(To: My daughter Tiffany, Mohammad Ali, Rafael Nada, Milos Raonic and all the injured athletes of the world)
Introduction:
When my daughter, a junior tennis player, injured her wrist this summer it took her about two months to recover and get back to the game. Having had to retire from a few important tournaments, I realized more of the significance and self-destruction that sport injuries could cause to a person. We all know about the consequences of sport injuries in famous world sport leaders such as Mohammad Ali who developed Parkinson syndrome (not the disease but what’s called in medicine “Punch Drunk Syndrome” with Parkinson-like symptoms). Sport injuries are almost unavoidable in athletes, and in the tennis the fans know how many operations the current world number one, Rafael Nadal has had just on his knees, or Canadian Milos Ranoic broke his hip at age 20 by falling on the grass court in Wimbledon.
Different sports are more prone to injuries and different parts of the body are more common to injuries in different sports. For example tendonitis of the wrist, elbow, shoulders and injuries to the knees, ankles and foot are more common in tennis. But head injuries are more common in boxing and hockey, while foot, legs and knees injuries are more common in soccer. Overall some sports are more prone to injuries due to the nature of the sport and the behavior of the athletes and due to more lenient rules and prohibition executed by the specific sport authorities and the referees in some specific sports such as hockey. While the physical injuries are more obvious and attended to, the mental and emotional injuries due to the stress and expectations of the athlete performance by the athlete, coaches, fans and families should not be ignored(1).
We need not to forget that sport injuries do not occur only in professional athletes that comprise a small population in sports in general, but in many healthy youngsters who engage in sports curricular in schools or extra-curricular sport activities. There are more than 30 millions injuries alone in the United States in teenagers and children. We also need to realize that some sport injuries when befall on the neck and head could lead to permanent disabilities and loss of lives that often happen to the otherwise healthy and young ones. We need not to be scared and avoid the sports for ourselves and our children, as playing sport or exercise is the best that we or they can do as a guarantee for a healthy life, but we need to know how to do it right so to prevent injuries. Although this article is focused on sport injuries in the athletes of all ages and different levels, but ordinary people who engage in harsh and in-calculated exercises could have injuries as well (2).
In this article after classifying the common sport injuries, considering different age groups, in non-professionals and professionals, and across different sports, and also among ordinary people regarding over-use and improper injuries, prevention of such injuries will be discussed.
Soft-Tissue Injuries:
Soft-tissue injuries are the most common type of injuries that include simple cuts, lacerations and bruises, easily seen by the naked eyes. But deep soft-tissue injuries that could affect tendons, muscles, blood vessels, nerves and could cause more pains, discomfort and longer disability mostly due to deep inflammations, may be ignored. The most common of these deep soft-tissue injuries are tendonitis and neuritis or neuralgic pains that demand longer and more specific treatments.
The main pathophysiological event underlying soft-tissue injuries, specially non-evident ones that cause pain, discomfort and retiring form the sports in athletes for short or long term, is bleeding under the soft-tissues and inflammation. The inflammatory stage is the first phase of healing during the injury, that may include a lengthy process with pains and discomfort that would delay the return of the athletes to his or her sport. Therefore the treatment and shortening the inflammatory phase of the injury would lead to accelerating the overall healing process. Unfortunately the treatment of such injuries are not anti-inflammatory, but more symptomatic and involve the use of pain killers that some are narcotics, working on the brain to block the reception of the pain and not on the focal areas of the injury where there is inflammation. The use of rest, casts and support of the area, ice packs and anti-inflammatory medications such as Iboprufen (Advil), Naprosen and Celebrex are the mainstay of minimizing the period of inflammation, reduction of the pain, discomfort and shortening the period of disabilities (3-4).
Some but very common soft-tissue injuries are caused by lack or short duration of preparation and warm ups in the athletes particularly the young ones, and the result of repeated movements of one focal area. One of the most common of these injuries are tennis elbows that occur from the repeated movement of the elbows in striking the ball. Similar injuries of repeated movements could happen to other focal areas of the body and joints such as wrists, shoulders, knees and ankles, specially when they are not warmed up and ready for an intense game. Therefore the prevention strategies, warm ups and also playing smart, not just tough are the keys to a long-term athleticism.
Hard-Tissue Injuries:
Hard-tissue injuries that are less common than soft-tissue injuries include fractures of the bones or dislocation of joints that require longer and more serious treatment, casts, internal fixation and surgery. These types of injuries specially to the head, neck and face could be lethal as well. Hard-tissue injuries are more extrinsic, meaning related to the external factors of the sport, such as playing rough or physical attacks by opponents specially in sports with loose prohibition rules, or in the physical circumstances such as wet surfaces that could lead to slip and fall injuries. Some of these injuries could be accidental, such as unintentionally being hit by a ball or stick. Some sports are more prone to these kinds of injuries such as boxing, hockey and American football (5-6).
Overuse Injuries:
Overuse injuries that are more of soft-tissue injuries classified in its own here due to its significance, commonality and more so its non-recognition. While overuse injuries are common in athletes for the repeated use of the specific parts of the body required for the sport, it is also seen in the ordinary people who engage in improper exercises without proper and stepwise preparation. While in the professional sports, the athletes get used to repeated or overuse injuries by developing conditioning and training the body gradually, these injuries are more common in ordinary people for lack of such gradual progression(5,7).
Doing the Right Thing:
In this section the prevention of sport injuries are discussed as many of these injuries are preventable through proper preparation and warm ups. This is generally well known by the coaches and athletes of different sports, specially the professionals, but often it is missed by the non-professional youngsters who ignore the significance of such preventive measures. Other than the warm up, preparation and gradual build up to the sport as discussed above, playing smart is also a key to stay in the sport for longer period of time. Unfortunately this importance is not considered much in the junior athletes specially their parents who are the force behind them for fast and premature achievements. This often leads to injuries and the premature withdrawal or dislike of the sport by the junior athletes (8).
Increased intensity of sports activities combined with a decrease in daily physical activity is making the overuse injuries in children more common. These injuries are located mainly in the epiphyseal cartilages, that is more of osteochondrosis nature rather than osteochondritis, which more specifically refers to inflammatory conditions of bone and cartilage. Most overuse injuries involve the lower limbs, especially the knees, ankle and feet. The most typical are Osgood-Schlatter disease and Sever’s disease where in both conditions, the tendons remain relatively short during the pubescent grown spurt. The main treatment for these injuries is temporary suspension of athletic activities, combined with physical therapy in many cases. While some of these injuries in otherwise healthy youth may lead to surgery, the preventive measures are the best and smartest approach to avoid disability and long retirement from the sport. Therefore pain and discomfort specially in children during sports should not be considered normal, but a warning sign of overtraining or lack of proper and sufficient preparation and warm up (9).
The overuse injuries in youth is a universal serious problem in this otherwise healthy young people that should be taken seriously by their family, coaches, medical field and the society at large. One example showing the extent of the problem is a recent study in Australia from 2005 to 2013 among children aged 5-15 suffered from such injuries (10). Surprisingly a total of 20,034 hospitalizations for sports-related injuries (2.7% of all hospitalizations in children aged 5-15 years), involving 21,346 recorded injuries in 19,576 children was recorded. Soccer and rugby combined represented nearly two thirds of the total (60%) injuries. The most common body regions affected were the forearm (31%) head (15%) and hand injuries (13%). Fractures accounted for 65% of injuries followed by dislocations (10%) and traumatic brain injury (10%). One in seven injuries sustained while playing rugby, baseball and hockey were traumatic brain injuries. A total of 444 (2.2%) of children had more than one hospitalization for sports-related injuries.
The statistics of sport injuries among children estimated and reported in US are more staggering with an overall 15,960,113 among children aged 5-18 between 2001-2013, that is almost half of the children of the same range age playing sports in this country. A total 485,515 of these traumatic sports injuries in the same age group have been severe enough to be taken to the emergency rooms within the same period of 2001-2013. The most common responsible sports for such injuries have been 1) football, 2)basketball, 3)soccer and 4)baseball. Surprisingly a non-directly but related sport activity, i.e. cheerleading had a share of 348,947 or 2.19% of the total injuries in the same age group in the same time period (11).
Conclusion:
On average, six children are hospitalized every day for sports-related injuries in the last decade in US with trends remaining stable. These injuries could range from soft-tissue to more serious hard-tissue injuries, and ranging in different disability levels from short to long-term retirement and even quitting the sports. The treatment that is very costly to the individual, health care system and society at large range from mild treatment of rest, physiotherapy and the use of anti-inflammatory medications to emergency referrals and surgical interventions (12). To avoid suffering of the athletes specially the juniors from pains, discomfort, disability and unnecessary long-term medical treatments such as surgical interventions, even occasional mortality, prevention strategies are the wisest approaches in addressing the sport injuries. This vital need is heavily on the shoulders of the family, coaches, schools and the sport facilities to take the matter of sport injuries particularly in the youth serious and consider preventive precautions (13).
The most important of these precautions is to lessen pressures and demands on the youth for achievement with strenuous and long hours of practice. The pressures and intense year-round training programs in a single sport, specially at an early age may result in more overuse injuries, burnout, and dropping out of sports, specially in the youth. Participation in more competitions, particularly in the young age group with a too early or premature early development of technical skills could lead to unnecessary injuries and ultimately burnout and total withdrawal from the sports in youth (14). It has been shown that exceeding 16 hours per week of total sports participation seems to carry the greatest risk. Nearly two-thirds of middle school–aged children receive medical treatment for injuries sustained during sports or physical activities. Additionally, athletes who participate in more competitive levels or higher volumes of training have an increased incidence of injury. One study of 1190 young athletes, 7 to 18 years old, comparing highly specialized athlete in one sport showed that they had more than twice greater risk of a serious overuse injury than an unspecialized young athlete, even when accounting for hours per week sports exposure and age (15).
Therefore haste by the junior athletes and more so by their families, coaches and others, specially at an inappropriate early age could lead more to the sports injuries, disability, treatments, psychological, financial costs and ultimately premature total withdrawal from the sports. Hence specialized training and preparation require long-term and short-term plans for junior athletes. The long-term plan needs to consider age appropriateness in the initiating the sport, so the earlier the better would be a myth and misconception. The long-term plan needs also to consider gradual increase in the amount of practice in time and severity. More importantly, the interest and the skill of the youth in the sport needs to be counted for, so not to push beyond the potentials (16-18). The short-term plan of preparation that is on weekly or daily basis should involve, warming up, fitness and preparation before each practice. This includes the encouragement and involvement of the youth to be moderately physically active daily in fitness exercises, specially stretching. Most importantly the interest of the youth in the specific sport needs to be respected and avoid to force them in a sport of no interest. Lastly good and proper nutrition, a normal and healthy sleep-wake cycle or circadian rhythm need also to be counted for (19-20).
Dr. Mostafa Showraki, MD, FRCPC
Lecturer, School of Medicine, University of Toronto
Author: ADHD:Revisited Book
Adhdrevisited.com/medicinerevisited.com
References:
1. DeHaven, Kenneth E.; Lintner, David M. Athletic injuries: Comaprison by age, sport and gender. The American Journal of Sports Medicine. 1986 May-Jun;14(3):218-24.
2. Martínez-Silván, Daniel; Díaz-Ocejo, Jaime; Murray, Andrew. Predictive indicators of overuse injuries in adolescent endurance athletes. International Journal of Sports Physiology and Performance. 2017 Apr; 12 (Suppl 2): S2–153-S2-156.
3.Pincus D, Kuhn JE, Sheth U, Rizzone K, Colbenson K, Dwyer T, Karpinos A, Marks PH, Wasserstein D. A Systematic Review and Appraisal of Clinical Practice Guidelines for Musculoskeletal Soft Tissue Injuries and Conditions. Am J Sports Med. 2017 May;45(6):1458-1464.
4. Ball S, Halaki M, Orr R. Training volume and soft tissue injury in professional and non-professional rugby union players: a systematic review. Br J Sports Med. 2017 Jul;51(13):1012-1020.
5. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016 Mar;50(5):273-80.
6. Avery DM, Rodner CM, Edgar CM. Sports-related wrist and hand injuries: a review.
J Orthop Surg Res. 2016 Sep 16;11(1):99.
7. Launay F. Sports-related overuse injuries in children. Orthop Traumatol Surg Res. 2015 Feb;101(1 Suppl):S139-47.
8.Rössler, Roland; Donath, Lars; Verhagen, Evert; Junge, Astrid; Schweizer, Thomas; Faude, Oliver (17 August 2014). “Exercise-Based Injury Prevention in Child and Adolescent Sport: A Systematic Review and Meta-Analysis”. Sports Medicine. 2014 Aug. 44 (12): 1733–1748.
9. Öztürk, Selcen. What is the economic burden of sports injuries? Joint Diseases and Related Surgery. 24 (2): 108–111.
10. Schneuer FJ, Bell JC, Adams SE, Brown J, Finch C, Nassar N. The burden of hospitalized sports-related injuries in children: an Australian population-based study, 2005-2013. Inj Epidemiol. 2018 Dec 17;5(1):45.
11. Bayt DR, Bell TM. Trends in paediatric sports-related injuries presenting to US emergency departments, 2001-2013. Inj Prev. 2016 Oct;22(5):361-4.
12. Myer GD, Jayanthi N, Difiori JP, Faigenbaum AD, Kiefer AW,
Logerstedt D, Micheli LJ. Sport Specialization, Part I: Does Early Sports specialization Increase Negative Outcomes and Reduce the Opportunity for Success in Young Athletes? Sports Health. 2015 Sep-Oct;7(5):437-42.
13.Abrams GD, Renstrom PA, Safran MR. Epidemiology of musculoskeletal injury in the tennis player. Br J Sports Med. 2012;46:492-498.
14. American Academy of Pediatrics. Intensive training and sports specialization in young athletes. Pediatrics. 2000;106:154-157.
15. Jayanthi NA, LaBella CR, Fischer D, Pasulka J, Dugas LR. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med. 2015;43:794-801.
16. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13:393-397.
17. Luke A, Lazaro RM, Bergeron MF, et al. Sports-related injuries in youth athletes: is overscheduling a risk factor? Clin J Sport Med. 2011;21:307-314.
18. Nader PR, Bradley RH, Houts RM, McRitchie SL, O’Brien M. Moderate-to-vigorous physical activity from ages 9 to 15 years. JAMA. 2008;300:295-305.
19. Stodden DJ, Goodway S, Langendorfer S, Robertson M, Rudisill M, Garcia C. A developmental perspective on the role of motor skill competence in physical activity: an emergent relationship. Quest. 2008;60:290-306.
20. Wall M, Côté J. Developmental activities that lead to dropout and investment in sport. Phys Educ Sport Pedagogy. 2007;12:77-87.