Sports Medicine Summary How are sports injuries classified and managed?

Sports medicine is concerned with prevention, assessment, management of, and recovery from, sports injury to enable both professional and recreational sports people to return to their sport.

~Ways to classify sports injuries Direct injuries- external force is applied from outside to the body. Eg. Facial injuries

Indirect injuries- internal force occurs within the body. Eg. Muscle strains/tears, joint sprains

Overuse injuries- due to long periods of overuse. Eg. Tendonitis (tennis elbow), shin splints

Soft tissue injuries- occurs in the parts of the body that include the layers of skin, fat, muscles, ligaments and tendons. Eg. Tears, sprains, contusion (bruises), inflammatory responses, skin abrasions (grazes), blisters and calluses

Hard tissue injuries- fractures (a break in the bone) and dislocations (displacement of a bone at a joint) NB/ Any break in skin can be infected. Wound needs to be cleaned and dressed with sterile dressing. Seek medical aid if serious or needs tetanus injection

Managing soft tissue injuries R- rest; to reduce bleeding into the injury and prevent further injury I- ice; to reduce pain, blood flow, swelling, spasm, tissue demand for oxygen C- compression; decreases bleeding, reduces swelling E- elevation; decreases bleeding, reduces swelling, reduces throbbing R- referral; to understand the extend of the injury and to seek guidance in a rehabilitation program

Avoid immediate: Heat- increases blood flow and swelling Alcohol- increases swelling and dehydration Running- increases blood flow and causes further damage Massage- increases blood flow

Managing hard tissue injuries Immobilisation- use a splint, bandage or sound body part to support an injured body part and keep it from moving Medical treatment- as soon as possible Dislocations. Eg. Shoulders, fingers 1) DRABC 2) Immobilise area 3) Ice, elevate, bandage area 4) Seek medical attention

- 1 - Fractures. (Most fracture type injuries require medical attention, especially if there is deformity, uncontrolled bleeding, or if the casualty can not complete the TOTAPS regime) 1) DRABC 2) Control bleeding 3) Treat shock 4) Splint and bandage to immobilise 5) Seek medical attention

Assessment of injuries T- talk; talk to the player to find out what happened. Provides valuable information on nature of injury O- observe; look at the injury, look for obvious deformity or swelling. Compare two sides of the body T- touch; feel the injury gently for deformity or swelling, try to pinpoint the pain A- active movement; ask the player to perform a range of movements. If they can be done without pain, the assessment can continue P- passive movement; the assessor physically moves the joint using a range of movement aimed at identifying painful areas and any instability of the joint S- skills test; they are asked to perform a test required during the game. Eg. Side steps How does sports medicine address the demands of specific athletes? ~Children and young athletes

Medical conditions Asthma may be induced by exercise, but it can be controlled by medication, exercise choice and sufficient warm-up before starting physical activity. Warm-up and cool down should be gradual.

Diabetic children can experience hypoglycaemia (low blood sugar) as a result of over-exercising. If they show signs of a diabetic emergency such as dizziness, drowsiness, confusion, rapid breathing and pulse rate, blood sugar levels need to be raised. Exercise is considered necessary in management of diabetes. Exercise increases the utilization of sugar therefore a pre-game meal to raise blood sugar levels is needed. If exercise is protracted, hourly glucose supplementation such as a banana is also necessary.

Epilepsy, is a disruption of brain functions, causing a brief alteration to the levels of consciousness and resulting in seizures or fits. Though controlled by medication, a child may have an occasional seizure or fit in the form of a mild blackout which resembles day-dreaming for a time or a more serious seizure which involves convulsions and uncontrolled muscle spasms. Those present should not stop or hold down

- 2 - the child but rather clear away any dangers such as nearby furniture or objects to protect the child from injury. Place the child on one side to clear the airway and call an ambulance.

Overuse injuries include stress fractures caused by abnormal or unusual exercise or overtraining. Stressfractures generally affect the bones of the legs and are minor cracks in the bones which become painful and swollen if exercise continues before rest and recovery. Treatment includes immediate rest (4-8 weeks), Ice to reduce inflammation and possible anti-inflammatory medication.

Thermoregulation. Children_s body temperature regulation systems are not as well developed as adults and care should be taken, especially when exercising in hot or humid conditions, to see that they drink plenty of fluid and adapt activity to the climatic conditions.

Matching opponents for growth and skill levels should occur in competitive sports. Many children’s sports are modified by rules and equipment suited to the maturity levels of the young players. In certain sports, for safety reasons, young children should be matched according to size, not age. Eg. Basketball

Resistance training must be conducted by properly qualified instructors to avoid the risk of injury. Young athletes need to be careful of overtraining due to the risk of injury to the growth plates before fusion. Low resistance, high repetitions are safe. It should not be competitive and power and absolute strength.

~Adult and aged athletes Heart conditions. Gentle exercise is encouraged as rehabilitation after heart surgery but people need to be careful not to over do it. Fractures can result from falls due to lower bone density in older people. Physical activity strengthens bone density and coordination Flexibility exercises and gentle exercise classes with stretching can improve joint mobility in older People

~Female athletes May be affected by: Eating disorders, resulting from concerns about weight gain in activities where body image is of concern. Eg. Dance, gymnastics, synchronised swimming. It is important that trainers and coaches be better educated to detect signs of eating disorders and use nutrition experts and counsellors. They should also invite parents to training to ensure athletes are not pressured to meet unreasonable body size demands.

Iron deficiency causes Anaemia (abnormally low levels of haemoglobin, resulting in less oxygen being available to tissues, hence tiredness and fatigue). It may be experienced by those participating in endurance events, high impact sports, pregnant women and as a result of menstruation. 35 to 50 mg of iron per kg of body weight is needed and many females consume less therefore supplements may be taken to correct the imbalance. Too much iron is toxic, contributing to liver disease, diabetes, heart problems and joint damage.

- 3 - Bone density in women is affected by oestrogen hormone levels which decreases in menopause. Irregular menstruation patterns in female athletes or cessation of menstruation during training may cause increased bone loss. Bone lacking in calcium are susceptible to fractures and structural weakening. Long-term, loss of done density carries the risk of developing osteoporosis in later life. An adequate intake of calcium is essential for female athletes.

Pregnancy is a normal condition and athletes should be able to enjoy sport at some level throughout pregnancy unless there are complications. Physiological and anatomical changes during pregnancy will affect the female athlete_s performance. These include weight gain, loosening of joints, increase in resting heart rate, blood pressure changes and the need to adapt to the intensity of exercise to ensure the growing baby has a good supply of oxygen. Moderation is the key, in the cool of the day. Ensure adequate hydration to avoid thermal stress, which can affect foetal development.

Menstruation changes can occur in female athletes due to training demands. When menstruation stops for a few months in non-pregnant women it is termed amenorrhoea (usually from hard training and this has no long-term affects). The menarche, or the first menstruation, may be delayed in young girls who are training in sports such as gymnastics, running and swimming. Reducing training intensity and gaining some weight may reverse changes. Some athletes have established world records during menstruation so exercise does not need to be avoided, except in case of undue pain or cramping. What role do preventive actions play in enhancing the well being of the athletes? ~Physical preparation Sporting injuries can be prevented with adequate preparation such as:

Safe sporting movement, for example, players are taught how to slide safely into base in softball or baseball.

Flexibility. Muscles lose elasticity with time and age, so stretching is vital 4-5 times a week. The muscles need to be stretched beyond the range required in sport prior to performance. Stretching also needs to be sport specific Eg. A high jumper stretches all major muscle groups, but additional specific stretching for calf and thighs.

Endurance needs to be both cardiovascular and muscular for the prevention of sports injuries. More fatigue = slow reaction time, tight muscles, deterioration of mental focus, less absorption of external forces = more injuries.

Strength is essential to prevent injury. The demand for strength (eg. Pushing in a scrum) that has not been developed can lead to muscle and joint injuries in the form of sprains, strains, fractures and dislocations. Strength imbalances in opposing muscles, is also more likely to suffer an injury. Eg. Quadriceps strengthened, but hamstrings ignored leads to hamstring and knee ligament injuries.

- 4 - Skill and technique. Many injuries relate to poor skill or technique and might be the result of a single direct blow (eg. Head position when making a tackle in rugby) or repetitive minor impacts (eg. From poor running technique leading to sprains and muscle tears)

Requirements specific to the sport and for the protection of players have resulted in changes to the rules of sports to prevent injury, for example the banning of head high tackles, spear tackles. Rules need to be strictly enforced. Protective equipment is compulsory in some sports such as helmets in cycling.

Individual participant_s needs are considered with pre-screening before play to ensure players are fit to play and proper rehabilitation from injury has taken place.

Warm-up before play, stretching before, during and after play, and cool-down to prevent muscle soreness at the end of play, enables safe participation.

~Sports policy and the sports environment G- grounds and facilities; In preparing a ground for sports participation, considerations must be taken to improve safety such as: even, flat, non-slippery grounds/surfaces (no potholes), padded posts, checking for dangerous items (glass, syringes) and adequate matting (high jump, gymnastics). A- responsibilities of the club, school, sports administrator; These bodies must ensure safety and minimise risk of injury by following guidelines such as: player competes in a safe environment, competitions organised to challenge players, adequate supervision, high standards of sportsmanship are upheld, parents and supporters are not exerting unreasonable pressure M- modified rules for children; E- even competition; consequences of uneven competition are: large number of drop outs, high number of injuries and a lack of motivation. The problem with the current grading system is that the teams are graded on age, not size and all the best players are placed in one A-grade team and all the bad players put into the B-grade team. R- rules of sports and activities; rules are enforced to promote safety and are there to assist the flow of the play and protect participants from injury.

Protective equipment If a sport requires protective equipment it should be used correctly for safety. A- apparel and protective guards; for head, neck, eyes, body, teeth and feet, should be the best available, fit properly and be worn as recommended for the sport. Prevention is better than cure and the basic purposes of protective equipment is to absorb and disperse energy from a direct blow (eg. helmet), deflect a blow and protect against sharp instruments (eg. chest guard) and limit excessive movement (eg. studs in football boots and spikes used in athletics). Protective gear may sometimes increase the risk of injury such as footwear causing injury to other players, and ill-fitted protection gear such as mouth guards and pads. C- safe court and field design; such as enough room between courts, away from any danger (creeks, roads) and have enough necessary padding on such things as goal posts. Courts and fields shouldnot be constructed on uneven or shifting ground or have rough, harsh surfaces. E- safe playing equipment; must be checked regularly, maintained and used as recommended by the manufacturers. Helmets, gloves, mitts, the box, leg guards, safety bases and board release on snowboard are all example of safe playing equipment.

- 5 - Thermoregulation Body temperature is regulated by controlling the rate of heat production and heat loss. When heat loss equals heat production the body is said to be in a state of heat balance. If heat production is greater than heat loss, the body loses heat through: *Radiation as heat radiates from the skin to the environment *Conduction when heat is transferred to an object, such as a cool railing *Convection when air currents cause heat to be transferred to the air *Evaporation by sweating cools the skin and the blood is cooled.

Environmental conditions of heat, humidity, cold, wind and cold water affect the safety of participants. *Excess heat increased blood temperature blood vessels increase in size (Vasodilation, or vessel opens up) heat lost in vessels near the skin (redness in face, hands, feet) *Too little heat decrease in blood temperature blood vessels decrease in size (Vasoconstriction, or vessel closes) blood moves away from skin and hence, is retained in the body (blueness of hands, feet)

Individuals exercising or playing sport in hot and humid conditions are at risk of hyperthermia, or overheating of the body. Heat disorders include heat cramps, heat exhaustion, heat stroke, increased heart rate, dizziness and dehydration. Hypothermia is a condition which can be fatal. It occurs when the body is unable to maintain normal temperature regulation due to cold conditions experienced. Signs/symptoms of hypothermia include confusion, numbness, lower heart rate and unconsciousness.

Guidelines for exercising in heat and humidity *Drink water before, after and during exercise *Wear loose clothing *Adapt the time of day and the duration of the exercise to the outside temperature *If too hot, cancel the event or modify it to keep the participants safe Guidelines for safety in cold conditions *Wear warm and waterproof clothing *Take protective equipment such as umbrellas and gloves when going outside in uncertain weather *Treat hypothermia by gradually warming the person after removing wet clothing

Taping and bandaging Preventive taping and bandaging are used to prevent injuries and to support joints where some previous injury has occurred.

Taping for isolation of injury restricts movement for safety. For example support bandaging for the ankle, such as the stirrup strap, maintains the ankle in the normal position. Therapeutic taping is where taping is required so that the athlete can participate in body conditioning exercises to maintain fitness during recuperation.

Bandaging immediately after injury can reduce swelling and pain and help with the healing and is necessary using the RICER regime. Bandaging may be used to restrict bleeding.

- 6 - Taping the ankle for an inversion sprain. 1) Positioning 2) Anchors 3) Stirrups 4) Anchors 5) Figure sixes 6) Heel locks 7) Close down How is recovery from injury managed? ~Injury management procedure Before returning to sport after injury the sport person needs to recover fully.

Progressive mobilisation *Follow use of RICER. It is important that movement be restored ASAP. *Gradually extending range of movement of the injured part. This is continued until the injured part is fully functional

Stretching *Ensures healing without scarring as scarring shortens muscle and makes it prone to further injury *PNF is best where muscle is stretched and strengthened during safe movements

Conditioning *Adapting the body to a range of agility strength and power skills such as running, hitting, kicking to ensure area is fully functional. This must be pain free *Followed by game skills in a non-competitive situation

Total body fitness *Regaining level of mental and physical fitness reached prior to injury such as coordination, strength, confidence, mobility, elasticity of fibres and absence of pain *Program must be progressive and gradually overload muscle groups and energy systems

Training *Full training can now resume *Must be pain free *Should be involved in warm-up, conditioning skills, cool-down

Taping *During rehab, taping may be used to support the injured area and protect it from further damage especially knee and ankle injuries (due to constant change in direction) *Prophylactic taping develops confidence and provides physical support by restricting the degree of movement

Use of heat and cold *This has been controversial for years Generally-

- 7 - -Cold for anything up to 4 days following injury -Hot is not used for two or three days after injury depending on injury type and extent of damage

Cold applications Commonly used cold applications include: *Ice massage *Ice water immersion *Vapocoolant sprays

Heat applications Thermotherapy is the application of heat in various forms to the injury. When internal bleeding has stopped (about 48hrs after the injury), heat may be used to: *Increase elasticity to the new fibres during the stretching process *Reduce pain *Reduce stiffness *Increase blood flow *Reduce inflammation Heat energy is transmitted through radiation, convection and conduction. Commonly used methods for heat application include: *Moist heat packs *Whirlpool baths, where injury is immersed in small spa bath and massaged by the movement of the fluid *Contrast baths, where the water temperature is alternated every 5 mins between cold and hot. This increases local circulation by causing vasodilation and vasoconstriction of the capillaries in the injured area.

Specific programs *Some players require specialised programs in addition to general programs. Eg. Resistance training focusing on strength and endurance or aerobic work to increase power. *Developed by coach or trainer with the player to stretch, strengthen and mobilise the injured area in readiness to play

Return to play Indicators of readiness to return to play Measurable improvements in the injured area including: *Elasticity *Strength *Mobility *Pain free *Balance

Specific warm-up procedures *Returning players must ensure they are fully warmed up and stretched before training or a game *Warm-up needs to be more specific to the injured area. Eg. If sprinter has torn a hamstring

- 8 - additional stretching to quadriceps and hamstrings is recommended

Taping *It may be necessary to tape the injury for a period of time depending on the extent of damage, for extra protection and strength *Taping at this stage is preventative and also provide psychological support (confidence)

Monitoring progress *Results from pre-test taken before injury occurred could be compared to past-test *Has player lost fitness? Eg. Speed, agility *Tests need to be specific to injury. Eg. If knee ligaments were damaged, an agility test could be conducted (such as the Illinois agility test).

Progressive involvement *Return to play needs to be gradual to ensure that undone burden and fatigue is not placed on the injured area. *Gradual exposure to stress (Eg. frequent substitutions or playing in a lower grade) What ethical questions are raised by the increased use of sports medicine? Playing with injury raises ethical questions about the pressure to participate, the timing of return to sport, the role of the coach and sports practitioner in decision-making with the athlete. Sports clubs and associations need to be aware of the legal issue involved in the prevention of further injury to athletes. Ultimately the responsibility at present, rests with the sportsperson. If the athlete returns pre-maturely after injury, the injury might worsen and the necessary recovery time extended.

Internal pressures include: *Not letting the team down *Drive for success *Boredom *Fear of losing position in the team

External pressures include: *Pressures from other players/coach *Pressures from sponsors *Pressures from spectators *Financial pressures *Pressures from the media

Who should be responsible for deciding when an athlete competes after injury? And should athletes be allowed to use pain-killers in order to compete with an injury? In some sports, there are guidelines regarding a return to play/competition such as boxing, where if the boxer has a loss of consciousness (LOC) they are not permitted to return to competition for a month. No

- 9 - less than 3 months after the boxer_s second LOC is allowed and 12months after the boxer_s third LOC.

~Drug use Human Growth Hormone (HGH) Reasons for use: *Increases size, strength and power of muscles *Decreases body fat Health risks: *Increased risk of heart disease *Adverse, irreversible effects on growth *Acromegaly (enlarged hands, feet, face) *Cancer *Infertility

EPO (Erythropoietin) Reasons for use: *Stimulates productions of red blood cells *Increases oxygen carrying capacity *Used in endurance events Health risks: *Strokes *Heart attacks *Seizures *Blood clots (Thickens blood)

Anabolic steroids Reasons for use: *Synthetic derivative of testosterone *Anabolic effect (muscle building) *Commonly used in strength and power events Health risks: *Liver dysfunction *Cancer *Infertility *Shrinking of testes in males *Menstrual dysfunctions in females *Development of male secondary sex characteristics in females *Increased acne *Increased heart problems

Masking drugs Diuretics Reasons for use: *To lose weight by passing urine, in sports with weight categories. *To mask other drugs (particularly anabolic steroids)

- 10 - Health risks: *Kidney damage *Heart failure *Dehydration *Dizziness *Loss of coordination *Headaches

Alcohol Reasons for use: *To mask other drugs (particularly anabolic steroids) Health risks: *All the health risks of Diuretics, as well as *Aggression *Vomiting *Unconsciousness *Loss of inhibition

Drug Testing What is drug testing? *Involves the testing of urine in general, random athletes and blood tests for search of specific drugs in certain athletes (Eg. an endurance medallist will be tested for different drugs to a 100m medallist)

How are athletes selected? *Athletes are randomly selected in or out of competition *Notified of the requirements by phone, in person or by letter *Once notified, an athlete is escorted by a chaperone to a private room where the procedure is explained and a urine sample is taken. *Sample is divided and placed in 2 containers marked A and B and then the paper work is competed by the athlete

Must an athlete comply with testing? *All athletes must comply or are deemed positive *It is the responsibility of the athlete to know what is banned and to comply

What happens if test is positive? *If sample A is positive, sample B is tested and the athlete and appropriate sporting organization is informed of the result of sample B *Only when both A and B is positive that action is taken *The ban period for athletes found positive varies on the sport, past history and the level of the competition (eg. regional championships or Olympic games). A 4-year ban for an Olympic gymnast is the same as a ban for life as they will no longer be at their peak stage in 4 years.

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