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Sports InjuriesPublication Date: April 2009 Handout on Health: Sports InjuriesThis booklet is for athletes at all ages and levels, for people who exercise, as well as for health care professionals, coaches, and others who want to find out more about sports injuries. This booklet describes the different types of sports injuries, how they can be treated and prevented, and recent treatment advances from research. It also highlights risk factors and contains a resource list. If you have further questions after reading this booklet, you may wish to discuss them with a health care professional. IntroductionIn recent years, increasing numbers of people of all ages have been heeding their health professionals' advice to get active for all of the health benefits exercise has to offer. But for some people—particularly those who overdo or who don't properly train or warm up—these benefits can come at a price: sports injuries. Fortunately, most sports injuries can be treated effectively, and most people who suffer injuries can return to a satisfying level of physical activity after an injury. Even better, many sports injuries can be prevented if people take the proper precautions. This booklet answers frequently asked questions about sports injuries. It discusses some of the most common injuries and their treatment, and injury prevention. The booklet is for anyone who has a sports injury or who is physically active and wants to prevent sports injuries. It is for casual and more serious athletes as well as the trainers, coaches, and health professionals who deal with sports injuries.
IllustrationsInformation BoxesAppendix
What Are Sports Injuries?The term sports injury, in the broadest sense, refers to the kinds of injuries that most commonly occur during sports or exercise. Some sports injuries result from accidents; others are due to poor training practices, improper equipment, lack of conditioning, or insufficient warmup and stretching. Although virtually any part of your body can be injured during sports or exercise, the term is usually reserved for injuries that involve the musculoskeletal system, which includes the muscles, bones, and associated tissues like cartilage. Traumatic brain and spinal cord injuries, (relatively rare during sports or exercise) and bruises are considered briefly in the appendix. Following are some of the most common sports injuries. Sprains and StrainsA sprain is a stretch or tear of a ligament, the band of connective tissues that joins the end of one bone with another. Sprains are caused by trauma such as a fall or blow to the body that knocks a joint out of position and, in the worst case, ruptures the supporting ligaments. Sprains can range from first degree (minimally stretched ligament) to third degree (a complete tear). Areas of the body most vulnerable to sprains are ankles, knees, and wrists. Signs of a sprain include varying degrees of tenderness or pain; bruising; inflammation; swelling; inability to move a limb or joint; or joint looseness, laxity, or instability. A strain is a twist, pull, or tear of a muscle or tendon, a cord of tissue connecting muscle to bone. It is an acute, noncontact injury that results from overstretching or overcontraction. Symptoms of a strain include pain, muscle spasm, and loss of strength. Although it's hard to tell the difference between mild and moderate strains, severe strains not treated professionally can cause damage and loss of function. Knee InjuriesBecause of its complex structure and weight-bearing capacity, the knee is the most commonly injured joint. Each year, more than 5.5 million people visit doctors for knee problems. Lateral View of the Knee Knee injuries can range from mild to severe. Some of the less severe, yet still painful and functionally limiting, knee problems are runner's knee (pain or tenderness close to or under the knee cap at the front or side of the knee), iliotibial band syndrome (pain on the outer side of the knee), and tendinitis, also called tendinosis (marked by degeneration within a tendon, usually where it joins the bone). More severe injuries include bone bruises or damage to the cartilage or ligaments. There are two types of cartilage in the knee. One is the meniscus, a crescent-shaped disc that absorbs shock between the thigh (femur) and lower leg bones (tibia and fibula). The other is a surface-coating (or articular) cartilage. It covers the ends of the bones where they meet, allowing them to glide against one another. The four major ligaments that support the knee are the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL), and the lateral collateral ligament (LCL). (See diagram.) Knee injuries can result from a blow to or twist of the knee; from improper landing after a jump; or from running too hard, too much, or without proper warmup. Compartment SyndromeIn many parts of the body, muscles (along with the nerves and blood vessels that run alongside and through them) are enclosed in a "compartment" formed of a tough membrane called fascia. When muscles become swollen, they can fill the compartment to capacity, causing interference with nerves and blood vessels as well as damage to the muscles themselves. The resulting painful condition is referred to as compartment syndrome. Compartment syndrome may be caused by a one-time traumatic injury (acute compartment syndrome), such as a fractured bone or a hard blow to the thigh, by repeated hard blows (depending upon the sport), or by ongoing overuse (chronic exertional compartment syndrome), which may occur, for example, in long-distance running. Shin SplintsAlthough the term "shin splints" has been widely used to describe any sort of leg pain associated with exercise, the term actually refers to pain along the tibia or shin bone, the large bone in the front of the lower leg. This pain can occur at the front outside part of the lower leg, including the foot and ankle (anterior shin splints) or at the inner edge of the bone where it meets the calf muscles (medial shin splints). Shin splints are primarily seen in runners, particularly those just starting a running program. Risk factors for shin splints include overuse or incorrect use of the lower leg; improper stretching, warmup, or exercise technique; overtraining; running or jumping on hard surfaces; and running in shoes that don't have enough support. These injuries are often associated with flat (overpronated) feet. Achilles Tendon InjuriesAn Achilles tendon injury results from a stretch, tear, or irritation to the tendon connecting the calf muscle to the back of the heel. These injuries can be so sudden and agonizing that they have been known to bring down charging professional football players in shocking fashion. The most common cause of Achilles tendon tears is a problem called tendinitis, a degenerative condition caused by aging or overuse. When a tendon is weakened, trauma can cause it to rupture. Achilles tendon injuries are common in middle-aged "weekend warriors" who may not exercise regularly or take time to stretch properly before an activity. Among professional athletes, most Achilles injuries seem to occur in quick-acceleration, jumping sports like football and basketball, and almost always end the season's competition for the athlete. Lateral View of the AnkleCommon Types of Sports Injuries
FracturesA fracture is a break in the bone that can occur from either a quick, one-time injury to the bone (acute fracture) or from repeated stress to the bone over time (stress fracture). Acute fractures: Acute fractures can be simple (a clean break with little damage to the surrounding tissue) or compound (a break in which the bone pierces the skin with little damage to the surrounding tissue). Most acute fractures are emergencies. One that breaks the skin is especially dangerous because there is a high risk of infection. Stress fractures: Stress fractures occur largely in the feet and legs and are common in sports that require repetitive impact, primarily running/jumping sports such as gymnastics or track and field. Running creates forces two to three times a person's body weight on the lower limbs. The most common symptom of a stress fracture is pain at the site that worsens with weight-bearing activity. Tenderness and swelling often accompany the pain. DislocationsWhen the two bones that come together to form a joint become separated, the joint is described as being dislocated. Contact sports such as football and basketball, as well as high-impact sports and sports that can result in excessive stretching or falling, cause the majority of dislocations. A dislocated joint is an emergency situation that requires medical treatment. The Shoulder JointThe joints most likely to be dislocated are some of the hand joints. Aside from these joints, the joint most frequently dislocated is the shoulder. Dislocations of the knees, hips, and elbows are uncommon. What's the Difference Between Acute and Chronic Injuries?Regardless of the specific structure affected, sports injuries can generally be classified in one of two ways: acute or chronic. Acute InjuriesAcute injuries, such as a sprained ankle, strained back, or fractured hand, occur suddenly during activity. Signs of an acute injury include the following:
Chronic InjuriesChronic injuries usually result from overusing one area of the body while playing a sport or exercising over a long period. The following are signs of a chronic injury:
What Should I Do if I Suffer an Injury?Whether an injury is acute or chronic, there is never a good reason to try to "work through" the pain of an injury. When you have pain from a particular movement or activity, STOP! Continuing the activity only causes further harm. Some injuries require prompt medical attention (see "Who Should I See for My Injury?"), while others can be self-treated. Here's what you need to know about both types: When to Seek Medical TreatmentYou should call a health professional if:
To learn about treating sports injuries, see "How Are Sports Injuries Treated?" When and How to Treat at HomeIf you don't have any of the above symptoms, it's probably safe to treat the injury at home—at least at first. If pain or other symptoms worsen, it's best to check with your health care provider. Use the RICE method to relieve pain and inflammation and speed healing. Follow these four steps immediately after injury and continue for at least 48 hours.
The Body's Healing ProcessFrom the moment a bone breaks or a ligament tears, your body goes to work to repair the damage. Here's what happens at each stage of the healing process: At the moment of injury: Chemicals are released from damaged cells, triggering a process called inflammation. Blood vessels at the injury site become dilated; blood flow increases to carry nutrients to the site of tissue damage. Within hours of injury: White blood cells (leukocytes) travel down the bloodstream to the injury site where they begin to tear down and remove damaged tissue, allowing other specialized cells to start developing scar tissue. Within days of injury: Scar tissue is formed on the skin or inside the body. The amount of scarring may be proportional to the amount of swelling, inflammation, or bleeding within. In the next few weeks, the damaged area will regain a great deal of strength as scar tissue continues to form. Within a month of injury: Scar tissue may start to shrink, bringing damaged, torn, or separated tissues back together. However, it may be several months or more before the injury is completely healed.
Who Should I See for My Injury?Although severe injuries will need to be seen immediately in an emergency room, particularly if they occur on the weekend or after office hours, most sports injuries can be evaluated and, in many cases, treated by your primary health care provider. Depending on your preference and the severity of your injury or the likelihood that your injury may cause ongoing, long-term problems, you may want to see, or have your primary health care professional refer you to, one of the following:
How Are Sports Injuries Treated?Although using the RICE technique described previously can be helpful for any sports injury, RICE is often just a starting point. Here are some other treatments your doctor or other health care provider may administer, recommend, or prescribe to help your injury heal. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) To reduce inflammation and pain, doctors and other health care providers often recommend taking an over-the-counter (OTC) nonsteroidal anti-inflammatory drug (NSAID) such as aspirin, ibuprofen (Advil,1 Motrin IB, Nuprin), ketoprofen (Actron, Orudis KT), or naproxen sodium (Aleve). For more severe pain and inflammation, doctors may prescribe one of several dozen NSAIDs available in prescription strength.2 1Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory. 2Like all medications, NSAIDs can have side effects. The list of possible adverse effects is long, but major problems are few. The intestinal tract heads the list with nausea, abdominal pain, vomiting, and diarrhea. Changes in liver function frequently occur in children (but not in adults) who use aspirin. Changes in liver function are rare in children using the other NSAIDs. Questions about the appropriate use of NSAIDs should be directed toward your health care provider or pharmacist. Though not an NSAID, another commonly used OTC medication, acetaminophen (Tylenol), may relieve pain. It has no effect on inflammation, however. ImmobilizationImmobilization is a common treatment for sports injuries that may be done immediately by a trainer or paramedic. Immobilization involves reducing movement in the area to prevent further damage. By enabling the blood supply to flow more directly to the injury (or the site of surgery to repair damage from an injury), immobilization reduces pain, swelling, and muscle spasm and helps the healing process begin. Following are some devices used for immobilization:
SurgeryIn some cases, surgery is needed to repair torn connective tissues or to realign bones with compound fractures. The vast majority of sports injuries, however, do not require surgery. Rehabilitation (Exercise)A key part of rehabilitation from sports injuries is a graduated exercise program designed to return the injured body part to a normal level of function. With most injuries, early mobilization—getting the part moving as soon as possible—will speed healing. Generally, early mobilization starts with gentle range-of-motion exercises and then moves on to stretching and strengthening exercise when you can without increasing pain. For example, if you have a sprained ankle, you may be able to work on range of motion for the first day or two after the sprain by gently tracing letters with your big toe. Once your range of motion is fairly good, you can start doing gentle stretching and strengthening exercises. When you are ready, weights may be added to your exercise routine to further strengthen the injured area. The key is to avoid movement that causes pain. As damaged tissue heals, scar tissue forms, which shrinks and brings torn or separated tissues back together. As a result, the injury site becomes tight or stiff, and damaged tissues are at risk of reinjury. That's why stretching and strengthening exercises are so important. You should continue to stretch the muscles daily and as the first part of your warmup before exercising. When planning your rehabilitation program with a health care professional, remember that progression is the key principle. Start with just a few exercises, do them often, and then gradually increase how much you do. A complete rehabilitation program should include exercises for flexibility, endurance, and strength; instruction in balance and proper body mechanics related to the sport; and a planned return to full participation. Throughout the rehabilitation process, avoid painful activities and concentrate on those exercises that will improve function in the injured part. Don't resume your sport until you are sure you can stretch the injured tissues without any pain, swelling, or restricted movement, and monitor any other symptoms. When you do return to your sport, start slowly and gradually build up to full participation. For more advice on how to prevent injuries as you return to active exercise, see the "Tips for Preventing Injury" box. RestAlthough it is important to get moving as soon as possible, you must also take time to rest following an injury. All injuries need time to heal; proper rest will help the process. Your health care professional can guide you regarding the proper balance between rest and rehabilitation. Other TherapiesOther therapies commonly used in rehabilitating sports injuries include:
Most of these therapies are administered or supervised by a licensed health care professional. Who Is at Greatest Risk for Sports Injuries?If a professional athlete dislocates a joint or tears a ligament, it makes the news. But anyone who plays sports can be injured. Three groups—children and adolescents, middle-aged athletes, and women—are particularly vulnerable. Children and AdolescentsAlthough playing sports can improve children's fitness, self-esteem, coordination, and self-discipline, it can also put them at risk for sports injuries: some minor, some serious, and still others that may result in lifelong medical problems. Young athletes are not small adults. Their bones, muscles, tendons, and ligaments are still growing and that makes them more prone to injury. Growth plates—the areas of developing cartilage where bone growth occurs in growing children—are weaker than the nearby ligaments and tendons. As a result, what is often a bruise or sprain in an adult can be a potentially serious growth-plate injury in a child. Also, a trauma that would tear a muscle or ligament in an adult would be far more likely to break a child's bone. Because young athletes of the same age can differ greatly in size and physical maturity, some may try to perform at levels beyond their ability to keep up with their peers. Contact sports have inherent dangers that put young athletes at special risk for severe injuries. Even with rigorous training and proper safety equipment, youngsters are still at risk for severe injuries to the neck, spinal cord, and growth plates. Evaluating potential sports injuries on the field in very young children can involve its own special issues for concerned parents and coaches. Some helpful hints are presented in the appendix. Adult AthletesMore adults than ever are participating in sports. Many factors contribute to sports injuries as the body grows older. The main one is that adults may not be as agile and resilient as they were when they were younger. It is also possible that some injuries occur when a person tries to move from inactive to a more active lifestyle too quickly. WomenMore women of all ages are participating in sports than ever before. In women's sports, the action is now faster and more aggressive and powerful than in the past. As a result, women are sustaining many more injuries, and the injuries tend to be sport specific. Female athletes have higher injury rates than men in many sports, particularly basketball, soccer, alpine skiing, volleyball, and gymnastics. Female college basketball players are about six times more likely to suffer a tear of the knee's anterior cruciate ligament (ACL) than men are, according to a study of 11,780 high school and college players. Information on injuries collected since 1982 by the National Collegiate Athletic Association shows that female basketball and soccer players have a much higher incidence of ACL injuries than their male counterparts. Previous assumptions that methods of training, risks of participation, and effects of exercise are the same for men and women are being challenged. Scientists are working to understand the gender differences in sports injuries. Although poor conditioning has not been related to an increased incidence of ACL injuries specifically, it has been associated with an increase in injuries in general. For most American women, the basic level of conditioning is much lower than that of men. Studies at the U.S. Naval Academy revealed that overuse injuries were more frequent in women; however, as women became used to the rigors of training, the injury rates for men and women became similar. Aside from conditioning level, other possible factors in women's sports injuries include structural difference of the knee and thigh muscles, fluctuating estrogen levels caused by menstruation, the fit of athletic shoes, and the way players jump, land, and twist. Also, "the female triad," a combination of disordered eating, curtailed menstruation (amenorrhea), and loss of bone mass (osteoporosis), is increasingly more common in female athletes in some sports. Its true prevalence is unknown, but it appears to be greater in athletes, adolescents, and young adults, especially in people who are perfectionists and overachievers. Scientists trying to better understand sports injuries in women met in June 1999 for a workshop sponsored jointly by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Academy of Orthopaedic Surgeons. The workshop proceedings were published in a book titled Women's Health in Sports & Exercise, edited by William Garrett, M.D., Ph.D., and Gayle Lester, Ph.D. The book may be purchased from the American Academy of Orthopaedic Surgeons (www.aaos.org). What Can Groups at High Risk Do to Prevent Sports Injuries?Anyone who exercises is potentially at risk for a sports injury and should follow the injury prevention tips. But additional measures can be taken by groups at higher risk of injury. ChildrenPreventing injuries in children is a team effort, requiring the support of parents, coaches, and the kids themselves. Here's what each should do to reduce injury risk. What parents and coaches can do:
What children can do:
Tips for Preventing InjuryWhether you've never had a sports injury and you're trying to keep it that way or you've had an injury and don't want another, the following tips can help.
Adult AthletesTo prevent injuries, adult athletes should take the following precautions:
WomenIncreased emphasis on muscle strength and conditioning should be a priority for all women. Women should also be encouraged to maintain a normal body weight and avoid excessive exercise that affects the menstrual cycle. In addition, women should follow precautions listed above for other groups. What Are Some Recent Advances in Treating Sports Injuries?Today, the outlook for an injured athlete is far more optimistic than in the past. Sports medicine has developed some near-miraculous ways to help athletes heal and, in most cases, return to sports. Following are some procedures that have greatly advanced the treatment of sports injuries: ArthroscopyMost doctors agree that the single most important advance in sports medicine has been the development of arthroscopic surgery, or arthroscopy. Arthroscopy uses a small fiberoptic scope inserted through a small incision in the skin to see inside a joint. It is primarily a diagnostic tool, allowing surgeons to view joint problems without major surgery. Depending on the problem found, surgeons may use small tools inserted through additional incisions to repair the damage, such as a torn meniscus or a torn ligament that fails to heal naturally. Using arthroscopy, for example, a surgeon may reattach the torn ends of a ligament or reconstruct the ligament by using a piece (graft) of healthy ligament from the patient or from a cadaver. Because arthroscopy uses tiny incisions, it results in less trauma, swelling, and scar tissue than conventional surgery, which in turn decreases hospitalization and rehabilitation times. Problems can be diagnosed earlier and treated without serious health risks or more invasive procedures. Furthermore, because injuries are often addressed at an earlier stage, operations are more likely to be successful. Tissue EngineeringWhen joint cartilage is damaged by an injury, it doesn't heal on its own the way other tissues do. In recent years, however, the field of sports medicine and orthopaedic surgery has begun to develop techniques such as transplantation of one's own healthy cartilage or cells to improve healing. At present, this technique is used for small cartilage defects. Questions remain about its usefulness and cost. Targeted Pain ReliefFor people with painful sports injuries, new pain-killing medicated patches can be applied directly to the injury site. The patch is an effective method of delivering pain relief, especially for many people who prefer to put their pain medication exactly where it's needed rather than throughout their entire system. What Advances Might We Expect in the Future?Recent advances in treating sports injuries are likely to be just the beginning. Watch for developments in these areas in the not-too-distant future:
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