05 July 2016
Professor Sanjiv Jari talks us through preventing injuries in sport.
We are all told, repeatedly that sport and exercise is good for us and important for us to do, for various reasons, including weight control, mental and physical wellbeing, reduction of body fat, improving lean muscle mass, social interaction and so forth. However, if you play sport or do exercise, then be prepared to suffer injuries, which ultimately are the bane of sportsman’s lives. Injuries can be major, such as broken bones, major ligament tears or joint dislocations. More commonly however, they are minor niggles and sprains. Nonetheless, the effect is that it will prevent sporting endeavours and exercise, and may even prevent day to day activities and work, depending on the severity of the injury.
In sport in general, the most commonly injured joint in the body is the ankle, followed by the knee. Niggles are common and many sportsmen will play with some type of niggling, minor injury. This includes elite, professional sportsmen and weekend warriors alike. The problem is, that if not addressed appropriately, the niggles can turn into more serious and restricting injuries, which will have a significant impact on the individual.
Looking after niggles and getting back to sport, following injury
Most niggles would encompass muscle sprains, muscle pulls and joint sprains.
We have all played some type of sport and gone over on the ankle and sprained, strained or torn the lateral ligaments of the ankle (the ligaments from the outside of the ankle). Initially, for the first few days, the ankle will swell and be painful to walk on. This will gradually improve, but we may be aware of aches and twinges in the outside of the ankle, with our everyday activities and if we try to return, we will find that we do not have the confidence, the control, or the lack of pain to function properly. If we do try and play through it, then the usual result is that we will go over on the ankle again and we are back to square one.
The initial treatment of most “niggles” will be to rest the affected limb, ice the joint or muscle (ideally cold and compression is preferable), take painkillers, such as anti-inflammatories if they can be tolerated by the individual. Some of these injuries may result in patients seeking physiotherapy treatment. Generally, the acute phase will last a few days and then as the swelling and pain starts to improve, that is potentially the danger period, as returning to sport at this time will predispose the individual to getting either a re-injury or a compensatory different injury.
The best course of action with most, relatively minor injuries would be to seek the input of a physiotherapist or a sports therapist, to work on stretching the injured muscles or joints, working to normalise range of movement and then to commence some strengthening exercises. However trivial an injury is, it will result in pain and swelling, which will then result in muscle wasting of the muscles controlling that joint. In order to get back to sport safely, it is important to work on muscle strength and muscle conditioning, to get it back to normal and ideally symmetrical strength compared to the uninjured limb, before trying to return back to sports.
Once the muscle strength is more or less symmetrical, then the preferable route is to commence some sports specific agility exercises, which will be very specific to the sport that the individual wants to return to.
The aim of these really is to connect the damaged muscles to the brain and to engender what is called neuromuscular coordination and will include activities such as balance control, straight line running, change of direction activities, all of which are progressively increased. If the individual plays a ball sport, they would initially be done without any ball or equipment, but then the specific ball or equipment would be introduced into the rehabilitation. Assuming the individual tolerates this, they would then be deemed fit to return to training, before returning to playing.
If these niggles are treated correctly, the downtime from the sport can be minimised and the individual can safely return back to their recreational or professional sporting activities.
Returning to sport involves both physical and mental preparation. The physical preparation can be the easier one, especially if the sportsman has sustained a more major injury, such as anterior cruciate ligament tear of the knee, or a broken bone. The physical preparation once the injury is dealt with, which may entail surgery, will encompass what has been covered above, which is to reduce swelling, improve range of motion, strengthen the limb and progress through sports specific activities including neuromuscular coordination, such as eye to foot coordination in football. The improvement of balance and coordination is what will give the individual the feeling that they are playing to a normal ability for them. If these types of activities are not included in the recovery programme, then an individual may well return to sports, but they will initially feel awkward and clumsy and will not have the confidence in their ability, until their coordination, control and balance are fully functional.
The mental aspect of returning to sports is just as important. Many elite and professional sports will now use the services of sports psychologists, to help with this. This is especially true with more major injuries, where the mental fear of re-injury or lack of confidence can significantly reduce a player’s effectiveness and ability to play. Usually, mental preparation goes hand in hand with physical return, but occasionally, specific aspects of mental preparation have to be addressed. This may be something as straightforward as talking to other patients, who have sustained the same injury and the returned back to sport and talking through the routes taken and any tips and tricks that were used. It will also encompass encouragement by the treating therapy and/or medical staff, as well as the player’s friends and families. Occasionally however, specialist services, such as sports psychology or cognitive behavioural therapy may need to be employed.
The aim of returning to play after an injury, whether major or minor is to allow the safe return to play, in the quickest time, but without increasing the risk of re-injury.
Injury prevention is a hot topic at the moment in many sports. It encompasses many aspects, from protective equipment, rules of the sport through to training and even warm up and stretching.
Some facets of injury prevention are very obvious. This may include the use of helmets in collision sports, such as American football or cricket. It can include other pieces of equipment, such as gum shields in combat sports or shin pads, in football.
Equipment is an important part of any sport and the wrong equipment will increase the risk of injury. An example may be used in the wrong type of boots, for the playing surface that is being played on, such as using the wrong type of trainer, or boot, while playing football on a different generation of Astroturf that the footwear was designed for. Sports equipment should be the right size, for the playing individual. It should be well fitting, in good condition and essentially up to the job it was designed for.
The rules of many sports are there to protect the players and therefore, are also important in injury prevention. There are many examples of this, including outlawing punching to the back of the head in combat sports, not allowing a player to raise their boot above a certain height when challenging for a ball in a tackle in football. Rule makers have to be cognisant of the ages of players. There is a lot of research currently being done into concussion and head trauma in many sports. There is even work suggesting that children under certain ages should not be allowed to head the ball, as the child’s developing brain is very susceptible to even low level repetitive trauma.
One important focus of injury prevention is stretching and warm ups before playing. However, even this seemingly innocuous subject is not without controversy. There is evidence within the appropriate literature, suggesting that stretching and warm up actually provides no real protection from getting an injury. There is even some evidence to suggest that overstretching can result in more muscle injuries occurring during sport.
The role of warm up and stretching in sport has many potential aims. This includes raising the muscles temperature, to the optimal required for muscle function and also thereby increasing blood flow within the muscles, which will bring the much needed oxygen to them, to allow them to function. It will also increase the elasticity of the muscles, thereby reducing the potential risk of muscle pulls and tears, which can be the bane of certain sportsmen, such as sprinters and sportsmen playing sports involving short bursts of sprinting and change of direction, such as football and basketball. The warm ups should also start to gently put the body through drills that will reproduce what the player is going to do during the game. Finally, in my opinion, the warm up and stretching is also important, to focus the players mind on the task ahead and to provide some minutes, for the players’ to mentally prepare for what is coming up. It allows one to focus away from the distractions of everyday life and to think about the upcoming activity.
There is more evidence for the benefits of warming up, than there is for stretching. There are various types of stretching, including static and dynamic stretching. Static stretching is where a muscle is stretched to its comfortable limit, and the position held for a period of time. Dynamic stretching is to gently move a joint and during this movement, increase the stretching and tension within the appropriate muscle. A simple example for the hamstrings, for example for a static stretch would be to stand with the knees straight and then bend from the waist down, reaching the fingers towards the toes and then holding this position. A dynamic hamstring stretch may be to stand and swing a leg forwards and upwards, with the knee straight, to take the foot upwards, towards the upper body, which would dynamically stretch the hamstrings, as the leg reaches its upper limit of forward movement.
There are advocates and dissenters for both types of stretching. With static stretching, it has been suggested that the muscle can be overstretched, which will then reduce the functional power of the muscle and thereby potentially weaken it. With dynamic stretching, if it is done too vigorously while the muscle is cold, it can result in tearing, or straining of the muscle.
Generally, where there is evidence suggesting support and rejection of different ways of doing the same thing, it commonly indicates that neither method is necessarily better than the other and in essence, “there is more than one way to skin a cat”.
Muscle temperatures can be raised without active exercise, by using passive massage techniques, which are commonly utilised in professional and elite sport.
Ultimately, the sensible option is to utilise a combination of passive and then dynamic stretching. The aim should be to gently stretch the muscles, increase the blood flow, raise the temperature of the muscles and also start increase individual’s heart rates. This will all prepare the individual for their sporting endeavour and can get them both physically and mentally ready for the challenge.
There are other, specific injury prevention initiatives, that are the subject of intense research and are specific to one particular type of injury or another and possibly, in one specific target group.
In football, one of the big topics in trying to potentially prevent anterior cruciate ligament injuries. The anterior cruciate ligament is a major stabilizing ligament of the knee which is commonly torn in rotational sports such as football, rugby, basketball, netball etc. Anterior cruciate ligament injuries are much more common in women, than they are in men. There are lots of theories as to why this is, including the differences in anatomy between men and women. Women have wider hips and therefore, a greater inclination from the hip to the knee, which puts specific forces on the knee, which is less common in men. It may be to do with hormone differences between men and women, as female hormones, such as oestrogen and progesterone tend to soften ligaments. It could be due to muscle strength and function differences between the sexes. It has also been theorised that there are imbalances in muscle coordination and contraction, which may predispose women to tearing their ACL. Additionally, there are theories revolving around the way men and women play the same sport being different.
For example, it has been shown that in women, they tend to play in a more upright position, whereas men tend to play with their knees more bent, which is seen more so in football and in basketball. When women land from jumps, they tend to do so with their legs straighter than men. These and many other factors, biomechanically, it is thought may be responsible for the higher risk of ACL tears in women.
Ultimately, one of the most important factors is that for a given height and weight, a woman’s anterior cruciate ligament is smaller than that of a man’s and this, in its own right, will increase the risk of damaging the anterior cruciate ligament in women.
There is much focus and attention at the moment, especially in the USA on prevention strategies, to try and reduce female ACL tears. This includes trying to teach female athletes how to jump and land and how to turn more safely, in a more bent knee position, by putting them through certain training programmes, to try and improve their neuromuscular coordination and engender these methods of jumping, landing and turning into the way that they sport. There have been some positive results with this, both in the sports of football and basketball from the USA, as well as from Scandinavia.
The problems however are that it is a lot easier to train someone to jump, land or turn in a certain manner, while they are training in a sport. However, when competing, people usually undertake what is natural to them, in the midst of sporting competition, during competitive play and many of the training methods, of learning how to jump, land and turn go out the window.
In order for these types of techniques to be ingrained, they would really have to start at a very young age, before the child “learns” their own way of playing sport and so these training techniques of jumping, landing and turning have been ingrained into their psyche.
The female ACL and its prevention of injuries is an important issue and research is ongoing in this. Ultimately, even though the numbers of injuries could be reduced, the likelihood is that it is always going to be more common in women, due to the fact that the ACL is smaller than it is in men.
Therefore, injury prevention covers lots of facets, as outlined above and will continue to be the subject of intense research.
Once the sport is completed, there is now focus and research on aiding an individual’s recovery from sport. In many professional sports, players are training 2 or 3 times a week and may play competitive matches once or twice, or occasionally 3 times a week. Therefore, their ability to recover from intense exercise is paramount. This has led into developments in nutrition, such as the use of recovery drinks, which contain optimal proportions of sugars, as well as protein. Exercise by its nature will result in muscle damage and muscle breakdown and therefore, if the building blocks of the muscle can be replenished, this should improve recovery, hence the theory of post-exercise protein based drinks. However, as with many other facets of sport, there is no agreement in the ideal type of recovery drink. It is important athletes are hydrated during their sport. Regular intake of fluid is important but again, the type of fluid is argued amongst experts.
Following playing, the recovery process begins. Nowadays, a commonly utilised tool to aid recovery is to bring the body temperature down, which will reduce the metabolism and will also protect the muscles from further breakdown. There are many ways of bringing body temperature down, whether this is using ice to the muscles, ice baths or even more scientifically, controlled methods of gradually reducing body temperature, such as using a device such as a Swellaway, which is soon to be launched, which will allow the ability to gradually reduce body temperature, but also to apply a determined amount of cooling to injured joints and muscles, which is something that cannot be done with ice alone or any other modality.
Therefore, the prevention of injury is a complex topic, but nonetheless an important topic, which is equally important for elite and professional sports, but also for the rest of us mere mortals, who enjoy undertaking exercise after work. The important things are to prepare the mind and body for the sport or exercise ahead. If one does sustain an injury, however minor or major it may be, it is important to recover from this and follow a sensible path, in returning back to sport, rather than just simply resting for a couple of weeks and then trying to play again, which, more often than not is doomed to cause either re-injury or further injury.
More information about injuries in various sports and specific problems associated with knee injuries and their rehabilitation can be found at www.thekneedoc.co.uk.
Sanjiv Jari is a consultant orthopaedic surgeon specialising in knee surgery. For more information or to book an appointment with Professor Sanjiv Jari, please call 0161 447 6700.
This article is only written to provide general information and should not be construed as specific advice, regarding specific injuries in individuals. If you have any queries or concerns, you should consult an appropriately qualified practitioner.