How Are Sports Injuries Classified and Managed?

Sports Medicine – Focus Question A

How are sports injuries classified and managed?

1K1: Ways to classify sports injuries
- Direct and indirect
- Soft and hard tissue
- Overuse

Direct and Indirect injuries

Direct injuries are caused by an external blow or force, they can be caused by:

• A collision with another person e.g. tackling
• Being struck by an object e.g. broken arm as a result of being hit by a bat

Indirect injuries result from internal forces built up by the actions of the performer, such may be caused by:

• Overstretching e.g. ballistic stretching (putting excessive pressure on the stretch reflex)
• Poor technique e.g. swinging a bat with the wrong technique
• Fatigue
• Lack of fitness

Soft and Hard tissue injuries

Soft tissue injuries are the most common injuries from participation in sport. These include:

• Skin injuries – abrasions, lacerations and blister
• Muscle injuries – tears or strains of muscle fibres and contusions
• Tendon injuries – tears or strains of muscle fibres and inflammation
• Ligament injuries – sprains and tears of ligament fibres

They may be acute (occurring suddenly, such as a sprain) or chronic (prolonged).

Ligaments join bone to bone and tendons join muscle to bone.

Hard tissue injuries are those involving damage to bones of the skeleton and teeth. Hard tissue injuries include breaks to bones and dislodged teeth. They are serious, many causing severe pain and discomfort.

Secondary injuries are those that occur as a result of a previous injury being poorly treated or not being fully healed. Athletes at risk of recurrence of injures should regain full strength and range of movement before returning to play.

Overuse injuries

Overuse injuries occur when excessive and repetitive forces are placed on the bones and other connective tissues of the body. Little or no pain might be experienced in the early stages of these injuries and the athlete might continue to place pressure on the injured site. By depriving the overused site of healing time, the damage around the site accumulates and becomes inflamed.
Overuse injuries are caused by:

• Poor technique - poor technique can instigate additional stress on the site
• Repetitive - low impact exercise e.g. jogging or stepping
• Poor equipment e.g. shoes with poor support, racquets that are too heavy.

Typical overuse injuries include anterior shin splints (irritation of front portion of the shinbone), tendonitis (irritation of the tendons).

Overuse often contributes to stress fractures, which are small incomplete bone fractures caused by repeated pounding, usually on hard surfaces.

1K2: Soft tissue injuries
- Tears, sprains, contusions
- Skin abrasions, lacerations, blisters
- Inflammatory response

Tears, sprains, contusions

A tear is a disruption of the fibres of a muscle or tendon. Tears occur when a muscle or tendon is over stretched or when a muscle contracts too quickly. The severity of the tear can range from the microscopic level (a strain), to a small number of fibres through to a complete rupture of all muscle fibres.

A sprain is a tear of the ligament fibres. These are strong rigid and relatively inelastic tissue. Their role is to connect bone to bone, thereby providing joint stability. Sprains occur when ligaments are stretched or torn resulting in pain, swelling and the inability to perform normal joint movements. Healing is a slow process because ligaments have a relatively poor blood supply. Sprains are classified according to the severity, first, second and third degree.

A strain is when a muscle or tendon is stretched or torn. Tendons join muscle to bone. They cause considerable pain and bleeding may cause discolouration around the injury. Any movement in the form of stretching and any pressure on or around the injury will result in sharp pain. Strains are also classified according to severity, first, second and third degree.

A contusion or bruise is bleeding into the soft tissue. This is usually caused by a collision with external agents. Contusions interrupt blood flow to the surrounding tissue; this can cause a blood clot in the connective tissue. In severe cases, this internal bleeding may occur for a long period of time. Contusions vary in intensity – with some remaining close to the skin while others penetrate deeply causing the bone to bruise.

THE RICER METHOD

When can you use heat?
Heat can be applied to loosen tissues and relax areas recovering from injury after the first 72 hours. Head pads, hot wet towels, spas, heat creams can be applied for 20 minutes at a time.

Skin abrasions, lacerations, blisters

These are forms of skin trauma; they are caused by the application of force, such as scraping or friction to the outer layer of the skin.

Skin abrasions results in the skin being scraped against a hard, dry surface, they usually cause pain and shallow bleeding. Upon the fall, dirt and other foreign material can enter through the skinned area therefore treatment requires gentle cleansing and sterilisation of the wound to prevent infections. The wound should then be covered with a non stick dressing.

Lacerations are wounds where the flesh has incurred an irregular tear. Lacerations can occur to the scalp, mouth and particularly to the lips and tongue.
Scalp lacerations: the area needs to be thoroughly cleansed with antiseptic soap, dried and a sterile gauze pad applied. Pressure may still need to be applied to prevent excessive bleeding. Lacerations longer than 1cm need to be referred to a doctor.
Mouth lacerations: require a thorough inspection to ensure there is no further damage, such as dislodged teeth. The mouth can be rinsed with antiseptic liquid. Sucking on ice assists in the control of bleeding and swelling.

Blisters are caused by a collection of fluid below or within the surface layer of skin. Blisters usually occur as a result of friction or rubbing with other objects and surfaces. Injury management requires the area be washed with soap and warm water, liquid antiseptic to be applied. The area should be dried and antibiotic ointment applied.

What does immediate management aim to do in skin injuries?

The aims of the immediate management of skin injuries include prevention of infection for both the victim and the first aider, minimisation of blood loss and tissue damage, and promotion of healing in order to reduce recovery time. Usually follows these steps:
1. Reduce dangers of infection – wearing gloves
2. Control bleeding with rest, pressure and elevation
3. Assess severity of the wound
4. Clean wound using clean water or saline solution
5. Apply an antiseptic to the wound; ensure person is not allergic
6. Dress wound with sterile pad and bandage.
7. If necessary, refer person to medical attention.

When should skin injuries be medically referred?
Skin injuries that should be referred to medical attention include wounds that require suturing, wounds that show signs of infection or cannot be properly cleaned of foreign material and wounds to the head. All head wounds usually should be referred to medical attention as even minor injuries to the head may be accompanied with more serious injuries such as concussion.

The Inflammatory response

When soft tissue is injured, the body activates a self healing process known as the inflammatory response. It may last up to 3-4 days depending on the extent of the damage.

Phase 1: The inflammatory stage – just after the injury has taken place, it is characterised by:

• pain and swelling
• loss of mobility
• damage to cells and surrounding tissues
• an increased blood flow to the area
• leakage of fluid that causes swelling
• formation of many blood vessels to promote healing.

Phase 2: The repair and regenerative stage – this stage usually lasts from 3-6 days, characterised by:

• the removal of debris from the area (dead cells etc)
• formation of new fibres
• production of scar tissue
• reduced swelling.

Phase 3: The remodelling stage – can last from 6 weeks to many months, characterised by:

• replacement of scar tissue
• Replacement tissue that needs to strengthen the area. The type of remodelling depends on the timing and degree of mobilisation of the injury. It also varies on the conditioning and rehabilitation strategies the athlete has implemented. Excessive exercise too early causes further damage. Too little movement allows large quantities of scar tissue to form, the decreases strength and flexibility.

Immediate treatment of soft tissue injuries aims to reduce swelling, prevent further damage and ease pain. In the long term the treatment aims to restore flexibility, regain full function, prevent recurrence and return the player to the field as soon as possible. Management of soft tissue injuries requires application of the RICER principle. Properly used, the RICER method ensures that the injury heals correctly and in the shortest period of time. If RICER is not used, or its use is delayed, the injury takes longer to repair, has less strength and flexibility.

In a) scar tissue is not properly targeted therefore is not properly removed, this affects the remodelling stage as much scar tissue is still present preventing optimum recovery of the site. The athlete may have problems regaining full strength and pre-injury results. The injury is also more likely to reoccur. In b) the tissue is fully healed, the fibres are more compact and therefore strength can be quickly regained without additional stress or issues.

1K3: Hard tissue injuries
- Fractures
- Dislocation

Fractures

A fracture is a hard tissue injury where there is a partial or complete break of a bone. The type of fracture will depend on the severity of the break to the bone. They can be:

• Complete, where the bone is broken into two parts (i.e. oblique)
• Incomplete, where the break is only part-way through the bone (i.e. greenstick)
• Comminuted, where there are more than two breaks in the bone

Fractures can also be classified as:

• Closed, where the broken bones do not pierce through the skin
• Open, where the bone protrudes through the skin
• Complicated, where the broken bone damages a major nerve, organ or blood vessel.

Causes of a fracture:
Fractures can be caused by either direct or indirect forces.

Signs and symptoms:
swelling, deformity, pain, limited movement. In an open fracture bone will be visible.

Management of fractures:
Immobilising a fracture is important to lessen the pain, reduce bleeding, treating shock, and prevent further damage. Managing a fracture involves the following steps:

1. Following DRABCD procedures in case player is unconscious. Danger should be checked for under all circumstances.
2. Control bleeding.
3. Identify type of fracture.
4. Immobilise the fracture with broad bandages and a splint, ensuring no circulation is cut off.
5. Immediate medical attention.

How to immobilise?
Management of hard tissue injuries aims to minimise movement of the injured area. This is achieved by immobilising the joint above and below the injury site. If the injury site is the shaft of a long bone (e.g. femur, humerus) the injury can be supported with a sling or splint.

A supporting splint should be long enough to extend beyond the nearest joints of the injured site, e.g. you can use, another limb, another part of the body, a firm, straight object.

The correct application of the splint is essential. Should be secured at 6 points:

• Above the joint of fracture, below the joint of fracture
• At the joint above the fracture, and at the joint below the fracture.
• Just above the fracture, and just below the fracture.

Why is immobilisation important?
Immobilisation is important in the treatment of hard tissue injuries for a number of reasons. By immobilising the area, the first aider prevents further injury to the bone and the surrounding soft tissue structures. This may help to reduce the amount of bleeding and swelling and it reduces the amount of pain to the patient as it stops grating and aggravating the nerve ending between the ends of the fracture. Immobilisation may also reduce the chances of the patient experiencing shock, a life threatening condition.

Dislocation

Dislocations are when bones are displaced from a joint. A dislocation can also result in damage to the surrounding ligaments and muscles.

Causes of dislocations:
Caused by excessive force that move joints out of their sockets. Shoulder and finger joints are more susceptible to dislocations, as the surrounding ligaments are less supportive.

Signs and symptoms of dislocation:
Deformation, pain, swelling, loss of function, bruising.

Management of a dislocation:
1. Follow DRABCD procedure.
2. Immobilise
3. Do not attempt to put the joint back in place; this must be done by a sports specialist, as there is a risk of nerve damage if the bone is not put back correctly.
4. Seek medical help.

Management of finger dislocation:
1. Secure with a splint to fully immobilise.
2. Ice, elevation and support using a bandage.
3. Medical attention.

Finger dislocations can be easily splinted and supported using a straight object. Shoulder dislocations should be immobilised using a sling or by holding the arm in place.

What is subluxation?
When a bone momentarily “pops out” of the joint and quickly returns to place. Although it stretches the ligaments, it may not cause additional damage at the time. However, the joint will be vulnerable.

Managing hard tissue injuries:
Because hard tissue injuries can be accompanied with damage to surrounding muscles, blood vessels’, surrounding organs and nerves, immediate treatment is required. For serious hard tissue injuries, the person should not be moved, and medical help should be called immediately.

1K4: Assessment of injuries
- TOTAPS (Talk, Observe, Touch, Active and Passive movement, Skills test)

TOTAPS procedure is used to assess the extent of injury to a player and determine whether or not the injured person can return to the field. If the player can complete all tasks required, they should be allowed to return to play. If not, player needs further assessment from a medical

Sports Medicine – Focus Question B

How does sports medicine address the demands of specific athletes?

2K1: Children and young athletes
- Medical conditions (asthma, diabetes, epilepsy)
- Overuse injuries (stress fractures)
- Thermoregulation
- Appropriateness of resistance training

Sports medicine is defined as the field of medicine concerned with physical fitness and the prevention, diagnosis and treatment of injuries sustained in sports or exercise related activities.

Children and young athletes face several limitations which may impede their performance in comparison with a fully functioning athlete. There are considerations which need to be taken into account when organising competition in sport of children and young athletes under the sports medicine approach. Issues such as medical conditions, overuse injuries, thermoregulation and the appropriateness of resistance training must be recognised to ensure safe participation.

Medical conditions

ASTHMA
Asthma is a condition characterised by the narrowing of the airways leading to the lungs, this causes breathing difficulties. Exercise can be a major trigger of an asthma attack due to an increased demand for oxygen. Children with asthma are encouraged to participate in physical activity, especially swimming as the warm and moist environment promotes the diffusion of oxygen into the lungs, increasing lung function. Asthmatics should take precautions in dry, cold weather and their coaches should be informed of the condition. A management plan for asthma consists of sitting down, giving 4 puffs from an inhaler (puffer), wait for 4 minutes and repeat. If the condition worsens, emergency services should be called.

DIABETES
Diabetes is a metabolic condition caused by the body’s incompetence to produce or utilise insulin. This places major stress on maintaining blood sugar levels as the levels in diabetics constantly fluctuate. For a young child diabetes can have a significant impact on participation in sport. The body uses glucose to fuel working muscles and if a person’s body is unable to produce this glucose they may start to feel unwell. An appropriate training and management plan needs to be devised for diabetics in order to avoid hypoglycaemia (low blood sugar levels) and hyperglycaemia (high blood sugar levels). To manage hypoglycaemia, the athlete should instantly consume fast-acting carbohydrates such as lollies, fruit juice, banana etc. Hyperglycaemia should be managed under proper medical advice.
Young diabetics should not be advised against physical activity, they can participate successfully and safely given that extra precautions are taken e.g. coaches allowing regular breaks to refuel and monitoring their levels throughout the training session.

EPILEPSY
Epilepsy is a condition caused by a disruption to electrical activity in the brain, causing a brief alteration to the level of consciousness, resulting in seizures. Epilepsy should not affect a child’s ability to perform, however sports such as swimming, rock climbing, contact sports should be avoided as they pose extra risks. A management plan that is familiar to parents, coaches and other team members is critical, if a seizure occurs, the area should be cleared of any hazards and the fit should be allowed to occur unrestrained, the person should be given time to rest afterwards and if the fit lasts longer than 5 minutes an ambulance is required.

Overuse injuries

Overuse injuries occur when excessive and repetitive forces are placed on the bones and other connective tissues of the body. By depriving the overused site of healing time, the damage around the site accumulates and becomes inflamed. Children and young athletes are more susceptible to overuse injury and are caused through a combination of poor technique, poor equipment, high volume, high intensity training requiring repeated movements of stepping and jumping. These injuries are serious when occurring in children as their bones are still developing and any disruption can hinder their growth. Therefore sports medicine values the fact that children require adequate breaks between training sessions and sufficient recovery time for injuries.