First aid, immediately following injury, is the start of rehabilitation. Much of the advice offered is not new; it is the first treatment in a continuing plan, rather than first aid. The more severe type of injury is dealt with because many of the knocks or damage sustained during sporting activity are of a minor nature and, though causing excruciating pain for a short while, can be treated effectively by ‘cold sponge, reassurance and a rub’.
The importance of fitness in preventing sports injuries is well documented and many authors have shown that consideration must also be given to clothing and equipment (Williams, 1965; O’Donoghue, 1970).
PRINCIPLES OF TREATMENT
Pitfalls are many and can best be avoided by experience; basically one must not be over-enthusiastic or too timid in approach. Often a rigorous attitude will achieve results but so also can a more conservative approach. A tremendous responsibility is placed upon the first person to treat an injury. The pressures can be enormous in assessing when to allow a player to restart; what are the economics and the match importance; what to do at the moment which will bring about a perfect result later; and there are many others. In gaining experience what does one consider? The following recommendations are offered as guidance and not intended to be absolute.
Functional anatomy and kinesiology
It is a distinct advantage to have a sound basis of functional anatomy and the study of movement in injury and in health. Study of movement is reinforced largely by experience and one needs to understand the movement that will cause injury (Browning, 1976).
This is the province of the doctor but those who are seeing the injury first should be able to diagnose the average sports injury. Many of the treatments recommended are only first aid, subsequent treatment has to be carried out under the supervision of a doctor who will make his own diagnosis.
Correct diagnosis is important, otherwise essential immediate treatment is directed towards the wrong aims and valuable time is lost. The work of Cyriax (1978) is a valuable aid.
Speed of treatment
Action must be taken at once and the injured person must be made to do something in return. In most sports injuries the length of the disability period depends upon the speed with which the initial treatment is made. This refers only to acute recent trauma which has a more pressing need for instant response. Stress injuries usually have a chronic cause but often they have an acute end or result which may require first aid treatment. Overuse injuries of ligaments or tendons are usually chronic conditions unless the overuse produces attenuation and then rupture.
Prevention of further injury
The steps taken during the first aid period should always consider prevention of further injury. For this reason, returning to competition supported by strapping or bandage is not favoured unless the latter is to cover a mild or moderate graze. Application of strapping or bandaging may mask a worsening situation or may serve to shift stress to some other area and cause injury.
No one who has had a local anaesthetic injection into a lower limb ligament or joint should be allowed to restart match play (Williams, 1965). A tennis or table tennis player may get away with it if it is the arm not being used to hold the bat or racket.
Know when to call a doctor
Recognise when you are out of your depth. The list provided by Williams (1965) gives some precise advice in this area. It includes, for example, all cases of head injury involving unconsciousness for more than ten seconds; all cases of minor injury where there is no marked improvement after 48 hours; and any or all cases of doubt.
The majority of sports injuries are slight, but severe and very severe injuries can be sustained and the first aider should be prepared for them. Here are some rules to follow.
Send for an ambulance without delay. Procrastination is pointless.
Bleeding should not be stopped by applying a tourniquet. If a tourniquet is forgotten or left on for too long, gangrene can follow devitalisation of tissue. The bleeding can usually be controlled by either digital pressure over a pressure point, or by dressings over the site of the injury. The technique is to soak up the blood by applying sufficient pads. A shell dressing of the type issued to HM Forces is ideal.
The unconscious person should not be moved until fully recovered. Concussion is an ever present danger. Loosen tight clothing and cover the person with a coat or blanket if conditions warrant it. Immobilise the injured person. If consciousness is regained quickly, allow the person to stay until his mental faculties are recovered. An escort must be provided to the dressing room or car where a period of rest should be encouraged.
In no circumstances should the injured person be allowed to resume play after prolonged unconsciousness.
In unconsciousness, steps must be taken to prevent the tongue falling back and the airway being blocked. This is achieved by: (a) Turning the head to one side with the person lying semi-prone. The tongue can be fixed by inserting an airway (if one is available). (b) Removing dentures. (c) Allowing ample fresh air. (d) Allowing nothing to be given by mouth while semi-conscious. This is particularly important after recovery of consciousness if there is any likelihood of an operation being necessary. Food or liquid contents of the stomach may delay anaesthesia because of the danger of vomiting. (e) It may be necessary to commence artificial resuscitation; ‘mouth-to-mouth’ or ‘mouth-to-nose’ breathing is the method of choice unless there are facial injuries (Figs. 34/1 and 34/2). External cardiac massage may be required if it is thought that breathing has ceased . Anoxia will lead to cardiac arrest. (f) If the person is pale, the head should be lowered if possible; and if the person is flushed, the head should be raised. The former indicates a drop in blood pressure and the latter a rise.
This is a disorder of the nervous system causing sudden complete loss of consciousness often with convulsions and coma. Some sufferers may have warning of an attack and can take the necessary steps to be in a position of safety.
First aid is relatively simple if the condition is recognised. There must be protection from injury at the two crucial periods – onset and convulsions. If possible, a gag consisting of a folded handkerchief should be inserted between the teeth to prevent the tongue being bitten. In the absence of a proper mouth gag, a well-padded dessertspoon is an asset in a first aid kit. It is not always possible to put in a gag as the rigidity is almost immediate.
All tight clothing must be loosened to prevent constriction and when recovery is effected the patient should be encouraged to sleep.
Most epilepsy sufferers are aware of their condition except in the case of the initial attack due to an injury. It is wise to remain nearby until medical assistance is obtained. With increasingly better treatment more epilepsy sufferers will participate in sport and thus present a possible risk to themselves and others.
This may occur for a variety of reasons – a car or bicycle crash, a rugby tackle, or an awkward fall on rough ground. The person should not be moved unless absolutely necessary and, unless removal is from a burning vehicle or a similar awkward situation, the following technique is adopted.
At least three or four persons are needed. One person should time or control the lift and should be stationed at the head. The head should be in the neutral position with slight traction in the long axis.
Two or three persons are then deployed both sides of the body and legs so that the lift can occur evenly and just sufficiently to put a stretcher underneath. Body alignment must be maintained during the lift and the stretcher padded to maintain alignment. Flexion must be prevented.
If a fracture is suspected, the part should be immobilised with no other interference except to control any bleeding. To immobilise the part, a sling, the other limb, or any rigid object such as a tree branch- or a broom handle may be used. Await medical assistance and arrange transfer to hospital.
At the time of the injury keep the treatment to a minimum, help the patient to bear the pain, offer reassurance and give no drinks. Do not offer a cigarette unless asked for one.
COMMON INJURIES AND TREATMENT
Skill in treatment comes by experience. All persons, medically and non-medically trained, who are responsible for sports teams or individual athletes, should enrol on first aid courses. The local branch of the St John Ambulance Brigade is always very willing to help in this respect.
Contusions or bruises
These are usually caused by direct blunt violence or crush or direct contact with another performer and/or playing surface. Often the skin is unbroken although there may be extravasation because of damage to blood vessels. There may be some occlusion of capillaries and normal nutrition is impeded. The affected part stiffens because of pain, swelling and muscle spasm.
The aim of first aid is to limit bleeding by the application of a dispersant such as a solution of heparinoid and hyaluronidase (Lasonil) or a heparinoid gel (Hirudoid) (Quiles, 1965; Bass, 1969), cold compresses and pressure bandaging. If the haematoma is not too severe, or the sport is non-contact or the bruise is in a part of the body not vitally important to the performance, then the player may be allowed to continue. If strapping or bandaging is necessary then it is preferable not to allow the individual to restart.
Judgement needs to be exercised in restricting, for example, soccer and basketball players with upper limb injury, or racket/bat players with opposite arm injury.
Cuts and abrasions
These may be trivial superficial cuts, grazes or scratches, or may be deeper. They can be caused by sharp or blunt pressure on the body acting obliquely or tangentially.
A superficial bruise is red with excoriation of the skin. Scratches may be patterned if left by finger nails, studs or spikes. An abrasion may present with streaking or directional markings if the person is dragged along the playing surface. It is helpful to remember these markings in cases of inquiry into violence or breaking of the rules.
Superficial cuts are best cleaned with an antiseptic such as chlorhexidine (Hibitane) or chlorhexidine and cetrimide (Savlon) and collodion, or a dry dressing may be applied after using an iodine spray. An alternative is to apply sterile paraffin gauze underneath the dry dressing. To allow a player to continue to play it may only be necessary to spray the area with iodine or collodion or allow sterile talcum powder to ‘cake’ on the area.
Deeper cuts may require suturing. A gaping wound can be overcome by using thin strips of Elastoplast and placing them under tension at right angles to the wound and then bandaging over them. A puncture wound may hide a deeper more serious damage with internal bleeding.
The skull is a closed box and if knocked, the brain and blood vessels will absorb the shock. If the force is great enough a skull fracture or ruptured blood vessels may result; this can lead to pressure and brain damage. Any blow will also directly damage brain cells.
Loss of consciousness must be regarded seriously and anyone knocked out for more than ten seconds should not be allowed to restart and should be kept under observation for 48 hours, preferably in hospital.
This is a sustained painful spasm of muscle. One cause is the disturbance of electrolyte and fluid balance which affects the level of excitability of motor units. As yet, the phenomenon has not been completely explained.
To overcome cramp it is best to put the muscles on physiological stretch by working the antagonist strongly, e.g. if the calf muscles cramp, then extension by flexion of the knee and dorsiflexion of the foot is needed (De Vries, 1961; 1962). A passive stretch may be added to supplement the action of the non-affected muscle group. A frequent sufferer from cramp should be clinically investigated or at least advised as to the maintenance of a good fluid intake (Norris et al, 1957; Denny-Brown, 1953). Massage and heat are helpful in alleviating the condition.
This term is used to describe damage to muscle tissue. There are two types (chronic and acute) and four categories of strain (Ryan, 1969).
Chronic strain describes the overuse syndrome leading to fatigue and muscle spasm; specialist treatment is required. Acute strain is the result of a single violent force, usually to those muscles passing over two joints, and occurs by forcing contracting muscle to lengthen, for example by a blow.
In Grade I strains, damage is to very few fibres and the sheath is intact. They are treated by immediate application of ice lasting 10 to 15 minutes (Wooton-
Whitling, 1977), then compression bandage for 30 minutes to one hour, followed by gentle active stretching. Normal weight-bearing is allowed. Ultrasound may be given immediately.
In Grade 2 strains, more cells are crushed or torn, the sheath is still intact but bleeding is considerable. They are treated immediately with ice for 10 to 20 minutes and a pressure bandage is then applied. No active movement, stretching or weight-bearing is allowed for 24 hours but rhythmic static contractions may be possible if the pain is tolerable.
In Grade 3 strains a very large area of muscle is involved and the sheath is at least partially torn. Damage may be found in more than one area. Bleeding is considerable but it is more diffuse because of the torn fascia. The treatment is as for Grade 2 strains but arrangements are made for admission to hospital.
A Grade 4 strain involves a complete rupture of the muscle with an obvious gap between the ends of the muscle. Hospital treatment is required but immobilisation, ice and compression are needed immediately.
A sprain is an overstretch injury of a ligament at the extremes of range. It can be chronic or acute with three categories, Grade 1, 2 or 3, I.e. minor strain, severe strain and total rupture (Colson and Armour, 1961; Featherstone, 1957). In all these injuries there is pain, swelling, tenderness at the site and some loss of function.
Movement will cause pain and thus the site may be either muscle or ligament, I.e. a contractile or non-contractile structure. To differentiate, the muscle is contracted strongly isometrically (static). If this causes no pain it is non-contractile tissue which is affected; conversely, if pain results contractile tissue is involved (Cyriax, 1978).
If damage is negligible, an aerosol refrigerant (Coolspray) may be applied and the player allowed to continue when the pain subsides.
If the injury is minor (Grade 1) although a few fibres are damaged then apply ice for 10 to 15 minutes, with cold compresses and a pressure bandage to the affected joint in the neutral position. If the injury is to the lower limb the patient is allowed to walk but is not allowed to do anything else for 24 hours. Rhythmic isometric contractions of the major muscle groups should be encouraged at once.
A Grade 2 sprain requires a greater force for the injury to occur and unless the therapist is experienced then the patient should see a doctor. Again, ice and a cold compress under a pressure bandage are essential, with the joint placed in the neutral or shortened position. Rest and elevation are required for at least hours, and no weight-bearing is allowed. If the subject is well-motivated then isometric rhythmic contractions should be encouraged. The doctor may give a local anaesthetic but on no account should the patient be allowed to continue or restart playing, as a relatively minor injury may become a more serious one.
In Grade 3 sprains or a complete tear there may be rapid effusion with exquisite pain and tenderness; there is instability and complete loss of function. The injury must be seen by a doctor. The first aid treatment is splinting and rest in an elevated position to allow for reduction of swelling by gravity. The part can be treated with ice, or cold compresses; a pressure bandage should be applied with the ligament in the shortened position.
If rib fractures are suspected then the patient should not restart unless in a non-contact sport and even this may be a doubtful procedure. At the very least the exertion will cause more pain and at most, further damage to the rib cage may puncture the pleura and lead to a pneumothorax developing.
It is essential that the patient sees a doctor but the immediate treatment is rest in a sitting position. Strapping, though providing some relief by splinting the ribs, is not recommended as it tends to restrict breathing even more. It is prudent to restrict any strapping to the area overlapping the fracture but not all round the chest, and this only in respect of the lower more mobile ribs. The patient can usually be taught to fix the affected area with muscular effort and use the unaffected parts. If there is bruising only, the decision to allow a restart will depend upon the distress felt by the patient-when breathing and upon the importance of the event.
Injuries to the testes and scrotum
Bruising of the testes and scrotum occurs by direct body contact or a blow from apparatus or sports equipment. The injury is extremely painful and incapacitating for a short while though at times it may be more prolonged. In the latter instances the player is removed from the playing area and a sponge or towel soaked in hot water is applied to the scrotum. When the pain subsides the patient is encouraged to micturate. If the urine contains any blood, the patient must see a doctor.
Locking of the knee
Locking of a joint can be caused by extreme pain due to muscle spasm or by the interposition of a foreign body or torn cartilage. The knee joint is particularly prone and care must be exercised as this joint may become locked either by spasm of the biceps femoris due to injury at its lower insertion to the head of the fibula, or it may be caused by a tear in the lateral meniscus (Williams, 1971).
The patient with a locked knee due to a meniscus tear should not be allowed to restart. If it is caused by muscle spasm, this may be relieved by the use of an aerosol refrigerant (Coolspray) but otherwise the treatment outlined previously applies. ‘Winded’ players
A blow to the solar plexus produces a momentary paralysis of the diaphragm with spasm of the abdominal muscles. Consequently, respiration is impaired and the player may feel nauseated; he is said to be ‘winded’. Treatment consists of reassurance and allowing the person to adopt a comfortable position. Recovery is usually rapid and a cold sponge at the nape of the neck can help. If recovery is slow with signs of shock and restlessness, the player should be taken out of play and medical advice sought.
The most usual joints to dislocate are the shoulder and the fingers, especially in rugby players. Fingers are also commonly dislocated in basketball and volleyball. Reduction of the shoulder should not be attempted by the inexperienced because of the possibility of damage to the axillary nerve; very often reduction can be effected by the person himself with a little help. More precise information may be found in textbooks on fractures or orthopaedics, e.g. Colson and Armour, 1961; Featherstone, 1957; Adams, 1978. It is not advisable to allow the player to restart play and there should be at least two to three days rest of the arm in a sling if it is the first dislocation, and longer if the condition occurs frequently.
With finger dislocations or partial dislocations it is possible, after using Coolspray, to apply force along the axis and so reduce the joint. The affected finger is then immobilised by strapping it to adjoining fingers. The player may be allowed to restart but must seek medical help later.
First aid is the start of rehabilitation and is the first treatment in a continuing plan. Everyone dealing with sports people should have some knowledge of first aid and the principles of treatment will assume knowledge of anatomy, movement, simple diagnosis, speed in treatment and prevention of further injury. It is essential that personal limitations be recognised so that more specialist treatment can be instituted. Finally, it is important that therapists involved with sports people should gain skill in treatment which can only come by experience gained in the ‘park’.
Adams, J. O. (1978). Outline of fractures including joint injuries. 7th edition, Churchill Livingstone, Edinburgh.
Bass, A. L. (1969). Treatment of muscle, tendon and minor joint injuries in sport. Proceedings of the Royal Society of Medicine. 62, 925-928.
Browning, G. G. (1976). Sports medicine and the physiotherapist. Physiotherapy, 621, 246-250.
Colson, J. H. C. and Armour, W. J. (1961). Sports injuries and their treatment, Stanley Paul, London.
Cyriax, J. (1978). Textbook of orthopaedic medicine. Volume I. Diagnosis of soft tissue lesions. 7th edition, Bailliere Tindall, London.
Denny-Brown, D. (1953). Clinical problems in neuromuscular physiology. American Journal of Physiology, 15, 368.
De Vries, H. A. (1961). Electromyographic observations of the effects of static stretching upon muscular distress. Research Quarterly, 32, 468-479.
De Vries, H. A. (1962). Evaluation of static stretching procedures for improvement of flexibility. Research Quarterly, 33, 222-229.
Featherstone, D. F. (1957). Sports injuries: their prevention and treatment. John Wright, Bristol.
Norris, F. H. Jr., Gastiger, E. L. and Chatfield, P. O. (1957). An electromyographic study of induced and spontaneous muscle cramps. Electroencephalography and Clinical Neurophysiology, 9, 139-147.
O’Donoghue, D. H. (1970). Treatment of injuries to athletes. W. B. Saunders Co., Philadelphia.
Quiles, J. (1965). Enzymes in the treatment of acute sports injuries. Proceedings of the 5th Latin Congress Physical and Sports Medicine.
Ryan, A. J. (1969). Quadriceps strains, rupture and charley-horse. Medicine and Science in Sports, 1, 106-111.
Williams, J. G. P. (1965). Medical aspects of sport and physical fitness. Pergamon Press, Oxford.
Williams, J. G. P. (1971). Diagnostic pitfalls in the sportsman’s knee. Proceedings of the Royal Society of ^Medicine, 64, 640-641.
Wooton-Whitling, Y. (1977). Ice in the treatment of sports injuries. British Journal of Sports Medicine ,11, 146.