Science and Profession Sports medicine is a field that has become popular as the number of people who exercise has increased. There has been a growing trend of participation in exercise as more and more studies have proved that exercise is beneficial to health; however, exercise places people at risk for injuries that a sedentary person would not have. This fact has led to the emergence of sports medicine, with its specially trained health care professionals. These professionals include physical therapists, athletic trainers, nutritionists, exercise physiologists, cardiologists, sports psychologists, family practitioners, internists, and orthopedic surgeons. They all contribute by bringing special knowledge and understanding to the care of athletes and athletic injuries. Such knowledge can relate to nutrition, strength training, cardiovascular conditioning, psychosocial issues, musculoskeletal care, and many other areas related to the health of athletes. Therefore, sports medicine is a very broad and diverse field that requires a team approach.
Athletic injuries occur with regularity, but very few injuries are unique to sports. Yet treating an injured athlete does not necessarily require the same process used to treat an injured sedentary person. The athlete tends to have greater expectations than does the average sedentary person. These expectations usually increase proportionately with the competitive level of the athlete. For example, the athlete with an ankle sprain will spend ten to twelve hours per day performing treatment and rehabilitation supervised by a physical therapist or athletic trainer. The sedentary person, however, might go to physical therapy three times per week. Although the philosophy of the treatment is the same, the number of treatments and the desired outcomes are completely different. Athletes also require an extensive amount of information regarding their injuries, treatment, and rehabilitation. Athletes are not afraid to ask questions regarding their injuries because they want to know when they will be able to return to competition. The average patient, however, is quite uncomfortable asking the physician about an injury or illness.
Sports medicine is a challenging and rewarding profession. It is enjoyable working with patients who have a high level of compliance and motivation. The reward of watching an athlete recover from an injury and compete is exceptional. The sports medicine physician must realize, however, that he or she will also be called upon by the athlete and the athlete’s coach and parents to communicate the severity of the injury and its significance—a process that can be quite difficult at times, especially when what the physician has to say is not what anyone wants to hear. Nevertheless, it is the role of the physician to act in the best interest of the athlete. In order for the physician to be prepared to handle this, he or she must fully understand the demands of each and every sport. Attendance at games is usually not enough to achieve this level of knowledge and experience. Observing practice sessions and workouts is often quite useful. With the exception of high-impact collision sports such as hockey and football, most injuries occur during practice and workout sessions. Furthermore, such observation gives the physician an opportunity to be involved in education and injury prevention. Many athletic injuries are witnessed by an athletic trainer or physician who may be called upon to administer first aid in the field or, in some instances, provide treatment for injuries.
By attending practices or competitions, the physician may also have the opportunity to observe the actual mechanism of injury, which can be quite useful in evaluating the type and severity of the injury. Many physicians call the first twenty minutes after an injury has occurred, prior to the onset of swelling and spasm, the “golden period.” It is at this time that an accurate and meaningful physical examination can be performed on the injured athlete. The recreational athlete, however, usually will arrive at the physician’s office one to two days after the injury, when swelling and spasm are maximal. At this time, examining the injured body part is quite difficult and may not be meaningful. This may result in delays in diagnosis and definitive treatment. For the sedentary person and the occasional athlete, such delays will probably not be significant. The highly competitive athlete, however, would be quite dissatisfied if an injury delayed his or her return to competition. So, although most athletic injuries differ very little from other cases of musculoskeletal trauma, the finer points of managing them are unique.
Most athletic injuries affect one of three structures in the body: bones, ligaments, or musculotendinous units. These injuries may be acute or chronic in onset. Most acute injuries occur as a result of trauma, with presentation being rather soon after the incident. Chronic injuries, which are often insidious in onset, usually result from a change in the athlete or the athletic environment. Chronic injuries tend to be difficult to recognize and treat effectively. The best approach to chronic injuries is prevention. Most acute injuries can be classified as sprains, strains, or fractures, and most chronic injuries can be classified as strains or stress fractures.
Sprains are injuries to ligaments; strains are injuries to the musculotendinous unit. Sprains occur when there is excessive abnormal motion at a joint. This results in overstretching of the ligaments and produces local pain, swelling, limitation of motion, and a sense of instability. Such overstretching can result in partial tears (mild) or complete tears (severe) of the ligament. Strains are usually the result of an abrupt increase in the tension of the musculotendinous unit (for example, they may occur when one lifts weights that are too heavy). This increase may result in partial or complete tears of the muscle, the tendon, or the bone to which the tendon is attached. The most important principle is to realize that strains are not the result of overstretching but occur well within the normal limits of motion. Strains are also graded from mild to severe. Often, there is an obvious deformity at the site of injury because the muscle rolls up into a ball. Fractures are simply breaks in the bones of the body. Stress fractures occur when excessive demands are placed on the bone. Eventually, the bone fails to accommodate these demands, and microscopic breaks result.
Diagnostic and Treatment Techniques The initial management of acute injuries is the same in athletics as it is in other musculoskeletal trauma. Treatment should be directed at prevention of bleeding and edema. These conditions usually lead to pain and decreased function of the injured body part, which requires the application of ice, compression, elevation, and rest. There are other methods of treatment used in the professional setting that are also useful in preventing or reducing bleeding and edema. These include electric stimulation, contrast baths, ultrasound, and compression stockings. After the initial phase of bleeding and edema, therapy should be directed at restoring range of motion, strength, and, finally, functional tasks that will ultimately result in the athlete’s return to competition. Chronic injuries, however, usually require elimination of the precipitating factors as well as increased rest while the injured body part is allowed to heal. This may require a special taping procedure, a brace, a change in footwear, the alteration of practice sessions, or simply refraining from that activity for a short period of time.
Chronic injuries and overuse injuries are usually caused by change. Change can occur in the athlete, the environment, or the activity. Identifying these changes can be helpful in injury prevention, since the majority of injuries in athletics are chronic. Also, the treatment requires elimination of the offending change and restoration of the proper condition. Strains to the musculotendinous unit can also occur chronically. They tend to result from muscle fatigue, too much training too fast, or poor training conditions. Many of these injuries are called tendinitis, which means inflammation of the tendon. The most prominent aspect of such an injury is pain. The pain is almost always located in the region of the injured structure. Management is directed at avoidance of painful activity, elimination of the offending factor, and symptomatic relief of pain with ice, ultrasound, injections, electric stimulation, and medicines. Rehabilitation is aimed at restoring strength and flexibility as well as avoiding the initial cause.
Most sprains can be treated with routine physical therapy and rehabilitation, but many severe sprains will require surgery. Average time lost from athletics ranges from seven days (for example, for a mild ankle sprain) to one year (for example, for a severe knee sprain with reconstruction of ligaments). With strains, complete tears of the tendon usually require surgery, while injury to the muscle itself does not. Treatment is similar to that for sprains; rehabilitation should be directed at regaining strength and flexibility. The diagnosis of a fracture can be made only with the aid of an x-ray picture. Treatment of fractures requires immobilization in a cast, special splint, or brace. Some fractures will require the placement of plates or screws by an \orthopedic surgeon. Rehabilitation of fractures involves restoration of motion, strength, flexibility, and proprioception. Proprioception is simply the unconscious awareness of where a body part is in space (for example, a person can tie his or her shoes with eyes closed because the brain knows where the hands are in space). The treatment of stress fractures is different from treatments of other fractures in that immobilization is almost never necessary. Adaptation of activity and relative rest are usually all that is required. Return to competition averages three to six weeks but may be longer.
Sports medicine personnel also provide education and guidance to coaches, athletes, and parents. They make themselves available to provide the best and most efficient care possible. It is the responsibility of the sports medicine physician to coordinate this care. This all begins with the preseason screening history and physical exam.
Prior to the commencement of each athletic season, athletes are usually required to provide a medical history and undergo a physical examination. The requirements of such examinations vary from state to state, college to college, and professional league to professional league. The purpose of these examinations is to identify athletes who may have potential problems in the sport in which they have chosen to compete.
For example, Johnny is a thirteen-year-old high school freshman trying out for the football team. The doctor listens to his heart and lungs and hears a small heart murmur. The physician recommends that Johnny see a cardiologist prior to beginning football practice. A further workup by the cardiologist reveals that Johnnie has a condition in which the arteries that supply his heart are abnormal. The cardiologist recommends that Johnny not participate in athletic activity that requires stress on the heart. Although this scenario is uncommon, it is a perfect example of the benefits of preseason history and physical exams. Johnny could have died as a result of his condition if it had gone unnoticed.
The preseason screening also identifies athletes who are at risk for developing strains and sprains because their flexibility is lower than normal. Identifying these athletes allows the athletic trainer to work with them on a stretching program intended to reduce the number and severity of such injuries. It is during the preseason that the athletes are at greatest risk for injury, since the workouts are long and numerous and most athletes are not yet in shape. Injuries may occur at any time during practice or a game. Most injuries occur during practice, however, and especially at the end of the session, because athletes are tired and their concentration level is low.
Dean is a twenty-year-old junior college soccer player who is kicked in the side during a slide-tackling drill. He is taken out of practice by the coach and then sent to the training room to see the athletic trainer. The athletic trainer astutely examines Dean’s urine and finds blood in it. Also, he finds that Dean’s blood pressure is somewhat low and that his heart rate is mildly elevated. Because of this, the trainer is concerned about injury to Dean’s kidney or spleen. He promptly phones the team physician, who advises that they meet him in the emergency room at the hospital. After being evaluated by the team doctor, Dean is brought to the operating room by a surgeon, who removes Dean’s extensively damaged spleen. Dean recovers quickly and returns to exercise within six weeks but is not allowed to play soccer until the following season. Without the aid of the trainer and prompt attention by the team physician, Dean might not have had such favorable results.
Mary is a fifteen-year-old high school all-state cross country runner. She is now entering her junior year and is expected to compete on the national level. Mary is also an excellent student and has always been an overachiever. Six weeks into the fall season, Mary’s times begin to fall off slightly. When asked about her performance, she states that she has been experiencing pain in both her shins, particularly the one on the right, for two weeks. Her coach, because of her concern, asks Mary to see her family doctor, since Mary’s school does not have an athletic trainer or team physician. Mary’s doctor, who is not trained in sports medicine, simply tells Mary that she has shin splints and that she should rest. Mary does not accept this, because everyone is counting on her to win for her school. She continues to run against his advice. In the next race, Mary finishes dead last. The pain has become quite unbearable. Mary is finally referred to a sports medicine physician, who discovers several relevant facts. Mary has not been eating well and has in fact been forcing herself to vomit for a number of days prior to each race. Also, Mary has not experienced her first menses, and her secondary sexual characteristics are somewhat immature. x-rays of Mary’s right leg reveal a stress fracture that is quite severe. Mary is referred to several people, including an orthopedic surgeon who places her in a cast, a nutritionist and a psychologist who evaluate and treat her eating disorder, and a gynecologist who proceeds with a workup for her late development. After several months of treatments from all three doctors, Mary begins retraining on a bicycle under the direction of an athletic trainer and a physical therapist. She moves on to compete in the spring season of track and field and becomes a national champion. Without the aid of the sports medicine team, Mary might have continued to have difficulty and might not have been evaluated properly until it was too late. This is a quite common scenario among adolescent athletes. The pressures placed upon them by friends, coaches, and parents can become detrimental to their emotional and physical well-being.
Henry is a fifty-five-year-old businessman who spends five days a week playing tennis at the local health club to stay in shape. After buying a new racket, he begins to experience pain in his right elbow. He is seen by an orthopedic surgeon in town who specializes in sports medicine. After speaking with Henry and examining his elbow, the doctor recommends anti-inflammatory medication, a special forearm strap, and use of the old racket. Henry’s condition, which is called tennis elbow, or lateral epicondylitis, is quite common. After several weeks of the initial treatment, Henry does not feel any better. His doctor, therefore, injects him with a medicine to ease the pain and calm the inflammation. Henry is instructed to rest his arm for a week prior to starting tennis again. Henry follows the doctor’s instructions carefully. He begins to play tennis again and feels fine for about a month, after which he begins to experience the same discomfort. This time, the doctor recommends surgery for Henry’s elbow. Three months after the surgery, Henry is free of pain.
These examples have demonstrated how sports medicine can be beneficial to athletes. Each scenario differs in type of athlete, location, diagnosis, and treatment.
Perspective and Prospects Sports medicine is assuming a significant role in the medical profession today. Sports medicine was first recognized in the days of the early Olympics. It was not until the final decades of the twentieth century, however, that it emerged into a field of its own. Sports medicine training programs have been developing at an exponential rate. Interest in sports medicine can be pursued in various ways. Most sports medicine physicians undergo a one-year fellowship after either a five-year orthopedic residency training program or a three-year family medicine residency training program. Athletic trainers must pass a national examination for certification. Most have master’s degrees, and all have some form of bachelor’s degree. Their expertise is in the prevention, treatment, and rehabilitation of athletic injuries. These are the primary caregivers of the sports medicine world. Certified athletic trainers are being hired at all major universities, many high schools, and many health clubs across the country. Various types of sports medicine centers are continually being developed. These centers offer a wide range of services to both professional and amateur athletes. As more and more people begin to exercise, the need for sports medicine professionals will increase.
Athletes’ needs and goals are different from those of most other people. Although the injuries that they experience are not unique to sports, the rapidity with which they recover is of utmost importance. This identifies them as a distinct group of people with special demands for medical care. It is because of this and because of the growing number of people who exercise on a daily basis that sports medicine has evolved into a viable medical field. Sports medicine will continue to grow and will play an important role in preventing many of the injuries that afflict people in the United States.
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