Cover Page > Croat Med J. 2007;48:281-8 Injuries in Water Polo Water polo originated in mid-19th century Eng- head and facial injuries (Figure 1). Sometimes, be- land and Scotland as an aquatic form of rugby foot- nign head injury can quickly deteriorate into a ball (1). Players used “pulu,” an inflated, vulcanized life-threatening condition and it is critical to en- rubber ball imported from India, pronounced sure maintenance of a proper airway in short time. “polo.” The game became known as water polo Water polo is unique because the physician or the and that name has been used ever since. Water coach must rely on other players to bring the in- polo first appeared in modern Olympics in Paris jured athlete to the pool side for evaluation. The in 1900, making it the earliest and longest-running most common types of injuries are facial lacera- olympic team competition. It has been traditional- tions, especially of the supraorbital region, requir- ly dominated by Europeans – Hungary, Spain, It- ing immediate treatment. Direct contact with an- aly, Croatia, Russia, Greece, and Serbia, but in the other player carries sufficient force to fracture the last decades the popularity of water polo has been thinner bones of the face. Fractures of the facial constantly growing in the USA, Australia, Canada, bones represent severe head and face injuries, and and Asia. immediate medical evaluation and x-ray assessment The modern game of water polo is a unique com- are necessary. In all facial or head injuries, players bination of swimming, throwing, and martial arts. must be closely monitored for signs of disorienta- Physiologically, it is extremely demanding, because it tion, poor balance, and coordination. Also, the pa- is comprised of intense burst activity of less than 15- tient must be awakened at regular intervals during second duration, followed by lower intensity inter- the night for the first 24 hours (5). vals of less than 20 seconds. Water polo is becoming more physical than ever (2). This results in a number Swimmer’s ear (otitis externa) of typical acute traumatic events such as contusions, Otitis externa is an inflammatory process of the ex- lacerations, sprains, dislocations, or fractures (3). On ternal auditory canal. It is so common among peo- the other hand, vigorous training with numerous ple who spend many hours in water that it has be- repetitions of ball throws, swims, or kicks may result in overuse injuries (4). This review covers, in system- atical fashion, the most important acute and overuse injuries in water polo by analyzing four different re- gions of the body: head, spine, upper extremities, and lower extremities. Head injuries Facial injuries Close contact among water polo players and high Figure 1. Close contact between players may result in different injuries ball velocities of 60-70 km/h frequently cause of the head, face, and hand. www.cmj.hr 281 Croat Med J 2007;48:xxx come known as the swimmer’s ear (6). The most Blow-out fracture of the orbita. Blow-out frac- common precipitant of the swimmer’s ear is ex- ture of the orbita is the result from a direct trau- cessive moisture that removes cerumen and in- ma caused by a fist or a ball. Compression of the creases pH of the external auditory canal, which globe and orbital contents produces a fracture in provides a good setting for bacterial growth (7). the weakest part of the orbita, the orbital floor. Thorough hygiene of the auditory canal is es- Contents of the orbita may herniate through sential for diagnosis and treatment. In addition, the defect. The patient typically presents with acidification with a topical solution of 2% acetic a periorbital hematoma, protruding or sunken or boric acid, combined with hydrocortisone for eye, double vision on upward gaze, and numb- inflammation is an effective treatment in most ness of the cheek. A detailed examination of the cases and, when used after exposure to moisture, eye must be performed to exclude intraocular is an excellent prophylactic. injuries. Surgery may be required to release the trapped muscle and repair the bony defect. Trauma to the ear drum Traumatic perforation of the ear drum is unfor- Spine injuries tunately a fairly common injury in water polo (8). The injury is the result of a slap on the side of Due to the fact that many anatomical structures the head with a cupped palm. This causes a dra- in the spine region may be the source of pain, it matic rise in pressure in the canal. The increased is often very difficult for a clinician to determine pressure causes rupturing and development of a the exact cause (5). hole in the tympanic membrane. In most of the Repetitive cervical spine rotation required for cases, this injury will heal without any significant breathing in freestyle swimming often produces impairment, but during the healing phase players neck pain in water polo players. A relatively com- should be kept out of water (9). If this is not ac- mon injury that can be extremely painful for the ceptable due to necessity of training or competi- player is acute wry neck. It is characterized by a tion, swimming may be allowed with molded ear sudden onset of sharp neck pain with deformity plug and a bathing cap. and limitation of movement. It occurs either af- ter a sudden, quick movement or on waking. Eye injuries After a direct blow from an opponent player, The most frequent eye injuries in water polo can be acute acceleration/deceleration injury to the cer- roughly divided into three main categories (10,11). vical spine can occur. Acute cervical nerve root Corneal abrasions. One of the most frequent is characterized by moderate to severe arm pain injuries to the eye occurs as a result of a scratch (12). Neck pain may or may not be a feature. The from either a fingernail or foreign body. The treat- pain is aggravated by the movements of the cervi- ment of corneal abrasions includes the instillation cal spine. There may be associated sensory symp- of antibiotic eye drops and padding of the eye. toms. In older athletes or those who had previ- Hyphema. Bleeding into the anterior cham- ously suffered trauma to the neck, osteoarthritis ber of the eye results from ruptured iris vessels may develop, particularly affecting the apophy- and may be visible on slit lamp examination. The seal joints. Headache, shoulder, and upper arm aim of the treatment is to prevent further bleed- pain are often associated with neck pain, which is ing, which may in turn result in uncontrollable very important in differential diagnosis. glaucoma or blood staining of the cornea. The Low back pain is a common symptom in wa- patient needs to rest in bed while the hemor- ter polo players because the amount of rotational rhage clears, usually 3 to 5 days. forces is significant during throwing and passing 282 Cover Page the ball (13). Any of the pain-producing struc- needs to be immobilized in a neutral position tures of the lumbar spine may cause low back and flexion and extension movements should be pain, but the intervertebral discs and the apoph- particularly avoided. yseal joints are the most common causes (14). With low back pain of lengthy duration, a num- Upper extremity injuries ber of factors will contribute to the overall clin- Shoulder trauma ical picture. These may include abnormalities of the ligaments of the intervertebral joints, mus- Water polo players are also at risk for traumatic cles and fascia, as well as neural structures. Low dislocations and subluxations of the glenohumer- back pain is usually associated with hypomobil- al and the acromioclavicular joints from contact ity of one or more intervertebral segments (15). with opponent players or the ball. Both injuries The assessment of the segments mobility is a ma- usually occur to the throwing arm during the act jor component of the examination of the athlete of shooting or passing the ball, when the player with low back pain. Correction of segmental hy- has the arm in the cocked position, holding the pomobility forms an important part of the treat- ball. The force may be great enough to rupture ment program. Acute nerve root compression in the anterior capsule and glenohumeral ligament the lumbar region is usually the result of an acute complex (Bankart lesion), resulting in anteroin- disk prolapse. In the acute phase, the most ap- ferior subluxation or dislocation (Figure 2) (18). propriate treatment is rest in a position of maxi- Posterior dislocation is less frequent. Closed re- mum comfort with administration of analgesics. duction of acute shoulder dislocation is a treat- Surgery may be required if neurological signs per- ment of choice. Although there are still some sist or worsen. If bowel or bladder symptoms are controversies regarding the necessity of opera- present, emergency surgery may be necessary. tion, most authors nowadays recommend imme- There is a number of different techniques diate arthroscopic stabilization in a subset of pa- available for the correction of these spine ab- tients who are younger than 30 years and are top normalities (16) – manual therapy to the joints athletes (19-21). Arthroscopic Bankart repair of (mobilization, manipulation, traction), muscles anterior capsulolabral lesions with use of suture (massage therapy and dry needling), and neural anchors is a treatment of choice (22). structures (neural stretching). When acute spinal injury is suspected, assess- Swimmer’s shoulder (shoulder pain) ment begins on the field, with the ABC proto- Shoulder pain is the most common musculoskele- col (17). Airway maintenance is vital as circula- tal complaint in water polo players.