Find out exactly how the injury occurred. This is essential to understand the mechanism of injury.
- Was there direct trauma?
- If so, where, how and in what direction?
- Try to assess the force of the impact.
- Was a rotating action involved?
- What was the position of the joints when it happened?
- Especially if you are not familiar with the sport, ask the athlete to explain exactly what was happening.
- Was there any sound with the injury? A crack may suggest a fracture. A popping sound implies a ruptured ligament.
- Was the athlete able to continue the game?
- How long ago was the injury?
- What has happened since? This may include marked improvement, little improvement or even deterioration. He may have attended A&E and been dismissed after an x-ray revealed no fracture.
- Has there been a similar injury before?
- The next part of the history may be completed before examination or between diagnosis and discussing management:
- How often does he compete?
- At what level does he compete?
- How often does he train? This may include number of times a week and number of hours a week.
This will give an indication of how seriously the athlete takes his sport. It may also indicate over-training. Training comes in many forms. There may be distance or endurance training, speed training, strength training and specific skills training. That part of the history is also important if the athlete is not complaining of an acute injury but a pain that is related to the sport. It may be a strain. It may be an overuse injury:
- How long has it been a problem?
- Has it been progressive?
- What brings it on?
- Exactly where is the pain?
- Ask about training regimes.
- Has he/she discussed it with his coach?
Poor technique predisposes to overuse or other injuries. Poor equipment may be at fault. A wider handle on a racket may aid tennis elbow. Trainers wear out and lose their spring and protection. They need to be replaced.
Examination must be adequate and competent. The knee is very often injured and ability to examine the knee must include the ability to detect instability of ligaments and effusion. Shortly after an injury, especially if there is effusion or spasm of muscles due to pain, it may not be possible to detect instability. The general principles of examining a joint are as follows:
- Look at the area. Is there bruising or swelling? Is there any distortion?
- Put the joint through its full range of passive movements in all direction. Some joints have a great variety of movements, for example the shoulder can flex, extend, abduct, adduct, internally and externally rotate.
- Ask the patient to perform that range of movement actively.
- Test active movement against resistance.
- Stress the joint to detect instability of ligaments.
- Palpate the joint and around it for local tenderness, swelling or effusion and muscle spasm.
- X-rays are mandatory if a fracture or dislocation is suspected but they are of little value otherwise as they do not show soft tissue well. It is important to get the balance right between excessive requests for x-rays and missing fractures. It should be possible to reduce the number of ankle x-rays whilst not missing fractures by application of the Ottawa rules as described in ankle injuries and Pott’s fracture.
- If a knee is swollen, aspiration of the joint, using a wide bore needle after appropriate infiltration of local anesthetic is a useful diagnostic and therapeutic exercise. The fluid may be straw-coloured and an inflammatory exudate. It may be blood stained or frank blood. If there is blood in the fluid or frank blood, something is torn. This may be a tendon or cartilage. If the fluid is left to stand and a layer of fat globules appears on the surface, this is bone marrow and there is a fracture at the joint. Removal of fluid helps pain and aids recovery, even if it reforms. Muscle wasting around the knee is accelerated by effusion. Blood is very irritating and damages joints, as shown by the joints of those with heamopilia. If the fluid seems purely inflammatory, there may be some benefit from injecting steroid into the joint.
- Imaging for soft tissue injury usually require MRI scan or ultrasound and it may be necessary to refer to secondary care to get access to this.
- The arthroscope is a useful, minimally invasive tool, to inspect the inside of joints and perhaps to undertake some repair. It is often used on the knee but some surgeons use artroscopy of the shoulder and ankle joint too. The hip is too deep for ready access.
Sportsmen may also suffer disease, as may anyone else and so other investigations may be indicated.