Sports injury

Editor-In-Chief: Robert G. Schwartz, M.D. [mailto:RGSHEAL@aol.com], Piedmont Physical Medicine and Rehabilitation, P.A.

Overview
Sports injuries are injuries that occur to athletes in major sporting events. In many cases, these types of injuries are due to overuse of a part of the body when participating in a certain activity. For example, runner's knee is a painful condition generally associated with running, while tennis elbow is a form of repetitive stress injury at the elbow, although it does not often occur with tennis players. Other types of injuries can be caused by a hard contact with something. This can often cause a broken bone or torn ligament or tendon

Injuries are a common occurrence in professional sports and most teams have a staff of Athletic Trainers and close connections to the medical community. Controversy has arisen at times when teams have made decisions that could threaten a players long-term health for short term gain.

Classification
Sports injuries can be broadly classified as either traumatic or overuse injuries. Traumatic injuries account for most injuries in contact sports such as Football, Rugby, Australian rules football, Gaelic football and American football because of the dynamic and high collision nature of these sports. These injuries range from bruises and muscle strains, to fractures and head injuries.

A bruise or contusion is damage to small blood vessels which causes bleeding within the tissues. A muscle strain is a small tear of muscle fibers and a ligament sprain is a small tear of ligament tissue. The body’s response to these sports injuries is the same in the initial five day period immediately following the traumatic incident - inflammation.

Signs and symptoms
Inflammation is characterized by pain, localized swelling, heat, redness and a loss of function.

Mechanism
All of these traumatic injuries cause damage to the cells that make up the soft tissues. The dead and damaged cells release chemicals, which initiate an inflammatory response. Small blood vessels are damaged and opened up, producing bleeding within the tissue. In the body’s normal reaction, a small blood clot is formed in order to stop this bleeding and from this clot special cells (called fibroblasts) begin the healing process by laying down scar tissue.

The inflammatory stage is therefore the first phase of healing. However, too much of an inflammatory response in the early stage can mean that the healing process takes longer and a return to activity is delayed. The sports injury treatments are intended to minimize the inflammatory phase of an injury, so that the overall healing process is accelerated.

Diagnosis
Diagnosing the underlying cause of sports injuries is usually done by a medical doctor, osteopathic physican, physiotherapist (physical therapist) or by a chiropractor.

History and Physical Examination
A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with the pain. The patient describes the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered. Imaging tests may be necessary to diagnose tumors or other possible sources of the pain.

A variety of diagnostic methods are available to confirm the presence of sports injuries:

X-Ray
X-ray imaging includes conventional and enhanced methods that can help diagnose the cause and site of pain. A conventional x-ray, often the first imaging technique used, looks for broken bones or an injured vertebra. A technician passes a concentrated beam of low-dose ionized radiation through the back and takes pictures that, within minutes, clearly show the bony structure and any misalignment or fractures. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.

Ultrasound imaging
Diagnostic musculoskeletal ultrasound imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the limbs, parvertebral soft tissues and to image various internal organs.

Electrodiagnostic procedures
Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes — one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain.

Computerized tomography
]]Computerized tomography]](CT) is a quick and painless process used when internal organ or spinal pathology is suspected. X-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional slices (1 mm each) of internal structures under study. This diagnostic exam is generally conducted at an imaging center or hospital.

Magnetic resonance imaging
Magnetic resonance imaging (MRI) is used to evaluate for bone degeneration or injury or disease in tissues and nerves, muscles, ligaments, and blood vessels. MRI scanning equipment creates a magnetic field around the body strong enough to temporarily realign water molecules in the tissues. Radio waves are then passed through the body to detect the “relaxation” of the molecules back to a random alignment and trigger a resonance signal at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional “slice” of the tissue being scanned, and differentiates between bone, soft tissues and fluid-filled spaces by their water content and structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.

Bone scans
Bone scan is used to diagnose and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.

Thermography
Thermography involves the use of infrared sensing devices to measure small temperature changes between the two sides of the body or the temperature of a specific organ. Thermography may be used to detect the presence or absence of sympathetic nerve involvement (unusual pain, swelling and weather sensitivity.

Treatment
For the vast majority of patients, sports injuries can be treated with non-surgical care. For those with acute, short-term pain, certain home remedies may be effective. Sports injuries can be treated and managed by using the P.R.I.C.E.R... DR. ABC and T.O.T.A.P.S regimes:
 * P - Protect
 * R - Rest
 * I - Ice
 * C - Compression
 * E - Elevation
 * R - Referral


 * D - Danger
 * R - Response
 * A - Airway
 * B - Breathing
 * C - Circulation


 * T - Talk
 * O - Observe
 * T - Touch
 * A - Active movement
 * P - Passive movement
 * S - Skills test

The inflammatory stage typically lasts around 5 days and all treatment during this time is designed to address the cardinal signs of inflammation – pain, swelling, redness, heat and a loss of function.

Most sports injuries can be treated without surgery. Treatment involves using analgesics, reducing inflammation, restoring proper function and strength, and preventing recurrence of the injury. Most patients recover without residual functional loss. Patients should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care.

Although ice and heat (the use of cold and hot compresses) have never been scientifically proven to quickly resolve injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals. As soon as possible following trauma, patients should apply a cold pack or a cold compress (such as a bag of ice or bag of frozen vegetables wrapped in a towel) to the tender spot several times a day for up to 20 minutes. After 2 to 3 days of cold treatment, they should then apply heat (such as a heating lamp or hot pad) for brief periods to relax muscles and increase blood flow. Warm baths may also help relax muscles. Patients should avoid sleeping on a heating pad, which can cause burns and lead to additional tissue damage.

Exercise may be the most effective way to speed recovery and help strengthen muscles. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Doctors and physical therapists can provide a list of gentle exercises that help keep muscles moving and speed the recovery process. A routine of healthy activities may include stretching exercises, swimming, walking, and movement therapy to improve coordination and develop proper posture and muscle balance. Yoga is another way to gently stretch muscles and ease pain. Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger. But if pain is more than mild and lasts more than 15 minutes during exercise, patients should stop exercising and contact a doctor.

Medications are often used to treat acute and chronic pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage.


 * Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain. Counter-irritants applied topically to the skin as a cream or spray stimulate the nerve endings in the skin to provide feelings of warmth or cold and dull the sense of pain. Topical analgesics can also reduce inflammation and stimulate blood flow. Many of these compounds contain salicylates, the same ingredient found in oral pain medications containing aspirin.
 * Muscle relaxants for acute or chronic pain.
 * Opioids such as codeine, oxycodone, hydrocodone, and morphine are often prescribed to manage severe acute pain but should be used only for a short period of time and under a physician’s supervision. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the patient, adding to depression and even increasing pain.

Spinal manipulation is literally a "hands-on" approach in which professionally licensed specialists (doctors of chiropractic care) use leverage and a series of exercises to adjust spinal structures and restore back mobility. or chronic pain. A clinical prediction rule can guide who is most likely to respond to manipulation.

When pain does not respond to more conventional approaches, patients may consider the following options:

Acupuncture involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules called peptides and keeps the body’s normal flow of energy unblocked. Clinical studies are measuring the effectiveness of acupuncture in comparison to more conventional procedures in the treatment of acute low back pain.

Interventional therapy can ease pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids or proliferative agents (Prolotherapy) into affected soft tissues, joints, or nerve roots. Chronic use of steroid injections may lead to increased functional impairment.

Traction involves the use of weights to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.

Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins (chemicals that have pain-relieving properties).


 * Muscle Energy Technique (MET) may help (PMID 14524509 - small study)

Ultrasound is a noninvasive therapy used to warm the body’s internal tissues, which causes muscles to relax. Sound waves pass through the skin and into the injured muscles and other soft tissues.

Although not proven some professional athletes use hyperbaric chambers to speed healing. Hines Ward of the Steelers sent his personal hyperbaric chamber,(similar to the one pictured), to his hotel to sleep in believing it would help heal his sprained medial collateral ligament he suffered in their playoff win against the Ravens. Hines went on to play in Super Bowl XLIII.

In the most serious cases, when the condition does not respond to other therapies, surgery can be an affective approach for serious musculoskeletal injuries. Some surgical procedures may be performed in a doctor’s office under local anesthesia (such as ultrasound guided percutaneous tenotomy), some are performed as an outpatient (such as arthroscopy) and others require hospitalization. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility.

Prevention
A comprehensive warm-up programme has been found to decrease injuries in soccer. Many athletes will partake in HGH Treatment for Athletic Enhancement as a way to prevent injuries.

Compression sportswear is becoming very popular with both professional and amateur athletes. These garments are thought to both reduce the risk of muscle injury and speed up muscle recovery.