- Advice needs to be adjusted to the person and the injury but as an example, specific advice to an athlete with an injured knee may go like this:
- For the next 4 or 5 days you need to keep off that knee as much as possible. Keep it elevated when you can. Take the anti-inflammatory pain-killers. If you need to train then just do upper body work. (Similarly, if the upper body is injured, the sportsman may do lower body training and cardio-respiratory fitness whilst resting the upper body). Static quads exercises can be done at an early stage. Extend the knee to the horizontal position. Pull tightly with the quads. Now invert the foot and feel how the tension moves to the lower vastus medialis. Keep any weights on the ankle light at an early stage.
- After that, it is possible to do some gentle lower body work, but start with low intensity and short duration. Avoid running. Cycling or a step machine, cross-trainer or rowing machine in a gym may be satisfactory.
- About 10 to 14 days from the injury there will be some muscle wasting around the knee and this needs to be built up again. When exercising the muscles, keep movements slow and controlled. Build up the quads but also, when building one group of muscles (agonists), work on the opposing group (antagonists) too. In this case it is the hamstrings.
- If the knee gets painful or starts to swell, ease back on training again and then gradually build it up.
- Fitness training can be started again using cycling, step machine or cross trainer. Swimming may be possible but see how it goes and avoid breast stroke.
- You can start some gentle jogging about 3 weeks after the injury. Keep it slow and in a straight line.
- As you get more confident, build up speed. When you can sprint at full speed in a straight line you are about half way through rehabilitation.
- Then start zig-zagging. Work on rapid changes in direction and twisting around. This builds up strength and position sense (proprioception).
- Only when you can do all of this with great confidence is it safe to go back to active competition.
This is only a brief overview of sports injuries but two injuries are so common that they are worthy of mention.
The knee is very susceptible to injury in sport. It is a vulnerable joint that is made stable by the medial collateral, lateral collateral and two cruciate ligaments along with the muscles around the knee. The muscles are extremely important and even if the anterior cruciate ligament is ruptured, good muscles can permit sport at a very high level. Top level football players may require ACL reconstruction but even sports such as football, rugby and judo can be managed at a high level if the muscles are adequate. The quadriceps waste rapidly when there is injury to the knee and this is accelerated if there is an effusion. The quadriceps pull upwards through the patella tendon but as the hips are wider apart than the knees, there is a tendency to pull the patella laterally. This requires attention to the lower part of vastus medialis. As mentioned above, if agonists are built up, antagonists must be built too. Usually the hamstrings should have about 70% of the power of the quads but with a deficient ACL, that figure may need to be higher.
Not everyone has access to a gym with quads and hamstring machines and so a couple of easy exercises to perform at home are useful:
- Stand with the feet parallel, a little further apart than the width of the shoulders. Dip down about 25 to 30cm and up again. Do not go right down or it creates enormous pressure inside the knee joint. Hence they are better called dips than squats. Start at about 60 repetitions and work up to 120.
- Lie on the back on the floor with feet up on a chair. Lift the buttocks off the ground and down again to exercise the hamstrings. Again, start at 60 repetitions, working up to 120.
Pulled muscles, especially hamstrings, are very common, as mentioned above. The injury probably represents some minor tear in the muscle fibres that may bleed a little but they need the chance to heal and regain tensile strength without being subjected to repetitive trauma. They are often attributed to poor warming up although the evidence for this is poor.
With a torn hamstring, avoid running at first. Some gentle stretching is in order without being too enthusiastic and aggravating the injury. Fitness may be maintained with cycling, swimming, rowing and steps or cross-trainer but avoid running, probably for a few weeks. Start running at a gentle pace and as confidence is built, it is possible to increase the pace until sprinting is possible. If the muscle gives discomfort, ease back on the training and gradually work up again over the next few days.
Injuries in children
Children often get injured in the fun and games of everyday playing and life and usually they heal very fast and without problem. For some children, sport is more than just some fun and they train very hard and long to a very high standard. This is particularly true of swimming, gymnastics and dancing. Children are still growing and the epiphyses of their bones have not yet fused. This makes them very vulnerable to overuse injuryand to injuries of those parts, including avulsion.Weight training before puberty should be with the utmost caution if at all. Beware of the coach who is pushing the child too hard. This is especially a problem if the coach is a parent. Some people try to live their own frustrated ambitions through their children. The child may be under enormous pressure and whereas they can usually go home and moan about the coach, if the coach is a parent this outlet is closed.
Some children, especially boys, get very awkward and accident-prone at the growth spurt of puberty. This is because their bodies are growing so fast and muscles and proprioception have not yet caught up. Reassurance is required whilst the body catches up with its growth.
Proper rehabilitation is essential to enable the injury to heal and to reduce the risk of recurrence.
Sportsmen will work very hard to recover as quickly as possible but their impatience must be tempered by the need to achieve full recovery, especially before returning to competition. Different people recover at different rates but, generally, healing is slower with older age.
As we encourage people to take more exercise, we can expect to see more sports related injuries. The rules of sport are often designed or amended to help reduce the risk of injury. There is a widely accepted dictum that warm up before exercise and, to lesser extent, warm down and stretching after exercise, reduces the risk of injury. The level of evidence for this is very poor but the dictum has not been shown to be untrue.
Before engaging in sport it is important to have adequate training to assure fitness, especially if sport is being taken up after a period of abstention. Equipment must be suitable and adequate. This does not apply simply to protective equipment.
The D2 medical will include sports physiology and nutrition, correct orthopedic exam and management. It is an excellent example of a multi-disciplinary organisation and speakers and delegates will include GPs, orthopaedic surgeons, A&E specialists, physiotherapists, podiatrists, dieticians and physiologists. It is very informative and very enjoyable but do get reasonable fit before attending as you will be expected to partake in some physical exercise too.
Dr John J Ryan medical director