A clear appreciation of the manner in which a disease or condition develops is of paramount importance in its diagnosis. While this is true of all conditions it is particularly important in the diagnosis and management of sporting injuries where a detailed and accurate understanding of the aetiology of a particular injury forms the corner-stone of its diagnosis and subsequent management. In order to facilitate this understanding it is important that anyone involved in the management of sporting injuries should have an appreciation of the activities undertaken by individual sportsmen in different fields at relatively close quarters. This should involve an understanding of the athlete’s training as well as his performance. It is fortunate that most athletes and sportsmen have a far greater proprioceptive awareness than other individuals, which can be invaluable in attempting to evaluate the complexity of individual injuries.
There are three basic categories of sporting activity, each of which has its own different and unique medical problems.
PHYSICAL CONTACT SPORTS
These require an understanding of the various injuries which can be sustained by physical contact as well as a detailed awareness of the individual function of a player within a team. This is well illustrated in the game of soccer where defensive players ‘attack the attacker’ while attacking players ‘attack the ball’. This must be partly responsible for the greater preponderance of injuries sustained by attacking and mid-field players noted in recent surveys of injuries sustained in this particular sport.
INDIVIDUAL PERFORMANCE ACTIVITIES
These demand a performance from the musculoskeletal system approaching the point of biochemical, physiological and mechanical fatigue. The point of fatigue is undoubtedly related to training schedules prior to competition but when the individual athlete demands a performance beyond the physiological or mechanical limit of an individual muscle or muscle group he is likely to sustain an injury in that area which is entirely related to those self-induced and excessive demands.
REPETITIVE TRAINING INJURIES
These are common to all athletes and have the tendency to be chronic in nature. They may be related to badly designed training schedules, unsatisfactory equipment used during training (this is particularly pertinent in terms of footwear used during training) and pursuing long training schedules in an environment which is not conducive to such activity. Inflammation’ around the Achilles tendon is a common problem which is invariably related to badly organised training schedules in sportsmen who wear unsatisfactory footwear and who run for long distances on hard surfaces to which they are not accustomed.
INJURIES RELATED TO TYPE OF ACTIVITY
In general terms, sportsmen involved in physical contact sports tend to suffer fractures, acute ligament injuries and massive haematomata in skeletal muscle, all of which are common sequelae of violent contact between competitors or result from subsequent falls. In contrast, individual performers suffer from acute muscle strains and sprains caused by competitive performances which drive individual muscles or muscle groups beyond the point of physiological and mechanical fatigue. Training injuries usually take the form of chronic tendinitis and are often precipitated by a change in training regime or develop during early training sessions at the beginning of a sporting season where the schedules are too demanding for the individual’s overall state of fitness at the time. This is particularly true in the pre-season fitness training of soccer and rugby players who are often invited to undertake sprinting activities on hard, unyielding grounds or tracks and who subsequently develop chronic tenosynovitis around the ankles and feet.
A fair understanding of the sportsman’s normal training and competitive activities is of invaluable assistance in assessing the aetiology of an individual sporting injury.
A particular injury should be assessed in terms of the athlete’s activity in three phases surrounding the injury itself. His activity immediately before the injury must be analysed in detail. In addition to his physical activity, this must also include a psychological assessment noting the degree of competition, aggression, fear or other emotion which the individual felt just before the injury happened. An understanding of the individual’s mental attitude is important, since this can have a profound influence on the musculoskeletal system and the way in which it responds subconsciously to potential impact or sudden excessive demands upon it. In assessing this phase of activity, it is useful to ask specific questions notably about the individual’s control with reference to his balance and foothold. He should also be questioned about his relationship with other competitors and their combined activity immediately before his injury. Was he wholly committed to a particular course of action before the injury or did he have an opportunity to opt out and avoid potential harm? To what extent was he competing in this phase, since it is well recognised that intense competition often overrides physical ability and can strain the physical resources of an athlete to the point of injury?
A detailed analysis of the events happening at the precise moment of injury should then be attempted. This must include the spacial relationships of his limbs in relation to other competitors or in relation to any apparatus which he or she is using at the time. He should then be questioned about the presence or absence of acute pain at the time of injury and whether or not he experienced any mechanical interference with his performance. Did he feel a tearing sensation in his muscles? Did the torn meniscus within his knee joint prevent free movement of the joint? Was there any loss of sensation in the limb?
This middle phase merges almost imperceptibly with the third phase of activity which is that immediately following injury. He must be questioned about the degree and distribution of pain, his inability to continue the pre-injury activity, the development of any swelling or bruising and whether his symptoms in this third phase became more or less severe with continued involvement. It must be remembered that continuing sporting commitment in the presence of aggression, achievement and spectator involvement can often lead to a lack of appreciation of severe injury by the athlete until after the game. Conversely, relatively trivial training injuries can impinge upon conscious pain thresholds when such psychological stimulants are absent.
Consideration of symptoms immediately after the injury usually involves a recognition by the athlete that all is not well. This is very much related to an appreciation of pain and limitation of activity. It must be appreciated that pain is a warning that ‘all is not well’ and that there is no excuse for the old and dangerous phrases such as ‘it is only pain’. Pain is a symptom, a warning and should be respected and investigated. It is essential that an accurate second by second assessment of the three phases of activity surrounding and including an injury should be made in order to reach an accurate diagnosis. It is often necessary to re-appraise these phases of activity on several occasions with the individual athlete before a clear understanding of the problem is reached. Without this understanding coupled with detailed physical examination, dangerous or ineffective management may be instituted.
PRE-REQUISITES FOR MANAGEMENT OF INJURY The accurate and expeditious treatment of sporting injuries depends upon an equally accurate diagnosis which can only be made by a detailed appreciation of the aetiology of a specific injury. This has an essential bearing on its eventual successful management. Sporting activity is often complex and is a combination of controlled, often complex, physical and psychological activities. It is only by detailed appreciation of the complexities of individual sporting activity, coupled with a detailed understanding of factors leading up to an individual injury, that one can arrive at a correct diagnosis which in turn is vital to expeditious treatment and restoration of full function.
It should be possible for a physiotherapist or doctor with a knowledge of musculoskeletal anatomy and physiology coupled with an appreciation of sporting activities to be able to make an accurate assessment of a particular injury through a knowledge of its aetiology combined with physical examination of the patient. Many errors in management of sporting injuries are made by failing to take a detailed and accurate history of the development of the individual problem before physical examination is undertaken. This is particularly unfortunate since expeditious management of sporting injuries is important not only in terms of the individual’s desire to regain full fitness, but mainly because musculoskeletal injuries are often most successfully treated when they are in the acute phase. Expeditious treatment, however, should always be directed towards the individual’s well-being and not towards ambition or commercial considerations.
An accurate assessment of the aetiology of sporting injuries demands an appreciation of the individual athlete’s sporting category, notably whether this involves physical contact or individual competition since these involve specific types of injury.
An accurate detailed history should be taken of the individual’s activity immediately before, during and immediately after the injury was sustained. This history should embody an enquiry into the athlete’s physical control, relationship with other competitors and the degree of psychological commitment coupled with the presence or absence of pain and the degree of mechanical interference with mobility at the time of injury.
There should be no commitment to continued activity in the presence of pain since this is an indication of dysfunction, nor should there be any attempt to treat the injury until an accurate diagnosis based upon the aetiology of the injury coupled with physical examination has been made. An accurate appreciation of the aetiology of an injury is an aid to its early diagnosis and expeditious treatment.