Sports Injuries

More than 100 million sports injuries are treated each year worldwide. The principles of sports medicine can be applied to the treatment of many musculoskeletal injuries, which resemble sports injuries but have different causes. For ex-ample, tennis elbow can be caused by carrying a suitcase, turning a screw, or opening a stuck door, and runner's knee can be caused by excessive in-ward rolling of the foot (pronation) while walking.

Causes

Sports injuries are caused by faulty training methods, structural abnormalities that stress certain parts of the body more than others, and weak-ness of muscles, tendons, and ligaments. Many of these injuries are caused by chronic wear and tear, which results from repetitive motion stressing susceptible tissue.

Faulty Training Methods

The most common cause of muscle and joint injuries is faulty training methods: The exerciser doesn't allow for adequate recovery after a workout or doesn't stop exercising when pain develops. Everytime muscles are stressed by an intensive workout, some muscle fibers are injured and others use up their available energy, which has been stored as the carbohydrate glycogen. More than 2 days are required for fibers to heal and glycogen to be replaced. Because only uninjured and adequately nourished fibers function properly, closely spaced, intensive workouts eventually require comparable work from fewer healthy fibers, increasing the likelihood of injury. Consequently, allowing at least 2 days between intensive work-outs or alternating workouts that stress different parts of the body can help prevent chronic injury.

Most training programs alternate a hard work-out one day with rest or an easy workout the next. For example, many weight lifters alternate a hard workout on one day with no workout the next. A runner may run 5-minute miles one day and 6- to 8-minute miles the next. If an athlete trains twice a day, each hard workout should be followed by at least three easy ones. Only swimmers can perform both a hard and an easy work-out every day without injury. The buoyancy of the water probably helps protect therir muscles and joints.

Pain, which precedes most wear-and-tear injuries, first occurs when a limited number of muscle or tendon fibers start to tear. Stopping exercise at the first sign of pain limits the injury to these fibers, resulting in a quicker recovery. Continuing to exercise with pain tears more fibers, extending the damage and delaying recovery.

Structural Abnormalities

Structural abnormalities can make a person susceptible to a sports injury by stressing parts of the body unevenly For example, when the legs are unequal in length, greater force is placed on the hip and knee of the longer leg. Habitually running along the sides of banked roads has the same effect; repeatedly hitting the slightly higher surface increases the risk of pain or injury on that side. A person who has an exaggerated curve in the spine may have back pain when swinging a baseball bat. In general, the pain disappears when the activity is stopped but recurs each time the same exercise intensity is reached.

The biomechanical factor that causes most foot, leg, and hip injuries is excessive pronation-an inward rolling of the feet after they strike the ground. Some degree of pronation is normal and prevents injuries by helping distribute the foot's striking force throughout the foot. However, excessive pronation can cause foot, knee, and leg pain. In people with excessive pronation, the ankles are so flexible that the arches of the feet touch the ground during walking or running, giving the appearance of flatfeet. A runner with excessive pronation may have knee pain when running long distances.

The opposite problem-too little pronation-can occur in people who have rigid ankles. In these people, the foot appears to have a very high arch and doesn't absorb shock well, increasing the risk of developing small cracks in the bones (stress fractures) of the feet and legs.

Muscle, Tendon, and Ligament Weakness

Muscles, tendons, and ligaments tear when subjected to forces greater than their inherent strength. For example, they may be injured if they're too weak or tight for the exercise being attempted. Joint are more prone to injury when the muscles and ligaments that support them are weak, as they are after a sprain. Bones weakened by osteoporosis may fracture easily.

Strengthening exercise help prevent injuries. Regular exercise neither enlarges nor strengthens muscles significantly. The only way to strengthen muscles is to exercise against progressively greater resistance, as in performing a sport more intensely, lifting progressively heavier weights, or using special strength training machines. Rehabilitation exercises to strengthen healed muscles and tendons are usually done by lifting or pressing against resistance, in sets of 8 to 12 repetitions, no more frequently than every other day.

Diagnosis

To diagnose a sports or other musculoskeletal injury, a doctor asks when and how the injury happened and what recreational and occupational activities the person has recently or routinely been engaged in. The doctor also examines the injured area. The person may be referred to a specialist for further testing. Diagnostic tests may include x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), arthroscopy (viewing the injured joint through a small scope inserted into the joint), electromy-ography, and computer-aided testing of muscle and joint function.

Prevention

Warming up before beginning strenuous exercise helps prevent injuries. Exercising at a relaxed pace for 3 to 10 minutes warms the muscles enough to make them more pliable and resistant to injury. This active method of warming up pre-pares muscles for strenuous exercise more effectively than passive methods such as warm water, heating pads, ultrasound, or an infrared lamp. Passive methods don't increase blood circulation significantly.

Cooling down-gradually slowing down before stopping exercise-prevents dizziness by keeping blood flowing. When strenuous exercise is stopped abruptly, blood may collect (pool) in the leg veins, temporarily reducing the flow of blood to the head. The result may be dizziness and even fainting. Cooling down also helps remove waste products such as lactic acid from the muscles, but it doesn't seem to prevent next-day muscle soreness, which is caused by damaged muscle fibers.

Stretching exercises don't seem to prevent in-juries, but they do lengthen muscles so they can contract more effectively and perform better. To avoid damaging muscles when stretching, a person should stretch after warming up or exercising, and each stretch should be comfortable enough to hold for a count of 10.

Shoe inserts (orthotics) can often correct foot problems such as pronation. The inserts, which may be flexible, semirigid, or rigid and may vary in length, should be fitted into appropriate running shoes. Good running shoes have a rigid heel counter (the back part of the shoe that surrounds the heel) to control movement of the back of the foot, a support across the instep (saddle) to pre-vent excessive pronation, and a padded opening (collar) to support the ankle. The shoe must have adequate space for the insert. Orthotics usually reduce the shoe's width by one letter size: For example, a D width shoe with an orthotic be-comes a C width.

Treatment

Immediate treatment for almost all sports injuries consists of rest, ice, compression, and elevation (RICE). The injured part is rested immediately to minimize internal bleeding and swelling and to prevent the injury from becommg worse. Ice causes blood vessels to constrict helping limit inflammation and reduce pain. Wrapping the injured part with, tape or an elastic bandage (compression) and raising the injured part above the heart (elevation) help limits welling. A commercial ice pack or a bag of crushed or chipped ice - which conforms to body contours better than ice cubes-can be placed on a towel over the injured part for 10 minutes. An elastic bandage can be wrapped loosely around the ice bag and the injured part. The injured part is kept elevated, but the ice is removed for 10 minutes, then reapplied for 10 minutes over a period of 1 to 1½ hours. This process can be repeated several times during the first 24 hours.

Ice reduces pain and swelling in several ways. The injured part swells because fluid leaks from blood vessels. By causing the blood vessels to constrict, cold reduces their tendency to leak, thus restricting the amount of fluid and swelling in the injured part. Lowering the temperature of the skin over the injury can reduce pain and muscle spasms. It also limits tissue destruction by slowing cellular processes.

Applying ice for too long, however, can damage tissue. The skin reacts reflexively when it reaches a low temperature (around 59° F.) by widening blood vessels in the area. The skin turns red, feels hot and itchy, and may hurt. These effects usually occur 9 to 16 minutes after the ice is applied and subside about 4 to 8 minutes after the ice has been removed. Therefore, the ice should be removed when these effects occur or after 10 minutes. whichever comes first, but it can be reapplied 10 minutes after removal.

Injections of corticosteroids into an injured joint or the surrounding tissue relieve pain, re-duce swelling, and can sometimes be a useful addition to rest. However, these injections can delay healing, increase the risk of tendon and cartilage damage, and enable a person to use an injured joint before it's fully healed, perhaps worsening the injury.

Physical therapists may incorporate heat, cold, electricity, sound waves, traction, or exercising in water into a treatment plan in addition to therapeutic exercises. Special shoe inserts or other orthotics may be recommended. How long physical therapy is needed depends on the severity and complexity of the injury.

The activity or sport that caused the injury should be avoided until the injury has healed. Substituting activities that don't stress the injured part is preferable to abstaining from all physical activity because complete inactivity causes muscles to lose mass, strength, and en-durance. For example, a week of rest requires at least 2 weeks of exercise to return to the level of fitness before the injury. Substitute activities include bicycling, swimming, skiing, and rowing when the lower leg or foot is injured; jogging in place or on a trampoline, swimming, and rowing when the upper leg is injured; bicycling and swimming when the lower back is injured; and jogging, skating, and skiing when the shoulder or arm is injured.

Common Sports Injuries

Common sports injuries include stress fractures, shin splints, tendinitis, runner's knee. ham-string injuries, weight lifter's back, tennis elbow. head injuries, and foot injuries. They can be caused by many different activities.

Stress Fractures of the Foot

Stress fractures are small cracks in bones that often develop from chronic, excessive impact.

In runners, the bones of the midfoot (metatarsals) are especially prone to these fractures. The bones most likely to fracture are the metatarsal bones of the middle three toes. The metatarsal bone of the big toe is relatively immune to injury because of its strength and larger size, and the metatarsal bone of the little toe is usually protected because the greatest force from pushing off (toeing off) is exerted on the big toe and the one next to it.

Risk factors for stress fractures in the foot include high arches, running shoes with inadequate shock absorption, and a sudden increase in the intensity or amount of exercise. Postmenopausal women may be particularly susceptible to stress fractures because of osteoporosis.

The primary symptom is pain in the front part of the foot, usually during a long or intense work-out. At first, the pain disappears within seconds of stopping exercise.

If workouts are continued, however, the pain returns earlier in the workout and lasts longer after stopping exercise. Ultimately, severe pain may make running impossible, and pain may persist even during rest. The area around the fracture may swell.

A doctor can often make the diagnosis from a history of the symptoms and an examination of the foot. The fracture site hurts when touched. Stress fractures are so fine that x-rays often can't detect them immediately, but they can detect the tissue (callus) that forms around the broken bone 2 or 3 weeks after the injury, as the bone heals. A bone scan can confirm the diagnosis earlier but is rarely needed.

A person should not run until the stress fracture has healed, but other exercises can be substituted. After the fracture has healed, wearing athletic shoes with adequate shock-absorbing support and running on grass or other soft surfaces can help prevent a recurrence. A cast is rarely needed. When used, it's removed after a week or two to prevent the muscles from becoming weak. Healing generally takes 3 to 12 weeks but may take longer in the elderly or infirm.

Shin Splints

A shin splint is pain resulting from damage to the muscles along the shin.

The usual cause is long-standing, repeated stress to the lower leg. Two groups of muscles in the shin are susceptible to shin splints. The location of the pain depends on which group is affected.

Anterolateral shin splints affect the muscles in the front (anterior) and outside (lateral) parts of the shin. This type of injury results from a natural imbalance in the size of opposing muscles. The shin muscles pull the foot up, and the larger and stronger calf muscles pull the foot down each time the heel touches the ground during walking or running. The calf muscles exert so much force that they can injure the shin muscles.

The main symptom of anterolateral shin splints is pain along the front and outside of the shin. At first, the pain is felt only immediately after the heel strikes the ground during running. If running is continued, the pain occurs throughout each step, eventually becoming constant. Usually by the time the person sees a doctor, the shin hurts when touched.

To allow this type of shin splint to heal, the runner must stop running temporarily and do other kinds of exercise. Exercises to stretch the calf muscles are helpful. Once the shin muscles start to heal, exercises to strengthen them, such as the bucket-handle exercise, can be done in 3 sets of 10 every other day.

Posteromedial shin splints affect the muscles in the back (posterior) and inner (medial) parts of the shin, which are responsible for lifting the heel just before the toes push off. This type of shin splint often results from running on banked tracks or crowned roads and can be worsened by rolling the feet inward excessively or by wearing running shoes that don't adequately prevent such rolling.

The pain produced by this type of shin splint usually starts along the inside of the lower leg, about 1 to 8 inches above the ankle, and worsens when a runner rises up on the toes or rolls the ankle in. If the person continues to run, the pain moves forward, affecting the inner ankle, and may extend up the shin to within 2 to 4 inches of the knee. The severity of the pain increases as the shin splints progress. At first, only the muscle tendons are inflamed and painful, but if the per-son persists in running, the muscles themselves can be affected. Eventually, tension on the in-flamed tendon can actually pull it from its attachment to bone, causing bleeding and further inflammation. Sometimes the part of the shinbone attached to the tendon is torn away.

The primary treatment is to stop running and do other types of exercise until running is no longer painful. Running shoes with a rigid heel counter (the back part of the shoe) and special arch supports can keep the foot from rolling in excessively. Avoiding running on banked surfaces can help prevent shin splints from recurring. Exercises to strengthen the injured muscles are useful. For severe cases in which a part of the shin-bone has been torn away, treatment may include surgery to reattach it. Afterward, the person must not run for along time. An experimental treatment consisting of calcitonin (a hormone that builds bone) injected daily or alendronate (a drug that slows bone loss) given by mouth has healed some shin splints that were unresponsive to other measures. Sometimes none of the available treatments are effective, and the runner must abandon running permanently.

Popliteus Tendinitis

Popliteus tendinitis is a tearin the popliteus tendon, which extends from the outer surface of the bottom of the thighbone (femur) diagonally across the hack of the knee to the inner side of the top of the shin-bone (tibia).

The popliteus tendon prevents the lower leg from twisting outward during running. Excessive inward rolling of the feet (pronation), as well as running downhill, tends to put excessive stress on this tendon, which can tear it.

Pain and soreness, particularly when running downhill, develop along the outside of the knee. A person shouldn't run until the area is free of pain and shouldn't run downhill for at least 3 weeks after resuming running. Bicycling is a good alternative exercise during healing. Shoe inserts, especially a triangular wedge (varus wedge) placed in front of the heel, can help keep the foot from rolling inward.

Achilles Tendinitis

Achilles tendinitis is an inflammation of the Achilles tendon, the tough band extending from the calf muscles to the heel.

The calf muscles and the Achilles tendon lower the forefoot after the heel touches the ground and raise the heel as the toes push off just before stepping to the other foot.

Achilles tendinitis occurs when stresses placed on the tendon are greater than the tendon's strength. Running downhill places extra stress on the Achilles tendon because the forefoot has farther to go before touching the ground. Running uphill also stresses this tendon because the calf muscles must exert greater force to raise the heel as the toes push off. A soft heel counter (the back part of the shoe that surrounds the heel) allows excessive movement of the heel, stressing the Achilles tendon unevenly and increasing the like-lihood that it will tear. Stiff-soled shoes that don't bend where the toes join the foot place great stress on the Achilles tendon just before the toes push off.

Various biomechanical factors predispose this tendon to injury. They include the excessive in-ward rolling of the feet (pronation), the habit of landing too far back on the heel (checking the sole of the running shoe can show where the heel is most worn), bowed legs, tight hamstring and calf muscles, high arches, tight Achilles tendons, and heel deformities.

Pain, the major symptom, is usually most severe when a person starts to move after sitting or lying down or starts to run or jog. It's often relieved by continuing to walk or run despite the pain and stiffness. The Achilles tendon is en-closed in a protective sheath; between the tendon and its sheath is a thin layer of fat, which enables the tendon to move freely. When the tendon is injured, scars form between it and its sheath, causing the tendon to pull on the sheath with each movement. That's why movement is painful. Continuing to walk or run relieves the pain because it increases the temperature of the sheath, making it more pliable, so that the tendon can move more freely. Usually, pressing on the tendon also causes pain.

If the person ignores the pain and continues to run, rigid scar tissue replaces the elastic tendon, and the tendon will always hurt during exercise, with no chance of a cure.

Refraining from running and pedaling a bicycle as long as the pain persists is an important part of treatment. Other measures depend on the probable cause or predisposing conditions and include wearing shoes with flexible soles and placing inserts in running shoes to reduce tension on the tendon and stabilize the heel. Exercises to stretch the hamstring muscles can be started as soon as they can be done without pain. Exercises to strengthen the Achilles tendon, such as toe raises, are helpful.

After running is resumed, the person shouldn't run uphill or downhill at a fast pace until the tendon is fully healed-which can be weeks to years later.

Runner's Knee

Runner's knee (patellofemoral stress syndrome) is a condition in which the kneecap (patella) rubs against the end of the thighbone (femur) when the knee moues.

The kneecap is a circular bone that's attached to ligaments and tendons around the knee. The kneecap normally moves up or down slightly without touching the thighbone during running.

Runner's knee may be caused by a structural defect, such as a kneecap located too high in the knee joint (patella alta), or tight hamstrings, tight Achilles tendons, and weak thigh muscles-which normally help stabilize the knee. The most common treatable cause is excessive inward rolling of the feet (pronation) when walking or running while the front thigh muscles (quadriceps) pull the kneecap outward. Together, these forces cause the kneecap to rub against the end of the thighbone.

Pain and sometimes swelling usually start during running and are concentrated on the under-surface of the kneecap. At first, only running downhill is painful, but later any running and eventually even other leg movements, particularly walking down steps, are painful.

Refraining from running until it can be done without pain is important. Other exercises, such as riding a bicycle (if not painful), rowing, and swimming, can be continued to maintain physical fitness. Exercises to stretch the muscles in the back (hamstrings) and front (quadriceps) of the thigh and to strengthen the vastus medialis, an inner thigh muscle that pulls the kneecap inward, are helpful. Commercially available arch supports placed in both exercise and street shoes may help. Sometimes, shoe inserts have to be custom-made.

Hamstring Injury

A hamstring injury (posteriorfemoral muscle strain, hamstring tear) is any injury to the hamstring muscles, the muscles in the back of the thigh.

The hamstrings, which straighten the hip and bend the knee, are weaker than the opposing quadriceps (muscles in the front of the thigh). If the hamstrings are not at least 60 percent as strong as the quadriceps, the quadriceps over-power and injure them. A hamstring injury usually causes sudden pain in the back of the thigh when the hamstrings are contracted suddenly and violently.

Immediate treatment includes rest, ice, compression, and elevation. A person shouldn't run or jump but may jog in place, row, or swim-unless these activities cause pain-while the muscle heals. After healing begins, exercises to strengthen the hamstrings can help prevent a recurrence.

Weight Lifter's Back

Weight lifters back (lumbar strain) is an injury to the tendons and muscles of the lower back causing muscle spasms and soreness.

Any great force can tear the muscles and ten-dons of the lower back (the lumbar region). This type of injury is common in sports that require pushing or pulling against great resistance, such as snatching a heavy weight from the ground in weight lifting or pushing against an opposing line-man in football. It also occurs in sports that re-quire sudden twisting of the back: turning to dribble after a rebound in basketball, swinging a bat in baseball, and swinging a club in golf.

Risk factors for a lower back injury include an exaggerated curve of the lower spine, a pelvis (hipbone) that tilts forward, inflexible or weak back muscles, weak abdominal muscles, and tight, inflexible hamstrings. The back is also prone to injury when the spine is weakened by arthritis, misaligned vertebrae, slipped or ruptured disks, or a spinal bone tumor.

A lower back injury usually causes sudden pain in the lower back during twisting, pushing, or pulling. At first, the pain isn't severe enough to pre-vent further exercise. However, the torn muscle or tendon continues to bleed and swell, and 2 or 3 hours later, it goes into spasm, causing severe pain. Because muscle spasms can be aggravated by virtually any back movement, a person usually prefers to remain still, often curled up in the fetal position. The lower back may be sore when touched and may feel worse when the person bends forward.

As soon as possible after the injury, the person should rest and apply ice and compression to the sore back. Exercises to strengthen the abdominal muscles, which help stabilize the back, and to stretch and strengthen the back muscles are beneficial after healing begins. A rowing machine is excellent for strengthening the back if using it isn't painful.

An exaggerated curve of the lower spine, which tends to put additional stress on the muscles sup-porting the lower back, is determined largely by the tilt of the pelvis. So an exaggerated curve can be decreased with a variety of exercises that tilt the top of the pelvis backward to a more normal position. Such exercises include strengthening the abdominal muscles (to shorten them) and stretching the thigh muscles (to lengthen them). Wearing a weight-lifting belt may help prevent injury to the back.

Backhand Tennis Elbow

Backhand tennis elbow (lateral epicondylitis) is damage to the tendons that bend the wrist backward away from the palm, causingpain on the outer, back side of the forearm.

The forearm muscles that are attached to the outer part of the elbow become sore when excessive stress is placed on the point of attachment. Backhand tennis elbow is most often evident during a backhand return. The force of the racket hitting the ball can damage the tendons as they roll over the end of the elbow. Factors that in-crease the chances of developing backhand tennis elbow include using improper backhand strokes, having weak shoulder and wrist muscles, playing with a racket that's too tightly strung or too short, hitting the ball off center on the racket, and hitting heavy, wet balls.

The first symptom is pain during a backhand stroke or other similar repetitive movements. Pain is felt along the outer, back side of the elbow and forearm on the same side as the thumb when the hand is by the side with the thumb away from the body. Continuing to play can extend the area of pain from the elbow down to the wrist and result in pain even at rest.

The elbow hurts when a person places the arm and hand palm down on a table and tries to raise the hand against resistance by bending the wrist.

Treatment consists of avoiding any exercise that produces pain. Exercises that don't use the wrist primarily, such as jogging, cycling, or basketball, or even racquetball or squash-in which the ball hits the racket with less force than in tennis-can be substituted to maintain physical fitness.

As the injury heals, strengthening exercises can be started. Generally, all the muscles that bend and straighten the wrist should be strengthened.

Forehand Tennis Elbow

Forehand tennis elbow (baseball elbow, suitcase elbow, medial epicondylitis) is damage to the tendons that bend the wrist toward the palm, causing pain on the palm side of the forearm from the elbow toward the wrist.

This injury is caused by bending the wrist to-ward the palm with excessive force. Factors that produce such force include having weak shoulder or hand muscles; serving with great force in tennis; using a spin serve; hitting heavy wet balls; using a racket that is too heavy, has a grip that's too small, or has strings that are too tight; pitching a baseball; throwing a javelin; and carrying a heavy suitcase. Continuing to exercise with pain can pull the tendons from the bone, causing bleeding.

The main symptom is pain along the palm side of the elbow and forearm on the same side as the thumb when bending the wrist toward the palm against resistance or when squeezing a hard rubber ball. To confirm the diagnosis, a doctor asks the person to sit in a chair with the injured arm resting on a table, palm up. The doctor holds the wrist down and asks the person to raise the hand by bending the wrist. A person who has forehand tennis elbow feels pain at the elbow.

The person shouldn't engage in any activity that causes pain when the wrist is bent toward the palm or turned so that the little finger is next to the body. After the injury has healed, a tennis player should strengthen the wrist and shoulder muscles, as well as the injured muscles.

Rotator Cuff Tendinitis

Rotator cuff tendinitis (swimmer's shoulder, tennis shoulder, pitcher's shoulder, shoulder impingement syndrome) is a tearing and swelling of the rotator cuff (the muscles and tendons that hold the upper arm in the shoulder joint).

These tendons are often injured in sports that require the arm to be moved over the head repeatedly, such as pitching in baseball. lifting heavy weights over the shoulder, serving the ball in racket sports, and swimming freestyle, butter-fly, or backstroke. Repeatedly moving the arm over the head causes the top of the arm bone to rub against part of the shoulder joint and its tendons, tearing individual fibers.

If the movement is continued despite the pain, the tendon can tear or actually pull off part of the bone.

Shoulder pain is the main symptom. Initially, the pain occurs only during activities that require lifting the arm over the head and forcibly bringing it forward. Later, pain can occur even when the arm is moved forward to shake hands. Usually, pushing objects away is painful, but pulling them in toward the body isn't.

The diagnosis is made when specific movements, especially raising the arm above the shoulder, cause pain and soreness. Sometimes arthrograms (x-rays taken after a substance visible on x-rays is injected into the joint) can detect complete tears of the rotator cuff tendon, but they usually aren't sensitive enough to detect partial tears.

Treatment consists of resting the injured ten-dons and strengthening the shoulder. Exercises that involve pushing something away or raising the elbows over the shoulder should be avoided.

However, upright rowing with free weights (by bending, not raising, the elbows) and downward lat pulls on a weight machine, which exercise the latissimus muscle in the back and shoulders, can be continued if they aren't painful. Surgery is sometimes needed when the injury is particularly severe, the tendon is completely torn, or the injury doesn't heal within a year.

Submitted By
H. R. Schumacher Md.

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