the extent of injury to a player and determine whether or not the injured person can return to the field. If the player can complete all tasks required, they should be allowed to return to play. If not, player needs further assessment from a medical Sports Medicine – Focus Question B How does sports medicine address the demands of specific athletes? 2K1: Children and young athletes - Medical conditions (asthma, diabetes, epilepsy) - Overuse injuries (stress fractures) - Thermoregulation - Appropriateness of resistance training Sports medicine is defined as the field of medicine concerned with physical fitness and the prevention, diagnosis and treatment of injuries sustained in sports or exercise related activities. Children and young athletes face several limitations which may impede their performance in comparison with a fully functioning athlete. There are considerations which need to be taken into account when organising competition in sport of children and young athletes under the sports medicine approach. Issues such as medical conditions, overuse injuries, thermoregulation and the appropriateness of resistance training must be recognised to ensure safe participation. Medical conditions ASTHMA Asthma is a condition characterised by the narrowing of the airways leading to the lungs, this causes breathing difficulties. Exercise can be a major trigger of an asthma attack due to an increased demand for oxygen. Children with asthma are encouraged to participate in physical activity, especially swimming as the warm and moist environment promotes the diffusion of oxygen into the lungs, increasing lung function. Asthmatics should take precautions in dry, cold weather and their coaches should be informed of the condition. A management plan for asthma consists of sitting down, giving 4 puffs from an inhaler (puffer), wait for 4 minutes and repeat. If the condition worsens, emergency services should be called. DIABETES Diabetes is a metabolic condition caused by the body’s incompetence to produce or utilise insulin. This places major stress on maintaining blood sugar levels as the levels in diabetics constantly fluctuate. For a young child diabetes can have a significant impact on participation in sport. The body uses glucose to fuel working muscles and if a person’s body is unable to produce this glucose they may start to feel unwell. An appropriate training and management plan needs to be devised for diabetics in order to avoid hypoglycaemia (low blood sugar levels) and hyperglycaemia (high blood sugar levels). To manage hypoglycaemia, the athlete should instantly consume fastacting carbohydrates such as lollies, fruit juice, banana etc. Hyperglycaemia should be managed under proper medical advice. Young diabetics should not be advised against physical activity, they can participate successfully and safely given that extra precautions are taken e.g. coaches allowing regular breaks to refuel and monitoring their levels throughout the training session. EPILEPSY Epilepsy is a condition caused by a disruption to electrical activity in the brain, causing a brief alteration to the level of consciousness, resulting in seizures. Epilepsy should not affect a child’s ability to perform, however sports such as swimming, rock climbing, contact sports should be avoided as they pose extra risks. A management plan that is familiar to parents, coaches and other team members is critical, if a seizure occurs, the area should be cleared of any hazards and the fit should be allowed to occur unrestrained, the person should be given time to rest afterwards and if the fit lasts longer than 5 minutes an ambulance is required. Overuse injuries Overuse injuries occur when excessive and repetitive forces are placed on the bones and other connective tissues of the body. By depriving the overused site of healing time, the damage around the site accumulates and becomes inflamed. Children and young athletes are more susceptible to overuse injury and are caused through a combination of poor technique, poor equipment, high volume, high intensity training requiring repeated movements of stepping and jumping. These injuries are serious when occurring in children as their bones are still developing and any disruption can hinder their growth. Therefore sports medicine values the fact that children require adequate breaks between training sessions and sufficient recovery time for injuries. Thermoregulation Thermoregulation is the mechanism, by which the body maintains a relatively stable core temperature of 37 degrees despite fluctuations in the ambient temperature, this is essential for proper metabolic functioning. Compared with adults, children are disadvantaged in thermoregulation; they have a larger surface area to body mass ratio, underdeveloped sweat glands and less muscular development. These factors can make mechanisms such as convection and evaporation ineffective and place them at higher risks of hyperthermia and hypothermia. Hyperthermia is when the body temperature is elevated above the optimum; this can lead to heat stress. Sweating is the mechanism by which the body cools itself, by having underdeveloped glands their cooling mechanism is less efficient. Heat stress is an issue that needs to be considered, sports medicine has implemented strategies of playing in shaded areas, limiting play time in extreme conditions, regular water breaks and advising children to wear light, breathable clothing. Hypothermia is a condition where the body temperature drops below the optimum. Children are more at risk of this than adults because their muscles are less able to generate heat. A lessened efficiency of gaining heat can place children at risks of injuries due to stiffness of muscles; therefore an adequate warm up procedure is crucial. It is also advised that children wear multiple layers of clothing. Children have a relatively large skin surface area in relation to body size, therefore they store less fluids and have greater opportunities to lose these minimal amounts. Dehydration needs to be addressed as it is a major contributor to fatigue. Children should be given regular breaks to rehydrate, assisting thermoregulation. These factors can place young athletes at a disadvantage when participating in sport, however through the knowledge and assistance of sports medicine management techniques are able to remedy these issues and promote a safe and enjoyable environment for children and young athletes. Appropriateness of resistance training Resistance training can provide great foundations for strength. For young athletes factors such as their physical and mental capability influences the suitability of such activities. Due to their ongoing skeletal development, resistance activities should be based upon their own weight to ensure there is no risk of injury of their growth plate (epiphyseal) and other soft/hard tissue injuries. Children of 7 years + can be introduced to basic exercises e.g. sit ups, push ups, chin ups etc with minimal weights and low volume, technique should be the main focus. As children build upon basic skills, weights can be gradually introduced, practising high repetitions on light loads and slowly progressing. Gradually sport specific components can be introduced and volume increased. By progressing through these stages appropriately, it ensures that the young athlete is not physically and psychologically placed under high demands and expectations. Sports medicine ensures that resistance training can be implemented and introduced to young athletes in a safe manner by considering their developing bodies. 2K2: Adult and aged athletes - Heart conditions - Fractures/bone density - Flexibility/joint mobility As Australia’s population continues to age, coaches need to address the specific needs of adult and aged athletes. As individuals grow older they have a likelihood of suffering from aging bones and muscles, which affect their physical capabilities to varying degrees. Physical activity for older people increases muscle capacity, stamina, balance, flexibility and overall physical co-ordination reducing the risk of diseases such as CVD, osteoporosis, diabetes and injuries, improving their quality of life. Sports medicine addresses these demands allowing sport and physical activity to be performed by aged athletes and adults that is both safe and of suitable intensity by taking into consideration their lifestyle changes. Heart conditions People with heart conditions include individuals suffering from high blood pressure, experienced heart attacks or other related conditions. As people age, the efficiency of their cardiovascular system declines, reducing the amount of oxygenated blood being transported to the muscles. This makes exercising a lot harder, placing a greater demand on their cardiorespiratory and cardiovascular systems. This highlights the need for regular sustained exercise for older people, before they begin they should obtain medical before starting an exercise program. Aerobic exercises such as walking, cycling, jogging and swimming present the best options for people who have not been active for long periods of time. It is important that they begin slowly and progress gradually using an exercise program that suits the individual. Key principles for older athletes: Medical clearance Aerobic exercise Gradual progression Low-moderate intensity Suited to the individual Fractures/bone density As people age, their bones lose some of their density and become brittle and a condition called osteoporosis can develop, it is a type of musculoskeletal condition in which there is deterioration in the bone structure. Inactivity should be avoided as this encourages calcium discharge from bone, making them weaker. Exercise and sport programs that are conducted safely can improve physical components such as strength. Endurance activities such as walking, cycling and swimming are recommended as well as, low impact, low intensity weight bearing activities focusing on the limbs, trunk and back. High loads and contact sports should be avoided and resistance to be developed gradually. Flexibility and joint mobility Exercise has a positive effect on flexibility and joint mobility in older people. Arthritis, aching joints and tight muscles are problems often faced by older people and respond positively to exercise programs that focus on safe stretching and improving the range of motion in joints. Programs should also increase balance and stability and aim to reduce injury. Programs need to: Be low impact Be specific to a person’s physical limitations Consider existing medical conditions that may restrict movement Options can include, walking, cycling swimming, aqua aerobics, tai chi. 2K3: Female athletes - Eating disorders - Iron deficiency - Bone density - Pregnancy Eating disorders Eating disorders are very common for athletes who compete in events where low body fat and an idealised boy shape and size are expected e.g. gymnastics, synchronised swimming and dance. Females have twice the risk of developing an eating disorder due to influences from media suggesting idealised physiques, social expectations and the need to conform to an ideal sporting image. These athletes find themselves under pressure to conform to an ideal body size and weight. Eating disorders can heavily impede on performance and general well being of the athlete. It contributes to fatigue, irregular menstruation cycles which can lead to amenorrhea, weak bones and dehydration. To avoid these risks, coaches should be aware of how to detect signs of eating disorders and adopt strategies to alleviate these problems e.g. encouraging healthy eating behaviours, setting good examples etc. Iron deficiency Iron is an essential mineral needed for the formation of red blood cells that contain haemoglobin which is essential for oxygen transportation. Female athletes and endurance athletes in particular are exposed to the increased risk of having low iron levels due to their training regimes. When iron stores are depleted, red blood cells are reduced, limiting the oxygen carrying capacity of blood, athletes can experience fatigue and loss of energy, this is a condition called anaemia. Females are more susceptible to iron deficiency as they consume less red meat and lose blood during menstruation. The recommended daily intake is 15-18 mg per day and can be achieved through a balanced nutrient rich diet of red meat, dark leafy vegetables and lentils etc. Iron supplements are also available under extreme circumstances. Bone density Calcium plays a crucial role in the functioning of the female body. It is responsible for muscle contractions, blood clotting, regulating energy metabolism and building strong bones. The strength of bones is linked to calcium intake, exercise and diet. Bone density is strongest when a person is in their twenties, with deterioration beginning in the mid thirties. Following menopause, women lose calcium faster than men causing a rapid deterioration of bone structure therefore women must take precautions when exercising and choosing activities such as aerobic sports (swimming, cycling, and aerobics). A well balanced diet also needs to be considered, foods rich in calcium. These can maintain healthy bone structure and prevent the occurrence of osteoporosis which is a condition where bones become frail and brittle. Women with osteoporosis should include adequate warm ups and gradual progressions in their training regimes. Pregnancy It is found that exercise during pregnancy can be very beneficial given that precautions are taken in order for the activity to be performed safely. Physical activity during pregnancy can reduce the risk of CVD, gestational diabetes, excessive weight gain, and improve physiological functioning which meets the increase demand of oxygen and energy required by the developing baby. While there are many benefits, it is firstly important to consider the health status of the individual, their stage of pregnancy and the type of sport in which they are participating in. There are specific guidelines that recommend activities to ensure safety; these include non contact sports (e.g. walking, swimming), avoiding hot and humid weather preventing possible heat stress. Sports Medicine – Focus Question C What role do preventative actions play in enhancing the wellbeing of the athlete? 3K1: Physical preparation - pre-screening - skill and technique - physical fitness - warm up, stretching, cool down Physical preparation enables the body to better cope with the demands of the sport or activity. The athlete undertakes training sessions that stress physiological capacities making them adapt to the pressures required in the competitive environment. Before a training program is designed and implemented, it is essential that individuals at risk be pre-screened. Prescreening considers risk factors such as age, gender, health status and previous experience as criteria in identifying potential health risks that may inhibit participation in a particular sport. By evaluating health symptoms in response to training, they are able to better understand the precautions when designing an exercise program. This ranges from type of sport, intensity, duration and the type of equipment that is suited for each individual’s capability. These measures are implemented to reduce the risk of injury. Another aspect of physical preparation involves the refining and development of an athlete’s skill and technique. Through the acquisition and practice of correct basic techniques the athlete will be able to control, pace and pattern their movements to reduce the risk of injury. Using poor technique can not only affect skill improvement but also increase the chance of injury. For example, footballers would have to learn the correct technique to tackle to minimise the impact for both themselves and others. A critical preventative action in enhancing the well being of athletes is to ensure that their level of physical fitness is comparable to the requirements of their sport and activity. The level of physical fitness required is dependent on the type of sport, for example footballers would require superior cardio respiratory fitness together with strength, power, speed, endurance and agility. By not developing these fitness components, the athlete can be at high risk of injury in which their bodies will not be able to cope with the demands of the game. Adequate warm ups and cool downs are important in enhancing performance and preventing injury. Warm ups have many physiological benefits that include the raising of heart rate, promoting efficient blood flow and increasing the range of movement. Warm and oxygen abundant muscles produce smoother contractions and hence reduce the risk of muscle tears and strains and also prevent soreness after. Cool downs assist returning the body to its pre-exercise state by reducing body temperature, circulation and respiratory rates to ensure that there is no excessive stress placed onto the body. Physical preparation is essential is preventing injury by considering factors that may place individuals at risk while participating in sports and activities. 3K2: Sports policy and the sports environment - rules of sports and activities - modified rules for children - matching of opponents e.g. growth and development, skill level - use of protective equipment - safe grounds, equipment and facilities Sports clubs, schools and government agencies involved in providing physical activity need to ensure safe environments in which athletes, coaches and spectators can participate safely. This involves the removal of hazards and the development of policies that engage in safety e.g. maintenance of playing areas and equipment, qualifications of coaches, first aid and code of conduct. These policies need to be written, protected and reviewed to ensure safety is always paramount. Rules of sports and activities The rules of a sport assist the flow of play and protect participants from injury. Rules are enforced by the referee to ensure fairness and safety within the game. In collision sports such a rugby, there is a considerable potential for injury. To protect the safety of players, policies are developed to illegalise movements such as the head high tackle. These rules are well defined to prevent dangerous activity and a range of penalties to punish the offence. Similar situations exist in other sports and activities, marathon runners are obliged to consume fluid during their event to avoid heat stroke. Through these measures, rules and policies are developed in order to protect the well-being of athletes and to uphold the integrity of the game. Modified rules for children Major modifications have been made to junior sports at most levels to accommodate the specific needs of children. Examples include: Lowering the backboard and ring in basketball to enhance the chance of successful shooting Modifying equipment size and shape Simplifying the rules, so children only require a basic understanding to participate Awarding recognition such as prizes to all teams These changes encourage children to take part and continue in physical activity. Children require modifications due to their stature and limited capabilities. These modifications recognise that they are still developing their skills, so factors such as equipment size, court dimensions, rules and the playing environment need to be considered. These add to their potential to learn and develop skills both safely and enjoyably. Matching of opponents The matching of opponents is a critical consideration to promote safety and enjoyment during a game. Opponents are generally matched according to age, however through the approach of sports medicine; other factors also need to be considered. Many injuries result from uneven matching where skills and physiques of opponents are incorrectly matched. To prevent these from happening, it is important to recognise that children grow and develop at different rates, while their ages are similar, children can have quite different physical strengths and capabilities. A grading system that encourages even competition not only reduces the risk of injury but also promotes enjoyment and enthusiasm. Use of protective equipment Protective equipment is essential for players in most team sports, they must be designed to provide adequate protection for the wearer as well as other players, allow freedom of movement and be comfortable. Protective equipment may absorb, disperse or deflect forces acting upon the body; it should be rigid, supportive and reliable. Examples of widely used equipment include mouthguards used in basketball, football, helmets in cricket and padding in hockey, football etc. Protective equipment must be regularly tested to maintain safety, equipment is only effective if designed and worn appropriately therefore coaches and sports officials must enforce policies to protect the well being of athletes. Safe grounds, equipment and facilities Grounds and facilities should be designed and maintained to provide a safe playing environment. Safe grounds are characterised by a level and firm playing surface free of obstruction, any likely dangers must be removed e.g. sprinkler heads, broken glass. Any fixtures e.g. goals, nets and posts should be well padded and anchored to the ground. The ground should also be well secured from spectators, positioned a safe distance from the fence. The area should also be well-lit. When the nature of the surface is changed by weather conditions, additional dangers need to be assessed for injury risks. Appropriate facilities should also be provided e.g. hygienic change rooms and a well stocked first aid room. All equipment should undergo regular maintenance and safety checks. Large fixtures such as goal posts should be securely anchored, stable and well padded. Equipment should also support the size of the user. 3K3: Environmental considerations - Thermoregulation (conduction, convection, radiation, evaporation) - Climatic conditions (temperature, humidity, rain, wind, altitude, pollution) - Guidelines for fluid intake - Acclimatisation Environmental conditions tend to change very quickly, placing extra demands on the body to adapt. Poor environmental conditions are inevitable and therefore careful planning is needed to ensure that the venue, time and duration of the activity is planned to ensure the well being of athletes. Thermoregulation is the mechanism by which the body maintains a relatively stable internal temperature of 37 degrees Celsius despite fluctuations in the ambient temperature. Thermoregulation, directed by the hypothalamus is essential to prevent hyperthermia (over-heating) and hypothermia (unable to retain heat) from occurring as both conditions can impede heavily on performance and well being of the athlete. The mechanisms that promote heat loss are convection, conduction, radiation and evaporation. Convection is the transfer of heat away from the skin by a moving medium e.g. air, wind. Conduction is the transfer of heat by contact with other objects e.g. icepacks and radiation is the removal of heat from infrared rays. The most effective and efficient mechanism in removing heat is evaporation; it is response by the body to sweat, evaporate and hence cool the body. Thermoregulation is essential to maintain metabolic efficiency, younger children experience greater problems with thermoregulation due to their under developed sweating mechanisms and are therefore more susceptible to heat stress and heat loss, extra measures are taken e.g. scheduling events at different times of the day and allocated breaks. Sports medicine recognises the importance of addressing thermoregulation for different athletes with different needs. Thermoregulation is highly dependent on climatic conditions, e.g. humidity, wind, rain and altitude. Humidity presents the greatest risks in high temperatures as it lessens the efficiency of the evaporation mechanism. When sweat develops on the surface of the skin, instead of evaporative cooling, it drips off the athlete due to an excess of moisture in the air. This is an extremely dangerous situation as they can suffer hyperthermia and also lose large amounts of water leading to dehydration. Wind and rain are conditions that promote hypothermia, jeopardising the body’s ability to retain heat. When body temperature drops below 37 degrees Celsius, the body activates heat conservation mechanisms, shivering (generating heat) and vasoconstriction (to decrease blood flow to the surface of skin). Cold and wet conditions also present hazards such as slippery grounds, and it also causes muscle stiffness, increasing the risk of injury. To combat these issues, coaches need to recommend appropriate clothing (lots of layers) and ensure adequate warm ups are taken. Fluid intake is a critical factor as thermoregulation depends on it, athletes should have a fluid replacement plan that matches their body’s requirements, duration, intensity and environmental conditions. A general fluid intake plan suggests that 500mLs for 30mins before competition and that 200-300mL of fluid should be consumed every 1520minutes during exercise. Sports drinks are recommended as they contain liquid carbohydrates and serve to both hydrate and energise. Acclimatisation is the process of developing physiological adaptations to different climatic conditions. Acclimatisation allows athlete’s to develop a tolerance to conditions such as altitude, heat, cold and humidity etc to minimise these effects on their performance. Acclimatisation can be achieved through exposure to training environment that mirrors the competition environment, e.g. at higher altitudes the air tends to be thinner, therefore to ensure that their cardiorespiratory systems are able to deal with the shortage of available oxygen, the haemoglobin in their blood needs to be more efficient in transporting oxygen. Generally acclimatisation to heat and humidity takes about 5-7 days, where as altitude acclimatisation takes 2-3 weeks. 3K4: Taping and bandaging - preventative taping - taping for isolation of injury - bandaging for immediate treatment of injury Taping and bandaging are used in sports to prevent injury and assist in injury treatment and rehabilitation. For taping and bandaging to be effective the person applying the tape must have knowledge of the nature of injury and physiology of the human body. Preventative taping Taping refers to the application of adhesive or non adhesive strapping to a joint area to protect, support or strengthen the joint during movement. Sports that require agility, speed, power and strength can place considerable stress on joints e.g. basketball, football, and netball. These sports demand explosive movements and frequent changes of direction, so joins periodically sustain levels of stress and can apply the risk of injury. Taping for isolation of injury One of the major aims of taping is to limit movement, or allow only limited movement. When a joint has been injured, to prevent additional damage and to promote successful recovery, taping can be used to isolate or immobilise the joint, assisting in the rehabilitation process. Bandaging for immediate treatment of injury The common uses of bandages for immediate treatment of injury: To control bleeding and prevent infection To apply pressure that will reduce swelling To immobilise and support an injured part. Bandages applied correctly can contribute significantly to the rehabilitation process following an injury. Sports Medicine – Focus Question D How is injury rehabilitation managed? 4K1: Rehabilitation procedures - Progressive mobilisation - Graduated exercise (stretching, conditioning, total body fitness) - Training - Use of heat and cold Rehabilitation is the process of restoring the athlete to the pre-injury state of physical fitness. It is important that a proper rehabilitation plan is followed through the various stages and that the injury is given adequate healing time before recommencing competition. Progressive mobilisation After RICER techniques are performed after the injury takes place, progressive mobilisation is essential. It involves gradually moving the injured area using light stretches and rotations. Progressive mobilisation helps the tissues to heal in the desired direction and minimise the amount of scar tissue. When injury is sustained, muscles and connective tissue will restrict the movement of that particular joint. Joint mobilisation is the freeing of hindered joints to allow a range of motion, it can be achieved through active exercises (performed by the athlete) or through passive exercises (manipulation of injured part by another person). Mobilisation should begin soon after injury because joint inactivity can increase the formation of scar tissue. Should not commence during the acute inflammatory stage – swelling etc. Circulation increased Relaxed Movements should be slow and progressive rather than sharp and rapid Movements should remain within a pain free range Graduated exercise STRETCHING Stretching exercises are beneficial to the recovery process as it restores and maintains flexibility in the injured site, reducing the formation of scar tissue to promote proper and effective healing. Flexibility can be restored through the use of slow static stretches and PNF stretching. The advantage of PNF stretching is that it also strengthens the area during the isometric contraction, it is also very safe. Stretching is gradually made more active, and is increased in time from about 5-10 seconds to 20-30 seconds and should be performed regularly within the pain free range. CONDITIONING Conditioning focuses on regaining the components of fitness through the use of adaptations to gradual increases in physical stress and to avoid the effects of reversibility. An effective conditioning process uses the overload principle to ensure that a greater load is progressively placed on the body. As swelling and pain lessens in the area a greater range of exercise involving pain free movements can be introduced. As strength is slowly regained, further resistance can be applied. This ensures that the effects of muscle atrophy are avoided. TOTAL BODY FITNESS Total body fitness is regaining the level of mental and physical fitness reached by the athlete before the injury occurred. The training program must progressively and gradually overload the muscle groups and energy systems so that the required adaptations are regained before competition is recommenced. Some adaptations include, muscle hypertrophy, increased elasticity of fibres, increase joint mobility, absence of all pain, full restoration of balance and co-ordination etc. Training An athlete who has completed the rehabilitation process is still not yet ready to return to competition. While the basic components of strength, flexibility and mobility have been restored, there is still a large risk of re-injury if an athlete were to return to competition. Important aspects of competition such as movement skills, specific game skills and coordination have not been re-established. In preparation for the physical and psychological demands of competition, the athlete must undertake active training. Training before recommencement of competition must be aimed at re-establishing all skills in an environment that mirrors the demands of the game. A graduated, progressive and specific program will allow the athlete to display skill proficiency and fluency of movement. Use of heat and cold Heat, cold and pressure are some of the forms of treatment used in sports rehabilitation. These modalities are delivered by ice, or by hot packs or by a number of machines. These treatments aim at reducing pain, muscle spasm and ischaemic (absent or reduced blood flow) responses of the body to injuries. Heat is used to increase circulation, decrease pain, relaxation, increased blood flow, reduced joint stiffness, enhanced inflammatory response due to an increase of healing fluids and blood to area, increased tissue healing. Heat is applied via heat packs, hydrotherapy and infrared lamps. The application of ice to an injury is called cryotherapy. The most common ways of applying cryotherapy during rehabilitation are through the use of icepacks, ice massage and ice immersion. The application of ice reduces pain, swelling, muscle spasm, and circulation. When used with rest, compression and elevation, cold treatment is especially effective in the treatment of swelling and pain associated with acute injuries. Cold should be applied at regular intervals during the first 24-48 hours following the injury, but not longer than 30minutes at a time. Care should be taken in the use of cryotherapy to avoid frostbite and other skin and nerve damage. 4K2: Return to play - Indicators of readiness (pain free, degree of mobility) - Monitoring progress (pre-test and post-test) - Psychological readiness - Specific warm up procedures - Return to play policies and procedures - Ethical considerations e.g. pressure to participate, use of pain killers Indicators of readiness Elasticity: new tissue has been stretched, promoting lengthways elasticity and resultant flexibility. Strength: new tissue is strong and able to support the body in stressful movements Mobility: athlete has gained full movement, particularly in terms of agility Pain free: injury is pain free during both light exercise and strenuous work Balance: the injured person is able to achieve balance An athlete returning from injury should be put through a sports specific test, some general skills that may be tested include sprinting, tackling, side stepping etc. For example a netballer returning from an ankle injury would be tested on their ability to sprint and agility through a variety of drills. Their results should be compared with previous test results. The athlete should also be monitored post training and testing to determine pain and degree of mobility. Monitoring progress (pre test and post test) To monitor progress, results from a pre-test taken before injury occurred could be compared to those of a post test taken after the injury was sustained. These can be achieved through visual observations, communication and use of video footage of the athlete. These will indicate whether the athlete has lost fitness components such as speed and agility. The tests need to incorporate sport specific movement patterns e.g. if knee ligaments damaged, then an Illinois agility test would be appropriate. Monitoring progress ensures that the injured area has returned to its normal functioning. Psychological readiness Physical readiness is not sufficient in itself to allow an athlete to return to play. Psychological preparedness needs to be considered as they reflect the athlete’s confidence to return. Coaches need to promote a supportive attitude to injured athletes reassuring them that there is no need to rush their recovery; this allows the injury to properly heal and confidence to be restored. By relieving the athlete of additional pressure on their psychological well being, athletes can recover quickly and return to play when it is safe to do so. Specific warm up procedures Athletes returning from injury must ensure they are fully warmed up and muscle groups have been properly stretched before training or playing a game. When returning from an injury, the warm up may need to be extended and more specific to the injured area, for example, a sprinter who has incurred a hamstring injury will need to additionally focus on stretching exercises to both quadriceps and hamstrings. This ensures that these muscle groups have been extended to a degree that will match the demands of the game. Return to play policies and procedures Sports clubs have a responsibility to ensure that policies and procedures are in place for players returning from an injury. Clubs have a duty of care to ensure athletes are fit to return to training and competition when they are injury free. For example, the Australia Rugby League recommends that if a player has suffered memory loss or loss of consciousness as a result of a head injury, they may not return to play for 1-2 weeks. Alternatively if the concussion was severe the player must not return within the month. These policies and procedures are enforced to protect the safety and well-being of athletes regarding their readiness to return to play. Ethical considerations PRESSURE TO PARTICIPATE For many injured athletes, especially those playing on an elite level, experience the pressure to participate. As a result of internal pressures such as a drive for success, fear or losing one’s position and sense of letting down the team, combined with external pressures such as financial pressures, sponsors, expectations place individuals under stress. These athletes who choose to return to play without adequate healing place themselves at risk of further complications. There are many ethical concerns surrounding the temptation and pressures placed on individuals affecting their well being and safety. USE OF PAINKILLERS Painkillers are taken to mask pain that would normally be present during the activity. The use of painkillers is attractive for athletes and for the sporting clubs who rely financially on their athletes to compete. With financial are various other pressures increasing, elite athletes may rely on painkiller use.
