This article is reprinted with p erm ission o f the S o u th A fric a n M e d ic a l J o urnal (10th O ct., 1970). Page 2 P H Y S I O T H E R A P Y JUNE, 1971 SPORTS and ATHLETIC INJURIES: A PHYSIOTHERAPIST S APPROACH P. P IL K IN G T O N , M .C .S.P ., M .S .A .S.P . C hartered P hysiotherapist, C ape Town. Injury is acknow ledged to be the occupational hazard o f sport, and is a constant threat to all sportsm en and athletes. A high proportion o f these injuries are m inor, but all prevent the sportsm an from taking part in his particular sport or greatly reduce his ability, and if neglected or ill- treated m ay easily becom e major disabilities. It is well k n ow n that a great number o f sportsm en lack confidence in the m edical profession and turn to quack treatment in search o f a rapid cure. This, I feel, is due m ainly to the fact that few doctors or physiotherapists realize that even a m inor injury to a keen sportsm an as­ sum es the proportions o f a major disaster, threatening his hard-w on fitness, sporting prowess, and possibly his posi­ tion in a team. T o o frequently, his reaction to injury is considered to be som ew hat neurotic, and he is sent o ff to rest at hom e, with little or n o instruction as to the length o f rest required, what steps he should take to hasten his recovery, and w h en or how to resume exercise. -Conse­ quently, either he is afraid to use the lim b at all-, or he walks too so o n o n an already-dam aged m uscle or joint, thereby putting further strain o n it. In either case he tends to return to sport before he is fit, once his pain is alleviated, and the lesion recurs or he suffers a secondary injury, with resultant lowering o f m orale and further loss o f confidence in m edical advice. In order to get the best results from the treatment o f this type o f patient, it is necessary to recognize the fact that he needs a sym pathetic and positive approach to the handling o f his injury; dem ands 100 per cent recovery in the shortest possible time; and has n o use at all for the widespread pre­ scription o f ‘rest’. There is n o doubt that lay-off periods, with the concom itan t drawbacks o f loss o f form and fit­ ness, are greatly reduced by the early initiation o f active intensive treatment, with the ideal balance o f rest and gentle exercises, graded according to the severity o f the iryury. Because so m any injuries occur o n a Saturday, when hospital and other m edical and physiotherapy departments are closed, the average sportsm an has to rely o n inadequate hom e remedies before he is able to obtain professional assistance. V aluable tim e is thereby lost, and the injury is already subacute or chronic before being seen. T o overcom e this time-lag it w ould be o f great value if regular Sunday- morning injury clinics were available which sportsm en could attend. S P O R T S IN J U R Y CLINIC S In large centres in such countries as Great Britain, Australia and the U .S .A ., Sports Injury C linics are attended by large numbers o f sportsm en. Sports enthusiasts like W . E . Tucker, W illiam s and D o n O ’D o n o g h u e consult in these, and intensive active treatment is carried out along the lines o f high-pressure rehabilitation units, the patients attending several tim es a day in the acute stage o f the injury. In a sport-loving country like South A frica there is a great need for this type o f centre, especially if interested orthopaedic consultants w ould be prepared to run them and be available to diagnose and prescribe for the injuries at the earliest possible m om ent. Such centres w ould, I feel sure, attract the interest o f coaches and sportsm en alike, and w ould gain recognition and support from the various sporting and athletics bodies. The essential team -w ork on beh alf o f the sportsm an from doctor, physiotherapist and coach or trainer could be obtained, the im portance o f early treatment explained, and the necessity o f full recovery and the regaining o f fitness before the resum ption o f full training or return to com ­ petitive sport stressed. The co-operation o f the coach , which is at present only obtainable am ong professional athletic and sports clubs (apart from the occasional doctor w ho coaches in his spare time, and som e sch ool coaches), is in any case essential in order to get the best results with this type o f case. Too often the amateur sportsm an disregards m edical advice, or attem pts to hide an injury, because his c oach insists on his taking part in training sessions, with the threat that he will not be considered for the team unless h e does so. Should recognized Sports Injury Clinics be established, the vital co-operation o f the coaches w ould be far more easily obtained; harmful practices such as m aking the sportsm an try to ‘run o u t’ a m uscle pull, in sp ite o f pain and spasm , could be stopped, and the chronic injuries (resulting from neglect o f m inor tears and strains) could be reduced, b oth in severity and number. P H Y S IC A L F IT N E S S A N D T R A IN IN G T he average sportsm an needs about 6-8 weeks’ pre-season and 4 or m ore weeks’ ‘during season ’ training in order to reach a sufficiently high standard o f fitness to enable him to avoid the less serious type o f injury. E ven if pre-season training has been carried out for m any weeks, soft-tissue and other injuries are m ost c om m on in the first m onth or 6 weeks o f the season, although naturally, the better the player has prepared him self, the less liable he is to sustain | an injury. A s the players get fitter and m ore hardened, especially in body-contact sports lik e rugby, the injury rate drops; then, tow ards the end o f the season, w hen fatigue and staleness set in, and chronic injuries begin to need not only treatment but also rest, a second peak o f injuries occurs. There are several types o f training, and the sportsman or athlete will c h o o se the kind m ost suited to his needs. In every case it is important to include graduated progressive resistance exercises, to increase the tone and strength of m uscles sufficiently to protect the joints over which they work, thus reducing the likelihood o f injury. A s it has been foun d that fully extensible m uscles are less prone to tears o n sudden exertion and fast m ovem ents, daily exercises to put the m uscles, especially those o f the legs, through their full range (plus a little overstretch) are also important. Bertie M ee, physiotherapist with the Arsenal F ootb all Club, states that the incidence o f pulled m uscles has been re d u c e d considerably since this practice was introduced as a routine in training, and before participation in any game. Other points which are invaluable in pre-season training are: practice in falling, ending in a roll or somersault; attem pting to land on the m ore heavily-padded parts o f the R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNE, 1971 to d y in a fall, thus reducing the point o f im p a c t; learning to ‘giye’ when receiving the impact of, say, a cricket ball; and, o f the greatest im portance, learning to relax unneed­ ed muscles, in order to conserve energy for the task in hand and so reduce the onset o f fatigue. (A great deal o f information on this subject can be fou n d in W ells’s b ook on Kinesiology.) A d e q u ate w a rm in g -u p exercises b e fo re p a rtic ip a tio n in strenuous gam es o r a th le tic ev en ts a re im p o rta n t as a safe­ guard a g ain st so ft-tissu e injuries, a s — especially w hen ®0ld — su d d e n e x e rtio n is a fre q u e n t cau se o f p u lls a n d tears. A ccid en ts a lso o c c u r w hen a s p o rts m a n is to o tire d to be a le rt, a n d th e m uscles a re fa tig u ed , w h ich u n d e rlin es the necessity o f c o m p le te fitness b e fo re c o m p e tin g in a n event o r p laying in a m a tc h . I am well aware that a great deal o f this is outside the province or control o f the physiotherapist, but it is o f interest to know , and it m ay be o f help in advising sportsmen as to the value o f these procedures. t y p e s o f i n j u r y F O U N D i n s o m e d i f f e r e n t S P O R T S The m ain injuries occurring in sport and athletics are muscular strains or tears; contusion s and haem atom as; joint injuries, with cartilage, capsule and ligam ent involve­ ment; and bony injuries, including fractures arid bony haematomata. In rugby, it is the backs w ho suffer the m ost leg injuries o f all kinds. Ham string injuries are m ost co m m o n am ong the wings, possibly because they are frequently called upon to make a sudden sprint, or swerve at speed after a period o f reduced activity, when the m uscles have lost som e o f their warmth and are unable to take the load without som e fibres being stretched or torn. These tears also tend to occur towards the end o f the game, when the player is fatigued or loses concentration. The backs also suffer shoulder injuries from tackles and falls. Scrum-halves get acrom ioclavicular strains and c o n ­ tusions from dive-passing, as well as being subjected to face and hand injuries. Am ong the forwards, back-strain is com m on , and face, head, ear and neck injuries prevail, with the constant danger o f a cervical fracture-dislocation if the scrum collapses. Consequently it is particularly im portant for them to strengthen neck and back muscles. All players are liable to get contusions and haem atom as, and it is am azing that a far greater number o f m ore serious injuries do not occur follow in g hard tackles, or rucks and loose m auls; in fact, one frequently w onders h ow the chaps at the bottom o f a struggling, hacking m ass o f bodies ever get up at all, let alone in one p ie ce ! In cricket, bowlers are the m ost injury-prone as, in addition to leg injuries, they tend to stretch and strain back muscles and frequently develop supraspinatus tendinitis. Fast-bowlers often pull their external obliqu e m uscles (found on the left in right-handed bowlers), and spin- bowlers develop soreness o f the spinning finger. Among batsmen one sees contusions o f fingers, thighs, ankles, feet and knees; pulled m edial ligam ents or m enisci; sprained ankles; pulled leg m uscles; and som etim es strained backs. Fielders, too, pull leg m uscles and tendons, but suffer more finger and hand injuries, as well as straining acrom io­ clavicular joints, or shoulder tendons from dive-catches and throw-ins. Among athletes, hurdlers pull adductors and hamstrings; get contusions and haem atom as from hitting high hurdles, t so™etjn?e s .strain their mid-tarsal joints. High-jumpers get ankle injuries, shoulder or elb ow injuries from falling, ana contusions to the thigh from hitting the bar; long- jumpers develop bruised heels, and often get backache or Page 3 sacro-iliac strain due to the jerk o f landing. Sprinters mainly pull leg muscles. Discus-throw ers tend to develop a triceps extensor strain, and javelin-throw ers a type o f tennis-elbow , know n as ‘javelin e lb ow ’, and som etim es strain o f the deep m uscles o f the back. I, personally, have little experience o f soccer injuries, m ainly because m y practice is in a rugby-playing centre, but D o n a ld Featherstone’s b ook o n S p o rts Injuries deals specifically with these. A s a matter o f general interest, Tucker gives the follow ing ages as those at which a sportsm an reaches his prime in his particular sp o r t: in athletics, at about 25; in tennis and similar games, a couple o f years later; in football, at an average o f 2 8; and in cricket and g o lf, at 30 or over. P A T H O L O G Y Before discussing treatment it w ill be useful to outline briefly the b od y’s reaction to injury, in which, incidentally, reparative measures far in excess o f those required to restore and repair dam age are produced. T he normal tissue reaction includes inflam m ation and haemorrhage from ruptured blood-vessels; serum plus fibrin and w hite cells exude from the surrounding blood-vessels, and adjacent structures are torn or stretched. T he part becom es sw ollen and painful o n pressure, and m ovem ents becom e limited. In the next, or repair stage, the phagocytes try to absorb the break-dow n products and later fibroblasts grow in to repair the damage. The repair o f m uscle fibres, and even o f tendinous lesions, is g ood , especially jn youth, when the tissues are so versatile that they can repair, replace and even grow after injury. I f absorption o f effusion and space-occupying haem ato­ mata is delayed, or does not take place, the lym ph becom es organized and form s adhesions. Therefore, the m ore rapidly on e can disperse the swelling, and the soon er gentle stretching o f the reparative tissue to prevent it from contracting can be started, the better, and the less likely the sportsm an will be to develop a chronic condition. It m ay be worth stressing at this stage that the treatment for inflammatory conditions due to trauma is opposite to that for those due to bacterial infection. T R EA TM EN T According to m ost authorities o n the subject, com plete rest is only required in a few sports injuries, such as com plete rupture o f m uscle or tendon; in fractures; after dislocations, especially o f the elb ow ; in the presence o f m yositis ossificans, and in som e cases o f tenosynovitis. The value o f accurate diagnosis, the prescription o f Tanderil, Varidase, or similar drugs, early first-aid treatment, and im m ediate steps to com bat the injury and start rehabilitation in all other sports injuries cannot be overstressed. The m anagem ent o f the less serious type o f injury can be varied according to whether the sportsm an is hurt at the end o f the season or near the beginning o f it. I f the former, he may be patched up sufficiently to continue play­ ing if he wishes, and can then rest in the closed season. If, however, the injury occurs at the start o f the season, he should be m ade to wait until recovery is com plete before being allow ed to return to sport. F or the initial first-aid treatment o f all these injuries (and by this I m ean m edical and physiotherapeutic first- aid) the key-word is I C E . That is (i) ice-cold water com ­ presses or ice packs over the site o f injury, which lessens the bleeding into the tissues by axon reflex and so prevents, or reduces, the size o f the haem atom a; (ii) compression bandage’ over the area, or the application o f a Sorbo-rubber or felt pad, held in place by a crepe bandage; and (iii) P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 elevation o f the lim b, to prevent the spread o f swelling. This should be d on e as a routine for the first 24-72 hours, depending on the severity o f the injury, and the m uscle or joint should be rested in its m ost com fortable position. A t the sam e tim e the sportsm an should be instructed to apply ice or co ld packs at hom e, and to persist with gentle nori-weight-bearing exercises hourly, in order to keep up m uscle tone, assist absorption, and prevent the form ation o f adhesions. P hysiotherapy is started im m ediately, if possible, and don e 2 or even 3 times a day in the acute phase, so that the sw elling does n o t have tim e to becom e consolidated, and the repair and recovery stage is speeded up. M assage over the area should be avoided at first, but I find that very gentle effleurage around and above the injury helps to disperse effusion and relieves pain. H eat is contraindicated for an average o f 48 hours, because o f the bleeding into the tissues, but is needed after that in order to prom ote absorption. D iatherm y o f any kind m ay further engorge an already- distended part if it is used to o early, so that it is best to start with infrared, or a m oist heat such as H ydropak, or hot wet tow els to reduce m uscle spasm. A s the con d ition improves, short-w ave or m icrowave can be substituted, the sportm an’s hom e treatment can be changed to hot packs or contrast bathing, and all active exercises can gradually be increased — graded progressive resistance exercises being added as so o n as possible, and, later, gentle graduated training. O pinions vary as to the use o f ultrasound, but I personally find it invaluable, particularly for reducing effusions and haem atom as. C om bined w ith m assage and other p h ysio­ therapy m odalities, I use it from the outset, starting with a very low dosage for a few m inutes around and above the lesion, gradually including the w h ole area o f injury. Tucker prefers the use o f short-wave, galvanism , faradism or interferential currents. H e believed that the claims m ade for ultrasound were exaggerated and that it was o f very lim ited use. Since the publication o f his b ook In ju ry in S p o rt, how ever, I find that he has been ‘converted’ and it is no w used a great deal in his clinic. Williams approves o f ultrasound, and states that ‘faradism and galvanism are o f no value in the treatment o f m uscle injuries in athletes’ ; C em ey advocates m oist heat, such as w hirlpool baths or infrared through w et tow els and stim u­ lating currents and m assage; and also describes the use o f ethyl chloride or similar spray for sprains and even muscle lesions. I have foun d this quite a useful variation in m any cases, especially for those patients w h ose time available for treatment is lim ited (such as in visiting teams). For those unfamiliar with the technique, I shall describe it briefly: Surface anaesthesia produces relaxation and relieves m uscle spasm. If com plete relief is obtained, for instance in a sprained ankle, a sim ple sprain is indicated; if, however, continued deep pain persists, the dam age is o f a more serious nature. The skin m ust be unbroken for this treatment, and a thin layer o f V aseline should be spread over the area to protect the skin. A fine spray o f anaesthetic is directed at the part for abou t 45 seconds, or until the skin blanches, and then the physiotherapist’s hand is placed over the area. This is repeated and then tests are d on e to localize the points o f pain. R epeat again o n trigger poin ts and re-test, doing active m ovem ents and gentle passive stretchings or m anipulations. T he lim b or joint should then be bandaged so as to give rest and support to the injured part, and the patient is instructed to apply cold packs and do gentle non-w eight- bearing exercises at hom e, in add ition to reporting for daily physiotherapy. A fter that, the routine progresses as it does JUNE, 1971 for the other__types o f treatment, with contrast bathing at hom e replacing cold packs, and so on. Physical fitness, which takes m any ‘weeks o f training to obtain, is only m aintained through physical activity; this level o f fitness falls o ff rapidly w hen training is discon­ tinued, even for a few weeks. T he enthusiastic sportsman needs no encouragem ent to take an active part in his own rehabilitation, and the m oralebuilding effect o f intensive active treatment, together with the use o f modified, graded progressive resistance and training during his recovery period, is o f enorm ous physical and psychological benefit. Featherstone, o f the Sou tham p ton F ootb all Club; Mee, o f the Arsenal F ootball Club; and Pye, who accompanied o n e o f the W est Indies cricket tours — all o f w hom are Chartered Physiotherapists — advocate im m ediate intensive active treatment along the lines I have m entioned, and obtain greatly reduced periods o f disability thereby. T he m ain problem one encounters with the average sportsm an is, in m y experience, that o f dissuading him from returning to sport too soon . M y com posite m ental picture o f som eon e suffering from a sports injury is that o f a patient, with an expression o f m ixed agony and apprehension, plus a touching dash o f faith, w h o hobbles in hardly able to put his fo o t to the ground, and turns out to have a severely sprained ankle; a partial tear o f hamstring or quadriceps; or a pulled m edial ligam ent with effusion of the knee; saying hopefully, ‘I will be able to play o n Satur­ day, w o n ’t I? ’ G enerally speaking, it is useless to warn a youn g sports­ m an that if he does not wait until his injury is healed before returning to sport, he may, for exam ple, injure a strained joint sufficiently badly to cause a traumatic arthritis and dam age him self for life. T o teenagers and those in their twenties, m iddle age is so far o ff that they cannot even envisage it, and they are quite prepared to risk a hypothetical permanent disability in their anxiety to resume playing. Consequently I usually find that the only w ay to restrain them is to stress the fact that they will let d ow n their teams if they are n o t com pletely m atch-fit, or if they have to leave the field, or com plete the gam e as a passenger if the injury breaks dow n. SP E C IFIC IN JU R IE S 1. M u sc le Lesions A m on g atheletes and sportsm en, muscle lesions occur in the follow in g order o f frequency: hamstrings, quadriceps, calf, adductors, external obliques, dorsal and intercostal m uscles. T endon pulls, which usually occur at the teno-( periosteal junction, are m ost c om m on in the tendo-calcaneus, and then the supraspinatus. Causes. There are m any theories put forward to explain the incidence o f m uscle tears, but the exact cause is not yet know n. Tucker believes they are due to a postural fault ; Williams thinks that a breakdow n occurs in the co-ordination of the ‘tw o-span’ m uscles (i.e. in the hamstrings, quadriceps and c a lf muscles, each o f which performs two actions), so that b oth prime m over and antagonist contract together, instead o f one giving w ay to the other. Travers c o n s id e rs that faulty technique (o f which ‘overstriding’ is a symptom, and which he blam es for ham string tears) is the cause; and b oth Lloyd and Archer believe that frictional resistance is to blam e, the former considering it occurs in a fully s tr e tc h e d m uscle, and the latter in the relaxation phase. S ig n s a n d sy m p to m s. A ‘pulled’, partially torn or r u p t u r e d m uscle presents with loss o f function, tenderness l o c a liz e d to the injured m uscle, and pain (dull or acute, a c c o r d i n g to the severity o f the lesion) which is produced on active m ovem ent or passive stretching, and, in m y e x p e r ie n c e , always provoked by resisted active m ovem ent. There may be protective m uscle spasm , and there is often m a r k e d P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNE, 1971 P H Y S I O T H E R A P Y Page 5 swelling; in the case o f a rupture, a gap can be felt in the muscle fibres. Treatm ent. Tucker stresses that rest and strapping only, even for 2 w eeks, will n o t cure m uscle tears, which are likely to recur as so o n as any strain is put o n them, but with proper treatment they should be at least 80 per cent recovered in that tim e. Full fun ction will have been regained a nd there should be n o pain o n ordinary normal m ovement, but the muscles need at least 1-2 m ore weeks, in which time strengthening and stretching exercises sh ould progress and training be gradually increased, before they will be fully fit to return to sport. R o u tin e p h y sio th e ra p y and hom e tre a tm e n t a re carried out, with the em phasis o n obtaining a full pain-free stretch o f the affected m uscle. Labile faradism can be given, as long as the fibres are n o t over-tired, and som e authorities advocate deep frictions as the condition im proves, to over­ come the form ation o f adhesions. This I have not usually found necessary, except in the chronic ‘k n otty’ type o f muscle, as long as active exercises and gentle passive stretchings have been don e from the com m encem ent o f treatment. In the case o f a hamstring or gastrocnem ius pull, I find that a Sorbo-rubber heel-lift, worn in the sh oe or boot, is a great help in reducing the strain o n the injured muscle fibres and in relieving pain. In strains resistant to treatment it is always wise to have the patient, how ever youn g, checked for a toxic focus — a fact stressed by Sir A d olp h e Abrahams. 2. Contusions a n d H a e m a to m a ta The sym ptom s o f a haem atom a are very similar to those o f a muscle lesion, but there is usually a history o f a definite blow or fall. T he sw elling m ay be m ore diffuse, the tissues being very tender, and often fun ction is lost. I f these are not treated early, shortening o f m uscles and tendons may develop and the sw elling becom e consolidated, recovery being retarded by the clot. Treatment. It is the op in ion o f a great m any authorities that the best w ay to deal with large haem atom as in the thigh or buttock, which will take weeks to disperse, or with those which form a fluctuant sw elling o n the surface o f muscles, is to aspirate or express them through a small incision. For those not requiring aspiration, the routine first-aid and physiotherapy are given. Ice should n o t be used for more than 2 days, as once the clotting has been controlled the further use o f ice will m ake the congealed b lood into a hard indissoluble m ass. I find it a g ood idea to keep the muscle stretched, w ithin the lim it o f pain, w hile applying ice and ultrasound in order to help prevent contractures. It is important to note here that in the case o f a haema­ toma o f the thigh, if there is any reduction in the range o f movement, or little or no relief o f pain after a couple o f treatments, the com m encem ent o f m yositis ossificans should be suspected, and the patient im m ediately referred back to the doctor, as physiotherapy or even active m ovem ent can encourage this condition. The period o f disability follow in g a haem atom a m ay be anything from a few days to 3 weeks or m ore, depending on the severity o f the con d ition and the speed with which treatment has been com m enced. •A P °in t to re m e m b e r w h e n tre a tin g a c o n tu s io n o v e r the Patella is th a t th is m a y b e follow ed b y c h o n d ro m a la c ia Patella, because o f th e u n d e rsu rfa c e suffering a c o n tre - coup injury. 3. Joint Injuries The m ost com m on o f these am ong sportsm en and athletes rc knee and ankle injuries, follow ed by those to the acrom io­ clavicular joint. Pain and tenderness are usually less localized in a jo in t injury than in a m uscle lesion, unless a ligament only is affected. M ovem ent is painful or there is a painful arc o f m ovem ent, and there m ay be protective spasm o f a group o f m uscles. (a) T h e k n e e jo in t. Particularly in rugby, the knee is the m ost often injured, by either direct or indirect means. Every variation is seen, including acute flexion injuries, which sprain the join t; abduction injuries, which involve medial and lateral ligam ents; and rotation injuries, with displacem ent or tearing o f menisci and ligaments. Traum atic synovitis is concurrent with nearly every acute knee injury, and the effusion occurs within 6 hours or there­ abouts. A m ore rapid or im m ediate sw elling m ay indicate an acute traumatic haemarthrosis, which needs m edical atten tion and aspiration at the earliest possible m om ent. It is not usually necessary to aspirate traumatic effusion if the first-aid routine o f ice packs, com pression bandage and rest in elevation has been carried out. A d ded to routine treatment, faradism under pressure is helpful in reducing effusion, as well as for stim ulating the vital quadriceps which should, if at all possible, be m ade stronger than they were before the injury, so as to protect the knee joint. Fortunately the sportsm an usually has a very well- developed quadriceps, so that he regains ton e and strength rapidly, but w h en treating a k n ee it is im portant to pay atten tion to the hamstrings as w ell. T o o often they are neglected and becom e shortened during the tim e the sports­ m an walks with a bent knee; consequently, after the knee injury has apparently fully recovered, the sportsm an fre­ quently suffers a ham string tear. Com plications to watch out for are Pellegrini’s disease, which is ossification at the femoral attachm ent o f the medial ligam ent, and chondrom alacia patella, in which localized tenderness develops on both sides o f the patellar tendon, and marked grating is present. I f either condition is suspected, treatment should be stopped and the patient referred back to the doctor. S p ecific e xercises f o r k n e e injuries. Beware o f allow ing too-early weight-bearing, w eight-lifting or strenuous m obi­ lization o n an injured knee, or there will be a recurrence o f effusion. The progression o f exercises sh ould be gradual, and the patient should be able to do a full knee-bend w ithout pain before being allow ed to return to sport. U seful strengthening exercises fo r the sportsm an include the use o f a weighted b oot, starting at 5 lb and building up in patterns o f 10 lifts before a rest period, and progressing both in weight and num ber o f lifts; resisted flexion and exten sion against a spring, or self-resisted; stepping-up activities onto a bench, carrying a progression o f weights in the hands, or across the shoulders on a bar-bell (M ee); knee-bend and stretch, carrying a gradual increase o f weights on a bar-bell across the shoulders (Featherstone); sw im m ing and bicycling, o f course, and Thorndike’s exercise o f raising the b od y from and lowering it to a chair, with the feet together and the arms folded across the chest. O ’D on ogh u e, incidentally, prefers three-quarter knee- bends to full, a s he feels that in deep knee-bends and ‘duck waddle’,, where the heel is jam m ed against the buttock, there is danger o f a posterior tear o f the medial or lateral m eniscus. (b) T he a n k le jo in t. In the ankle, the lateral ligam ent is the m ost com m on ly to m , due to sudden inversion strains. M any cases o f chronic sprain and ‘weak ankle! are due to neglect o f tears, or ill-treated original injuries, and routine early first-aid and progressive treatment, including a slow build-up o f m obility and strengthening exercises, is m ost important. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y JUNE, 1971 Table I. D etails o f sports and athletic injuries treated C ric ke t - tIP << 22 14 6 5 10 12 6 5 11 62 24 26 11 3 6 228 a v. S! iS"® Injury M uscle lesions Ham strings Quadriceps A dductors C alf Externa] obliques Scapular m uscles K nee injuries M edial ligam ents M edial m eniscus Lateral ligam ents Lateral m eniscus Capsular and synovitis H aem atom as Back and neck strains Sprained ankles Shoulder ~\ Including injuries >■ strains and Arm injuries J sprains A chilles tendon pulls Total cases •R ecurrences: ham strings, 9; adductors, 2; rectus femoris, 3. ■(•Complications: chondrom alacia patella, 3; Pellegrini’s disease, 2. {C om p lication : m yositis ossificans, 1 case. ■ &•4eo s§ £ 5 .5 S to J?'S to a 3 to i Total 2 1 12 2 — — — — 1 — 40* 1 6 1 22* 3 5 ____ — — — 1 — — 15* 2 — — — — — 1 2 10 6 ___ 2 — — 1 — — — — 9 1 — 2 — 8 4 3 2 3 ____ 2 — 1 4 2 311" 3 2 2 2 — 2 — 2 1 3 29 2 1 2 2 — 2 — 2 1 — 18 1 1 1 ____ 1 — 3 — 1 13 2 4 2 1 — 2 — 3 — 1 26 4 12 7 8 — 2 — 3 — — 98* 13 3 4 3 5 5 — 4 2 1 64 3 7 7 5 — — — — 4 3 55 7 3 5 — — 1 4 — — — 31 7 ___ ____ 3 ____ — 7 20 1 2 ____ 3 — — — — 6 2 20 ___ ________ ________ ____ ___ ---- ---- ---- ---- ---- ---- 53 40 66 31 5 18 7 19 20 22 509 A ll ankle injuries o f any severity should be X-rayed to elim inate fractures, and this is one jo in t in which strapping for up to several m onths sh ould be applied w hen the sports­ m an returns to sport, because o f the frequency o f recurrences o f sprain. In the treatment o f these injuries, because o f the frequency o f adhesion form ation, active flexion and extension exercises, modified weight-bearing and early walking are encouraged. Except in severe cases, the use o f crutches is n o t desirable. A Sorbo-rubber heel-lift in the shoe, to keep the ligament in its shortest position , and a not-too-elastic crepe bandage, correctly applied, are great aids in returning the patient to walking w ithout a lim p at the earliest possible m om ent. C om plications. T he follow in g should be watched for and dealt with during treatment: concurrent strains o f the longitudinal arch; tenosynovitis in front o f the ankle and along the dorsum o f the f o o t ; thickenings, which m ay form o n either side o f the A chilles tendon, due to bleeding from the strained ligam ent, and occasion ally wasting o f the quadriceps, due to early tip-toe gait. T o avoid adhesions, full-range ankle exercises against resistance, with particular em phasis on obtainin g full plantar flexion (especially in the case o f footballers, as the fo o t is forced into plantar flexion w hen kicking a ball with pow er), and gentle passive m anipu­ lations at every treatment are necessary. I f pain and stiffness persist after about 8 w eeks,-adhesions have probably form ed, and a m anipulation under anaesthesia will be indicated. A s adhesions take at least 2 m onth s or longer to becom e avascular, how ever, a too-vigorous m anipulation before this tim e will tear fleshy vascular tissues, resulting in haem orrhage, fibrin and serum exudate and so on, and the patient will be back to square one! Specific exercises f o r a n k le injuries. A d ded to routjne exercises are tip-toe walking; heel raising and low ering w hile standing o n a brick to increase dorsiflexion; progressed to the sam e exercise carrying a w eight across the shoulders; bicycling; walking up and d ow n an incline board (the greater the incline, the greater the stress o n the ligaments); heel raise and lower, follow ed by deep knee-bends; pushing balls o f varying weights and sizes with the fo o t in soft sand or water; and the norm al progression from walking to jogging, skipping, stop-start running, and finally sprinting and swerving at speed. In the treatm ent o f the sprained ankle, there is a marked im provem ent for the first few days, which is follow ed by a static period o f 3-4 days — abou t which the sportsman sh ould be warned — after which there is a second rapid- recovery stage (Featherstone). T he best w ay o f strapping an ankle for sport is to use a stirrup o f 3-in. extension plaster, fixed, with the pull towards the side o f the injured ligam ent, by a figure-of-eight in 3-in. Elastoplast. T his will lim it inversion and eversion as well as extreme plantar flexion, but if it is to o firmly applied a mid-tarsal strain m ay be produced w hen a football is kicked. (c) O ther injuries. I shall not discuss any other injuries, except to m ention that — again because o f the danger o f adhesion form ation — all shoulder injuries should be given m odified active exercises from the outset, starting with pendulum m ovem ents, but n o forcible m ovem ents or manipu­ lation s should be attem pted until all pain, especially pain at nigh t, has ceased. It is also worth noting that in a sprained shoulder, with lo ca l sw elling and pain o n m ovem ent, if m ovem ents decrease in spite o f treatment or the m uscles fibrillate o n initiation o f m ovem ent, the patient sh ould be referred' back to be checked for a toxic focus. P E R S O N A L F IN D IN G S O n goin g through m y case cards for the last 6 years, I find that I have treated 585 sports and athletic injuries, o f which R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNE, 1971 males m ake up at least 80 per cent. Seventy-six o f these cases comprised fractures, subluxations, bursitis, tenosyn o­ vitis, and postoperative patients, and the rem aining 509 cases are analysed in T able I, The treatments I use as routine are those I have already outlined, and once the acute phase has passed I am a great believer in the ‘tre a t and tr a in ’ m ethod as advocated by F e a th e rsto n e. Early intensive treatment reduces disability time greatly, the risk o f m inor injuries becom ing chronic due to neglect is lessened, and general fitness and morale are kept high. In Table II I have com pared the average disability tim es o f patients w ho were referred imm ediately or within 48 hours o f injury for treatment, and those who reported after varying periods o f rest. W hen com piling this table I did not differentiate between mild and moderate or severe cases, so that these are over-all averages for the specific injuries m entioned. Table H Disability Time in Relation to D elay in Receiving Treatment T reatm ent A verage tim e Injury c o m m enced w ithin: o f f training Muscle lesions 48 hours 6 days 3-24 days 18 days Injured knee ligam ents 48 hours 10 days 3-21 days 32 days Sprained ankles 48 hours 5 days 3-21 days 15 days Haematomas 48 hours 5 days 3-22 days 24 days A s will be seen, the tim e spent o ff training was reduced to one-third in the cases o f m uscle lesions, knee-ligam ent injuries and sprained ankles, and to less than one-quarter in the case o f haem atom as. I have been pleasantly surprised by these figures, but have, o f course, n o w ay o f comparing them with results achieved by other m ethods. Rehabilitation after injury is extremely im portant, and a full physical fitness test should always precede the sports­ man’s return to full participation in his particular sport. Thus the recurrences o f m uscle lesions and sprained ankles, so often seen, would be reduced, and aggravation o f existing injuries lessened. T his is, o f course, the ideal condition, seldom attained w ith amateurs, except perhaps am ong schoolchildren, w h o are m ore strictly controlled by coaches on the staff, or top-flight athletes, w hose trainers guard and nurse them. F or the rest, it is usually left to the individual to make a decision as to when he is fit to return to sport, and the best advice o n e can give them is ‘W hen in doubt, don’t'.' T o carry out the intensive active treatment outlined, and to return the sportsm an to his particular sport as so o n and m as fit a condition as possible, one needs early diagnosis and prescription o f the required drugs and treatment by a sports-minded doctor; intensive but carefully graded treat­ ment by the physiotherapist; the carp'ing-out o f hom e treatment and the perseverance with active exercises by the patient, and, ideally, co-operation o f coach or trainer. This type o f work is m ost rewarding, and the co-operation, enthusiasm and gratitude o f the sportsm an or athlete for any assistance in his battle for recovery from injury m akes him a pleasure to treat. S U M M A R Y J h e isoft-tissue injuries m ost frequently occurring in sports and ahtletics are briefly discussed, and the routine active Page 7 treatments fou n d m ost successful are outlined. The incidence o f these injuries sustained in different sporting and athletic activities am ong 509 cases treated in a 6-year period is recorded, and so m e statistics o f relative disability periods are given. There remains little doubt that the essence o f h a n d l i ng sports and athletic injuries is prom pt diagnosis and the initiation o f early intensive active treatment, follow ed by a planned cam paign o f rehabilitation. This could be the m ost easily obtained if recognized sports injury clinics were established, with the stress on full co-operation between patient, doctor, physiotherapist and coach or trainer. B IB L IO G R A P H Y Cerney, J. V. (1963). E ncyclopedia o f A th le tic Injuries. Springfield, 111.: Charles C. Thom as. C olson , J. H . C., and Arm our, W . J. (1968). S p o rts Injuries. L on d on : Stanley Paul. F eatherstone, D . F . (1957). S p o r ts Injuries. Bristol: John W right & Sons. G ranville, M . (1965). Chartered Society o f Physiotherapists Journal, 51, 114. M ee, B. (1965). Ibid., 51, 117. O’D o n o g h u e, D . H . (1962). T he T rea tm e n t o f Injuries to A th le te s. Philadelphia: W . B. Saunders. Pye, D . (1965). Chartered Society o f Physiotherapists Journal, 51, 121. ' ’ T horndike, A . (1948). A th le tic Injuries. L ond on: Henry K im pton. Tucker, W. E. and Arm strong, J. R . (1964). Injury in S p o rt. L ond on Staples Press. W ells, K . F . (1961). K inesiology. Philadelphia: W . B. Saunders. W illiam s, J. G . P. (1962): S p o rts M edicine. L ond on: Edward Arnold. S H O U L D E R F L A S H — S O U T H A F R IC A N SO C IE T Y O F P H Y SIO T H E R A P Y Blue base with silver-grey embroidery. Obtainable from Branch Secretaries. P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )