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Dance/Ballet
From its origin in Italy about the time of the Renaissance, to its development in the court of the French kings, ballet has retained a traditional and rigorous approach to form and performance. Within the last decade there has been a surge in the popularity of ballet. Because of the strong interrelationship between form and aesthetic quality of the dancer, unique problems and injuries may result. Because the female ballet dancer not only goes up on demi-pointe (dancing on the ball of the foot), but also on pointe (dancing on the toes), the incidence of lower-extremity injuries can be relatively high.
Menarche
Having a thin, svelte figure is paramount for a young female dancer, and this may produce significant consequences. For example, because dancers are considerably thinner than their cohorts, they tend to have a delayed menarche. In conjunction with the delayed menarche they tend to have a reduced height of their upper body with respect to the lower body. Generally the average age of menarche is approximately 12-14 with menarche and after 15 is considered delayed but in female adult ballet performers fully 70% reported a delay in menarche. Such delays in menarche are also found in other young female sports participants who have weight restrictions associated with their sport, for example, young gymnasts or ice skaters. In comparison, young female swimmers were less likely to have menarche delays.
Amenorrhea
Amenorrhea also appears to be associated with the relatively low body weights associated with adult female dancers. Almost 80% of adult female dancers and over half of adolescent dancers who were surveyed indicated extended periods of amenorrhea. The prolonged hypoestrogenism associated with amenorrhea may have adverse consequences on skeletal growth and contribute to a greater likelihood for stress fractures or scoliosis. It has been reported those dancers who have scoliotic conditions also have a higher incidence of eating disorders such as anorexic behavior.
Strict dieting is not uncommon for ballet dancers, and several nutritional surveys have found the dancers to be substantially less nourished compared to their cohorts who are nondancers. Although many professional dancers spend up to four hours per day, it is also not unusual for dancers to consume less than the optimal recommended daily allowance of calories.
Anorexia Nervosa
Dance students have a seven times greater probability of developing anorexia nervosa than their peers. Other eating disorders such as bulimia are also frequently reported.
Although dancing can be strenuous, it has been found the energy requirements for ballet tends to be lower than in endurance sports. In fact, the expenditure of energy in ballet can be quite intermittent. The activity lends itself to anaerobic activity. For example, women in a one hour ballet class may only expend 200 calories.
Morton's Foot
The toes and forefoot of a ballet dancer have tremendously high forces concentrated on them during demi-pointe and, particularly, full point maneuvers. If a dancer has a Morton's foot there is a greater probability of chronic injury. Morton's foot is a condition in which the dancer has a short first toe and a long second toe. Bunions and corns are recurring problems with many dancers.
Sesamoid Fractures
Dancers are also prone to sesamoiditis (inflammation of the sesamoid bones) or sesamoid fractures. Sesamoiditis may result from multiple contusions to the ball of the foot during demi-point activities. Stress fractures or a avulsion fractures in the sesamoid region can produce inflammation or osteonecrosis can occur--followed by osteoarthritic changes in the intra-articular joint surfaces. Inflammation of the sesamoids may also be related to entrapment neuropathies. Typically conservative therapy is sufficient to alleviate the inflammation, although this may take up to a year.
Metarsalgia/Freiberg's Disease
Metatarsalgia is a relatively small problem in dancers, however, Freiberg's disease can occur in the metatarsal heads and may ultimately require a resection arthroplasty if there is extensive necrosis and destruction of the metatarsal heads. Dancers with Freiberg's disease usually have pain, swelling and stiffness at the metatarsal phalangeal joint.
Stress Fractures
Metatarsal stress fractures can occur in dancers, and particularly the base of the second metatarsal is prone to stress fractures. Bone scans or radiographs are advised when pain and tenderness are found in the metatarsal region. If a dancer is amenorrheaic and somewhat anorexic, she has a greater likelihood of stress fractures. In addition, dancers with Morton's foot or a cavus foot are also predisposed to metatarsal stress fractures.
Osteochondritis
Osteochondritis dissecans of the talus is an injury appearing to be associated with male dancers in an adolescent age group. If the fragment is loose and cannot heal, then the joint should be arthroscopically debrided.
Tendinitis
Tendinitis of the flexor hallicus longus tendon which passes behind the medial malleolus of the ankle has frequently been termed the dancers tendinitis. It results from the excessive loading occuring to the tendon as it passes behind the medial malleolus. Typically, rest and standard physical therapy can reduce the inflammation.
Achilles tendinitis results from an actual injury to the tendon itself and is typically related to chronic overload of the tendon. Frequently, the terms tendinitis, bursitis and tenosynovitis are used interchangeably--but they should not be. Tendinitis is an inflammation of the tendon, whereas tenosynovitis is the inflammation of the synovial lining surrounding the tendon, and bursitis is an inflammation of the synovial sac that may be located between the skin and underlying bone or tendon.
Achilles tendinitis tends to be more common in post-adolescent and adult dancers than in the very young. In many sports involving jumping and landing on the foot, Achilles tendinitis can represent up to 20% of all types of tendinitis related to the foot and ankle (13). Particularly in individuals with foot deformities (forefoot pronation or excessive heel varus), the Achilles tendon is stressed abnormally. Repetitive trauma associated with landing and forceful contractions of the triceps surae complex can produce microtears and inflammation. In addition, in the young dancer there can be an inflammation of the calcaneal apophysis with apophysitis. Calcaneal apophysitis is an inflammation of the an open growth plate of the calcaneus. Symptoms can include pain over the posterior calcaneus--typically at the insertion site of the Achilles tendon. Sever's disease is the term used to describe this condition. Sever's disease occurs in the age range of 8-13 years old. If an individual has a lack of flexibility at the ankle joint, with a tight Achilles tendon--coupled with four foot pronation and internal tibial rotation--there is an increased likelihood of the occurrence of Sever's disease. In many cases, a heel wedge may alleviate the symptoms, and strengthening and stretching exercises should emphasize the tricep surae and hamstrings.
Ankle Sprain
Ankle sprains are typical in dance as well as in many other activities than involve running, landing and jumping. Lateral ankle injuries associated with inversion are common. Typically, ankle sprains are categorized as first, second or third degree. With a first degree sprain the lateral ligament complex may have partial tears, but generally there is stability of the ankle joint. A second degree sprain results in additional damage to the ligament and the joint may reveal laxity when tested, but basic function of the ankle is maintained. In a third degree sprain there is complete ligament disruption, and there is a lack of functional stability in the ankle joint.
Inversion Sprains
Partial tears of the anterior talofibular ligament are the most common outcomes of inversion sprains. Treatment of inversion sprains includes early mobilization and compressive dressings with early cryo therapy followed by hot-cold contrast baths. Range of motion exercises are encouraged in the whirlpool. As pain subsides, strengthening of the peroneal musculature laterally and the posterior tibial muscles medially is strongly advised.
Jumper's Knee
The most common knee problem in dancers is the "painful patella syndrome". This general category of pain can be associated with many different etiologies, including patellar malalignment and subluxation, chondromalacia patella, plica syndrome, quadriceps or infrapatellar tendinitis, or osteochondritis dissecans. Because of the substantial amount of leaping and landing occuring in dance, the inflammation of the tendon just below the insertion to the patella (infrapatellar tendinitis) can frequently occur; this condition is sometimes referred to as "jumper's knee".
Damage to the collateral or cruciate ligaments in the knee can be particularly debilitating for the dancer and in many cases result from the hyperextension and/or torsional loading of the knee during landing activities. Because of the various positions associated with classical ballet, there is an increased likelihood of lordosis in young teenage dancers. In particular, stress fractures of the pars interarticularis of the lower lumbar spine may result in spondylolysis. These fractures, if detected early, can be treated, and the dancer can typically return to full activity.
Shin Splints
"Shin splints" may be related to stress fractures. In x-rays taken on professional dancers, it is not uncommon to observe various sites of multiple stress fractures in either the proximal or distal region of the tibia. Fibular stress fractures are also observed. In many cases the dancer has "danced through the injury," and the stress fracture has resolved. If a stress fracture is suspected, however, radiographs or bone scans should be taken, and the pain-producing activity should be curtailed.
Baseball
Baseball is sport stressing quickness and skill, and many of the injuries to the musculoskeletal system resulting from playing baseball are associated with chronic, overuse of the joints of the upper-extremity. Progressive training and conditioning, as in most sports, are essential for reducing the frequency and severity of baseball-related injuries. Overuse injuries can occur to adult performers, but also the pre-adolescent and adolescent baseball players are particularly susceptible to injuries of the upper extremity during throwing. Because of the former, widespread injuries of young pitchers, in particular, sports organizations drafted guidelines to reduce the allowable pitching limits for youngsters. Because growth plates associated with the humerus, radius, and ulna can be unfused up to about 17 years of age, there is a danger of marked insult to the growth plates with excessive growing through the adolescent years. Repetitive high-speed throwing may produce osteonecrosis in various regions of the joint because of repeated compression, or vascular trauma and osteochondrosis may develop.
During an overarm throw (e.g., pitching), the momentum generated by the forward motion of the body, movements of the lower extremities and torso, and upper-extremity motions are combined to produce the high velocities associated with pitching. Tremendously large accelerations and forces can be applied to the shoulder and elbow, during the time the ball is stopping its backward motion during the wind-up and beginning its forward motion for the pitch. It is important for a baseball player to not only concentrate on strengthening the upper body but also the lower extremities to optimize performance and minimize the likelihood of musculoskeletal injuries during pitching.
Chronic or acute instability of the shoulder joint can lead to a host of problems associated with throwing. The abduction of the shoulder and external/internal rotation found in the throwing motion can place substantial stresses on the rotator cuff and joint capsule. As the arm is brought back in preparation for the forward throw, there can be a significant load applied to the anterior muscles of the rotator cuff (supraspinatus and subscapularis), as well as the anterior capsule of the glenohumeral joint. As the arm is brought forward with the humerus in an abducted position, the change from external rotation to internal rotation may cause impingement of the tendons of the rotator cuff. A strengthening program for the muscles of the rotator cuff is essential for reducing tendinitis. Chronic shoulder instability and the pain associated with overuse syndromes in throwing, have caused many people to stop pitching.
Different classification systems have been used to describe shoulder instabilities. Common to several of these classification systems are the categories of:
frequency of occurrence
etiology
direction of instability
degrees of instability
In the glenohumeral joint, either a subluxation or dislocation is termed acute or recurrent. Etiology refers to the source of the initial instability. Categories associated with etiology include:
traumatic
atraumatic
repetitive microtrauma
Traumatic typically refers to a specific episode in which a force tended to cause the disruption in the joint.
Atraumatic generally refers to a situation where there is no external force supplied, but the force is related to the inertial forces generated by the body itself. For example, during a throwing activity there are large forces generated at the shoulder during the wind-up and delivery of a pitch. Thus no external direct blow is applied to the joint but, nevertheless, large forces develop in the joint.
Repetitive microtrauma refers to the long term degenerative changes that can occur to the surrounding articular structures. With excessive wear and repeated inflammation, laxity of the joint can increase, and thus the instability of the joint can be heightened.
The direction of the instability generally refers to anatomical locations. Anterior, posterior and inferior are the classical primary directions, with anterior instability the most prominent form of laxity at the glenohumeral joint.
The degree of instability is associated with either subluxation or dislocation. Each of these terms is defined relative to the amount of displacement or movement between the humeral head and the matching glenoid fossa. A complete loss of articular contact between the humerus and the glenoid fossa is a dislocation. Subluxation, in comparison, only refers to an excessive or increased humeral head movements--above normal limits.
Shoulder Impingement Syndromes
Shoulder impingement syndromes are common in both young and old pitchers and may produce a variety of painful results. For example, subacromial pain can be related to a tension injury to the supraspinatus tendon or to subacromial bursitis. If pain is noted in the lateral region of the shoulder, a likely source is tendinitis associated with the following rotator cuff muscles--supraspinatus and infraspinatus. If the tenderness is on the tip of the acromion, however, deltoid tendinitis may be the culprit.
During the throwing motion, and particularly during follow through, significant decelerative forces exerted on the posterior capsule and muscle-tendon units. If anterior laxity is greater than normal, it is possible the head of the humerus may move anteriorly and put additional tension on the already stretched tissues of the posterior capsule.
Proximal Humeral Epiphysiolysis
Another potential source of deep shoulder pain may be a traction injury to the proximal humeral epiphysis. This can be seen in young adolescent pitchers and has been called proximal humeral epiphysiolysis. The source of the pain may be a disrupted or widened epiphyseal plate. Rest of several months may be essential to reduce this injury.
Flexor Contractures
At the elbow joint, anterior pain is typically associated with flexor contractures. With excessive and repetitive throwing, there can be a progressive decrease in the range of motion of elbow extension. Typically, elbow flexion contractures can be treated with non-steroidal anti-inflammatories to decrease inflammation and pain.
Pitcher's Elbow
Lateral epicondylitis (sometimes called Tennis Elbow) is relatively uncommon in throwers, but it may occur with batting. Medial epicondylitis (Pitcher's Elbow), however, is common in baseball pitchers. The pain in the medial side of the elbow is related to the forceful valgus loads applied during the acceleration phase of the pitching motion. Various etiologies for the pain have been described. One of the possible causes of medial epicondylitis is tendinitis of the flexor-pronator muscles attaching to the medial epicondyle of the humerus. These muscles are contracted vigorously during the throwing motion. Flexor-pronator tendinitis is identified by a tenderness over the muscle mass just distal to its origin on the medial epichondyle. Wrist flexion will produce pain. In young pitcher's, the excessive tension applied to the medial epicondyle of the humerus may result in damage to the growth plate in that region.
Medial Collateral Ligament Sprain
The medial collateral ligament, spanning the humeroulnar joint, and the medial portion of the joint capsule are sites of potential tension injuries during the throwing motion. The range of injury or sprain to the medial collateral ligament can range from a mild to severe involvement. A mild sprain involves a few microtears in the ligament with accompanying inflammation, moderate sprains involve a partial tear of the ligament but the joint integrity and stability remains. In a severe sprain the ligament is fully ruptured, and the joint function is compromised. This ligament injury must be treated as any other ligament injury, with appropriate physical therapy, rest and surgery if required.
Ulnar Neuritis
Ulnar neuritis is an inflammation of the ulnar nerve. This condition can occur in three specific situations: a hyper mobile nerve with excessive anterior laxity of the joint, traction of the ulnar nerve produced by a valgus instability, or cubital tunnel irritation. Where an individual also has inflammation of the ligaments on the medial side of the elbow joint, that inflammation and swelling can also inflame the ulnar nerve. Rest is effective in reducing the neural inflammation.
Osteophyte Dissecans
In the posterior region of the elbow, excessive hyperextension during the throwing motion can produce an impingement between the olecranon process and the distal humerus. The multiple impacts resulting from the throwing motion can produce osteophyte formation on the olecranon process. With a build up of the bony, calcified material, the amount of extension available to the pitcher is reduced. In a forceful hyperextension the osteophyte can break-off and enter the elbow joint. When osteophyte chips enter the joint, they are called "loose bodies".
Football
Football, as played in North America, is a multifaceted game requiring a spectrum of skills, including throwing, catching, blocking, tackling, and running. This broad range of activities produces a great range of injury exposure, for example, the injury exposure of an interior lineman is very different from the wide receiver, the running back, and the quarterback.
Generally, football is regarded as having the highest injury rate among organized school sports. Since the beginnings of football, in the late 1860's, there have been numerous changes in rules to better protect the players. Padding, helmets, shoes, and face masks have evolved to today's standards, with accompanying reductions in the incidence of injuries. Rules have also changed over the years to prohibit injury-producing practices, such as "spearing" (tackling by using the head as a battering ram), "crack-back blocks" (a blindside block, hitting the opposing player at the knees), and the "flying wedge" (linking arms to block more effectively). Furthermore, as in many sports, today there is better education for the players and coaches in proper conditioning, rehabilitation, and the avoidance of injury.
Since the introduction of artificial turf, there has been a continuing debate about its potential role in producing or reducing injuries. Research and the debate continue to this day, but because of the great durability of the artificial surfaces, they appear to be here to stay. What has been noted by some is with the artificial turf, there is a decreased impact-absorption capacity and greater likelihood of prepatellar and olecranon bursitis. Whether there are more knee injuries or ankle sprains with the artificial turf or with natural turf has not been answered definitively.
Head and Neck Injuries
Head and neck injuries have the potential to be the most catastrophic of all injuries. Today, even with rule changes and modern helmets, there are cases of football players becoming quadriplegic or getting subdural hematomas as a result of impacts on the football field. Before the rule change outlawing "spearing" (tackling headfirst), the number of paralyzed football players each year was significantly higher than it is now that spearing is prohibited. If an athlete is unconscious and a neck injury is suspected, the helmet must not be removed on the field, and a cervical collar and spinal board used to transport the player to a hospital to get a radiographic assessment. Although catastrophic neck injuries have markedly decreased, because during tackling the neck can be twisted and forcibly flexed or extended, there can be painful pinching of nerve roots.
Concussions
Severe concussions were prevalent before the modern helmet, and face and eye injuries were rampant before the introduction of the face mask. But the helmet does not solve all the problems, and concussions can still occur, although the degree of the concussion is generally only "mild" ("seeing stars", confused behavior, incoordination). The effects of a mild concussion are transient, and after carefully observing the athlete's behavior, generally he is allowed to return to play. With a Grade II concussion (moderate), the player may experience a period of unconsciousness, followed by some post-traumatic amnesia. Players with these symptoms should be kept out of that day's activities and watched carefully.
Spondylolysis
Low back pain is common in football players, and spondylolysis is a frequent cause of the pain. In most cases, even though the player may be mildly or moderately symptomatic, there is a strong probability the player can compete with out progression of the spondylolysis.
Dislocations
Anterior dislocations are the most frequent shoulder injuries in football. Landing on an outstretched arm or receiving a direct blow to the arm or shoulder can produce the dislocation. As with any shoulder dislocation, recurrence can be a major problem because of the increased joint laxity caused by the first dislocation. For some players with persistent problems with shoulder laxity, it may be possible to wear a special harness to restrict glenohumeral joint motion; this prophylactic technique, however, usually is only possible for offensive line men, who are not required to catch, throw, or tackle.
Fractures
Fractures of the proximal humerus can have long-term consequences for young football players, because physeal-metaphyseal damage can occur. Generally, however, with the rapid growth occuring in these bones and the fundamental mobility of the shoulder girdle, the person can learn to adapt and compensate.
Seperations
During tackling or during falls, the acromiocla vicular joint is vulnerable to impact and potential separation. Properly fitting shoulder pads, however, can greatly reduce the incidence of severe separations of this joint.
Dislocations
Injuries to the wrist and hand are also common in football. With tackling or landing, high-velocity impacts occur between players or between a player and the ground. In these situations, dislocations of interphalangeal or metacarpal-phalangeal joints may result or the bones of the hand can be fractured. Dislocated fingers should only be reduced by qualified medical personnel. With splinting of an injured finger to adjacent fingers, a player can return to play relatively quickly (especially if he is not required to catch or throw the ball in his position).
Contusions
In the lower extremity, major fractures are not particularly common, but contusions are frequent. Collisions between players during tackling or blocking can produce local impact trauma. In the upper extremity, the biceps brachii is muscle easily contused. Also, if a player's hip pads are not worn properly or are ill-fitting, a blow to the crest of the ilium may cause a "hip pointer". This injury can be very painful, and in some instances the hematoma over the crest of the ilium must be aspirated. Generally, hip pointers can be treated with cryotherapy, compression dressings, and non-steroidal anti-inflammatory drugs. Nonetheless, point tenderness or impaired gait can persist for several days.
Hematomas
Before thigh pads became standard equipment, contusions of the quadriceps muscles were much more common than now. But if pads slip out of position or are poorly fitting, direct impacts to unprotected muscle bellies may produce intramuscular hematomas. Typically with cryotherapy, adequate protection, and continued range of motion exercises, these hematomas will resolve without complications. In some cases, however, the hematoma may persist, become fibrotic, and eventually mineralize. This condition is called myositis ossificans (ossification of the muscle). Players with this condition can usually return to action (with protective padding over the injured region) with normal muscle strength; surgical resection of the mineralized intramuscular mass is rarely needed.
Knee Injuries
As with many sports, in football the knee is one of the most-frequently injured joints. The football player not only puts his knees at risk during high-speed cutting, stopping, and turning maneuvers, but also there is the added danger from impact with opponents who are blocking and tackling. The classic injury to the knee, and one of the most devastating, is the combined tearing of the anterior cruciate ligament, the medial collateral ligament, and the medial meniscus. This injury is produced by a valgus load being applied to the knee (e.g., get ting hit from the side), while the knee is slightly flexed and the foot is firmly planted on the turf. Because the impact happens when the foot is planted, the knee joint is the structure at greatest risk.
When a player has had his anterior cruciate ruptured, it is advisable to have a surgical repair and reconstruction of the damaged tissue. Today, many surgeons take a portion of the patellar tendon to fashion a replacement tissue for the torn anterior cruciate ligament. There is essentially no evidence to suggest a fully ruptured anterior cruciate ligament will adequately heal, without surgical repair and reconstruction. If the athlete is not committed to returning to full playing ability, conservative treatment may be all that is necessary; but if a full return is the goal, then surgery is indicated. This is not the same as in the collateral ligaments of the knee, where conservative management can lead to very satisfactory recovery of function.
Prophylactic bracing of the knee, after a ligament injury, has had mixed results. Some researchers have shown a reduced likelihood of re-injury when knee braces are used, but other data indicate no positive effect of the braces. More studies are needed to produce a clear answer, but some athletes have found the braces to be useful for providing moderate support while rehabilitating and gradually returning to regular activity.
Ankle Sprains
Ankle sprains are so common in football, it is accepted practice to tape the ankles prior to each practice and game. In spite of the prophylactic taping, ankle injuries rank just behind knee injuries as the greatest cause of lost practice and game time. Taping of the ankle can provide some, temporary, increased stability to the joint, but in many instances, the added support is quickly reduced as the player begins to sweat and vigorously move the ankle through its range of motion.
After the pain and swelling subsides from the sprain, it is advisable for a player (particularly one with a history of recurring sprains) to vigorously and progessively strengthen the muscles crossing the ankle joint and to undergo a training program heightening his proprioceptive awareness of the joint.
Turf Toe
Although seemingly less important, a player's toes can produce a great deal of pain and discomfort. For example, an injury to the first metatarsophalangeal joint (sometimes called "turf toe") sounds like a relatively minor injury. But the great toe carries substantial load with each push off the foot during running, and even moderate tenderness or swelling can make a player lame. Sprains to the metatarsophalangeal joint run the gamut from mild (local tenderness and ecchymosis) to severe (extensive pain and ecchymosis, with joint dislocation). The term "turf toe" has been applied to this condition, because it is believed hyperextending the joint during an impact with the surface of the artificial turf is a leading cause of the injury.
Heat Illnesses
Although not one of the impact-related injuries usually associated with football, heat related illnesses can be very serious problems for a player, especially in the two-a-day workouts of late summer. Heat-related illnesses can be categorized along a continuum of severity: heat cramps generally occur in the triceps surae muscles and are treated with ice applications, rehydration, and rest; heat syncope presents as a general fatigue, dizziness, and rapid pulse and is treated with rest, cooling of the player, and rehydration; heat exhaustion requires more aggressive actions because the player may be delirious, have an elevated body temperature, be thirsty and sweat profusely this player may have to be hospitalized for fluid and electrolyte replacement; and heat stroke which can be fatal if not detected early enough. If a player has heat stroke, he will have a greatly elevated body temperature (which must be lowered as quickly as possible), hot-dry skin, and a rapid pulse. Fluids and electrolytes must be given to prevent damage to blood vessels and kidneys.
During practices and games, players should have ready access to fluids, and players' weights should be monitored throughout the season to detect potential weight loss related to dehydration. During a practice or game, any player who appears to need extra "rest" and is sweating profusely should be watched carefully, rehydrated orally, and rested until his resting pulse is back to normal and the abnormal sweating has stopped.
Gymnastics
Gymnastics has evolved into a popular sport throughout the world. The origins of gymnastics competition are grounded in the ancient civilizations of Egypt, Greece and Rome. Following the Renaissance there was a surge of interest in physical and mental training which included the use of maneuvers still evident in today's gymnastic events. Modern gymnastics excellerated its growth and general appeal during the mid 70's as the media highlighted the grace discipline, and spectacle associated with Olympic-level gymnastics.
The commitment and dedication some individuals have to gymnastics is extraordinary. Today children may begin participating in gymnastics at the age of 5 or 6, up to 24 hours per week, every day of the year. This intensive training is occurring during the years of rapid growth and development. The female gymnast may begin at the age of 6 years, advance to higher level competition by the age of 16 and, at elite levels, retire at 18 years of age. Male gymnasts on the other hand typically begin the sport at a later age (9 years), reach peak competitive levels at the age of 22, and generally retire from competition at about the age of 24. Thus, the female gymnast, particularly at the elite level tends to be more vulnerable to injury because of the younger age and skeletal immaturity.
Womens gymnastics, in the modern age, comprise four different events:
uneven parallel bars
floor exercise
balance beam
vault
Mens gymnastics events are six in number:
| rings | high bar |
| parallel bar | floor exercise |
| vault | pommel horse |
Because of the different events, the male gymnast depends to a greater extent on strength of the upper extremities, while the female gymnast requires a great deal of rhythm, dance, as well as strength.
Eating Disorders
Because the size and geometry of a gymnast influences performance in gymnastic events, it is not uncommon for gymnasts to be concerned about their weight. Indeed a significant problem may exist in young female gymnasts in respect to eating disorders or nutritional abnormalities. The etiology of the disorders is not clear, but anorexia nervosa and bulimia are frequently found in young female gymnasts. The relative malnutrition occuring puts an additional stress on the growing gymnast. The high level of mechanical loading, physical stress, and relative poor nutrition can, in many cases, be related to greater incidence of overuse injuries.
Overuse Injuries
Orthopaedic (musculoskeletal) injuries are pervasive in gymnastics. The incidence of injuries, for example, for women gymnasts is greatest in the lower extremity, followed by the upper extremity and the trunk. Generally, ankle sprains are the most common of all traumatic and overuse injuries. Interestingly, the incidence of injury has been shown to be greater with greater skill levels; this may be related to the skills and routines attempted, and undoubtedly, the practice time and number of exposures will increase with skill level. The floor exercise generally has been shown to have the greatest injury rate in women gymnastics, followed by the balance beam and uneven parallel bars, with the vault the lowest injury rate.
Wrist Pain
Wrist pain is a significant problem in young gymnastic participants; for young female gymnasts, about 70% will report wrist pain. At the collegiate level, an incidence of greater than 70% in wrist pain is reported by male gymnasts and greater than 30% by collegiate female gymnasts. One reason for this high incidence of wrist injuries may be related to the high impact forces associated with tumbling activities and the twisting generated at the wrist during round offs. The development of wrist pain has been linked to the long-term cyclic (repetitive) upper-extremity weight bearing occuring during growth and development while a person is participating in gymnastics. It is believed wrist trauma, in many cases, is related to injury to the distal radial physis during development. A range of pathologies can be identified in gymnasts. These pathologies at the wrist include chondromalacia of the articular surfaces of the lunate, triquetrium, scaphoid, and the distal radius. In addition, ganglion cysts of the tendon sheaths or wrist capsule may be present.
The overuse injuries to the bone or physis of the radius follow a sequence of increased pain: during activity, pain during and after activity, and finally pain before, during and after activity. Routine radiographs are important for determining specific sites of abnormalities or potential pathologies. From anteroposterior and lateral projections, it is important to examine ulnar variance and changes in the physis of the distal radius or ulna. Fractures and ligament and joint instabilities are important signs to look for.
Stress Injuries
Stress injuries can be treated with standard orthopaedic techniques of rest, immobilization (if necessary), and rehabilitation. If the pain is severe and persists, it may be necessary to perform a wrist arthroscopy to identify the problem--particularly if a triangular fibrocartilage tear is suspected.
The prevention of chronic overuse injuries at the wrist should be a prime goal. Gymnasts should obtain anteroposterior radiographs of the wrist at least twice a year to rule out a widening of the epiphyseal plate and positive ulnar variance. Also, there should be an emphasis on avoiding excessive loading of the wrists at a very early age. Wrist flexibility and exercises for increasing strength of the muscles crossing the wrists should be highlighted. Training in a progressive manner is advised and swimming and support events should be alternated during workouts. The use of a foam pad during vaulting or pommel horse activities is advised.
Forearm Fractures
Injuries to the forearm include acute fractures to the radius and ulna. For example, in the high bar, male gymnasts may use a dowel grip made of leather to permit the spectacular high speed swings--such as the one-armed giant. If the grip "seizes" because of a sudden increase in friction, it is possible for the gymnasts forearm to fracture or for the wrist to be severely sprained. Young gymnasts should be carefully instructed in the use of dowel grips, and the grips should be frequently examined for signs of wear.
Elbow Dislocation
The young female gymnast is prone to elbow dislocations when participating on the uneven parallel bars; typically the dislocation results from a hyperextension, and the capsule and posterior as well as medial ligaments can be affected. In addition, medial epichondylitis (called pitcher's elbow in throwing sports) can be found in gymnasts. In many cases this is related to a flexor tendon inflammation resulting from the high-level loadbearing forces applied at the elbow with a valgus carrying angle.
Shoulder Injuries
Gymnasts' shoulder joints must be particularly flexible to achieve many of the routines, but this flexibility can also lead to increased joint laxity. Subluxation and dislocation of the glenohumeral joint can be a thorny and persistent problem for gymnasts. It is important to identify the reason for the shoulder pain for an accurate diagnosis of the specific injured tissue and how it should be treated. For example, it is very important to discriminate between impingement syndromes, with or without rotator cuff injuries. Impingement syndromes are not unusual for gynmasts and may be related to supraspinatus and/or bicipital tendonitis. Generally these can be treated with non-steroidal anti-inflammatories, icing, and rest.
Ankle Injuries
Ankle sprains are the most common injury in athletics, and also in gymnastics. There is debate about the best approach to treat acute ligamentous injuries at the ankle, because although surgical repair can produce favourable results, it has also been shown conservative management also leads to a return of full function. Surgical repair of acute ligamentous injuries is performed only rarely.
Knee Injuries
Knee injuries are frequently encountered during dismounts and during landings in the floor exercise. The high levels of impact energy can lead to tears of extrinsic and intrinsic knee ligaments, damage to the meniscus, and fractures. In the young and adolescent gymnast (with open growth plates) generally repair and/or reconstruction of torn ligaments is delayed until physial closure.
Spinal Injuries
Spinal injuries can be devastating and catastrophic. The types of injuries that can occur include both acute trauma or overuse injuries. Chronic overuse injuries to the spine have become more and more a problem for the young gymnast. Chronic cyclic flexion, rotation and extension of the spine can injure the spinal elements. It is not uncommon for young gymnasts to experience damage to the parsinterarticularis with resulting spondylolysis and spondylolithesis and vertebral endplate abnormalities. Spondylolysis refers to a defect in the pars interarticularis. This defect may consist of either a break or an elongation and generally the defect occurs at the connection between L5 and S1. Spondylolithesis is a term given to the slippage of one vertebra over another because of the instability in the posterior elements.
The classification of spondylolysis and spondylolithesis is generally the following: degenerative spondylolithesis, includes the degeneration of the L5-S1 disk and facet joints and is typically associated with the elderly; traumatic spondylolithesis is an acute situation of fracture dislocation and may include areas other than the pars interarticularis (e.g., pedicle, lamina, or facet joint); pathological spondylolithesis generally occurs in disease conditions such as tumors or metabolic bone disease; and, the defect most commonly encountered in young athletes, isthmic spondylolithesis. The defect in the parsinterarticularis maybe a stress fracture, an acute fracture, or the elongation of the bone. Treatment of a gymnast with an injury to the parsinterarticularis remains controversial. However, the goals must be pain relief, healing of the defect and prevention of further slip. It is generally recommended with a low-level spondylolytic pain the gymnast participate in generalized maintenance (e.g., swimming, cycling, and moderate weightlifting) and bed rest may be useful for reducing acute pain. In some patients restricted activities maybe necessary for a minimum of three months--or sometimes longer--to resolve the pain. In some cases, braces are necessary until the radiographic or bone scan shows a return to normal (sometimes up to six months). The young gymnast with a known spondylolysis that is asymptomatic should be followed carefully, radiographically, to access her or his current condition. The athlete, family, and coach should all be advised of the condition. If a gymnast has a spondylolithesis greater than 50%, generally, they should not be allowed to participate further. In these individuals, surgical treatment may be necessary to prevent further slippage.
As with most activities associated with the young athlete, it is important that appropriate and progressive training be used to minimize the incidence of chronic overuse injuries and strengthening exercises should be used to reduce the likelihood of traumatic injuries.
Hockey
Skating was believed to be practised already in the Stone Age, but it was in the 14th Century metal replaced bone for the blades of skates, and by the Middle Ages skating was quite popular in the Netherlands. There is evidence of both figure skating and hockey during these times. After becoming more popular, it was at about the turn of this century professional hockey was started, and currently hundreds of thousands of participants play hockey around the world.
Hockey is a "collision" sport, and most of the injuries are related to impacts. The types of impacts can either be high speed--low mass impacts (contusions, lacerations or concussions caused by puck or stick impact) or low speed--high mass impacts (collisions between players or with the boards surrounding the rink). Contact or impact accounts for more than 80% of the injuries in hockey. Many of the earlier high-frequency injuries in hockey were related to the lack of protective equipment, particularly around the head and face. With the adoption of rules for appropriate helmet and face mask use, the number of head and neck injuries have decreased. Nevertheless, examining the frequency of injuries, typically a puck or stick impact is responsible for more than 50% of the injuries in hockey, and impacts between players or boards account for more than 30% of the injuries. Typically the areas most frequently injured are the head and lower-extremity. The injury rate in hockey increases with age, tends to be greater in games rather than in practice, and greater in early season as opposed to late season.
Although a variety of injuries can occur in hockey, there are some injuries that are specific--more so--to hockey than to other sports.
Hockey Ankle
Of the injuries to the lower extremity, the "hockey ankle" is an eversion and external rotation ankle sprain. This is an opposite mechanism to that found in other sports (inversion sprain). The spraining of a "hockey ankle" typically occurs from catching the support blade in an ice rut; this forces the skate and shoe outward, tending to evert and externally rotate the ankle. This loading puts excessive stress on the deltoid or medial collateral ligaments of the ankle joint. Avulsion fractures or ligament sprains can result. Treatment for this injury is typical for sprains and includes compression, ice, and elevation. Progressive range of motion and gradual return to training is advised.
Hip Adductor Sprains
Because of the large forces transmitted across the hip and lower extremity at the time of push off during skating, there are a relatively large number of hip-adductor strains with hockey. There is a greater chance of injury to the hip adductors in early season when muscle strength and conditioning is at a lower level. It is important strengthening and stretching be used with hip adductors to reduce the incidence of these overuse injuries. Typically a hockey player who has a hip-adductor strain will have tenderness in the groin (proximal attachment of the adductors) and pain associated with adduction of the hip joint. Following rest, a gradual increase in range of motion and strengthening will help to reduce the likelihood of future strains.
Shoulder Injuries
Because of the contacts or impacts in hockey, the shoulder is a vulnerable joint. Falls can be particularly dangerous, because landing on an out-stretched arm can produce dislocations or subluxation of the shoulder or acromioclavicular joints.
Acromioclavicular sprains typically result from a fall directly on the tip of the shoulder or a compression of the shoulder occuring while impacting the ice or boards. Grade I and II injuries generally tender and a grade III separation may result in a slight elevation of the distal clavicle. Acromioclavicular sprains are treated conservatively, with the hockey player wearing a sling for approximately 2-4 weeks. As pain subsides, increased range of motion is encouraged, and the prognosis for complete symptomatic recovery is generally excellent.
Shoulder dislocations occur in hockey, but their incidence is lower than acromioclavicular separations. Unfortunately, if shoulder dislocations occur at a young age, the occurrence rate can be greater than 90%. After a shoulder has been reduced and returned to its original anatomical location, conservative treatment with the arm immobilized (in adduction and internal rotation) will provide for effective healing of the injured tissues. After approximately 3 weeks of immobilization, rehabilitation begins with emphasis on internal and external rotation of the shoulder joint.
Clavicle Fractures
With the effective design of new pads, in recent years, the incidence of clavicle fractures has decreased in hockey. Older shoulder pads provided little production against impact to the clavicle, and thus a relatively high number of clavicle fractures were seen in hockey. The fracture of a clavicle in hockey is treated conservatively, with a harness worn full-time for 2-3 weeks and then for an additional 2-3 weeks during day-time use. Prognosis for complete recovery is usually excellent.
Impact-related injuries in hockey will never be eliminated completely, but the appropriate use of protective equipment, adherence to rules prohibiting aggressive behaviour, and effective stretching and strengthening exercises will greatly reduce the number of injuries to competitors.
Running
Millions of runners and joggers are found around the world. Running provides an excellent form of cardiovascular conditioning and helps with weight control. If progressively and sensibly approached, running can maintain tone in muscles, primarily in the lower extremities and help to prevent bone-mineral losses.
Whether young or old, most runners' injuries are linked to overuse. During running, the bones, cartilage, muscles, and tendons of the weightbearing joints must withstand large, repetitive forces. During running, it is not uncommon to have forces greater than two times body weight develop between the shoe and the ground. Inside the ankle, knee, and hip joints, these contact forces coupled with muscle forces can then generate compressive forces approaching six-to-eight times body weight. When one stops to consider how many times these large forces are applied to these musculoskeletal tissues during a jog of a few miles (or marathon!), it is readily apparent why overuse injuries happen.
In addition to these repetitive forces, when analyzing injuries it is important to consider the condition of the runner, the runner's shoes, the running surface, and the training regimen. If the jogger or runner is first starting, it is essential he or she gets advice about proper footwear and training. In the past two decades, there has been a revolution in the design and testing of running shoes. Biomechanical analyses of runners feet and lower extremities, as well as the use of improved new energy-absorbing materials and foot stabilizers, have helped to reduce the rate of injuries that otherwise would have happened.
Stress Fractures
Nevertheless, overtraining or improper training continue to generate a wide range of injuries in runners' hips, thighs, knees, shins, ankles, and feet. Problems at the hip joint are comparatively less than knee problems, but stress fractures and apophysitis (in younger runners) can develop. The stress fractures in the femur, typically concentrated at the neck of the femur, are usually a result of compressive forces. Radiographs or bone-scans may be used to confirm the stress fracture, and rest and conservative treatment will usually resolve the problem. Sometimes adolescent runners complain of "hip pain" focused in the region of the iliac crest. Because of the muscular attachments to that region and the cyclic muscular contractions during running, there can be an inflammation of the apophysis (iliac crest apophysitis), with pain along the iliac crest. With rest or greatly reduced running, the inflammation generally subsides.
Muscle-Tendon Strains
Of the thigh muscles, the hamstrings are strained ("pulled") most frequently with the adductors and quadriceps following. A muscle strain can include a range of damage to a muscle-tendon complex. The strain injury can be mild, moderate, or severe (Grade I, II, or III). With a mild strain, there is pain and inflammation with only a few muscle or tendon fibers damaged; the muscle can still function normally (albeit with pain). With a moderate strain, there is a partial tear in either the muscle, tendon, or at the muscle-tendon junction. Pain and inflammation are comparatively greater, but the muscle-tendon unit can still provide contractile forces to move the joints. In a severe muscle sprain, there is a complete rupture of the muscle or tendon, and function of the complex is lost. With complete rupture, surgical repair may be advisable.
One of the classic circumstances in which the hamstrings are strained is in sprinting and overstriding. Muscle fatigue may also be a factor in muscle strains. The hip adductor muscles are more likely to be strained during jumping or hurdling, when extreme ranges of hip motion or rotation happen. After a muscle strain, ice, compression, and elevation for up to 48 hours post-injury will be helpful, with later gradual range of motion exercise and return to activity. Proper stretching before and after running will help to reduce the incidence of muscle pulls. Tendinitis is an inflammation the tendon proper, and tenosynovitis is the inflammation of the synovial sheath covering many tendons. A bursa is a structure that may be interposed between a bony prominence and a tendon to reduce friction between these tissues; if the bursa becomes inflamed, the condition is called bursitis. At the hip and proximal thigh, tendinitis problems are less common than in the more distal joints of the lower extremity. In some instances, however, the proximal tendons of the hamstring muscles can become inflamed, and this problem generally will happen in long distance runners.
Bursitis
The iliotibial band, on the other hand, can present more frequent problems for runners. The pain may result from bursitis developing at the level of the greater trochanter where a bursa is located to smooth the motion of the iliotibial band over the bony prominence. Sometimes the runner or examiner can feel a "snap" as the tendon of the iliotibial band rides over the greater trochanter during hip flexion and extension. The runners most likely to develop this bursitis tend to have tight gluteus maximus and tensor fascia lata muscles, which produces the tight iliotibial band. Stretching of these tight muscles is strongly advised, and non-steroidal anti-inflammatory drugs and rest may be useful to reduce the inflamed bursa.
Runner's Knee
At the knee, a common injury site is the patello femoral joint. In runners, this syndrome is so common it has been referred to as "runner's knee". The exact etiology is not always obvious. Osteoarthritic, degenerative changes to the articular cartilage on the backside of the patella (retropatellar surface) may, in some cases, be a factor.
Chondromalacia patella is the term given to the degenerative changes occuring to the patellar articular cartilage. Some of the reasons for the degenerative changes include the high contact forces developing between the back of the patella and the femur as the quadriceps forcefully contract during the weightbearing phase of each running stride. Also, poor "tracking" of the patella in the intercondylar groove of the distal femur may also concentrate the stresses on the cartilage in an abnormal way. If a runner's alignment between the femur and tibia is such that there is a "knock-kneed" condition (a large "Q-angle"), the tracking of the patella can also be adversely affected. In some instances, orthotic supports in the runner's shoes can help to alleviate the malalignment at the knee joint and provide better patellar tracking.
Lateral knee pain in runners is most likely a consequence of a tight iliotibial band. At the knee like at the hip, there is a bursa helping to minimize the friction of the tendon moving over the femoral epicondyle. This bursa can also become inflamed and/or the tendon itself can become inflamed as a result of the repetitive overloading.
Shin Splints
In the lower leg, stress fractures and "shin splints" are recurring problems for many runners. The location for stress fractures is frequently in the proximal or distal third of the tibia or in the fibula. There can be pain and tenderness over the site of the stress fracture, and about three weeks after the presentation of the pain, a "hot" spot can be detected with a bone scan or radiograph. Treatment of stress fractures requires stopping the loading causing the breakdown in the bone running. Other activities, such as cycling, underwater running, or swimming can be substituted to help the runner maintain cardiovascular fitness.
Sometimes stress fractures to the tibia or fibula are included in the general category of "shin splints". "Shin splints" is a generic term used to describe a wide variety of conditions producing pain in the leg, between the knee and the ankle joints. Besides stress fractures, the other tissues producing the pain are muscles, tendons, periosteum, and nerves. Sometimes the term "anterior compartment syndrome" is used to describe the problems associated with the muscles of the anterior lower leg. In particular, the tibialis anterior muscle and its tendon can be implicated in shin splints. If, as a result of the repeated contractions of the muscle, the proximal tendon of the tibialis anterior (attached to the tibia) is inflamed, "shin splints" pain will develop.
Thus, tendinitis can be a cause of the shin pain, or the pain may be related to an inflammation of bony periosteum of the tibia. If excessive and repetitive tensile forces are applied by the proximal tibialis anterior tendon to the periosteum covering the proximal tibia, the periosteum can become inflamed. Myositis, or muscle inflammation can also cause the pain in the shin.
Another suggested reason for the anterior compartment pain syndrome is a disproportionate development of muscle tissue, compared to its enveloping connective tissue covering. With exercise, muscle fibers can get larger hypertrophy. If the muscle becomes larger, too quickly, the fibrous connective tissue surrounding the muscle may not be able to keep up. The muscle fibers, blood vessels, and nerves can then be compressed as pressure builds. The pressure, presumably, produces the resulting pain. In some extreme cases, surgical fasciotomy (cutting of the muscle's connective tissue covering) has been done to relieve the pain emanating from the anterior compartment.
Pain in the foot and ankle can be grouped according to the regions of the structures: lateral (distal fibula stress fracture or peroneal tendinitis), posterior (Achilles tendinitis or retrocalcaneal bursitis), posteromedial (retrocal caneal bursitis, calcaneal apophysitis, or Achilles tendinitis), medial (posterior tibial tendinitis or medial malleolus stress fracture), anteromedial (navicular stress fracture), and plantar (plantar fasciitis or sesamoid injuries).
Achilles Tendinitis
Achilles tendinitis or tenosynovitis is one of the most common tendon problems with runners. Tenderness and pain can become quite severe. Sometimes it is not clear whether it is inflammation of the tendon or if the problem is an inflammation of the bursa that lies between the Achilles tendon and the calcaneous. In either case, however, rest, ice, and other rehabilitation modalities are needed to reduce the inflammation. Stretching of the tendon is advisable, and strengthening of the triceps surae muscles should be emphasized. Steroid injections of the inflamed area are, generally, not advised because of the danger of further weakening the tendon and predisposing it to rupture.
Stress Fractures
In the foot, stress fractures are a common problem in runners, even though today's better quality running shoes help to cushion and absorb more of the impact forces during running. The navicular bone and the metatarsals are the foot bones more likely to be fractured.
Plantar Fasciitis
The plantar fascia of the foot is stretched each time a player pushes off the ball of the foot. During this force ful maneuver, the triceps surae (calf) muscles pull on the calcaneous to cause the needed plantar flexion, and at the same time reaction forces from the ground push upward on the ball of the foot to propel the body forward. These combined forces cause the arch of foot to be flattened, an action the plantar fascia must resist. If too many high-force stretches are applied to the fascia, microdamage to the collagen fibers may result, with local inflammation. This inflammation is called plantar fasciitis. As with most fibrous connective tissue injuries, the inflamed plantar fascia usually responds well to rest, cryotherapy, aspirin, and/or non-steroidal anti-inflammatory drugs (if a persistent injury).
Skiing
Alpine (downhill) skiing participation has increased dramatically since the early 1970's. Although people of almost all ages ski, the largest increases in number of skiers are in those less than 20 years old. With the greater numbers of skiers and better equipment and instruction to enhance speed and performance, however, there have been marked increases in high-energy falls and serious injuries.
The types of injuries occuring 20 years ago were different than those occuring today. Earlier epidemiological data indicate the tibia and ankle were at greatest risk on the ski slopes. But with significant advances in binding design, ski-boot construction, changes in poles and skis, and new skiing techniques, the types of injuries have shifted. Surveys reveal the overall injury rates have declined by up to 50% since the early 1970's. The major reductions came in lower extremity injuries (ankle sprains and tibial fractures including spiral decreased by more than 80%), while at the same time the incidence of ruptures of knee ligaments (e.g., anterior cruciate ligaments) rose by more than 150%. Skiers 17 years old or younger generate more than 45% of all reported ski injuries. Children 10 years old or younger tend to have a high rate of fractures, whereas skiers in the 11 to 14-year-old range have the highest injury rates, but most of their injuries are sprains, abrasions, or bruises. The most common sites of injury to teenage and adult skiers, now, are the knee joint, ankle, and the upper extremities. The great increase in the percentage of upper extremity injuries is linked to the decreased percentage of tibial fractures and the increased number of high-speed falls. In these types of falls, the bindings can release to save the bone, but the knee ligaments give way, and the skier's upper extremities can be injured as he or she tries to brake the high-speed fall.
Contusions and Lacerations
Contusions and lacerations are the most frequent injuries on the ski slopes. Because the head and face are more exposed than those regions of the body covered by thick winter clothing, they are the most frequently lacerated and bruised. Ski edges, poles, and collisions with other objects (including other skiers) are the most likely sources for these injuries. Lacerations must be irrigated and, possibly, sutured, whereas contusions should be iced in the first 24-48 hours after injury and then moist heat applied to facilitate healing.
Skier's Thumb
In the upper extremity, the most frequent sites of injury are the thumb and the shoulder. Studies indicate 40% of all upper-extremity skiing injuries involve the thumb, and of those thumb injuries almost all are to the ulnar collateral ligament of the metacarpal phalangeal joint (Skier's Thumb). The typical injury sequence involves the forceful abduction and hyperextension of the joint during a forward fall. Because younger children (open growth plates) also receive a substantial number of thumb injuries, it is important to determine if their injury is only to the ligament or if damage to the epiphysis has occurred in the fall.
Shoulder Dislocation
As a result of falls, shoulder dislocations readily happen in skiing. After dislocations, the next most-frequently occurring shoulder injury is a rotator cuff tear, followed by acromioclavicular separation. In the young skier, a shoulder dislocation can be especially problematic because of the high likelihood of recurrent dislocations
Ankle Sprains
With modern boots, the probability of ankle fractures or boot-top fractures including the ankle-joint surface is dramatically reduced. But, additionally, the new boots can concentrate a great deal of force at the skier's knee joint. Thus, there has been a significant increase in the number and percentage of knee-ligament ruptures during skiing. Nevertheless, ankle injuries do happen, as well as lacerations, contusions, and fractures. Ankle sprains can be a problem, particularly in young children with ill-fitting boots. Boot-top fractures also still occur, but with the changed design of the boots, the site of the fracture is more proximal on the tibia and fibula. With high-speed, high-energy crashes, comminuted fractures may be found in any of the lower extremity bones.
Knee Injuries
Sprains (either mild, moderate, or severe) of the anterior cruciate ligament are the most common soft tissue injury of the knee joint. Frequently, the mechanism for an anterior cruciate tear is when the tip of the ski catches a ridge or mogul, and the knee is forced into a flexed-externally rotated-valgus position. Another mechanism can be one of forced hyperextension of the knee joint, as might occur when a skier unexpectedly passes from a groomed trail to a rough area. With expert skiers, some have suggested rupture of the anterior cruciate ligaments can happen when the skier forcefully contracts his or her quadriceps muscles to try to rise up from an out-of-control seated position. Full or partial rupture of the anterior cruciate ligaments can be particularly debilitating, in the short term, and in the long term the increased joint laxity that accompanies an unrepaired anterior cruciate ligament may lead to osteoarthritis later in life. Typically, damage to the anterior cruciate ligament is accompanied by tears in the medial collateral ligament and the medial meniscus. In most cases, rupture of an anterior cruciate ligament is an indication for surgical repair. Most often, the repair and reconstruction of the anterior cruciate ligament are achieved with a graft fashioned from a portion of the patellar tendon. Extensive physical therapy is essential for effective return from a knee-ligament injury, but with motivation and progressive rehabilition, most people can again return to a full menu of activities, including skiing.
Swimming
Competitive and recreational swimming is one of the most popular physical activities, as it provides both lower and upper body strength development as well as contributes to cardiovascular fitness. In the lower-level recreational swimmer relatively few orthopaedic complaints are found, but in competitive and elite swimmers problems with the musculoskeletal system are not uncommon.
Competitive swimming has four basic strokes, including the back stroke, front crawl, breast stroke and butterfly. Training for competitive swimming can be extensive, with many age-group or national calibre swimmers practising two times a day for at least five days a week. During each of these sessions, which may last approximately two hours, swimmers may swim a total of 4000-8000 meters. This amount of activity does not include the dry-land training involving other aerobic activities such as cycling or running and strength exercises.
Swimmer's Shoulder
The shoulder is the most commonly injured site in swimmers. "Swimmers shoulder" is a term used to describe the tendinitis occuring in the rotator cuff as a result of the thousands of stroke repetitions occurring during a workout. Shoulder pain has been reported to occur in up to 50% of "serious" swimmers. The progression of tendinitis in the shoulder can proceed through three stages. In the first stage edema and haemorrhage can be found, typically in younger swimmers, and in the second stage, fibrosis and tendon inflammation (tendonitis) will occur - usually found in individuals who are 25-40 years of age. The final stage is usually found in individuals over 40, and, here, osteophytes may form under the acromion process and either partial or complete tears of the tendon can develop. Infringement tendonitis is typically attributed to overwork, subacromial loading, and reduced vascular flow. Proper training, technique, and strengthening exercises can all help to alleviate the tendinitis problem. It is typically when the arm and shoulder are in an overhead position the greatest likelihood of wear, tear, and damage to the shoulder joint occur. In this abducted overhead position the tendons of the rotator cuff can be pinched between the roof formed by the coracoid process and the relatively rigid coracoacromial ligament and the underlying humerus. If the femur is then rotated internally or externally with the arm in this position, excessive wear and tear can occur in the rotator cuff tendons.
Overuse and overwork are factors in tendinitis in swimmers, but genetic factors may also be of importance. If an individual has relatively loose shoulders, the greater laxity in the joint may make excessive demands on muscles for maintaining joint stability. It is important that training techniques and weight training of swimmers include both internal and external-shoulder rotation exercises to provide a balance between the internal and external rotators and, thus a more stable joint.
Overuse syndromes of the shoulder are typically easier to prevent than to treat. The swimmers training regime should be one of progressive and gradual increase in distance and intensity with proper warm up and cool down after a practice. Weight training and strengthening exercises should definitely be included for external shoulder rotators and muscles surrounding the scapula. Proper stretching and motion of the joint through a full range of motion as well as emphasis on proper stroke mechanics can be invaluable for preventing tendinitis. Stretching can be particularly important and is strongly advised before each workout. Restricted flexibility has been strongly linked to the tendency to develop tendinitis. The treatment of tendinitis of the shoulder depends on the severity of involvement.
Grade I tendinitis can typically be treated with application of ice immediately following workout, changing stroke mechanics, extra stretching, and emphasizing on strengthening of the external rotators.
With a Grade II (moderate) a period of rest and physical therapy may be required. Swimming may be permitted on strokes that do not elicit pain, and kick boards can be used to maintain lower extremity mechanics and fitness. Non steroidal anti-inflammatory medication, at times, can be useful. Physical therapy may be related to several modalities including ultrasound, iontophoresis, or transcutaneous nerve stimulation (TENS).
With more severe tendonitis (Grade III) it may be necessary for the athlete to consider a change of sport or surgery.
With a Grade IV level of tendonitis (pain with any activity), there may be a complete tear of the rotator cuff. Conservative treatment may not produce satisfactory relief of symptoms and arthroscopic surgery may be required to repair the lesion.
Lateral Epicondylitis
Some of the strokes involved in swimming, namely the butterfly and breast stroke, can cause overuse injuries at the elbow. The inflammation is sometimes called "tennis elbow" or lateral epicondylitis. There can be inflammation of the extensor carpi radialis brevis and extensor communisaponeurosis at the lateral insertion on the humeral epichondyle. Treatment of the lateral epicondylitis should include relief of inflammation, strengthening of wrist extensors, and correction of poor stroke mechanics - if applicable.
Knee Injuries
At the knee the three most frequently reported injuries are related to medial collateral ligament stress, patello femoral pain, and medial synovitis. Excessive stretching or sprains of the medial collateral ligament are a common complaint in some breast strokers. During the kicking action of the breast stroke there is a valgus stress coupled with an external rotation at the knee which greatly increases the tension on the medial collateral ligament. During examination, a point tenderness can be found along the course of the ligament, and a valgus plus external rotation force applied to the flexed knee can generate the pain.
Patello femoral pain can be related to a hypermobility or instability of the patello femoral joint. The pain can be elicited to applying a direct pressure to the patella or by applying a lateral force to the patella. Tenderness can be noted by palpating the patellar facets or femoral condyles. Medial synovitis can occur, and appears to be more frequent, in swimmers who concentrate on the breast stroke. Other problems associated with the knee can be injuries to the medial meniscus or osteochondritis dessicans.
Foot and Ankle Pain
Although less frequent than injuries to the shoulder or to the knee, foot and ankle pain are also found in some swimmers. Particularly the extensor tendons of the ankle can be a weak point in some swimmers. The flutter kick and the dolphin kick can be the most demanding on this region.
Low Back Pain
Because of the current techniques being used in the breast stroke, the swimmer typically has a lordosis in the lower back, and an individual with a predisposition to back problems may be at risk. Some of the problems occuring involve stress fractures of the pars interarticularis or spondoylolisthesis. Typically however, these swimmers may present mild symptomatic low back pain occuring with posterior facets irritation. Radiologic exams are typically used to make a precise diagnosis following a period of rest, a gradual return to training may be tolerated. It is important hamstring stretching and abdominal strengthening be an integral part of the training and rehabilitation program.
Tennis
Tennis is a popular sport allowing people of almost every age to be active at self-paced levels of effort. Neuromuscular coordination and skill are required for playing tennis, and agility and endurance are required even at a beginning level. As the skill level of the game increases, the physical demands also increase. Nevertheless, for both theserious, regular tennis player and for the weekend player, chronic musculoskeletal injuries can develop because of the repetitive, forceful running, volleying, serving, and hitting.
Common areas injured in tennis are the elbow, shoulder, and lower extremities. These injuries can include: ankle sprains, patellofemoral and meniscal knee injuries, and muscle-tendon strains in the lower extremity, and inflammation may develop in the tendons of the triceps surae, shoulder, elbow, or patella. Furthermore, in adolescents, there is always a potential problem associated with apophysitis (e.g., elbow, knee, or calcaneous) or osteochondritis of the elbow capitellum. One of the problems with many recreational tennis players is the lack of dedication to training and overall conditioning. The well-conditioned player is less likely to be injured. In addition, whenever possible, players should try to practice or play on clay, grass, or composition surfaces, rather than cement or asphalt. The stiffer and harder surfaces are more likely to produce injuries than a more compliant surface. The use of ball machines or of a wall to practice strokes can be helpful for focusing practice, but the player should also be aware of the substantial increase number of hits or strokes their usage provides. Extra care must be taken to avoid overuse injuries.
The strength of the legs is particularly important, not only for quality tennis, but also to decrease the stresses (and injuries) in the racket arm. The best tennis players place a great emphasis on running and balance, as produced by the legs. By getting to the ball and into proper position more quickly, the player is better able to return the shot with appropriate balance and stroke mechanics, rather than relying mostly on the strength of the upper limb.
Shoulder Injuries
During the serve or an overhand volley, the shoulder joint goes through a motion similar to an over hand throwing pattern. As the racket is "cocked" or brought back in preparation for the forward acceleration, the muscles and tendons of the rotator cuff are markedly stretched. In particular, the anterior rotator cuff muscle-tendon units and the anterior deltoid and pectoralis major muscles are stretched. As this stretching occurs, there is a possible impingement or compression happening at the posterior lip of the glenoid fossa. Thus, during the preliminary portion of the serve, traction injuries to the anterior shoulder muscles and compression injuries to the posterior articular structures are possible. As the body is moved forward during the serve, the shoulder is forced further into external rotation and abduction. In this orientation of the shoulder, the tendons of the rotator cuff tend to be pinched between the bony surface of the proximal humerus and the stiff coracoacromial ligament complex overlying the glenohumeral joint. With repetitive cyclic pinching of these fibrous tendons, inflammation (tendinitis) can develop. Also during the forward motion of the serve, as the humerus is internally rotated so the racket will contact the falling ball, the rotator cuff tendons continue to be trapped between the humerus and the overlying coracoacromial ligament. Finally, during the follow through (after ball-racket contact), the player's arm and the mass of the racket must be decelerated. This deceleration is achieved, primarily, by the posterior muscles of the rotator cuff (e.g., teres minor and infraspinatus) and the posterior deltoid. During this decelerative stage, there is an increased likelihood of muscle-tendon strains, including partial or complete tears. At the terminal stage of the follow through, the anterior rim of the glenoid fossa may be impacted by the internally rotating head of the humerus; this can cause impingement and, potentially, produce an osteophyte or calcium deposit on the anterior rim of the glenoid fossa. With the build up of the bony material on the anterior rim, the normal range of motion of humeral internal rotation will be reduced, and with each follow through, the impingement will be aggravated.
Individuals with lax shoulder joints are more likely to experience shoulder tendinitis. Subtle subluxations can occur in lax shoulders, with each serve, and can aggravate the damage to the rotator cuff tendons. If an individual has a lax shoulder joint, and also poorly conditioned scapular and trunk muscles, the rate of damage to the joint can be accelerated. It is important trapezius, rhomboid, subscapularis, and levator scapulae muscles are systematically and progressively trained to help stabilize the shoulder during the tennis serve.
Tennis Elbow
At the elbow, the classic problem is lateral epicondylitis (Tennis Elbow). This injury most often develops when contacting the ball during a backhand stroke. As the ball hits the racket, the momentum of the ball and the inertia of the racket tend to produce flexion of the wrist and pronation at the radioulnar joint. The muscles and ligaments counteracting those motions attach to the lateral epicondyle of the humerus. The strongly contracting muscles pull at their insertion on the lateral epicondyle of the humerus, and the repetitive loading can produce a variety of overuse injuries, all of which tend to be grouped under the term "Tennis Elbow".
Strains (mild, moderate or severe) of the wrist extensors (e.g., extensor carpi ulnaris and extensor brevis) will cause inflammation and a tenderness to the lateral elbow joint. But, in addition to these muscle-tendon injuries, there may be an inflammation of the periosteum where the tendon inserts to the lateral epicondyle of the humerus. The lateral collateral ligament of the elbow joint can also be sprained during a forceful backhand stroke.
These chronic overuse injuries, generally, resolve with conservative treatment, including cryotherapy, ultrasound, stretching, and gradual return of motion and activity. It is rare surgical intervention is needed to treat tennis elbow.
Pitcher's Elbow
Although not as common as lateral epicondylitis, medial epicondylitis of the elbow also occurs in tennis. This condition is reminiscent of "pitcher's elbow", and the pain is concentrated on the medial aspect of the player's elbow. The cause of the injury is, again, linked to large repetitive forces, but in this case, the forces are produced during a forehand stroke. Now the combined mass and momentum of the ball and racket tend to force the elbow into a greater valgus condition, with the wrist flexors (e.g., flexor carpi radialis) and pronators of the radioulnar joint (e.g., pronator teres) being forcibly stretched. Because of these forces, the medial side of the elbow joint tends to "open up" (the medial capsule and medial collateral ligaments are stretched), and the lateral side of the elbow joint is pinched (the head of the radius is compressed by the distal humerus). Under these conditions (analogous to the problems associated with lateral epicondylitis), the flexor-pronator muscle-tendon units can be strained, the periosteum surface can be detached, or the medial joint capsule and collateral ligament can be sprained. When any of these injuries occur, the course of treatment is essentially the same as with the classic Tennis Elbow injuries.
Apophysitis
With preadolescent tennis players, there is an additional danger of apophysitis (inflammation of the apophysis), either on the lateral or medial epicondyle of the humerus. Until the growth plates of the distal humerus close, traction forces from either wrist extensor and supinators (attaching to lateral epicondyle) or the wrist flexors and pronators (attaching to medial epicondyle) can cause a disruption and inflammation in the growth plates at these sites. In severe cases, avulsion fractures can occur, as well as capitellar osteochondritis dissecans. If these conditions are suspected, radiographs are advisable to confirm the injury.
As with other overarm activities (see Baseball), when the elbow is vigorously extended in the following through stage of the serve, excessive forces can be developed between the olecranon process of the ulna and the distal humerus. These bone-on-bone contact forces can disrupt normal bone growth of the olecranon process. Furthermore, because the triceps muscles attach to the tip of the olecranon process and they are forcefully active during the overhead volley or serve, large muscle forces can cause an inflammation of the olecranon apophysis. This condition is analogous to Osgood-Schlatter's Disease at the knee or Sever's Disease at the calcaneous. To relieve the inflammation the usual sequence of rest, ice, compression, medication, and modalities is recommended. If there is disruption to the olecranon region, there is also a potential problem with the ulnar nerve passing posterolateral to the elbow joint. If too much mechanical loading is transmitted to the nerve, ulnar neuritis may develop.
Osteochondritis
During various strokes, the compressive forces on the joint surfaces of the distal humerus can be high. The forceful contractions of the muscles spanning the elbow joint tend to pull down (distally) on the humerus and up (proximally) on the radius or ulna to compress the ends of these bones. In addition during the backstroke, the proximal ulnar and distal humeral heads tend to be compressed because of the varus loading of the joint from the inertia of the mass of the forearm, racket, and ball. During forehand strokes, a valgus loading occurs in the elbow joint, and the primary compression occurs between the proximal head of the radius and the distal head of the humerus. With the excessive compression of joint surfaces, regions of articular cartilage can degenerate and eventually become detached from the underlying subchondral bone. This condition is called osteochondritis, and at the elbow an example of this condition is capitellar osteochondritis.
At the wrist, frequently occurring problems are associated with capsular synovitis (impingement) of the radiocarpal joint and a ganglion of the radiocarpal joint. Also common are chronic wear and degenerative changes in the triangular fibrocartilage complex. If the triangular fibrocartilage complex is inflamed, pain and tenderness are noted in the dorsal aspect of the distal radioulnar joint during combined flexion and supination. A sprain to the triangular fibrocartilage complex can range from mild to severe; in severe cases, a complete tear of the midsubstance of the complex has occurred or the distal styloid of the ulna has avulsed. Magnetic resonance imaging can be useful to confirm the diagnosis. Less frequent problems at the wrist include synovitis of the distal radioulnar joint, sprains of the ulnar collateral ligament, or tendinitis of the extensor carpi ulnaris tendon. Many of these "wrist" problems can be traced to a player's excessive reliance on wrist shots, rather than using on the full arm, torso, and legs to power and control the racket.
Achilles Tendinitis
Common injuries to tennis player's lower extremities include injuries to the Achilles tendon, plantar fascia, as well as stress fractures to the tibia, fibula, or metatarsals. As with most high-speed, weightbearing sports, soft-tissue inflammations and stress fractures are related to the forceful, repetitive loading of tendon, fascia, and bone. Microdamage develops, and over time, there is inflammation, pain and restriction of activity.
The Achilles tendon is particularly vulnerable in middle-aged weekend tennis players. This group of players, more so in men, is most likely to get inflammation of the Achilles tendon and, after chronic inflammation, are most at risk for partial or complete rupture of the Achilles tendon. The typical scenario involves a middle-aged man who has a relatively sedentary job during the week and then vigorously plays tennis, occasionally, on the weekend. Because of the atrophy of the tendon and the weakened bone at the calcaneal insertion occuring with inactivity, the loads the tendon can withstand prior to rupture are reduced dramatically. When the loads are highest on the tendon (e.g., forcefully pushing off to position himself to return a shot or forcefully planting the foot to stop his momentum), he may experience a feeling of "someone kicked my heel". A clear "snap" can be heard. With a complete rupture of the Achilles tendon, plantarflexion power is lost. Today, surgical repair is generally advised for full ruptures of the Achilles tendon, especially, if return to full activity is one of the player's goals.
Plantar Fasciitis
The plantar fascia of the foot is stretched each time a player pushes off the ball of the foot. During this forceful maneuver, the triceps surae (calf) muscles pull on the calcaneous to cause the needed plantar flexion, and at the same time reaction forces from the ground push upward on the ball of the foot to propel the body forward. These combined forces cause the arch of foot to be flattened, an action the plantar fascia must resist. If too many high-force stretches are applied to the fascia, microdamage to the collagen fibers may result, with local inflammation. This inflammation is called plantar fasciitis. As with most fibrous connective tissue injuries, the inflamed plantar fascia usually responds well to rest, cryotherapy, aspirin, and/or non-steroidal anti-inflammatory drugs (if a persistent injury).
Wrestling
Wrestling is a sport originating thousands of years ago. Today, amateur wrestling is a popular activity for individuals at the youth, high school and college and adult levels. Compared to other sports, such as football, wrestling has a surprisingly high number of injuries associated with it. Wrestling has been described as a "contact sport" and high levels of speed, impact and force combine to generate the relatively high number of injuries. Organized, amateur wrestling has generated a comprehensive set of rules to prohibit illegal and dangerous moves. Nevertheless, injuries can and do occur.
Concussions
Injuries to the face, head and neck constitute about 30% of all injuries in wrestling. A concussion can occur when the head of a wrestler attempting a take down, for example, impacts the knee or head of his opponent. Concussion is a reversible injury situation in which there is transient physiological disruption to the brain but no permanent anatomical damage.
Concussions can be divided into three categories:
Mild
Moderate
Severe
Mild concussion produces a slight disorientation in the wrestler without loss of consciousness; moderate concussion is the loss of consciousness for 3-5 minutes, subsequent disorientation, retrograde amnesia which might last up to 24 hours; and severe concussion involves the loss of consciousness for more than 5 minutes, with post-traumatic amnesia lasting for more than 24 hours. With a severe concussion, the wrestler is at risk of developing intracranial haemorrhage. Following a concussion, various criteria should be met prior to the return of the wrestler to competition. Among these criteria are a fully alert state, no dizziness or headache and absence of amnesia or impaired concentration.
Lacerations
Lacerations typically occur to a wrestlers' eye brows and lips. Usually these injuries occur during take-down attempts. If the bleeding is more than minimal, the match may be stopped to assess whether the athlete is able to continue. Pressure dressings, Steri strips, or Butterfly strips may be used on an interim basis for some lacerations until after a match when sutures can be applied. Facial lacerations may be closed safely in the first 24 hours after the injury.
Auricular Haematoma (Cauliflower Ear)
Auricular haematoma is a characteristic injury to athletes such as wrestlers or boxers who have multiple impacts to the outer ear. Impact forces or abrasive (frictional) forces can produce haematomas when wrestlers do not wear headgear. Furthermore, ill-fitting headgear can also produce auricular haematomas (cauliflower ear). If an acute haematoma develops, needle aspiration can be used to remove the excess fluid. Infection can be a significant problem and should be watched for carefully. Following aspiration, pressure dressings can be used to inhibit refilling of the injured region.
Neck Injuries
The neck of the wrestler is a region strained because of impact with the mat, the opponent, or because of extreme muscular contraction associated with certain maneuvers (bridging to avoid a pinning situation). A cervical strain involves the tearing of a muscle-tendon unit in the neck region. The muscles most frequently involved include the trapezius, sternocleidomastoid, scalene, erectors spinae, levator scapulae, and rhomboids. As with sprains, strains to musculo-tendinous units can be mild, moderate or severe. A mild strain involves a stretching of the muscle-tendon unit with possible microtears in either the muscle or tendon components. Moderate strains involve greater disruption of fibres in either the tendon, muscle-tendon junction or muscle, but the function of the muscle-tendon unit persists. With a severe strain, however, there is a complete tear or disruption of the muscle tendon unit. With a strain injury to the cervical region, bending the neck to the opposite side of the injury tends to produce pain. Generally, rest and immobilization of the neck region (cervical collar), non-steroidal anti-inflammatory drugs and cryotherapy can be useful to rehabilitate the injury.
When a wrestler stretches or pinches the brachial plexus or nerve roots, neurogenic pain can result. For example, if the wrestler's neck is forced into hyperextension and lateral flexion, he may experience a stinging or shooting pain extending from his shoulder to fingertips. The numbness or weakness associated with this event can last for a few seconds, but usually less than 5 minutes. If complete recovery is not evident within a few minutes, participation should be stopped and neurological examinations should be instituted. Immediate treatment should include icing to reduce bleeding and muscle spasms. Repeated trauma including compression and hyperextension of the neck may contribute to osteophyte development which may further impinge on cervical nerve roots.
Shoulder Injuries
Injuries to the upper-extremity constitute 20% of all wrestling injuries, and the shoulder is one of the most commonly injured joints in wrestling. The mechanism of injury involves a situation where a wrestler is thrown to the mat and lands on his shoulder or in falling to the mat the wrestler may attempt to "catch" himself with his extended arm. Although glenohumeral-joint dislocations are relatively rare in wrestling, a more common injury is an anterior glenohumeral subluxation. Because of the structure of the shoulder joint, the anterior direction is most prone to subluxation. If tendonitis or other inflammations are present with the subluxation, non-steroidal anti-inflammatory drugs can be useful. Thereafter, a series of progressive exercise is essential, with manual resist ance exercises, range of motion training, and gradual return to painless function.
Acromioclavicular sprains happen with a similar frequency as glenohumeral joint subluxations. These two shoulder injuries account for a majority of injuries to the shoulder in wrestling. The acromioclavicular sprain typically occurs when the wrestler is thrown to the mat, striking the top of his shoulder. The ligaments surrounding the acromio clavicular joint and the joint capsule may be damaged. Typical rehabilitation therapies including cryotherapy, analgesics, and transcutaneous neural stimulation are advised.
Finger Sprains
Sprains to thumbs and fingers are commonplace in wrestling. By far the most common sprain is associated with the metacarpophalangeal and proximal interphalangeal joints. Typically these sprains are treated by splinting and taping.
Rib Contusions
Because of collisions occuring between opposing wrestlers or between a wrestler and the mat, the rib cage is susceptible to trauma. Rib contusions, and sometimes rib fractures, can occur as well as costochondral separations. Twisting motions of the trunk, or coughing or sneezing can produce pain in the injured area. The symptoms are treated, typically, with cryotherapy and TENS for pain control.
Knee Injuries
Lower-extremity injuries comprise 40% of wrestling injuries, and the majority of those injuries are to the knee. The types of injuries to the knee are classic to many different sporting activities. Injuries may occur to the lateral collateral ligaments, cruciate ligaments and/or the menisci. Usually, in wrestling most knee injuries occur during take downs. In contrast to sports such as football, basketball, or skiing, there is a relatively low incidence of anterior cruciate ligament sprains in wrestling. The most common injuries to the knee in wrestling are pre-patellar bursitis, sprains of the medial and lateral collateral ligaments, and medial and lateral meniscal tears. Interestingly, tears to the lateral meniscus are proportionally greater in wrestling than in any other sport. Prepatellar bursitis is the most common knee injury and is the most recurrent of knee injuries in wrestling. Prepatellar bursitis is easy to diagnose as swelling occurs superficial to the patella. Knee range of motion--except with maximum flexion--is relatively painless. Because wrestlers continually impact the knee joint during take downs and in the "down position" there is a high likelihood of this bursitis developing. Typically this condition can be treated with phonophoresis with 5% hydrocortisone, in conjunction with aspirin or non-steroidal anti-inflammatory drugs. Appropriate knee pads can reduce the likelihood of initial development of the bursitis or inhibit its recurrence. If the condition reoccurs repeatedly, a bursectomy may eventually be advised.
Ankle Sprains
Ankle sprains occur in wrestling as in many other activities. Inversion sprains causing damage to the lateral ankle ligaments, almost always occur during take downs. Treatment includes a standard protocol beginning with ice, then ultra sound or hydrocortisone phonophoresis after two days post injury. Tape or elastic wraps may help to reduce swelling.
Nutrition/Weight Loss
Achieving a certain body weight can be a difficult but major goal for some wrestlers. In addition to "make weight", wrestlers use many techniques to lose large amounts of weight in a short amount of time. In high school and college, wrestlers can lose from 3-20% of their preseason body weight prior to competition. Commonly, wrestlers use both food and fluid restriction to achieve the weight loss. With acute and prolonged dehydration, significant reductions can occur in blood plasma volume, wrestler's performance and muscular strength. If fluid loss exceeds 2% of the wrestler's normal body weight, marked changes can occur in heart rate, stroke volume and cardiac output. These changes in cardiovascular function can be dangerous, particularly when accompanied by elevated core temperature, altered electrolyte balance and potential changes in renal function. Fluid replacement is essential for a wrestler. Because thirst can be an unreliable indication of hydration, it is important a wrestler drink beyond satiation to insure proper rehydration occurs.
Dermatitis
Besides orthopaedic problems, the physical contact involved in wrestling can produce dermatological problems. Communicable diseases of the skin should be carefully in wrestlers. Staphylococcal infections, such as folliculitis or furunculitis are enhanced by the moisture associated with physical insertion in wrestling. Thus clothing and footwear, closely opposing skin surfaces, are likely locations for the growth of staphylococci. Proper skin hygiene is important, and cleansing the skin with soap containing anti-bacterial agents is advisable. In addition, the athletes should be advised to wash work-out clothes daily, and the mats used in wrestling should be cleaned daily. Folliculitis or staphyloccolan infections are associated with hair follicles. These lesions are typically seen on the thighs and the popliteal area. Furun culitis is the acute inflammation deep in a hair follicle. Treatment includes systemic antibiotics and daily applications of moist hot compresses. Impetigo may be secondarily related to staphylococci. The face is the most common site, but it may also occur on the arms and the legs. Systemic antibiotics should be given, and the crusts associated with the lesion should be periodically removed with warm-water soaks prior to applying topical antibiotics. The athlete should not come in contact with other athletes until the lesions are gone. Viral infections, including Herpes simplex type I are common among wrestlers. Because it is highly contagious, wrestlers should be restricted from competing while infected. Typically these infections appear as a cluster of serous-filled vesicles. Symptoms may include tingling or burning of the skin prior to the eruption of the vesicles. Although lesions may appear on any part of the skin, common sites include the area around the lips and adjacent parts of the face. Recurrence is common, and the vesicles can readily burst and become infected. Herpes virus has a tendency to persist throughout life with varying episodes of appearance and remission. In many cases, stress can trigger an occurrence.
Superficial fungus infections, or tinea infections, can be persistent problems associated with the feet and the groin of the wrestler. Body moisture contributes to the development of the infection. The inflammation associated with the fungulan infections may include slight scaling or fissuring or more extensive dry and reddish scaling of the skin. Proper foot and skin hygiene can greatly reduce the likelihood of contracting the infection, and medicated topical ointments may help to alleviate symptoms.
Dermatitis is a general term used to classify any inflammation of the skin. Contact dermatitis may be a result of friction between the skin and some other surface or the hypersensitive reaction of the skin to various chemical agents. Contact dermatitis can frequently be treated with wet, cool compresses and topical application of 1% hydrocortisone cream.
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