The generally held view of fitness for sport includes concepts such as the ability to reach high levels of performance, and the ability to withstand the stresses imposed on the sportsman by his participation. These two concepts are closely linked, but do lead to contextual applications which may generate conflicting aims and objectives in the minds of those who are concerned with the acquisition of fitness by sportsmen. In particular, increasing levels of performance are accompanied frequently by increasing levels of stress on the performer. If fitness to perform is improved without a simultaneous enhancement of fitness to withstand competition stress, the performer is prone to become overstressed. In other words, the result is that the individual is strained or injured.
Clearly therefore, the development of sport fitness in training must include injury preventive elements, since the occurrence of injuries is counter-productive in performance terms. The fitness status at which training is initiated may he anywhere along the continuum of fitness, and is often temporarily depressed by injury. Rehabilitation from a sports injury is a special example of fitness training, but is still subject to the same criteria and principles as normal fitness training.
The majority of those who participate in sport, whether as trainers, players, spectators or others, have an imperfect and narrow view of what constitutes total fitness in sport. Most of those who participate actively, that is the trainers and players, are not educated in the theory of sport, and are unqualified in a formal sense for the task of achieving optimal fitness. The professional preparation even of qualified coaches and trainers, in this country and many others, is sadly deficient in the general theory of sport fitness and methods of achieving fitness. National governing bodies of sport tend to concentrate on sport techniques and tactics in the training of coaches, and make little provision for the education of players. Attempts are currently being made to rectify this situation by the introduction of diploma and postgraduate degree courses in coaching theory and practice.
The major parameters of fitness in a modern performance context are: strength – the ability to exert force. speed – the ability to react and/or move quickly. This includes an optimal degree of joint mobility. stamina – the ability to maintain function over time. skill – the ability to select and execute effective and efficient methods of achieving sporting objectives. spirit – the ability to optimally motivate performance. sports medicine – the avoidance or minimising of injurious effects of competition and training stress.
While identifying these parameters separately, it is quite apparent that they are integrated completely in the sport performance. Strength cannot be viewed in isolation in a sport context. It must manifest itself for example in movement, e.g. speed; in isometric positions, e.g. stamina; in extreme positions, e.g. suppleness; in difficult manoeuvres, e.g. skill; with explosive determination, e.g. spirit; and without or despite injury, e.g. sports medicine. Similar links can be established between all the parameters, and fitness training programmes must reflect the concept of integration between them. The achievement of this integration is an extremely complex matter, involving constant optimisation of interaction between training elements, and frequent assessment of comparative priorities of different parameters.
Of particular importance in the sports injury context is the pan played by stamina. It should be appreciated that the capacity of a given function to cope with stress fluctuates during the competitive event. Particularly during phases of fatigue, there will be a diminishing of functional capacity which may fall below the level required to avoid strain. This phenomenon occurs during both local (or specific) fatigue and general fatigue. Local and general stamina (or endurance) training is an essential element of training for all sports, even those which would not be classed as endurance sports. In the latter case, the training routines for short duration sports may constitute a considerable test of endurance – quite apart from the endurance demands of repeated performances of a short duration activity during a competition. For example, a weightlifter’s activity is of very short duration, but the training sessions demand considerable endurance – as also does a competition, where the warm-up and series of competitive lifts generate significant levels of local fatigue.
An effective total fitness training programme should include elements catering for all fitness parameters. The prevention of, or rehabilitation from, sports injuries includes a large element of what may be termed ‘physical medicine’. The aims of physical medicine in this context may be in terms of strength, speed, stamina, skill and spirit. The physical medicine component of sports medicine is allied with other components, for example prophylactic, psychiatric, pharmaceutical. The total sports medical package should be thoughtfully integrated and the most desirable approach to the sports fitness/injury prevention may be achieved by the team approach .
The responsibility for prevention is shared between the coach and the doctor. Despite insightful prevention, injury may occur. First aid in the great majority of cases is undertaken by the players and/or the coach. This first aid is largely unqualified, usually idiosyncratic and superstitious, and frequently harmful. A fundamental necessity in the process of achieving and maintaining sporting fitness is proper sports first aid personnel. In most cases, the coach is the most feasible person to be trained to provide effective first aid.
The assessment of an injury and the prescription of immediate and successive remedy should be, in all except trivial cases, the business of a sports medical specialist. These specialists can be distinguished by their great scarcity, and by their difficulty of access to sportsmen. It ought to be the practice of all sports organisations to institute systems of immediate access to specialist medical attention. In very few instances is this practice a reality.
The rehabilitation of the injured sportsman must be a concerted effort involving the coach and doctor, and on many occasions the exercise therapist – either physiotherapist or remedial gymnast. There should be communication between these, and agreement on the aim of sport rehabilitation – which is to facilitate the return of the player to training and competition at as high a standard and in as short a time as the specific priorities of each player determine. It is perhaps superfluous to comment that this team-work in sports medicine generally, and rehabilitation particularly, is almost always distinguishably absent.
The stresses which, by virtue of being more powerful than the ability of the sportsman to withstand them, cause injuries may be classified into normal and abnormal. These apply both to acute and chronic stresses. Normal stresses may be defined as those which have a significant probability of occurrence during sporting activities. As usual in medical statistics, the level of significance will be determined by the critical nature of the injury which may be caused by the stress. If partial rupture of the hamstrings is sufficiently common in sprint running, and is such a critical injury as to prevent further competition for such a period of time as is likely to upset the competitive programme of the runner, then the causative stresses of hamstring rupture may be defined as ‘normal’ in sprinting. At the other extreme, peripheral soft tissue injuries suffered by professional soccer players who become the targets of missiles thrown by irate supporters are so infrequent, and of such little disabling effect, that they would fall outside the definition of’normal’ in a soccer context.
The implication of this classification for the fitness training of sportsmen is clear. Trainers should have clearly defined objectives which are stated in terms of the normal stresses of the sport, embracing both the achievement of excellent performance and the avoidance of injury. The training programme should be designed to equip the sportsman to deal successfully with these stresses. By definition, the training programme does not need to include elements which cater for abnormal stresses, except for a general training described later.
The relationship between the two training elements of performance and stress is not always obvious to the trainer. Some stresses are inherent in the performance itself, and are proportional to the level of performance. Of these some are exacerbated by the increased intensity of performance without the increased fitness operating as a preventive; for example, the degenerative effects of deep squat heavy weightlifting on the articular cartilage of the knee are proportionate to the amount and intensity of such lifting performed. On the other hand, others are prevented by the increasing fitness generated by the increased activity. An example of this phenomenon is the effect of increasing levels of performance on the ability of the cardiac muscle and circulation to cope with the increased stress.
Other stresses are not inherent in the performance itself, but are the product of a breakdown in performance caused either by a lack of fitness or by external forces which are not anticipated. The first of these present the trainer with the problem of developing the fitness of the performer in advance of the demands of competition, that is, to give the performer a level of fitness which is greater than that required for even maximal competition and thereby provide a margin of safety. Since all competitive performance involves an integration of many performance elements, it is very rare for any single element to operate at maximum even though the integration may be maximal. By carefully structuring training programmes, it is possible to isolate each major element of the performance, and stress it maximally by controlled overload. In many instances training is harder than competition.
Competitive strain from abnormal, unanticipated stresses is by definition impossible to plan for in training. If the stress is unanticipated its prediction cannot form the basis of a training plan. On the other hand, a ‘general avoidance skill’ can be developed in training. Such skill involves the development of awareness to danger, practice of avoidance manoeuvres, and effective use of stress absorption techniques. The Brazilian national football team includes training in gymnastic manoeuvres for this purpose.
The competitive requirements of sportsmen need to be analysed carefully from a stress viewpoint so that training programmes can be devised which will cater specifically for each of the categories of stress. Just as a failure to achieve high levels of performance may be viewed as a defect in an athlete’s potential or in his training, so may the occurrence of a sports injury be seen as a defect in an athlete’s basic medical integrity or in his training.
Sportsmen may compete for a variety of reasons, ranging from intense aggression and ambition to mild socialisation and well-being. Their motivation for competing may vary, therefore, both in intensity and in kind. When recuperating from an injury the treatment that a sportsman receives must be responsive to his personal motivations. Two extreme examples of this moderation of rehabilitation may be considered.
The first example would be a middle-aged sedentary person participating in sport mainly as a means of developing positive health. If such a sportsman suffered an acute injury to the Achilles tendon, the treatment should be conservative and accompanied by a lengthy period of rest in order to avoid the development of a chronic tendinitis since that would be counter-productive in health terms.
The second example would be a mature world class runner suffering a similar injury a few weeks before his last Olympic Games prior to retirement – with a significant chance of winning a gold medal. In that case many an athlete would choose to receive the most radical treatment, with no break in training, even if he realised that there was a high probability of incurring a severe chronic tendinitis which might necessitate a subsequent tendon strip.
Sports medicine, or rather the medical treatment of sportsmen, is bedevilled by an unsympathetic and unenlightened attitude from many practitioners. They should point out the risks of radical treatment to the intensely motivated sportsman, but should allow the sportsman to decide whether the risk is compatible with the rewards he seeks.
Such intense motivation on the part of a rehabilitating sportsman not only modifies the normal safety margins of conservative treatment, but also may affect significantly the normal recovery time from injuries. Particularly in cases where recovery is dependent upon initial fitness status, and upon the degree of effort in rehabilitation by the patient, sportsmen may decimate the normal recuperative period.
It has long been a medical precept that it is the patient who should be treated rather than the disease. Patients are individuals. In the case of fitness for sport, both preventive and remedial medical practice should be based on an enlightened attitude to the needs of competitors (of their specific sports and their specific personae), and an understanding of the place of medi- cal treatment within the training programmes of sportsmen. This can only be achieved by a conscious and concerted effort by competitors, trainers/coaches, administrators, doctors and paramedical practitioners to inform and learn from one another. All must realise that fitness for sport and the training programmes which develop fitness, involve not only the concept of ‘capacity for activity’, but also the concept of’freedom from injury’.