Sérgio Rocha Piedade

Andreas B. Imhoff
Mark Clatworthy
Moises Cohen
João Espregueira-Mendes
Editors

The
Sports Medicine
Physician
The Sports Medicine Physician
Sérgio Rocha Piedade  •  Andreas B. Imhoff
Mark Clatworthy  •  Moises Cohen
João Espregueira-Mendes
Editors

The Sports Medicine

Physician
Editors
Sérgio Rocha Piedade Andreas B. Imhoff
Orthopedics and Traumatology Orthopaedic Sports Medicine
State University University of Munich (TUM)
of Campinas – UNICAMP München, Bayern
Campinas / Sao Paulo Germany
Brazil
Moises Cohen
Mark Clatworthy Department of Orthopedics &
Ascot Hospital Traumatology
Auckland Federal University of São Paulo
New Zealand Vila Clementino - São Paulo
São Paulo
João Espregueira-Mendes Brazil
Espregueira-Mendes Sports Centre
Clínica do Dragão
Porto
Portugal

ISBN 978-3-030-10432-0    ISBN 978-3-030-10433-7 (eBook)

https://doi.org/10.1007/978-3-030-10433-7

© ISAKOS 2019
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Preface

Throughout our life, we are driven toward our dreams; we define paths and
strategies and fight for them to become true; we are all moved by challenges.
Since ancient times, strife, conquest, and defeat are part of human nature; and
this explains why sports are so amazing to practice, watch, and support.
Sports offer us magic moments in which we vent our anxieties and disap-
pointments, share dreams and emotions, and also learn to win and lose.
Moreover, sports play a fundamental role in health and education, as they
make us aware of the importance of healthy habits, teamwork, and respect for
others.
Sports are not only related to recreational and professional competitions,
but they are also a tool to reach a quality lifestyle. It strengthens the impor-
tance of sports medicine in the management of the effects of physical, recre-
ational, or competitive activity on people. The broad spectrum of sports
medicine area accounts to sports practice principles, overtraining injuries,
neurological disorders, sports trauma, special clinical conditions, different
scenarios in sports (indoor and winter), sports footwear, biologics in sports
injuries, major events in sports, and PROMs in sports. Moreover, it allows us
to navigate throughout all life phases: childhood, adolescence, adult life, and,
the “most experienced of all,” old age.
The Sports Medicine Physician book has involved professionals of sports
medicine area and orthopedic surgeons from over 20 countries in the world.
This book has 50 chapters organized in 10 parts covering different aspects
and domains in sports medicine.
Like any huge project, there is a great Team involved. I would like to thank
the ISAKOS President Mark Safran and Former President Philippe Neyret,
ISAKOS Board, Andreas B. Imhoff, Mark Clatworthy, Moises Cohen, Joao
Espregueira-Mendes, Mark R.  Hutchinson, Committee members, and all
health professionals that have accepted to work in this book, sharing their
academic and clinical knowledge as well as experience in sports medicine.
Thanks to all of you, my Team, Ge, Cezar, Mariana and Ana Karina Piedade,
and Magda S. Kimoto, for supporting me in this amazing project.
Sports make us better, stronger, and true because, in sports, we learn the
importance of teamwork.

Campinas, Sao Paulo, Brazil Sérgio Rocha Piedade

v
Contents

Part I Sports Practice Principles

1 Multidisciplinary Sport Medicine Team����������������������������������������   3

Francesco Della Villa, Stefano Della Villa,
and Joäo Espregueira Mendes
2 Pre-participation Evaluation in Sports Practice ��������������������������  13
Sérgio Rocha Piedade, Daniel Miranda Ferreira,
Mario Ferreti Filho, Rodrigo Kallas Zogiab,
Ivan Córcoles Martínez, Vitaliy Zayats, and Philippe Neyret
3 Biomechanics of Musculoskeletal Injuries������������������������������������  27
Alan Getgood, Yuichi Hoshino, Philip P. Roessler,
Ryosuke Kuroroda, and Sérgio Rocha Piedade
4 Physiological Demands in Sports Practice������������������������������������  37
Ana Sousa, João Ribeiro, and Pedro Figueiredo
5 Sports Activity at Childhood and Adolescence������������������������������  45
Anderson Marques de Moraes, Vagner Roberto Bergamo,
and Gil Guerra-Júnior
6 Physical Activity at Adulthood and Old Age ��������������������������������  59
Sérgio Rocha Piedade, Mauro Mitsuo Inada,
Gerson Muraro Laurito, Diego Navarro e Paiva,
Gustavo Pereira Fraga, Rodrigo Goncalves Pagnano,
Andre luis Lugnani de Andrade, and Tulio Pereira Cardoso
7 Oriented Warm-Up��������������������������������������������������������������������������  71
Karina Mayumi Hatano
8 Nutrition and Hydration ����������������������������������������������������������������  85
Daniéla Oliveira Magro
9 Sports Rehabilitation ����������������������������������������������������������������������  99
Knut Beitzel, Daniel Berthold, and Manuel Klose
10 The Role of a Strength and Conditioning Coach�������������������������� 107
Telmo Sousa

vii
viii Contents

11 Sport Injury Primary and Secondary Prevention������������������������ 121

Rogério Pereira, Renato Andrade, Alexandre Rebelo-Marques,
and João Espregueira-Mendes
12 Return to Play (RTP) ���������������������������������������������������������������������� 149
Alexandre Rebelo-Marques, Renato Andrade,
Rogério Pereira, and João Espregueira-Mendes

Part II Overtraining Injuries

13 Treatment of Achilles Tendinopathies�������������������������������������������� 173

Jon Karlsson, Annelie Brorsson, Unnur Jónsdóttir,
and Karin Grävare Silbernagel
14 Muscle Injuries�������������������������������������������������������������������������������� 187
Gian Luigi Canata, Valentina Casale, Marco Davico,
and Simone Lapi
15 Stress Fractures�������������������������������������������������������������������������������� 197
Timothy L. Miller and Christopher C. Kaeding
16 Shin Pain ������������������������������������������������������������������������������������������ 211
Sérgio Rocha Piedade, Luis António Mendes,
Leonardo Manoel Carvalho, Ramon Medeiros Fagundes
dos Santos, Luis Carlos Marques,
and Daniel Miranda Ferreira
17 Groin Injuries���������������������������������������������������������������������������������� 223
Per Hölmich, Lasse Ishøi, Andreas Serner,
and Kristian Thorborg

Part III Neurological Disorders

18 Epilepsy and Seizures���������������������������������������������������������������������� 235

Jorge Roberto Pagura and Rudá Alessi
19 Spine Injuries ���������������������������������������������������������������������������������� 241
Elcio Landim, Paulo Tadeu Maia Cavali, Marcelo Italo
Risso Neto, and Mauricio Coelho Lima

Part IV Sports Trauma

20 Facial Trauma���������������������������������������������������������������������������������� 261

Sérgio Rocha Piedade, Leonardo Manoel Carvalho,
Luis António Mendes, Milton Possedente,
and Daniel Miranda Ferreira
21 Thoracic�������������������������������������������������������������������������������������������� 275
Ivan Felizardo Contrera Toro and Ricardo Kalaf Mussi
Contents ix

22 Abdomen������������������������������������������������������������������������������������������ 289
Rui Pedro Borlido Escaleira
23 Shoulder: The Thrower’s Shoulder������������������������������������������������ 307
Lukas N. Muench, Andreas B. Imhoff, and Sebastian
Siebenlist
24 Sports Trauma: Elbow�������������������������������������������������������������������� 317
Sebastian Siebenlist, Lucca Lacheta, Christine L. Redmond,
and Gregory I. Bain
25 Sports Trauma: Wrist and Hand���������������������������������������������������� 331
Margaret W. M. Fok, Christine L. Redmond,
and Gregory I. Bain
26 Sports Trauma: The Hip����������������������������������������������������������������� 347
Molly C. Meadows and Marc R. Safran
27 Traumatic Knee Injuries ���������������������������������������������������������������� 357
Steffen Sauer and Mark Clatworthy
28 Sports Trauma: Ankle and Foot ���������������������������������������������������� 375
Bruno Silva Pereira and C. Niek van Dijk

Part V Special Conditions

29 Female Athlete Triad and RED-S �������������������������������������������������� 395

Samantha Tayne, Melody Hrubes, Mark R. Hutchinson,
and Margo Mountjoy
30 Sudden Cardiac Arrest�������������������������������������������������������������������� 413
Clea Simone S. S. Colombo, Michael Papadakis,
and Nabil Ghorayeb
31 Concussion���������������������������������������������������������������������������������������� 429
Natalie Sherry and Michael W. Collins
32 Doping ���������������������������������������������������������������������������������������������� 439
Maria João Cascais
33 Dermatological Injuries������������������������������������������������������������������ 447
Margarida Gonçalo and Luis Santiago
34 Oral Health �������������������������������������������������������������������������������������� 459
Silvia Maria Rocha Piedade Damasceno, Marly Kimie
Sonohara Gonzalez, Renata Bastos Del Hoyo Fernandes,
and Vera Lucia Gramuglia
35 Traveling Management�������������������������������������������������������������������� 471
Steven R. Joseph
36 Sports Under Extreme Conditions ������������������������������������������������ 481
Helge Krusemark and Annika Hackemann
x Contents

37 Sports After Knee Arthroplasty������������������������������������������������������ 489

Bujar Shabani, Dafina Bytyqi, Cécile Batailler, Elvire Servien,
and Sébastien Lustig
38 Ringside Medicine���������������������������������������������������������������������������� 497
Joseph John Estwanik

Part VI Different Scenarios in Sports

39 Indoor Sports������������������������������������������������������������������������������������ 517

Alex Behar, Mark R. Hutchinson, Aimee Bobko,
Benjamin Mayo, Garrett Schartzman, Erwin Secretov,
Matthew Steffes, and Samantha Tayne
40 Outdoor Sports: Winter������������������������������������������������������������������ 553
R. Kyle Martin, Mitchell I. Kennedy, J. P. Begly,
Rob LaPrade, and Lars Engebretsen

Part VII Sports Equipment

41 Sports Footwear: Problems and Advances������������������������������������ 571

Marcelo Pires Prado and Guilherme Honda Saito

Part VIII Biologics in Sports Injuries

42 Biologic Treatment in Tendon and Muscle Injuries���������������������� 581

Moises Cohen, Gustavo Gonçalves Arliani,
and Camila Cohen Kaleka
43 Biologic Treatment of Ligament Injuries by the Sports
Physician ������������������������������������������������������������������������������������������ 591
Jonas Pogorzelski, Mitchell Kennedy, and Robert F. LaPrade
44 Biological Treatment in Cartilage Injuries������������������������������������ 599
Elizaveta Kon, Berardo Di Matteo, Francesco Iacono,
Filippo Vandenbulcke, Nicolò Danilo Vitale,
and Maurilio Marcacci

Part IX Major Events in Sports

45 Olympic Games: Special Considerations—Medical Care for

Olympians���������������������������������������������������������������������������������������� 617
David J. Pohl, Garrett Schwartzman, Mark R. Hutchinson,
William Moreau, Roald Bahr, Robert McCormack,
Juan-Manuel Alonzo, Andre Pedrenelli, and Roberto Nahon
46 Paralympic Sport ���������������������������������������������������������������������������� 631
Yetsa A. Tuakli-Wosornu, Fiona Doolan, and Jan Lexell
Contents xi

47 FIFA World Cup������������������������������������������������������������������������������ 641

Andre Pedrinelli and Caio Senise Drolshagen
48 Extreme Sports�������������������������������������������������������������������������������� 657
Torrey Parry, Empryss Tolliver, and Scott C. Faucett
49 Judo, Brazilian Jiu-Jitsu, Wrestling, and Mixed
Martial Arts�������������������������������������������������������������������������������������� 671
John A. Bergfeld, Jonathan Gelber, Scott A. Lynch,
Peter H. Seidenberg, and Sérgio Rocha Piedade

Part X PROMs

50 PROMs in Sports Medicine������������������������������������������������������������ 685

Sérgio Rocha Piedade, Mario Ferreti Filho,
Daniel Miranda Ferreira, Daniel A. Slullitel, Sarthak Patnaik,
Gonzalo Samitier, and Nicola Maffulli
 Part I
Sports Practice Principles
 Multidisciplinary Sport
Medicine Team
1
Francesco Della Villa, Stefano Della Villa,
and Joäo Espregueira Mendes

1.1 Outline fessional figures, is warranted to maximize health

and functional outcomes of our patients, either in
The Sports Medicine care, either in a Sport team primary prevention or rehabilitation setting. The
setting or in a Sports rehabilitation one, should be central role of the caregiver team is highlighted in
always based on a team effort. A patient- or athlete-­ this first chapter in which we wish to present our
centered approach, with different contributing pro- experience in the basic principles of both playing in
and managing a team around the patient in a Sports
Medicine setting.
F. D. Villa (*)
Education and Research Department, Isokinetic
Medical Group—FIFA Medical Centre of Excellence, A proper team, with a high performance cul-
Bologna, Italy
e-mail: [email protected]
ture is key for successful Sports Medicine
practice.
S. D. Villa
Educational and Research Department, Isokinetic
Medical Group—FIFA Medical Centre of Excellence,
Bologna, Italy
e-mail: [email protected]
1.2 The Crucial Principles
J. E. Mendes
In building a Sport Medicine team, we’d like to
Clínica do Dragão—Espregueira-Mendes Sports
Centre, FIFA Medical Centre of Excellence, FC Porto share few important concepts at the beginning of
Stadium, Porto, Portugal this chapter: “No one professional nowadays can
Orthopaedic Department, Minho University, handle by his own the complexity of a sport reha-
Minho, Portugal bilitation path or injury prevention and training
Publication Committee of the International Society of program.” This concept is very easy and applies
Arthroscopy, Knee Surgery and Orthopaedic Sports both to primary and secondary prevention of Sport
Medicine (ISAKOS), San Ramon, CA, USA injuries. If you play in team, your odds of winning
Patellofemoral Foundation, Farmington, CT, USA (achieving good outcomes) are much higher.
FIFA MCE, Porto, Portugal A proper team, with a high-performance culture, is
warranted to carry on a successful Sport Medicine
Porto University, Porto, Portugal
practice. With high-performance culture, we mean
European Society of Sports Traumatology, Knee
the ability to give your maximal effort in the day-
Surgery and Arthroscopy (ESSKA) 2012-2014,
Bologna, Italy by-day activity, helping the patient to reach the
e-mail: [email protected] maximal possible functional recovery.

© ISAKOS 2019 3
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_1
4 F. D. Villa et al.

Sport Medicine Physician

Physical therapist Athletic trainer

Fig. 1.1  Proper team. Sport Medicine physician, a physical therapist, and an athletic trainer. A patient-first approach is
warranted as he/she needs to be guided in the recovery process

In our vision, considering Sport rehabilitation pools, gyms, and sports field is key to optimize
as a model of practice, you will need at least (1) loading. The adoption of an on-field rehabilita-
a Sport Medicine physician, (2) a physical thera- tion (OFR) setting is crucial to really complete
pist, and (3) an athletic trainer to face a correct the recovery path of a competitive athlete
rehabilitation program (Fig. 1.1). (Fig. 1.3).
The Sports Medicine team should always Third and last general point, the team should
adopt a patient-centered approach. The patient is follow an appropriate method. In our experience
the leading actor in every functional recovery the method should be based on (1) a leader of the
path. The program must be tailored on his and her group, (2) an appropriate communication model,
needs. Stated that, apart the professional figures and (3) a proper and updated clinical method
listed above, the team can be larger. Chiropractors, (Fig. 1.4).
specialists in nutrition, and sport psychologists First, besides shared decisionmaking, the
can cover specific areas of functional recovery, team must be lead properly. The figure of the
optimizing specific areas of concern (Fig. 1.2). leader is always important and crucial in giving a
Second point, you need to give the team the precise tactical and strategic direction to the
possibility to do a great job. Proper facilities are group, both in the day-by-day activity and in key
another important issue. If you wish to deliver an decisionmaking. In organizing a rehabilitation
updated service, you will need also appropriate service, we introduced the so-called concept of
facilities to do this. For example, we strongly the case manager. The case manager is the doctor
believe in different environments to give progres- in charge of the patient, from the beginning to the
sive stimuli during functional recovery, the use of end of functional recovery. He is also in charge of
1  Multidisciplinary Sport Medicine Team 5

Fig. 1.2 Patient-­
centered approach.
A Sport Medicine
physician talking with
the physical therapist
and the patient during a
gym rehabilitation
session. High-quality
communication, also
based on nonformal
meeting, is key to
control the recovery
process

Medical Offices

Rehabilitation Pool Rehabilitation Gym

Rehabilitation Field

Fig. 1.3  Proper facilities. Different environments are crucial to customize treatments and allow a complete functional
recovery
6 F. D. Villa et al.

Case manager

Update clinical method Communication model

Fig. 1.4  Proper method. These three aspects are of paramount importance in the organization of teamwork

coordinating the team around the patient and acceptable in the modern Sport Medicine land-
communicating with patient environment. Such a scape. Updated practice based on evidence-based
figure is warranted in every recovery process. recommendation has now to be imbedded in the
A continuous and effective communication is practice. Considering again a rehabilitation per-
warranted within the caregivers’ team. Having a spective, we strongly believe in criteria-based,
communication model (e.g., digital clinical rather than time-based, rehabilitation protocols.
records) and periodically (daily if necessary) In respect of the ACL-injured athletes, this state-
meetings are the milestones of a well-organized ment is not based merely on a personal perspec-
service. Formal and informal communication is tive but on the evidence that certain criteria
key to strengthen the relationship between the should be met in order to RTP safely [1]. Current
different players. The more you communicate clinical guidelines are also recommending such
within the team, the more you can maximize an approach [2, 3]. Translating medical innova-
patient or athlete’s perception of the recovery tions inside this paradigm is not easy as new does
path and minimization of the risk of misleading not always mean effective. It is recommended to
information to the patient. apply innovations that guarantee a reasonable
Adopting a proper and updated clinical optimization of functional outcomes, helping the
method is the last aspect to be underlined. patients and athletes to do better. For this reason,
Statements like “I am doing like this because we tracking patient’s outcome is always wise to eval-
have always done in this way” are no longer uate recent addictions.
1  Multidisciplinary Sport Medicine Team 7

1.3  e Are Doctors: Health

W competing at their desired levels with a minimal
and Performance risk of injury. The Sport Medicine team should
Considerations help them to achieve this goal. When an injury
happens, there should be a correct strategy to
Another factor we need to consider is the exist- face it. As injuries are part of Sports, it is appro-
ing relation between health, functional outcome, priate to speak about injury reduction strategies,
and performance. In the Sport Medicine sce- as complete prevention is not possible.
nario, our patients are athletes, and they need to
perform, sometimes at elite level, at their best.
Either working in a Sport team or in Sports reha- 1.4 The Case Manager Concept
bilitation facility, we need to prepare them to a
sustainable performance. Winning in Sports is a In the first section of this chapter, we introduce
key aspect, but, as doctors, we need to take care the concept of the case manager. We would like
about the health of our athletes and patients, to underline the importance of such a figure in
finding the correct balance for a sustainable (for the recovery process after Sport injuries. In the
the athlete) performance and short- and long- clinical practice, often, the patients see different
term outcomes. A good example of this concept professional’s figures, in different places, poten-
is a possible existing relationship between the tially giving conflictual, sometimes opposite,
application of injury prevention and winning in suggestions. This is a common story that our
football: the lower the injury rate, the higher the patient faces every day. This situation is confus-
team success [4]. Another good example is the ing and nonoptimal for the patient. To minimize
functional outcomes after anterior cruciate liga- the risk of this scenario, we introduced the con-
ment reconstruction (ACLR). The patient faces cept of the case manager. The case manager
two main outcomes; on one side there is the (same Sport Medicine physician following the
return to play at pre-injury level, and on the other patient) oversees the patient through his or her
side there is the second ACL injury risk. Again, whole recovery process. When surgery is
we need to prepare the patient to perform again, needed, the case manager is in charge of cross
minimizing the physical deficit related to the talking with the surgeon and the surgical team.
injury and surgery while reducing, as much as We really believe that surgery and rehabilitation
we can, the risk factors for the second injury. are part of the same path; there is no stand-alone
The goal of any sportsman or sportswoman is in this process (Fig. 1.5).

Fig. 1.5  The case

manager. The physician
should be the key
figure for the patient. Case Manager:
A reference point to
guide the recovery - Coordinate the team around the patient;
process - Plan the customized treatment protocol;
- Communicate regularly with the surgeon
(if needed)
- Communicate regularly with patient
environment;
- Overseas the process from the time of
injury to the Return to play
8 F. D. Villa et al.

Diagnosis
and
surgery

Return Post
to play operative
treatment

Good

Sport
Recovery
specific
of ADL
gesture

Pretty
Poor
good

Metabolic Strength
recovery recovery

Movement
patterns

Fig. 1.6  The injury to recovery process. Many steps and phases, but we generally lack in control over the last steps.
obstacles must be overcome to reach a successful RTP. As This deficit has to be solved
a community we have a very good control of the first

Either with conservative or surgical (Fig.  1.6) requiring surgery, it is not enough to
patients, there is a clear need of taking and do half of the way to the top.
maintaining a precise direction in every recov-
ery path, and the patient will benefit from this
The same Sport Medicine team should
approach.
­follow the patient from the time of injury
We also believe that the same Sport Medicine
to RTP.
team should follow the patient from the time of
injury to the time of official return to play. The
injury to recovery process is tough for the ath- Generally, we have a good control of the
lete, and we should have a perfect control of the first  steps (including diagnosis, surgery, and
whole path. Taking the example of a major injury ­postoperative treatment). It is a pretty good con-
1  Multidisciplinary Sport Medicine Team 9

trol of the strengthening phase, but we lack in (and not reductionistic) return-to-play strategy.
control of the last crucial phases, when the patient Once focusing the RTP, we have the opportunity
is generally left alone, in the grey area before to highlight some crucial, and often overlooked,
returning to play. We need to focus also the last aspects especially focusing our focus on end-­
part of the recovery process. To reach this goal, stage rehabilitation concepts:
we need to challenge our physicians’ mind and
change our point of view. • Criteria-based return-to-play progression
• Movement patterns treatment and motor
learning techniques
1.5  hanging the Status Quo:
C • On-field rehabilitation and optimization of the
Return-to-Play Philosophy acute on chronic workload

To change the status quo, we need to challenge

our vision of Sports injuries as doctors. As clini- 1.5.1 Criteria-Based Return-to-Play
cian our focus is on the lesion, on the injured site. Progression
We want to fix it as soon as we can. This is right,
but we also need to focus the athlete’s function- The common sense, supported by emerging evi-
ing at 360°, shifting the focus from the injured dence, is that rehabilitation after major knee inju-
site to the athlete (Fig. 1.7). ries should be criteria based rather than time
Focusing the return to play from the very first based [5, 6]. Criteria-based protocols have been
day allows the team to establish a comprehensive suggested also for muscle injuries [7]. With this

Injured joint Athlete

Fig. 1.7  Shift the focus. Shifting the focus on athlete at 360° allows the team to consider other key factors in the reha-
bilitation process
10 F. D. Villa et al.

kind of approach, certain criteria or pitfalls have been developed to enhance motor learning, help-
to be reached in order to progress in the recovery ing the patient to optimize his or her movement
process. In this way a comprehensive and really patterns [11].
customized program may be carried out for every Although the greater amount of research on this
patient. This approach has been recently demon- aspect is related to RTP after ACLR, there is a
strated to reduce the risk of second ACL injury growing body of evidence and common sense that
after ACLR [1]. The same approach can be the dynamic control of the entire kinetic chain is a
applied to every recovery process. key aspect also for other kinds of patients [12].
There needs to be an increased focus on biome-
chanical and movement pattern aspects after inju-
1.5.2 Movement Pattern Treatment ries. However, this consideration has to be coupled
and Motor Learning with an underlined importance of the previous and
Techniques concomitant work on knee and hip strength. It is
nonsense to work on complex movement patterns
The comprehension of biomechanical and neuro- if the patient has not recovered isolated strength
physiological factors is affecting deeply the way yet; for this reason a battery of tests, instead of a
of considering the whole recovery process after single-dimension assessment, is warranted.
lower limb injuries (Fig.  1.8). Clinical, user-­
friendly, qualitative movement analysis test has
been proposed [8–10] and should be part, together 1.5.3 On-Field Rehabilitation
with targeted neuromuscular training, of the and Optimization of the Acute
return-to-sport process after lower limb injuries. on Chronic Workload
On the other hand, feedback techniques have
The completion of a stepwise OFR program has
been previously presented and correlated to suc-
cessful outcomes after major knee injuries
­[13–15]. The OFR program is key to fill the gap
between standard rehabilitation and return to play.
As stated above, the patient is often left alone. This
situation is potentially threatening all the previous
efforts, as a nonoptimal management of the RTP
phase may be dangerous. At this time, the patient
generally starts loading more the injured joint. The
key aspects of OFR are (1) movement quality in
high speed and unpredictable movements, (2)
complete aerobic and anaerobic reconditioning,
(3) optimal progression of patient workload, and
(4) sport-specific gesture recovery.
The transition between the rehabilitation envi-
ronment and the training fields has to be as
smooth as possible. Measuring workloads pro-
gressively, with real-time feedback, can help in
targeting the desired amount of load.

Fig. 1.8  Risky movement patterns, with dynamic knee

End-stage functional recovery is as impor-
valgus loading, are frequently present at the time of return tant as early stage rehabilitation.
to play, especially in young patients
1  Multidisciplinary Sport Medicine Team 11

The objective of this chapter is not covering rehabilitation progression. J Orthop Sports Phys
Ther. 2013;42(7):601–14. https://doi.org/10.2519/
technical aspects but instead giving an inspiration jospt.2012.3871.
of some new area of potential clinical application 6. Myer GD, Paterno MV, Ford KR, Quatman CE,
in nowadays Sport Medicine. Hewett TE.  Rehabilitation after anterior cruciate
ligament reconstruction: criteria-based progression
through the return-to-sport phase. J Orthop Sports
Phys Ther. 2006;36(6):385–402.
1.6 Conclusions 7. Heiderscheit BC, et  al. Hamstring strain injuries:
recommendations for diagnosis, rehabilitation,
Providing a Sport Medicine practice should be and injury prevention. J Orthop Sports Phys Ther.
2010;40(2):67–81.
always based on a team effort. Proper facilities 8. Padua DA, DiStefano LJ, Beutler AI, De La Motte SJ,
and proper logistic and clinical organizations are DiStefano MJ, Marshall SW. The landing error scor-
other important points not to be overlooked. A ing system as a screening tool for an anterior cruci-
team of caregivers covering from the beginning ate ligament injury-prevention program in elite-youth
soccer athletes. J Athl Train. 2015;50(6):589–95.
to the end of the rehabilitation process is war- https://doi.org/10.4085/1062-6050-50.1.10.
ranted in conjunction to an increased attention to 9. Garrison JC, Shanley E, Thigpen C, Geary R, Osler
the last part of the process. As Sport Medicine is M, Delgiorno J. The reliability of the vail sport test™
a young and active branch of medicine, the Sport as a measure of physical performance following ante-
rior cruciate ligament reconstruction. Int J Sports
Medicine team should embrace new addictions in Phys Ther. 2012;7(1):20–30.
practice, always considering the clinical benefit 10. Myer GD, Ford KR, Hewett TE.  Tuck jump assess-
for the patients. ment for reducing anterior cruciate ligament injury
risk. Athl Ther Today. 2008;13(5):39–44.
11. Benjaminse A, Gokeler A, Dowling AV, Faigenbaum
A, Ford KR, Hewett TE, et  al. Optimization of the
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Neeter C, Van Tienen T, Hullegie W, Der Sanden comes and return-to-sports participation of 50 soccer
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practice guidelines for anterior cruciate ligament tion through a sport-specific rehabilitation proto-
rehabilitation based on a systematic review and col. Sports Health. 2012;4(1):17–24. https://doi.
multidisciplinary consensus. Br J Sports Med. org/10.1177/1941738111417564.
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bjsports-2015-095898. tion permit early return to sport without compro-
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 Pre-participation Evaluation
in Sports Practice
2
Sérgio Rocha Piedade, Daniel Miranda Ferreira,
Mario Ferreti Filho, Rodrigo Kallas Zogiab,
Ivan Córcoles Martínez, Vitaliy Zayats,
and Philippe Neyret

2.1 Background However, sports practice is not an injury-free

activity because it involves aspects of the modal-
Since ancient times, sports practice is ity of practiced sports, athletes’ biological, and
­well-­recognized as a health-promoting activity as physical conditions. The intensity of physical
it has an effect act on our biological reserve, posi- demands is particular to each sports modality,
tively impacting the musculoskeletal, cardiovas- varying according to its dynamic (soccer, basket-
cular, and immunological systems, athletes’ ball, volleyball, tennis, cricket, MMA, judo, surf),
self-esteem and confidence, and improving their field, and environmental conditions where the
social integration [1–4]. This apart, participating sport is practised (indoor, outdoor) [5–8]. Within
in sports activities pushes people to compete and this context, the rules of the sport should be
face challenges and also strengthens the desire to adjusted and improved whenever necessary such
work as a team. as the implementation of protective measures
(helmets, mouth guards, gloves), time of the dis-
S. R. Piedade (*) · R. K. Zogiab pute, and rest intervals during the games, resulting
Department of Orthopedics and Traumatology, in fairer dispute and contributing to decreasing the
State University of Campinas—UNICAMP,
athlete’s exposure to injuries [9–13].
Exercise and Sports Medicine, Campinas, SP, Brazil
e-mail: [email protected] However, the athletes’ clinical and physical
conditions are influenced by their age, gender,
D. M. Ferreira
Department of Radiology, State University presence of chronic diseases (diabetes, hyperten-
of Campinas—UNICAMP, Exercise and Sports sion, heart disease), overweight, previous inju-
Medicine, Campinas, SP, Brazil ries, neurological disorders, psychological
M. F. Filho distress, and handicaps. All these conditions do
Department of Orthopedics and Traumatology, not necessarily preclude sports practice, but they
UNIFESP, Sao Paulo, Brazil
must be identified and appropriately treated to
I. C. Martínez define the best approach before starting sports
Hospital Universitario Joan XXII de Tarragona,
practice and allowing the athlete to perform his/
Cataluña, Spain
her activities within a safe zone, minimizing
V. Zayats
exposure to clinical adverse effects [14–17].
Trauma and Orthopedic Department,
Pavlov First St. Petersburg State Unfortunately, sudden cardiac arrest, one of
Medical University, Petersburg, Russia the most overwhelming events in sports practice,
P. Neyret could signal the first clinical presentation of an
University Lyon 1, Lyon, France underlying cardiovascular disease. Without a

© ISAKOS 2019 13
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_2
14 S. R. Piedade et al.

doubt, this dramatic and stressful clinical event spinal cord injury due to the dynamics of these
could happen in a sports physician’s practice and sports [30–32]. Transient quadriplegia is a sports
may cause traumatic effects to the sports com- injury commonly seen in American football and
munity (athletes, coaches, fitness instructors, and contact sports. This injury results from axial
sports fans) as it could touch young individuals in trauma with flexion/extension of the athlete’s
the prime of their lives [18–25]. head with underlying cervical spinal canal steno-
In this context, pre-participation evaluation (PPE) sis, a structural disorder that should be investi-
is considered the cornerstone of sports injury pre- gated and ruled out in these athletes during PPE.
vention as it plays a vital role to assess athlete’s over- In athletes of wilderness watersports, one of the
all health, recognizing health problems, and defining concerns is that the athlete’s breath holding and
medical strategies and recommendations to achieve buoyancy capacities are limited to their physical
and maintain the athletes’ “wellness” [26–28]. The status that decreases when exposed to cold water
PPE main goals are to previously identify: condition due to muscle overload in an attempt to
control body temperature and avoid the occurrence
• Clinical conditions that may be life-threating of hypothermia [33]. In these athletes, PPE can
and impose relative or formal contraindication focus on assessing acute and chronic clinical condi-
to sports practice tions that could impair the athlete’s ability to swim.
• Prior injuries that can be treated and appropri- In endurance sports, In endurance sports,
ately rehabilitated before starting sports weight-classified sports and aesthetic sports, there
activities is a close relationship with pathogenic weight con-
• Clinical comorbidities and handicaps that pre- trol behaviors, clinically manifested by disordered
dispose to illness and injury, recognizing eating, the decrease of bone mass density, and
high-risk individuals for sports practice menstrual dysfunction in females. As this patho-
• Also, to assess fitness for a specific sport logical condition impacts negatively on athletes’
performance, the PPE should take it into account
Although PPE presents a valuable tool to mon- [33, 34]. Therefore, all these points reinforce the
itor the athletes’ health during their lifetime in importance of PPE to athletes’ health care.
sports, offering numerous benefits to their health This chapter presents and discusses elements
care, this approach is not well-­ standardized involved in PPE and particularities related to dif-
worldwide. An example of that is seen in Europe, ferent athletes’ population according to their gen-
where PPE rules and strategies are not similar der, age (childhood and adolescence, adulthood
among the countries [29]. In France, a general and old age), and level of sports practice (recre-
clinical assessment is well-accepted such as PPE ational, disabled, and professional athletes).
for amateur athletes, but, for competitive athletes,
a more rigorous health control to certify the
absence of contraindications to sports practice is 2.2 Pre-participation Evaluation
required. For more than 35 years, the Italian gov-
ernment has regulated and established PPE as A well-structured PPE should be based on ath-
mandatory for competitive athletes, while, in the letes’ medical and sports injury history and their
Netherlands, citizens are regularly evaluated [29]. family’s medical history. It is considered the first
According to the modality of sports, PPE step to screen and identify possible cardiovascu-
should pay particular attention to clinical aspects lar injuries related to sudden death. This strategy
which are commonly associated with specific is a useful tool to map populations of athletes
sports injuries. In contact sports such as rugby, and tailor PPE regardless of their age, gender,
martial arts, football, and ice hockey, the spine is modality of sports, and level of sports practice.
exposed to high-energy trauma that potentializes In general, PPE has the same structure and
the occurrence of concussion, facial trauma, design for every athlete, but it should be tailored
2  Pre-participation Evaluation in Sports Practice 15

for each athlete according to their age, gender, to evaluate the athlete’s physical health properly
clinical condition, handicap, as well as the level and, at the same time, rule out adverse clinical
of sports practice (recreational, amateur, and conditions to sports practice.
professional) reported.

2.4 Anamnesis
2.3 Periodization of PPE
The PPE anamnesis has a three-key point struc-
In clinical practice, it is recommended that PPE ture namely: the athlete’s general health, sports
be applied 6–8 weeks before starting sports prac- injuries, and family health history. All these
tice because it allows enough time to rehabilitate elements are a sensitive tool to analyze the ath-
injuries, identify, and manage any medical disor- lete’s health status and screen for potential clin-
ders properly, minimizing the risk of exposing ical problems or deficits that can impair the
athletes to injury. athlete’s performance or expose him/her to
PPE applied to athletes, recreational or profes- injury or illness. Moreover, it is helpful to carry
sional, before starting a new program of sports out the physical assessment according to the
practice is advisable, an important step to mini- reported data. Before starting PPE application,
mize the athlete’s exposure to adverse clinical the sports medicine physician should try to
events such as a sudden cardiac arrest. Although, offer a comfortable environment so that the ath-
PPE is a dynamic issue, its advancements involve letes feel more confident to reply to questions.
costs which should be justified by the cost-benefit. The physician should start talking and asking
It presents excellent sensitivity, specificity, and the athletes informally about their motivation to
effectiveness in reducing adverse effects and sports practice, sports/quality of life, and health
mortality [33–36]. However, its implementation concerns:
also depends on national/regional settings to
achieve the most accurate physical examination. • How motivated are you to play sports?
As discussed above, PPE may contribute to • Do you feel in good shape to practise sports?
injury prevention and evaluation of prior clinical • Have you been sleeping well?
conditions that may predispose the athlete to ill- • Do you have any concerns about healthy
ness or injuries as well as to the identification of eating?
conditions that do not present overt symptoms, • Do you have any complaints when playing
reinforcing PPE periodization. In clinical prac- sports?
tice, the sports physician’s decision-making takes
into consideration the questions listed below:
2.4.1 A
 thlete’s General Health
• Is there a formal risk to the athlete? History
• Can the athlete:
–– Under medical treatment compete safely? It comprises of the data of complaints or clinical
–– Participate in another sports activity? problems related to body systems, psychological
–– Be cleared for certain sports? status, exertional symptoms, dietary, oral health,
• Could this problem affect other athletes? social behavior, infectious diseases, hospitaliza-
tions, and surgical procedures. A point to be rein-
PPE involves anamnesis, an athlete’s general forced is the role of oral health assessment in
health history and sports injuries report and also monitoring nutritional deficiency and also sys-
the family health history [33–36]. These data are tematic diseases that could affect athletes’
useful as they guide the physical assessment as ­performance. Table 2.1 summarizes some of the
well as laboratory and radiological exams needed relevant points.
16 S. R. Piedade et al.

Table 2.1  Points to be assessed during an athlete’s gen- high-intensity exercises should be carefully inves-
eral health exam
tigated by the sports physician [37].
Skin
 Dermatitis, allergies (triggered by food, insects,
medicines), infections (bacteria, virus), acne
(wrestlers) 2.4.3 Family Medical History
Psychological distress or disorders
 Anxiety, depression, OCD, eating disorders, Considering that people from the same family have
anorexia, REDS
many aspects in common such as genetics, envi-
Oral
 Gingivitis, tooth loss, tooth pain, herpex simplex ronment, and life style, the athlete’s family medical
Gastrointestinal disorders history has a vital role in PPE. It allows tracking
 Gastritis, hepatitis, abdominal tenderness or masses health information about the athlete’s close rela-
Neurological tives and helps to identify chronic diseases that
 Mental status, suspicious of sports-related
could impact the athlete’s health when practicing
concussion, confusion or memory loss after a head
trauma sports like a cardiovascular diseases such as cardio-
Cardiovascular vascular disease (hypertension, myocardiopathy),
 Palpitations or irregular heartbeat, exertional chest pain, diabetes, asthma and exercise-induced broncho-
syncope, shortness of breath, and fatigue on exertion spasm, gastrointestinal disorders, hematological
Urinary
 Calculus, infections, nephritis, kidney agenesis
disorders, neurological diseases, eating disorders,
Respiratory psychiatric disorders and, cancer that could impact
 Chronic respiratory problems (asthma, bk) or acute the athlete’s health when practising sports.
(infections, pneumonia), exercise-induced
bronchospasm
Musculoskeletal
 Arthrosis, ligament injury, fracture, muscle injury,
2.5 Musculoskeletal Screening
sprain, patellofemoral dislocation, hernia,
rheumatologic diseases, miopathy A physical examination plays an essential role on
Medication for chronic diseases the PPE process. It allows the screening and eval-
 Beta blocker, diuretic, antidepressive, steroids,
uation of muscle and joint function regarding bal-
anti-inflammatory drugs
Prior surgeries ance and motion range symmetry as well as the
 Fracture, ligament reconstruction, arthrodesis, heart level of muscle force between limbs [37–39].
revascularization Moreover, a physical examination can reveal
Endocrinological clues and identify previous or even unknown
 Diabetes, hyperparathyroidism, hypercholesterolemia
injuries besides muscle weakness, stretching def-
Hospitalization/previous surgeries
 Fracture, ligament reconstruction, arthrodesis, heart icit, uni- or bilateral joint motion restriction, limb
heart revascularization, prothesis discrepancy or malalignment, collagene disease
Special clinical signs in females (such as Marfan from low expression (hiperlax-
 Menstrual dysfunction, amenorrhea or ity) to server) which could present clinical disor-
oligomenorrhea, osteoporosis (young female)
ders that will expose the athlete to injuries.

2.4.2 A
 thlete’s Sports Injury
and Clinical Complaints 2.6  tarting the Physical
S
Related to Sports Practice Examination

Recording the athlete’s prior injuries, their surgi- 2.6.1 Inspection

cal and rehabilitation treatments after sports
trauma, and the reports on the regular use of pro- The athlete is asked to wear underwear and no shirt
tective equipment in sports practice allows a better for a general view of their body. Starting with the
understanding of athlete’s health status and physi- athlete’s gait, the sports physician seeks to identify
cal condition. In this context, sprains, f­ractures, any changes in gait such as limping. Then, with the
ligament injuries, hernia, cervical and head trauma, athlete in standing position, the skin is screened for
chest pain, fatigue, and difficulty breathing during lesions and scars and also if the spine is aligned.
2  Pre-participation Evaluation in Sports Practice 17

2.6.2 Oral Health Assessment sidered an important factor associated with health
in adulthood and old age, and, therefore, it is vital
The athlete is requested to open their mouth by to public health actions [40–42]. Consequently,
placing two folded fingers (index and middle) at millions of children and adolescents are involved
the distal interphalangeal joints of the mouth in organized sports worldwide every year.
which allows the physician to check any restricted However, it should be taken into account that this
motion of TMDs (temporomandibular disorders). population involves individuals that are develop-
Besides that, the oral health status is checked ing their biological patterns as well as social
regarding the status and color of the lips, muco- behaviors that will manifest during the rest of
sas, and teeth conditions (integrity, biofilm stag- their lives. It should be kept in mind that the bone
nation (bacterial plaque), the presence of calculus and joint maturation is a high energy process that
(tartar), dental loss, and also tooth wear (indirect involves biomechanical changes of the living tis-
signs of anxiety, depression, or stress that could sues. In childhood, a bone is defined as an imma-
commonly be associated with bruxism). The ture structure which is weaker (less mineralized)
oral health exam is vital to assess the athletes’ and ductile, while during adolescence it starts
oral hygiene and its maintenance (periodical becoming more mineralized, conferring a stiff
exams) as well as to identify clues of systemic and brittle characteristic to it, until bone matura-
diseases that impact the athletes’ performance. tion takes places (Fig. 2.2). In this context, indi-
viduals younger than 18  years old should be
followed closely due to the huge and rapid body
2.6.3 Dynamic Physical Evaluation changes occurring in childhood and adolescence.
Therefore, childhood involves biological and clin-
It should be emphasized that the physical exami- ical patterns that make these athletes different
nation is guided by the anamnesis (athletes’ gen- from adult athletes, and, therefore, children can-
eral health history, athletes’ sports injuries and not be considered as “small adults”.
clinical complaints related to sports practice, and In children and adolescents starting regular
also their family medical history). In clinical physical exercises and sports practice, PPE is
practice, the physical exam starts with the spine helpful to screen unfavorable athletes’ clinical
motion and then goes on to upper limbs and fin- conditions to some modalities of sports. For
ishes with lower limbs; the most common clinical instance, in contact sports, the athletes are sub-
tests performed in this evaluation are presented in mitted to high-energy trauma as well as physical
Fig. 2.1. However, it should be emphasized that demands (Fig. 2.3).
the physical assessment is carried out according An example of that is a young patient with a
to the reported data in the anamnesis (athlete’s medical health history of rhinitis or recurrent
general health history, sports injuries, clinical sinusitis willing to practice swimming. This
complaints related to sports practice, and also condition does not necessarily exclude its prac-
their family medical history). tice but allows the sports physician to identify
the problem previously and treat the athlete
adequately before letting him practise water
2.7  egarding PPE in Different
R sports.
Age Groups Regarding the psychological aspects, a young
athlete can became stressed due to training, com-
2.7.1 In Childhood and Adolescence petiting, and also their parents’ unconscious
behavior of projecting their own personal desire
In many countries and regions due to the eco- to be champion on their sons and daughters. All
nomic conditions, sports participation is a huge these aspects may impact a young athlete’s social
opportunity for children and adolescents to behavior, and, therefore, alcohol, smoking, and
change their lives and also have access to health. also drug addiction should be carefully investi-
Thus, PPE plays an essential role in it. Sports gated. Thus, it is recommended that the athlete’s
practice during childhood and adolescence is con- parents or guardian be present at PPE to confirm
18 S. R. Piedade et al.

Fig. 2.1 Dynamic SPINE ASSESSMENT

physical evaluation

observation (alignment and symmetry) flexion / extension

flexion / extension lateral flexion / rotation

UPPER / LOWER LIMB ASSESSMENT

shoulder abdution + external rotation elbow external / internal rotation

internal shoulder rotation and adduction elbow flexion / extension

shoulder abduction shoulder shrug hand and finger

against resistance against resistance flexion / extension

duck walk test standing on heels and toes

and add details of the athlete and family medical problem that affects both men and women and
history [27–29]. involves low energy availability (involving eating
As stated before, the periodicity of PPE is disorders or not), low bone mineral density, and
essential as it can identify the initial stages of menstrual dysfunction and, therefore, should be
energy deficiency in sports (REDs), a clinical carefully investigated [43, 44].
2  Pre-participation Evaluation in Sports Practice 19

Fig. 2.2  Coronal T1 (a) and T2 fat sat (b) weighted of normal MRI views of the knee in young patients aged 4, 8, 12,
and 17 years old

Fig. 2.3  Female rugby

athletes
20 S. R. Piedade et al.

In general, the physical assessment in child developed the American Heart Association/
and adolescent athletes focuses on the symmetry American College of Sports Medicine Pre-
of lower-and-upper-limb joint movement participation Questionnaire (AAPQ) to enable
strength, according to the modality of sports and cost-effective screening for cardiovascular risk
its physical demands on the joints and muscles. among individuals who desire to initiate a fitness
In child and adolescent athletes, laboratory tests program [53]. If a subject responds positively to
and radiological evaluation are requested, any of the statements regarding cardiac history or
depending on the specific clinical disorder symptoms, or to two or more of the statements
reported during the anamnesis or suspected in the regarding risk factors, a recommendation is made
physical assessment. for a pre-participation evaluation.
The 2001 Masters Athletics Working Group
developed pre-participation guidelines for those
2.7.2 Adulthood and Old Age who desire to participate in more competitive
sporting events [54]:
Data from the World Health Organization has
shown an increase in life expectancy in recent • Stress test for men aged >40 years and women
decades. In 2016 the average life expectancy at aged >50 years who also have one of the fol-
birth was 72 years. The global average life expec- lowing conditions: hypercholesterolemia, sys-
tancy increased by 5.5  years between 2000 and temic hypertension, current or recent cigarette
2016, the fastest increase since the 1960s [45]. smoking, diabetes mellitus, or history of myo-
Adulthood and old age are periods of life in cardial infarction or sudden cardiac death in a
which degenerative and chronic diseases begin to first-degree relative aged <60 years
manifest (Fig.  2.4). Figure  2.3 compares the • Stress testing for all athletes aged ≥65 years
radiological patterns of a normal knee joint to a • Electrocardiogram (ECG) for all athletes male
medial degenerative one. and female aged >40 years
According to a person’s social habits, obesity,
hypertension, diabetes, hypercholesterolemia, Self-administered surveys such as the Physical
arthrosis, and cardiovascular diseases will take Activity Readiness Questionnaire for Everyone
place. With the increasing ageing of the popula- (PAR-Q+) [55], the European Association of
tion, many people have begun to take up physical Cardiovascular Prevention and Rehabilitation
activity on a voluntary basis for a better quality of (EACPR) recommendations [56], and the
life and health benefits in the treatment and pre- Framingham Risk Score (FRS) can be used in pre-
vention of various diseases [46–50]. participation screening of masters athletes [57].
The population aged 35  years and older, so-­ Although some imaging tests that have sensi-
called “masters” athletes, represents a challenge tivity approaching close to 100% would be ideal
for health-care providers who are asked to make to ascertain the prevalence of cardiovascular dis-
decisions regarding assessments of cardiovascular ease (Fig. 2.5), they are not performed routinely
risk associated with different types of physical in PPE.  The main reasons are that the current
activity. Currently, there are no validated tools to evidence for incorporating cardiac imaging into
help physicians assess the risk of physical activity pre-­participation screening is insufficient,
in master athletes because most tools are geared expensive, potentially radioactive, and not indi-
towards screening younger participants [51]. cated for testing generally healthy asymptomatic
Ageing athletes are exposed to exercise-­induced low-risk patients [58].
cardiovascular events related to undiagnosed cor- The optimal method to screen masters athletes
onary artery disease, which is the primary cause requires continued study to decrease the number
of sudden cardiac death in masters’ athletes [52]. of false-positive with available and cost-effective
The American Heart Association (AHA) and screening tools to identify potentially at-risk
the American College of Sports Medicine (ACSM) individuals.
2  Pre-participation Evaluation in Sports Practice 21

Fig. 2.4  Anteroposterior, lateral, and axial X-ray views lar space, subchondral sclerosis, and femorotibial and
of the knee (a) in the healthy knee of a 20-year-old patient. femoropatellar osteophytes) in a 65-year-old patient
(b) Osteodegenerative changes (narrow of medial articu-

2.7.3 Disabled Athletes of ­athletes’ injury in sports practice and competi-

tion events. In this context, the main reasons for
Disabled athletes are a particular group of individu- functional impairment are summarized in Table 2.2.
als that have functional impairment that could vary In clinical practice, the ten most common
according to its cause. Considering that sports physical impairments reported in disabled ath-
practice requires significant physical demands, dis- letes are listed in Table 2.3. They serve as one of
abled athletes should be subcategorized and also the parameters adopted to classify the athletes’
classified according to the type of physical handi- functional level. However, it should be empha-
cap [59]. This allows the classification of athletes sized that the disabled athletes’ classification
according to their functional impairment, estab- remains a dynamic process. Each year, the
lishes fair competition, and also minimizes the risk ­technological advancement in the sports medicine
22 S. R. Piedade et al.

Fig. 2.5  Normal CT coronary angiography with no ath- technique. RCA right coronary artery, LAD left anterior
eromatous plaques (a). Three-dimensional volume ren- descending, and CX circumflex artery
dering technique and (b) maximum intensity projection

Table 2.2  Main reasons for functional impairment in 2.7.4 Elite Athletes
disabled athletes
Spinal cord injury Amputations In general, in professional sports, the modality of
Cerebral palsy Collagenosis sports and its dynamic (contact and noncontact
Muscular dystrophy Limb malformation sports) involve different physical demands. In
Myelomeningocele Acquired injuries due to traumas this context, PPE focus should take into account
Poliomyelitis Blindness and low vision
the athlete’s position in the field and its inherent
risk, psychological and physical maturity, as well
Table 2.3  Most common physical impairments reported level of competition.
in clinical practice Elite athletes work under an elevated level of
Severely affected muscle power Hypertonia physical and psychological stress due to their level
Impaired passive range of Ataxia of competition, financial interests, and ­ injuries.
motion Therefore, in high-performance athletes of long
Total or partial limb loss Athetosis
running, cycling, endurance sports, football, bas-
Limb length discrepancy Visual impairment
Short Intellectual
ketball, volleyball, and MMA, PPE should involve
impairment a careful cardiological screening with a specialist,
a
Athletes with intellectual disability as well as youngsters including an electrocardiogram at rest, laboratory
with learning disabilities should be more explicitly tests for levels of glycemia, and cholesterol and tri-
instructed before starting regular sports practice glyceride levels. The heart structure and function
adapted to physical activity are screened by a
area has caused improvements in medical evalua- Doppler echocardiogram, while an ergometric and
tion and diagnosis and consequently has promoted cardiopulmonary test should be performed until
update on disabled athletes’ functional classifica- exhaustion or stopped if the athlete presents adverse
tion for the Paralympics [60]. clinical signs or symptoms during the exam.
2  Pre-participation Evaluation in Sports Practice 23

Table 2.4  Laboratory exams commonly performed by to evaluate the joints related to previous inju-
Premier League soccer teams before athletes’ admission
ries or athlete’s complaints; however, due to the
and clinical follow-up
substantial investment on the elite athletes,
Complete blood count (CBC)
additional radiological evaluation can be
Coagulation tests
 Activated partial thromboplastin time required. In Brazil, most of the professional
 Prothrombin time and international normalized ratio soccer teams submit their soccer players rou-
(INR) tinely to the following radiological exams of
 Platelet count the lower limbs:
 Bleeding time
Glucose
• Weight-bearing, anteroposterior knee view, lat-
Kidney tests
 Blood urea nitrogen, creatinine
eral view at 30°, and patellar axial view at 30°.
Liver tests • IRM and spine anteroposterior and lateral
 Alkaline phosphatase (ALP) weight-bearing view.
 Alanine aminotransferase (ALT) • IRM is mandatory for athletes that have been
 Aspartate aminotransferase (AST) submitted to the surgical procedure of the
 Creatine phosphokinase (CPK)
 Lactate dehydrogenase (LDH) knee and ankle.
Serology
 Hepatitis A, B, and C In elite and professional sports, radiological
 Chagas disease serology evaluation plays an essential role on the athletes’
 HIV serology
pre-evaluation before concluding the athletes’
Lipid profile
team acquisition.
 Total cholesterol, HDL, LDL, and triglycerides
Hormones
 Thyroid profile: thyroid-stimulating hormone (TSH), Take-Home Messages
T3, T4 • A sudden cardiac arrest could signal the first
 Total and free testosterone clinical presentation of an underlying cardio-
 Dehydroepiandrosterone
 Dihydrotestosterone vascular disease.
 Uric acid • The athletes could differ in age, sex, intellec-
Rheumatoid factor tual level, and physical impairment, and, there-
 C-reactive protein fore, PPE focus should be tailored to that end.
 Antinuclear factor (ANF)
Urinalysis • Disabled athletes are a particular group of
individuals that have functional impairment
that could vary according to its cause.
Moreover, creatinine, urine, and blood count • The three-key point structure of PPE anamne-
should be demanded to evaluate the kidney func- sis is valuable in defining the strategy of phys-
tion status. Contagious diseases are a common ical assessment.
concern in sports practice, and, therefore, screen- • Some modalities of sports have a close rela-
ing is recommended for hepatitis, AIDS, medical tionship with specific sports injuries (contact
history of transfusion, tattoos, and risky social sports and spinal cord injuries).
behavior related to drugs, alcohol, smoking, and • The oral health exam assesses the athletes’
sex. Table  2.4 presents the most common lab oral hygiene and its maintenance (periodical
tests performed by the Premier League soccer exams) and could also identify clues of sys-
team in Brazil. temic diseases that impact on the athletes’
performance.
• PPE should be applied 6–8 weeks before start-
2.8 Radiological Evaluation ing sports practice as it allows enough time to
rehabilitate, identify, and manage injuries.
Regarding the musculoskeletal evaluation, the • Although PPE has a vital role in promoting a
athlete’s medical history of sports injuries will safe enviroment for sports practice, PPE rules
guide the required radiological exams. In gen- and strategies are not standardized among
eral, X-rays, IRM, and ultrasound are p­ erformed countries.
24 S. R. Piedade et al.

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 Biomechanics of Musculoskeletal
Injuries
3
Alan Getgood, Yuichi Hoshino, Philip P. Roessler,
Ryosuke Kuroroda, and Sérgio Rocha Piedade

3.1 Introduction p­ revention. In an effort to address these injuries,

it is of paramount importance to understand the
Musculoskeletal injury is one of the most common biomechanical principals behind the injury, to
reasons for days off work and reduced activity with enable an effective treatment or prevention strat-
approximately 126.6 million patients affected in egy to be implemented.
the United States on an annual basis (Source: This chapter will focus on providing an over-
American Academy of Orthopaedic Surgeons, view of the pertinent biomechanical principals
2016). This has a significant impact on work- behind MSK injury. An overview of tissue-­
related productivity, quality of life, and health specific biomechanical properties will also be
expenditure in corresponding health-care systems. provided, with these terms and principals then
While there are many modalities available to illustrated in sport-specific injury scenarios and
treat MSK injury of varying kinds, one of the mechanisms.
most effective methods of treatment is injury

A. Getgood (*) 3.2 Biomechanical Principals

Fowler Kennedy Sports Medicine Clinic/Department Relating to MSK Injury
of Surgery, Western University, London, ON, Canada
e-mail: [email protected] When considering the mechanism of injury, it is
Y. Hoshino important to understand the forces acting on the
Department of Orthopaedic Surgery, Jichi Medical body and how they may affect the different tis-
University, Tochigi, Japan
sues. The term kinematics describes the motion
P. P. Roessler of body segments, while kinetics deals with a
Fowler Kennedy Sports Medicine Clinic,
Western University, London, ON, Canada description of the forces that produce the specific
e-mail: [email protected] motions [1].
R. Kuroroda When considering sports injuries, there are a
Department of Orthopaedic Surgery, Kobe University number of simple units of measurement that must
Graduate School of Medicine, Kobe, Japan be taken into consideration to determine the mag-
e-mail: [email protected] nitude of force acting on individuals. One such
S. R. Piedade key measure is mass. Mass is a measure of iner-
Department of Orthopedics and Traumatology, tia, being the property of an object to resist the
State University of Campinas—UNICAMP,
Exercise and Sports Medicine, Campinas, SP, Brazil changes in motion that affect it. A running back
e-mail: [email protected] in American football, for example, must

© ISAKOS 2019 27
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_3
28 A. Getgood et al.

o­ vercome inertia to start running; but his mass of forces acting perpendicular to this plane.
will also make it more challenging for him to be Again, with the example of the above knee
stopped. Weight, on the other hand, is the force of injury, shear stress observed in the lateral
gravity acting on an object. compartment may result in abnormal lateral
In dynamic situations such as sports, Newton’s meniscal loading and can result in a meniscal
laws of motion is important to understand, when tear.
considering how forces are acting on objects and,
of course, participants or subjects in a game [2]. The majority of sports injuries do not occur as
a result of simple uniaxial forces applied to the
• Newton’s first law states that a body continues body. There are often combined loads such as the
in a state of rest, or of uniform motion in a simultaneous compression and tension that is
straight line, unless it is compelled to change applied to a long bone when landing a ski jump.
that state by forces impressed upon in. In the event of a ski catching an edge, the leg may
• Newton’s second law tells us that the change have a torsional load applied to it; that is a load
in motion of an object is proportional to the that acts about the long axis of the bone in rota-
force impressed and is made in the direction tion, due to the large lever arm and subsequent
of the straight line in which it is impressed. rotational moment applied by the ski. This may
This law essentially describes acceleration, result in a spiral fracture of the tibia or femur [3].
which is derived from length, time, and mass. When external forces are applied to a body,
• Newton’s third law of motion states that to deformations occur. Strain is the quantification
every action, there is an equal and opposite of the deformation of a material. When tensile or
reaction. This means that when the running compressive forces are applied to an object, lin-
back collides with the linebacker, the force of ear strain occurs due to the change in the object’s
impact will be felt similarly on both players. length. This can be described in terms of the per-
centage of length change in relation to its original
Stress and strain: Stress is defined as the length [2].
force applied to an object divided by the cross-­ Staying with the example of the MCL injury, a
sectional area of the surface onto which the force tensile force is applied to the medial aspect of the
is applied. There are three principal stresses that knee, secondary to the direct lateral blow. The
act on a body [2]: tensile force exerts a linear stress to the MCL
which in turn will cause a change in length of the
1. Tension—Tensile stress is that which occurs tissue—also known as strain. The close relation-
as a result of force that pulls apart molecules ship between stress and strain explains the behav-
that bond the structure together. A lateral blow ior of a material or, in this instance, the MCL,
to the knee in soccer will result in tensile under load.
stress being applied to the medial collateral The relationship of stress and strain can be
ligament (MCL), often resulting in a tear of illustrated via the stress-strain curve (Fig.  3.1).
that structure. In the initial linear portion, there is a direct cor-
2. Compression—Compressive stress is the relation between stress and strain. This is known
axial stress that occurs when a load pushes or as elastic behavior, where the material returns to
squashes molecules together. Take the exam- its original dimensions following removal of the
ple of the lateral blow to the knee. Tension is applied load. The steeper the line, the stiffer the
applied to the medial side, but a compressive material, with the slope of the stress-strain curve
stress may be experienced in the lateral tibio- representing the elastic (Young’s) modulus of the
femoral compartment that may result in a material [2].
bone bruise or osteochondral injury. With continued applied load, the relationship
3. Shear—While tension and compression act in will eventually not be directly proportional or lin-
the axial plane, shear stress occurs as a result ear; at this point it reaches the material yield
3  Biomechanics of Musculoskeletal Injuries 29

Toe region Linear region Yield point

D
C
Stress [N]

AUC

Strain [mm]

Fig. 3.1 The sinusoidal curve of the biomechanical fied. The point C is the transition between the elastic limit
behavior of the ligament submitted to the uniaxial tensile and plastic region (yield point) and the maximum strength
load. In the segment A of the diagram (toe region), lower of the material, while the tissue damage (irreversible or
force/stress followed by higher strain is observed, reflect- permanent deformation) is present in D.  The involved
ing the crimp and nonuniform pattern of the fibers as they energy of rupture in the process is calculated by the area
elongate. In B (linear region), a progressive stretching of under the curve (AUC)
fibers characterized by linear and elastic behavior is veri-

point and enters the plastic region. In this region, other components [1, 6]. Abrahams states that
the material no longer returns to its original viscoelastic tissues work as a combined elastic
dimensions and displays plastic deformation. solid and viscous fluid [7]. The elastic compo-
Once the material starts to continue to display nent presents a proportional deformation to the
increased strain with no further stress applied, it applied force, while the response of the viscous
reaches its ultimate strength, with the failure component is time-dependent. In certain condi-
strength encountered on discontinuity or break- tions, one of these mechanical responses becomes
age of the material. For the MCL, a grade II MCL more prevalent than the other, depending on the
strain will result in a degree of plastic deforma- physical demand. Otherwise, their mechanical
tion and discontinuity of some of its fibers, with behavior has geometrical and structure specific-
some remaining intact. Therefore, a complete ity, as their anatomical site qualifies them
MCL injury may not be observed [4, 5]. mechanically.
The degree of injury that is observed with an Different viscoelastic materials behave dif-
applied load is related to the viscoelastic behav- ferently depending on how quickly load is
ior of musculoskeletal tissues. These material applied to them. Cortical bone, for example, is
properties, and the way forces are applied to the stronger and stiffer if a load is applied quickly,
material, will determine the nature and the sever- whereas it is weaker if applied slowly. This phe-
ity of the injury [4]. nomenon of strain rate can help explain why
Viscoelasticity: Musculoskeletal tissues, such avulsion fractures occur (Fig.  3.2). In the sce-
as the bone, muscle, tendon, and ligament, are nario of an eversion ankle injury, load applied
known as viscoelastic materials, and their biome- quickly across the joint will more likely result in
chanical behavior is time-dependent, which a deltoid ligament tear, whereas, if it is applied
results from a complex interaction between mol- slowly, an avulsion of the tip of the medial mal-
ecules of proteoglycans, water, collagen, and leolus may occur.
30 A. Getgood et al.

Fig. 3.2  PCL tibial avulsion fracture of the left knee in a 22-year-old BMX athlete

Understanding these principles of how load is illustrates the nonlinear mechanical response
applied to the body during sport may help (sinusoidal curve), which is a characteristic of the
­understand the mechanism of injury, the injury ligament when stressed at different levels of
pattern, and the methods to prevent injury. We strain.
will now look at specific tissues and how they Bone: Bones are harder and stronger than car-
have adapted to respond to these external loads. tilage, because their structure combines hard
mineral (hydroxyapatite carbonate) and flexible
collagen, without being brittle. Bones are ductile
3.3 Biomechanical Principals structures, which are able to adapt their mechani-
of Specific MSK Tissues cal response according to the direction of the
applied force (anisotropy). A remarkable exam-
Tendons and ligaments: Tendons and liga- ple is that bones can resist 30% more load applied
ments are made up of bands of collagen fibers through their longitudinal axis compared to their
organized in parallel along their long axis. Both transversal axis (15  MPa and 12  MPa, respec-
are extremely specialized structures, specifi- tively). Moreover, they have the ability of remod-
cally adapted to bear tensile forces across eling and will adapt their structural density to the
joints. However, the variations of the ultrastruc- mechanical environment and are highly special-
ture pattern of ligament fibers (wavy pattern, ized in supporting load, mainly in compression.
called crimping) and their orientation allow In the elastic phase, the bone can deform up to
them to resist higher levels of strain compared 0.75%, and, with the deformation of 2–4%, a
to tendons [4]. fracture often occurs. During the plastic deforma-
When applying tension to the ligament, elon- tion phase, the bone can absorb six times more
gation takes place, and more ligament fibers are energy before a fracture during the elastic period
recruited. The fibers become gradually uncrimped [9, 10].
and oriented in a parallel fashion toward the During the human biological development,
applied force [1, 8]. As mechanical stress contin- the biomechanical properties of the bone differ
ues, the ligament gradually stiffens until it according to age. Compared to the immature
reaches its ultimate strength and fails. Figure 3.1 bone of children, the adult bone is stiffer
3  Biomechanics of Musculoskeletal Injuries 31

(more  mineralized) and more brittle, while in Stress fractures: In sport, stress fractures can
children it is weaker (less mineralized) and duc- result from abnormal loads to the bone and can
tile, which is a point to consider when developing also occur due to muscle fatigue [11]. They fre-
a regimen of sports training for children [10]. quently occur in individuals who are not ade-
In sports, athletes perform high-demand phys- quately prepared for vigorous physical exercises
ical activities at different levels of speed in short and also in high-performance athletes of sports in
periods, exposing them to direct and indirect which repetitive impact actions are performed,
loads. Take the example again of the running such as volleyball, athletics, and distance run-
back colliding with the linebacker. Both players ning. Dancers may also be subject to this type of
have adapted their bodies to be able to withstand injury. From a biomechanical point of view, it can
with levels of external load. In some circum- be concluded that in these clinical situations, it is
stances, the energy of the associated trauma over- observed that constant load or strain, close to the
powers the bones’ ability to withstand the applied physiological limit of tissue, could cause plastic
load, depending on its direction of application, deformation and consequently fracture. Besides
and thus a fracture may occur. that, osteoporosis (elderly athletes), preexisting
Frequently, low-energy traumas are linear and metabolic bone disease (hyperparathyroidism,
do not promote large displacements, while higher- adrenal disorders), bone neoplasms, drug and
energy traumas will promote significant fracture alcohol use, vitamin D deficiency, and steroids
comminution and dislocation and, subsequently, a could predispose to stress fracture (Fig. 3.4).
substantial associated soft tissue damage. Muscle: Muscle injuries represent one of the
Therefore, the magnitude, duration, direction, and most common clinical problems that cause sus-
rate of the applying load play a critical role in pension of sports activity for athletes. Skeletal
defining the fracture pattern [9, 10]. muscle is the largest tissue in the body, account-
A fracture occurs in the weakest plane of the ing for 40–45% of body weight. Indirect (intrin-
bone, where there is a maximum of shear and ten- sic) muscle injuries, also called stretching, and
sile stress. According to the loading mode, differ- direct injury (extrinsic) are quite common in
ent configurations of fractures could be produced; sports and recreational activities and are produced
for example, a torsional load causes a spiral frac- by direct and indirect trauma. Delayed-­onset mus-
ture, while compressive load leads to oblique cle soreness (DOMS) pain is another muscle
fractures and combinations of bending and com- problem that occurs with extreme exertion.
pressive forces result in transverse fractures or a It is the mechanism of traumatic injury of the
so-called “butterfly” fragment [8] (Fig. 3.3). muscle where the direct force can produce

Fig. 3.3 Examples
of fracture patterns
according to the applied
load
bending and
torsional compressive
compressive
load load
load

spiral oblique “butterfly’’

32 A. Getgood et al.

Fig. 3.4  Mechanism of STRESS PATOLOGIC

stress fracture according
to the quality of bone
and mechanical stress
(Source: adapted from
Greenspan A, editor.
Orthopedic Imaging: A
Practical Approach. 4th
ed. Philadelphia (PA):
Lippincott Williams &
Wilkins, c2004. Chapter
4, Radiologic Evaluation fatigue insufficiency bone abnormality
of Trauma, Figure 4.27, abnormal stress normal stress preexisting disease
p. 57)

(bone tumor,
normal bone Osteoporosis hyperparathyroidism, adrenal
(muscle imbalance or fatigue) (elderly) disorders, use of drugs)

s­uperficial injury, called muscular contusion 3.4 Sports-Specific Injury

(bruise), or deeply, characterizing more extensive Mechanisms
muscular injury. Bleeding within the muscle can
create increased pressure, cell necrosis, and Mechanical factors that cause a musculoskeletal
inflammation. Moreover, heterotopic ossification injury can be divided into both extrinsic (from
may occur, which can be a major issue for ath- factors outside the body) and intrinsic (from fac-
lete, eventually also leading to disability to con- tors within the body) [13]. The primary extrinsic
tinue sporting activity. factor is physical contacts either between athletes
Muscle activation produces force within the or with other objects including the ground, shoes,
muscle. During a concentric contraction, the or orthotic equipment. These additional extrinsic
resistance load is lower than the force generated factors can aggravate mechanical stresses on mus-
by the muscle, and hence it shortens. culoskeletal structures. Intrinsic factors include
On the other hand, if the resistive force is muscle strength and imbalance, body size, flexi-
higher than the force generated by the muscle, bility, anatomic alignment, and morphology.
the muscle is elongated, and an eccentric con- In order to estimate the relative risk of an
traction takes place. This type of muscle con- injury to the athlete, the frequency and magni-
traction is particularly vital in absorbing energy tude of the physical contacts in each sport should
and protecting the joints, as in the case of the be recognized. Categorization of sports estab-
landing of the heel, where the quadriceps mus- lished by the American Academy of Pediatrics
cle contracts, protecting the knee. Loss of Council on Sports Medicine and Fitness
eccentric quadriceps strength in the postopera- (Table 3.1) is most commonly used and quite use-
tive phase of anterior cruciate ligament (ACL) ful for sports physicians [14]. Contact sports
reconstruction can result in a stiff knee landing (e.g., soccer and basketball) include those where
with an inability to absorb load, predisposing athletes routinely make contact with each other
athletes to a higher risk of ACL reinjury. Indirect or with static objects, and some of them are clas-
muscle injury results from eccentric muscle sified as collision sports where the players’ hits
contraction, which presents a clinical situation are made with great force. Limited-contact sports
where the physiological limit of muscle elonga- (e.g., baseball and handball) involve infrequent
tion is exceeded and muscle fiber rupture occurs. contact between athletes or between athletes and
These mechanisms usually are loads or velocity static objects. Non-contact sports (e.g., golf and
dependent [12]. swimming) are those where physical contact is
3  Biomechanics of Musculoskeletal Injuries 33

Table 3.1 Sports classification based on contact Acute traumatic fracture by applying a single
(Proposed by the American Academy of Pediatrics
high-magnitude load to the bone is one of the
Council on Sports Medicine and Fitness)
typical injuries. Such a fracture happens when
Contact Limited contact Non-contact
the force exceeds over the bone’s ability to resist
Basketball Adventure racing Badminton
Cheerleading Baseball Bodybuilding it. Traumatic fractures are often seen in player-to-­
Diving Bicycling Bowling player contact, and the highest rate of fractures
Extreme sports Canoeing or Canoeing or was reported as being more than 10% in American
Field hockey kayaking (white kayaking (flat
football according to the epidemiological study
Gymnastics water) water)
Martial Fencing Crew or rowing of high school athletes [17].
arts—sparring Field events Curling Contusion is also common in collision and
Judo High jump Dance contact sports, since it occurs when a direct blow
Jujitsu Pole vault Field events
or repeated blows from other players or a blunt
Karate Floor hockey Discus
Kung-Fu Flag or touch Javelin object strike part of the body, crushing underly-
Taekwondo football Slot-put ing muscle fibers and connective tissue. It con-
Rodeo Handball Golf sists of 20‑30% of all the injuries in rugby players
Skiing, Horseback riding Orienteering
[18], whereas basketball, a contact sport, has
downhill Martial Power lifting
Ski jumping arts—forms Race walking fewer contusions, e.g., 15.3% on the professional
Snowboarding Racquetball Riflery league level [19]. However, most of these injuries
Soccer Skating Rope jumping are minor and heal quickly, without taking the
Team handball Ice Running
athlete away from competition. But, once deep
Ultimate In-line Sailing
Frisbee Roller Scuba diving tissue is damaged, it may keep the athlete out of
Water polo Skiing Swimming sports for months.
Wrestling Cross-country Table tennis Contact sports: Musculoskeletal injuries in
Collision sports Water Tennis
contact sports commonly occur by direct contact
American Skateboarding Track
Softball with another player. In basketball, player-to-­
football
Boxing Squash player contact accounted for 79.8% of contact
Ice hockey Volleyball injuries and 34.9% of all injuries [20]. The most
Lacrosse Weight lifting
common injury is lateral ankle sprain, accounting
Roller derby Windsurfing or
surfing for 13.2% of all injuries on the professional
Rugby football
league level [19]. Lateral ankle sprains occur by
landing on another player’s foot and/or out of
rare and mostly unexpected. Typical injuries and balance due to contact with other players, while
their mechanisms in each category of sports are most of the player’s attention is paid to the ball
illustrated in this section. and the rim above his/her head. Forceful ankle
Collision sports: Physical contact with great plantar flexion and inversion may damage the lat-
force, or simply collision, is the main characteris- eral ligaments of the ankle. Considering that the
tic of collision sports and the primary reason for greatest number of injuries occurred within the
a high prevalence of musculoskeletal injuries. In three-point line [20], the amount of playing time
collisions, energy is transferred from one body to spent is the key (greater exposure), and the
another. In blocking and tackling, for example, increased player-to-player contact due to higher
transfer of energy between bodies can result in player concentration could be a major reason for
injury when the energy transferred exceeds the high prevalence of lateral ankle sprains in basket-
tolerance of the involved tissues (e.g., bones, ten- ball. Much attention has focused on prevention of
dons, ligaments). It is reported that American ankle inversion injuries in basketball. The design
football has the highest injury rates at both the of the shoes has been adapted subsequently to
high school [15] and collegiate [16] levels. Thus, protect the ankle, and many players also tape
collision sports have undoubtedly the highest risk their ankles or additionally wear braces. However,
of injuries among all categories. the persisting high frequency of ankle injuries
34 A. Getgood et al.

suggests that more clinical and biomechanical such as football, soccer, or basketball [25].
research is necessary to improve protective shoe Furthermore, stress fractures are generally more
and ankle equipment. difficult to be diagnosed and treated than trau-
Limited contact sports: Although the fre- matic fractures.
quency and magnitude of contacts are fewer and The categorization of sports indicates the
smaller in limited contact sports compared to col- comparative likelihood that participation in dif-
lision or contact sports, injuries in limited contact ferent sports will result in acute traumatic inju-
sports still mainly result from direct physical ries from blows to the body. On the other hand,
contact. overuse injuries are also typical in athletes and
Fractures of the hand are quite characteristic mostly not related to contact or collision but to
of baseball and softball and are frequent causes repetitive microtraumas. Furthermore, overuse
for surgery [17] and subsequent disqualification injuries generally are not acute. Therefore, the
from the game [21]. Rare but quite strong force is applied categorization might be insufficient to
applied when the high-speed ball hits the player’s adequately attribute relative risks of such overuse
hand at the time of batting or catching. Hand injuries. Further assessment of sports participa-
fractures can significantly limit sport participa- tion in terms of duration and intensity should be
tion [22], since most of the players have to utilize considered here.
their hands independent of the sport practiced. Additionally, the prevalence of the injury can
Non-contact sports: Musculoskeletal injuries be differing among field positions, especially in
in non-contact sports are mostly caused by repet- team sports. For example, shoulder injury rates
itive or extreme force that is generated by ath- are much higher in flanker and five-eighths than
letes’ own exertion. in halfbacks in rugby [26]. Besides the field posi-
Muscle strain is a quite common injury which tion, physicians might also consider the level of
refers to damage of a musculotendinous unit (or competition, the maturity of the competitors, the
muscle-tendon complex). Acute muscular strain relative physical size, and the availability of
can result from overstretching an inactive muscle effective protective equipment for further biome-
or dynamically overloading an active muscle chanical assessment of musculoskeletal injury.
either in concentric (active shortening) or eccen- In summary, musculoskeletal injuries occur as
tric (active lengthening) action. The leg or groin a result of forces that are applied to the body.
muscles, such as quadriceps and hamstring mus- Understanding these forces and how they interact
cles, are most frequently affected. Hamstring with individual MSK tissues is extremely impor-
muscle strain is more often seen in track athletes tant when treating sports injuries. Injury mecha-
than in any other sports according to the report of nisms can be specific to individual sports, and the
NCAA athletes [23]. sports categorization based on the contact level is
Fractures typically occur by applying a single useful to estimate the relative risk of musculo-
great external force directly to the bone. But skeletal injuries.
bones may also fracture in response to repeated
low-magnitude loads, which results in what has
been described as a stress fracture previously References
[11]. The magnitude of forces is less than the
maximum tolerated by the bone, but applied 1. Fung Y-C. The meaning of constitutive equation. In:
Fung Y-C, editor. Biomechanics. New  York City:
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letic population is approximately 1%; however, 3rd ed. Champaign: Human Kinetics; 2013.
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London: Routledge Taylor & Francis; 2012.
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track and field athletes have a higher incidence of ments. I. Quasi-static and nonlinear viscoelastic prop-
stress fractures than participants of contact sports, erties. Biorheology. 1982;19:385–96.
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5. Woo SL, Gomez MA, Woo YK, Akeson among competitive collegiate athletes. J Athl Train.
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Lippincott Williams & Wilkins; 1996. p. 3–120. Comstock RD.  Epidemiology of high school sports-­
10. Wu Z, Ovaert TC, Niebur GL. Viscoelastic properties related injuries resulting in medical disqualification:
of human cortical bone tissue depend on gender and 2005-2006 through 2013-2014 academic years. Am J
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11. Bolin D, Kemper A, Brolinson PG. Current concepts 22. Messina DF, Farney WC, DeLee JC. The incidence of
in the evaluation and management of stress fractures. injury in Texas high school basketball. A prospective
Curr Sports Med Rep. 2005;4:295–300. study among male and female athletes. Am J Sports
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Biomech. 2014;47:687–93. hamstring strains in 25 NCAA sports in the 2009-­
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Greaser MC.  Foot and ankle stress fractures
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 Physiological Demands
in Sports Practice
4
Ana Sousa, João Ribeiro, and Pedro Figueiredo

4.1 Energy Transfer During the chemical energy released must be stored in
Exercise the form of adenosine triphosphate (ATP). This
molecule forms from a molecule of adenine and
Humans obtain energy either by consuming ribose (called adenosine) linked to three phos-
plants or by eating animals that feed on plants. phates, each consisting of phosphorus and oxy-
The macronutrients—carbohydrates, fats, and gen atoms. The bonds that link the two phosphates
proteins—from these ingested foods are ulti- represent high-energy bonds because they release
mately broken down to release the stored energy. considerable useful energy (approximately
This energy can be used in different processes, 7.3  Kcal per molecule of ATP). In the specific
such as building muscle mass, repairing muscle case of muscle contraction, the myosin head con-
damage, active transport of many substances tains a binding site for the molecule of ATP. The
across cell membranes (e.g., sodium and potas- adenosine triphosphatase (ATPase), located here,
sium), and, for the epitome of mechanical energy, splits the ATP to yield adenosine diphosphate
muscle action and, consequently, human move- (ADP), inorganic phosphate (Pi), and, mostly
ment. However, for all these processes to occur, important, energy. Therefore, by releasing energy
when broken down, ATP is the chemical energy
A. Sousa (*) source of the mechanical muscle contraction
Research Centre for Sports, Exercise and Human process.
Development, CIDESD, Vila Real, Portugal However, cells can store only limited amounts
University Institute of Maia, ISMAI, Maia, Portugal of ATP (80‑100 g at any time under normal rest-
J. Ribeiro ing conditions), which implies that they must be
Research Centre for Sports, Exercise and Human constantly generating new ATP to provide energy
Development, CIDESD, Vila Real, Portugal for all cellular ATP-dependent mechanisms,
University Institute of Maia, ISMAI, Maia, Portugal including muscle contraction. In this way, cells
Department of Performance Optimization, Sporting can generate ATP throughout three metabolic
Clube de Braga, SAD, Braga, Portugal pathways—ATP-CP, glycolytic, and oxidative
P. Figueiredo systems—as might expected, depending on exer-
Research Centre for Sports, Exercise and Human cise intensity. Energy transfer can increase about
Development, CIDESD, Vila Real, Portugal fourfold in the transition from rest to light exer-
University Institute of Maia, ISMAI, Maia, Portugal cise but can be higher than 100-fold within the
Portugal Football School, Portuguese Football supramaximal exercise. From the three energy
Federation, Oeiras, Portugal metabolic pathways, the first two can be

© ISAKOS 2019 37
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_4
38 A. Sousa et al.

d­ eveloped in the absence of oxygen, and there- ATP and vice versa. Another possibility to simply
fore, and jointly termed anaerobic metabolism. produce ATP comes from the adenylate kinase
The last system, because it requires the presence reaction, in which two ADP molecules are used
of oxygen, is generally termed aerobic metabo- to produce one molecule of ATP and AMP.
lism, which comprises both carbohydrates and fat During the first seconds of supramaximal
oxidation. exercise (e.g., sprinting, c.f. Fig. 4.2), within the
muscular cell, the need for higher concentrations
of ATP is extremely high, and this is maintained,
4.1.1 I mmediate Energy: ATP-PCr at a relatively constant level, mainly due to
System PCr  breakdown. Consequently, PCr concentra-
tion declines as it is used to resynthesize
To overcome the ATP storage’s limitation, cells ATP.  However, beyond ~14  s of exercise, both
contain another high-energy phosphate com- ATP and PCr concentrations are insufficient to
pound—phosphocreatine (PCr, sometimes called fulfill the energy requirements for muscle con-
creatine phosphate). PCr share a similar charac- traction, and therefore, muscles must rely on
teristic to ATP, as a large amount of free energy is other energy processes.
released. Some of this energy for ATP resynthesis
comes directly from the anaerobic splitting of
PCr into Pi and creatine (catalyzed by the enzyme 4.1.2 S
 hort-Term Energy: Glycolytic
creatine kinase—ck). This pathway comprises System
simply the donation of one molecule of Pi to
ADP to form ATP (cf. Fig. 4.1). After the immediate source of energy for muscle
In contrast to ATP, the energy released from contraction (ATP and PCr) have reached exhaus-
the breakdown of PCr is not directly used for cel- tion, the next process, more complex than the
lular work, and therefore, is essentially used to ATP-PCr system, begins to take action within the
maintain a constant regeneration of ATP.  Cells cytosol. This is concerned with the breakdown of
store approximately four to six times more PCr carbohydrate in the form of glucose or glycogen.
than ATP, and approximately 90% of PCr’s In a series of 10‑12 enzymatic reactions, the for-
hydrolysis occurs in the cytosol. The main regu- mer is broken down to produce two molecules of
lating factors of this system are the concentra- pyruvate (glycolysis) and four molecules of ATP,
tions of ADP, Pi, and ATP. Therefore, following but the initial process is ATP-dependent (two
the principle of negative feedback, when molecules), which means that the final balance is
­concentrations of ADP and Pi are elevated, cre- two molecules of ATP.  In contrast, glycogen’s
atine kinase activity is enhanced to synthesized breaking down (glycogenolysis) to pyruvate only

Fig. 4.1  In the

Creatine
ATP-PCr system, the
(Cr)
energy liberated from
the hydrolysis of
phosphocreatine (PCr) is
used to synthesized ck Free
Phosphocreatine
adenosine triphosphate (PCr) Energy
(ATP) via the binding of
inorganic phosphate (Pi)
to adenosine phosphate
(ADP) Pi ADP

ATP
4  Physiological Demands in Sports Practice 39

Fig. 4.2  The energy 100

released from the
breakdown of
phosphocreatine (PCr) is
80
used to synthesize ATP
during 14 s of
supramaximal exercise

% of Resting Value
(sprinting), preventing 60
the ATP level from PCr
decreasing in the first ATP
10 s of exercise. 40
However, at exhaustion
(~14 s) both ATP and
PCr levels are low, and
if the exercise goes 20
Exhaustion
beyond, energy for
continual ATP
resynthesis must be 0
originate from less-rapid
0 2 4 6 8 10 12 14
catabolism of the stored
macronutrients Time (s)

consumes one ATP molecule, and therefore, the the Krebs cycle (also known as a citric acid cycle
final balance is more attractive (three ATP). or tricyclic acid cycle; cf. Fig. 4.3b). Like stated
Ultimately, pyruvic acid is then converted to lac- for the ATP-PCr energetic pathway, the Krebs
tic acid. However, in both cases, the amount of cycle is regulated by negative feedback, and addi-
energy produced is relatively small, and the avail- tionally, because glycolytic pathway feeds it,
able capacity of this system is ~1 min (cf. Fig. 4.3a). both are upregulated by ADP and Pi and down-
Despite the amount of ATP produced being scarce, regulated by ATP.
the combined actions of both ATP-PCr and gly- The Krebs cycle process will end up with
colytic systems allow the muscles to generate the production of CO2 and two molecules of
force when oxygen availability is low. However, ATP. Moreover, the several hydrogen ions here
if sufficient oxygen is available to the muscle released, together with the hydrogen ions
cell during glycolysis, the oxidative system released in the previous chemical reactions,
begins to assume the preponderance in energy cannot remain in the system. Otherwise, the
production. cell milieu would become too acidic. Therefore,
these ions combined with two coenzymes, in
its reduced form (nicotinamide adenine dinu-
4.1.3 L
 ong-Term Energy: Oxidative cleotide: NADH, and flavin adenine dinucleo-
System tide: FADH2), will carry the hydrogen atoms
(electrons—e−) to the electron transport chain
As stated above, the oxidative system begins to into the inner mitochondrial membrane (cf.
gain preponderance when intense exercise con- Fig.  4.3c). This e− will pass from complex to
tinues beyond the first minute of exercise. complex along this chain (with the final accep-
However, more than 2 h of intense exercise can tor being O2, forming consequently H2O), and
deplete the glycogen stores, so, for events lasting the energy that is released will be used to pump
longer than this, fats (lipids) are the likeliest the hydrogen ions from the matrix to the mito-
source of energy. Regardless of the energy source chondrial outer membrane. Following the con-
used, oxidation starts in the mitochondria once centration gradient, these hydrogen ions move
acetyl coenzyme-A (acetyl Co-A) is formed, ini- back across the membrane through an enzyme
tiating a complex series of chemical reactions called ATP synthase, and, transferring energy
that will allow its complete oxidation throughout to ADP, ATP is formed. The amount of ATP
40 A. Sousa et al.

Fig. 4.3  The production

a
of ATP starts in Cytosol
Glucose Glycogen
glycolysis (breakdown
of glucose) or
glycogenolysis with the
production of pyruvate
(a), which is further –1 –1 –1
catalyzed into acetyl
coenzyme A (which may
also result from fat acid)
to enter the Krebs cycle
Lactic Acid 2 Piruvate Lactic Acid
(b). The hydrogen ions
released in this latter are
carried to the electron ATP ATP Net Gain ATP ATP ATP
transport chain where a
large amount of ATP is
formed (c)
Mitochondria b Inner Mitochondrial Membrane c
2 Acetyl
Co-A -
e
Fat Acid
- Electron
e Transport
Pyruvate
Chain
-
e
Krebs
CO2 Cycle -
e

- O2
e

H2O
ATP ATP 28 ATP

formed is dependent on the coenzymes NADH c­onsequently, enhancement (cf. Fig.  4.4).
and FADH2 (every transported pair of e− yields Throughout the years, different suggestions have
three molecules of ATP, respectively). Already been presented, depending on the methods used to
counting with the energy required to pump the calculate the relative contribution of each energy
hydrogen ions throughout the membrane, the pathway; however, analysis of the current litera-
net energy gain is 28 ATP.  Notwithstanding, ture suggests that all physical activities derive
the oxidation of fat contributes to an important some energy from each of the three energy-­
energy input to the system, as its available supplying processes.
capacity is unlimited. Therefore, to be used for At one extreme, within very high-intensity
energy, the free fatty acid must be converted efforts lasting ~14  s, the intramuscular high-­
into acetyl Co-A (a process called β-oxidation), energy phosphates supply almost all the energy
and then, the Krebs cycle and electron trans- for exercise performance and that in the first ~10 s
port chain pathways occur as described of exercise, approximately 75‑85% of the decline
previously. in PCr occurs [1, 2]. Examples of these efforts are
weightlifter’s performances and 100 m track-field
running. In these cases, the rate of energy release
4.1.4 Energy Spectrum of Exercise is critical to success in the maintenance of high-
power outputs during a short period of times.
Identifying the predominant source(s) of energy However, the capacity to produce that energy is
required for an activity provides the basis for an extremely low (Fig. 4.5). When maximal efforts,
effective exercise training prescription and, lasting until ~1 min, are performed, ~60% of the
4  Physiological Demands in Sports Practice 41

Fig. 4.4  The interaction 100

and the relative
contribution of the 90 Oxidative System
energy systems
80
throughout different
durations of single bouts 70
of maximal exercise
until exhaustion 60

Energy (%)
50

40

30 Glycolitic System
20

10 ATP-PCr System

0
20 40 60 80 100 120 140 160 180 200 220 240

Time (s)

a b
Not limited
10 100
mmol ATP . kg dry mass-1 . s-1

8 80

6 60
mmol ATP

4 40

2 20

0 0
PCr Glycolysis CHO Fat PCr Glycolysis CHO Fat
Oxidation Oxidation Oxidation Oxidation

Fig. 4.5  The inverse relationship among the different energy systems regarding the maximal rate (power of the system)
at which ATP can be synthesized (a) and the amount (capacity of the system) of ATP that can be produced (b)

total energy is derived from anaerobic sources, c­ onsequently the aerobic energy supply increases
where the majority of this comes from the glyco- as exercise distance/time increases and, conse-
lytic pathway [2]. Examples of this effort is the quently, exercise intensity decreases.
400-m run and the 100-m swim. Initial attempts
suggested that the crossover point from anaerobic
sources to predominantly aerobic energy supply 4.2 Measurement of Human
occurred around 100 s [3], 120 s [4], or between 2 Energy Expenditure
and 3 min [5]. Current knowledge suggests that a
maximal effort of about 75 s derives equal energy The measurement of human metabolism can
from both the aerobic and anaerobic energy sys- involve direct calorimetry as well as indirect
tems (cf. Gastin [6] for more details), from which, calorimetry. In direct calorimetry (first described
the oxidative system predominates—e.g., 800 m by Zuntz and Hagemann), energy expenditure is
run and 200  m swim. The importance of the measured through the body’s heat production, as
anaerobic energy supply diminishes, and only ~40% of the energy liberated during the
42 A. Sousa et al.

metabolism of glucose and fats is used to pro- later studies. Although the Douglas bag method
duce ATP and the remaining 60% is converted to was considered as the gold standard for gas
heat. Therefore, measuring the body’s heat pro- exchange measurements, the need for faster and
duction (traditionally in a specific closed cham- more efficient techniques led to the development
ber) allows assessing the energy production. of other gas analysis systems (the 1950s and
However, these chambers are expensive to con- 1960s), such as pneumotachography, mass spec-
struct and operate, generating results in a slower trometers, infrared CO2 analyzers and polaro-
pace, and consequently, the indirect calorimetry graphic, thermal conductivity, and paramagnetic
method is widely used. O2 sensors [9]. Later in the 1970s, gas-­analyzing
As discussed previously, oxidative metabolism systems used a computerized metabolic system
utilizes O2 and produces CO2 and water (cf. fitted with mixing chambers (e.g., Sensormedics
Fig. 4.3b, c). Considering that the rate of O2 and 2900 oximeter, USA) measuring mixed dead
CO2 exchanged in the lungs equals the rate of space and alveolar gases (representative of the
their usage by the body tissues, indirect calorim- mixed expired gas) [10]. It was now that the for-
etry assesses energy expenditure by measuring mal real-time breath-by-breath (B × B) measure-
respiratory gases. These have traditionally been ment of pulmonary gas exchange during exercise
assessed to study the energetics of many individ- started (cf. Ward [9] for more details). Over recent
ual sports since the beginning of the twentieth years, the need to evaluate the subjects in ecologi-
century. Trying to describe the changes in differ- cal conditions (especially athletes in different
ent cardiorespiratory parameters during light or modes of exercise) and technological advances
heavy cycling exercise, Krogh and Lindhard [7] has resulted in a portable, lightweight, telemetric,
were pioneers as providing the first description of and automated metabolic gas analysis systems
oxygen uptake (VO2) time course at the onset of (cf. MacFarlane [11] for more details). The first
constant-work-rate exercise. A decade later, Hill significant commercial development of truly por-
and Lupton [8] proposed the concept of maximal table and telemetric metabolic system occurred in
oxygen uptake (VO2max) during exercise in 1989—Cosmed K2, Italy [12]—and until today,
humans, and by using a specific bag (rubber-­lined the portable metabolic gas analysis remains the
canvas bag invented by Douglas in 1911 for col- gold standard for most field studies on energy
lecting expired air), they provided the impetus for expenditure (Fig. 4.6).

Fig. 4.6 A
methodological Energy Expenditure
overview of the methods
used to estimate energy
expenditure

Direct Indirect
Calorimetry Calorimetry

Open Closed
Circuit Circuit

Chambers Portable Systems

Douglas Bags Laboratory-based Systems

4  Physiological Demands in Sports Practice 43

4.3 Physiological Assessment meaningful. The work rate, or O2 consumption,

for Athletes just below that point at which metabolic acidosis
and associated changes in gas exchange occur is
Although it is not an aim of this chapter to dis- described as the anaerobic threshold [16]. Above
cuss the importance of field testing, logistically this specific boundary, ventilation exceeds its
it is somehow difficult to get an athlete or team proportionality with a work rate that is in excess
of athletes to be tested in laboratory, despite of O2 consumption but matching CO2 production.
accurate assessment of an athlete’s aerobic So, the anaerobic threshold is commonly
function may be optimal during laboratory con- described by reference either to (1) a metabolic
ditions, which led to the design of valid and change in blood lactate concentration, the anaer-
reliable field tests. These tests are popular obic metabolic threshold, or (2) ventilatory gas
within coaches, athletes, and sports scientists exchange data, when the exercise intensity asso-
due to their simplicity, time efficiency, and lack ciated with anaerobic threshold exceeded due to a
of equipment required and often produce a nonlinear increase in ventilatory data—the venti-
measure that relates to a specific physiological latory anaerobic threshold. Hence, for the deter-
state, for example, velocity at maximal oxygen mination of the anaerobic threshold during
uptake or maximal aerobic speed. Both these exercise, basically two different methods are
concepts can be understood as the minimum used: direct invasive measurement of blood lac-
speed at which VO2max. In fact, VO2max reveals tate (obtained from capillary samples) or nonin-
itself as an important physiological parameter, vasive measurement of the ventilatory and gas
expressing the subjects’ maximal metabolic exchange response [17–19].
aerobic performance, being one of the primary Considering the outcome of the tests used
areas of interest in training and performance (either laboratory or field ones), speed or time
diagnosis [13]. and distance corresponding to these specific
A variety of incremental exercise test proto- physiological boundaries—VO2max and anaero-
cols, either continuous or discontinuous, have bic threshold, as a measure of external work,
been proposed in the last decades to measure can be easily applied in a practical setting, for
VO2max within laboratory conditions [14], with prescribing exercise intensities, monitoring
the most classical protocol for VO2max testing training adaptations, and subsequently enhanc-
being the incremental intermittent Astrand-type ing performance [20].
test [15]. Alongside this, several field tests have
been developed to access the aerobic capacity, as
time and distance trials (1-mile, 1600  m), the References
University of Montreal Track Test, the 20-m
shuttle run test, the Yo-Yo Intermittent Recovery 1. Lakomy HA. Physiology and biochemistry of sprint-
tests, and the 30–15 intermittent fitness test, to ing. In: Hawley JA, editor. Running: handbook of
name a few, which can be used for individual or sports medicine and science. Oxford: Blackwell
Science; 2000. p. 1–13.
team sports. These tests (performed either in lab- 2. Maughan RJ, Gleeson M, Greenhaff PL. Biochemistry
oratory or field conditions) are traditionally used, of exercise and training. Oxford: Oxford University
as well, for the assessment of another submaxi- Press; 1997.
mal cardiorespiratory parameter—anaerobic 3. Bouchard C, Taylor AW, Simoneau J, Dulac S. Testing
anaerobic power and capacity. In: MacDougall JD,
threshold. Wenger HA, Green HJ, editors. Physiological testing
During incremental exercise, O2 uptake of the high-performance athlete. Champaign: Human
increases in proportion to the growing work rate Kinetics; 1991.
to fuel aerobic muscle contraction until a point 4. Astrand P, Rodahl K. Textbook of work physiology.
New York: McGraw-Hill; 1970.
where aerobic metabolism alone cannot supply 5. Lamb DR.  Basic principles for improving sport
the energy needed and, consequently, the contri- performance. GSSI Sports Science Exchange.
bution from anaerobic metabolism becomes 1995;8(2):1–6.
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6. Gastin PB.  Energy system interaction and relative mance diagnostics in endurance athletes. Sports Med.
contribution during maximal exercise. Sports Med. 2007;37:575–86.
2001;31(10):725–41. 15.
Astrand PO, Rodahl K, Dahl HA, Strømme
7. Krogh A, Lindhard J.  The regulation of respiration SB.  Textbook of work physiology. Physiological
and circulation during the initial stages of muscular bases of exercise. 4th ed. Champaign: Human
work. J Physiol. 1913;47:112–36. Kinetics; 2003.
8. Hill A, Lupton H.  The oxygen consumption during 16.
Wasserman K, Whipp BJ, Koyal SN, Beaver
running. J Physiol. 1922;56:32–3. WL.  Anaerobic threshold and respiratory gas
9. Ward S.  Open-circuit respirometry: real-time, exchange during exercise. J Appl Physiol. 1973;35:
laboratory-based systems. Eur J Appl Physiol. 236–43.
2018;118(5):875–98. 17. Hollmann W. 42 years ago—development of the con-
10. Sousa A, Figueiredo P, Pendergast D, Kjendlie P,
cepts of ventilatory and lactate threshold. Sports Med.
Vilas-Boas J, Fernandes R.  Critical evaluation of 2001;31(5):315–20.
oxygen uptake assessment in swimming. Int J Sports 18. Binder RK, Wonisch M, Corra U, Cohen-Solal A,
Physiol Perform. 2014;9:190–202. Vanhees L, Saner H, et al. Methodological approach
11. MacFarlane DJ.  Open-circuit respirometry: a his-
to the first and second lactate threshold in incremental
torical review of portable gas analysis systems. Eur J cardiopulmonary exercise testing. Eur J Cardiovasc
Appl Physiol. 2018;117(12):2369–86. Prev Rehabil. 2008;15(6):726–34.
12. Dal Monte A, Faina M, Leonardi L, Todaro A, Guidl 19. Faude O, Kindermann W, Meyer T.  Lactate thresh-
G, Petrelli G.  II consumo massimo di ossígeno in old concepts: how valid are they? Sports Med.
telemetría. Riv Cult Sport. 1989;15:35–44. 2009;39(6):469–90.
13. Levine BD. VO2max: what do we know, and what do 20. Beneke R, Leithauser RM, Ochentel O.  Blood

we still need to know? J Physiol. 2008;586:25–34. lactate diagnostics in exercise testing and train-
14. Bentley DJ, Newell J, Bishop D.  Incremental exer- ing. Int J Sports Physiol Perform. 2011;6(1):
cise test design and analysis. Implications for perfor- 8–24.
 Sports Activity at Childhood and
Adolescence
5
Anderson Marques de Moraes,
Vagner Roberto Bergamo, and Gil Guerra-Júnior

5.1 Introduction The key is not only to identify the biological

profile of experienced athletes but also to follow
The international literature contains many studies the development process of young athletes
concerning the technical and biological profiles because specific choices, solely based on physi-
of athletes. However, these studies neither cover cal abilities, are related to short-term results.
athletes who participate in team sports nor assess The physical changes that occur during the
the changes in physical characteristics of athletes growth process and are accompanied by critical
during the growth process. Most studies have behavioral transformations deserve greater atten-
focused on elite adult athletes. tion in the case of young athletes.
Thus, professionals working with children and
young athletes must monitor changes during dif-
ferent developmental stages and design appropri-
ate training programs for these athletes during
A. M. de Moraes the growth process to yield effective results while
Faculdade Educação Física (FEF), Pontifícia
Universidade Católica de Campinas considering not only physical but also cognitive
(PUC-­Campinas), São Paulo, Brazil and social skills.
Laboratório de Crescimento e Desenvolvimento, When studies employ a more comprehensive
Centro de Investigação em Pediatria (CIPED), approach, the perspective on athlete development
São Paulo, Brazil is broadened. Thus, learners and/or youths should
Faculdade de Ciências Médicas (FCM), Universidade be observed regarding their transformations in
Estadual de Campinas (UNICAMP), Campinas, this period of life, biological age, coordination,
São Paulo, Brazil cognitive skills, and psychological and social
e-mail: [email protected]
characteristics. It is unwise to indicate who is or
V. R. Bergamo will be an athlete of excellence in a specific sport
Faculdade Educação Física, PUC-Campinas,
Campinas, São Paulo, Brazil based on a single criterion. The procedure of mak-
e-mail: [email protected] ing specific (early) choices diminishes the impor-
G. Guerra-Júnior (*) tance of the environment and its multiple effects
Departamento de Pediatria, FCM, UNICAMP, on the long-term development process in children.
São Paulo, Brazil Therefore, the physical changes that occur at this
Laboratório de Crescimento e Desenvolvimento, stage and that are accompanied by critical behav-
CIPED, FCM, UNICAMP, Campinas, ioral transformations deserve greater attention
São Paulo, Brazil
during the development of young athletes.
e-mail: [email protected]

© ISAKOS 2019 45
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_5
46 A. M. de Moraes et al.

According to Rowland [1], another factor that the biological and behavioral context related to
should be considered is the difficulty in the improvement of the systems that contribute to
­understanding physiological responses to exer- the function of the organism [2].
cise in the case of children and young athletes, in Conversely, biological maturation simply refers
addition to difficulties in establishing relation- to developmental progress toward a complete state
ships between variables during the growth pro- of morphological, physiological, and psychologi-
cess. This is problematic and may induce errors cal maturity that is necessarily affected by genetic
in the development of future athletes because and environmental factors. Possible differences
most teachers and coaches neither respect bio- between individuals of the same sex may reflect
logical individuality nor assign due preparation different degrees of biological maturity [3].
time for technical development, especially con- These transformations occur in an orderly
sidering that competitions are organized based on and sequential manner, albeit at varying speeds
age groups. according to the individual. The transforma-
Thus, training/competition programs must be tions can be classified as normal, early (fast), or
designed according to the stage of biological late (slow) [2]. Furthermore, although growth
maturation of athletes and not according to their and maturation are genetically regulated, envi-
chronological age. Training and competition ronmental factors, which may positively or
models for young athletes should differ accord- negatively affect development, must not be dis-
ing to the level of growth and development and regarded. Furthermore, sports training is among
learning stage. these multiple (external) factors.
Another mistake is the wide variety of early Chronological age and biological age are not
competition models focused on training special- necessarily correlated with the physiological and
ization, which promote early specialization while somatic changes caused by puberty. Thus, when
favoring young athletes who physically mature professionals evaluate the general development
earlier and who, therefore, fail to develop essen- and sports skills of adolescents, they should con-
tial skills (multi-faceted development). sider different developmental areas, including
This chapter aims to show readers the impor- somatic, neurological, cognitive, and psychosocial
tance of using biological maturation to detect the functions, in an integrated and interdependent
key developmental stages of physical skills for manner. Therefore, individuals must be classified
appropriately shaping young athletes. For this according to their biological age because individu-
reason, the relationship between the development als of the same chronological age differ with
of physical skills and the key training phases was respect to growth rate. Those with a faster rate of
used considering the development of general, maturation have an advantage in sports perfor-
neural, and reproductive systems. mance over individuals with normal or slower mat-
uration rates. Therefore, classifying an individual
as a talented sportsperson before the maturation
5.2 Growth and Development process is completed can be a major mistake.
Assessment and Prediction For example, physical tests may be problem-
Methods atic because children of the same age do not nec-
essarily have the same growth rate and, most
Pediatric physiology is dynamic, and children can- often, children with early maturation (often chil-
not simply be regarded as adults in miniature.
(Rowland, 2005)
dren born in the first school semester) are selected
for competitive sports through the relative age
Growth is related to the quantitative changes effect (RAE), leading children of the same age
that increase the total body dimensions or the who were born in the second school semester to
dimensions of parts of the body as a function of be disregarded. This initial advantage does not
time, whereas development refers to the quantita- necessarily ensure future success because s­ urveys
tive and qualitative transformations that occur in on adult athlete success have indicated that the
5  Sports Activity at Childhood and Adolescence 47

most successful athletes in different sports were height velocity (PHV) occurs in this phase and
born in the second school semester [4]. is an indicator of the maximum development in
Regarding childhood stages, height increases different ages depending on the rhythms of matu-
fast in the first stage of childhood before a grad- ration of its underlying functional systems. The
ual deceleration. In this phase, children are not optimal age to start training is mostly assessed
involved in sports training. In the second stage of based on this factor [7]. During adolescence, sex
childhood, height increases slowly and regularly, differences also become more evident and may
and athletic training begins. During adolescence, significantly affect participation in sports [8].
growth rate increases again as a result of puberty, In this period, the effects of maturation must
and during this period training occurs more inten- be analyzed both when classifying sports in child-
sively and may impact growth [5]. Thus, adoles- hood and adolescence and when conducting
cence is a crucial period for linear growth, and research studies. All prospective studies on physi-
sports training during this period can contribute ological processes in children should analyze
positively or negatively to some physiological maturity in some manner. The equitable classifi-
processes, including growth [6]. cation of sports participants in this phase remains
It should be noted that childhood is charac- a key but unresolved issue [9]. Thus, acquiring
terized by the prepubertal stage, whereas ado- knowledge of differences in biological maturation
lescence covers the pubertal and postpubertal between boys and girls of the same chronological
stages. Puberty is defined by physical growth, age requires the use of a precise measure of matu-
the development of secondary sexual character- rational level in sports involving children and ado-
istics, and the maturation of psychosocial skills. lescents. Biological maturity status and time are
Furthermore, the onset and rate of progression commonly assessed using methods such as skele-
of pubertal changes varies among adolescents, tal age, pubertal stage, age of menarche, percent-
albeit predictably and gradually (Fig. 5.1). Peak age of adult height, and age at PHV [2, 10].

Fig. 5.1  Life stage of

important physical and
maturational changes Puberty peak

Pre-puberty
minimum

IV
1st Childhood I III V
2nd Childhood
II Adolescence Adult
48 A. M. de Moraes et al.

The biological age assessment model most individual according to stages, such as prepu-
used by sports coaches and specialists is that bertal, pubertal, and postpubertal, without iden-
proposed by Marshall and Tanner for boys [11] tifying how long the individual remains in the
and girls [12]. This model uses secondary sex- same stage (beginning, middle, and end of the
ual characteristics, such as the stage of devel- stage), complicating the design of training pro-
opment of pubic hair, breasts, and genitals, as grams because each stage has a different length
standards. The most appropriate procedure (the prepubertal stage lasts approximately
involves an experienced pediatrician or pediat- 10  years, puberty lasts 2–4  years, and postpu-
ric endocrinologist performing the assessment; berty is indefinite).
however, clinical evaluation of secondary sex- Thus, in order to solve the problems associ-
ual characteristics requires invading the ado- ated with pubertal stage assessments, noninva-
lescent’s privacy at a time when young people sive, simple methods have been suggested for the
are learning to cope with important physiologi- assessment of biological maturity, such as PHV
cal changes. Therefore, monitoring these char- prediction using sex-specific regression equa-
acteristics requires the utmost care and tions found in the literature.
sensitivity for the young person undergoing the Mirwald et al. [9] proposed a noninvasive and
evaluation [13]. practical method of assessing maturity based on
Accordingly, other options are used to evalu- measurements that predict years from peak height
ate puberty in boys and girls, such as the self-­ velocity (a maturity compensation value) and
assessment of pubertal stages proposed by maturity offset (MO) (Eqs. 5.1 and 5.2), wherein
Marshall and Tanner. However, the literature (decimal) age is determined by calculating the
still shows controversial results on the use of decimal fraction [16]. To define age groups, after
self-­evaluation; for example, Jaruratanasirikul determining the decimal age, the intervals of
et al. [14] evaluated the reliability of self-assess- each age are determined for subjects ranging
ment and concluded that the method is reliable from −0.50 to 0.49 of the integer of each age. For
for assessing pubic maturation in boys and girls example, the age of 10  years includes all indi-
and less reliable for assessing breast matura- viduals with a decimal age ranging from 9.50 to
tion in girls. Conversely, Rasmussen et  al. [15] 10.49 years.
examined the reliability of assessment by par- The age at PHV is also estimated from mea-
ents, boys, and girls and found that younger sures required by the model presented above.
children tend to underestimate, whereas older Because this model returns continuous values
children tended to overestimate development. and maturity is categorized into integer values,
Furthermore, girls and their parents tended to for descriptive purposes, these values are
underestimate their pubertal stage, whereas rounded to the nearest integers. Because Yi is
boys tended to overestimate theirs. Therefore, the level of maturity of the i-th individual, the
the authors concluded that pubertal assessments classification is defined into eight levels (−4 to
performed by children or their parents are not a 3  years), with a negative sign indicating time
reliable measure of pubertal stage and that these before PHV and a positive sign indicating time
assessments should be performed by physicians. after PHV.  This categorization makes it possi-
However, for large epidemiological studies, ble to identify the maturity stage with the short-
self-­assessment may be considered sufficiently est interval from the model by Marshall and
precise for making a simple distinction between Tanner and, therefore, the most precise interval
prepuberty and puberty. for designing training programs for young
These results show that self-assessment is a athletes.
flawed procedure for evaluating the pubertal Sex-specific multiple regression equations are
stage of children and adolescents. Furthermore, derived, and the coefficient of determination (R2)
the assessment proposed by Marshall and can be calculated for models for boys and girls.
Tanner reveals the degree of maturity of an These models are described below:
5  Sports Activity at Childhood and Adolescence 49

Predictive equation for boys: In another study, Campos et  al. [19] also
adjusted the equations (Eqs.  5.6 and 5.7) pro-
Maturity offset = -9.236 + 0.0002708
posed by Mirwald et al. [9] and derived the fol-
´ ( leg length and sitting height interaction )
lowing equations:
- 0.001663 ´ ( age and leg length interaction ) Predictive equation for boys:
+0.007216 ´ ( age and sitting height interaction )
+0.02292 ´ ( weighht by height ratio ) Maturity offset = -12.8 + ( 0.444 ´ age )
(5.1)
+ ( 0.0746 ´ body mass ) + ( 0.084 ´ height )
Wherein, R = 0.94, R2 = 0.891, and SEE = 0.592. - ( 0.103 ´ length of lower limbs ) -
(5.6)
Predictive equation for girls: (11.6 ´ ( body mass / height )

Maturity offset = -9.376 + 0.0001882
Wherein, R2 = 0.99 and SEE = 0.090.
´ ( leg length and sitting height interaction )
Predictive equation for girls:
+ 0.0022 ´ ( age and leg length interaction )
+0.0005841´ ( age and sitting height interaction ) Maturity offset = -12.5 + ( 0.732 ´ age )
-0.002658 ´ ( age and weight interaction ) + ( 0.168 ´ body mass )

+0.07693 ´ ( weight by height ratio ) (5.2) + ( 0.0442 ´ height ) - 0.052
´length of lower limbs) (5.7)
- ( 20.6 ´ ( body mass / height ) )

Wherein, R2 = 0.890 and SEE = 0.569.
However, the results from three longitudinal Wherein, R2 = 0.99 and SEE = 0.130.
studies [11, 12, 17] published in the last decade Some studies related to sports [20, 21] have
highlight the possible limitations of these equa- employed equations to assess the maturity status
tions. In their study, Moore et al. [18] identified of athletes, to identify talent, or to assess func-
and addressed issues relating to the correlation tional or performance changes after activity-­
between subjects and an over-fit of the original related interventions. However, developing a
study by Mirwald et  al. [9]. Considering these classification model for young people for sports
issues, specific regression equations (Eqs.  5.3– participation [22] and competition remains chal-
5.5) have been reconstructed for each sex and lenging. Prediction errors likely remain slightly
may more adequately predict MO and PHV in higher in children with early or late maturation,
growing children. and, unsurprisingly, prediction errors also
Predictive equation for boys: increase with the distance from the expected
Maturity offset = -8.128741 PHV [18].
In addition to these means of evaluating or
+ ( 0.0070346 ´ ( age ´ sitting height ) ) (5.3)
predicting the biological age of children and
young people, some authors have used the allo-
Wherein, R2 = 0.906 and SEE = 0.514. metric scale function (Eq. 5.8) to mathematically
Maturity offset = -7.999994 demonstrate how much a physiological, anatomi-
cal, or temporal variable is related to body size
+ ( 0.0036124 ´ ( age ´ height ) ) (5.4)
(usually body mass) [1].
The allometric analysis or classification is
Wherein, R2 = 0.896 and SEE = 0.542. described by the following equation:
Predictive equation for girls:
Y =a ×Xb (5.8)
Maturity offset = -7.709133
Wherein Y is the dependent variable, X is the
+ ( 0.0042232 ´ ( age ´ height ) ) (5.5)
independent variable, α is the regression inter-
cept in the Y axis, and b is the slope used to model
Wherein, R2 = 0.898 and SEE = 0.528. the relationship between Y and X. The values of α
50 A. M. de Moraes et al.

and b are derived from linear regressions by loga- increasing worldwide, which may affect the
rithmic transformation (Eq. 5.9) [23]: development of children. This aspect may lead to
mistakes in the development of young athletes
log Y = log a + b × log X (5.9)
because trainers who focus on competition show
The exponent b can be found by transforming the a markedly increased use of training volumes and
equation of the allometric scale into a linear loga- intensities inappropriate for children and
rithmic model to fit the chosen independent vari- adolescents.
able. An example is the estimate by MacAn and The methodological techniques used (short-­
Adams [24] of the resting metabolic rate in chil- term development) cause competitive specializa-
dren (6–12  years), which was the exponent of tion, leading to training specialization and,
0.67 and determined to be more appropriate consequently, early specialization. Thus, these
(mL kg−0.67 min−1) [23]. treatments, both by sports bodies and teachers
In the context of sports, some authors have and/or coaches, should be reviewed given the
used the allometric scale to better understand the importance of risk factors for the development of
relationship between physical fitness variables young athletes. Furthermore, the norms proposed
and the size of individuals in sports such as soc- by the organization should also be reviewed
cer [25, 26], long-distance running [27], and bas- according to the development of the sport in the
ketball [24], to name a few examples. case of competitions at early ages (under-12 and
It should be noted that using these equations is under-13) because these ages are inappropriate
more useful in similar populations, and models for unilateral training or for participation in com-
should also be externally validated using data petitions in their current form.
acquired from children with early or late matu- Regardless of how careful the training proto-
rity, such as athletes, clinical populations, or eth- col is or whether alternative programs and diet
nic groups. are chosen, many factors may positively or nega-
Furthermore, regarding sports, tools that are tively affect the training of young athletes
easy to use and understand must be developed to because the physical and psychological skills
enable their application to various contexts of required for success change and evolve with age.
sports training in young athletes. In addition, assuming what skills are required for
Despite all the limitations mentioned herein, success early is risky because with the shift from
assessing the maturity stage of young athletes is an early to an advanced stage, extensive practice,
still of paramount importance for adjusting the and experience, the pattern of key support skills
planned training loads and abilities and/or skills required for successful performance gradually
that will be developed throughout the season. changes.
Finally, the models should be used carefully, Most professionals managing children and
making the necessary adjustments to obtain more adolescents under pressure to show results some-
reliable parameters. times fail to respect the biological individuality
of the children and to provide sufficient prepara-
tion time. This may cause physical and mental
5.3 Tailoring Training fatigue and may adversely affect both training
to the Growth Phases and school performance, hindering certain devel-
of Young Athletes opmental areas. If this becomes routine in a
child’s lives, the child could drop out of school
Discourses and studies on the training of young (more commonly) or stop participating in the
athletes remain somewhat controversial because sport.
the approach is complex considering the various Trudeau and Shephard [28] found that the
growth stages: prepuberty, puberty, and adoles- available literature suggests that academic perfor-
cence. The introduction of a competitive level of mance is more likely to benefit from sporting
performance for younger age groups has been activities when they are offered at school and not
5  Sports Activity at Childhood and Adolescence 51

in other contexts, given the close proximity to opment curves; therefore, it is a mistake to select
educational resources and the school environ- young athletes only based on physical skills.
ment. Thus, because the high-intensity training of Accordingly, training programs should integrate
young athletes occurs in its own setting (i.e., out- physical and mental/cognitive activities, whereas
side the school) and requires maximum effort, this technical development in the first training stage
training should not occur after school activities should focus on motor coordination activities
with a high intellectual demand and vice versa. because the neurological system has already
Corroborating Trudeau and Shephard’s find- reached 90% of its development at this stage,
ings [28] regarding the possibilities of individu- thereby enabling the training of coordination
als being subjected to technical/physical training skills.
mistakes, Carazzato [29] classified these areas of However, early specialization is a major pitfall
development as physical-motor, mental, and due to its possible cascade effect. Bringing for-
technical development. Each area has specific ward the process of physical-motor development
characteristics of development. For example, in directly compromises the motor apparatus,
the area of physical motor development, 40% of resulting in a loss of approximately 20% of its
development occurs up to 7 years of age and 50% maximum potential. At the same time, mental
from 8 to 20 years of age. In the area of mental development is impaired because early “profes-
development, 35% of development occurs up to sionalization” impairs school performance, pre-
7  years and 40% from 8 to 17  years of age. venting the athlete from reaching their mental
Conversely, in the area of technical development, and intellectual peak and, indirectly, from gain-
15% of development occurs up to 7 years of age ing a full understanding of sports tactics.
and 70% from 8 to 20 years. The remainder of all Technical development is further impaired
areas of development occurs until 25  years of because early specialization before completing
age, as shown in Fig. 5.2. the myelination process compromises the ath-
The analysis of the training of young athletes lete’s full development.
in team sports (Fig. 5.2) shows a similar pattern It should be noted that these skills may or may
of development in the physical and mental devel- not be affected by external factors, namely, the

100
Physical – skills
90
Mental – decision-making
80
%
Technical – gestures 50
70
Development (%)

60
%
50 40
40% %
40 70

30

20 35%

10 15%

0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Age (years)

Fig. 5.2  Classification of physical, motor, mental, and technical development according to age (adapted from
Carazzato, 1999)
52 A. M. de Moraes et al.

work environment offered to these people. Thus, phase (18–21 years) may be considered the most
each coach should adjust the maturity stage and important period in the young athlete’s transition
the physical, technical, and tactical stimuli and to a possible high-performance and professional
their development rhythms to the specificity of sports career. Therefore, in addition to perfecting
the sport, ensuring the proportional development technical, tactical, and physical skills, the optimi-
of these training variables. zation of psychological and social skills should
In the case of team sports, the training process be prioritized. The high-level phase is character-
should enable the children/young people to per- ized by the stabilization, improvement, and mas-
form their technical, tactical, and affective skills tery of technical-tactical performance and
and to develop their biological potential. physical and psychological skills attained in the
Accordingly, numerous authors advocate that the previous phases. This phase, which usually starts
training process should be divided into stages. at 21  years, has no predicted length because it
Among these authors, Bompa and Haff [30] indi- will depend on many variables affecting sports
cated the need for three stages of development in performance (Fig. 5.3).
training young athletes. The first stage encom- Another compromising factor that should be
passes general training subdivided into initiation considered is the training system used to develop
(6–10  years of age) and athletic training (11– the young athlete because the training plan should
14 years of age); the second stage comprises spe- be designed to avoid physical or mental overload.
cialized training (15–18 years of age), and the third Most athlete development models are cou-
stage is characterized by high-performance train- pled to the long-term training process, which
ing. Thus, the biological and psychological changes partly ensures their success. However, some dif-
common to these stages of life are preserved. ficulties and limitations must not be overlooked,
Greco and Benda [31] suggest a model con- including the cultural characteristics of the soci-
sisting of nine phases covering all developmental ety, socioeconomic level, poor analysis of the
stages and age groups. In this chapter, universal results, lack of statistical models, and lack of
sports initiation, or the approach from the univer- specific tests. These difficulties are further high-
sal stage, is highlighted. The universal phase lighted when the process is accompanied by
(6–12  years of age) is the broadest and richest prediction mistakes, particularly when using a
within the sports training process, during which single variable as a predictor of talent and the
the aim is to generally develop all conditioning same model for both team and individual sports.
and coordination skills through fun and games This process does not guarantee permanent
(often using popular culture games), thus creat- success because the stability of physical skills or
ing a wide and varied base of movements empha- even of a single variable in an individual may
sizing playfulness. The orientation phase (from remain in a relative position within a group over
11–12 to 13–14  years of age) is the most indi- time. Therefore, the efficiency of the training
cated for initiating and developing technical model of young athletes should be linked to the
sports skills because, by this age, the athletes’ monitoring of the growth, development, and mat-
ability to perceive other stimuli is already well uration process.
developed, which simultaneously enables the
automatization of most movements. The direc-
tion phase (from 13–14 to 15–16 years of age) is 5.4  hysical Skills and Sensitive
P
marked by improvement and technical special- Phases in the Training
ization in one sport. The specialization phase of Young Athletes
(from 15–16 to 17–18 years of age) is the peak of
the development process, when technical and tac- Age periods when specific training effects on the
human body trigger a strong reaction response,
tical potential should be optimized toward which ensures the considerable growth rates of
enhancing high-level tactical performance and the trained function, are termed sensitive (or
stabilizing psychological skills. The approach critical) periods. If, in the athlete’s process of
5  Sports Activity at Childhood and Adolescence 53

High Level
Skills Application
Basic Life
General Sports/games Approach
Specific Basketball
Specialized Specific positions Specialization 18 to 21 years of age

16 to 18 years of age

Sports initiation

Direction
Initial, elementary
and mature motor 14 to 16 years of age
pattern,
Rudimentary motor skills,
and fundamental Introduction to sports
manipulation,
movements Recreation/ Readaptation
stabilization Orientation
and reflections health
Universal 12 to 14 years of age

School 6 a 12 anos
3 to 6 years of age

(GRECO, BENDA, RIBAS)

Fig. 5.3  Timeline, from initiation to high performance (adapted from Brenda and Greco)

preparation, for many years, favorable periods phase, ensuring an optimal correlation with the
are not used to improve motor skills, it is often development of young athletes.
impossible to recover what was lost. (Zacharov
& Gomes, 1992) [32] The proportional development of these skills
is crucial for the preparation process. However,
The process of using organizational means, this process should be combined with the techni-
methods, and forms of monitoring the develop- cal/tactical improvement process. Accordingly,
ment of young athletes ensures the focus on train- Gallahue [33] describes the stages of develop-
ing redirection toward avoiding the negative ment of motor skills in terms of levels, from the
consequences of training effects and introducing development of fundamental motor skills through
the necessary content correction in the training specialized motor skills to the development of
process at all phases of the long-term preparation special skills characterized by the enhancement
by respecting the biological growth of young ath- of sports skills. Training should predominate
letes. This monitoring may be performed using only after completing the motor development
different protocols addressed in Sect. 5.2 of this stage. Training cannot precede teaching!
chapter. In the early stages of motor development,
Conversely, motor skills and abilities must be movement should be used to positively affect
assessed as young athletes develop their poten- both cognitive and affective development.
tial through tests and assessment criteria for
[...] skills relevant to affectivity, cognition, and
specific indices of high-performance athletes in movement not only interact but also have the
the same age group. Through this process, potential to modify and be modified by each other
coaches should seek to proportionally develop when fighting for motor control and motor compe-
the main physical abilities in each training tence. (Gallahue, 2012)
54 A. M. de Moraes et al.

Similarly, no human behavioral skill will be These considerations lead to the important
superior to or more important than any other, and conclusion that training young athletes involves
all of them will have to be related/connected to finding optimal values for critical system vari-
and communicate/cooperate with each other. ables, which are more sensitive to appropriate
Thus, no single dimension will be more neces- interventions, thus favoring positive develop-
sary, superior to, or more important than any ment approaches more than the same interven-
other, and all of them will have to be compatible. tion performed earlier or later. In the training
Similarly, all of them will have to communicate phase of young athletes, attempting to maximize
and cooperate with each other. rather than optimize any variable alone will
Using team sports as an analogy, training a invariably lead to the destruction of the system
muscle in isolation from others (e.g., through as a whole.
exercise performed outside the context of a sport) Considering the different training stages,
neither encompasses the contemporary perspec- the main objective of training young athletes
tive of sports training nor the training process of is special technical preparation toward learn-
young athletes. ing and improving the technique of competitive
According to Choshi [34], researchers exercises.
excessively focus on energy aspects when The effectiveness of sports improvement for
seeking to understand human movement. The athletes depends on the optimal balance
author uses the term “horse” to represent between physical preparation and technical
energy and “rider” to represent the information learning. Therefore, the technique should be
guiding and controlling the horse. In an organ- analyzed in close relationship with the level of
ism, the horse corresponds to the muscle sys- development of the physical skills of young
tem and the rider to the central nervous system. athletes.
However, this way of conceiving movement The models traditionally used (Fig.  5.4) to
overlooks a key aspect: energy only becomes classify motor skills aim to gather data from two
effective (capable of producing effective work) clearly defined segments: (a) the group of coordi-
when it is controlled, and what controls it is nation skills and (b) the group of conditioning
information. skills.
Accordingly, Hollmann et  al. [35] indicated The first group (a), coordination skills, is
that performance capacity is, in turn, a somatic based on collecting, preparing, and processing
value consisting of isolated strengths, such as information and on controlling the execution of
physical skills, specific intelligence, technical movements through tactile, visual, acoustic,
and tactical skills, and specific experience. static-dynamic, and kinesthetic analyzers. The
Thus, when addressing motor development second group (b) consists of the set of motor
studies, although the focus is on motor skills, skills whose main factors are muscle activity
this does not mean that the other skills are dis- characteristics, biological energy availability,
regarded. On the contrary, all skills are strongly and, therefore, organic conditions of the motor
related, and the focus on one in particular is control of the young athlete that are responsible
merely an issue of predominance. Conversely, for organizing and forming movements. Thus,
the principle of specificity suggests that conditioning skills are identified as traits associ-
although all skills may be involved in a behav- ated with endurance, strength, speed, and combi-
ior, each skill must be analyzed specifically to nations of these phenomena [36].
account for the predominance of some over Thus, the potential of the athletes’ sports
others. The contributions of studies and analy- results depends on their level of development of
ses of each specific skill, albeit without forget- physical skills and on their rate of biological
ting their interactions with others, presumably growth and development (Fig. 5.5 and Box 5.1).
makes it possible to understand and examine Furthermore, mental and technical development
overall human behavior [33]. should be respected (Fig. 5.2).
5  Sports Activity at Childhood and Adolescence 55

Fig. 5.4 Classification MOTOR SKILLS

model of motor skills

COORDINATING INTERMEDIATE CONDITIONING

KILLS SKILLS SKILLS

- Motor learning Speed - Strength (manifestations)

- Motor control - Aerobic power
- Motor adaptation and re-adaptation - Anaerobic power

MOTOR SKILLS
PVC

M
A
T
U
R
A
T
I
COORDINATING O CONDITIONING
CAPACITIES N CAPACITIES
12 years 14

100 ++ ++ +++ +++

++ ++ +++ +++
Hierarchical order of physical capacity development

Sensitive stages of development of physical skills

80

60

+ + ++
+ + +
40
G-4
M-3

20

(training initiation – 1 to 2 x/week) Neural system

(methodical training – 2 to 5 x/week) General system
(performance training; – number of sessions Reproductive system
based on needs)

Fig. 5.5  Favorable conditions for training toward developing physical skills
56 A. M. de Moraes et al.

Box 5.1 Sensitive Phases of Training in Young Athletes

PHYSICAL AGE IN YEARS

QUALITIES 6 7 8 9 10 11 12 13 14 15 16
Maximum + + ++
strength ++ ++ +++
Speed strength + + ++ ++ +++
+ + ++ ++ +++ +++ +++
Endurance + + ++
strength + + ++ ++ +++
+ + + + ++ ++ ++ ++ ++ ++ +++
Aerobic power + + ++ ++ +++
+ + + + +
+ + ++
Anaerobic power
+ + ++ ++ +++
+ + ++ ++ ++ ++ ++ ++ ++ +++
Reaction time + + ++ ++ ++ ++ ++ ++ ++ +++
+ + ++ ++ ++ ++ ++ ++ ++ +++
Gestural speed + + ++ ++ ++ ++ ++ ++ ++ +++
+ + ++ ++ ++ ++ ++ ++ ++ +++
Travel speed + + ++ ++ ++ ++ ++ ++ ++ +++
++ ++ ++ ++ ++ +++ +++ +++ +++ +++ +++
Flexibility ++ ++ ++ ++ ++ +++ +++ +++ +++ +++ +++
+ (training initiation – 1 to 2 ×/week)
Male +
++ (methodical training – 2 to 5 ×/week)
Female + +++ (performance training; number of sessions based on needs)

The analysis of Fig.  5.5 and Box 5.1 clearly ibility, and aerobic power skills because these
shows that in the initial stage (from 6 to 12 years skills require methodical and flexibility training
of age), the training of young athletes must for performance due to early maturity.
focus on coordination skills because the neuro- Sometimes, speed-related attributes are con-
developmental curve responsible for the motor sidered intermediate motor skills (Fig.  5.4) and
coordination process reaches 90% of maximum not necessarily conditioning skills because, when
development at 6 years of age before considerably required, there may be no predominance of limit-
decreasing in the following ages. In this period, ing energy factors other than a close relationship
reaction speed and agility during work and jumps and effect of regulatory and therefore coordina-
should be incorporated into coordination train- tive mechanisms. Flexibility-derived attributes
ing because coordination skills are based on col- should not be characterized solely by condition-
lecting, preparing, and processing information ing or coordination factors but by the involve-
and on controlling the execution of movements ment of both types of factors.
through tactile, visual, acoustic, static-dynamic, Assuming that motor performance is charac-
and kinesthetic analyzers. Coaches should focus terized by the high specificity of each motor
on the rapid development of this system because, skill and replacing the notion of general motor
as previously described, an intervention applied performance by the concept that each young
outside the sensitive period does not have the athlete shows a specific performance of each
same effect as an intervention performed during motor skill, another proposal has emerged more
this period. recently.
In the 12–14  years age group, during which Adolescents older than 14 years have already
adolescents experience a growth spurt, the focus experienced their growth spurt, and, after this
should shift to conditioning speed, mobility, flex- time, they should undergo performance training
5  Sports Activity at Childhood and Adolescence 57

to maximize conditioning skills, including aero- performance of physical skills according to their
bic and lactic anaerobic endurance and muscle phases of growth and development and how to
strength. Performance training should start 1 year estimate the growth curve according to the indi-
after PHV. vidual level of maturity and the future level based
Long-term preparation aims to enhance the on the potential of each skill (sensitive phases)
potential development of children and adoles- according to information present and its relation-
cents at different stages of biological develop- ship with sports-specific criteria and/or tactical
ment while favoring the final selection process function. Therefore, this is a continuous and
because the ideal type of children with the mor- cyclical process.
phological, functional, and psychological quali- Thus, all training stages, particularly for phys-
ties crucial for further specialization cannot be ical skills, must be designed not based on chrono-
identified. logical age but on biological age, especially in
This system enables children and adolescents the prepubertal and pubertal phases.
to reveal their potential for physical, technical, Therefore, training prescription is crucial for
and tactical accomplishments at the appropriate promoting development before specialization,
time [37]. making it possible to prescribe training programs
Hence, in addition to biological aspects, pro- according to the biological evolution of each
fessionals must assess the effects of integrating variable while prioritizing variables that mature
variables classified as compensation, p­ otentiation, earlier to avoiding overloading physical variables
and suppression phenomena, particularly in team that have not yet reached maturity.
sports and especially in younger age groups. The It should be noted that at this phase, a training
integration of these phenomena is related to the program will succeed only if the training system
fact that performance in a specific sport involves observes the stages of development of young ath-
several combinations of biopsychosocial phe- letes, avoiding the physical and mental overloads
nomena, enabling young athletes, regardless of that explain many cases of early dropout.
the maturity stage, to reach the optimal level, Therefore, physical training based on these
namely, physiological development that is consid- criteria should be prescribed considering not
ered not ideal for the time and/or sport but that only the absolute value, which provides a tem-
may be offset by motor, cognitive, and/or socio- porary diagnosis, but also the variable maturation
affective development. Therefore, individual curve, which provides a dynamic and prognostic
diagnosis must be conducted at all training stages. perspective.
Thus, we believe that the training of young
athletes should be periodically reconsidered,
5.5 Final Considerations restructured, and redesigned according to the
needs of the child in each growth stage.
Professionals working with children and young Accordingly, professionals responsible for
people should receive good technical, pedagogi- training athletes in this age group must base
cal, and ethical training and some discernment to their decision-making process on research, con-
plan and develop appropriate training because sidering new sports training methods and
numerous transformations occur during the approaches.
growth and development of children that directly
affect their sports performance.
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 Physical Activity at Adulthood
and Old Age
6
Sérgio Rocha Piedade, Mauro Mitsuo Inada,
Gerson Muraro Laurito, Diego Navarro e Paiva,
Gustavo Pereira Fraga,
Rodrigo Goncalves Pagnano,
Andre luis Lugnani de Andrade,
and Tulio Pereira Cardoso

6.1 Introduction improvement in human skills to perform physical

and sports activities as well as daily tasks [4, 5].
Biological growth and development guide our Adulthood and old age play a distinct part of
lifetime  via dynamic process of changes in the our biological development, as they prsent the
human body, clearly manisfeted by the musculo- final phases of biological maturity. However, the
skeletal system development. Despite being exact period that involves early and late adulthood
extremely powerful during childhood and adoles- and also old age has been changing over decades
cence, this biological process is continuous and as life expectancy has increased. Nowadays, it is
follows a hierarchical sequence of tissue maturity, accepted that early adulthood starts in the 20s,
natural weakness and deterioration, and death while the apex of human maturity arrives around
[1–3]. Musculoskeletal and neurological systems 30s, when late adulthood starts, ending around
have their process of maturity starting with the 50s, reinforcing the premisse that human biologi-
fine motor development, which is followed by cal development is a dynamic process. At this
stage, huge biomechanical changes will occur in
the human body because a natural biological dete-
S. R. Piedade (*) · M. M. Inada · G. M. Laurito rioration takes place slowly  and progressively
R. G. Pagnano · A. l. L. de Andrade
during the following years of our lifetime [6, 7].
Department of Orthopedics and Traumatology, State
University of Campinas—UNICAMP, Exercise and Regarding the life-­span, Fig. 6.1 shows the bone
Sports Medicine, Campinas, SP, Brazil mass density according to age and gender.
e-mail: [email protected]; In the past, it was believed that most of the bio-
[email protected]
logical growth and development occurred during
D. Navarro e Paiva infancy and adolescence, and, consequently, sports
Department of Radiology, State University of
practice was not a common activity in adulthood
Campinas—UNICAMP, Exercise and Sports
Medicine, Campinas, SP, Brazil and old age. Sun et al. [8] published a systematic
literature revision of 53 papers since 2000, search-
G. P. Fraga
State University of Campinas—UNICAMP, ing the involvement of adults over 60 years old in
Campinas, SP, Brazil physical activities. They found a great variation
T. P. Cardoso related to sex, different age groups, and regularity
Pontifícia Universidade Católica—PUC, of practising exercises and concluded that further
Soracaba, SP, Brazil studies are necessary to validate any conclusion.

© ISAKOS 2019 59
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_6
60 S. R. Piedade et al.

Fig. 6.1  Bone mass growth peak decline

density growth, peak,
gradual loss pronounced

bone mass density

and loss during male and
female life-span
men

women

10 20 30 40 50 60 70 80
lifespan (years)

Considering that life expectancy has lar physical activity could impact on the
increased every decade, people should be aware of prevention, onset, and control of the main chronic
that. Ageing is defined as a time-dependent func- diseases of ageing which are directly related to the
tional decline of the human body, where the elder- high mortality rate worldwide [17].
ly’s capacity to remain independent is reduced and This chapter aims to discuss the effects of
fall risks are higher; therefore, staying inactive aging, physical performance, sarcopenia, senes-
could be risky for the elderly population as it cence of the metabolic axis, and related clinical
increases neuromuscular impairment [9, 10]. conditions such as osteoporosis and osteoarthritis
The quality of life is directly related to  how as well as the importance of sports practice and
prepared we are to live longer because a price regular physical activity in adults and elderly pop-
should be paid for it. Nevertheless, the speed of ulation. Moreover, the chapter will discuss the
this process could vary from person to person, best strategy to design a customized plan for
according to their genetics, nutrition, social sports practice and/or physical activity according
behavior (sedentarism, smoking, alcohol), and to the individual needs of this age group.
comorbidities such as hypertension, diabetes, car-
diopathy, as well as psychological impairment,
reflecting on the person’s behavior [11, 12]. It is 6.2 Ageing, Physical
well-known that sedentarism could impact peo- Performance,
ple’s lives negatively, and changing human behav- and Sarcopenia
ior remains a huge challenge for the government,
medical institutions, and physicians [13]. The increasing worldwide aging has stimulated
Moreover, osteoporosis, overweight, and obesity the need to understand aging consequences, and
is an epidemic behavior worldwide. The literature how to manage the modifiable factors to promote
has emphasized that sports practice presents one quality of life, and consequently minimizing the
of the key healthy behaviors to improve human impact of chronic diseases. Among the modifi-
health and quality of life [14, 15]. able factors, physical activity and sports practice
Fighting against these health problems and are well-recognized as a powerful modifier on
human health behavior, it has been emphasized aging effects [18, 19].
that sports practice and regular physical activities Ageing is a biological process that impacts
critically contribute to human health, especially in different aspects of physical performance such as
adult life and old age [16]. Physical activity could power, strength, and endurance [20, 21]. After
be defined as any voluntary movement that causes 50s, the ability to perform daily tasks progres-
energy expenditure, while exercising comprises sively weakens, falls happen due to muscle
of planning, regularity, load, speed, and intensity, imbalance with all its negative impacts such as
aiming for the improvement of fitness and physi- fractures, and restriction mobility occurs more
cal capacity. Moreover, sports practice and regu- frequent [22].
6  Physical Activity at Adulthood and Old Age 61

The progressive loss of the maximum capacity 6.4 The Senescence

of an individual’s strength is clinically observed of the Metabolic Axis
after 50s, being more pronounced at 60s. The last and Sarcopenia
factor, involving the senescence of muscle cells,
is muscle endurance, defined as “failure of mus- A remarkable decline of the anabolic hormone
cles to maintain a required or determined force, production is expected in advanced ages and a
characterizing the inability to withstand exertion stressed fall of total testosterone level, particu-
before muscle fatigue [23, 24]”. larly their metabolic active portion (free portion),
in elderly  men [33, 34]. Although this mecha-
nism has not been fully understood, it seems to
6.3 The Pathophysiology have a cross-reaction with exercise practice and
of Sarcopenia the level of  this hormone, as observed by its
increased response to sports and physical activ-
Sarcopenia is defined as a progressive and global ity, suggesting that the sarcopenia cycle, activity,
loss of skeletal muscle mass that involves endo- and muscle function loss can be directly related
crine, metabolic and nutritional factors, and cyto- to sports and physical activity practice.
logical aspects of the senescence of muscle cells. The decline of the hypothalamic-pituitary-­
In the endocrinological viewpoint, the progres- gonadal axis as well as insulin-like growth factor
sive reduction of the secretion and sensitivity to 1 (IGF-1), both linked to loss of muscle mass in
anabolic hormones (growth hormone, testoster- elderly, is more pronounced in women, given its
one, and insulin-like growth factor) affects the relevance to an anabolic hormone in this group
maintenance of muscle mass. Due to a lower deg- [35–37]. Moreover, the skeletal muscle shows an
radation of proinflammatory cytokines (particu- increase of insulin resistance and a closer rela-
larly, interleukin 6), the catabolic action enhances, tionship to the loss of muscle function and devel-
consequently increasing muscle loss [25–27]. opment of diabetes type II, especially among
Imbalance progressively grows owing to people with sarcopenic obesity [38]. It results in
lower muscle function and decrease of the ana- muscle contraction and increased glucose uptake
bolic hormone production. Besides that, a into the muscle cell, a process that involves ade-
remarkable progressive loss of the absorption nosine 5′-monophosphate-activated protein
capacity and protein synthesis in muscle cells kinase (AMPK), and also relates to increased
occurs in the elderly [22]. The protein metabo- insulin secretion, activation of adipose metabo-
lism falls because of the low response to hyper- lism, cholesterol, and triglycerides [39].
aminoacidemia, causing an enhancement of Although multiple attempts at supplementa-
adipose deposition, and, consequently, a lower tion of these hormones to treat sarcopenia were
muscle mass per body mass takes place. This pro- tested, the isolated approach did not have a satis-
cess potentializes the deleterious effects of obe- factory response [40], possibly due to other
sity in the population named “sarcopenic obesity mechanisms involved in the perpetuation of the
[28, 29].” sarcopenic cycle.
in the 60s, lower muscle stimulation as well
as direct denervation cause a progressive loss of
motor neurons in the spinal cord, loss of periph- 6.5  he Relationship Between
T
eral neurons, and degeneration of the neuromus- Diabetes Type II, Aging,
cular units, and consequently, sarcopenia takes and Physical Activity
place at the cellular level [30]. Some studies have
shown up to 25% of motor functioning unit loss Metabolic changes take place in the aging pro-
in senility that is a useful marker in the differen- cess, where the loss of muscle function and neu-
tiation between other causes of muscle function roendocrine system regulate the predisposition to
loss [31, 32]. develop diabetes type II.  Nevertheless, physical
62 S. R. Piedade et al.

activity and sports practice are an important and In athletes, osteopenia and osteoporosis could
modifiable factor in this cascade of events, as it be caused by higher intensity and volume of
potentializes muscle mass gain and generates training, nutrition, psychological disorders
direct and indirect valuable effects on the neuro- (stress), and chronological age [49]. Besides
endocrine axis [18]. that, sex (women), age, familial history (genet-
Randomized studies have found that physical ics), the bone (small bones), and ethnic features
activity and weight loss correlate with diet, (white, oriental descendants) have implications
reducing glucose intolerance progression to dia- for osteoporosis onset. Also, it is essential to
betes by up to 58%, and reinforce the benefits of evoke that hyperparathyroidism, diabetes, sed-
physical activity on controlling patients’ glyce- entarism, and even metastasis (bone or others)
mia and decreasing cardiovascular risk and mor- could be present as co-existing causes in adult-
tality rate in general. Therefore, there is a formal hood and old age. Therefore, regarding all of
recommendation for sports and physical exercise these aspects, the sports physician should care-
practice [41, 42]. fully investigate and rule out other causes of
A Korean study [43] has demonstrated a clear osteopenia and osteoporosis when dealing with
connection between diabetes and sarcopenia, reduced BMD.
with a threefold risk of developing this condition The diagnosis is based on clinical history, lab-
in this group of patients. This correlation makes oratory exams, and BMD quantification through
us think about how much physical activity can dual-energy X-ray absorptiometry (DXA), com-
impact on the treatment of these patients. Also, it paring the obtained values to the normal range
can be a double benefit when a physical activity for each age and gender. Osteoporosis is con-
causes muscle mass improvement and glycemic firmed when the levels are below 2.5 SD (T-score
control, with a possible feedback mechanism of −2.5), while osteopenia is between −1 and
between these two factors with cumulative −2.5 SD [50].
benefits. Risk factors that involve osteoporosis are
didactically classified as non-modifiable and
modifiable [51]. Sex, age, family history, bone
6.6 Osteopenia size, and ethnicity are non-modifiable factors
and Osteoporosis because they comprise  of biological conditions
inherent to each of them. Women are more
Bones are living tissues that have the ability to affected because they are submitted to the effects
adapt to biomechanical stress and to remodel. of menopause and have lighter and thinner bones
The bone mass density (BMD) increases until compared to men.
20s and 30s, stabilizes during maturity, and Although not all older adults present the clini-
becomes negative after 40s, presenting 1% of cal picture of osteoporosis, longevity implies a
BMD loss each year (primary osteoporosis). more significant risk. It is estimated that 15% of
Osteopenia is defined as a decrease of BMD that women aged 50  years have osteoporosis while
precedes osteoporosis, a systematic and meta- 50% at 80  years of age. Some studies have
bolic disease which causes bone weakness and a reported the genetic potential for osteoporosis-­
higher risk of fracture because of BMD decrease specific genes [52]. Individuals with white and
and deterioration of bone tissue microarchitec- eastern ethnicity are more likely to develop
ture [44, 45]. Due to its clinical and biological osteoporosis and twice to have fractures when
behavior, it is manifested insidiously and silently. compared to African descendants.
A bone fracture occurs when there is 30–40% of Certain diseases such as hyperthyroidism,
BMD loss, especially on the trabecular bone, and hyperparathyroidism, diabetes, and other chronic
the vertebrae, distal third of the radius, humerus, diseases, ingestion of some medications such as
proximal femur, and metatarsal bones are com- anticonvulsants, aluminum-based antacids, and
monly affected [46–48]. others may affect bone metabolism. Bone metab-
6  Physical Activity at Adulthood and Old Age 63

olism monitoring is done by measuring hormone in combination with exercises, can help increase
levels of estrogens (women) and testosterone or at least prevent the decline of bone mass with
(men), as they play an important role in guiding aging, especially in postmenopausal women [54,
drug prescription. 57, 58].
Therefore, the treatment approach of osteopo-
rosis includes a proper diet, adding supplements
(calcium, sodium, vitamin D, estrogens, alendro- 6.7 Osteoarthritis
nate, risedronate, and other drugs), reducing
ingestion of alcohol and coffee, and smoking, Physical exercises can have antagonistic facets as
and agents such as anabolics and parathyroid hor- they may contribute to the development of osteo-
mones. Even though, new drugs have been intro- arthritis as well as they may act as adjuvants in
duced on the market, sports activity remains as the treatment and prevention of osteoarthritis.
one of the most important modifiable factors in Whereas physical activity causes joint overload,
osteopenia and clinical osteoporosis onset. excessive immobility also impairs joint function-
Physical exercises promote an essential mechani- ing, contributing to weakness, muscle retraction,
cal stimulus to bone formation due to muscle joint stiffness, loss of bone mass, and consequent
actions and weight-bearing [53, 54]. early joint “wear and tear”. Thus, all these have
Although new drugs have been developed for to be taken into consideration when trying to
the treatment of osteoporosis, the importance of reach an appropriate balance of joint functioning.
regular physical activity and sports practice in It reinforces that the best exercise program should
controlling BMD loss in old age is well-known. be customized, and, therefore, it should take into
In this context, high-impact exercises like jump- account the athlete’s age, his prior level of sports
ing, aerobics, and running, as well as low- practice (if sedentary or not), and mainly his
impact workouts  such as walking, and physical status [59–61].
weightlifting training, resistance load training There is a considerable gap between medical
and repeated exercises, such as plyometrics recommendations on the benefits of regular phys-
training (rapid and muscle blast exercises in ical exercise and how people are involved in per-
eccentric and concentric contraction sequences), forming exercises in their daily practice. Different
and weight lifting, showed positive effects on causes could be responsible for that, such as lack
bones of all ages [55]. of time, motivation, difficulty in moving, and
The efficacy of moderate to vigorous physical resources to perform exercises in health clubs
activities in maintaining bone health has been and centers of sports practice. Moreover, there
demonstrated [56, 57]. Exercises such as walking seems to be a lack of information on the benefits
are part of the initial approach as it helps to of sports or regular physical exercises in improv-
restore body balance, reducing the risk of falls in ing the symptoms of osteoarthritis and quality of
sedentary and old age population. Cycling, yoga, life [62].
and swimming comprise of activities commonly Although joints can tolerate prolonged and
prescribed to older adults to improve their physi- even strenuous exercise without causing injury or
cal fitness condition. They are considered low symptomatology, a biological threshold exists
impact activity and, like walking, have low osteo- and should be respected. When it is overtaken, an
genic potential. On the other hand, weightlifting imbalance between injury and cartilage repair
training and aerobic training are high impact and regeneration occurs, and joint degeneration
exercises that contribute to the prevention of takes place. In some work and sports activities,
senile bone loss as it increases hip and spine joints are submitted to important and constant
BMD. Specific training programs and multicom- overload that can cause injury, and high-yielding
ponent strength training, aerobic, high-impact athletes are more likely to develop early joint
and/or weight-bearing exercises, as well as degeneration as they are commonly exposed to
whole-body vibration (IVC), exercises alone or this condition.
64 S. R. Piedade et al.

The body’s physical performance could be Osteoarthritis can affect shoulders, elbows,
expanded and improved by guided training; hands, hips, knees, ankles, feet, and cervical
moreover, physical exercises and sports practice spine causing pain, weakness, joint stiffness, and
play an essential role in muscle balance, improv- functional limitation for daily activities. The ben-
ing joint functioning and the nutrition of articular efits of exercise in the clinical improvement of
cartilage. As for the elderly, physical activity is patients with hip and knee osteoarthritis are well
recommended for patients with rheumatic dis- established in the literature as well as improve-
eases like spondyloarthritis, rheumatoid arthritis, ment of pain relief and joint mobility [7–9].
and hip and knee arthritis. The EULAR— However, the effects of exercises on the treatment
European League Against Rheumatism—orga- of osteoarthritis of shoulders, elbows, hands,
nized in 2018, developed a physical activity ankles, feet, and cervical spine need further stud-
recommendation applicable for inflammatory ies [65, 66].
and degenerative arthritis patients. It suggests Among the exercise modalities for the treat-
that physical activity is beneficial for people suf- ment of hip and knee osteoarthritis, there are
fering from spondyloarthritis, rheumatoid arthri- reports of aquatic exercises, stretching and mus-
tis, and hip and knee arthritis [60]. cular training, walking, isometric exercises, and
Physical exercises have been used both in the isotonic and isokinetic exercises, with benefits in
treatment and in the prevention of osteoarthritis improving clinical symptoms and joint function
since they lead to an improvement in pain, joint [64, 67, 68]. Hanada et  al. 2018 [69] reported
function, and quality of life [59, 60]. In Denmark, functional improvement in patients who under-
after 3  years of initiation of the neuromuscular went quadriceps muscle strengthening exercises
exercise program supervised by physiotherapists while maintaining the tibia in the internal rota-
for the prevention and treatment of osteoarthritis, tion when compared to groups of patients main-
patients showed an  improvement in symptoms taining neutral rotation of the tibia in patients
and joint function, with less  need of  analgesic with medial knee arthrosis. However, c onserva-
and less  abscence from work, improvinge life- tive treatment for lumbar osteoarthritis is incon-
style, general health, and reduced health costs. sistent. Most studies show improvement of
Rehabilitation with physiotherapy for analgesia, chronic low back pain with exercise therapy and
and later for joint mobility, strength and proprio- improvement in cases of lumbar osteoarthritis
ception. Physical exercises, and reduction of [70].
mechanical overload on the affected joint can The lack of randomized studies, range of vari-
provide an improvement in pain and maintenance eties in the types of physical exercise modalities,
of joint function, reflecting positively on  the associated comorbidities, unicompartmental or
patients’ quality of life [59]. polyarticular joint degeneration, and no unifor-
Exercise prescription should be individual- mity of study methodology makes it difficult to
ized, based on the patient’s clinical and cardio- have a consensus on the type, intensity, duration,
vascular conditions, pain intensity, and joint and modality of exercises to osteoarthritis treat-
impairment (limitation) phases, according to the ment [63–67]. Therefore, the exercise prescrip-
degree of joint wear, physical capacity, biological tion should be individualized, based on
threshold, and individual physical tolerance, ori- individuals’ clinical and cardiovascular
ented by physiotherapists and physical educators. ­conditions, intensity of pain, and joint impair-
Regarding exercise intensity, more studies are ment (limitation) according to the stage of joint
needed to determine the minimum intensity to degeneration. In addition to the physical capacity,
obtain a clinical improvement as well as to assess individual’s physical tolerance should be consid-
the level of tolerance of patients for high-­intensity ered by physiotherapists and physical educators
exercises [63, 64]. [62, 68].
6  Physical Activity at Adulthood and Old Age 65

6.8  hysical Activity and Sports

P tise regular physical activity for a long time, to
Practice start with exercises targeting balance and coordi-
nation, like yoga, tai chi, and light dancing. Two
There is no doubt that physical activity is very types of physical activity should be done every
important to maintain healthy body and mind week: aerobic and strength exercises. It is also
shape (Mens sana in corpore sano), and it is criti- important to improve flexibility.
cal in preventing diseases, keeping independence Sports practice and regular physical activity
and quality of life in adulthood and definetely in are well-known as a key healthy behavior that
old age. Over the years, life-span has become lon- could impact on the prevention and onset of main
ger, changing people’s behavior and increasing chronic diseases of aging which are directly
the number of adults and older adults that are related to high mortality rate worldwide. In the
starting or even maintaining regular sports activ- musculoskeletal system, it improves muscle and
ity. Physical activity could be defined as any vol- bone mass, minimizing the risk of falls and also
untary movement that causes energy expenditure, controlling weight gain. Besides that, it has a
while exercising and sports practice comprise positive effect on depression and dementia as it
planning, regularity, load, speed, and intensity, may improve sleep and control anxiety [77, 78].
aiming the improvement of fitness and physical As a rule, 1 minute of vigorous activity provides
capacity. Physical activities done in later life can the same health benefits as 2 minutes of moderate
bring health benefits reducing disabilities and activity. Therefore, performing 75 minutes of
increasing years of independent life, presenting vigorous activity can give similar health benefits
one of the most promising non-pharmacological, to 150 minutes of moderate activity.
noninvasive, and cost-effective methods of health Sedentary behavior is considered an indepen-
promotion, and even a modest increase in physi- dent risk factor for ill health, no matter how much
cal activity can have a significant impact on health exercise you do. It is recommended to break long
and quality of life. Older populations adopting periods of sitting with light activities such as lit-
physical activities will diminish the  health and tle shopping, cooking, or light housework. Peak
social care burden due to healthy aging [71–73]. muscle mass is reached in the third decade of life,
A Chinese prospective cohort study published with a progressive decline in muscle power, start-
in 2011 found that for every 15  min of daily ing in the fifth decade of life, but becoming more
physical activity, up to 100 min per day decreases prominent in the sixth decade.
4% of any mortality cause [74]. von Berens et al. Ageing is directly linked to progressive loss of
[75] observed community-dwelling older adults, muscle mass and muscle strength, which is called
71–86 years old, with minor mobility limitations, sarcopenia.The literature has pointed out that
reporting the negative health effects of sedentary after 50s, the human body will present a muscle
lifestyle and how to begin to change it. Although, mass reduction of 40–50%, presenting a deficit in
the patients’ main objective was to lose weight, muscle control, worsening musculoskeletal bal-
while the authors’ aim was to prevent sarcope- ance [18, 21, 24].
nia, and a combination of regular exercise with Moreover, ageing could be associated with
nutritional support proved to be effective in con- loss of quality of life due to different factors, and
trolling loss of muscle mass and strength. not only by musculoskeletal imbalance. The
The British NHS Guidelines for older adults ­process of ageing has a clsoe link to chronic dis-
aged 65 and over consider different age ranges, eases responsible for great morbidity and increase
fitness condition, and health state to determine in health costs, such as osteoporosis , type II dia-
the recommended physical activity (duration, betes mellitus, coronary disease, primary hyper-
intensity, modality) [76]. It is advisable for peo- tension, osteoarthritis, and obesity [18, 42, 43,
ple who have a sedentary lifestyle or do not prac- 46, 47].
66 S. R. Piedade et al.

Fig. 6.2  Physical activity: vigorous aerobic activity of a 45-year-old runner and moderate activity of a 72-year-old man
walking

In this context, sports practice and regular jumping, such as dancing; heavy gardening, such
physical activities improve muscle and bone as digging or shoveling; and exercises that use
mass, minimizing the risk of falls and also con- your body weight for resistance, such as push-­
trolling weight gain. As general recommenda- ups or sit-ups, yoga, and, of course, lifting
tions for prescribing physical activity for adults weights. Remember that muscle-strengthening
and the elderly  population, the sports physician exercises are not an aerobic activity; therefore,
as well the physical educator should focus on the they should be added to the exercise program.
individual’s cardiorespiratory fitness, muscle Some vigorous activities like circuit training,
strength, flexibility, neuromotor performance, running, football, basketball, rugby, hockey, net-
comorbidities, individual’s reported preferences ball, and aerobics count as both an aerobic activ-
of sports, and physical activity to define a cus- ity and a muscle-strengthening activity.
tomized approach. Physical activity can be clas-
sified as moderate aerobic activity: walking, Take-Home Messages
water aerobics, dancing, riding a bike on level • Ageing involves a series of metabolic, endo-
ground, double tennis, pushing a lawn mower, crine and muscular system dysfunctions that
canoeing, and volleyball. Vigorous aerobic activ- impacts negatively on one’s quality of life,
ity includes jogging or running, gym aerobics, and is also related to chronic diseases.
fast swimming, fast biking or on hills, single ten- • Regular physical activity contributes in reduc-
nis, football, martial arts, hiking uphill, and ener- ing the overall risk of mortality and morbidity,
getic dancing. Figure 6.2 presents two examples and also acting in the treatment of many
of different levels of physical activity. chronic diseases in adulthood and the elderly;
Activities to strengthen muscles are necessary • Customized physical activity is the safer strat-
for all daily movement, building and maintaining egy in adulthood and the elderly population,
strong bones, regulating blood sugar and blood because its focus is on the patient's profile of
pressure, and maintaining a healthy weight. cardiorespiratory fitness, muscle strength,
Examples of muscle-strengthening activities flexibility, neuromotor performance, co-mor-
include carrying or moving heavy loads, such as bidities, and preferences of sports and physi-
groceries; activities that involve stepping and cal activity.
6  Physical Activity at Adulthood and Old Age 67

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 Oriented Warm-Up
7
Karina Mayumi Hatano

7.1 Introduction professional athletes, as observed in such high-­

speed contact sports as football [5]. It is impres-
Participation in sports has experienced huge sive that noncontact sports also have a high
growth in the last decade. People are practicing prevalence of this type of injury, as muscle inju-
sports for different reasons, such as promoting ries were the most prevalent type to be sustained
health or improving performance, and the among both male and female tennis players dur-
American College of Sports Medicine (ACSM) ing the Australian Open Grand Slam event [6].
has recommended regular moderate and intensive As a result of muscle concern injuries, it is
exercises for optimal health [1]. However, for any imperative to utilize the most effective means to
physically active individual, there is the possibil- aid in deterring these injuries [2]. By following a
ity of sustaining an injury. While some injuries few simple guidelines, injuries including muscle
are difficult to prevent, such as an ankle sprain or strains, tendonitis, and overuse injuries can be
fracture, many other injuries are indeed prevent- reduced. Warm-up prior to the start of physical
able. In this article, I will discuss techniques that activities is one of the most common methods
can be used by anyone to minimize common pre- recommended by health professionals, coaches,
ventable sports-related injuries. and athletes [7]. The beneficial effects of warm-
One of the major concerns facing today’s ath- ­up are seen in the overall improvement in sports
letes, both recreational and professional, is skel- performance and reduction in sports injuries due
etal muscle injury. Indeed, damage to skeletal to physiological factors [8]. However, there are
muscle is estimated to comprise over 30% of the conflicting opinions regarding different methods
injuries seen in sports medicine clinics [2]. It has of reducing muscular injury through warm-up
been shown that mechanical joint loading during and stretching techniques [2].
various sports has the potential to exceed the ten-
sile capacities of connecting tissue surrounding
• Thirty percent of the injuries seen in
musculature [3]. Even recreational activities such
sports medicine are skeletal muscle
as stand-up paddle boarding can lead to injury,
injury.
most commonly to muscles/tendons (50.4%) and
• Warm-up may prevent muscle/tendon
to joints/ligaments (22.6%) [4]. The risk of mus-
and joint/ligament injuries.
culoskeletal injury increases dramatically for

K. M. Hatano (*)
Instituto Cohen Ortop, Sao Paulo, Brazil

© ISAKOS 2019 71
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_7
72 K. M. Hatano

7.2 Definition 7.4 Physiological Effects

of Warm-Up
Warm-up can be defined in different ways:
The human body can adjust to almost anything.
• Any activity that increases the body tempera- But one thing it cannot do is adjust immediately
ture by a few degrees Celsius [9] from rest to exercise. Instead, we need to gradu-
• A protocol or session specifically undertaken ally shift from rest to almost any level of physi-
prior to and in preparation for the onset of sub- cal work. Going from rest to very hard work
sequent physical activity [7] without a warm-up is hard on the heart and skel-
• Simply as an activity that “prepares the body etal muscle system. When a proper warm-up is
for exercise” [10] applied, the subsequent exercise is more com-
fortable, and the risk of injury is reduced [14].
Warm-up is intended to perform the following
7.3 Types of Warm-Up two major functions: improve a muscle’s
dynamics so that it is less inclined to injury, and
Warm-up can be either passive or active. Active prepare the athlete for the demands of exercise
warm-up can further be classified as either a gen- [15]. Thus, the purpose of warm-up is to prepare
eral warm-up or a specific warm-up [11]. A pas- the body to transition from rest to the maximally
sive warm-up is one in which muscle temperature active state of the body. The warm-up should
or core body temperature is increased by exter- produce a mild sweat without fatiguing the indi-
nal means, without depleting energy substrate vidual [2]. Both passive and active warm-ups
stores, as occurs during the physical activity can evoke temperature and metabolic, neural,
associated with active warm-up [11]. Passive and psychological effects, including increased
warm-up can include, for example, hot showers, anaerobic metabolism, elevated oxygen uptake
saunas, or heating pads. The general active kinetics, and postactivation potentiation [11].
warm-up involves some type of physical activity Active warm-up induces greater metabolic
featuring non-specific body movements such as changes, leading to increased preparedness for a
jogging, cycling, or calisthenics. In contrast, the subsequent exercise task.
specific warm-up utilizes activities and stretches Physiologically, warm-up raises body and
that are specific to the sports for which one is muscle temperature, and subsequent power
preparing [2]. output is increased by accelerating metabolic
The preferred mode is active warm-up in reactions [16]. As a result, exercise perfor-
professional athletes, but the cumulative mance is proposed to be improved via decreased
effects of passive or active warm-up on muscle muscle and joint viscous resistance, greater
performance and dynamic stability seem to be unloading of oxygen from hemoglobin and
equally effective in recreational sports players myoglobin, speeding of oxygen kinetics,
[8]. The most effective of the warm-up tech- increased anaerobic metabolism, and increased
niques appears to be the specific warm-up, nerve conduction rates [17]. Moreover, warm-
likely due to the fact that it mimics the activity up elevates muscle enzyme activity while dilat-
to be performed [2]. However, the choice of ing blood vessels that provide blood flow for
best warm-up program must consider the age, better muscle oxidation during work [18]. The
sex, physical condition, type of sport to be elevation of body temperature also augments
practiced, and level of competition [12]. the release of oxygen from hemoglobin in
A typical warm-up protocol of a physical edu- active muscles, so that the time to exhaustion
cation lesson consists of low-intensity aerobic at maximal endurance exercise is extended.
activity followed by a variety of stretching These physiological changes induced by warm-
methods [13]. up may enhance performance in not only
7  Oriented Warm-Up 73

­ aximal and supramaximal exercise but also

m 7.5  arm-Up Prevents Injuries
W
submaximal endurance exercises [16]. and Improves Performance?
Warming up gently raises the work demands
on the cardiovascular system, and at the same As discussed above, the effectiveness of warm-
time, the body is diverting blood flow away ­up in different types of sports has been demon-
from areas not directly involved in exercise strated for all ages and types of athletes. Most
(e.g., the gastrointestinal system) to areas with professional and recreational athletes perform
higher blood requirements (e.g., working mus- preconditioning warm-up exercises to prepare for
cles and skin). The extra energy expended raises a competitive task or routine exercises. The main
temperature, and warmer blood gives up oxygen objective of warming-up is to induce both tem-
to the working muscles faster than resting body perature- and non-temperature-related responses
temperature blood. Muscle is actually not as to optimize performance. These responses
dense as people think, so when body tempera- include increasing muscle temperature, initiating
ture rises, muscle becomes suppler and more metabolic and circulatory adjustments, and pre-
compliant which helps with circulation and flex- paring psychologically for the upcoming task
ibility. The added blood flow and elevated tem- [19]. Also important for sports is having an
perature also help increase the elasticity of appropriate level of range of movement and flex-
tendons and ligaments, which gives more bene- ibility at specific joints and soft tissues in order to
fits with respect to flexibility [14]. An active perform, as enhanced flexibility and musculo-
warm-up has also been proposed to impart non- skeletal compliance have been associated with
temperature-related benefits on subsequent protection from injury [3].
exercise performance, such as increased blood However, the exact mechanisms and outcomes
flow and oxygen delivery to the working mus- of various warm-up modes are still not fully clear
cles, elevation of baseline oxygen consumption, [7]. Even though warm-up is a well-accepted
and postactivation potentiation [17]. practice and considered to be essential by many
The aforementioned physiological mecha- athletes for optimum performance, there is con-
nisms facilitate greater muscle force and power flicting evidence in the scientific literature about
production which are important in team sports the effectiveness of various methods to prevent
requiring acceleration, deceleration, or change of muscle injuries and enhance performance [15].
direction [13, 18]. Combine all those mecha- Although there is no agreement on which is the
nisms together, and it should be apparent that a best heating protocol, it is accepted that the pro-
well-thought-out warm-up regimen has effects all tocol should be as sport-specific as possible [20].
over the body [14]. Consequently, acute effects of Based on players’ perceptions on injury pre-
warm-up protocols may improve change-of-­ vention, 91.5% of athletes perform stretching to
direction speed, reaction time, and movement prevent injuries, and 54% do neuromuscular
time in sport [13]. warm-up exercises. The perception of risk factors
and performed preventive strategies is inconsis-
tent with scientific evidence. Generally, current
approaches regarding injury prevention focus on
Warm-Up Physiological Effects the transfer of evidence into daily practice, but
• Elevate body and muscle temperature future transfer strategies should incorporate the
• Increase muscle oxygenation players’ beliefs and attitudes [21].
• Increase nerve conductions The research into injury prevention programs
• Elevate muscle enzyme activity has been of keen interest over the past 10–15
• Increase the elasticity of tendon and years, and a number of programs have been
ligaments shown to reduce overall injuries by approxi-
mately one-third, with much more dramatic
74 K. M. Hatano

reductions for specific injuries [14]. In particular d­istances greater than 200  m, demonstrating
for soccer, this pre-workout focuses on (a) spatial that warm-up can prevent the early onset of
orientation, anticipation, and attention, particu- fatigue. It is recommended that swimmers warm
larly while dual-tasking (to avoid unintended up for a relatively moderate distance (between
contact with other players or objects); (b) body 1000 and 1500  m) with a proper intensity (a
stability and movement coordination (more gen- brief approach to race-­pace velocity), as well as
eral than specific neuromuscular or propriocep- sufficient recovery time to prevent the early
tive training); and (c) learning appropriate fall onset of fatigue and allow restoration of energy
techniques (to minimize the consequences of reserves (8–20 min) [25].
unavoidable falls) [22]. As injuries can often lead to extended time
lost to training and competition, as well as sub-
stantial healthcare expenses, everyone involved
Warm-Up Routine should welcome injury reductions like those
• Well-accepted by athletes and coaches. highlighted above. One critical factor that is an
• 91.5% of athletes perform stretching to underlying requirement to any program’s effec-
prevent injuries. tiveness is compliance. The programs are only
• Fifty-four percent do neuromuscular effective if players perform the warm-up before
warm-up exercises. at least 75% of the training sessions. When there
is poor compliance with the programs, little dif-
ference in injury rates is reported [14].
Some protocols have been shown to be effective
in preventing injuries for soccer. Implementation of
a specific warm-up protocol improved physical 7.6 Science and Practice
performance compared with traditional warm-up
routines in youth soccer players [22]. Additionally, Warm-up strategies have continued to develop
this protocol reduced all injuries by 32%, training largely on a trial-and-error basis, utilizing coach
injuries by 32%, match injuries by 28%, severe and athlete experiences rather than scientific
injuries by 45%, and overuse injuries by 53%. evidence. However, over the past decade, new
Further evidence that generalized warm-up effec- research has emerged, providing greater insight
tively reduces injuries comes from a Canadian pro- into how and why warm-up influences subse-
gram tested on girls’ and boys’ soccer that resulted quent performance [11]. Warming up prior to
in a 38% reduction in all injuries, 43% reduction in exercise is vital for the attainment of optimum
acute injuries, 50% reduction in ankle injuries, and performance. The aim of warm-up is not over-
62% fewer knee injuries [14]. load of the musculoskeletal system but to do
Similar programs have been reported to slow movements activating all the muscles and
reduce injury in a wide variety of sports such as joints involved in the sport [11]. The most
basketball, netball, team handball, and important reason for doing a warm-up is to pre-
Australian rules football [14]. Another study vent injury during exercise, as keeping the mus-
confirmed the effectiveness of cycling warm-up cles warm will prevent acute injuries such as
as a preparatory activity for sprint bicycle exer- hamstring strains and will stave off overuse
cises [23]. Additionally, a specific warm-up pro- injuries by allowing the body to prepare steadily
gram led to a low prevalence of musculoskeletal and safely.
injuries in recreational volleyball and was posi- In more static sports, such as cricket, it is a
tively assessed by volleyball players and coaches good idea to stretch throughout the game as this
with respect to its relevancy, suitability, and activity will keep the muscles warm and allow
usability [24]. them to function effectively; substitutes should
Furthermore, warm-up has a positive effect also continue to run and stretch while they are
on swimmer’s performance, especially for waiting to join a game. This strategy is ­commonly
7  Oriented Warm-Up 75

seen in football matches where the substitutes Lastly, the use of equipment can increase
jog, jump, and stretch along the sidelines [14]. p­erformance effectiveness during warm-up.
Recent studies suggest that aerobic warm-­up and A  dynamic warm-up performed with a vest
dynamic stretching are beneficial for sprint, weighted with 2% of body mass may be the most
jump, and agility tasks. On the other hand, static effective warm-up protocol for enhancing jumping
stretching schemes with intensity at or above a performance in high school female athletes [28].
point of discomfort or used with duration not lon-
ger than 45 s are discouraged in performance set-
tings for delivering detrimental effects; in 7.7 Warm-Up Intensity
contrast, a cyclic static stretch may reduce the
debilitative effects of static stretching [18]. The warm-up effect on performance is determined
Some coaches use complex training in warm-­up by the intensity, duration, and recovery interval
sessions. Complex training involves a set of between warm-up and exercise [29]. The purpose
strength training exercise (isometric or dynamic) of warm-up is to prepare the athlete’s body for
followed by a biomechanically similar plyometric sports, without requiring great energetic demand.
exercise. This concept is based on a phenomenon The warm-up should produce a mild sweat with-
called postactivation potentiation and has presented out fatiguing the individual [2]. The warm-up
positive results for muscle performance, especially should be structured in such a way that the indi-
in terms of twitch contractions, rate of force devel- vidual experiences an increase in muscle tempera-
opment, and explosive movements [26]. ture but does not experience a significant decrease
For some sports, studies have suggested the in high-energy phosphate availability. The inten-
use of maximum or near-maximum loaded iso- sity of the warm-up should be tailored to meet the
metric warm-up schemes. Using a protocol based needs and abilities of each individual. For exam-
on prolonged intermittent low-intensity isometric ple, a poorly conditioned athlete will not require
exercises in warm-up settings in soccer players, a the same intensity or duration of warm-up as the
low-intensity intermittent isometric exercise as a well-conditioned athlete to achieve the same ele-
preconditioning stimulus in warm-up would pos- vation in muscle temperature [15].
itively influence the jump, sprint, and agility per- Many studies have used percent maximal
formance [18]. oxygen uptake (VO2 max) as a guide for warm-
Sprint performance may show greatest up intensity [17]. Maximal oxygen consumption
improvement without stretching and through the (VO2), is defined by the Fick equation VO2 = CO
use of a walking generalized warm-up on a tread- * a-VO2diff, where a-VO2 difference is the arte-
mill. According to Wallmann et al., these findings riovenous oxygen difference [30]. Usually, it is
have clinically meaningful implications for rec- suggested that moderate volume and that an
reational and competitive runners who include intensity of 40–60% of a person’s VO2 max
iliopsoas muscle stretching as a component of the should be utilized to increase muscle tempera-
warm-up [27]. ture while also limiting high-energy phosphate
depletion [15].
The heart rate and lactate concentrations could
Sports Aspects That May Be Improved by be used to control the intensity of warm-up.
Warm-Up However, it must be considered that it has previ-
• Endurance ously been shown that heart rate and blood ­lactate
• Strength concentrations differed between participants of
• Flexibility varying fitness levels when exercise was performed
• Agility at a percent of VO2 max but were similar during
• Motor control exercise performed at a percentage of the anaerobic
• Balance threshold depicted as a rapid rise in blood lactate
concentrations during incremental tests [17].
76 K. M. Hatano

There are many sports medicine tools to esti- muscular power, essentially when the anaerobic
mate the intensity of warm-up exercises: field exercise performance is applied immediately
tests (e.g., Cooper test) and ergospirometry [31]. after the warm-up. However, the 15-min warm-
The Borg scale is a classic and easy tool to orien- ­up duration is better when followed by a 5-min
tate the recreational and competitive athlete to rest interval. This recovery interval did not cause
achieve the proposed protocol [32]. However, in a drop in core temperature or in anaerobic perfor-
the absence of appropriate measurement instru- mance [29].
ments, it appears to be the general consensus that
under normal conditions, light to mild sweating,
without fatigue, is a reliable indicator of an ade- Duration and Intensity
quate increase in muscle temperature [15]. • Intensity and duration should be enough
to activate the body muscles, without
causing exhaustion.
7.8 Warm-Up Duration • Generally the intensity of exercises is
40–60% VO2 max or light to moderate
There are more aspects to consider besides the level.
intensity of the warm-up program. Physically • Generally duration is about 20–30 min.
active people, competitive athletes, and coaches • Recovery interval should be considered
must take into account the duration of warm-up between the exercises.
and the subsequent recovery interval when prac-
ticing or assessing activities requiring powerful
lower limb muscle contractions [29].
Warm-up enhances anaerobic performance 7.9 Types of Warm-Up Programs
through increasing muscle temperature and con-
comitantly enhancing muscular power [29]. An effective warm-up protocol provides the ath-
There is no consensus on the effects of short (spe- lete increased flexibility, balance, agility, motor
cific) or long (general+ specific) warm-up, and it control, endurance, strength, and power output
must be specifically tailored for the athlete and specific for the sport played. A smooth transition
sport to optimize its benefits [33]. Most warm-up from the warm-up to a specific activity is an opti-
sessions last between 20  min and half an hour; mal way to prevent injuries. For example, a soc-
this gives the body plenty of time to gradually get cer player could pass, dribble, and shoot a ball; a
ready for physical activity and gives the player weightlifter could lift light weights before mov-
time to prepare themselves mentally [14]. ing onto greater resistance [34]. Sprint drills or
A short warm-up is as effective as a long jumps gently increase the level of intensity and
warm-up for intermediate performance. prepare the body for sudden movements in the
Therefore, athletes can choose for themselves if game [14].
they want to include a general part in their warm-
­up routines, even though it would not enhance
their performance more compared with only 7.9.1 Passive Heat and Cooling
using a short, specific warm-up. However, to
increase efficiency of time for training or compe- Passive warm-up includes heating and/or cooling
tition, these short, specific warm-ups should be strategies. This method has limited use as a
performed instead of long warm-ups [33]. warm-up mode and is indicated more for light to
Another important aspect is the recovery moderate physically active people. Passive heat-
interval between the warm-up activities. ing or cooling warm-ups do not affect endurance
According to Frikha et al., a 5-min aerobic warm- outcomes but might benefit strength training for
­up is a sufficient duration for the improvement of improving muscle mass [35] and positively affect
7  Oriented Warm-Up 77

flexibility [7]. This type of pre-workout warm-up contrast, dynamic stretching consists of con-
that passively heats muscles before a fatiguing trolled movement (arm or leg swings) through
eccentric exercise is likely to significantly mini- the active range of motion for a joint [13].
mize losses in flexibility for up to 8 days follow- Proprioceptive neuromuscular facilitation is a
ing the fatiguing exercise [7]. different type of stretching. The PNF protocol
Historically, heat has been used in various used a “contract-relax-agonist-contraction”
clinical and sports rehabilitation settings to treat method (contract-release-contract) to minimize
soft tissue injuries. More recently, interest has the intrusion of autogenic inhibition, myostatic
emerged in using heat to precondition muscle reflexes, and neural activity in the involved mus-
against injury. Heating muscle may also enhance culature [3]. That PNF was also equally effective
the benefits of strength training for improving in flexibility conditioning would suggest that this
muscle mass in humans. Further research is mode of flexibility training should be used over
needed to identify the most effective forms of passive to help preserve dynamic joint stability
heat therapy and to investigate the benefits of capabilities at this extended and vulnerable joint
heat therapy for restricting muscle wasting in the position [3]. Also, PNF stretching causes signifi-
elderly and those individuals recovering from cant decrements in the bilateral and unilateral
serious injury or illness [35]. flexibility limitations on the body [38].
In moderately active individuals, short dura-
tions of stretching seem to temporarily improve
7.9.2 Stretching flexibility without the detrimental strength losses
[39]. Lobel et  al. demonstrated that static,
The warm-up should gently prepare the body for dynamic, and PNF stretching increases flexibility
exercises by gradually increasing the heart rate in dancers [40]. Some authors and athletes agree
and circulation; this will loosen the joints and that if stretching is to be performed as part of a
increase blood flow to the muscles. Stretching warm-up, dynamic stretching should be favored
helps prepare your body for your workout and aids over static stretching [41], especially for upper
in your body’s recovery process after your work- extremity sports [42]. Flexibility programs
out preventing injuries [36]. ACSM recommends (including static, dynamic, and PNF methods)
that flexibility exercises should be a part of an should be designed specifically to meet the needs
overall fitness program, sufficient to develop and and demands of the individual’s lifestyle. For
maintain range of motion. These exercises should most adults, flexibility training will help to
stretch the major muscle groups and be performed improve balance and postural stability. Figure 7.1
a minimum of 2 to 3 days a week [9, 34, 37]. shows examples of static stretching, while
Flexibility is an important part of physical fit- Figs.  7.2, 7.3, and 7.4 present examples of
ness and thereby can allow people to more easily dynamic stretching.
do activities that require greater range of motion.
Although flexibility may not impact health indi-
cators as shown with aerobic or muscular fitness, 7.9.3 Foam Rolling
stretching exercises should be considered as a
valuable component of a complete exercise pro- Foam rolling has been proposed to improve muscle
gram [9, 34, 37]. function, performance, and joint range of motion in
There are several distinct types of stretches. order to improve flexibility and muscle strength.
Static stretching involves slowly moving a mus- According to Su et al., comparing the acute effects
cle to the end of its range of motion and then of foam rolling with static stretching and dynamic
holding the position for a period of time. Some stretching, foam rolling is more effective in acutely
examples of static stretching include calf stretch, increasing flexibility and may be recommended as
sitting hamstring stretch, and shoulder stretch. In part of a warm-up program [43].
78 K. M. Hatano

Fig. 7.1  Static stretching of upper body

Fig. 7.2  Dynamic stretching, balance, and body control

7  Oriented Warm-Up 79

Fig. 7.3  Dynamic stretching using the whole body

Fig. 7.4  Dynamic stretching using hip and leg accessories

7.9.4 Isometric Exercises enhanced as a result of prior contractile activity

[44]. PAP is defined as the acute enhancement
A low-intensity intermittent isometric exercise of muscular power output produced by perform-
with maximum or near-maximum isometric load, ing a preload stimulus before an actual activity.
as a preconditioning stimulus in warm-up, would It is known that any previous muscle activity
positively influence the jump, sprint, and agility can trigger both PAP and fatigue mechanisms.
performance [18]. Contractile history of a muscle is said to have a
positive effect on muscle performance, espe-
cially in terms of twitch contractions, the rate of
7.9.5 Postactivation Potentiation force development, and explosive movements.
Theory (PAP) This improved muscular performance can be
attributed to increased phosphorylation of myo-
Postactivation potentiation theory is a phenom- sin light chains and increased motor neuron
enon in which muscular force is acutely excitability [26].
80 K. M. Hatano

After maximal muscular contraction, the sprints [51]. Plyometric training on young soc-
muscles are in both a potentiated and fatigued cer players revealed significant increases in per-
state. However, fatigue dissipates faster than formance when compared with regular soccer
potentiation, creating a window of opportunity training [52].
for possible performance enhancement [45].
PAP was shown to enhance vertical and hori-
zontal jump performance, shot put performance, 7.9.7 Vibration
and sprint performance among collegiate male
and female athletes [45], and PAP may improve Vibration exercise is a safe modality with the
sprint performance [46], suggesting that strength capability to be included or used as a stand-alone
and conditioning practitioners should poten- warm-up modality to increase the intramuscular
tially alter their warm-up programs to include temperature at a faster rate with low metabolic
PAP protocols to enhance performance of power cost compared to other conventional warm-up
athletes [45]. modalities [53]. However, vibration exercise
Moreover, PAP substantially enhances 100 m does not provide any additional neurogenic ben-
freestyle performance in collegiate swimmers efits compared to conventional dynamic and pas-
and presents a valid technique for competitive sive warm-up interventions [53].
performance enhancement [45]. Some sports as Body vibration alone showed some positive
judo and baseball can result in improved perfor- effects on flexibility [53] but no evidence to
mance and peak power using PAP [7, 47]. Sport-­ improve endurance, strength, power, and per-
specific conditioning contractions can be used to formance in sports [7]. However, the combina-
enhance performance [44] and association with tion with other warm-up modalities could
other warm-up methods, as whole-body vibration improve performance, as a study revealed that
has been suggested as a potential way to acutely body-­loaded squats with whole-body vibration
improve sprint performance in cycling [48]. could be incorporated into preparations for
Hammami et  al. studied the efficacy and specific sprint training to improve the quality
characteristics of warm-up in soccer players and of the sprint training and also in order to
showed that static stretching reduced subse- improve sprint performance in relevant compe-
quent acute performance, while warm-up activi- titions [54].
ties that include dynamic stretching and
PAP-based exercises can elicit positive effects
in soccer players [49]. 7.9.8 Training Accessories

For improved practice assistance, some acces-

7.9.6 Plyometric Exercises sories can be helpful to improve the warm-up
program. It is important to use proper equip-
Plyometric training is used to increase move- ment that fits correctly and meets safety stan-
ment speed and power. This is a type of physical dards. Too often, old, faulty, or improperly
conditioning that emphasizes the stretch-short- fitted equipment (such as footwear, mouth
ening cycle and typically involves both open and guards, helmets, goggles, or shin pads) can
closed kinetic chain exercises, such as jumping cause injuries.
or medicine ball throws [50]. PAP in the form of A practical warm-up using relatively inexpen-
a plyometric during warm-ups has been shown sive and portable equipment such as elastic resis-
to improve performance in some speed/power tance bands were just as effective as a warm-up
events. Including a plyometric exercise during protocol that requires more substantial and less
warm-ups can improve sprint performance in transportable equipment such as a squat rack and
collegiate-aged male sprinters during short associated free weights [55].
7  Oriented Warm-Up 81

whole-body temperature should be limited in hot

Types of Warm-Up Programs environments [19].
• Passive heat and cooling Combining precooling (ice slurry and ice vest)
• Stretching (static, dynamic, PNF) and warm-up prior to endurance exercise in the
• Foam rolling heat may exploit the benefits of both strategies
• Isometric exercises while avoiding the potential negative conse-
• Postactivation potentiation exercises quences of each on performance [58].
• Plyometric exercises
• Vibration
7.11 Warm-Up Plan Program

Typically, an optimized warm-up will consist of

7.10 Weather Conditions light cardiovascular exercises combined with
stretches. The warm-up can be important not just
7.10.1 Warm-Up in Cold Weather for metabolic responses but also will involve car-
diovascular exercises, stretching, and strength
Passive and active warm-up, alone or in combina- drills, to work agility, coordination, and balance.
tion, should be practiced in cold weather [7]. The combination of these can be worked in uni-
Endurance performance does not seem to be and multilateral directions [14].
affected by cold weather, but the benefit of warm-
­up during cold days is almost self-evident, as the • Choose a general warm-up (jogging, cycling)
blood flow increases body temperature and acti- and/or warm-up modalities: stretching, vibra-
vates muscles for exercise [56]. tion, PAP, plyometric exercises, isometric,
foam rolling, and other passive and active
techniques.
7.10.2 Warm-Up in High Temperature For recreational physical activities, the warm-
and Humidity ­up plan can include jumping jacks, walking
knee hugs, arm circles, side shuffles, back
Athletes generally perform active warm-up to pedaling, lungs, squats, leg swings, inch-
prepare for an upcoming event, which is pro- worms, and karaoke.
posed to induce beneficial physiological For competitive or professional athletes, it is
responses. However, warm-up also elevates the recommended to include activities involving
core temperature; as a result, this effect may pre- the movements and muscles used in the
cipitate neuromuscular and cardiovascular sport.
impairments limiting endurance capacity [19], • Equipment use.
resulting in fatigue and reduced endurance per- Choose equipment in proper maintenance and
formance in the heat [57]. suitable for the athlete and the sporting
Preparations for competing in the heat should activity.
include an acclimatization regimen and manipu- • Always prepare your body for an upcoming
lation of the warm-up to suit the demands of event
competition in hot environments, along with It is important to warm up in hot weather
other strategies to avoid heating up [19]. Athletes because even though the environment tem-
should also consider cooling interventions to perature is elevated, the athlete’s muscle
curtail heat gain during the warm-up and mini- and  articulations are not ready to start
mize dehydration. Indeed, although it forms an exercising.
essential part of the pre-competition preparation • Wear comfortable clothes.
in all environmental conditions, the rise in • Start easy and slow.
82 K. M. Hatano

Start slowly with a general cardiovascular Variable Evidence-based recommendation

exercise such as walking, jogging, or biking Pattern Two to four repetitions of each stretch is
for at least 5 min. recommended
Volume Provide a total of 60 s of stretching time
• Warm-ups can also be used to practice skills per target muscle group for any stretching
and team drills. method utilized
Include light running exercises, dynamic flex-
ibility, some agility work, motor control activ- • Multidirectional.
ities, some static and dynamic balance, and Do exercises in 360°, in order to activate mus-
plyometrics. cles and work equilibrium and coordination
• Smooth transition from the warm-up to a spe- • Stay hydrated.
cific activity. Hydration is very important, particularly for
The warm-up should focus on muscles and children and the elderly, since they are more
movements more specific to the exercise activ- susceptible to dehydration. Be sure to drink
ity planned and work up to the harder work fluids frequently before, during, and after
that precedes training or competition. For exercise [39].
example, a soccer player could pass, dribble, –– Drink 16–20 fluid ounces of water or sports
and shoot a ball; a weightlifter could lift light beverage at least 4 h before exercise.
weights before moving onto greater –– Drink 8–12 fluid ounces of water 10–15 min
resistance. before exercise.
• Slowly increase the amount of time of each –– During exercise, drink 3–8 fluid ounces of
workout, the intensity of the workout, and the water every 15–20 min when exercising for
resistance of the weights. ACSM recommends less than 60 min.
a 5% increase is a safe progression as the exer- –– Drink 3–8 fluid ounces of a sports beverage
cise becomes too easy (5–8% carbohydrate with electrolytes)
• Stretch the major and minor muscles. every 15–20  min when exercising greater
It is essential to activate all the muscles than 60 min. Do not drink more than one
involved in the sports activity, especially areas quart/hour during exercise.
known to be a problem. –– Enhancing palatability of fluid will help to
Perform static stretching after working out or encourage fluid consumption. This can be
alone on its own, and avoid bouncing while done with proper flavoring, proper salt
stretching, as this can cause injuries. (sodium) content, and drinking a cold bev-
For dynamic stretching, it is best to hold the erage (15–21 °C)
stretch in one position and slowly move it • Body signs.
through its range of motion. The muscle should be heated and stretched
enough to feel light to moderate discomfort,
but not to feel pain.
7.12 A
 CSM Flexibility Exercise • The warm-up is also a good opportunity for an
Recommendations individual to prepare themselves mentally for
the game ahead and for a team to work together
Variable Evidence-based recommendation before starting of the game.
Frequency ≥2–3 days/week of stretching the major
muscle groups; greater gains will be
attained if done daily Oriented Warm-Up
Intensity Stretch to the point of slight discomfort or • Plan a specific program for the sport/
feeling of tightness in muscle physical activity.
Time 10–30 s of static stretching holds for older
persons; 30–60 s of static stretching holds
• Choose warm-up modalities (general
for most adults and specific),
PNF 3–6 s of a muscle contraction at 20–75% • Start easy and slow (walking, jogging,
stretches of maximum intensity followed by or biking).
10–30 s of an assisted stretch
7  Oriented Warm-Up 83

9. Andrade DC, et  al. Effects of general, specific and

• Soothe transition to a specific activity combined warm-up on explosive muscular perfor-
mance. Biol Sport. 2015;32(2):123–8.
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ball). cine. Physiother Can. 2014;66(1):109–10.
• Slowly increase the intensity. 11. McGowan CJ, et al. Warm-up strategies for sport and
• Multidirectional. exercise: mechanisms and applications. Sports Med.
2015;45(11):1523–46.
• Stretch. 12. Slauterbeck JR, et al. Characterization of prepractice
• Stay hydrated. injury prevention exercises of high school athletic
• Listen to body signs. teams. Sports Health. 2017;9(6):511–7.
• Choose proper training equipments. 13. Chatzopoulos DE, et al. Warm-up protocols for high
school students. Percept Mot Skills. 2015;121(1):1–13.
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Aspetar Sports Med J. 2012;1(2):128–35.
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 Nutrition and Hydration
8
Daniéla Oliveira Magro

8.1 Introduction This chapter will be divided mainly into the

following topics: (a) energy needs, (b) carbohy-
The purpose of this chapter is to provide evidence-­ drate in exercise (before, during, after), (c) pro-
based information regarding nutrition and hydra- tein in exercise, (d) fat in exercise, (e) hydration
tion for physical sports and their benefits as well in exercise (before, during, after), and (f) vita-
as recommendation to prevent nutrition deficits, mins and minerals and strategic of exercise length
low performance during the sports exercises and accordingly.
recovery, and health risks. The aspects related to nutrition and hydration
To support and promote optimal performance, in sports will be discussed for the main categories
various aspects related to nutrition can cause of sports: endurance and resistance training.
fatigue and deterioration in the outputs of perfor-
mance (e.g., power strength, agility, skill, and
concentration) throughout or toward the end of 8.2 Energy Needs During
the sporting event. These factors include dehy- Exercise
dration, electrolyte imbalances, glycogen deple-
tion, hypoglycemia, gastrointestinal discomfort, According to the International Olympic
and disturbances to acid-base balance. Committee (IOC), an athlete’s energy require-
The amount of food intake throughout the day ments consist of several components: baseline
must provide to athlete’s adequate proportion of metabolic needs (such as the energy required to
macro- and micronutrients according to the tim- support cellular maintenance, temperature regu-
ing and exercise type. lation, and immune health) and growth and phys-
Macronutrients are carbohydrates, protein, ical activity [1].
and fat which are important for athletes’ nutrition Energy balance occurs when total energy
to keep performance up, avoid fatigue and associ- intake (EI) equals total energy expenditure
ated injuries, maintain immune function, prevent (TEE), which then consists of the summation of
overtraining, and achieve goals. Vitamins and basal metabolic rate (BMR), the thermic effect of
mineral are micronutrients that are essential for food (TEF), and the thermic effect of activity
the metabolism and athletes’ performance. (TEA  =  planned exercise expenditure, more
spontaneous physical activity, more no-exercise
D. O. Magro (*) activity thermogenesis) [2].
Department of Surgery, Faculty of Medical Sciences,
State University of Campinas (Unicamp), TEE = BMR + TEF + TEA
Campinas, SP, Brazil

© ISAKOS 2019 85
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_8
86 D. O. Magro

BMR can be obtained by using Cunningham [3] From a historical perspective, the nutrient tim-
or Harris-Benedict [4] equations, as an appropriate ing was first conceptualized in the 1970s and
activity factor to estimate TEE.  The first compo- 1980s with the initial work that examined the
nent to optimize training and performance through effects of increased carbohydrate feedings on
nutrition is to ensure the athlete is consuming glycogen status and exercise performance [8].
enough calories to offset energy expenditure [5]. A variety of carbohydrate sources from both food
Athlete’s energy requirements depend on the and fluids are effective in restoring glycogen
periodized training and competition cycle and stores, the choices being determined by athlete
will vary from day to day according to volume preference (taste), practicality, and availability
and intensity. Factors that increase energy needs [7]. Ivy and collaborators were one of the first
above normal baseline levels include exposure to groups to demonstrate that carbohydrate timing
cold or heat, fear, stress, high altitude, and others could influence postexercise rates of glycogen
[2]. Athletes are vulnerable to changes in energy resynthesis [9]. Moderate to high glycemic index
availability and fast weight loss programs, or carbohydrate choices are adequate because gly-
those who are afraid of eating proper fuel are cogen storage will, in part, be regulated by rapid
associated with health and performance decre- glucose supply and insulin response [7] and the
ments, including impairment of hormone, intake of carbohydrates is suboptimal; the addi-
immune, and metabolic function and irreversible tion of protein (0.3–4 g/kg/h) may help maximize
loss of bone mass [1]. glycogen resynthesis during recovery [10].
According to the International Society for There are differences in the quantity of carbo-
Sports Nutrition (ISSN), people who participate hydrate requirement that vary according to ath-
in a general fitness program (e.g., exercising letes’ needs, based on training intensity, type of
30–40 min per day, three times per week) need to workout, and timing during the session. Higher
follow a normal diet (e.g., 1800–2400 kcal/day or intakes of carbohydrate are associated with better
about 25–35 kcal/day for a 50–80 kg individual) performance.
because their caloric demands to exercise are not In general, athletes will need to consume
too great (e.g., 200–400  kcal/session). Athletes 3–5 g per kilogram body weight (BW) daily for
involved in moderate levels of intense training low activity [1–3] and 8–12 g per kg BW per day
(e.g., 2–3  h/day, 5–6 times a week) need for high intense training (≥70% VO2 max) of
50–80  kcal/kg/day (2500–8000  kcal/day for a 12 h per week [2, 6, 8]. The carbohydrate intake
50–100  kg athlete). For elite athletes, energy level has been shown to maximize glycogen stor-
expenditure during heavy training or competition age and to avoid muscle damage. The dietary ref-
may be huge (e.g., 100–150  kcal/kg/day for a erence intake (DRI) for carbohydrate (60–70% of
60–80  kg athlete may range between 6000 and total daily caloric intake) has fallen out due to
12,000  kcal/day) depending on the volume and inability to appropriately prescribe required car-
intensity of different training phases [5, 6]. bohydrate amounts in athletes eating high
amounts of food or in those who may be follow-
ing a restricted energy intake [8] (Table 8.1).
8.3 Carbohydrate in Exercise Carbohydrate intake should be consumed
throughout the day, as well as before or during
Carbohydrates are the main energy source during the session or recovery period.
high-intensity activity [6] for the central nervous Before session, the carbohydrate choice may
system as well as muscle fuel [2, 6]. The inade- be poor fat, protein, fiber, and residues and easily
quate endogenous carbohydrate availability is consumed and to meet goals, gut comfort and
associated with an impaired team sports perfor- “racing weight” [2]. Athletes’ individual prefer-
mance [7], fatigue in the form of reduced work ences and experiences should be respected.
rates, impaired skill and concentration, and Carbohydrate-rich food and drink may help to
increased perception of effort [2]. achieve target and consumption during the
8  Nutrition and Hydration 87

Table 8.1  Summary of carbohydrate intake guideline: daily needs for fuel and recovery
Sports activity level/organization The timing of carbohydrate intake g/kg body weight per day
Low
ISSN Physical activities in general, 30–60 min/ 3–5
IOC day, 3–4 times a week 3–5
Moderate
ISSN 2–3 h/day, 5–6 times a week 5–8
IOC Exercise program—1 h/day 5–7
High
ISSN 3–6 h/day, 1–2 sessions, 5–6 times a 8–10
week
IOC Endurance program—1–3 h/day 6–10
Very high
IOC Extreme commitment >4–5 h/day 8–12
Strength-trained athletes
IOC Undetermined period 4–7
Acute fueling strategies (high carbohydrate to promote optimal performance)
General fueling up Preparation for events <90 min 7–12 g/kg/24 h as for daily fuel
needs
Carbohydrate loading Preparation for events >90 min of 10–12 g/kg/24 h (by 36–48 h)
sustained/intermittent exercise
Speedy refueling <8 h recovery between two fuel-­ 1–1.2 g/kg/h for first 4 h and then
demanding sessions resume daily fuel needs
Pre-event fueling Before exercise >60 min 1–4 g/kg consumed, 1–4 h before
exercise
Fueling strategies during exercise
During brief exercise <45 min Not needed
During sustained high-intensity 45–75 min Small amount including mouth
exercise rinse
During endurance exercise, including 1–2.5 h 30–60 g/h
“stop-and-start” sports
During ultra-endurance exercise ≥2.5–3 h Up to 90 g/h
ISSN International Society for Sports Nutrition, IOC International Olympic Committee [1]
Table adapted by Thomas et al. [2] and Jeffrey R. Bytomski, DO [6]

s­essions according to rules and nature of each 8.4 Protein in Exercise

sport. Sports products (sports drinks, gels, and
bars) with multiple transportable carbohydrates Proteins are at the macronutrients’ level. They
(glucose, fructose mixtures) achieve high rates are comprised of two types of amino acids, essen-
of oxidation of carbohydrate consumed during tial (phenylalanine, valine, threonine, tryptophan,
exercise [2]. Consumption of 1.5–2 cups fluid methionine, leucine, isoleucine, lysine, and histi-
with 6–8% carbohydrate solution per 100  mL dine) and nonessential (alanine, arginine, aspartic
sustains blood glucose levels and maximizes acid, cysteine, glutamic acid, glutamine, glycine,
performance [8]. proline, serine, tyrosine, asparagine, selenocyste-
According to the IOC, several everyday food ine, pyrrolysine), with the former only being
and drink such as fruit, juices, and soft drinks fully obtained through nutrition because our bod-
may also be suitable. The athlete should practice ies cannot produce them [6], and the latter is syn-
in training to develop a race or event fueling plan. thesized by our organism.
This plan will need to take into account the There are many questions on how much pro-
opportunities provided in the athlete’s event to tein is needed for athletes. DRI [11] for protein is
consume drink or food [1]. 0.8  g per kilogram body weight for sedentary
88 D. O. Magro

individuals [6, 11, 12]. Many studies showed that of MPS during recovery compared with a
athletes have higher daily protein requirements slowly digested protein of lower leucine com-
[13, 14]. Proteins are important for several meta- position, such as soy, micellar casein, and
bolic processes. They are responsible for build- wheat [7, 15]. Endurance exercise increases
ing blocks of the muscle and tendons and essential leucine oxidation [14].
for building enzymes, hormones, and neurotrans- It is known that resistance training is very dif-
mitters for several bodily functions which include ferent from endurance training, and the result is
facilitating muscle repair, muscle and immune that the muscle requires more of the specific pro-
function remodeling, and injury recovery [6, 7, 8, teins needed to reach a higher level of perfor-
15]. Protein provides only a small source of fuel mance. A recent updated published by ISSN, in
for the exercising muscle but has a substantial 2017 [14], included new information on the most
anabolic effect on protein synthesis when com- important dietary protein for exercise perfor-
bined with exercise [1]. mance, categorized in endurance and resistance
The key component of the muscle remodel- exercise performance (increases in maximal
ing is muscle protein synthesis (MPS), the syn- strength). The main information is described in
thesis of amino acids into functional contractile Table 8.2.
myofibrillar proteins and end-energy-producing There is consensus from ACSM, ISSN, and
mitochondrial proteins [7]. Multiple factors, IOC on the beneficial effect of the ingestion of
including the source, per meal dose, daytime ~20 g protein with carbohydrates within 30 min
pattern, and timing (about exercise) of ingested postexercise because it might support an
protein, as well as co-ingestion of other nutri- enhanced performance, to facilitate muscle pro-
ents, all modulate the response of MPS to pro- tein synthesis; however, no plausible mechanism
tein intake [7, 15, 16]. for this effect is readily available until now [1, 2,
The American College of Sports Medicine 9]. Protein serves both as a substrate and a trigger
(ACSM), International Society for Sports for adaptation after both resistance and aerobic
Nutrition (ISSN), and International Olympic exercises. Protein intake that exceeds this recom-
Committee (IOC) provide a consensus which mended amount does not promote MPS but can
stated that the daily protein requirements of ath- result in protein oxidation. This recovery strategy
letes range between 1.2 and 2.0 per kilogram can be achieved through dietary sources.
body weight per day. IOC recommends 1.8–2.7 g Additional supplementation is not essential [1].
per kilogram BW per day when the athlete is try- ISSN recommends and IOC recognizes that
ing to lose fat while gaining lean mass in a slight the addition of creatine monohydrate as a supple-
caloric deficit and proper training program [1, 6, ment after exercise can increase skeletal muscle
15]. It should be taken into consideration whether hypertrophy after resistance training. The practi-
the athlete has a normal kidney function because cal application of this is questionable [2, 13].
some authors discussed the deleterious effects of Creatine is a nonessential nutrient that is pro-
high-protein diets including kidney failure and duced endogenously in the liver, pancreas, and
osteoporosis [6]. Recommended sources of pro- kidneys and is also consumed through the diet
tein for athletes include lean meats (chicken, [7]. It is normally found in meat and fish, but the
pork, beef) and fish, cottage cheese, eggs, milk, doses that are commonly used (20 g per day for
Greek yogurts, and protein shakes. Protein 4–5 days to load and then 2–3 g per day for main-
sources for vegetarian athletes may include tenance) are more than those found in normal
beans, lentils, quinoa, black beans, peas, chick- food. Supplementation of creatine after exercise
peas, almonds, and vegetarian protein shakes. is not necessary and can even be harmful to health
The protein supplements are used when needed. [1]. The same results can be achieved with the
Leucine supplement, essential amino acid, ingestion of sufficient carbohydrate and high bio-
such as whey protein is rapidly digested. Both logical value protein after exercise [2]. Creatine
have been shown to elicit a greater stimulation supplementation might be important for vegan
8  Nutrition and Hydration 89

Table 8.2  Summary of protein intake guideline

Endurance exercise performance Resistance exercise performance
Protein • Adequate carbohydrate is delivered; adding • Hyperenergetic diet, a heavy resistance training
recommendation protein to carbohydrate does not appear to program, and protein supplementation may
improve endurance performance over the promote increases in skeletal muscle cross-
course of a few days or weeks sectional area and lean body mass
• Protein doses should contain 700–3000 mg • An elevated daily intake of protein (2–3 × the
of leucine and a higher relative leucine RDA) can promote greater losses of fat mass and
content, in addition to a balanced array of greater overall improvements in body composition
the essential amino acids (EAAs). These • Resistance exercise and protein ingestion both
protein doses should ideally be evenly stimulate synthesis MPS and are synergistic
distributed, every 3–4 h, across the day. when protein consumption occurs before or after
Rapidly digested proteins that contain high resistance exercise. There is novel evidence that
proportions of EAAs and adequate leucine suggests higher protein intakes (>3.0 g/kg/day)
are most effective in stimulating MPS may have positive effects on body composition
• Recommendations regarding the optimal
protein intake per serving for athletes to
maximize MPS are mixed and are dependent
upon age and recent resistance exercise stimuli
Protein before • Endurance athletes should focus on • Pre-event meal resistance exercise can be
exercise achieving adequate carbohydrate intake to achieved by including 0.15–0.25 g/kg BW
promote optimal performance; the addition protein with the recommended 1–2 g/kg BW
of protein may help to offset muscle carbohydrates, 3–4 h before training or
damage and promote recovery competition
Protein during • Adding protein during an intensive Not needed
exercise endurance exercise may suppress the rise in
plasma proteins linked to myofibrillar
damage and reduce feelings of muscle
soreness 12–24 h post-exercise.
• It is recommended for endurance athletes to
ingest approximately 0.25 g of protein/kg
body weight per hour of endurance exercise
(in addition to the athlete’s regular
carbohydrate intake)
• The addition of protein to carbohydrates
(carbohydrates to protein ratio of 3–4:1)
during exercise has shown promise
• Ingestion of carbohydrate + protein or amino
acids (EAAs) during endurance exercise can
help to maintain a favorable anabolic
hormone profile, promote increases in
muscle cross-sectional area, and increase the
time to exhaustion during prolonged training
Post-exercise • Administration of protein when combined • General recommendations are 0.25 g of a
with suboptimal intake of carbohydrates high-quality protein per kg of body weight, or
(<1.2/kg/day) can increase muscle glycogen an absolute dose of 20–40 g (10–12 g of EAAs,
recovery and may help mitigate changes in 1–3 g of leucine) stimulates MPS, which can
muscle damage help to promote a positive nitrogen balance
• Adding protein after an intensive endurance • Skeletal muscle is sensitized to the effects of
exercise may damage and reduce feelings protein and amino acids (EAAs) for up to 24 h
of muscle soreness 12–24 h post-exercise. after completion of a bout of resistance
The recommendation for recovery is a exercise
carbohydrate to protein ratio of 3–4:1 or
0.2–0.5 g/kg BW protein
• ISSN also recommends that ingestion of
essential amino acid (EAA) stimulates by
adding 6–20 g EAA to at least 30–40 g high
glycemic carbohydrates which should be
ingested immediately or within 3 h
post-exercise
90 D. O. Magro

athletes to consider and compensate for reduced Fat in the form of plasma-free fatty acids,
muscle creatine stores experienced as a result of intramuscular triglycerides, and adipose tissue
their lifestyle choices [17]. provides a fuel substrate that is both relatively
plentiful and increased in availability to the
muscle as a result of endurance exercise
­
8.5 Fat in Exercise (>90 min). Athletes consuming less than 10% of
their calories from carbohydrates can oxidize fat
Fat requirements for athletes are similar to those between 1.2 and 1.5 g/min during a progressive-
for nonathletes (20–35% total daily calories) intensity exercise near 65% VO2 max. A fat-burn-
[12]. IOC does not recommend consuming less ing adapted ironman triathlete can use the fat
than 15–20% of total calories from fat, because stored in his/her body to fuel the race effectively
it is essential for many metabolic processes, at that oxidation rate for the entire race compared
including cell membrane structure, absorption with a carbohydrate-burning athlete who needed
of fat-­ soluble vitamins, hormone regulation, to consume another 90–105 g per hour to main-
brain health, and energy for muscle metabolism tain performance [2, 6, 7].
[2, 13]. During resistance training, such as weight lift-
There are two essential fatty acids, alpha-­ ing, creatine phosphate (CP) and carbohydrate
linolenic acid (omega-3 fatty acid—fish, nuts, are predominant as an energy source, being
chia) and linoleic acid (omega-6 fatty acid—veg- ­proportionally lower to the contribution of lipids
etable oils, margarine, grains, fast and processed to energy synthesis [18].
food), that our organism cannot synthesize them
and must be supplied by food [2]. The main
symptoms of essential fatty acid deficiencies are 8.6 Hydration in Sports
skin lesions, infertility, and increased susceptibil-
ity to infections. Athletes usually need to hydrate before, during,
Athletes should focus on good sources of fat and after exercise. The main goals of hydration
which are high in unsaturated fats and essential are optimization of the performance, prevention
fatty acids (requirement: 2% total calories of metabolic strain, and thermoregulation dur-
omega-6; at least 1.3% total calories omega-3). ing exercise. Most authorities warn that athletes
The proportion of energy from saturated fats losing >2% body weight during activity (e.g.,
should be limited to less than 10% and trans fat 1.0 kg for 50 kg person, 1.5 kg for a 75 kg per-
ingestion avoided [2, 6]. Healthy sources of fat son, and 2  kg for a 100  kg person) may show
include salmon, nuts and nut butters, and avo- decrease in cognitive function and performance
cado, as well as olive oil. Athletes may also [1, 2, 6, 19, 20]. Thirst is often not a good indi-
consider taking omega-3 (PUFA) supplements cator of dehydration. An athlete can lose until
(3 g/day, of 1.3 g of EPA and 0.3 g of DHA), as 1.5  L before thirst is perceived [6]. Athletes
they can also counteract inflammatory may lose from 0.3 to 2.4 L per hour of sweat,
(increased interleukin (IL)-2 production and and rates vary based on environment, sex, body
the cytotoxic activity of natural killer cells dur- size, and type and length of activity [1]. Sweat
ing 3  h of exercise recovery) and free radical comprises water, sodium, potassium, calcium,
formation sustained from training. Recently magnesium, and chloride, so athletes should
studies showed that omega-3 promoted muscle replace both fluids and electrolytes with their
remodeling, muscle repair, and immune sur- recovery strategy [6]. Dehydration refers to the
veillance and also exhibit immunomodulatory process of losing body water and leads to
properties [7, 13]. ­hypohydration [2].
8  Nutrition and Hydration 91

8.6.1 I s There Any Need to Hydrate sweat losses. The problems can occur when the
If Training Session Lasts Less fluid intake is rapid and excessive leading to
Than an Hour? hyponatremia (dilution of blood sodium con-
centration) [1, 2].
It is not necessary to drink during exercise that Strategies to reduce high skin temperatures
lasts less than about 40  min unless the athlete and large sweat (fluid and electrolyte) in hot envi-
starts the session dehydrated. When it is not pos- ronments should include acclimatization, indi-
sible to drink during “heavy-sweating”-type vidualized hydration plans, regular monitoring of
exercise lasting longer than 30 min, an alternative hydration status, beginning exercise hydrated,
is to hydrate 15  min before starting the session consuming cold fluids during exercise, and the
(e.g., 300–800 mL) [1]. inclusion of electrolyte [2] (Fig. 8.1).
In cold environments, the primary strategy is
the maintenance of euhydration and body tem-
8.6.2 H
 ot Days/Cold Days: Is There perature with appropriate clothing. Several fac-
Any Difference Regarding tors can increase the risk of hypohydration,
How to Hydrate? such as cold-induced diuresis, impaired thirst
sensation, reduced desire to drink, limited
Hot environments (when the ambient tempera- access to fluids, self-restricted fluid intake to
ture exceeds body temperature heat) and exer- minimize urination, sweat losses from over-
cise reinforce a higher risk of impaired dressing, and increased respiration with high-
performance and heat illness. A more feasible altitude exposure. Fluid intakes should be
alternative is to try to minimize dehydration. In regularly assessed and changes in BW and
some situations, athletes overhydrate during hydration status when exercising in both hot
exercise if they are drinking more than their and cold environments [2].

Fig. 8.1  Athlete with

ice bag in her back
92 D. O. Magro

Table 8.3  How to estimate sweat losses and sweat ratesa Before exercise. Athletes should intake a fluid
1. Measure body mass before and after at least 1 h of volume equivalent to 5–10 mL/kg BW (~2–4 mL/
exercise under conditions similar to competition or a lb) for 2–4 h pre-session to achieve pale yellow
hard practice
urine color allowing enough time to empty excess
2. Take these body mass measurements wearing
minimal clothing and while bare footed. Towel dry fluid. Sodium consumed in pre-exercise fluids
after exercise, and obtain body mass as soon as is and food may help with fluid retention. Glycerol
practical after exercise (e.g., less than 10 min and and other plasma expanders for this purpose are
before eating, drinking, or going to the toilet)
prohibited by the World Anti-Doping Agency
Example: Pre-exercise weight = 74.5 kg. Post-­
exercise weight = 72.8 kg. Fluid deficit = 1.7 kg (WADA) [2, 21].
3. Estimate the weight of any fluid or food you have During exercise. An hour exercise duration
consumed during the workout can lead to fatigue, so athletes are advised to con-
Example: 800 mL of fluid = 800 g or 0.8 kg sume some liquid carbohydrate source that is rap-
4. Sweat loss (liters) = body mass before exercise (in
kg) − body mass after exercise (kg) + weight of
idly converted to blood glucose [1]. Routine
fluids/foods consumed (kg) measurement of body weight pre- and post-­
Example: 74.5 kg − 72.8 kg = 1.7 kg deficit + 0.80 kg exercise, in addition to urinary losses and drink
(800 mL fluid) = sweat loss of 2.5 kg or 2500 mL volume, can help athletes estimate sweat losses
To convert to a sweat rate per hour, divide by the
exercise time in minutes, and multiply by 60
during sporting activities and customize their
5. Weight deficit at the end of the session provides a fluid replacement strategies (Table  8.3). Fluid
guide to hydrate during the session and how much is plan that suits most athletes and athletic events
needed to rehydrate afterward will typically achieve an intake of 0.4–0.8  L/h,
To convert kg to % body mass, divide the weight
although it is needed to customize the athlete’s
deficit by starting body mass, and multiply by 100:
Example: 1.7 kg/74.5 × 100 = 2.3% tolerance and experience, their opportunities for
Note: 2.2 pounds equals 1.0 kg and converts to a drinking fluids, and the benefits of consuming
volume of 1000 mL or 1 L other nutrients (e.g., carbohydrate) in drink form
a
Source: Nutrition for athletes—A practical guide to (Figs. 8.2 and 8.3).
eating for health and performance IOC [1]

Fig. 8.2  An athlete

having fluid drinks
during Ironman Brazil,
on a sunny day
8  Nutrition and Hydration 93

Fig. 8.3  An athlete

having fluid drinks
during Ironman Brazil,
on a cloudy day

8.6.3 Overhydration or After exercise. Most athletes need to restore

Hypohydration: What Might euhydration during recovery period consumption
Happen? of water and sodium at a modest rate that mini-
mizes diuresis and urinary losses. The increase in
Overdrinking fluids and sweat and urinary losses plasma sodium concentration and osmolality with
in excess might be the primary cause of hypona- sodium ingestion stimulates renal water reabsorp-
tremia (plasma sodium <135  mmol/L), also tion (e.g., decreases diuresis) and promotes
known as water intoxication, although this can be plasma volume restoration [7]. Sodium replace-
exacerbated in cases where there are excessive ment can be achieved via sodium-­containing flu-
losses of sodium in sweat and fluid replacement ids such as sports drinks and pharmacy oral
involving low sodium beverages. Symptoms of rehydration solutions. However, a meal (e.g.,
hyponatremia include bloating, puffiness, weight bread, cheese, and breakfast cereal), snack (e.g.,
gain, nausea, vomiting, headache, confusion, peanuts, crackers), or use of table salt added on
delirium, seizures, respiratory distress, loss of food can ­supply the sodium necessity. Effective
consciousness, and possibly death if untreated [2]. rehydration requires volume of fluid intake (e.g.,
Sodium should be ingested during exercise 125–150%) greater than the final fluid deficit
­
when large sweat sodium losses (>1.2 L/h), salty (e.g., 1.25–1.5 L fluid for every 1 kg BW lost) to
sweat, or prolonged exercise exceeding 1–2 h in restore fluid losses and optimize glycogen resyn-
duration (e.g., 3–4 g of sodium, in hot and humid thesis when the length of time separating one bout
climate) occurs [1, 2]. of exercise from another is 8 h [2, 16]. Excessive
Skeletal muscle cramps are typically caused by intake of alcohol in the recovery period is discour-
muscle fatigue and may be associated with hypo- aged due to its diuretic effects [2] (Fig. 8.4).
hydration and electrolyte imbalances. Sports drinks An important and easy hydration indicator can
with sodium (e.g., 300–500 mg sodium per 500 mL be urine color post training. The darker is the
liquid) may help reduce the risk of cramps [1]. color (copper brown until ruby brown), the more
94 D. O. Magro

Fig. 8.4 Post-race
Hydration, ironman
Brazil

is dehydration, requiring larger quantities of liq- als’ requirements may be increased during ath-
uids for recovery. Recovery after exercise is part letes training. Most athletes should obtain
of the preparation for the next exercise session, sufficient micronutrients through a balanced diet,
and rehydration should be considered as an but athletes who practice extreme dietary or
important part of the strategy. weight loss patterns or eliminate whole food
IOC presents a very interesting guide to assess groups such as vegetarians may be a risk for cer-
the level of post-training dehydration (Table 8.3) tain deficiencies and need micronutrient supple-
[1]. mentation, as well as in special conditions with
illness, injury, and recovery [1, 2, 6].
Some vitamin and mineral deficiency may
8.7 Micronutrients in Exercise decrease performance. The most common defi-
ciencies are iron, vitamin D, calcium, and some
Micronutrients are comprised of vitamins and antioxidants such as vitamins E and C, vitamin
minerals which help the body to function, acting B12, and zinc, mainly for vegetarian athletes
as cofactors in metabolism. Vitamins’ and miner- [2, 6, 17]. Monitoring blood levels of these
8  Nutrition and Hydration 95

Table 8.4  Deficiencies, requirement, and supplementation of the micronutrients in sports

Requirement and Toxicity and adverse
Micronutrients Function Deficiencies supplementation effects
Iron A key component in Most common in DRI—18 mg for women Effects of
oxygen transport via female athletes. and 8 mg for men/day supplementation include
hemoglobin (blood) Causes include [11] gastrointestinal
and myoglobin heavy menstruation, Female athletes may discomfort, constipation,
(muscle) in energy inadequate dietary have increased and nausea [2, 6]
pathways in the intake (vegan diet),requirement of 70%
body [1, 6] gastrointestinal which is more than the
losses, and trainingaverage [6]
losses both Vegan athletes: 33 mg
intravascularly and for women and 14 mg
via sweat for men/day [17]
Athletes can be ironTreatment includes
deficient without dietary intake (with
anemia heme iron (from meats)),
oral supplementation
Serum ferritin is the
(with vitamin C), and
best indicator of the
iron store; levels intramuscular injections
between <35 and Routine use of iron
<10 ng/mL and supplements is not
hemoglobin of <12 g/recommended [1]
dL have been used toDosages are
describe deficiency controversies but 20 mg
with or without of elemental iron
anemia [2, 6] 6–8 weeks is
recommended [6]
Intramuscular and/or
intravenous injections
should be used only in
severe deficiency or
those who do not
respond to dietary and
oral supplementation [6]
Vitamin D It is essential for Low exposure to DRI recommends Blood 25 OHD values
(25OHD) calcium absorption. ultraviolet B (UVB), 600 IU/day [11], and the >150 ng/mL (plus
Helps regulate many stress fracture UK Department of hypercalcemia); include
metabolic pathways (overtraining), Health recommends nausea, vomiting, poor
in bone health, muscle pain, or 400 IU/day [17]. appetite, weight loss,
inflammation, weakness. Sources of dietary constipation, weakness,
immune function, Insufficiency is include fish, dairy, and mental confusion,
and muscle function defined as <30 ng/ eggs irregularities in cardiac
[6, 17, 22] mL and deficiency as Supplementation: rhythm, and calcification
Vitamin D status <20 ng/mL [2, 6, 17] Daily (2–4000 IU) or of soft tissues [6, 17]
(blood 25OHD) weekly (25–50,000 IU)
30–50 ng/L [7] or 4–500 IU/day for
The major source of vegan athletes [6, 17].
vitamin D is Testing 8 weeks to avoid
provided through the toxicity [6]
interaction of the 5–30 min of direct sun
skin with UVB light, exposure (arms and legs)
and its production is several times per week
affected by age, between 10:00 and
season, geographic 14:00 hrs is
location, and skin recommended [13]
pigmentation [1, 22]
(continued)
96 D. O. Magro

Table 8.4 (continued)
Requirement and Toxicity and adverse
Micronutrients Function Deficiencies supplementation effects
Calcium It is important for Low dietary calcium DRI for calcium Intake of calcium through
metabolic processes, is associated with (1000 mg/day) [11] diet is preferable,
including bone disordered eating IOC recommends considering the increased
health (with vitamin and low energy 1500 mg per day of risk of adverse effects,
D) and muscle availability, calcium, with 1500– which are kidney stones
contraction, nerve especially in 2000 IU vitamin D and cardiovascular events
conduction, and adolescents and in [1, 2, 6]
clotting functions [6] female athletes [1]
Stress fractures are
increased, and low
bone mineral density
may occur [6]
Vegan athletes have a
higher risk of
fracture due to lower
calcium intake [17]
Antioxidants Antioxidants have Increase oxidative Increase food that is High doses of vitamins C
(vitamins C important roles in stress [6] higher in antioxidants and E can be prooxidant,
and E) protecting cell Greatest risks for such as vitamins C and E and large doses of vitamin
membranes from poor antioxidant (fruits, vegetables, and E can also impede vitamin
oxidative damage. intakes are those whole grains) K metabolism and platelet
Vitamin C promotes who restrict energy There is little evidence function [6]
collagen synthesis, intake, follow a that antioxidant
facilitates glycogen chronic low-fat diet, supplementation
storage, and may or limit dietary enhances athletic
prevent exercise-­ intake of fruits, performance but may
induced oxidative vegetables, and be beneficial in athletes
changes whole grains [2] recovering from
Vitamin E blocks the injury [1]
propagation of free
radical formation [6]
Vitamin B12 Vitamin B12 Lead to DRI—2.4 μg day, both The body appears to have
(cobalamin) is morphological sexes [11] a limited capacity to
essential for normal chances to the blood Vegan absorb vitamin B12
nervous system cells, megaloblastic athletes—6.0 μg day supplements orally which
function, anemia, and Monitoring B12 status is limited by the presence
homocysteine neuropathy [17] carefully might be of intrinsic factor, a
metabolism, and necessary for vegan glycoprotein secreted by
DNA synthesis [17] athletes [17] the stomach’s parietal
cells that combine with
B12 before absorption in
the distal ileum via
receptor-mediated
endocytosis [17]
Zinc It is an essential Impaired immunity DRI— 11 mg for men
trace element with and growth and 8 mg/day for women
numerous biological retardation [23] [11]
functions, including Vegan athletes: 16.5 mg
immunity, energy for men and 12 mg/day
metabolism, and for women [17]
antioxidative Source of dietary include
processes [23] meat, beans, nuts, seeds,
oats, wheat germ, egg,
and dairy
8  Nutrition and Hydration 97

micronutrients should be mandatory; whenever

they are deficient, supplementation is needed, • The inadequate intake of carbohydrates
as well as periodical evaluations. There are no leads to damage to muscle contraction
general micronutrient guidelines for athletes. process, while its availability is inversely
Public health guidelines such as the DRIs pro- related to the rate of protein catabolism
vide micronutrient intake recommendations for during the exercise.
sports dietitians to help athletes avoid both defi- • General recommendation post-­exercise is
ciency and safety concerns associated with 0.25 g of a high-quality protein per kg of
excessive intake [2, 11]. body weight, or an absolute dose of
Below, Table 8.4 describes the main deficien- 20–40 g (10–12 g of EAAs, 1–3 g of leu-
cies, requirement, and supplementation of micro- cine) stimulates MPS.
nutrients for athletes. • Protein intake that exceeds this recom-
mended amount does not promote MPS,
but it can result in protein oxidation.
8.8 Final Considerations

Appropriate nutritional recommendations for

macronutrients, micronutrients, and fluids consti-
tute the pinnacle to promote optimal performance Fact Box 2
and recovery after training and competition. • Hydration aims to optimize the perfor-
Sports nutrition practice should help athletes and mance, prevention of metabolic strain,
teams work toward their performance-related and thermoregulation during exercise.
goals, avoid fatigue and deterioration in skill, or • Athletes losing <2% body weight during
concentrate over the course of the event. All ath- activity may show a decrease in cognitive
letes should adopt specific nutritional strategies function and performance.
before, during, and after training and competi- • Sodium should be ingested during exer-
tion. These aspects may depend on the sports cat- cise when large sweat sodium losses
egories as well as the timing and intensity of the occur.
session. • Appropriate fluid intake before, during,
Athletes are different, and diet and their needs and after is important for health and
cannot be generalized. Nutritional recommenda- performance.
tions need to be individualized for each athlete; • Overdrinking fluids and sweat and uri-
they also need to change across the season and nary losses in excess might be the pri-
training goals. mary causes of hyponatremia.
Essential nutrients can be obtained in adequate • Vitamin D, iron, and omega-3 polyunsat-
amounts from normal foods. A varied and whole- urated fatty acids are potentially benefi-
some nutrient-rich diet that encompasses vegeta- cial micronutrients and supplements to
bles, fruits, beans, legumes, grains, lean animal help support performance and recovery,
meats, fish, oil, and carbohydrates should ensure when necessary.
an adequate intake of all essential vitamins and • A well-balanced diet with the inclusion of
fruits and vegetables to obtain a variety of
antioxidants may be more appropriate
supplementation.
Fact Box 1 • Monitoring micronutrients status carefully
• Exercise produces catabolic conditions in might be necessary for vegan athletes.
skeletal muscle, and these effects depend
on the intensity and duration.
98 D. O. Magro

minerals. Supplementation recommendations muscle protein synthesis in humans. J Appl Physiol.

2009;106(4):1394–402.
should always be individualized, granting that 11. Institute of Medicine, Food and Nutrition Board.

targeted supplementation may be warranted to Dietary reference intakes for energy, carbohydrate,
treat or prevent deficiency. fiber, fat, fatty acids, cholesterol, protein, and amino
Evidence-based guidelines on the amount, acids. Washington, DC: The National Academies;
2005.
composition, and timing of food intake have been 12. US Department of Health and Human Services and
defined to help athletes perform and train more US Department of Agriculture. 2015–2020 dietary
effectively, with less risk of illness and injury. guidelines for Americans [Internet]. 8th ed. 2015
Athletes should be careful about the indis- [cited 2018 Jan 18]. Available from: http://health.gov/
dietaryguidelines/2015/guidelines.
criminate use of dietary supplements. The use of 13. Potgieter S.  Sport nutrition: a review of the latest
a small and lawful number of supplements and guidelines for exercise and sport nutrition from the
sports food may benefit some athletes. American College of Sport Nutrition, the International
Olympic Committee and the International Society for
Sports Nutrition. Afr J Clin Nutr. 2013;26(1):6–16.
14. Jäger R, Kerksick CM, Campbell BI, Cribb PJ, Wells
References SD, Skwiat TM, et al. International Society of Sports
Nutrition Position Stand: protein and exercise. J Int
1. Nutrition for athletes—a practical guide to eating Soc Sports Nutr [Internet]. 2017 Dec [cited 2018 Jan
for health and performance [Internet]. Lausanne: 2];14(1). Available from: http://jissn.biomedcentral.
International Olympic Committee; 2016. 37 p. www. com/articles/10.1186/s12970-017-0177-8.
olympic.org. 15. Phillips SM, Van Loon LJC. Dietary protein for ath-
2. Thomas DT, Erdman KA, Burke LM.  Position of letes: from requirements to optimum adaptation. J
the Academy of Nutrition and Dietetics, Dietitians Sports Sci. 2011;29(Suppl 1):S29–38.
of Canada, and the American College of Sports 16. McCartney D, Desbrow B, Irwin C.  Post-exercise

Medicine: nutrition and athletic performance. J Acad Ingestion of carbohydrate, protein and water: a sys-
Nutr Diet. 2016;116(3):501–28. tematic review and meta-analysis for effects on sub-
3. Cunningham J. A reanalysis of the factors influencing sequent athletic performance. Sports Med [Internet].
basal metabolic rate in normal adults. Am J Clin Nutr. 2017 Nov 2 [cited 2018 Jan 6]. Available from: http://
1980;33(11):2372–4. link.springer.com/10.1007/s40279-017-0800-5.
4. Roza A, Shizgal H.  The Harris Benedict equation 17. Rogerson D.  Vegan diets: practical advice for ath-
reevaluated: resting energy requirements and the body letes and exercisers. J Int Soc Sports Nutr [Internet].
cell mass. Am J Clin Nutr. 1984;40(1):168–82. 2017 Dec [cited 2018 Jan 18];14(1). Available from:
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Almada AL, Collins R, et al. ISSN exercise & sport s12970-017-0192-9.
nutrition review: research & recommendations. J Int 18. Chidnok W, Fulford J, Bailey SJ, DiMenna FJ, Skiba
Soc Sports Nutr. 2010;7(1):7. PF, Vanhatalo A, et  al. Muscle metabolic determi-
6. Bytomski JR. Fueling for performance. Sports Health nants of exercise tolerance following exhaustion:
Multidiscip Approach. 2018;10(1):47–53. relationship to the “critical power”. J Appl Physiol.
7. Heaton LE, Davis JK, Rawson ES, Nuccio RP, 2013;115(2):243–50.
Witard OC, Stein KW, et  al. Selected in-season 19. Akerman AP, Tipton M, Minson CT, Cotter JD. Heat
nutritional strategies to enhance recovery for team stress and dehydration in adapting for perfor-
sport athletes: a practical overview. Sports Med. mance: good, bad, both, or neither? Temperature.
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 Sports Rehabilitation
9
Knut Beitzel, Daniel Berthold, and Manuel Klose

9.1 Introduction coach and, in some cases, a sports psychologist

and a dietitian.
Sports injuries, such as damage to the muscles, Close coordination with trainers and coaches
ligaments or bone, often require surgery as well and the understanding of injury and subsequent
as a developed rehabilitation protocol. The reha- problems by athlete and coaches are key in each
bilitation process should be focused on the initial rehabilitation protocol. Injury prevention during
diagnosis of the injured athlete and include a the reconditioning phase is crucial and requires
wide number of therapeutic approaches. The pri- data maintenance by teams and trainers.
mary aim is a return to sports at a preinjury physi- Rehabilitation protocols should be focused on
cal and emotional level and, with injury, early passive mobilization considering the initial
prevention as key point. However, tissue healing diagnosis of the patient. An experienced physio-
after injury as the natural healing process should therapist should guide the patient through the dif-
be considered while developing a rehabilitation ferent phases of rehabilitation. Understanding the
programme. sports, biomechanical and physiological demands
Focuses on sports rehabilitation are physio- are crucial.
therapy, performed by an experienced therapist, Rehabilitation includes immediate immobili-
medical training therapy and sports-specific zation up to early, passive postoperative and early
training. Further therapies such as ergotherapy, active exercises such as shoulder pendulum exer-
massage, electrotherapy, hydrotherapy, kinesiol- cise or slight knee extensions/flexions. Meta-­
ogy and osteopathy should be considered indi- analyses of randomized clinical comparative
vidually in each rehabilitation protocol. Modern studies showed no significant differences between
rehabilitation protocols require teamwork and early and delayed passive exercise in terms of
proper rehabilitation planning, with sports phys- clinical outcome and re-rupture rate regarding
iotherapist and sports physician in leading posi- shoulder injuries. The full range of motion
tions. The team should be completed by an (ROM) can be achieved more quickly after early
experienced athletic (strength and conditioning) passive exercise. However, early aggressive
active exercise can affect the healing and should
not be performed in the first weeks after injury or
K. Beitzel (*) · D. Berthold · M. Klose surgery. Athlete and therapist should take into
Abteilung für Sportorthopädie, Klinikum rechts account the change of biomechanical properties
der Isar, München, München, Germany
e-mail: [email protected]; [email protected]; of the injured part of the body in the first weeks
[email protected]; [email protected] and months. The length of immobilization varies

© ISAKOS 2019 99
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_9
100 K. Beitzel et al.

between 4 and 8 weeks. The orthosis can be used includes general symptoms of exhaustion and
to avoid aggressive active exercise or inappropri- fatigue (tiredness, fatigue, lack of motivation),
ate movements, especially in patients with caused by too much training or too intense
reduced compliance. Regarding shoulder injuries rehabilitation.
such as rotator cuff lesions, studies showed The third principle of a rehabilitation protocol
increased blood circulation in the repaired tendon is seen as the “cause-effect chain”. In other
and significantly reduced stress on tendon-suture words, rehabilitation should take into account the
construct in patients with abduction (15–45°) complex reactions and compensation strategies
orthosis. Therefore, immobilization in slight of the body after injuries or surgeries.
abduction should be considered. As injured athletes tend to be impatient after
Recent studies investigated different rehabili- long injuries or absences from sports activities,
tation approaches, especially in patients suffering secondary dysfunctions seen as the “cause-effect
from ACL injuries. Criterion-based protocols chain” can cause problems during rehabilitation.
seem to be significantly superior in athletes after The body and the related diagnosis or surgery
undergoing ACL surgery than time-based proto- should be seen as a whole complex unit. Injured
cols. Time-based protocols are standardized parts of the body are linked to physical dysfunc-
rehabilitation protocols with fixed time tables tion in a chain of effects. An experienced thera-
and deadlines. Patients undergoing a time-based pist has to take care of dysfunctions and include
protocol seem to undergo less physiotherapy and them in training.
shorter rehabilitation time which leads to a Core stability is seen as the fourth principle in
quicker return to sports. Risks and complications physiotherapist protocols. A well-trained core is
such as ACL elongations, re-rupture or injuries essential to optimal force flow in the kinetic chain
can be the causes. Patients undergoing criterion-­ (Figs.  9.1 and 9.2), as all the force couples are
based programmes need to achieve fixed goals in generated from our core. Injured athletes should
order to proceed in their rehabilitation. For exam- be aware of the importance of core stability and
ple, running can only be allowed after finishing
strength or coordination training. This leads to a
more individualized rehabilitation protocol, tak-
ing into account the different characteristics of
the athlete as well as the initial diagnosis, in order
to decrease potential injury risks.

9.2 Physiotherapy

The first principle of the rehabilitation should

take into account the different diagnoses and sur-
geries of the injured athlete. Physician or surgeon
should define a postoperative protocol for the
upcoming weeks which takes into account the
different stages of wound healing, as well as the
biomechanical aspects of the sport, injury and/or
surgery.
The second principle pays careful attention to
signs or indications of progressive overload,
overtraining or stress. First hints of overloading
can be signs of inflammation such as dolour, Fig. 9.1  Training of the leg axis with combined training
rubor, calor, tumour or functio laesa. This also of core strength
9  Sports Rehabilitation 101

Recent studies also showed the importance of

clean and healthy eating and adequate water sup-
ply during this time. This can help to eliminate
metabolites much faster and increase recovery
time.
Soon after completing the first phase, the
inflammatory phase in injured athletes starts.
Anti-inflammatory measures can also be applied.
The proliferation phase is seen as the third
phase in physiotherapy. While starting with
mobilization, the therapist should start with light
endurance activities in order to increase the oxy-
gen input.
Functional training and return to sports-related
activities or movements are seen as the remodel-
ling phase.
In summary, therapist and athlete should work
on individual rehabilitation protocols with the
main focus on personal aspects of the injured
patient. All the activities should be performed
without greater pain (VAS 1–3). Communications
between all people included can prevent over-
Fig. 9.2  Proprioceptive training of the lower extremity
training, dysfunction or reduced compliance.

include coordination, core strength and func- Key Facts

tional training in their rehabilitation protocol. • Criterion-based protocols are superior than
The fifth principle includes continuous com- time-based protocols.
munication between the patient and the whole • The five principles of physiotherapy are diag-
rehabilitation team such as physiotherapist, phy- nosis, indications of overload, cause-effect
sician or coaches. chain, core strength and communication
The athlete should be informed in detail between athlete and rehabilitation team.
about his injury, the biomechanical aspects of
his injury/surgery or the planed therapies. The
more the patient brings understanding about the 9.3 Manual Therapy
details, the higher should be the compliance,
especially in activity restriction or absence from While completing the different stages of physio-
sports. therapy, the rehabilitation process is enhanced by
As those five principles are the spine of each manual therapy. Manual therapy involves exam-
rehabilitation protocol, physiotherapist should be ining, detecting, assessing and treating reversible
aware of compliance, subjective feeling and pain disorders of the locomotor system. This means
of the athlete. Furthermore, each rehab can be that the therapist must be familiar with the mutual
classified into four phases. Immediately after influence of arthrogenous, muscular and neuro-
injury or surgery, the first phase is defined as the genic structures, filter out the primary symptom-
post-injury or acute postoperative phase. During atic structure, consider possible contraindications
this time, the importance should be set on rest and recognize the sensitivity of the structure to be
and reducing inflammatories such as swelling treated, in order to be able to draw up an indi-
with ice and cold therapy and compression. vidual treatment plan. Medical training therapy is
Medication can also be taken into account. an equipment-supported form of training for
102 K. Beitzel et al.

9.4 Core Strength

Core training is vital for each rehabilitation pro-

tocol. It provides stability and increases effi-
ciency in force production as well as movement
patterns. The literature showed that strong
extremities in combination with weak core
strength result in less force production and mus-
cular dysfunction. It helps reducing pain in the
lower back, sacroiliac joint, hamstring, shoulders
and groin. Elite athletes require much higher lev-
Fig. 9.3  Technique of manual therapy to detonize the els of core stability, in order to maintain and max-
pectoralis group imize sports performances and promote efficient
biomechanics. Core stabilization exercises
should be integrated in rehabilitation pro-
grammes, as it shows decreased injury rates,
especially for the lower extremity.
Core musculature can be divided into local
and global categories. Muscles attached to the
lumbar vertebrae are defined as local muscles.
They can influence intersegmental motion and
improve the coordination and proprioception.
Global muscles attach to the hips and pelvis and
increase the mobility of the spine. If there is a
dysfunction in one of the local muscles, this can
cause a significant imbalance between all the
Fig. 9.4  Proprioceptive training and strengthening of the
muscles involved. This leads to inefficient move-
shoulder muscles
ments and increases the risk of injuries, with a
high number of musculoskeletal injuries. The
strength, endurance, coordination and movement abdominal muscles such as rectus abdominis,
under medical supervision. The objective of med- transversus abdominis and internal or external
ical training therapy (MTT) is to regain and stabi- obliques are the key muscles in positioning spine
lize a person’s physical capabilities. and pelvis correctly. Up to this, intra-abdominal
The main focus should be set on optimizing pressure, as well as stabilization of the spine, is
the quality of the movement. As soon as an opti- guaranteed by the transversus abdominis and the
mal quality of the movement, rhythm and extent thoracolumbar fascia. The thoracolumbar fascia
is achieved, the load can be increased. The phys- is seen as the connection of the upper and lower
iotherapist and the athlete should work on coor- extremities. It maintains the kinetic chain and
dination, proprioception (Figs.  9.3 and 9.4) as guarantees an optimal force couple for the
well as the interaction between different muscles extremities involved. Trapezius, latissimus dorsi,
and core. In addition to passive and active exer- deltoid and pectoralis major can be seen as axial-­
cises, fitness equipment can be a useful asset in appendicular attachments, which transfer force
manual therapy. It allows working step by step and momentum between extremities and core.
on strength, power and endurance. An experi- Even the diaphragm plays its own role in core
enced athlete can even perform their training strength and stabilization by contracting and
after an appropriate introduction and under con- increasing intra-abdominal pressure and generat-
stant control. ing a co-contraction of the pelvic floor muscles
9  Sports Rehabilitation 103

Fig. 9.5  Training of core strength combined with pro-

prioceptive training

Fig. 9.6  Training of core strength combined with pro- Fig. 9.7  Training of core strength combined with pro-
prioceptive training prioceptive training

prior to limb movement. Diaphragmatic ­breathing Overall deficiencies in core stabilization and load
exercises can improve core stability, as it serves transfer muscles are be related to lower extremity
as the superior boundary of the abdominal function and injury.
cavity.
The lumbopelvic hip complex, like the gluteal
muscles, pelvic floor and hip girdle, provides a 9.5 Mobility
corset-lie stabilization on the trunk and spine.
Gluteus maximus and medius, hip adductors, rec- Stretching and continuous increase of flexibility
tus femoris and iliopsoas are seen as the core sta- and mobility should be part of each rehabilitation
bilization muscles. protocol, as it increases muscles length and full
The focus on core stability lays on keeping range of motion.
a neutral spinal alignment, optimal trunk posi- Reduced joint flexibility or range of motion
tion and the transfer of loads along the kinetic can be caused by many reasons or factors such as
chain. muscles or capsuloligamentous structures sur-
Core stability needs be trained in a progressive rounding the joint.
way (Figs.  9.5, 9.6 and 9.7) beginning with The anatomy of a muscle provides both pas-
recruitment of local muscle, moving it to core sive and active tension. The passive tension is
stabilization and total body dynamic movements. dependent on the surrounding fascia as well as
104 K. Beitzel et al.

the anatomic properties of the muscle. Active ten- 9.6 Nutrition

sion is given by dynamic muscle contraction and
results from neuroreflexive properties as During sports rehabilitation, nutrition is seen
­peripheral motor neuron innervation and reflex- as one of the most important factors in the
ive activation. overall healing and post-injury performance.
Athletes often describe a stiff muscle as mus- Injuries, which limit limb or body mobility,
cle “tightness”. In fact, muscles can become sig- will lead after few weeks to a significant lower
nificantly shorter due to contraction or spasm. metabolic turnover. Athletes can suffer from an
Overall, this can prevent optimal healing during increase of muscle strength or neuromuscular
rehabilitation or cause muscle or joint damage control by losing proteins or carbohydrates.
and lead to absence from sports. Deficiencies of energy, protein and other nutri-
In sports rehabilitation, three muscle stretch- ents should be avoided, as it can lead to a lon-
ing techniques are applied and described in the ger absence from sports. The right diet, in
literature: static, dynamic and pre-contraction. combination with the right rehabilitation pro-
Static stretching can be either performed actively tocol, should see the athlete back to his perfor-
by the subject or passively by a partner and is the mance faster than expected.
most common type of stretching. A specific posi- During injury, immobilization or reduced
tion is held with the muscle on tension to the physical activity can be divided in two main
point of a stretching feeling and can be repeated stages. The first stage is seen as the healing and
from seconds up to few minutes. recovery phase with inflammation, proliferation
Dynamic stretching is described as active or and remodelling. The second stage is the return to
ballistic stretching. While active stretching is per- activity with increased activity and rehabilitation.
formed in order to restore the full range of motion Both stages can be influenced by nutrition or a
of a limb while moving it through its full range of right diet.
motion to the end range, ballistic stretching In severe injuries, the metabolic outcome
includes rapid or alternating movements at end can decrease up to 20%. In order to prevent
range of motion. Studies showed an increased muscle loss, a small weight gain can be benefi-
risk of injury for ballistic stretching which is no cial. If there is a loss in energy, muscle growth
longer recommended in sports rehabilitation. can be limited, and the overall loss can be
The third form of stretching is described as greater. During the rehabilitation, protein
pre-contraction stretching. While stretching, the (2–2.5  g/kg/day), carbohydrate and fat intake
muscle should be contracted up to 75–100% of (esp. omega-3) as well as vitamins (esp. vita-
maximal contraction. One of the most described mins A and C) and minerals should be part of
techniques is proprioceptive neuromuscular each diet. Sports beverages, gels, sodas, con-
facilitation (PNF) stretching. centrated sweets and alcohol should be
In terms of orthopaedic and sport orthopae- avoided.
dic injuries, stretching should be seen as effec-
tive physiotherapeutic tool. In patients with Key Facts
hamstring strains, one of the most common inju- • Manual therapy treats reversible structures in
ries in soccer players, static stretching is seen as the locomotor system.
more effective as dynamic stretching. In addi- • It is important to restore the perfect interac-
tion, intensive stretching was shown as more tion between core stability and mobility in
effective than by less intensive stretching. order to achieve the best possible result of the
Overall, studies showed that 6–8 weeks of static rehab.
stretching is sufficient to increase hamstring • Unfortunately, often neglected, a balanced
length. diet supports sports rehab in all areas.
9  Sports Rehabilitation 105

Take-Home Message strength, mobility and nutrition should be seen as

Rehabilitation protocols require teamwork, the key facts in order to prevent from injury
steady communication between athlete, medical through dysfunction. Criteria-based protocols
team and coaches as well as a detailed under- should be favoured in injured athletes, as time-­
standing of injury or surgery. Vital to each reha- based protocols do not take individual character-
bilitation are physiotherapy and manual therapy. istics of patients into account and increase risks
Signs of overtraining, stress, inflammation or of failure or injury.
pain should be considered carefully. Core
 The Role of a Strength
and Conditioning Coach
10
Telmo Sousa

10.1 Introduction system. The main actions of a coach include

communicating, motivating, and relating with
Working in elite level teams requires that profes- various people. Technical qualities, acquired
sionals from interrelated fields have expertise and mainly by the permanent search for updated sci-
knowledge to reach the collective goal—achiev- entific evidence, are the basis for high-quality
ing sports success. Establishing optimal commu- work, but besides that, as in any other profession,
nication between diverse professionals is crucial soft skills are a very important part of the work:
to upgrade your system and benefit your motivation, commitment, creativity, problem
athletes. solving, flexibility, and teamwork are keys for
With the advances in sports science, monitor- implementing proper strategies and achieving
ing software and technology, the amount of data success.
we have available is huge, but the key is not the The closest analogy for an elite athlete is to
amount of data we collect. The winning formula compare him with a Formula 1 car. When this
is to select and monitor important data, to share special car has a “screw” that is not properly
information with all collaborators, and to under- attached, it can work with minor problems for a
stand a common strategy of intervention in order short period of time, but later, this minor issue
to optimize performance. will become bigger and affect performance. We
It seems easy, but it isn’t. With the level of also have to remind ourselves that we are not the
specialization required by high-performance only person working with players. Injury preven-
training, we usually have more staff members tion and athletic performance directly depend on
than athletes. Throughout this chapter, my exam- the sum of a player’s multidisciplinary interven-
ples are mostly related to football, as it is my tions. In his daily routine, a player will work with
daily sport. An elite football team can have a masseur, physio, nutritionist, and S&C coach,
around 25–30 players but a greater number of among others, and will also have team training,
staff, including technical, medical, strength and so it’s crucial to understand the dynamic and the
conditioning (S&C), and sports science staff. influence of all these workers in a highly com-
Whether integrated into the technical or medi- plex global system. Also, the relation between
cal department, or as an independent department, accumulating fatigue and recovering effectively
a S&C coach should be a part of an integrated during a competitive week cycle determines what
we usually call training load (Fig. 10.1).
T. Sousa (*) Elite athletes, particularly football players, are
Futebol Clube do Porto, Porto, Portugal often exposed to year-long training with ­congested
e-mail: [email protected]

© ISAKOS 2019 107

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_10
108 T. Sousa

Fig. 10.1  Example of a

Formula 1 pit crew

fixtures competition, play consecutive matches, As long as the coaches are not involved in the
and are frequently limited to 3 days of recovery strategies of complementary work, the system of
[1]. Therefore, a minor problem can easily result injury prevention and performance simply will
in a major problem. In this case, a major problem not work.
is an injury that stops an athlete from training and Collective strategies should be made accord-
competition. Also, it will automatically decrease ing to a global model while respecting individual
his performance and athletic capacities. We need needs.
to individualize and adapt programs, as their In my perspective, instead of talking about
responses to training and competition depend on injury prevention, we should talk about training.
several factors and vary from day to day and week We should speak about making players robust
to week. We always have to interpret, make deci- enough to withstand technical and tactical train-
sions, and adapt strategies in a permanent search ing without getting injured.
to improve performance. This means that we want
to have athletes always in their best condition for
training and competition. They should be able to 10.2 Characterizing the Game/
tolerate high training loads and therefore maxi- Physical Parameters
mize exposure to technical and tactical coaching.
We have to prepare them for thousands of hours of Different sports require different approaches to
training and competition. physical training programs. To improve physical
In my opinion, the most important of all is to conditioning, and thereby enhance sports perfor-
have a club vision of developing athleticism mance, at both the individual and collective lev-
through the physical aspects of high performance. els, it is extremely important to have deep
The head coach and coaching staff should valo- knowledge regarding the physiological demands
rize and share this philosophy of work, under- of the game. It is likewise essential to have a
stand the importance of complementary work, baseline testing battery, early in the preparatory
and define global strategies with S&C coaches phase, to realize where we stand and to define a
and medical staff in order to have a common plan for where we want to go.
strategy and implementation. Above all, players In a football match, according to several stud-
should feel that this is a global strategy and that ies [2, 3], the total distance covered in the 1950s
we all must have mental resilience to create a cul- was between 4000 and 5000 m, which increased
ture of success through hard work in order to to 10,000 m in the 1990s.
achieve our main goal: excellence in a long-term Today, the mean total distance covered is
season. reported to be between 10,000 and 11,000  m,
10  The Role of a Strength and Conditioning Coach 109

with some players covering up to 14,000 m, and can decide a game, have become more frequent
almost one-fourth of this distance is covered in and intense.
high-intensity running (>14.4 km/h) [4]. Over the years, from the physical point of
Clearly, the total distances covered in the view, football has become increasingly demand-
modern elite-standard English League are much ing. Players are fitter, faster, and stronger than
higher than 40 years ago [5]. Also, the amount of ever before. Therefore, we must create strategies
high-intensity running is similar to that in the to develop our athletes in terms of physical
Italian Serie A and the Spanish La Liga [6]. capacities if we want to reach and stay at the top.
Thus, in terms of physical demands, team Football is characterized as a high-intensity,
sports are becoming more and more intense. intermittent game with both aerobic and anaero-
Barnes et al. studied more than 1000 individ- bic elements.
ual players across 7 seasons (between 2006/2007 Based on several studies [6, 8, 9], Solé J. cited
and 2012/2013  in the English Premier League) the distribution of effort time and the intensity at
and concluded [7]: which it is performed [10]:

• The total distance covered during a match • 49–54′—The player is standing or walking.
was 2% lower, which means that there were • 30–35′—Efforts of intensity less than 15 km/h
no significant changes between those 7 (70–80% VO2 max).
seasons. • 3–5′—Effort at intensities 15–25  km/h (90–
• The mean total of high-intensity running dis- 115% VO2 max).
tance (19.8–25.1  km/h) increased by 30%, • 2–3′—Effort at intensities greater than
with an associated increase of 50% in the 25 km/h (alactic-lactic).
number of high-intensity running actions.
• High-intensity running (with ball possession) Most of the investigations agree that the match
was lower in 2006/2007 (373 ± 238 m) com- HR average intensity is close to the anaerobic
pared with other seasons, apart from threshold (80–90% of maximal heart rate) [11,
2008/2009 (389  ±  242  m), peaking in 12].
2012/2013 (478 ± 260 m). Match average oxygen consumption is
• High-intensity running (without ball posses- 3.5 L/m, which is equivalent to 76% of VO2 max.
sion) was lower in 2006/2007 (451 ± 162 m) Different percentages of VO2 max are presented,
compared to other seasons, peaking in depending on the position occupied: 69%
2012/2013 (589 ± 198 m), as well as increas- defenses, 66% midfielders, and 43.3% forwards.
ing in mean by 22%. The approximate energy expenditure is 1530 kcal
• Total sprint distance increased by 50% den- in 90 min [13].
sity, as estimated by the number of sprints Therefore, athletes should be prepared to per-
against the percentage of explosive sprints form with relative ease these physical demands,
over the 7 premiership seasons. without showing symptoms of excessive fatigue.
• The number of sprints increased by 80%, and Fatigue following a soccer match is multifac-
an increased proportion of these sprints were torial and related to dehydration, glycogen deple-
explosive in nature (38%). tion, muscle damage, and mental fatigue [14].
• Maximal running speed attained increased 5%. The level of dehydration depends upon cli-
• Mean sprint distance was shorter by −15%, matic and atmospheric conditions (weather,
but the proportion of explosive sprints wind, temperature, humidity, and altitude).
increased by 35%. Moderate fluid deficits corresponding to ~2% of
body mass are common even in football matches
In conclusion, everything that is considered an played in neutral conditions [15].
intense action during the game, actions that are Scientific research helps to recognize the evo-
decisive in the creation of imbalances and that lution of sports’ physical parameters, particularly
110 T. Sousa

in football. This knowledge should be useful in and to understand the training load impact and its
talent identification and also when designing and effect on each athlete and the entire group.
monitoring training processes. Therefore, clubs Today, it is recognized that external and inter-
should invest in the individual development of nal loads are relevant components of load quanti-
young players if they want to increase the possi- fication for an effective monitoring system [18].
bility of achieving first team and higher competi- However, there is frequently dissociation between
tion levels. external and internal load units. So, to monitor an
athlete’s state of fatigue, individualization cannot
be over emphasized. External and internal mea-
10.3 Monitoring Training Load surements must be taken in account to make indi-
vidual adjustments and design programs.
Load is determined by the interaction of exer- But how can we monitor internal and external
cise duration, intensity, and frequency and can loads in our team sports teams?
be quantified by external and/or internal There is no absolute truth about the type of
­parameters [16]. monitoring tools that coaches should adopt [17].
Load monitoring is a common practice in pro- They should consider what is really important to
fessional sports, with 40 of 41 surveyed profes- evaluate and select effective tools for this
sional soccer teams reporting that they collect purpose.
load data for every player during every field
training session [17].
Enhancing performance requires a scientific 10.3.1 Internal Load
approach to load monitoring, managing risks
associated with possible inappropriate designs of Recent evidence suggests the importance of indi-
training programs. vidual load monitoring for detecting possible
Appropriate monitoring of training load can negative outcomes and reducing the risk of over-
provide important information to coaches, ath- training, illness, and injury. Also, the relationship
letes, and support staff. Monitoring systems between internal load (in the form of athlete self-­
should be intuitive and provide efficient data that reported wellness and subjective measurements)
can be easy-to-interpret in order to have proper and external load (objective measurements) on
feedback and understand individual and group match performance should be considered.
responses to training stimuli. In this way, coaches and support staff are
In elite sports, optimizing performance increasingly seeking a more current and scientific
requires exposing athletes to high training loads, approach for the monitoring process.
at their limits, so the associated probability of Rating of perceived exertion (RPE) is proba-
injury is high. At this level, that often means bly the most common means of assessing internal
training stimuli are on the borderline between load. Foster developed the session-RPE method,
optimal outcomes and injury risk. and evidence shows it to be a simple, free, valid,
To achieve the best physical condition requires and reliable tool of quantifying training load
optimal adaptation. For example, in team sports, [19]. Workload is quantified by multiplying the
postsession and accumulative fatigue must occur athlete’s RPE (on a 1–10 scale) by the duration of
during a match-to-match microcycle in order to the session (in min).
create proper adaptations and recovery and have Although moderate to strong correlations exist
athletes be fresh and better prepared for the between s-RPE- and HR-based measures of
weekend competition. internal load, none of these methods are consid-
With an increased number of technologies ered preferential or superior than the other. If
available, coaches should adopt scientifically possible, they should be used together because
valid tools to monitor internal and external loads they give complementary information.
10  The Role of a Strength and Conditioning Coach 111

The mean of the overall daily wellness scores a­ thletes with higher markers of stress will be less
can include athlete self-report questionnaire and available for strength training. Scientific insights
also can be used to quantify weekly wellness. derived from HR and HRV data suggest the need
Coaches can use pre-training self-reported well- for individualized training and recovery
ness to make adjustments to training if guidance.
warranted. Also, real-time HR monitors permit knowing
Results in Australian football confirm the and adjusting the time spent in HR zones.
value of quantifying load and determining train- However, measures of heart rate cannot pro-
ing status using self-reported measures and high- vide data on all aspects of wellness, fatigue, and
light the importance of a mixed-method approach performance, so they are still not widely imple-
to comprehensively assess athlete status [20]. mented to monitor athletes’ responses to training
Monitoring internal loads will give coaches load, probably because of apparent contradictory
feedbacks of athletes at risk of overtraining and findings in the literature [23].
others failing to reach a sufficient training Therefore, it is important to cross-check all
stimulus. information combining internal and external
Furthermore, the positive association between loads to take a more holistic approach to monitor-
field-based loads and objective match perfor- ing training status.
mance suggests higher loads improved perfor-
mance, particularly when combined with reduced 10.3.1.2  Self-Reported Wellness/
wellness scores. s-­RPE/A/C RPE Workload
Internal training load represents the psychobio-
10.3.1.1  Heart Rate Monitoring logical response to a given external load and can
Heart rate monitors have become commonly used be measured via numerous objective and subjec-
in all sports. In the last years, heart rate variabil- tive parameters.
ity (HRV) has become more popular. HRV can be Daily and/or weekly questionnaires and the
measured during ultrashort recordings (1–3 min) rate of perceived exertion are commonly used in
with the athlete in standing, seated, or supine field-based sports. However, like any subjective
positions. HRV reflects the variation in time parameter, consideration should be given to play-
between each heartbeat and appears to correlate ing experience, position, and time-trial perfor-
with recovery status. mance when interpreting athletes’ internal load.
Research has focused on identifying its asso- Research suggests that monitoring pre-­
ciation with athletic performance and recovery training perceived wellness may provide coaches
and illness. Furthermore, HRV has been investi- with information about the intensity of output
gated as a diagnostic marker of overreaching and that can be expected from individual players dur-
overtraining [21]. It can also be used to identify ing a training session [24]. Daily questionnaires
when the athlete may be more or less adaptive to commonly include rating of fatigue, sleep qual-
training (aiding training prescription) and poten- ity, general muscle soreness, stress levels, and
tially predict when an athlete may perform better mood.
or worse on a particular day [22]. It is agreed that The acute/chronic workload ratio (A/C) has
athletes with higher scores in HRV will be more received growing interest in recent years for
able to perform in endurance activities and monitoring injury risk in a variety of team sports.

Workload ratio acute / chronic = ( accumulated last 7 days ) / ( accumulated last 21 or 28 days )
112 T. Sousa

According to Malone S. and colleagues [25], different approaches, such as by installing cam-
players who were exposed to large and rapid eras around the facility (e.g., stadium or training
increases in high-speed distance (HSR) and ground) or, most commonly, having athletes wear
sprint distance (SR) had increased odds of vests with small devices that can be tracked by
injury. Conversely, better intermittent aerobic satellite. Then, at the end of a training session,
fitness and higher chronic training loads data will be downloaded to software for further
(weekly sums ≥2584  AU) counterbalance by analysis. This software must be easy-to-use and
decreasing the lower limb injury risk associated intuitive and give coaches information on total
with these running distances. An A/C workload distance covered, high-speed distance, maximal
at 1:3 weeks between 1.00 and 1.25 is consid- speed, number of accelerations and decelera-
ered to be protective for professional soccer tions, player load, and acute/chronic workload
players [25]. ratio, as well as many other parameters that can
A/C workload ratios at 1:3 and 1:4  weeks be chosen.
were associated with noncontact injury. Recently, In addition, this software allows coaches to
in a study of elite football, a greater risk of injury select the type of parameters they wish to ana-
was found for players with A/C workloads at lyze and also perform cuts to each exercise to
1:4  weeks of 0.97–1.38 and >1.38, compared understand and analyze the behavior of each
with players whose A/C workloads were 0.60– athlete in each exercise. Essentially, it gives
0.97. An A/C workload at 1:3  weeks of >1.42 coaches the possibility to interpret and make
compared with 0.59–0.97 displayed 1.94 times better decisions when planning training sessions
higher risk of injury. In conclusion, internal A/C and to adapt according to individual needs when
workload ratio (measured using s-RPE) is con- necessary. Also, in terms of the rehabilitation
sidered to be predictive of risk factors for non- process after injury, it is an excellent tool that
contact injuries in elite European footballers; allows comparing players’ individual values
however, it should be complemented by other before being injured, as well as comparing with
methods [26]. team demands during each training day and
This A/C workload ratio can be used for inter- cumulative training load for a week microcycle
nal load (session-rate of perceive exertion before the match. Thus, GPS allows for progres-
(session-­RPE)  ×  duration) and external load sive and controlled integration in the training
(often tracking variables such as total distance or process, thereby reducing the risk of reinjury
high-speed running distance). and allowing a secure and successful return to
play.

10.3.2 External Load 10.3.2.2  Neuromuscular Function

and Assessment
For external load monitoring, elite sports teams For S&C coaches, neuromuscular function is
usually adopt Global Positioning System (GPS), of crucial importance. Therefore, special empha-
time motion analyses, and power output measur- sis is given to monitoring devices that can evalu-
ing devices, such as strength training machines ate different movements/actions. Jump tests;
with the possibility to test, monitor, and analyze isokinetic, isoinertial flywheel equipment for
performance. eccentric training (also known as Yoyos such as
squat, hamstrings, and VersaPulley™); forces
10.3.2.1  GPS Analysis Software platforms; linear and rotational encoders; electro-
Athlete performance tracking systems are used myography sensors; and dynamometers are often
by elite teams all over the world in training and utilized in the team sport environment (Figs. 10.2
competition. This type of monitoring can have and 10.3).
10  The Role of a Strength and Conditioning Coach 113

10.4 Principles for Developing

Athletic Performance

About 20  years ago, a group of professionals

with diverse experiences but linked to team sports
emerged in Barcelona under the leadership of
Paco Seirul-lo. A new training paradigm was
emerging for team sports, and Julio Tous was
responsible for developing and specializing the
theme of Strength (Fig. 10.4).
I have been positively influenced by Julio
Tous’ guiding principles and methodology, along
with other decisive factors such as my ongoing
Fig. 10.2  Dynamometer testing adductor strength
reflective practice, experience, training, and the
expertise of many professionals that I have had
the privilege of working with over the years.
These crucial factors have both inspired and
molded my work in this field and lay the founda-
tion for what I believe to be the decisive premises
for a “Strength Training” approach at a profes-
sional level for team athletes.

10.4.1 Robustness as Primary

Prevention

Strength is surely the best prevention tool in elite

sports, and every S&C should always be alert to
injuries. Above, I discussed monitoring tools,
assessments/measurements, and different types
of tests. Testing is very important to achieve indi-
vidual enhancement, but there is another deter-
Fig. 10.3  Flywheel Yoyo squat mining factor—training!

Fig. 10.4  Adapted by: “Everything is strength”

Fajardo T. J. “Strength RPA STRENGTH Power
as a fundamental
physical capacity. El
entrenamiento en los
deportes de equipo”
(2017) (RPA repeated Endurance Speed
power ability: ROM
range of motion) Physical capacities that helps

Helps to maintain levels of strength Depends directly from strength

ROM Coordination
114 T. Sousa

The road to success is to study extensively, reg- Therefore, in order to decrease the odds for injury,
ularly apply science-based evidence, and be asser- coaching staff must consider player rotation, even
tive in the implementation of training programs. when time between matches is up to 5 days.
That makes the difference in terms of injury reduc- Hamstring strain injury is the most common
tion (because injuries will always happen) and injury in football, and there is scientific evidence
keeping athletes performing on the field. Some for large-scale interventions employing the
trainers spend a lot of time testing and little time Nordic hamstring. This exercise has reported
investing in what is really important—training! 50–70% reductions in hamstring injuries in foot-
In my opinion, in team sports, the application of ball when athletes are compliant [34–36].
individual programs to improve performance In addition, hamstring rehabilitation protocols
makes perfect sense as a complementary strategy. applying long length exercises are significantly
That is, in the preseason, detailed evaluation more effective in accelerating time to return to
(energy systems, strength, power, speed, flexibility, play from injury than conventional exercises [37].
and detecting postural imbalances) should be made Besides these observations, hamstring injury
of all players that compose the team, and a collec- prevention using Nordic hamstring protocols and
tive strategy should be defined. Then, based on the evidence-based injury prevention has not been
individual responses that are daily evaluated with adopted by the majority of Champions League
the available monitoring systems, individual adjust- football teams [38] (Fig. 10.5).
ments should be made in order to enhance perfor- As cited by Bourne M. et  al. [39], scientific
mance and reduce the risk of injury for each player. research has established that eccentric knee flexor
Thus, individual strategies must be as the strength reduces the risk of hamstring strain
name implies complementary work. They cannot injury when compliance is adequate and also
overlap collective strategies. Usually when this partly mediated by increases in biceps femoris
happens, it means that either there are no collec- long head fascicle length and, possibly, a right-
tive strategies or they are inadequate. ward shift in the angle of peak knee flexor torque,
In professional football, muscle injuries are as well as other adaptations that can also occur.
the most common injury type [27]. The authors also claim that acute responses and
Hamstring strains are the most prevalent mus- chronic adaptations to training with different
cle injuries reported in sport [28] and also have a hamstring exercises are heterogeneous. Muscle
high recurrence rate [29, 30], with lost training activation may be an important determinant of
and playing time in running-based sports [31]. training-induced hypertrophy; however, contrac-
Hamstring injuries are estimated to cost elite tion mode appears to be the largest driver of
soccer clubs as much as €280,000 per injury [32]. architectural changes within the hamstring [39].
Top-level professional football teams regu-
larly play within a 72-h interval (representing
one-third of matches), which increases neuro-
muscular fatigue and the risk of injury [4].
According to Bengtsson [33], in a 14-year pro-
spective study with more than 130,000 match
observations, there were no match congestion-­
related differences in total match injury rates, but
muscle injury rates during matches were lower
when players were given at least 6 days between
their match exposures. Furthermore, statistically
significant more hip/groin muscle injuries were
observed when matches were separated by ≤3 days
compared with ≥6 days since the last match expo-
sure, for male professional football players [33]. Fig. 10.5  Nordic hamstring exercise
10  The Role of a Strength and Conditioning Coach 115

Strength training appears to be the most effec- 10.4.2 Developing Single-Leg

tive way of reducing hamstring injury rates, Strength
although acute responses and chronic adaptations
to training with different exercises are not uni- Over the years, team sports have adapted strength
form. Furthermore, S&C coaches may design methods, characterized by classical bilateral
training interventions based on scientific evi- movements and which predominantly occur in
dence, sensitivity, and expertise. It’s also very the vertical plane, from weightlifting. In team
important to take into account players’ experi- sports, movements are mostly unilateral, and
ences and histories of practice because different lower body strength must be used to improve
players can have different responses to the same agility (commonly called COD ability).
stimulus. The nature of the exercise stimulus These whole-body movements involve decel-
(i.e., the intensity, duration, and number of series erating, changing direction, and accelerating
performed, as well as the duration and activity while also maintaining balance during these
patterns during recovery) and timing of applying maneuvers. Figure  10.6 shows an example of a
these exercises should depend on the best day, VersaPulley exercise based on horizontal forces
according to a match-to-match microcycle. In to improve COD ability, thus ensuring best trans-
addition, players’ levels of experience and indi- fer from the weight room to the playing field.
vidual responses, team periodization, and accu- Taking another example, now in a vertical
mulative fatigue should be considered when exercise, a squat in a unilateral pattern (single-leg
carrying out these programs before (having fresh squat) will be substantially more demanding
athletes) or after training (consider training under from a neuromuscular point of view. Doing this
fatigue). For example, when planning an in-­ obtains a greater activity of action of the ham-
season 7-day microcycle (if matches always fall strings, gluteus medius, and trunk stabilizers. The
on a Sunday) and including one gym session to one-leg box squat is the most “famous” of the
maintain strength levels, the best day would single-leg exercises. It requires stability from the
probably be Wednesday (+72  h after the match opposite leg and pelvic stabilizers must function
day —MD  +  3) or Thursday (−72  h before the as stabilizers. This stabilization is needed for
match, MD − 3). In this case, taking advantage of acceleration and sprinting actions. Therefore, this
the midweek means having athletes be fresh and exercise is closer to game actions in team sports.
recovered from the game and still having time for
the athletes to recover fully from the strength S&C should create efficient and effective workouts
stimulus before the next game. based on:
In my personal opinion, the most effective • Working with body weight
• Improving core stability and strength
way to reduce hamstring injury rates is to define
• Adding functionality to your program
global strategies (in agreement with technical • Enhancing/optimizing movement efficiency
and medical staff) and then make adjustments for • Building strength in key movement patterns
individual needs. It’s important to involve every- • Looking for “movement quality” instead of
one in the process, especially the athletes. repetitions/series

Fig. 10.6  VersaPulley crossed COD

116 T. Sousa

10.4.3 Taking Advantages While concentric contractions initiate move-

of Eccentric Training ments, eccentric contractions slow or stop them.
The figure below shows an example of a crossed
The benefits of eccentric overload training are change of direction (COD) in VersaPulley. This
well accepted and well-known by professionals exercise simulates the deceleration-acceleration
in the field of injury prevention and sports that happens in the field when a player changes
training. direction (eccentric overload monitored with
Maximal decelerations are key movements in Smartcoach analysis software) (Fig. 10.7). In this
team sports, and deceleration (eccentric action) way, it allows us to have real-time feedback of
reduces the great moment of horizontal force, the intensity of each repetition (and the type of
thereby facilitating a more efficient support in the contraction—concentric or eccentric), as well as
moment to apply a greater propulsive force to record and compare different moments and
(acceleration—concentric action). follow its progression.
Eccentric contractions force muscles to lengthen
and concentric contractions force muscles to
shorten. Depending on periodized training, the ath- 10.4.4 Power Sessions/Explosive
lete’s level and historical of practice, after eccentric Performance
exercise muscle pain can occur, the so-called
delayed onset muscle soreness (DOMS). Examining the great players of modern-day
Periodizing your training session carefully is cru- team sports shows that they all share common
cial in order to achieve the best results. Thus, when characteristics—speed and power. Thus, all
planning workouts, coaches must be conscious of coaches try to enhance these characteristics in
athletes that are unaccustomed to eccentric training their players so that they can put them into prac-
and thus increase the intensity and duration of the tice in the field.
proposed exercises in a progressive way. What a few years ago would be unthinkable,
The available evidence indicates that eccentric such as doing power sessions on the day before
overload exercises are more effective in strength an important game, is now a regular practice in
gains and hypertrophy, and there is scientific evi- many teams.
dence showing positive effects after the damage There is increasing scientific evidence that
caused by lengthened muscle contractions. As a shows the benefits of these low volume ses-
consequence, this causes an adaptation process with sions, with long and full recovery rests, which
an increase in sarcomere numbers in muscle fibers. include exercises with low/moderate loads exe-
Following the damage created by eccentric cuted at maximal speed. Tsoukos and col-
exercises, muscles rapidly adapt to the optimum leagues [40] concluded that five sets of four
length for active tension, thereby decreasing the repetitions of jump squats with 3  min of rest
injury risk by protecting muscles against more improved neuromuscular performance in the
major injuries. lower limbs 24 as well as 48 h after a resistance

Fig. 10.7  Examples of Smartcoach overviews

10  The Role of a Strength and Conditioning Coach 117

Fig. 10.8  Lateral eccentric squat (COD)

transfer (with a low number of repetitions, full

rest, and low load and based on speed execution)
(Figs. 10.8 and 10.9).

Take-Home Messages
• Build robust players to reduce the odds of
injury.
• Develop athleticism to support technical
skills.
• Don’t forget that athletes should perform on
the pitch, as many times as possible, in train-
ing and competition.
• Design workout programs based on “high-­
quality movements,” speed, power, and
agility.
• Develop unilateral (single arm/leg), multidi-
rectional, and velocity-based workouts.
Fig. 10.9  Example of COD exercise transfer • Individual approaches should focus on an ath-
lete’s weaknesses.
training session, with greater enhancement • Athletes benefit from eccentric overload,
observed after 24  h. Therefore, low volume either for enhancing their performance or
resistance training and a high-quality training helping them recover from injuries. Even so, it
session 1 day before an important competition may induce DOMS, especially in the case of
improve athletes’ performance in all power- an unusual exercise.
based sports [40]. The success of a “strength program” depends
The images below show an example of com- on everyone involved in the training process:
bining a sequence of two exercises with a COD coaches, medical staff, and athletes.
118 T. Sousa

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 Sport Injury Primary
and Secondary Prevention
11
Rogério Pereira, Renato Andrade,
Alexandre Rebelo-Marques,
and João Espregueira-Mendes

11.1 Background constantly interact). Athletes and other sports

agents are always in a hurry to return to play after
In the former three decades, there is a growing injury, and more people in general are being
body of evidence concerning the efficacy of pre- enrolled on large-scale actions striving for physi-
ventive measures of sports injuries [1–3] and cally active life styles’ promotion as it is the case
reinjuries (defined as an injury of the same type of the World Health Organization (WHO) Global
and at the same site as an index injury in the pre- action plan on physical activity and health 2018–
ceding year) [4, 5]. This comes handy as the 2030: “More active people for a healthier world.”
number of participants in organized youth sports Hence, sports injury preventive evidence-based
is on the rise, with increasing number of games, measures should be strongly stimulated, continu-
and more competitive sporting modalities seem ously developed, and widely and systematically
to be demanding more from human development implemented in broad ecological settings to
domains (and these are not discrete, i.e., they reduce injuries, narrow gaps between research

R. Pereira (*) Dom Henrique Research Centre, Porto, Portugal

Clínica do Dragão, Espregueira-Mendes Sports Faculty of Medicine, University of Coimbra,
Centre—FIFA Medical Centre of Excellence, Coimbra, Portugal
Porto, Portugal
Coimbra Institute for Clinical and Biomedical
Dom Henrique Research Centre, Porto, Portugal Research (iCBR), Coimbra, Portugal
Faculty of Sports, University of Porto, Porto, Portugal J. Espregueira-Mendes
University Fernando Pessoa, Porto, Portugal Clínica do Dragão, Espregueira-Mendes Sports
e-mail: [email protected] Centre—FIFA Medical Centre of Excellence,
Porto, Portugal
R. Andrade
Clínica do Dragão, Espregueira-Mendes Sports Dom Henrique Research Centre, Porto, Portugal
Centre—FIFA Medical Centre of Excellence, Medicine School of Minho University, Braga,
Porto, Portugal Portugal
Dom Henrique Research Centre, Porto, Portugal ICVS/3B’s–PT Government Associate Laboratory,
Faculty of Sports, University of Porto, Porto, Portugal Braga/Guimarães, Portugal
e-mail: [email protected] e-mail: [email protected]
A. Rebelo-Marques
Clínica do Dragão, Espregueira-Mendes Sports
Centre—FIFA Medical Centre of Excellence,
Porto, Portugal

© ISAKOS 2019 121

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_11
122 R. Pereira et al.

and athletic community uptake, decrease the significant facts to lever all stakeholders embrac-
asymmetries in access, and aim for comprehen- ing injury prevention mandatory cause. If up to
sive public health strategies. Risk management today prediction is not possible [11, 12], effective
strategies may lead the way to reduce the sport and cost-effective preventive interventions asso-
activity-related injuries and increase the outcome ciated with sports-related injuries are not utopic
of benefit-risk ratio in all participation levels. [13]. Compliance and maintenance of evidence-­
These strategies comprehend injury surveillance, based injury prevention programs and broad
pre- and in-season meetings to refine strategies community adoption is what is lacking the most
with technical staff, accounting with their plan- [14]. A more comprehensive knowledge of the
ning, overlooked and/or unpredictable facts, reg- risk factors and injury mechanisms, with their
ular screening of athletes, and implementation of complex interplay, and to what extent they could
prevention programs. All stakeholders should work in a synergistic manner to influence the out-
work together to provide regular participation in come is also lagging. This will certainly allow
sports or physical activity, ensuring a safe and improved interventions aiming for prevention
effective exposure to reach the most from health-­ within an ever-changing context, in which a
related benefits and performance goals. This sports-related injury may occur or prevail.
must be accomplished as part of health profes- This chapter will address in a step-by-step
sionals’ governance and will impact positively in (with chronological sequences of knowledge
sports and health achievements and, at the same development and with incidence on research
time, reduce the societal and economic burden translation into practice) and critical approach
from injuries. In the European Union, there is a the sports injuries challenge. This, fortunately
cost higher than two billion euros only with direct will engage readers by providing key rationales
medical costs associated with sports injuries and facts to keep athletes healthy while continu-
treatment [6]. ous and simultaneously developing their athletic
There is strong scientific evidence reporting skills and teams’ sporting and financial perfor-
efficacy and effectiveness particularly of exercise-­ mance [15].
based interventions in reducing most common
sports injuries within adult semi- and profes-
sional levels [2, 7–9]. Beneficial effects of injury-­ 11.2 P
 redisposing Risk Factors
specific and multimodal exercise-based and Injury Mechanisms
prevention programs have also been reported in
youth athletes with high efficiency in reducing Several risk factors have been identified that may
sports injuries (injury reduction superior to 40%) predispose the athlete to risk of injury including
[6, 10]. For purposes of intelligibility of this anatomical, biomechanical, neuromuscular, envi-
chapter, the authors consider primary prevention ronmental, developmental, hormonal, and geneti-
as all actions aiming to avoid a first-time injury, cal [16–18]. These can be divided into intrinsic
which may imply a functional or structural (within the body) and extrinsic (outside the body)
impairment, and secondary prevention as inci- and to modifiable and non-modifiable risk factors.
dence of a reinjury of early recurrence (within Both the intrinsic and the extrinsic risk factors may
2  months after full return to participation from interact making the athlete susceptible to injury
the index injury), late recurrence (after more than [19, 20]. Intrinsic risk factors often include occur-
2 months), or delayed recurrence (after more than rence of previous injury, increased body mass
12 months). index, gender, age, individual genetic predisposi-
Despite the need to acknowledge and work on tion, neuromuscular and strength impairments,
its complexity—if we are to truly address the anatomical malalignments, anthropometric varia-
dynamic web of causation—to enable and facili- tions, abnormal kinematics, and genetic predispo-
tate fundamentals acquisition, some simplified sition. In turn, extrinsic risk factors comprise
pedagogic exercises will be presented as fast and environmental conditions, training and match sur-
11  Sport Injury Primary and Secondary Prevention 123

faces, high total exposures hours, inappropriate vention strategies of those at risk of sustaining
training (volume, magnitude, speed of loading, injury. These are often related with biomechanical,
frequency, inclination, fatigue, wrong sportive neuromuscular, and structural deficits which can
gesture, abrupt or acute modifications in amount be addressed in order to reduce the predisposition
or type of load), player position, and poor equip- to the specific injury. On the other hand, although
ment utilization (e.g., wrong footwear). Still, these most of extrinsic risk factors can be modifiable,
risk factors will not directly cause an injury, but these depend upon on a myriad of external factors,
rather predispose the athlete to a certain level of which may be due to random circumstances (e.g.,
risk, before an injury-inciting event takes place environmental conditions of the training or match
[19]. Inciting events can appear at any time (train- or a player-to-­player interaction).
ing or match situations) and comprise several fac- As female athletic participation has been fast
tors, such as playing situation, player and/or growing worldwide—in Europe there are 6 coun-
opponent behavior, individual gross (whole body), tries with more than 100,000 football players and
and specific biomechanical characteristics [20, 30  million at worldwide level [25]—it is of
21]. Thus, a precise and comprehensive descrip- upmost importance to understand the gender-­
tion of the inciting event, by extending the tradi- specific risk factors, such as developmental dif-
tional biomechanical model, is key to better ferences; anatomical, biomechanical, and
understand the multifactorial nature of injuries and neuromuscular differences; hormonal-specific
better match prevention strategies that can either characteristics; sexual maturation; and anthropo-
address intrinsic and extrinsic risk factors, proxies, metric specifications [26–28]. Moreover, female
and their interplay. This interplay can be illustrated athletes have different sport-specific biomechani-
by picturing a player with an increased risk of sus- cal and skills performance [29–33], and there is a
taining an anterior cruciate ligament (ACL) tear, need to adapt the training loads and intensities to
which is a female (intrinsic and non-modifiable their physical demands and capacities [26].
risk factor for ACL), associated with artificial In the last few decades, a considerable amount
floors [22] when playing handball (extrinsic and of research has been conducted to explain the aeti-
modifiable factor and proxy that seems to predis- ology of sports injuries and to propose implemen-
pose to an injury mechanism), which may be aug- tation models for sports injury prevention
mented by unanticipated perturbation of the trunk (Table 11.1). Initially, there was a trend to linear
[23] and/or gender differences in proximal control causal-effect models, i.e., identify a specific pre-
of the knee joint [24]. Thus, knowing facts, it disposing risk factor and implement a preventive
becomes evident that preventive strategies must strategy on this specific risk factor [34]. Then, it
address several dimensions of the player and the was understood that there was no linear casual-
game including athletes’ physical and motor prep- effect relationship between a single risk factor, but
aration, floor type, rules of the game, and others an interaction of a complex web of several differ-
identified either as risk factors or injury-inciting ent factors which led to the development of several
event components, particularly, if these are prone multifactorial risk of injury models [35, 36].
to modification or manageable in nature. The main More recently, the exposure to training
focus of preventive measures is on those risk fac- and  workload-injury relationships has gained
tors that are modifiable, but all those players and increasing interest as one of the main risk factors
individuals that are at higher risk of injury (either for athletic injury and reinjury. Within this line,
modifiable or non-modifiable) should take part in Gabbett has disseminated the training-injury
prevention programs. prevention paradox based on a ratio of the ath-
The intrinsic risk factors are directly related to lete loading exposure—the acute-chronic work-
the individual characteristics, and its modifiability load ratio (last week load, divided by the last
is not always possible. Nevertheless, knowledge 4 weeks load) [46]. The workloads may be inter-
regarding both modifiable and non-modifiable nal (e.g., individual perceived effort) or external
intrinsic risk factors may be used to target inter- (e.g., exposure ­measured as training and match
124 R. Pereira et al.

Table 11.1  Relevant scientific references on aetiology of sports injuries and models for injury prevention
Year Model First author Reference Citations
1983 First randomized controlled trial on sports injury J. Ekstrand Ekstrand et al. (1983). Int J 438
prevention [37] Sports Med. 4:124–28
1992 Stage sequence of prevention [34] W. van van Mechelen et al. (1992) 1341
Mechelen Sports Med. 14:82–99
1994 Dynamic, multifactorial model of sports injury W. Meeuwisse Meeuwisse (1994). Clin J 417
aetiology [38] Sport Med. 4:171–5
2003 Adapted Meeuwisse model [14] R. Bahr Bahr et al. (2003). Br J Sports 636
Med. 37:384–92
2005 Injury risk model [39] A. McIntosh McIntosh (2005). Br J Sports 95
Med. 39:2–3
2005 Understanding injury mechanisms [21] R. Bahr Bahr et al. Br J Sports Med. 817
39:324–9
2006 TRIPP framework [40] C. Finch Finch (2006). J Sci Med Sport. 508
9:3–9
2007 A dynamic, recursive model of aetiology in W. Meeuwisse Meeuwisse et al. (2007). Clin 330
sports injury [19] J Sport Med. 17:215–9
2010 Behavior factor for sports injury prevention [41] E. Verhagen Verhagen et al. (2010). Sports 91
Med. 40:899–906
2010 RE-AIM framework expanded [42] C. Finch Finch et al. (2010). Br J Sport 163
Med. 44:973–8
2011 “No long lost in translation”—Implementation C. Finch Finch (2011). Br J Sports Med. 92
science notes [43] 45:1253–7
2014 Seven steps for developing and implementing a D. Padua Padua et al. (2014) Clin Sport 25
prevention model [44] Med. 33:615–32
2015 Complementary and alternative conceptual A. Hulme Hulme et al. (2015). Inj 22
approach for prevention of sports injury [36] Epidemiol. 2:31
2016 Complex model for sports injuries [35] N. Bittencourt Bittencourt et al. (2016). Br J 66
Sports Med. 50:1309–14
2018 Revisiting the first step of the “sequence of C. Bolling Bolling et al. (2018). Sports NA
prevention” [45] Med. (Epub)

hours). The concept suggests that inadequate increased or decreased [47]. Despite the athlete’s
planning of periodization of team may raise the cumulative training workloads, load spikes
probability of players sustaining an injury. Thus, should be avoided especially in undertrained
it is important to both consider the acute and athletes, as they may lead to fatigue and increase
chronic workloads and, through a detailed and the injury risk [46, 48–50]. Rather, a consistent
programed training schedule, find the so-called training may provide resilience and result in pro-
sweet spot for the individual athlete and, consid- tection from injuries [49]. This concept is not
ering the athlete’s profile, manage the acceptable exclusive to the individual athlete and may be
level of injury risk if beyond. This will vary for used planning the periodization of a team [47].
each individual or team and depends on the cur- Guidelines for interpreting and applying training
rent athlete characteristics (development stage, monitoring data have been published [51, 52].
recovery of an injury, specific physical demands) Recently, the acute-chronic workload ratio has
and the sport-­specific and extrinsic factors (type been reported considering different sports,
of sports, season timing, proximity of an impor- including football [53, 54], rugby [55–57], gaelic
tant game). Nevertheless, this should not lead to football [58], and others.
the misconception that the acute-chronic work- One of the cornerstones of injury prevention
load ratio is capable of predicting injuries and programs is correctly identify and describe the
should be rather used to make informed deci- extent of sports injury, i.e., the injury incidence
sions when the athlete’s injury risk may be and severity. While it is only possible to treat or
11  Sport Injury Primary and Secondary Prevention 125

prevent what is known, the extent of injury is also ments, previous injury) which reveal an associa-
determinant to achieve risk matrix calculations, tion with a specific type of injury and may be
i.e., to support risk assessment by considering the manageable by effective evidence-based preven-
category of probability or likelihood against the tive interventions. While some of these are modi-
category of consequence severity. This qualita- fiable (e.g., strength and neuromuscular deficits),
tive risk analysis is a simple mechanism to others are not (e.g., previous injury). Thus, the
increase visibility of risks and assist stakeholders dynamic nature of some risk factors and recur-
to effectively manage it within a sporting setting. sive nature of athletes’ participation endorse peri-
Along with the promotion of sport and physical odic surveillance in order to update and manage
activity and acknowledgment of all the related risk profile. A more comprehensive understand-
benefits, there is a risk to sustain injuries. In turn, ing of causality supports the development and
this correlates to dropouts of youth participation implementation of more effective preventive
in sport and physical activity which can hamper strategies and suitable countermeasures. Ditto,
long-term health and well-being. Thus, evidence-­ this will reduce the number of athletes that will
based injury prevention programs and their trans- experience potential injury mechanisms if the
lation to community-based scenarios—with a number needed to treat is observed according to
strong focus on adherence and its evaluation— the absolute risk reduction. Despite that effective
are a priority to make the most from countermea- sports injury prevention to some extent is an
sures. This implies a previous assessment of option and taken just by a few, those with delayed
causation by a multifactorial point of view, onset of call of duty are in opposition to another
weighing how potential interactions between reality where some athletes could be spared from
intrinsic and extrinsic risk factors predispose an injury.
individual to injury.
The inciting event (e.g., pitch with greater
grip, slippery surface, contact with an opponent) 11.3 Exposure
is the final and proximal link in the web causation
which enables an injury mechanism lead to injury A comprehensive and precise registration of
[38]. A comprehensive and multidimensional athlete exposure is crucial as denominator for
characterization of the inciting event is important accurate data collection procedures. This, espe-
to underpin the different domains, including the cially within prospective cohort studies, allows
athlete’s (physical fitness, skill level) and sports’ to seek for relationships between the number of
(rules, turf type) related factors and others which new injuries during a specified time period and
may be addressed to prevent injuries [21]. Even the variables or risk factors within a population
though injury mechanisms—especially under a of athletes. Beyond attendance and duration (in
classical and isolated biomechanical point of minutes) in training and matches, other descrip-
view—often received the focus from the health tive information for each individual may be
professionals actuating within sports medicine, explored. This may include weather conditions
prevention practices have been evolving. [59, 60], floor or turf type [22, 61], training and
Fortunately, the neuromuscular and biomechani- match load [53, 54], pitch count [62, 63], and
cal screening and load management strategies compliance with use of protective equipment
that are being applied more frequently nowadays [64, 65], just to mention a few. These variables
are good examples that more attention is being may be sorted according to study-related spe-
directed to risk factors that, even being distant to cific purposes [66]. The incidence of injuries
the outcome and/or injury, need to be managed to should preferably be reported as the number of
reduce likelihood and/or severity of sports inju- injuries per 1000 player-hours, rather than ath-
ries. These may be referred to as prospective risk lete-exposures (being an exposure a training
factors (e.g., strength deficits and/or bilateral or session or match), as the duration of exposure
unilateral asymmetries, motor control impair- units will vary. Naturally, it is also interesting to
126 R. Pereira et al.

have incidence rates in relation to training or 1. The need for understanding the implementa-
match exposures or type of floor (wooden or tion context (personal, environmental, soci-
artificial) exposures, and these can and should etal, and sports delivery factors).
also be recorded. When reporting injuries or 2. The evaluation of implementation process of
reinjuries—irrespective of type of exposure—it preventive measures.
is also essential to adopt the same definition of
injury [66] (i.e., “all,” “medical-­attention,” or TRIPP model builds on the unquestionable
“time-loss” injuries) as it is well known that the fact that only research that can and will be
injury definition can often underestimate the adopted by sports main stakeholders (such as par-
extent of overuse injuries. The modified version ticipants and their coaches or health providers)
of the overuse injury questionnaire (mOIQ) will prevent injuries. This is critical, since it is
which was developed and validated by the Oslo known that even having identified effective inter-
Sports Trauma Research Center (OSTRC) [67] ventions, the process frequently falters at the dis-
provided a superior insight of the magnitude semination, implementation, and maintenance
and burden of knee injuries in volleyball play- phases. Moreover, feasibility assessment and
ers. Using the time-loss definition—an injury potential for broad uptake of preventive interven-
that results in a player being unable to take full tions should precede large investments in trial-­
part in future training or match—20% of partici- based evaluation as there is little to be gained
pants reported that they had knee injuries, but, from proving efficacy of an intervention that, for
in opposition, when using the mOIQ, 85% whatever the reasons may be, will never be
reported a knee problem and 67% sustained a accepted by sports main stakeholders [69]. The
substantial knee problem [68]. Therefore, along TRIPP framework was considered to provide a
with surveillance methodology, it is determinant practical and meaningful approach to research
to be aware of the injury definition used in order within sports injury prevention, and therefore its
to provide consistency in injury occurrence and adoption was recommended to all researchers in
burden reporting and interstudy comparison the field [69].
[66, 68]. Later, Padua and colleagues [44] reported that
the TRIPP framework did not provide specific
guidance on the steps required to develop (TRIPP
stage 3) and implement injury prevention pro-
11.4 Models for Research grams (TRIPP stage 5) that have been proven to
on Sports Injuries be effective. The seven steps are indexed to the
Prevention and Translation stages 3 and 5 of the TRIPP framework (Fig. 11.1),
of Evidence into Practice being highlighted that key stakeholder’s involve-
ment and the development of an interdisciplinary
The “sequence of prevention” of sports injuries implementation team facilitates the identification
of van Mechelen et al. [34] has been revisited for of barriers and solutions for the development of
more than 25 years. First, Finch [40] added two an evidence-based and context-­specific exercise-
steps to the “sequence of prevention,” advancing based injury prevention program. This increases
a new sports injury prevention research frame- odds of buy-in, high-level implementation com-
work—the Translating Research into Injury pliance and maintenance of the program, and
Prevention Practice (TRIPP) framework. This related implementation strategies, i.e., these seven
was intended to overcome the real-world imple- new steps optimize the translation into practice of
mentation limitations of the former model by evidence-based prevention programs within real-
describing and assessing the intervention imple- world settings. Nonetheless, it has to be acknowl-
mentation context and the effectiveness of injury edged that Finch and Donaldson [42] had
prevention programs. The two steps added previously recognized that despite the availability
include: of ­evidence-­ based interventions, there was a
 The sequence of prevention TRIPP framework
7 steps for developing and implementing a prevention model
van Mechelen et al. (1992) Finch (2006) J Sci Med Sport. 9:3-9
Sports Med. 14:82-99 Padua et al. (2014) Clin Sport Med. 33:615-32

1. Establishing the extent of injury ENSURE SUPPORT FROM STAKEHOLDERS 1

1. Injury survailance
(incidence and severity)

2. Establishing the aetiology and 2. Establishing the aetiology and DEVELOP MULTI- AND INTERDISCIPLINARY TEAM 2
mechanism of injury mechanism of injury

IDENTIFY BARRIERS AND SEARCH FOR SOLUTIONS 3

3. Introducing the preventive measure 3. Develop preventive measures
11  Sport Injury Primary and Secondary Prevention

4. Assessing its effectiveness by 4. "Ideal conditions" / scientific DEVELOP CONTEXT-SPECIFIC EVIDENCE-BASED PREVENTION PROGRAMME 4
repeating step 1 evaluation

5. Describe intervention context to EDUCATE AND SUPPORT THE DELIVERS OF PREVENTION PROGRAMME 5
inform implementation strategies

6. Evaluate effectiveness in MONITOR THE PREVENTION PROGRAMME IMPLEMENTATION AND PROVIDE FEEDBACK 6
implementation context

ENSURE SMOOTH SUPPORT WITHDRAWAL AND EMBED IMPLEMENTATION STRATEGIES 7

Fig. 11.1  Adaptation of the seven-step model for effective injury prevention program design and implementation from Padua et al. [44], incorporating the “sequence of preven-
tion” [34] and TRIPP [40] models
127
128 R. Pereira et al.

major gap in injury prevention implementation (up to March 2010) investigated implementation
and, therefore, provided a novel extension to the and effectiveness. This fact reflects part of why
RE-AIM framework (Reach, perceived implementation and maintenance of preventive
Effectiveness, Adoption, Implementation, and measures often fail and the existing gaps that sep-
Maintenance)—the RE-AIM Sports Setting arate the complementary different kinds of con-
Matrix—as a way to embrace the delivery-setting tent, process, and context experts [14]. Particularly,
complexity and optimize intervention delivery stepwise approaches for implementation and eval-
and evaluation. Additionally, Finch [43] previ- uation of evidence- and exercise-­based injury pre-
ously discussed that the way interventions were vention programs are still lagging. Thus, studies
developed and delivered was the reason why such as the one above referred by Finch et  al.
implementation of preventive strategies often fail facilitating the widespread and adherence of an
and that scientific literature of injury intervention evidence-based injury prevention program [71],
implementation studies was lagging. Thus, sup- the one of Bizzini et al. [72] developed to imple-
ported on the six steps of the Intervention Mapping ment the FIFA 11+ in national member football
protocol, an iterative path from problem identifi- associations, that on awareness and use of the 11+
cation to problem-solving or mitigation devel- injury prevention program among coaches of ado-
oped a scaffold within which empirical evidence, lescent female football teams in Football
relevant theoretical constructs, contextual knowl- Federation Victoria [73], and the above referred of
edge, and context-specific experience come Padua et al. [44] are crucial for an effective reduc-
together to inform the development, implementa- tion of sports injuries and optimization of the
tion, and evaluation of injury prevention pro- benefit-risk ratio.
grams—https://interventionmapping.com/. Finch
[43] also gave insight on social theories such as
diffusion of innovations theory which relies on 11.4.1 Gap into Practice
communication of new ideas within multilevel
ecological structures, with the purpose of achiev- Even when a specific prevention program proves
ing some form of behavioral or social change, its efficacy under controlled study conditions, this
outlining an agenda for sports injury intervention rarely translates into practice. Thus, it is crucial to
implementation research. In a subsequent publi- advance with implementation research, providing
cation [70] extends the discussion on the need to detailed information about context-­specific imple-
use concepts from Implementation Science as mentation strategies. These must be supported by
requirements for successful intervention imple- a strong theoretical basis and should cover ques-
mentation. In fact, to make a point on the rele- tions such as why and how the injury prevention
vance of implementation drivers, Finch and program or specific exercises were selected and
colleagues [71] show how they could be applied delivered and to what extent these were effective
to facilitate the widespread and adherence of an in reaching and changing the behavior of targeted
evidence-based coach-delivered lower limb injury audience [70]. Thus, the health belief model [74]
prevention program in a community-level and RE-AIM framework [42] can help to system-
Australian football clubs [71]. Also in this line, atize outcomes of the interventions and knowl-
Bolling et al. [45] recently revisited the first step edge about drivers for engagement [75]. Despite
of the “sequence of prevention” and acknowl- that underpinning concepts of Implementation
edged the complexity of sports injuries and their Science such as engaging intervention end users
prevention and, particularly, the need to establish in the planning and operationalizing of imple-
the extent of the injury problem considering the mentation activities were already adopted into
athlete in the center of a socioecological model. sports injury prevention implementation, it seems
Interestingly, a work done by Klügl et  al. [13] that implementation drivers such as competency,
found that only 1% of all English language publi- organizational, and leadership need to be consid-
cations related to sports injury prevention research ered with a p­rofound understanding of their
11  Sport Injury Primary and Secondary Prevention 129

p­ urpose and application within an ecological set- is still insufficient [89]. Responsibility and gov-
ting of a sports injury prevention evidence-based ernance have to be called into action with partic-
program [70]. ular incidence in children and adolescent in sport.
The wide variety of effective prevention strat- Hence, the sports medicine professionals sup-
egies reported in the literature did not close the ported on evidence-based preventable measures
gap between injury prevention research and and their positive outcomes at different levels
player safety behavior and practices [14]. In fact, (health-related, competitive, and financial) must
looking at sports-related injury prevention inter- play a major role bringing together a responsibil-
ventions, the involvement from context and pro- ity hierarchy based on potential influence [90].
cess experts is scarce. Therefore, if multiple Injury prevention measures have to merge as core
interrelated contextual factors are not addressed, value and culture signature of every sports orga-
a big gap between efficacy and effectiveness will nization and ruling bodies.
persist. Moreover, it must be kept in mind that
internal validity does not assure external
validity. 11.5 Injury Primary Prevention
The transition from stage 3 (scientific devel-
opment and testing of interventions) to stage 4 Ekstrand et  al. [30] published in 1983 the first
(dissemination and widespread adoption) of the randomized controlled trial (RCT) reporting the
public health model [14] is the greater challenge. results of the implementation of an injury preven-
However, even within the third step of the public tion program in 180 amateur male football play-
health model, there are several challenges that ers achieving 75% of reduction of the injury
need to be overcome. Compliance (often used rates. Since this major landmark study, injury
interchangeably as implementation fidelity [76]) prevention programs have been evolving, and
is used to indicate if the athlete is correctly fol- there is a growing body of evidence of their sub-
lowing prescribed instructions of a sports injury stantial injury-preventing effect.
prevention program, for example, dosage, timing,
and frequency. In an intention-to-treat approach,
compliance to the injury prevention program is 11.5.1 Multimodal Injury Prevention
crucial to better judge the efficacy of a preventive Programs
strategy. In large RCTs on injury prevention, con-
trolling and influencing the individuals may Multimodal injury prevention programs often
become an almost impossible task as this is include general and specific muscle strengthening
dependent on their own motivation levels and and conditioning activities as running drills
others stakeholders’ interference [77]. Thus, pre- (recently with special focus on running tech-
vention strategies should be designed consider- nique), motor learning and motor control exer-
ing the end-user context [78]. Higher compliance cises, strengthening, plyometrics, proper
to injury prevention programs has shown to sig- technique during landing, agility, specific ana-
nificantly decrease the overall injury rate [79– tomical regions mobility, and kinetic chain
83]. In turn, adherence involves behavioral improvement [91]. All these exercise categories
changes which may be influenced by the environ- are intended to improve general health, prevent
ment, social and personal contexts, motivations, sports injuries, and scale up general sports and
skills, and resources [84, 85]. However, the often-­ skills performance, either gender- or sports- or
long follow-up periods required in injury preven- position-specific skills, or even related to environ-
tion studies for behavior changes can take place mental conditions. These hardly take more than
can lead to a significant loss to follow-up [86– 20 minutes and often replace the traditional warm-
88]. Even at the elite European football clubs up. This is in favor of overruling barriers such as
(UEFA Elite Club Injury Study), the number of adding additional time to training ­sessions which
players that adhere to injury prevention programs is definitely going to boost player ­compliance.
130 R. Pereira et al.

This is often an issue along with lack of aware- (F-MARC) in collaboration with the OSTRC and
ness [73, 79]. More importantly, exercise-­based the Santa Monica Sports Medicine Foundation
programs have been found efficacious in reducing (SMSMF). It includes 15 structured exercises
lower and upper limbs injury incidence, preva- including core stabilization, eccentric thigh mus-
lence, and burden [1–3, 92, 93]. This is accom- cle training, proprioceptive training, dynamic
plished due to the fact that the exercise categories stabilization, and plyometric exercises, all per-
are intended to manage the already known risk formed focusing postural alignment. This pro-
factors and reduce the probability and/or severity gram has proven to reduce 39% of football
of injury. Due to their easy accessibility and effi- injuries in female, male adolescent, and senior
cacy, exercise-based injury prevention programs football players [2].
became frequent within the context of RCTs In the particular case of children, the injury
applied to different sports. Their dissemination prevention program for children’s football (“11+
and potential for broad uptake at the sporting Kids”) reduced the overall injury risk by 48%
community level may yield significant societal and the risk for severe injuries by 74% [94]. The
and economic positive impact. There is convinc- “icing in the cake” is that after a cost-­effectiveness
ing evidence that multimodal injury prevention analysis, comparing the “11+ Kids” with a usual
programs can reduce the overall injury rate by warm-up, it was reported that a countrywide
40% in child and adolescent, both those aiming all implementation (in Switzerland) would be domi-
or specific injuries [94]. These programs improve nant, i.e., lower injuries and 1.48 million Swiss
several neuromuscular performance measures as Francs in healthcare costs could be avoided in
balance/stability and leg power (small effects), just one season [99]. This adds strength to its
reaching medium effect for isokinetic leg strength widespread implementation and makes room for
at low speeds and large effects for sprint abilities political actions.
and sport-specific tests [95]. In the year 2000, the SMSMF presented the
The ideal combination of training components Prevent Injury and Enhance Performance (PEP)
within multimodal programs remains unclear program. The PEP program focused on proper
[91]. Thus, injury prevention programs (such as landing, cutting, and decelerating techniques. It
FIFA 11+, PEP, IPEP, OSTRC shoulder injury takes 20  minutes and can replace a traditional
prevention program) can be enhanced in open warm-up. In a cohort study involving competitive
source way, i.e., these may benefit from the addi- female youth football players, there was an 88%
tion of one or more evidence-based exercises or overall reduction in ACL injury in the first year of
components. For example, low adductor strength study and 74% in the second [100]. In turn, the
has been shown to represent a risk factor for OSTRC performed a cluster RCT in female ado-
groin injury in soccer [96]. Therefore, Harøy lescent handball (16-year and 17-year division),
et al. [97] suggested the inclusion of the Adductor reporting that acute knee or ankle injuries can be
Strengthening Programme into the FIFA 11+ reduced by 50% and severe injuries even more
multimodal exercise-based program, to match the [10]. The intervention consisted in a structured
specificity principle of exercise, as there is an warm-up program to improve running, cutting,
improvement of eccentric force of the adductors and landing technique as well as neuromuscular
and, more importantly, a reduction in 41% of the control, balance, and strength.
risk of reporting groin problems in football play- In Sweden, the Knee Control Injury Prevention
ers, through the Copenhagen Adduction exercise Exercise Programme (IPEP) is a project initiated
[98]. Naturally, the implementation of the exer- in 2008 by the Swedish Football Association and
cise is not program-dependent. the insurance company Folksam, aiming to reduce
A good example of efficacious and collabora- the burden of severe knee injuries. The IPEP con-
tive program is the FIFA 11+ Neuromuscular tains six different principal exercises focusing on
Training Programme developed by the Medical neuromuscular control, landing and cutting tech-
Assessment and Research Center of FIFA nique, core and lower limb strength, and lower
11  Sport Injury Primary and Secondary Prevention 131

limb alignment. All exercises have four levels of 11.5.2 Injury-Specific Prevention:
progression, and the entire program takes about Fast Facts
15 minutes to perform. It was reported to be the
largest RCT on sports injury prevention (230 This subsection will cover some of the best evi-
clubs, 4564 players). The IPEP resulted in a 64% dence available of four injury-specific prevention
lower rate of ACL injury in the intervention group, measures and their respective implementation
82% reduction in the rates of severe knee injury outcomes (fast facts). The classical four-step
and 47% reduction in any acute knee injury. model is still part of the foundations for research
Compliance with the program was decisive [3]. on sports injury prevention, even acknowledging
Due to the lacking evidence on implementa- to be supported in a linear framework. However,
tion of preventive measures of overuse shoulder the “sequence of prevention” allows a first
injuries, which are common within several over- approach to fundamental literacy within sports-­
head and throwing sports, research on overuse related injuries knowledge and competencies.
shoulder injury prevention was mandatory [1]. Thus, examples of pedagogic exercises will be
For elite handball players, the average prevalence presented covering all the four below-discussed
of shoulder problems throughout the season was injuries as a path to match facts and build a first
reported to be 28% (95% confidence interval and determinant layer of knowledge for interven-
25–31%) and 12% (95% CI 11–13%) for sub- tion purposes. Naturally, these steps should all be
stantial shoulder problems (leading to moderate fed by evidence-based data, context-driven as
or severe reductions in handball participation or discussed before, and public health models and
performance). Among others, reduced glenohu- Implementation Science are mandatory if success
meral rotation, external rotators weakness, and is an option.
scapular dyskinesis were identified as risk factors
for elite shoulder injuries in male handball play- 11.5.2.1 A  CL Injury Prevention:
ers [101]. Thus, Stig and collaborators [1] Fast Facts
recently performed the first RCT in overuse ACL ruptures are severe injuries with high nega-
shoulder-specific injury prevention to implement tive impact in individual and team performance,
the OSTRC Shoulder Injury Prevention substantial economic burden (total healthcare uti-
Programme based on identified risk factors. It lization cost is $13,403 to $38,121 for each
includes five exercises that were prescribed to patient undergoing arthroscopic ACL reconstruc-
increase the glenohumeral internal range of tion [102, 103]), and potential negative impact in
motion, external rotation strength, and scapular long-term health and well-being [104, 105].
muscle strength, as well to improve the kinetic According a recent systematic review with meta-­
chain and thoracic mobility. Despite that compli- analysis [106], the incidence rate of ACL injury
ance was challenging (1.6 times per week of the in sports is 0.9 per 10,000 athlete-exposures in
recommended three weekly sessions), it did not male players and 1.5 per 10,000 exposures in
influence the risk of shoulder problems. female players. Irrespective of the participation
Moreover, a 28% lower risk of shoulder problems level, the incidence rate among women was 1.5
(odds ratio of 0.72, 95% confidence interval times higher than in men.
0.52–0.98, p = 0.038) and 22% lower risk of sub- While evidence regarding neuromuscular and
stantial shoulder problems (odds ratio of 0.78, biomechanical risk factor for ACL injury in male
95% confidence interval 0.53–1.16, p  =  0.23) athletes is lagging [18], risk factors for ACL inju-
were observed in the intervention group. Thus, ries female athletes seem to be well established
the OSTRC Shoulder Injury Prevention [16, 23, 107]. Increased dynamic knee valgus,
Programme, which takes only 10 min to perform, high knee abduction loads, dynamic trunk insta-
can have an important role in preventing shoulder bility, and gender-specific asymmetries after
overuse injuries with plausible application in puberty—females exhibit measurable quadriceps
other overhead and/or throwing sports. dominance, ligament dominance, leg dominance,
132 R. Pereira et al.

and trunk dominance [108–111]. The multimodal cular deficits linked to ACL rupture, especially
injury prevention programs may play a major when emphasizing the individualized biome-
role in injury prevention in female adolescent chanical technique correction [125, 126].
since they may induce the neuromuscular spurt, Recently, clinical practice guidelines on exercise-­
tackling several of the referred risk factors. based knee and ACL injury prevention report
A video analysis of 39 ACL injury cases useful recommendations that may be used by cli-
reported that 85% of the ACL injuries in male nicians, coaches, parents, and athletes [127].
professional football players resulted either from A pedagogic example of the four-step injury
non-contact or indirect contact mechanisms, prevention model applied to ACL injury is pre-
being the three predominant mechanisms: press- sented in Fig. 11.2.
ing situations, regaining balance after kicking,
and landing after heading. While knee valgus was 11.5.2.2 A  nkle Injury Prevention:
frequent, dynamic valgus collapse was not [112]. Fast Facts
It was reported that 77% of ACL ruptures occur The incidence rates of lateral ankle sprains are
while defending which is consistent with a previ- high, vary significantly according to sports, and
ous work—73% [113]. Video analysis of ACL are one of the most common musculoskeletal
injuries on other sports has been published, injuries. The direct costs of ankle sprain manage-
including American football [100], rugby [114], ment range from $292 to $2268 per patient,
netball [115], alpine skiing [116], basketball, and depending on the injury severity and treatment
handball [117, 118]. An overview of several strategy [128]. Pooled cumulative incidence of
video analysis studies suggested that ACL injury ankle sprains is 7 per 1000 exposures (95% con-
prevention programs should focus on enhancing fidence interval 6.8–7.2) for court sports, 3.7 per
cutting and landing technique that avoids knee 1000 exposures (95% CI 3.3–4.17) for ice/water
valgus and internal rotation during knee flexion, sports, 1.0 per 1000 exposures (95% CI 0.95–
as well as proper hip flexion to absorb energy 1.05) for field sports, and 0.88 per 1000 expo-
from ground reaction force and avoid excessive sures (95% CI 0.73–1.02) for outdoor sports.
hip internal rotation [119]. Additionally, females are at a higher risk of sus-
More recently, a systematic review and meta-­ taining an ankle sprain compared with males, as
analysis of overlapping meta-analyses on ACL well as children compared with adolescents and
injury prevention programs reported conclusive adults [129].
evidence that they reduce the risk of all ACL inju- Considering best-evidence recommendations
ries in 50% in all athletes and non-contact ACL from a recent evidence-based clinical guideline,
injuries in 67% in female athletes [120]. A total the intrinsic modifiable risk factors included lim-
of 108 (95% confidence interval, 86–150) and ited dorsiflexion range of motion, reduced pro-
120 (95% confidence interval, 74–316) individu- prioception and (preseason) deficiencies in
als would need to be trained to prevent one non-­ single-leg postural balance test, which substan-
contact or one overall ACL injury over the course tially increase the risk of sustaining a lateral
of one competitive season, respectively [121]. In ankle sprain (level 1). In turn, considering extrin-
female athletes, lower body strengthening, proxi- sic modifiable risk factors, irrespective of its like-
mal control exercises (specific focus on landing lihood of modification, included type of sport
stabilization), and multi-exercise genres increase (e.g., basketball, indoor volleyball; level 2), male
the efficacy of ACL neuromuscular interventions participation, landing after a jump in volleyball,
[122, 123], while age, dosage, exercise varia- playing soccer in natural grass, and being
tions, and utilization of verbal feedback are pre- defender (level 3) [130]. In volleyball lateral
dictors for optimization of prophylactic effects in ankle sprains were found to be the most frequent
ACL neuromuscular training [124]. These exer- injury (54% of all injuries, with 89% of this
cises have the potential to enhance cutting and occurring at the net), being 68% result of landing
landing biomechanics by improving neuromus- in the foot of an opponent and 19% in a
11  Sport Injury Primary and Secondary Prevention 133

1.5 per 10 000 exposures in female players Risk factors

0.9/10 000 exposures in male athletes
Increased dynamic knee valgus, high knee abduction loads, dynamic
trunk instability and gender-specific asymmetries after puberty.
Montalvo et al. (2018). Br J Sports Med.
(Epub).
Mechanism of injury
In football: there are three predominant mechanisms (noncontact or
indirect contact mechanisms): pressing situations, re-gaining balance
1. 2. after kicking and landing after heading.

Hewett et al. (2016). J Orthop Research, 34(11):1843-1855.

Waldén et al. (2015). Br J Sports Med, 49:1452-1460.

4. 3.

G1: Education, stretching, strengthening, plyometrics, and sports-

88% (relative risk 0.114) and 74% (relative risk
specific agility drills designed to replace the traditional warm-up
0.259) decrease ACL injuries in the enrolled subjects
(PEP program)
compared to the age- and skill-matched controls, in
the first and second years, respectively.
G2: Untrained age- and skill-matched controls
Mandelbaum et al. (2005). Am J Sports
Med, 33(7):1003-1010. Mandelbaum et al. (2005). Am J Sports Med, 33(7):1003-1010.

Fig. 11.2  Pedagogic example of the four-step injury pre- aetiology [23] and mechanism of injury [112]; (3) intro-
vention model applied to ACL injury: (1) establishing the ducing preventive measure [93]; (4) assessing its effec-
extent of the sports injury problem [106]; (2) establishing tiveness by repeating step 1 [93]

t­eammate’s foot [131]. Recent evidence supports 95% confidence interval 0.21–0.43) [130]. For
this finding reporting that majority of injuries recurrence of ankle sprains, the use of ankle brac-
occur while blocking, often landing on an oppo- ing is more effective (relative risk 0.69, 95% con-
nent with rapid inversion with no plantarflexion, fidence interval 0.49–0.96) [130]. When
rather than previously thought that these occurred comparing ankle bracing to neuromuscular train-
in plantarflexion [132]. This playing situation ing, the relative risk is 0.53 (95% confidence
related to inversion injury mechanisms is also interval 0.29–0.97). An unsupervised propriocep-
common in basketball [133]. In turn, in football tive training program to reduce the recurrence of
the injury mechanism usually comprises player-­ lateral ankle sprains can reduce a mean of €81
to-­player contact with impact by an opponent on (standard deviation, €134) per athlete and €114
the medial aspect of the leg just before or at foot (€325) per injured athlete [136].
strike, resulting in a laterally directed force caus- A pedagogic example of the four-step injury
ing the player to land with the ankle in a vulner- prevention model applied to lateral ankle sprains
able, inverted position or a forced plantar flexion is presented in Fig. 11.3.
where the injured player hit the opponent’s foot
when attempting to shoot or clear the ball [134]. 11.5.2.3 M  uscle Injuries Prevention:
In a Cochrane review, it was reported that Fast Facts
using an external ankle support, there is signifi- Muscle injuries represent more than one third of
cant reduction in the number of ankle sprains all time-loss injuries (elite European professional
(relative risk 0.53, 95% CI 0.40–0.69) [135]. football clubs) [140]. A recurrence rate of 17%
More recently, it was reported that the use of has been reported in elite football players [141].
ankle braces or tape can reduce the risk of first-­ The hamstring, quadriceps (mainly the rectus
time lateral ankle sprains (relative risk of 0.30, femoris), the adductor, and the calf muscles are
134 R. Pereira et al.

1080 lateral ankle sprains (0.7/1000 h) - Risk factors

average 3% season (A) eccentric isokinetic ankle flexion strength asymmetries (OR=8.88; 95%
Cl 1.95-40.36)
Elite football player over 11 years
(B) increased body mass index (OR=8.16; 95% Cl 1.42-46.63)
(1,057,201 exposure hours)
(C) increased body weight (OR=5.72; 95% Cl, 1.37-23.95)

Injury rate (number of injuries / 1000h):

match (IR=2.02) and training (IR=0.24) Mechanism of injury
(1) laterally directed force by opponent at the medial aspect of the leg just
before or at foot strike (football)
Severity: mean lay-off = 15 ± 19 days
(2) forced plantar flexion when the injured player hit the opponent’s foot
Injury burden: 7.7 lay-off days/ 1000 h while attempting to shoot or clear the ball (football)
(3) landing in the foot of an opponent (voileyball)
Waldén et al. (2013) Br J Sports Med,
47(12):748-753. Fousekis et al. (2012). Am J Sport Med, 40(8), 1842-1850.
Andersen et al. (2004). Am J Sport Med, 32(1_suppl):69-79.
Skazalski et al. (2018). Br J Sports Med 52:74-82.

1. 2.

4. 3.

G1: Neuromuscular training programme (30 min/session, 3x/week

Reinjuries: 27% in the NM training group, 15% in with progressive difficulty for 8 weeks)
the brace group and 19% in the combi group.
G2: Semirigid ankle brace worn during all sports activities for
Relative risk for reinjury in the brace group vs. 12 months
training group was 0.53 (95% Cl 0.29 to 0.97).
G3: Combined NM training and brace for 8 weeks
Janssen et al. (2014). Br J Sports Med, 48:1235-
1239 Janssen et al. (2014). Br J Sports Med, 48:1235-1239

Fig. 11.3  Pedagogic example of the four-step injury pre- establishing aetiology [138] and mechanism of injury
vention model applied to lateral ankle sprains: (1) estab- [132, 134]; (3) introducing preventive measure [139]; (4)
lishing the extent of the sports injury problem [137]; (2) assessing its effectiveness by repeating step 1 [139]

the most affected accounting for 92% of all mus- [142]. Hamstring reinjuries most commonly
cle injuries, being the hamstring the most com- occur in biceps femoris injuries than semitendi-
mon subtype, representing 12% of all injuries nosus and semimembranosus [144].
[140]. This means that, within a team with 25 There is evidence on the association of older
players, around 5–6 hamstring injuries will occur age, increased quadriceps peak torque, past his-
each season [140]. In addition, the average injury tory of hamstring injury, and kicking leg with
burden is 19.7 days/1000 h [142]. This has a very increased risk of hamstring muscle strain-type
high financial impact as the average cost for a injuries in sport [145, 146]. For recurrent ham-
first team player being injured for 1  month is string injuries, there is limited evidence that ath-
around 500,000 € [143]. According to more letes with a larger volume size of initial trauma, a
recent reports, the training-related hamstring Grade 1 hamstring injury, and a previous ipsilat-
injury rate and injury burden is on the raise since eral ACL reconstruction are at increased risk
2001 (2.3% increase in the injury rate and 4.1% [147]. Direct muscle injuries are caused by an
increase in the total hamstring injury burden) external force (contusion or laceration) and by
11  Sport Injury Primary and Secondary Prevention 135

Overall injury rate 1.20 injuries per 1000 h Risk factors

Older age, increased quadriceps peak torque, past history of
Match injury rate 4.77 injuries per 1000 h hamstring injury and kicking leg.
Training injury rate 0.51 injuries per 1000 h

Mechanism of injury
13-year period (1614 hamstring injuries, 639130 h
High speed running in late swing phase.
of exposure, n=2393 players) - elite football

Hägglund et al. (2013). Am J Sports Med 41:327-335.

Ekstrand et al. (2016). Br J Sports Med, 50(12):731-
Freckleton et al. (2013). Br J Sports Med, 47:351-358.
737.
Askling et al. (2007) Am J Sports Med 35:197-206.

1. 2.

4. 3.

Injury rate 3.8 (G1) versus 13.1 (G2) per 100 player
seasons of acute hamstrings injuries G1: 10-week progressive eccentric training program (27 sessions of
the Nordic hamstring exercise) + their usual training program
Injury rate 7.1 (G1) versus 45.8 (G2) per 100 player
seasons of recurrent injuries G2: Followed their usual training program (control)

Petersen et al. (2011) AM J Sports Med, 39:2296-2303. Petersen et al. (2011) AM J Sports Med, 39:2296-2303.

Fig. 11.4  Pedagogic example of the four-step injury pre- establishing aetiology [145, 146] and mechanism of injury
vention model applied to hamstring injuries: (1) establish- [149]; (3) introducing preventive measure [152]; (4)
ing the extent of the sports injury problem [142]; (2) assessing its effectiveness by repeating step 1 [152]

their nature cannot be prevented. In turn, indirect [156]. Thus, this exercise could be complemented
muscle injuries occur without an external trauma with other potential preventive measures, such as
and are classified as either functional (nonstruc- the core stability training reducing hamstring
tural)—without evidence of a tear—or structural stiffness [157] and pelvic stability, as hip flexor
[148]. Acute hamstring injuries often occur at tightness leads to reciprocal inhibition of gluteus
high-speed running in late swing phase [149] and maximus and synergistic dominance of the ham-
are often considered as either a sprinting or strings [158]. Moreover, when managing players
stretching type [149, 150]. Stretching injuries with very high volumes of high sprint running—
affect more often the proximal semimembrano- in which the risk of hamstring injury is higher—
sus at the muscle or tendon level [149, 151]. ensuring an adequate acute-chronic workload
Despite that there is evidence-based hamstring ratio (as described previously), controlling
injury prevention available to reduce the risk of fatigue (often due to insufficient recovery), and
new acute hamstring injuries in football up to avoiding acute load peaks has a key role in pre-
59% [152, 153], the adoption and implementa- venting hamstring injuries [159, 160].
tion of the Nordic hamstring exercise at the high- A pedagogic example of the four-step injury
est level of football in Europe is low [154]. At prevention model applied to hamstring injuries is
amateur football level, the Nordic hamstring presented in Fig. 11.4.
exercise also significantly reduces hamstring
injury incidence with an excellent compliance 11.5.2.4 G  roin Pain Prevention:
level (91%) [155]. Nevertheless, when translat- Fast Facts
ing the evidence into practice, the Nordic ham- At the European professional football (UEFA
string exercise does not act directly to the main elite study), hip and groin injuries account for
injury mechanism of hamstring injury which is, 12–16% of all time-loss injuries per season.
as previously described, high sprint running However, in the last years, it was reported a slight
136 R. Pereira et al.

decrease in time-loss injuries rates but not in showed a 19% reduction of groin injuries ­(relative
injury burden [161]. In another report, compris- risk 0.81; 95% confidence intervals 0.60–1.09)
ing two consecutive seasons of the entire Qatar following specific groin injury prevention pro-
Stars League, the incidence rate of hip and groin grams but without a statistically significant
injuries was 1.0 injuries/1000 h (time-loss injury reduction in sports-related groin injuries. Despite
approach), being 68% of all time-loss groin inju- the lack of statistical significance, the authors
ries adductor-related [162]. Hip and groin injury reported that the groin injury prevention pro-
is the most common non-time-loss injury in grams may be of clinical relevance and poten-
female amateur football, and around three-­ tially worthwhile to consider in football players
quarters of the players with long-standing hip [167]. Based on the video analysis of adductor
and groin injuries within the previous season longus injuries, it is suggested a focus on tripla-
show residual problems at the start of the follow- nar exercises leading to an increased capacity of
ing season [163]. the adductor longus/muscle-tendon unit with-
Most relevant risk factors for hip and groin stand a rapid activation at a lengthened state
injuries in field-based sports are a previous (which may be achieved with eccentric training).
groin/hip injury (odds ratio 2.6–7.3), older age This may be an effective injury prevention strat-
(odds ratio 0.9), and weak adductor muscles egy. Additionally, it is also advised a focus on
(odds ratio 4.28). Other significant risk factors synergists actuating in the four above reported
include early maturing players, smaller domi- predominant mechanisms (change of direction,
nant femur diameter, increased/decreased BM, kicking, reaching, and jumping), as a way to
decreased hip abduction and total hip rotation reducing load on the adductor longus which may
range of motion, abduction and adduction-with- decrease injury risk [166]. Considering exercise
rotation peak torque, strength ratio of hip muscle selection and progression, particularly, for target-
groups, and bilateral difference in extension ing the adductor longus, evidence exists for the
peak torque [164]. More recently, a systematic Copenhagen Adduction exercise on both muscle
review concluded that there is strong evidence activation patterns [168] and strength gains [97,
that total bilateral hip rotation (<85°) measured 128, 169]. In a cluster RCT, the Copenhagen
at the preseason screening is a risk factor for Adduction exercise reduced the prevalence and
groin pain development and that internal rota- risk of groin problems in male football players by
tion, abduction, and extension are not associated 41%. Considering all physical complaints, the
with the risk or presence of groin pain [165]. A average weekly prevalence of all groin problems
recent video analysis study [166] identified that during the competitive season was 13.5% in the
71% of acute adductor longus injuries in male intervention group and 21.3% in the control
football players resulted from non-contact mech- group [98]. Moreover, if strong evidence exists
anisms, both in closed and open chain mecha- based on a single-exercise approach, a more com-
nisms. Four distinct predominant mechanisms prehensive and now informed preventive strategy
were reported: change of direction (35%), kick- may even lead to superior outcomes. The authors
ing (29%), ­reaching (24%), and jumping (12%). point out that similarities related to structural
The adductor longus injury accounts for 90% of adaptations from eccentric strengthening and its
the two-thirds of hip adductor-related acute preventive effect on hamstrings and mechanisms
groin injuries and a rapid muscle activation, in open chain category [170–172] may raise simi-
while the muscle that is rapidly lengthened was lar benefits in relation to adductor longus
admitted to be its fundamental injury injuries.
mechanism. A pedagogic example of the four-step injury
Evidence on the prevention of hip and groin prevention model applied to groin injuries is pre-
injuries is still evolving. A meta-analysis of RCTs sented in Fig. 11.5.
11  Sport Injury Primary and Secondary Prevention 137

Injury rate 1.0 injuries per 1000 hours Risk factors

206 injuries by 150 players over a 2-year period
Previous groin/hip injury (OR 2.6 to 7.3), older age (OR 0.9) and
(professional football)
weak adductor muscles (OR 4.28)

12 to 16% of all time-loss injuries per season

Mechanism of injury
In football: Change of direction, kicking, reaching and jumping.
Mosler et al. (2018). Br J Sports Med, 52:292-297

Ryan et al. (2014). Br J Sports Med, 48(14):1089-96

1. 2. Serner et al. (2018) Br J Sports Med. (Epub)

4. 3.

G1 had 13.5% (95% Cl 12.3% to 14.7%) groin problems

during the season vs. 21.3% (95% Cl 20.0% to 22.6%) G1: Adductor Strengthening exercise, with 3 progression levels,
in G2. 3x/week during the preseason (6-8 weeks) and 1x/week during the
competitive season (28 weeks).
Risk of reporting groin problems was 41% lower in the
intervention group (OR 0.59, 95% Cl 0.40 to 0.86). G2: The control group were instructed to train as normal.

Harøy et al. (2018). Br J Sports Med. (Epub) Harøy et al. (2018). Br J Sports Med. (Epub)

Fig. 11.5  Pedagogic example of the four-step injury pre- lishing aetiology [164] and mechanism of injury [166];
vention model applied to groin injuries: (1) establishing (3) introducing preventive measure [98]; (4) assessing its
the extent of the sports injury problem [162]; (2) estab- effectiveness by repeating step 1 [98]

11.5.3 Improving Reach of Proven program delivered either through a mobile App
Exercise-Based Prevention or a booklet has led to similar results in compli-
Programs Through mHealth ance rates, mobile health (mHealth), as a branch
of information and communications technology
Despite large-scale RCTs proving that exercise-­ (ICT), may help at fostering widespread adoption
based programs substantially decrease injuries of those programs. In particular, using a mobile
and are cost-effective [136, 139], broad uptake by App (“Strengthen your ankle”) in comparison to
sports teams and community is lagging [154], a printed booklet produced an incremental cost-­
i.e., even the most effective programs will fail if effectiveness of 361.5€ [173] and a higher level
you do not actually do it. Moreover, recent reports of satisfaction [174], which can lead to potential
on elite football pointed out a raise in injuries as changes in practice guidelines for general practi-
it is the case of hamstring injuries [142]—the tioners [175]. Given the continuous growing
number 1 lesion in elite professional football. uptake of smartphones and consume of mobile
Among other reasons, this paradox may be Apps, this may be a smart way to channel oppor-
explained by lack of reach and/or awareness of tunities. What digital tools bring may be sup-
the injury prevention programs by different ported by the implicit buy-in from policy makers.
stakeholders as coaches and players; lack of In fact, this is implicit to the eHealth Action Plan
fidelity when implementing them (which may 2012–2020—Innovative healthcare for the
affect effectiveness); coaches and/or players may twenty-first century from the European Union—
opt not to use it; and poor compliance (only com- which also includes a special focus on mHealth.
pliant athletes will benefit from the preventive Familiarity and high penetration of smartphones
effect) or maintenance. Although a prevention among general population and in particular
138 R. Pereira et al.

within athletes may frame digital tools as part of an injury, there is an evolutive process of
the solution to stimulate injury prevention ­rehabilitation to accomplish. There are possible
­measures uptake while enabling feedback and and/or established validated criteria (chronobio-
interaction between stakeholders (e.g., health logical, functional, and psychosocial) to progress
staff, technical team, athletes). Therefore, while within rehabilitation phases and to clear the
gamification techniques [176] and virtual reality player to return to play (please see the following
(clinical trials.gov/NCT02933008) ongoing chapter on return to play). For instance, in the
research may yield positive results which may case of ACL reconstruction, if the established
add to prevention interventions, we may find return to play criteria are not matched, there is a
free-­downloadable injury prevention mobile fourfold greater risk of re-rupture [180]. Thus,
phone applications via App Store and Google the rehabilitation should be stepwise with
Play such as: criterion-­
based progressions and supported by
the available and most up-to-date scientific evi-
• IOC’s APP (so far 7 languages available and it dence [181, 182]. Different domains such as
includes the FIFA 11+): Get set—Train timeframe of tissue healing, pain management,
smarter APP (https://play.google.com/store/ kinematics and kinetics restoration, and general
apps/details?id=org.olympic.app. and specific conditioning [180–183] have to be
getset&hl=pt_PT). mastered by sports medicine teams. Moreover,
• The knee control programme (available in when an athlete is reintegrated to training and
german): KnieKontrolle (https://play.google. competition, extrinsic factors (along with even-
com/store/apps/details?id=de.inventivo. tual unmatched rehabilitation goals and criteria
kniekontrolle). categories to return to play) such as load and
• “Strengthen Your Ankle” by VeiligheidNL match congestion may particularly predispose an
(available in dutch): Versterk je enkel (https:// athlete to reinjury [184]. Along with this line,
play.google.com/store/apps/details?id=nl. prospective surveillance of predisposing risk fac-
veiligheid.versterkjeenkel). tors and potentially identified deficits is impor-
tant to prevent the occurrence of a reinjury.
Athletes younger than 25 years old who return
11.6 Secondary Prevention to play have a secondary ACL injury rate of 23%.
This means that almost one in four young players
The likelihood of sustaining a reinjury is often that return to play after an ACL reconstruction
higher compared with uninjured athletes. will have a retear [177]. Also, poor self-­
Compared with uninjured adolescents, a young confidence, poor performance on the triple hop
athlete who returns to sport after ACL recon- for distance, hip and knee altered neuromuscular
struction may be at a 30–40 times greater risk of control during a dynamic landing task, and pos-
ACL injury [177]. Reinjuries are often more tural stability deficits after ACL reconstruction
severe [178]. In football, previous injury is prob- may be managed in a subgroup of individuals
ably the most reported and prominent risk factor that may require extended rehabilitation to
for injury. Reinjuries overall rate is about 17%, decrease the risk of reinjury [185, 186]. An
which is low if compared with amateur football approximation to neurosciences for improving
teams (35%). Early recurrences (within 2 months) rehabilitation techniques, skills, and efficacy may
stand for 77% of those [179]. yield good results in motor control development,
Primary prevention and evidence-based man- restoration, or enhancement, suppressing, for
agement of rehabilitation, return to play, and sec- instance, deficits in motor control that were
ondary prevention should be major priorities reported to persist even after 2  years of ACL
concerning health and well-being, with perfor- reconstruction [187]. In this sense, novel video
mance and financial implications. When facing feedback, virtual reality, and verbally directed
11  Sport Injury Primary and Secondary Prevention 139

optimization techniques have emerged to enhance Take-Home Message

the ACL injury prevention programs [188–193]. Prevention of sports-related injury is an exercise
Fortunately, it appears that following simple of professionalism and governance. Knowledge
decision rules (meeting the return to play criteria) and its translation into practice require hard work
can reduce the reinjury risk by 84% [183]. But, and bringing together the competencies of many
are we followers of available good practices professionals from different areas. There is a
while pursuing new evidence? responsibility hierarchy that needs to be definitely
Hamstring reinjuries are very frequent in pro- and entirely called into action. However, every
fessional football, and most of all recurrent ham- sports medicine health professional entails part of
string injuries occur within the first month after a mission that could and should be accomplished.
returning to competition [22, 178, 194, 195]. No doubts could subsist that Prevention is the best
Additionally, an increased susceptibility for rein- remedy (Portuguese saying) for the health and
jury seems to be present for several months after well-being, societal and economic partial achiev-
the initial injury [22, 195–199]. This high recur- able goals of the whole sports family.
rence rate may be related to the fact that these
players may have been exposed inappropriately
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ries in elite track and field athletes. Am J Sports 2018;21(10):1019–24.
Med. 2011;39:304–10. 201. Doherty C, Bleakley C, Delahunt E, Holden
199. Verrall GM, Slavotinek JP, Barnes PG, Fon GT, S. Treatment and prevention of acute and recurrent
Esterman A.  Assessment of physical examination ankle sprain: an overview of systematic reviews with
and magnetic resonance imaging findings of ham- meta-analysis. Br J Sports Med. 2017;51(2):113–25.
string injury as predictors for recurrent injury. J
Orthop Sports Phys Ther. 2006;36:215–24.
 Return to Play (RTP)
12
Alexandre Rebelo-Marques, Renato Andrade,
Rogério Pereira, and João Espregueira-Mendes

12.1 Background to-play (RTP) decisions are often difficult and

complex [2]. These circumstances involve an
The popularity of sports in all of its forms contin- array of individuals that are involved in this deci-
ues to steadily increase. We live in an age where sion, including the medial department with the
sport became a business. Winning or losing has a sports physicians and physiotherapists, the
tremendous impact; it is more than just pride but ­athlete, parents or guardians, coaches, the athletic
also an important financial and social aspect. trainer, and many others. The appropriate syn-
Thus, there are a wide number of different ergy of these views and inputs, along with the
circumstances that play a role in the
­ athlete’s own feelings and self-efficacy, makes a
­decision-­making process that determine when an significant contribution and is the key to a suc-
athlete should return to competition [1]. Return- cessful outcome.

R. Pereira
Clínica do Dragão, Espregueira-Mendes Sports
A. Rebelo-Marques (*)
Centre—FIFA Medical Centre of Excellence,
Clínica do Dragão, Espregueira-Mendes Sports
Porto, Portugal
Centre—FIFA Medical Centre of Excellence,
Porto, Portugal Dom Henrique Research Centre, Porto, Portugal
Dom Henrique Research Centre, Porto, Portugal Faculty of Sports, University of Porto, Porto, Portugal
Faculty of Medicine, University of Coimbra, University Fernando Pessoa, Porto, Portugal
Coimbra, Portugal e-mail: [email protected]
Coimbra Institute for Clinical and Biomedical J. Espregueira-Mendes
Research (iCBR), Coimbra, Portugal Clínica do Dragão, Espregueira-Mendes Sports
Centre—FIFA Medical Centre of Excellence,
R. Andrade
Porto, Portugal
Clínica do Dragão, Espregueira-Mendes Sports
Centre—FIFA Medical Centre of Excellence, Dom Henrique Research Centre, Porto, Portugal
Porto, Portugal
Medicine School of Minho University,
Dom Henrique Research Centre, Porto, Portugal Braga, Portugal
Faculty of Sports, University of Porto, ICVS/3B’s–PT Government Associate Laboratory,
Porto, Portugal Braga/Guimarães, Portugal
e-mail: [email protected] e-mail: [email protected]

© ISAKOS 2019 149

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_12
150 A. Rebelo-Marques et al.

The RTP decision will be better understood and Regarding the cultural context, we know we
accepted if all stakeholders are properly informed can find different approaches of dealing the RTP
and considered. However, determining prognosis process: (1) the athlete could be capable of an
could be tricky, and including the inputs of such a autonomous decision, and (2) the decision could
wide range of specialist staff in a fully integrated be left to the medical staff or (3) is expected that
way is very complex, often leading to disagree- the clinician determine the course of action.
ments regarding the RTP [3]. The clinician is Anyway, the clinician is usually legally respon-
expected to provide an opinion based on a large sible for any consequences of the decision.
number of factors including the history of the Besides that, a transparent framework for arriv-
injury, physical examination, type of injury, reha- ing RTP decision is indispensable to downplay
bilitation, type of activity psychological state, com- potential conflicts.
petitive level, and ability to protect the injury [4].
Yet, sociocultural and clinical differences and per-
spectives between the stakeholders involved may 12.2 Reconditioning
lead to a number of negative scenarios, such as (1) and Performance
miscommunication, (2) loss of trust, (3) potential Enhancement
litigation, (4) decrease in sport participation rates
as sometimes the player cannot “get back in the Sports are complex and present a considerable
game,” and (5) potentially coming back with seri- number of factors affecting performance. Injuries
ous medical complications after unsuccessful RTP are one of the athlete’s major fears and that is
or return while still at unacceptable levels of risk why the reliable understanding of injury mecha-
for subsequent sport-­related injury [5–7]. nisms and etiology are crucial steps in any effec-
Returning to competition can be a confusing tive injury prevention. For a successful return to
scenario when all the possible circumstances that performance, athletes need to be healthy (proper
might be involved are considered. Thus, it is impor- nutrition [8] and sleep [9], as well as, adequate
tant to consider the expectations of the athlete whenpsychological status and well-being), since
they return to training and competition, such as [1]:injury load is correlated to team performance
[10, 11].
(a) Pain-free, normal range of motion (ROM) (if A successful rehabilitation is of utmost
applicable), and reestablishment of sport-­ importance to return the player as fast and as
specific movements. safe as possible to sports competition within the
(b) Restored power and strength to approxi- preinjury level and prevent reinjury and long-

mately the preinjury levels. term sequelae. Within this line, a stepwise and
(c) Metabolic and neuromuscular fatigue resis- individualized rehabilitation program with
tance to high-intensity sporting performance. criteria-­based progression should be followed to
(d) Self-confidence and competitiveness in the ensure safe progression through the different
technical performance of sporting skills. phases based on objective criteria and allow the
RTP with lower risk of reinjuries. Many pro-
Moreover, it is also essential to minimize the gression objective criteria can be applied
risk of potential conflicts in the process, and this through different phases of the rehabilitation
is only achieved through two important factors: and may involve effusion grading [12], muscle
soreness [13], running progression [14], sport-
(a) A well-defined process outlining how the specific agility progression [15, 16], and func-
RTP decision should be made. tional testing [17].
(b) A formal process to guide the individuals’ Reconditioning is a crucial component of the
interactions between those contributing to stepwise rehabilitation program (Fig. 12.1) and
the RTP process. has a major role on making sure the injured ath-
12  Return to Play (RTP) 151

CLINICAL CARE
T5 RETURN-TO-ACTIVITY
Surgical or non- STEPWISE CRITERIA-BASED
surgical REHABILITATION
T6 RETURN-TO-SPORTS
PRE-HABILITATION
RETURN-TO-PLAY
T7
(TEAM TRAINING)
T1 T2 T3

T8
RETURN TO COMPETITION
P1 REHABILITATION FIRST PARTICIPATION IN COMPETITIVE MATCH
P2
T0
Completion of team sport-specific training
RECONDITIONING Full recovery of agility / motor control
T4 Restored power / strength to approx. pre-injury levels
Self-efficacy and no kinesiophobia
RECONDITIONING
Strengthening and cardiovascular reconditioning
INJURY
Physiological principles of exercise
Progressive loading and sport-specific exercises (as allowed)

Fig. 12.1  Progressive stepwise criteria-based diagram, of rehabilitation, T4 beginning of physical reconditioning,
from injury to RTP and competition (P1 primary prevention, T5 criteria to return to activity, T6 criteria to return to
T0 injury occurrence, T1 pre-habilitation before treatment, sports, T7 criteria to RTP, T8 criteria to return to
T2 treatment (surgical or nonsurgical care), T3 beginning competition, P2 secondary prevention). Adapted from [18]

lete is ready to perform at 100 percent when he

or she returns to competition. For the injured
athlete return to training, it is important to dem-
onstrate the physical and technical qualities
required by their particular sport of participa-
tion. Regardless of the affected area (excluding
some cases that require complete rest, such as
concussion or a severe cardiac condition), the
reconditioning should start as soon as possible
and can be introduced into the rehabilitation pro-
cess in many ways. For instance, if a lower limb
injury is involved (e.g., an anterior cruciate liga-
ment injury), cardiovascular and respiratory sys-
tems may be challenged with upper limb cycle
ergometer and upper body muscle strengthening.
Moreover, when involving athletes, including
sport-specific exercises will increase their adher-
ence and compliance to the rehabilitation. Thus,
in case of the previous example, the athlete may
perform a single-leg stance on an unstable board
Fig. 12.2 Example of a non-weight-bearing sport-
with the uninvolved lower limb (maintaining/ specific exercise of the injured lower limb
increasing balance skills and strengthening the
uninjured lower limb and core muscles) while
performing non-weight-bearing sport-specific the best and safest return. In order to achieve this,
exercises with the injured limb (Fig. 12.2). we must prepare the athlete in terms of (1) power,
It is extremely important to develop the athlete (2) speed, (3) strength, (4) endurance, and (5)
up to preinjury fitness levels in order to promote metabolic/cardiovascular capacity.
152 A. Rebelo-Marques et al.

Strength is an essential component of all reha- decrease dependence on glycolysis to supply

bilitation and performance enhancement pro- energy. Endurance training eliminates the dis-
grams. It is the ability of the muscle to exert force parity between the anaerobic and aerobic abili-
or torque at a specified velocity [19]. Because all ties of muscles and lactate accumulation [25].
muscles function concentrically, isometrically, Nowadays we can differentiate two types of
and eccentrically in the frontal, sagittal, and endurance: general endurance, the base level of
transverse planes, an integrated training program cardiorespiratory ability, and special endurance
should use a wide training approach using the that is related to specific activities (metabolic
entire muscle and velocity contraction spectrum capacity) [25].
[20, 21]. Eccentric training produces more force In addition, plyometric, agility and sport-­
than concentric training [22–24]. specific activities to the patient’s home exercise
Training programs for power demand both program can be added, as long as the patient has
high-force and high-quality movements. Power no contraindications (e.g., loading restrictions or
is characterized by work per unit of time (force increased effusion) and exhibits pain-free and
× distance/time) or force × velocity (distance × full-ROM performance of loading activities.
time). Rate of force development is the rate at Before adding these higher-level activities to a
which strength increases [25], and it is the home program, it is important that the athlete
most important neural adaptation for the major- show proper technique under supervision. Agility
ity of athletes [26]. Complex training could be drills can assist the athlete in most of sport-­
used to improve power in the athlete by alter- specific activities, such as changing directions,
nating biomechanically similar high-load accelerating, and decelerating [30]. Plyometrics
weight training with plyometric exercises in can improve neuromuscular control in athletes,
the same workout [27]. which can become a learned skill that transfers to
Speed production have two components: return to competitive play [31].
stride frequency and stride length [28]. Stride With all this, it is well accepted that loading
length can be developed by bounding drills, run- can change and develop fitness, and it’s known
ning uphill, or power skips [28, 29]. Stride fre- that different fitness areas involved at the same
quency can be upgraded with fast leg drills, time modulate sports performance. In addition,
resisted sprints, or assisted sprints [29]. When other areas of extreme importance cannot be
training for speed, intensity and training volume ignored: sleep, rest, and nutrition. Like Pickett
must be monitored. In addition, volume should and Morris [32] said, “next to the air we breathe,
increase gradually, as proper technique is required food and sleep are the most crucial physical
to prevent compensations or altered movement essentials for maintaining a sound and healthful
patterns. With fatigue, sprinting form is poten- state of living.” The foods and liquids ingested
tially sacrificed, thereby overcoming the positive will provide energy during physical activity and
effects of speed training. Therefore, to maximize help the body recover from strenuous activity
speed production, speed practice drills should be [33]. Sleep is recognized as a critical factor in
performed at the beginning of training sessions, athlete’s performance. Sleep is thought to affect
before the player getting fatigued. Rest periods both physiological and cognitive function, which
are necessary and should allow full recovery can affect sports performance. Athletes have
between sets. lower quality of sleep as well as lower quantity
Increasing aerobic sources of energy can of sleep, compared with the nonathlete, particu-
enhance endurance, by delaying the onset of larly during periods of intensified training
blood lactate accumulation [25], which is depen- [34–36].
dent on maximal oxygen consumption and the Hence, a manifold of loading features and fit-
intramuscular adaptations that facilitate pro- ness areas are involved in the players’ recondi-
longed work [25]. To improve endurance, mus- tioning, and an attempt to simplify this giant and
cles must oxidize lactate during work and complex relationship is displayed on Fig. 12.3.
12  Return to Play (RTP) 153

BRAIN FUNCTION MOOD

AROUSAL
COGNITION
AEROBIC LOW-INTENSITY
CORE BODY TEMPERATURE
THERMOREGULATION
AEROBIC MOD-INTENSITY METABOLIC RESTING O2 MUSCLE MASS
FITNESS CONSUMPTION
AEROBIC HIGH-INTENSITY GLUCOSE TOLERANCE
SUBSTRATE AVAILABILITY
SUBSTRATE METABOLISM
SPEED ENDURANCE ACID-BASE BALANCE FAT PERCENTAGE
CARDIOVASCULAR
HEART RATE AND RHYTHM ATHLETIC
SPEED, STRENGTH AND RESPIRATORY BLOOD PRESSURE
STROKE VOLUME
FITNESS PERFORMANCE
BLOOD PRESSURE
BONE IMPACT VO2 MAX
BODY FLUID VOLUME
LOADING COAGULATION
POSTURAL BALANCE
VASCULAR FUNCTION
MUSCULOSKELET SYMPATHETIC ACTIVITY
AL FITNESS BONE MASS
NUTRITION
INJURY RATE
LIGAMENT LAXITY
SLEEP AND REST
LOW BACK PAIN
VENTILATION LOADING
SENSORY MOTOR CHRONIC DISEASE MEASURES
AND PERCEPTION

PERFORMANCE
MEASURES
FITNESS AREAS

Fig. 12.3  Overview of the impact of different types of physical loading on various fitness capacities and its influence
on the different components of physical performance. Adapted from [37–39]

Nowadays, there is a dogma that higher train- health professionals responsible for health and
ing load has been linked to higher injury rates [40]. recovery of athletes. Therefore, considering rele-
Gabbett and his team introduce in this fitness area vant factors including level of competition, season
the training-injury prevention paradox, where time, age, and career status is crucial to take part of
there is a relationship between high training loads the injury clinical reasoning [18]. When involved
and injury, but the problem is not with training per in team sports, it is important to also consider the
se but more likely the inappropriate training that is individual response to the stimulus. Performance
being prescribed [40]. So, they consider that both of a sports team is multifactorial and depends on
acute (previous week) and chronic (previous several factors such as team spirit, technique, tac-
4 weeks) training loads have a better way to model tics, team organization, fan support, and other pri-
the training and to minimize injury risk. Training vate circumstances. Legal, religious, cultural,
loads have also a major role during the recondi- linguistic, and family norms play also a role.
tioning and RTP phases. Recording and monitor- Hence, it is important to understand the theoretical
ing the individual player loads allow to follow the model on the influence of the load on the different
player’s rehabilitation and reconditioning progress systems (fitness), how this variation is perceived,
and maintain within safer load ranges and avoid and how it can be assessed. Independent from the
load spikes [41, 42]. Several biofeedback wearable league or the degree of professionalism, team
devices have been developed that can be used to sports lead to considerable physiological and psy-
monitor the player’s loading progression [43–46]. chological challenges. It is important for the team
At a high level, sports imply massive social physician to recognize all pathological states,
media coverage and tremendous financial impact which may require treatment or rest. Nowadays, it
encompassing great pressure from the club stake- is known that certain subgroups of players like
holders. With all this, it is natural that there is also females or veterans need additional  attention to
great pressure from all the related stakeholders on phenomena which are specific for them.
154 A. Rebelo-Marques et al.

Baseline testing for individual reference data

CLINICAL CARE 1
PH IO Y
H SS ILIT
AS N
ES
UG RE IB

Surgical or non-surgical treatment

RO OG NS
TH PR PO
S

RETURN-TO-ACTIVITY 2
RE

Progression to unspecific rehabilitation

RETURN-TO-SPORTS 3

Progression to sport-specific rehabilitation

RETURN-TO-PLAY 4
M AT
ED HL
IC ET Progression to unrestricted team training
AL E CO
ST AC
AF
F H RETURN-TO-COMPETITION 5

First participation in competitive match

Fig. 12.4  Milestones of the RTP process and the compilation of responsibilities from the medical staff, coaches, and
the athlete. Adapted from [48, 50]

12.3 Return-To-Play (RTP) These findings allow the involved professionals

Milestone to control, monitor, and adjust the rehabilitation
process in order to ensure a safe progression.
Establishing and setting up RTP guidelines are The prioritized balance of all factors will depend
essential for a safe and effective RTP. RTP crite- upon the type and severity of the initial injury and
ria are always dependent on the type and severity a coordinated and truly integrated team effort,
of injury, demands of the specific sport, the which involves respecting each other’s profes-
affected body region, and potential associated sionals’ abilities [49]. These milestones include
lesions [47]. These should be shared with the several progressions of rehabilitation and RTP
coaches, athletes, parents, and all other stake- process, and the involvement and responsibility
holders. Confusing or absent criteria and policies of the coach and medical staff change as the reha-
can lead to challenges for all. Thus, the RTP bilitation and RTP progress overtime (Fig. 12.4).
milestone is crucial and has a particular impor-
tance for clubs, insurance institutions, and the
injured athlete, as it marks the athlete’s end of 12.3.1 Preinjury Screening
short-term disability and herewith associated and Clinical Care (PRE-CC)
remuneration payments [48]. Nevertheless, there
is no single formula that can serve as an RTP Sports participation has always an inherent risk
guideline for all conditions. Still, a panel of of injury. Before the clinical approach to the
experts agreed on five distinctive milestones in injury, it is crucial to have a preseason or base-
which the injured athletes will go through during line screening (preinjury screening), which is no
an ideal rehabilitation process [48]. Milestones more than a prospective data collection that pro-
are passages from one rehabilitation phase to the vides the rehabilitation staff with important ref-
next, which are mostly associated to significant erence values for the injured athlete that can be
gains in performance and progress in specific used in the event of an injury. Besides that, the
skills and based on objective verifiable criteria. preinjury screening offers the opportunity to
12  Return to Play (RTP) 155

identify any underlying performance deficits 12.3.4 Return to Play (RTP):

and abnormalities. This is helpful to modulate Progression to Unrestricted
the training process and derive targeted individ- Team Training
ual primary prevention measures before an
injury occurs. Deficits in regarding propriocep- RTP is the progression to unrestricted team
tion, muscular strength, and neuromuscular training, i.e., from the individualized and
control (i.e., activation patterns) are extremely restricted team training to unrestricted partici-
common. pation in team and pre-competition training.
It is very important to establish a treatment This is an extremely sensitive progression for all
plan with achievable goals. Moreover, this can be involved, as in one hand for the athlete who
started through conservative or surgical treatment wants to return as soon as possible and, in the
or even a combination of both. other hand, for the medical department who
wants to prevent further injuries. Following a
comprehensive test battery, it is important to
12.3.2 Return to Activity (RTA): have a multidisciplinary decision-­making team.
Progression to Unspecific After consensus, it should be the team physician
Rehabilitation responsible to make the RTP decision and, in a
manner, promote unrestricted participation in
Return to activity is the progression to unspe- competitive training.
cific rehabilitation—a transition from the clini-
cal care (phase I) to general rehabilitation
training (phase II)—and describes the first post- 12.3.5 Return to Competition (RTC):
traumatic milestone that the injured athlete can First Participation
achieve. The clinician should perform a clinical in Competitive Match
examination and decide whether the athlete can
start the general rehabilitation training, which is The return to competition milestone corresponds
often focused on symptomatic control, regain- to the first participation in competition, which is
ing pain-free range of motion, stability, and the ultimate athlete’s main goal. This phase is the
movement control during basic movement pat- culmination of the whole process of treatment
terns. The biologic rebuilding mechanisms are and rehabilitation, comprising the entire reinte-
part of the rehabilitation process, so when estab- gration process from the time of the injury to the
lishing the treatment plan, examining the athlete first competition play.
is essential to recognize the biological healing The agreement between medical depart-
process timeframes so as not to advance steps ment, technical team, and the athlete is recom-
faster than it should. mended for a safe and effective integration into
competition. However, the time span from the
positive RTP decision and the athlete’s first
12.3.3 Return to Sport (RTS): selection is mainly the responsibility of the
Progression to Sport-Specific head coach.
Rehabilitation

Return to sport is a crucial phase since it marks 12.4 S

 trategic Assessment of Risk
the starting point of including the athlete in the and Risk Tolerance (StARRT)
sport-specific rehabilitation training and individ-
ualized competition training (phase III). At this In 2010, a group of researchers [51] adapted a
milestone, the athlete should already meet basic three-step decision-based theoretic model for
clinical and functional requirements as a result RTP. The medical factors and sport risk modifiers
from the previous rehabilitation phase. assess the risk, and the third step evaluates the
 156 A. Rebelo-Marques et al.

effect of decision modifiers. However, categoriz- the decision should indicate to not allow to
ing biological and physiological causes into soci- RTP. Injury or reinjury may occur whenever the
ological constructs may lead to significant stress applied to the tissue is greater than the
challenges and confusion, so they realized that stress the tissue can absorb. The next sections
they need to improve their first work. expand on these principles and show how the
In 2015 Shrier and colleagues [52] proposed a new terminology provides a more consistent
modified model, the Strategic Assessment of framework.
Risk and Risk Tolerance (StARRT) framework
for RTP decisions. This framework addresses the
limitations of the original three-step model and 12.4.1 Medical Factors: Step 1,
can be applied to any injury or RTP definition. The Tissue Health
This framework organizes the available informa-
tion into different factors that determine the risk The first step is to assess the amount of stress that
of participation and risk tolerance. the tissue can absorb before becoming dam-
The StARRT framework (Fig.  12.5) simply aged—tissue function health. Usually, tissue
uses the risk assessment of the outcome. If the damage is assessed through the presence or
risk assessment is greater than the risk tolerance, absence of symptoms and signs, such as pain or

Fig. 12.5  The Strategic Assessment of Risk and Risk Tolerance (StARRT) framework. Adapted from [52]
12  Return to Play (RTP) 157

swelling, or through diagnostic tests. For the same 12.4.3 Decision Modifiers: Step 3,
level of activity, the risk of reinjury increases with The Risk Tolerance Modifiers
increasing damage to the tissue. This information
comes from the health professional, so these fac- The third step is clearly designed to express the
tors were considered “medical.” clinician’s threshold for an acceptable risk (risk
tolerance), which factors affect this risk, and
why two athletes with same risk assessment may
12.4.2 Sport Risk Modifiers: Step 2, lead to different RTP decisions. The risk of new
The Tissue Stresses injury or reinjury represents one of the several
outcomes that affect the athlete’s overall health
The second step is to assess the stress that will or well-­being. For instance, if the athlete is a
be applied to the tissue. If an unhealthy tissue 15-year-old male track and field high school ath-
is exposed to only minimal stress, it continues lete, the clinician’s risk tolerance is different
the healing process. But, if the stress exceeds when compared to an athlete on the way to an
the capacity of the tissue, a new injury or rein- Olympic competition.
jury will occur. Nowadays, there are many dif- Regardless who is responsible for the RTP
ferent ways to categorize activity. It is possible decision, it should be considered if there is any
to use the “FITT” training principle and mod- context where changing the factor would shift the
ify activity through the frequency (F), intensity threshold of an acceptable risk [4]. So, this relates
(I), time (T), or type (T), for instance, 4 days the risk tolerance to the patient’s well-being and
per week, vigorous intensity, 45  min per ses- is consistent with societal values.
sion, and playing football. Within this line, tis-
sue stress is directly related to the planned
activity. Within this biological framework, it is 12.4.4 The Integrated Model: Beyond
best to think of “type” in relation to the bio- Injury Risk
logical stresses that increase with the specific
activity and might cause injury rather than in The purpose of the StARRT framework is to reach
general terms such as running or swimming. at a decision based on whether the risk assessment
This is important because the biomechanics exceeds the risk tolerance. It is important to
requirement is different between positions understand that in clinical terms, the RTP may be
(football or handball), styles (swimming), and referred to “full return without restrictions,” “par-
others and may impose different tissue stress tial return,” “allowed to practice,” and so forth.
(e.g., in football a wing player will have more The StARRT framework can be applied to any
sprint and deceleration situations than a center decision-making process and will work uniformly
back player). The medical staff should focus with any definition of RTP.  Any decision-­maker
on activities that increase stress in the muscu- can follow this process, whether it is a clinician,
loskeletal system. By changing or reducing an athlete, a judge, or a shared decision-making
stress (e.g., switching players positions or process. In summary, this framework organizes
style), the injury risk will decrease. the available information into different factors
Psychological readiness (in the original that determine the risk of participation and risk
framework was in step 1) measures of functional tolerance. Thus, the risk of participation depends
capacity, and it’s here in step 2, because we on the interaction between the tissue health and
know they can affect risk of reinjury via the way tissue stresses (steps 1 and 2). These decisions are
the athlete approaches and plays the game and inappropriate when the risk assessment is poor or
therefore the potential stresses applied to the when (1) risk tolerance depends on factors unre-
body. You can read more about this subject later lated to the patient’s well-­being or (2) personal
in this chapter. values conflict with societal values.
158 A. Rebelo-Marques et al.

12.5 Injury-Psychological tractions by paying attention to the present

Readiness to Return moment can improve attentional processes.
to Sports 3. Cognitive behavioral stress management that
through imagery and cognitive restructuring,
Sport psychology is the discipline that uses psy- the control of diaphragmatic breathing and
chological knowledge and skills to give optimal incorporating relaxation can help deal with
performance and well-being of athletes and stressful situations and with emotions, thus
developmental and social aspects of sports par- impact behavioral compliance.
ticipation [53]. Since the psychological part is 4. Combined imagery and positive self-talk,

related with injuries, this area becomes a topic of which help athletes cope with the pressure,
considerable investigation. When athletes get increasing confidence and coping with adver-
injured, the experiences are not only physical sity, thus improving concentration on appro-
loss but also psychological loss [54–56], that is priate environmental conditions.
why this must be a priority for clinicians.
Sport psychology researchers have examined
athletes’ emotional, cognitive, and behavioral 12.5.1 Psychological Readiness
responses to injury. Because cognitive and emo- to Return to Sport Assessment
tional responses may affect physiological healing
processes, the understanding of this responses is Addressing the multitude of challenges faced by
important for facilitating adaptive forms of cop- returning athletes, a number of investigators have
ing, enhancing key rehabilitation behaviors such examined constructs associated with psychologi-
as adherence and compliance [57]. Advances in cal readiness to return to sport. The athlete’s psy-
treatment and rehabilitation interventions have chological readiness to return to sports assessment
helped advance recovery processes. Unfortunately, is of upmost importance for the RTP decision
the athletes’ physical recovery is not always [66, 67]. Although multifactorial, psychological
matched with athletes’ perceptions of psychologi- readiness is majorly influenced by an athlete’s
cal readiness to return to competitive sport emotions and self-confidence [68]. The Injury-­
[58–60]. Psychological Readiness to Return to Sport
Neurocognitive, behavioral, and psychophysi- (I-PRRS) scale [58] and the Reinjury Anxiety
ological changes can be behind the increase of Inventory [60] have been developed to assess ath-
the risk of acute or overuse injuries (or increased letes’ psychological mind-set during the reentry
risk of injury and/or increased injury time-loss) period. In addition to the I-PPRS scale, injury-­
through the individual psychosocial characteris- specific scales have been developed, such as in
tics [61]. Appropriate use of psychological inter- the case of anterior cruciate ligament (ACL) inju-
ventions can modify each of these potential ries and anterior cruciate ligament-return to sport
mechanisms [62, 63]. after injury (ACL-RSI) [69]. These scales repre-
To optimize the RTP, it is very important sent an important advance in terms of objective
that clinicians should be empowered to consider measurement and assessment of the athlete’s psy-
confidently all the psychological aspects. There chological readiness to return to sports.
are several intervention techniques with potential Kinesiophobia, fear of reinjury, and lack of
injury reduction benefits [61–65], such as: self-efficacy are often barriers that inhibit the ath-
lete’s readiness to return to sport and may also
1. Progressive muscular relaxation that poten- affect the quality of their performance. The
tially decreases muscle tension and increases capacity to believe in being successful in a given
rate of recovery. situation, it is called self-efficacy. As the athlete
2.
Mindfulness-acceptance and commitment recovers from the injury, there is a significant
that can reduce attention disruption and dis- improvement of this. In addition, higher levels
of  self-efficacy are associated with patient
12  Return to Play (RTP) 159

s­atisfaction and better outcomes [70]. Self- Table 12.1  Example of Injury-Psychological Readiness
to Return to Sport (I-PRRS) scale
efficacy following knee injuries may be assessed
by the knee self-efficacy scale [71], and, in the Scoring (rate the current
level of confidence,
case of ACL reconstruction, it was reported that 0 = no confidence to
higher levels of self-efficacy are positively cor- 100 = complete
related with higher levels of postoperative activ- Item confidence)
ity [72]. Kinesiophobia and/or fear of reinjury 1. Overall confidence to play 0–100
has been reported as one of the main reasons for 2. Confidence to play without 0–100
pain
not returning to the previous level of activity
3. Confidence to give 100% 0–100
[73] and can be assessed through the Tampa effort
Scale of Kinesiophobia [74]. Yet, the exact con- 4. Confidence in the injured 0–100
stitution of what is fear of reinjury is unclear. It body part to handle the
might be the fear implications for time off work demands of the situation
5. Confidence in skill level/ 0–100
and the related loss of income, fear of not being ability
able to return to the previous level, fear of the 6. Confidence to not 0–100
pain of injury itself, or any combination of these concentrate on the injury
[70]. Fear of reinjury is often referred as main Total score = Sum of items 1 to 6
reason to not returning to sports, and there are divided by 10
studies that fear of reinjury precludes RTP in
nearly  half  of the ACL-­reconstructed patients low overall confidence. A scale like this is neces-
[75]. Moreover, athletes who had successfully sary to determine when the athlete is ready for
returned to their preinjury sport generally par- RTP since this preparation is personal and each
ticipated without fear of reinjury [76]. injured athlete regain their confidence at different
Returning injured athletes to sport before they times during their own rehabilitation [80].
are psychologically ready can lead to anxiety, This scale is simple, can be easily used
fear, reinjury, depression, injury to different body throughout the rehabilitation process, and can be
parts, and a decrease in performance [77] and applied by health professionals or coaches for
potentially to greater risk of secondary injury monitoring athletes’ psychological readiness to
[67, 78]. In turn, positive psychological responses return to sport participation. Besides that, profes-
including motivation, confidence, and low fear sionals involved (health or training) can deter-
are associated with a higher likelihood of return- mine with greater accuracy a more appropriate
ing to the preinjury level of sports participation time for injured athletes return to competition
and returning faster [79]. Glazer [58] established [58]. Therefore, this scale should be applied to
the six-item I-PRRS scale (Table 12.1) to assess every RTP progression and can help identify
athletes’ psychological readiness to RTP after an those athletes that are not ready to return to com-
injury, which was validated through the Delphi petition and provide the health professional any
method with numerous experts and achieved eventual psychological readiness deficits that
good reliability and validity. Scoring of each item may require intervention before the athlete return
of the scale ranges from 0 to 100 with intervals of to competition.
10. A score of 0 implies that the athlete has little
to no confidence, a score of 50 indicates moder-
ate confidence, and a score of 100 implies that the 12.6 Decision-Maker Process:
athlete had utmost confidence for that item. Then, Who’s Responsibility?
the final scores of the 6 items are summed and
divided by 10, with a final score up to 60 points. RTP decisions can be complex, multifactorial, and
A score of 60 implies that an athlete is confident many times specific to the athlete and type of sport
to return to sport at that time; 40, the athlete has and often influenced by “decision modification”
only moderate confidence; and 20, the athlete had factors (e.g., pressure to return for a major event)
160 A. Rebelo-Marques et al.

[51]. There are implications for the injured athlete, must be evaluated. When fully competent,
organizations, and technical department, and even the athlete will decide based in professional and
the medical personnel can be impacted. On the personal circumstances and experience.
other hand, these decisions are often made in team Nevertheless, at the highest-level sports, there
environments comprised by individuals with vast are a wide range of implications in individual
experience and knowledge surrounding athletic events and team performance. Therefore, this is
injuries [81]. Yet, the goal would be to achieve a not an isolated decision, but the athlete’s input
unanimous decision concerning RTP of a given is a prerequisite [83].
athlete for optimal congruency and management The primary role of the coach is to maximize
[52]. But this is not always easy to conquer. athletic performance. They see their role as man-
Power relationships are widely studied in aging the unrealistic athlete expectations about
medical sociology, but this has not occurred the RTP process [4]. The main contribution from
within the RTP context [4]. Shrier et al. [82] con- the coach to the RTP process is related with the
ducted a survey questionnaire of Canadian sports sport-specific context. In elite sports, the coach is
medical department to determine which profes- the only one that can take the “ability-to-­perform”
sion is best perceived to evaluate an athlete’s decision, by evaluating the athlete knowledge
RTP.  It was concluded that medical doctors, and missing training, functional progression, and
physiotherapists, and athletic therapists were the information provided by the healthcare
considered best able to assess factors related to professional.
risk of injury and associated complications. Friends, family, agent, and corporate or insti-
Informed decisions require information from tutional managers have interests in the RTP deci-
several sources. Besides that, it is important to sion; however, their interactions can be
eliminate all potential sources of bias, for exam- misleading. Since the decision should always be
ple, any professional (from the medical doctor to in the best interest of the athlete, their role should
the athlete) that is worried about losing his/her be to support and comfort.
status or position, can make unconscious deci- The involvement of different professions in the
sion, and put all his work at risk. A shared RTP process calls for a multilateral implementa-
decision-­making process is the best way to tion strategy to enable a widespread distribution
achieve an effective result. However, each profes- within the target group of elite and semi-elite foot-
sional has duties in the process. There are three ball clubs (i.e., players, coaches, athletic coaches,
key steps in this decision: (1) choice, athlete and physiotherapists, team physicians, club decision-
coach should be aware of the options; (2) option, makers) is essential. The healthcare professional’s
different options must be detailed; and (3) deci- role or objective is to inform the athlete and coach
sion, guiding the athlete and coach to consider about healthcare status and risk [83]. Clear, effec-
and decide what is best [83, 84]. tive, and consistent communication is vital to
When several healthcare professionals are achieve trust among the key people involved and
involved, a straight line of communication and to a good RTP decision.
authority must be clearly defined [2]. This pro-
fessional group is the most appropriated to assess
the health status of the athlete and provide advice 12.7 Injury-Focused Examples
on management options and possible clinical out- of Return to Play
comes following RTP (usually a sports physician
and/or physiotherapist). When taking care of the RTP is multifactorial and is dependent of a myr-
athlete, it is important to consider the external iad of intrinsic and extrinsic factors. These may
pressure always present in sports environment affect the rate of RTP at the preinjury level and
(social and financial factors) and minimize the the time to RTP. Intrinsic factors may include the
influence of own values and beliefs [2, 81]. damaged tissue healing timeframes, reestablish-
In elite sports, the RTP advice is usually ment of muscle strength and joint ROM, regain-
informed. Short- and long-term consequences ing of proper motor control and proprioception,
12  Return to Play (RTP) 161

psychological readiness, recovery of functional across the surgical techniques employed, the time
ability (e.g., hop test for lower limb injuries or Y to RTP varies considerably and should be consid-
balance test for upper limb injuries), and sport-­ ered when the surgical decision is made (may
specific skills, among others. Extrinsic factors depend level of competition, time into the season,
often include the time into the season, career or and career status). Hence, the return to sports at
contract status, proximity of an important compe- any level, at the preinjury level, and time to return
tition, and pressure from related stakeholders to sports are reported below according to the sur-
(e.g., the coach or the club directors). The next gical technique employed [102–104]:
subsections of this chapter explore the RTP rates
and respective time to RTP of some common • Osteochondral autologous transplantation:
sports injuries. RTP is 89–93% at any level, 70% at the prein-
jury level, and 5.2–7.1  months for return to
sports.
12.7.1 ACL Reconstruction • Osteochondral allograft transplantation: RTP
is 88% at any level, 79% at the preinjury level,
A systematic review of the scientific literature and 9.2–9.6 months for return to sports.
[85] reported that following ACL reconstruction, • Microfracture: RTP is 58–75% at any level,
a pooled rate of 83% of athletes return to sports 68–69% at the preinjury level, and 7.0–
within 6–13 months. Despite the athletic perfor- 9.1 months for return to sports.
mance was decreased overtime from the preinjury • Autologous chondrocyte implantation: RTP is
levels, when comparing to the uninjured control 67–84% at any level, 71–76% at the preinjury
group, no significant deterioration of the athletic level, and 11.8–18.0  months for return to
performance was found. However, around 5% of sports.
those who RTP reported re-rupture.
The return to sports timing after ACL recon- Similarly, when focusing football players
struction is multifactorial and may depend on sev- [105], the return to sports rates were similar, with
eral factors including the level of participation the osteochondral autologous transplantation
and sports type. Thus, mean ranges of time to providing a faster return (4.5 months), followed
return to sports vary considerably according to the by microfractures (8  months) and autologous
sports type: football from 6.0 to 10.2 months [86– chondrocyte implantation (13.1 months).
89], basketball from 10.7 to 11.8 months [90–92],
American football from 7.8 to 12.8 months [93–
97], ice hockey from 9.8 to 13 months [98, 99], 12.7.3 Meniscal Surgery
and rugby under or equal to 6 months [100].
When focusing adolescent and children with Just as previously seen for knee cartilage injuries,
ACL reconstruction, the pooled rates were 92% the timing to RTP in meniscal injuries may vary
of return to any sport participation, 79% return to considerably according to the approach employed.
preinjury level of sport, and 81% to competitive The indications of each surgical technique may
level of sport. A total of 13% (n = 93 of the 717 often reflect the surgeon’s preference but mostly
athletes) reported graft ruptures, and 14% depend on the pattern of the tear, the presence of
(n  =  91 of 652 patients) reported contralateral associated injuries, the age and goals of the
ACL injuries [101]. patient, and the level of competition [106]. In
competing athletes, the surgical options mostly
include partial meniscectomy, meniscal allograft
12.7.2 Knee Cartilage Injuries transplantation, and meniscal repair:

Several systematic reviews have been published • Partial meniscectomy: 61% of RTP at the pre-
reporting the RTP rates and timing after knee car- injury level (n = 47 of 77 lateral partial menis-
tilage surgery. Although RTP rates are similar cectomies in American football players)
162 A. Rebelo-Marques et al.

within an average of 8.5 months [107]. If con- (strain). Mean absence (time to full training) of
sidering football players (n = 90, n = 42 lat- all thigh muscle injuries was 17.2 ± 18.9 (range,
eral, and n = 48 medial partial meniscectomy), 0–247) days. After indirect injury, the absence
the median time to RTP was longer in the lat- time was significantly longer 18.5 ± 19.5 (range,
eral partial meniscectomies (7  weeks, range 1–247) days compared to direct injuries 7.0 ± 9.1
5–18 weeks) than the medial group (5 weeks, (range, 0–93) days [115]. In the case of ham-
range 3–6  weeks). However, the cumulative string injuries (UEFA study, years 2007–2014),
probability of returning to play was six times the magnetic resonance parameters, more specifi-
greater for players with a partial medial men- cally the radiological grade and size of the edema,
iscectomy when comparing to partial lateral correlate with time to RTP for both grade 1 and 2
meniscectomy [108]. injuries. However, no correlations were found
• Meniscal allograft transplantation: Reports of between time to RTP and the location and type of
RTP following meniscal allograft transplanta- injury [116]. Reinjuries are most common in
tion are scarce, and only a few case series have biceps femoris injuries but rare in semitendino-
been reported [109–111]. The return to prein- sus and semimembranosus injuries [114].
jury levels of competition mean rates range Hip and groin injuries constitute a consider-
from 77 to 96% (pooled sample size of 39 ath- able part of all time-loss injuries in men’s profes-
letes, n  =  26 football, and n  =  13 multiple sional football. In the elite UEFA study (years
sports) within an average of 7.6–16.5 months. 2001–2016) [117], hip and groin injuries
• Meniscal repair: A pooled 89% of RTP at the accounted for 14% of all injuries (n = 1812, 11%
preinjury level was reported (86% in profes- were reinjuries), with adductor-related injury as
sional athletes) within a mean time to return to the most common of hip and groin injuries
sports of 4.3–6.5  months. Failure rate was (n = 1139, 63%; incidence rate 0.6/1000 h). The
lower in professional athletes (9%) when mean layoff for all hip and groin pain was
comparing to samples comprising different 16  ±  23  days and 15  ±  20 for adductor-related
levels of competition (22%) [112]. injuries.

12.7.4 Muscle Injuries 12.7.5 Shoulder Surgery

Muscle injuries account for 35% of all injuries in RTP after rotator cuff tears is challenging and
professional football and cause 25% of total few guidelines have been published. According
absence. Within this line, a male elite football to the type of lesion, its symptoms, and the
team of 25 players can expect 15 muscle injuries player role, the treatment of rotator cuff tears can
each season. Overall, muscle injuries affect be surgical (tendon repair) or conservative
mostly four muscle groups (the hamstring, the (shoulder immobilization, pain control, and
quadriceps (mainly rectus femoris), the adductor, restoring full range of motion with physiother-
and the calf muscles) accounting for 92% of all apy) [118]. A systematic review [119] account-
muscle injuries [113]. Return to training in elite ing 635 athletes (n  =  286 professional and
professional men’s football players is signifi- n = 349 recreational) and different sports (base-
cantly faster in groin muscle injuries (median, ball, n = 224; tennis, n = 104; and golf, n = 54)
9 days) than hamstring (median, 13 days), quad- reported an overall rate of return to any level of
riceps (median, 12  days), and calf muscle sports of 85 and 66% to the preinjury level of
(median, 13 days) injuries [114]. sports, after 4–17 months. Focusing the profes-
The UEFA elite study (years 2001–2013) sional athletes, half of them returned to the pre-
reported a total of 2287 thigh muscle injuries injury level of sports.
(25% of all injuries), of these 11.5% were direct Anterior shoulder dislocation and subsequent
injuries (contusion) and 88.5% indirect injuries chronic instability are common in young athletes.
12  Return to Play (RTP) 163

Athletes managed nonoperatively often show a median RTP of 77 days (range, 56–127 days)
unacceptably high rates of recurrent instability for isolated lateral ligamentous injuries and
and are less likely to successfully RTP [120]. 105  days (range, 82–178  days) for those with
Hence, athletes with recurrent instability that are concomitant injuries [127].
unable to perform the sport-specific drills are
indicated for surgical stabilization. Within this
line, arthroscopic approaches have become popu- 12.7.7 Patellar Dislocation
lar with high rates of success [121]. In a com-
parative study [122], 90% of athletes who Acute lateral patellar dislocations are common
underwent arthroscopic stabilization returned to in the active young population. Around 50–60%
sports in the subsequent season without recurrent of initial first-time lateral patellar dislocations
instability and were 5.8 times more likely return will occur secondary to a sports-related injury
to competition without recurrent instability in the [128]. Depending on the underlying individual
subsequent season compared to athletes who risk factors for dislocation recurrence, conser-
underwent nonoperative management. In a sys- vative or surgical management may be applied
tematic review, 1036 patients that underwent sur- efficiently.
gical management of shoulder stabilization Nonoperative management still remains the
reported higher RTP rates at the preinjury level standard of care for first-time patellar disloca-
following arthroscopic Bankart repair (71%) or tions [129]. A retrospective review of patients
the Latarjet procedure (73%) than open stabiliza- with primary lateral patellar dislocations treated
tion (66%). conservatively showed that 73% of patients
reported no further dislocation events. Of these,
86% of the patients returned to their most impor-
12.7.6 Ankle Lateral Ligamentous tant physical activity, but only 26% were able to
Injury return without limitations [130]. In another
report, although 69% of patients RTP within
After a lateral ligamentous injury, it is difficult to 6  months without recurrence episodes, 58%
determine when a football player can RTP.  The reported limitations upon intense activity [131].
non-elite or recreational player will undergo a Surgical stabilization surgery most often includes
conservative three-phase rehabilitation program medial patellofemoral ligament reconstruction,
for 3 months and in case of continued instability tibial tubercle osteotomy, or trochleoplasty,
will follow for stabilization surgery [123]. In the which is performed in isolate or in combination.
case of elite athletes, the acute repair is most The RTP rate varies from 84 to 100%, with
often considered [124]. 33–77% of return to the preinjury level. The time
In the elite UEFA study, within a timeframe to RTP is highly variable, ranging from 3 to
of 11 years, a total of 729 ankle sprains were 12 months [132].
recorded (68% of all ankle injuries and an inci-
dence rate of 0.7/1000  h), accounting with
10% of those classified as reinjuries. The mean 12.8 Summary
layoff time (time to training) was 15 days. The
average layoff days was not significantly dif- A successful RTP program returns the athlete as
ferent between recurrent sprains and other fast and as safe to preinjury levels of competition,
sprains [125]. without fear or increase risk of reinjury and with-
Following lateral ligament surgery, a system- out long-term comorbidities. This process should
atic review reported a return to sports rate of 85% be progressive in terms of loading and movement
within an average of 4.7  months (range, 2.4– complexity and should drive by “what” the ath-
6.8  months) [126]. When considering profes- lete is able to do rather than “when.” The final
sional players, a case series of 42 athletes reported decision to return an athlete to competition
164 A. Rebelo-Marques et al.

should be given when all the stakeholders—from ies of sports-related injury (research in the sociology
of sport); 2004. p. 269–86.
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 Part II
Overtraining Injuries
 Treatment of Achilles
Tendinopathies
13
Jon Karlsson, Annelie Brorsson, Unnur Jónsdóttir,
and Karin Grävare Silbernagel

13.1 Achilles Tendinopathy

The overuse type of injury to the Achilles tendon

is a painful type of injury that occurs when the
body’s reparative capability is exceeded by repet-
itive microtrauma [1, 2]. The injury can be in an
acute or chronic phase. The exact time criteria
that are used to classify the injury as acute or
chronic are arbitrary. In the literature, definitions
for the injury to be chronic range from 4 weeks to
3  months or pain on and off for more than
6  months [3–6]. The injury can be divided into
distal Achilles tendinopathy and midportion
Achilles tendinopathy depending on the location
of the pain (Fig. 13.1).
Achilles tendinopathy is particularly com-
mon in recreational athletes, and the annual
incidence in runners is between 7 and 9% [7,
8]. However, Achilles tendinopathy may also
occur in individuals that are not physically
active [9]. Risk factors may be intrinsic or
extrinsic. Examples of intrinsic risk factors are
abnormal tendon structure, high BMI,

J. Karlsson (*) · A. Brorsson · U. Jónsdóttir

Department of Orthopaedics, Institute of Clinical
Sciences at Sahlgrenska Academy, Gothenburg
University, Gothenburg, Sweden Fig. 13.1  Location of the pain for midportion and distal
e-mail: [email protected] Achilles tendinopathy
K. G. Silbernagel
Department of Physical Therapy, University
of Delaware, Newark, DE, USA

© ISAKOS 2019 173

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_13
174 J. Karlsson et al.

decreased ankle plantar flexion strength, or Clinically, a distinction between midportion

increased foot pronation, while repetitive over- (2–6 cm proximal to tendon insertion) and dis-
use injuries and inappropriate ­equipment are tal (insertion to the calcaneus) Achilles tendi-
extrinsic risk factors [10–12]. In 163 patients nopathy can be made on the basis of the location
with Achilles tendinopathy, surgical and histo- of the pain. The typical symptoms of Achilles
pathological findings showed that 90% had tendinopathy are pain during and after physical
degenerative changes, the so-called tendinosis activity, tenderness on palpation, and morning
[13]. On the other hand, degenerative changes stiffness [19–21]. With increased severity,
were also found in 20% of non-symptomatic patients may also have pain during daily func-
tendons. Another finding showed that 19% of tional activities [20, 21].
the patients had partial ruptures that always
occurred in the tendinosis area. There was also
a lack of inflammatory cells and poor healing 13.2.1 Midportion Achilles
response in the biopsies. Tendinopathy
The degenerative changes in the tendon can
be divided into several subcategories such as Midportion Achilles tendinopathy is reported to
hypoxic, mucoid, hyaline, lipoid, fibrinoid, cal- account for 55–65% of all the Achilles tendon
cific, or a combination of these [14, 15]. The injuries [22–25]. Patients usually describe a
degenerative changes can be the result of a vari- gradual onset of pain. Many patients have had
ety of causes such as aging, microtrauma, vas- pain for many months or on and off for many
cular compromise, or other reasons, and they years. Initially, the symptoms occur after heavy
may vary from tendon to tendon [14]. The histo- physical activity, but as the injury progresses,
pathological findings of tendinosis are collagen some patients develop pain during physical
disorientation, disorganization, and fiber sepa- activity. Patients may also have pain with daily
ration. Tendinosis might also occur together activities, such as walking. Morning stiffness
with the involvement of the paratenon. This can and/or stiffness after sitting for longer periods
present itself as crepitation due to adhesions of time are also common. Correlation between
between the tendon and the paratenon. In addi- pain level, morning stiffness, and severity of
tion to degenerative changes in the tendon, it has disease is reported in the literature [20, 21, 26,
recently been suggested that sensitization of the 27]. Clinically, the patients report pain on palpa-
central nervous system may play a part in the tion in the middle part of the tendon (2–6  cm
pain presented in patients with Achilles tendi- proximal to the tendon insertion), and some-
nopathy [16, 17]. times there is a palpable thickening in the same
area, usually in the more chronic stages. With
these findings together with the arc sign [28]
13.2 Diagnosis and Royal London Hospital [28] test (Fig. 13.2),
it is possible to diagnose midportion Achilles
Achilles tendinopathy is a clinical diagnosis for tendinopathy [29]. Noticeable crepitation can be
the clinical syndrome, characterized by a com- indicative of adhesions of the paratenon and
bination of pain, swelling (diffuse or localized), paratendinopathy in more acute stages. A thor-
and impaired performance of the Achilles ten- ough physical examination is important in order
don. Pain on palpation of the tendon (sensitivity to rule out any other causes of the pain. Examples
84%) and the subjective reporting of pain of differential diagnosis are involvement of the
2–6  cm above the insertion into the calcaneus plantaris tendon [30], acute Achilles tendon rup-
(sensitivity 78%) has also been found to be ture or partial tear of the Achilles tendon [31,
­reliable and valid tests for diagnosing Achilles 32], os trigonum syndrome [33], accessory
tendinopathy in the midportion of the tendon soleus muscle [34], and irritation or neuroma of
when compared to ultrasound scanning [18]. the sural nerve [31].
13  Treatment of Achilles Tendinopathies 175

Fig. 13.2  Royal London Hospital test

13.2.2 Distal Achilles Tendinopathy 13.3 Treatment

Approximately 20–25% of all Achilles tendon In the literature various types of treatments such
injuries are reported to be distal. This condition as ultrasound, deep friction massage, anti-­
is also called insertional Achilles tendinopathy inflammatory medication, surgery, injection ther-
[35]. In a study of patients with Achilles tendon apies, extracorporeal shock wave therapy,
injury during the years 1976–1986, 23% had photobiomodulation (laser) therapy, and exercise
pain distally, and, of these, 61% were diagnosed are described to be used as treatments for Achilles
with insertion tendinitis, 21% with retrocalca- tendinopathy [29]. Systematic reviews indicate
neal bursitis, and 18% with both [25]. These that exercise, especially eccentric exercise, has
patients report the same complaints as in mid- the most evidence of effectiveness but has been
portion injury and/or pain related to the type of less successful in the patients with insertional
shoe/athletic wear. In this case the pain can Achilles tendinopathy compared to those with
occur due to external compression on the tendon midportion injury [38, 39]. Today the consensus
insertion. Swelling around the Achilles tendon is that Achilles tendinopathy should initially be
insertion to the calcaneus, with redness and treated with exercise for at least 3–6  months.
warmth, could also be present and might be Even with other types of treatments, some type of
related to active bursitis. The patients some- exercise is recommended.
times also report pain after having run uphill,
standing on a ladder, or walking barefoot on
sand. Clinically, there is pain when the tendon 13.3.1 Therapeutic Exercise
insertion is palpated. This type of injury can
also be caused by compression injury of the ten- The basis of exercise as treatment for Achilles
don and the bursa onto the calcaneus, the so- tendinopathy is to address possible impairments
called posterior impingement. A prominent and deficiencies in strength, range of motion, bal-
superior projection of the calcaneus, i.e., ance, proprioception, and function and to pro-
Haglund’s deformity, can be the cause of the mote healing of the tendon. Since the tendon is
posterior impingement. Magnetic resonance subjected to the highest loads eccentrically,
imaging (MRI) as well as ultrasound imaging eccentric training has always been an important
can be used for examination both of soft tissue part of the prescribed exercise. However, it has
and bony changes [36] even if 0–19% of the been questioned if there is a need for an eccentric-­
patients with symptomatic Achilles tendinopa- only exercise protocol since it can be difficult to
thy present normal appearance when examined isolate eccentric contractions from concentric
with MRI or ultrasound imaging [37]. and there is little evidence that isolated eccentric
176 J. Karlsson et al.

contractions are clinically and mechanically were completely pain-free at 5  years and, with
superior to concentric-eccentric contractions [40, the comprehensive treatment protocol, 80% were
41]. Increased speed of movement also increases fully recovered after 5 years [45, 46].
the load of the tendon during the eccentric mus- The eccentric-only protocol has also been eval-
cle activation, and, to increase the load on the uated in patients with distal Achilles tendinopathy
tendon during exercise, both the external load [42]. It was found that this exercise program was
and the speed of movement can be increased. It more successful in patients with distal Achilles
has also been found that heavy-load slow-speed tendinopathy if the amount of dorsiflexion was
exercise gives equally good results as eccentric limited. It is therefore recommended, with both of
training in patients with Achilles tendinopathy. It the eccentric-only and the comprehensive treat-
is important to note that for patients with distal ment protocols, that patients with distal Achilles
Achilles tendinopathy, it is recommended to per- tendinopathy should be standing flat on the ground
form the heel-rises on a plain surface and avoid instead of standing at the edge of a step.
excessive dorsiflexion during exercise [42]. The third exercise protocol is the heavy slow
resistance protocol [47]. This protocol showed
13.3.1.1 Current Rehabilitation superior patient satisfaction after 3 months com-
Protocols pared to the eccentric-only protocol [43] but
There are currently three exercise programs that equally good results after 1 year.
have been used in various studies evaluating
treatment in patients with Achilles tendinopathy. 13.3.1.2 Eccentric-Only Exercise
One of the protocols, the so-called eccentric-only Protocol
protocol [43], uses eccentric loading only, Alfredson et al. [43] published in 1998 a nonran-
whereas another protocol, the so-called compre- domized study using a protocol with only eccen-
hensive treatment protocol [44], includes both tric heel-rises with both the knee straight and the
concentric and eccentric strengthening. These knee bent. The patients are instructed to use the
two protocols have been shown to have good uninjured side to get up on the toes and then place
short-term results in patients with midportion the weight on the injured side and then lower the
tendinopathy. When evaluating the long-term heel all the way down (Fig.  13.3). The patient
outcome of the protocols, it was found that with performs 3 sets of 15 repetitions of the 2 exer-
the eccentric-only protocol, 38% of the patients cises, twice a day for a total of 12  weeks.

Fig. 13.3  Eccentric heel-rise

13  Treatment of Achilles Tendinopathies 177

The  treatment program is also supposed to be [44]. The reason for this is that both concentric
painful, and if the exercises could be performed and eccentric activations are included in all phys-
without experiencing any minor pain or discom- ical activities and it has been shown that patients
fort, the patients were instructed to increase the with Achilles tendinopathy have both concentric
load by wearing a backpack with added weights. and eccentric strength deficits [48]. The program
consists of single- (Fig. 13.4) and double-legged
13.3.1.3 A Comprehensive Treatment standing heel-rises (Fig. 13.5), seated heel-rises,
Protocol eccentric heel-rises, and quick rebounding
This protocol includes both concentric and heel-rises.
eccentric exercises of the calf muscles together There are four different phases of the pro-
with a pain-monitoring model and a training log gram with gradually increasing strength

Fig. 13.4  Single-legged standing heel-rise

Fig. 13.5  Double-legged standing heel-rise

178 J. Karlsson et al.

Phase 1: Week 1-2

Patient status: Pain and difficulty with all activities, difficulty performing 10 single-leg heel-rises

Goal: Start to exercise, understanding nature of their injury and of pain monitoring model
Treatment program: Perform exercises every day
• Pain monitoring model information and advice on exercise activity
• Circulation exercises (foot up/down)
• Double-leg heel-rises standing on the floor (3x10-15)
• Single-leg heel-rises standing on the floor (3x10)
• Sitting heel-rises (3x10)
• Eccentric heel-rises standing on the floor (3x10)
Phase 2: Week 2-5 (If pain distally continue standing on the floor)
Patient status: Pain with exercise, morning stiffness, pain when performing heel-rises
Goal: Start strengthening
Treatment program: Perform exercises every day
• Double-leg heel-rises standing on edge of stair (3x15)
• Single-leg heel-rises standing on edge of stair (3x15)
• Sitting heel-rises (3x15)
• Eccentric heel-rises standing on edge of stair (3x15)
• Quick rebounding heel-rises 3x20
Phase 3: Week 3-12 (or longer if needed) (If pain distally continue standing on the floor)
Patient status: Handle the phase 2 exercise program, no pain distally in tendon insertion,
possibly decreased or increased morning stiffness
Goal: Heavier strength training, increase or start running and/or jumping activity
Treatment program: Perform exercises every day and with heavier load 2-3 times per week
• Single-leg heel-rises standing on edge of stair with added weight (3x15)
• Sitting heel-rises (3x15)
• Eccentric heel-rises standing on edge of stair with added weight (3x15)
• Quick rebounding heel-rises (3x20)
• Plyometrics training

Phase 4: 3-6 months (or longer if needed) (If pain distally continue standing on the floor)
Patient status: Minimal symptoms, not morning stiffness every day, can participate in sports without difficulty
Goal: Maintenance exercise, No symptoms
Treatment program: Perform exercises 2-3 times per week
• Single-leg heel-rises standing on edge of stair with added weight (3x15)
• Eccentric heel-rises standing on edge of stair with added weight (3x15)
• Quick rebounding heel-rises (3x20)

Fig. 13.6  The comprehensive treatment protocol

demands, and what phase the patient is in is (Fig.  13.7). The model was initially developed
dependent on their symptoms and function by Thomeé [49] and presented in a randomized
(Fig.  13.6). This treatment protocol allows the controlled trial in 1997 for patients with patello-
patient to experience pain during and after exer- femoral pain syndrome. The pain-monitoring
cise. The pain-­monitoring model is used to facil- model and training log are tools that also help
itate the patients’ understanding of the amount the clinician and patient to d­ etermine how the
of pain allowed during and after exercise exercise program should progress and also how
13  Treatment of Achilles Tendinopathies 179

much is the optimal amount of exercise overall. s­ignificant improvements in patients with mid-
The exercise program, complemented with the portion Achilles t­ endinopathy [44, 50].
pain-monitoring model, has been evaluated in
two randomized controlled trials and led to 13.3.1.4 H  eavy Slow Resistance
Protocol
Beyer et al. [47] presented in 2015 a heavy-load
Visual Analog Scale-VAS slow-speed protocol for patients with midportion
Safe Acceptable
High risk zone
Achilles tendinopathy. The program consists of
zone zone
three bilateral heel-rises in full range of motion:
0 2 5 10 (1) seated with the knees in 90° in a calf muscle
No pain Worst pain imaginable
weight-training machine, (2) standing with
1. The pain is allowed to reach 5 on the VAS during the exercises. extended knees with a barbell on shoulders, and
2. The pain after the whole exercise programme is allowed to reach (3) a leg press machine with extended knees
5 on the VAS but should have subsided the following morning.
3. Pain and stiffness is not allowed to increase from week to week.
(Fig. 13.8). Every repetition was performed at a
speed of 6 s. The program went on for 12 weeks,
Fig. 13.7  The pain-monitoring model and during this time the weight was progressively

Fig. 13.8  The heavy slow resistance protocol

180 J. Karlsson et al.

increased, while the numbers of repetitions [55], and systematic reviews have not been able to
­successively decreased. This study was a prospec- prove that orthotics for patients with Achilles ten-
tive randomized single-blind controlled trial, and dinopathy is beneficial [39, 56]. Clinically, some
the patients were randomized to either the heavy patients report no effects with orthotics, whereas
slow resistance protocol or the eccentric-only others report significant improvements with its
exercise protocol. The heavy slow resistance pro- use. Until there is research showing that corrective
tocol showed superior patient satisfaction after orthotics is effective in relieving symptoms, its use
3 months compared to the eccentric-only protocol should be based on clinical judgment.
but equally good results after 1 year [47].

13.3.1.5 Stretching 13.3.3 Taping

Stretching of the ankle plantar flexors may be used
to reduce pain in patients with midportion Achilles There is limited evidence that taping can reduce
tendinopathy if the patient experience limited pain, but rigid taping can be used to alter foot
ankle dorsiflexion [51]. The stretching can be per- posture or reduce strain on the Achilles tendon
formed both with the knee extended and flexed. [56, 57].

13.3.1.6 Neuromuscular Reeducation

It has been found that runners with Achilles tendi- 13.3.4 Nonsteroidal
nopathy present decreased muscle activity in the Anti-­Inflammatory
lower extremity compared to a control group [52]. Drugs (NSAIDs)
Chang and Kulig [53] have also presented evi-
dence for if tendinotic changes are present within Since Achilles tendinopathy is mainly a non-­
the Achilles tendon, this may lead to adaptations inflammatory condition, apart from a possible
in motor control within the central nervous sys- short initial inflammatory phase, the use of
tem. However, it can be discussed if decreased NSAIDs will have no major therapeutic effect
muscle activation is a cause or a result in patients [13, 58, 59]. NSAIDs might, however, have an
with midportion Achilles tendinopathy. Clinicians analgesic effect for the patient. Åström and
can be recommended to use neuromuscular exer- Westlin [60] found no beneficial effect from
cises for lower leg with the aim to avoid an atypi- NSAIDs in patients with Achilles tendinopathy.
cal biomechanical movement pattern. In a review of the literature, the investigators
report insufficient evidence for determining the
13.3.1.7 Manual Therapy efficacy of NSAIDs in chronic tendon injury [61].
There is some evidence that soft tissue mobiliza-
tion can be used to improve mobility and func-
tion [54], but no studies have investigated soft 13.3.5 Injections
tissue mobilization particularly for patients with
Achilles tendinopathy. A systematic review investigating platelet-rich
plasma (PRP) injections, autologous blood
­injections, sclerosing polidocanol injections, and
13.3.2 Orthotics corticosteroid injections could not find any evi-
dence that injections of any kind alone could be
It has been suggested that biomechanical malalign- favorable for patients with Achilles tendinopathy
ments are risk factors for Achilles tendinopathy. even if there could be some benefits used together
Corrective orthotics is therefore often prescribed with physical therapy [62]. Total and partial rup-
for patients with Achilles tendinopathy. No differ- tures in the Achilles tendon have been reported as
ence has been found between patients who had a complication after injections with corticoste-
customized orthosis compared to sham orthoses roids and polidocanol [63, 64].
13  Treatment of Achilles Tendinopathies 181

13.3.5.1 Platelet-Rich Plasma than other options in the intermediate and long
Injection terms [73]. A recent study has shown more posi-
The use of platelet-rich plasma injections has tive results [74]. The effects might also vary
mainly been investigated in midportion Achilles depending on the site for tendinopathy, and due
tendinopathy. There are some evidences that this to the heavy load on the Achilles tendon and the
type of injection may have benefits together with potential increased risk for Achilles tendon rup-
eccentric training [65] even if recent meta-­ ture, it is not recommended as an option.
analyses have not been able to confirm these
findings [66, 67].
13.3.6 Extracorporeal Shock
13.3.5.2 High-Volume Image-Guided Wave Therapy
Injection
High-volume image-guided injection (HVIGI) is Extracorporeal shock wave therapy (ESWT) is
a technique where ultrasound image is used to used for pain relief and to promote tendon heal-
guide the needle with the aim to reach the area ing; however, the underlying mechanism is not
between the anterior aspect of the Achilles ten- clear (Fig.  13.9). The published trials for the
don and Kager’s fat pad. It is believed that this use of ESWT in tendinopathy also vary in
area has the maximal neovascularization around intensity, frequency, and duration [75–79].
the Achilles tendon. The injection consists of A  systematic review including 11 trails con-
saline and local anesthetic with or without added cluded that for patients with distal Achilles ten-
corticosteroids [68]. dinopathy, ESWT was superior to eccentric
In a randomized double-blinded prospective loading in the short term, while for patients
study, Boesen et al. [65] found that high-volume with midportion Achilles tendinopathy, a com-
injection together with eccentric training had bination with ESWT and eccentric loading was
superior effect on chronic midportion Achilles the best choice [80]. The general recommenda-
tendinopathy than eccentric training alone. The tion is that it might be beneficial to use ESWT
effect has been confirmed in other studies [68– in conjunction with optimal therapeutic exer-
70], but there is, at this time point, a lack of high-­ cise and patients with distal Achilles tendinopa-
level evidence in this field. thy might benefit more than patients with
midportion injury. However, the optimal dosage
13.3.5.3 Sclerotherapy is still unclear [29].
Sclerotherapy means injections with the sub-
stance polidocanol in the neovascularization zone
in a pathological Achilles tendon. Early studies
showed excellent results [71], but more recent
studies and systematic reviews have not been
able to confirm these results [64, 72].

13.3.5.4 Corticosteroids
Corticosteriods are commonly used for their anti-­
inflammatory effect. In a review of the use of cor-
ticosteroids in chronic tendon injuries, it was
found that they might provide some initial pain
relief but that their beneficial effect on the out-
come remained uncertain [61]. One systematic
review reported that corticosteriod injections for
tendinopathy may show positive short-term Fig. 13.9  Treatment with extracorporeal shock wave
results, but this treatment was found to be worse therapy (ESWT)
182 J. Karlsson et al.

13.3.7 Laser clinical studies show positive results. For Achilles

tendinopathy therapeutic ultrasound has been
The photobiostimulation that occurs when treating shown to be inferior to eccentric exercise [88].
the tissue with laser has been reported to reduce Systematic reviews and meta-analyses have
inflammation [81] and have positive effects on failed to show that active ultrasound is more
angiogenesis [82] and collagen ­ synthesis [83]. effective than placebo [89].
Controversy exists over dosage recommendations,
and consensus does not exist of the most effica-
cious dose [84]. A systematic review evaluating 13.3.9 Surgery
the effect of low-level laser therapy (LLLT) on
tendinopathy indicated favorable outcome with There appears to be consensus in the literature
this treatment, but the results vary between differ- that surgery should only be performed after
ent studies [84]. However, none of the studies has patients have been treated unsuccessfully with a
evaluated the effect of LLLT on patients with the treatment protocol involving exercise for a mini-
distal-type injury. More recent studies have mum of 6 months [20, 21, 58, 90]. The surgical
showed conflicting results; Hutchison et  al. [85] techniques vary but usually include removing
found no difference between LLLT and placebo abnormal tendon tissue and releasing adhesion
laser, while Tumilty et  al. [86] concluded that and scarring [20, 21, 90]. In patients with distal
LLLT together with exercise could be as beneficial Achilles tendinopathy, the surgical methods often
compared to exercise together with placebo laser. include removal of the calcaneal prominence, the
Because of this conflicting results, a recent pub- retrocalcaneal bursa, and, if present, calcifica-
lished guideline cannot recommend LLLT for tions together with pathological parts of the
patients with Achilles tendinopathy [29]. Achilles tendon [37] (Fig. 13.10). It is not clear
why surgery sometimes helps and the postopera-
tive rehabilitation may be as important as the
13.3.8 Therapeutic Ultrasound actual surgery [58]. The success rates for surgery
vary between 70 and 90% in different studies [21,
In animal studies therapeutic ultrasound has been 91, 92], and the mean success rate (according to
found to enhance tendon healing [87], but few Coleman et  al. [93]) for surgery performed in

Fig. 13.10  Before and

after removal of the
calcaneal prominence
13  Treatment of Achilles Tendinopathies 183

midportion Achilles tendinopathy is recently shock wave therapy, laser therapy, and the use of
reported to be 83.4% [91]. Complications after orthotics. Surgery is to be considered as the last
surgery also need to be considered, and, in a sys- option, and when performed, there is a need for
tematic review included 20 studies with 714 the patient to complete an individualized reha-
patients and 801 tendons altogether, the compli- bilitation program designed for gradually load-
cation rate was reported to be 6.3% [91]. With ing. Patients with insertional Achilles
improvements in nonsurgical treatment, there tendinopathy are more likely to need surgery
will, however, be fewer requests for surgery. compared to patients with midportion Achilles
tendinopathy.

13.3.10  Nitric Oxide

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 Muscle Injuries
14
Gian Luigi Canata, Valentina Casale, Marco Davico,
and Simone Lapi

14.1 Overreaching • Functional overreaching (FOR): A short-term

and Overtraining reduction of performance (days to few weeks)
followed by a supercompensation after recov-
Musculoskeletal overuse injuries are of impor- ery, with a consequent improvement of
tant concern in athletics, especially in endurance performance
sports where the balance between workload and • Nonfunctional recovery (FNOR): A short-­
rest is often ignored for obtaining maximal per- term decrease in performance (weeks to
formance results [1–3]. months, longer than FOR) followed by a full
In fact, overloading is often deliberately pro- recovery, but the previous performance abili-
grammed as part of the endurance in the athlete’s ties may not always be reestablished
training process, stimulating physiological and • Overtraining syndrome (OTS): After a long-­
psychological adaptations and improving physi- term recovery (usually several months), com-
cal performance. To do that, the training stimuli bines decrease of performance abilities and
must be high enough to cause disturbance of psychological symptoms
homeostasis: this way the body is forced to adap-
tation [4]. Unfortunately, excessive and repetitive While an overreaching condition frequently
overloading followed by inadequate recovery affects athletes with an incidence between 5 and
may lead to overreaching and overtraining syn- 60% [7–9], the OTS is much less prevalent [3, 10].
drome, characterized by acute feelings of fatigue The OTS may be described as a condition caused
and decreases in performance [3, 5]. Hooper by training too hard for too long, leading to a gen-
et al. suggest that volume of training rather than eral breakdown in physiological functions [4].
intensity may be the primary cause of develop- It is difficult to draw a clear distinction among
ment of the overtraining syndrome [6]. these three conditions [5]. The clinical signs and
The spectrum of underperformance conditions symptoms caused by the imbalance between
includes: training and recovery may be confused with ill-
ness, stress, sleep disorders, or inadequate nutri-
tion [3]. Several synonyms around overreaching
conditions do exist: training stress syndrome,
under-recovery, failure adaptation, burnout, mus-
G. L. Canata (*) · V. Casale · M. Davico · S. Lapi cle failure syndrome, and excessive exercise [11].
Centre of Sports Traumatology, Koelliker Hospital, However, as cited before, the ultimate result con-
Torino, Italy sists in dysfunctions of immune, inflammatory,
e-mail: [email protected]

© ISAKOS 2019 187

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_14
188 G. L. Canata et al.

neurological, hormonal, and metabolic system, The “central fatigue hypothesis” describes the
causing the inability to manage chronic exposure connection between increased levels of serotonin
to intensive metabolic and tissue stresses [5]. and a reduction of performance [10, 20, 21].
Establishing the optimal training regimen is Well-trained athletes show a low sensitivity to
difficult, because the volume of training and the serotonin [22]; in fact, marathon runners receiv-
best rest period to improve performance are not ing branched chain amino acids supplementation
easily determined: the suitable scheme for some feel energized and mentally clear, showing lower
athletes may cause undertraining or overtraining levels of serotonin synthesis [21]. Conversely,
in others [12]. Furthermore, if the interval overtrained athletes have an increased neurologic
between workouts is too long, the overcompensa- sensitivity to serotonin, even though few studies
tion may impair the original function conditions, have analyzed serotonin activity in overtrained
and progressive improvement will not occur; athletes so far [21].
conversely, too frequent training stimulus may The “glutamine hypothesis” is related to the
reduce the recovery ability, and adaptation will immune cell functions. Low glutamine levels
not be possible [13]. after exercise may cause upper respiratory tract
Overreaching and overtraining negatively infections in overtrained athletes [23–25]. The
affect muscle strength, power, and velocity [14– low levels of glutamine after activity are related
16]. Unlike overreaching subjects, the reduction to an overutilization and/or a reduced production
in maximal force production persists in over- by overworked muscles [26]. Although the gluta-
trained athletes, even after several weeks of mine amount in immune cells does not necessar-
recovery [14]. ily change after its reduction caused by exercise
[26], the glutamine supplementation has been
proved to decrease early rates of infection [27]. It
14.2 Overtraining Syndrome is important to remind that the connection
Pathophysiology between low levels of glutamine and upper respi-
ratory tract infections is not clear, even because
Overtraining pathophysiology hypothesis glutamine amount is influenced by nutritional
1. Glycogen hypothesis
state, trauma, or infections [26].
2. Central fatigue hypothesis
3. Glutamine hypothesis The “oxidative stress hypothesis” focuses on
4. Oxidative stress hypothesis the role of reactive oxygen species (ROS)
5. Autonomic nervous system hypothesis released from damaged muscles (i.e., superoxide,
6. Cytokine hypothesis hydrogen peroxide, and hydroxyl radical) [17].
Initially, these species regulate cellular repair
Numerous hypotheses which should consider the [28], with positive effects for muscular homeo-
complexity and variability of symptoms have stasis; nevertheless, when oxidative stress
been suggested to explain the development of the becomes pathologic, the reactive oxygen species
overtraining fatigue [17, 18]. may cause inflammation, muscle fatigue, and
The “glycogen hypothesis” indicates the low soreness, leading to reduced performance [29].
muscle glycogen levels as the cause of increased Overtrained athletes show high resting markers
oxidation and decreased branched chain amino of oxidative stress, which raise during exercise
acids, leading to an altered synthesis of central [29, 30]. Among damages to proteins and lipids
neurotransmitters involved in fatigue [19]. in the contracting myocytes, it has been reported
Although these concepts are not strictly that oxidants regulate several cell signaling path-
­connected to the overtraining syndrome onset, ways and influence the expression of numerous
they explain how the exercise-induced fatigue genes [31], resulting in changes at transcrip-
develops [11]. tional, mRNA stability, and signal transduction
14  Muscle Injuries 189

levels [31]. What is more, ROS may promote an running and training, such as the surface and run-
inflammatory response during repair of the dam- ning distance, the shoe used, the running partici-
aged overtrained muscles, leading to neutrophil pation rates, and the athlete experience [41].
and macrophage infiltration of muscles [28, 32]
and a consequent leukocytosis which lasts sev-
eral days [33]. 14.2.1 Overtraining Effects
The “autonomic nervous system hypothesis” on Skeletal Muscle
explains a reduced sympathetic activation and a Metabolism and Homeostasis
parasympathetic dominance typically present in
overtrained athletes, responsible for muscle Overtrained athletes show an altered hormonal
fatigue, bradycardia, and performance inhibition response to stress, such as lower heart rate, blood
[20, 34]. The balance between sympathetic and lactate, and plasma cortisol reduction by down-
parasympathetic systems is restored after a week regulation, as a consequence of repetitive large
of rest [35]. stress responses [42]. Gleeson summarized the
The “hypothalamic hypothesis” explores the most commonly reported physiological and psy-
alterations among the hypothalamic-pituitary-­ chological changes as:
adrenal and hypothalamic-pituitary-gonadal
axes: the results are variations in cortisol, adreno- • Underperformance
corticotropic hormone (ACTH), testosterone, and • Muscle weakness
other hormone levels [20, 34, 36–38]. • Chronic fatigue and muscles soreness
Nevertheless, several other stimuli influence • Increased perceived stress during activity
these hormonal axes; thus the correlation with the • Reduced motivation
overtraining condition is not such clear [17]. • Sleep disturbance
The “cytokine hypothesis” analyzes the • Increased early morning or sleeping heart rate
inflammatory cascade induced by repetitive • Altered mood state
microtrauma on tissues. Tissue healing and • Loss of appetite
strengthening derives from the recruitment of • Gastrointestinal disturbance
cytokines (i.e., interleukin 1 beta or IL-1ß, IL-6, • Recurrent infection
and the tumor necrosis factor α or TNF-α) as a
physiological reaction to exercise, although As for the musculoskeletal metabolic changes,
amplification and pathological response may the three major adaptations to exercise determine
occur if the required resting phase is not respected an increase in density of mitochondria, a modifi-
[24, 34, 39]. Although this theory may explain cation of muscle types, and an orientation of the
“why” the overtraining injuries develop, the exact use of energy substrates [43]. The resulting con-
correlation between cytokines and overtraining ditions consist in a capillary proliferation around
remains unclear [34]. muscles, higher intramuscular glycogen and tri-
A further reference deals with the predispos- glyceride reserves, and an increase in maximal
ing factors to overuse injuries. For example, the oxygen uptake [44]. The higher volume of mito-
structure of coordinative variability may reduce chondria per muscle unit promotes a preferential
or increase the injury rates [40]. Nevertheless, it use of lipids, which is further simplified by an
is still unclear if a low coordinative variability is increase in intramuscular lipid content [45].
a cause or an effect of overuse injuries, as well as Furthermore, since moderate- to high-intensity
a too high variability sometimes may be associ- exercises use carbohydrates as the primary source
ated to higher lesions rates [40]. of energy, overtraining has been demonstrated to
As for running overuse injuries, van der Worp reduce levels of muscle glycogen despite the
et  al. reported the risk factors associated with dietary intake remains unchanged [46]. Muscle
190 G. L. Canata et al.

glycogen resynthesis delays and performance overtraining syndromes [11]. Therefore, it is

levels decrease [47]. Along with a reduced energy essential to rule out the more common medical
storage, low muscle glycogen levels may also diseases, such as anemia, asthma, cardiovascular
cause a dropping of the branched amino acids affections (especially in masters athletes), mood
due to oxidation of glucose, thus developing a disorder, and infections [11, 18].
central fatigue [48]. The reflection of overtrain- Nevertheless, some markers may be helpful if
ing on the ultrastructural level of skeletal muscle evaluated once an athlete reports clinical signs of
highlights that the negative effect depends on the overtraining muscle fatigue [3, 17, 38].
muscle fiber type [49]. It has been well reported Since several metabolic and psychologic dis-
that endurance training produces a change from eases may cause underperformance and symp-
glycolytic-type fibers (type II) to slower toms of overtraining syndrome, a thorough
oxidative-­type fibers (type I) [43] and from type clinical history must always be collected [3, 10,
IIb glycolytic fast fibers to type IIa oxidative fast 17, 18]. Furthermore, the patient usually reports a
fibers [50]. This entails a decrease of the muscle persisting, reduced performance despite weeks or
fatigue due to a better diffusion of oxygen toward months of rest, as well as disorders of mood,
the mitochondria, but a concurrent reduction of without clear signs of other possible causes of
the force capacity per motor unites [43]. During underperformance [3].
overtraining, changes in the skeletal muscle myo- Significant organic diseases must be excluded,
fibrillar apparatus may develop, especially the as well as infection diseases, endocrinological
destruction of contractile proteins [13], with a disorders, autoimmune diseases, deficiencies of
final development of an exercise myopathy [49]. carbohydrate/protein intake, iron, vitamin D, and
Furthermore, it has been reported a diminished magnesium [3, 9, 17, 21, 30]. In particular, moni-
synthesis of muscle proteins, especially myofi- toring heart rate and blood lactate seems to be
brillar proteins, as well as an increased protein effective to classify a high percentage of athletes
degradation in skeletal muscles [4]. Overtraining who may be entering overtraining fatigue [53,
affects neuromuscular junctions too. The nerve-­ 54]. Part of the clinical diagnosis of overtraining
muscle transfer is gradually disrupted in over- fatigue takes into account mood changes. The
trained muscles, cell regeneration slows down, Profile of Mood States questionnaire (POMS) is
and muscle fiber atrophy develops. An initial widely used for diagnosing alterations of the
clinical sign may be the delayed onset muscle mood among athletes [55].
soreness (DOMS). It usually begins 12–24 h after Among the triggers for a correct diagnosis of
an excessive workload. Tenderness and stiffness overtraining injuries, there are training errors
develop, soreness reaches the climax 48 h later, which imply an imbalance between load and
and then symptoms resolve within 10 days [51]. recovery, the monotony of training, too many
As the severity of this condition depends on the competitions, and psychological issues [3].
intensity and volume of training, persisting in However, the diagnosis of overtraining syn-
hard workload during the DOMS symptomatic drome is still possible only after the exclusion of
period may compromise shock wave absorption all the other possible causes of underperfor-
ability, strength output, force steadiness, and mance [3, 11].
coordination [52], finally resulting in overtrain- In case a DOMS is suspected, magnetic res-
ing muscle lesions. onance (MR) imaging may be helpful [56],
while ultrasound (US) is considered not sensi-
tive enough to detect the changes secondary to
14.3 Diagnosis of Overtrained this condition [57] (Fig. 14.1a, b). In particular,
Muscle Injuries muscle edema may be found as a high-intensity
signal at the muscle belly on MRI, and perifas-
As several reviews discuss, there is no definitive cial fluid may be present in the early injury
biomarker able to differentiate functional stage [56] (Fig. 14.2a, b). Usually, no fiber dis-
overreaching, nonfunctional overreaching, and
­ ruption or tears are associated with DOMS
14  Muscle Injuries 191

a b

Fig. 14.1  The absence of any muscular alteration on US (a). MRI shows a perivascular myofascial edema with high
signal intensity of the perivascular venous spaces (b)

(Fig. 14.3a, b). It is important to remember that

though symptoms have been completely solved,
usually within 10–12 days, the MR images may
take even 80 days to detect no abnormal signal
intensity [58]. To assess the muscle healing
response, US can be used to look for persistent
focal abnormality, although MRI is highly sen-
sitive and more specific for detecting small
residual areas of injury that US cannot be visu-
a
alized [59].

14.4 H
 ow to Manage Overtraining
Muscle Injuries

As Kreher and Schwartz underline, when the

cause of OTS is an organic disease, an appropri-
ate treatment is strongly recommended [17]. In
case of functional overreaching condition, the
most effective management is balancing overload
training with appropriate rest [10]. If nonfunc-
tional or overtraining syndrome is present, the
only effective treatment is rest [17]. Rest may be
b absolute or relative; in any case it is important to
introduce physical activity gradually, for exam-
ple, starting from 5 to 10 min daily until 1 h if the
Fig. 14.2  Axial (a) and coronal (b) MR images show athlete tolerates it [60]. If stress, depression, or
interfascial edema, with hyperemia and thickening of the anxiety does not reduce or even increase during
fascia between soleus and the medial head of gastrocne-
mius. No alterations of muscular trophism are detectable full rest, relative rest is advisable [10].
192 G. L. Canata et al.

a Prevention of the overtraining syndrome is

widely approved as fundamental [3]. Since the
main cause of overtraining injuries is the imbal-
ance in the training recovery ratio, an effective
prevention injury program is to monitor the ath-
lete daily training loads [61, 62]. The most used
methods are training diaries, retrospective ques-
tionnaires, physiological screenings, and direct
observation [63]. The psychological aspects also
need to be considered, as well as the rate of per-
ceived exertion (RPE) [3, 11] and the periodiza-
tion and individualization of the athlete’s
b nutritional requirements [64]. Among the several
biochemical processes as causes of overtraining
injuries, much of the prevention may be simply
the education to risk factors and the ways to avoid
excessive stress without adequate rest [11].
Working on modifiable risk factors can be a
further effective prevention strategy. For exam-
ple, it is well known that high training frequency
and running distance are more susceptible to
overuse injuries [65], but even one run a week
prevents the musculoskeletal system adapting to
that type of exercise [66, 67]. In fact, it has been
reported that training may play a protective role
and undertraining may increase injury risks [68].
Pluim and Drew proposed six load management
tips to optimize this concept related to tennis
Fig. 14.3  The high-definition axial (a) and coronal (b) overload injuries [69]:
MR images are enable to diagnose a typical DOMS condi-
tion. An edema of the contractile fibrils is evident, without 1 . Establish a basic fitness level
discontinuity of myofascial bands 2. Minimize the week-to-week changes
3. Try to avoid peaks in load
14.5 P
 revention of Overtrained 4. Make sure you maintain a correct work-rest
Muscle Injuries balance
5. Maintain a minimum training load
How to Prevent Overtraining Syndrome 6. Do not overdo it!
1. To monitor athlete’s daily training loads
2. To consider psychological aspects
3. To work on modifiable risk factors (i.e., high training It is also suggested to adopt a standardized
frequency, running distance) workout routine or to do a performance test peri-
4. To adopt a standardized performance test to be done odically, for relating any possible variation in the
periodically results to the athlete’s condition [17, 18, 38].
5. To remember that every athlete has different tipping Nevertheless, every athlete has to be consid-
points for overtraining fatigue
6. To educate athletes, coaches, and sports medicine
ered as an individual with different tipping points
professionals to recognize first signals and to for overtraining fatigue and different stress
communicate with each other capacities [19]. The main purpose should be
14  Muscle Injuries 193

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 Stress Fractures
15
Timothy L. Miller and Christopher C. Kaeding

Stress fractures of bone, also known as fatigue stress fractures and their implications is the key
fractures or march fractures, are common and to providing optimal care to all patients with
troublesome injuries in athletes in military per- stress fractures, especially those with an injury at
sonnel. A multitude of biological and mechanical a high-risk site.
factors influence the body’s ability to remodel
bone and impact an individual’s risk for develop-
ing a bony stress injury. These factors include 15.1 T
 he Holistic Approach
sex, age, race, hormonal status, nutrition, neuro- to Stress Fractures
muscular function, and genetic factors. Other
predisposing factors to consider include abnor- Stress fractures are the result of the loss of the
mal bony alignment, improper technique/biome- normal balance between the creation and repair
chanics, poor running form, inadequate blood of microcracks in bone. Treatment principles
supply to specific bones, improper or worn-out include taking a holistic and systemic approach
footwear, and hard training surfaces. to individuals presenting with this injury. In order
Understanding the classification and grade of to decrease the creation of microcracks, one must
evaluate the patient’s training regimen, biome-
chanics, and equipment. Maximizing the patient’s
T. L. Miller (*) biologic capacity to repair microcracks requires
Orthopaedic Surgery and Sports Medicine, an assessment of the athlete’s general health.
The Ohio State University Wexner Medical Center,
This includes nutritional status, hormonal status,
Jameson Crane Sports Medicine Institute,
Columbus, OH, USA emotional status, and medication use.
Stress fractures are not a single consistent
Ohio State University Athletics, The Ohio State
University Wexner Medical Center Endurance entity. They occur along a continuum of severity
Medicine Team, Columbus, OH, USA which can impact treatment and prognosis [1–
e-mail: [email protected] 4]. Not only does the extent of these injuries
C. C. Kaeding vary, but the clinical behavior of these injuries
Department of Orthopaedics, The Ohio State varies by location and causative activity [5, 6].
University Wexner Medical Center Sports Medicine,
It should be borne in mind that no two stress
Jameson Crane Sports Medicine Institute,
Columbus, OH, USA fractures behave exactly alike. Treatment proto-
cols should be individualized to the patient, the
Department of Athletics, The Ohio State University,
Columbus, OH, USA causative activity, the anatomical site, and the
e-mail: [email protected] severity of the fracture. The key principles for

© ISAKOS 2019 197

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_15
198 T. L. Miller and C. C. Kaeding

treating stress fractures in athletes are summa- The goal of treating bony injuries is to decrease
rized in Table  15.1, and a treatment algorithm the repetitive stress at the fracture site enough to
that has been successfully employed by the allow the body to restore the dynamic balance
authors is shown in Fig. 15.1. between damage and repair. This may include
decreasing volume and intensity of activity, equip-
Table 15.1 Key treatment principles for a holistic ment changes, technique changes, or cross-training.
approach to bony stress injuries One benefit to such a strategy is that the individual
• Biomechanical and technique modification typically does not endure a substantial loss of con-
• Alternative training including training surfaces ditioning while still allowing his or her body to
• Nutritional optimization repair the bony damage. If pain intensifies and
• Hormonal balance activity modification alone is inadequate for heal-
• Mental and emotional fitness and coping skills ing, treatment should be intensified to include com-
• Surgical stabilization
plete rest, immobilization, or surgical intervention.

Stress Injury Diagnosed

Optimize patient’s nutritional,

hormonal, and psychological status

Grade*

I II III IV V

Anatomic Site Anatomic Site

Observation† Surgical Surgical
fixation fixation
Low Risk High Risk Low Risk High Risk
with bone
grafting
Relative Rest †† Complete Rest††† Surgical
fixation
Symptoms persistent
Symptoms persistent
or no imaging
or no imaging
evidence of interval
evidence of interval
healing after 6 weeks.
healing after 6 weeks.

Complete Rest
Surgical
Symptoms persistent or fixation
no imaging evidence of
healing after 6 weeks.

Surgical fixation

Fig. 15.1  Recommended treatment algorithm for stress ††

Relative Rest = Decrease frequency or intensity of incit-
injuries of bone (Reproduced from Rockwood and ing activity. May cross-train. Gradual return to full pain-­
Wilkins, Fractures in Adults, 9th Edition). *Grading based free activity. †††Complete Rest = Discontinuation of any
on the Kaeding-Miller classification system presented in activity that places stress at fracture site. May include
Table  15.2 [1]. †Observation  =  Return to activity with immobilization
close follow-up. Consider relative rest and cross-training.
15  Stress Fractures 199

15.2 A
 thletes at Risk for Stress incidence of stress fractures [9, 10]. Dietary intake
Fractures and disordered eating patterns have been linked to
amenorrhea in a number of studies. A concept that
15.2.1 Vitamin D Insufficiency has been developed supporting the link between
dietary intake and amenorrhea is the so-called
It is recommended that most athletes receive at energy drain hypothesis. If caloric intake is too
least 800–1000  IU (or perhaps as much as low, production of hormones such as estrogen and
5000 IU) of vitamin D3 daily. This level of sup- progesterone is moved lower on the body’s list of
plementation is safe and has a high therapeutic priorities. These hormones may not be produced
index. Serum 25(OH)D3 level is the study of in amounts high enough to allow menstruation to
choice for identifying Vitamin D deficiency [7]. occur [11]. Oligomenorrheic or amenorrheic
In those individuals with low vitamin D or low female athletes are at increased risk secondary to
bone mineral density, the therapeutic goal for decreased estrogen levels and increased osteo-
supplementation should range from at least clastic activity [12].
50  nmol/L (20  ng/mL) to as high as Endocrine and malabsorption conditions can
90–100  nmol/L (36–40  ng/mL) based on the impair the delicate balance between bone forma-
Food and Nutrition Board recommendations [7]. tion and resorption, thus predisposing athletes to
In general a serum level the ideal level for the bony stress injuries. Stress fractures are associ-
athlete is 40–50 ng/mL. To achieve this goal as ated with lower fat intake, lower calorie intake,
much 50,000 IU per may be prescribed for indi- eating disorders, and body weight of less than
viduals with severe hypovitaminosis D. Although 75% of ideal body weight. The female athlete
higher dietary intake of Vitamin D3 may provide triad (menstrual irregularity, inadequate caloric
some protective effect against fractures, the intake, and decreased bone mineral density) has
exact role of Vitamin D in fracture prevention is been associated with increased susceptibility to
still up for debate. stress fractures. This increased risk is most com-
Recent studies have evaluated the potential monly seen among female distance runners and
association between serum Vitamin D3 levels and military recruits and is increased compared with
stress fractures. A prospective study of Finnish males performing the same activities [13].
military recruits found that the average serum High-­
­ intensity training may suppress menses,
vitamin D3 concentration was significantly lower which may exacerbate these risk factors [10].
in the group that had sustained a stress frac- Muscle fatigue may be a collaborative culprit
ture  [8]. Another randomized, double-blind, in the development of stress fractures in
­placebo-­controlled study examined whether cal- ­overtrained athletes. Since the late twentieth cen-
cium and Vitamin D3 intervention could reduce tury, it has been widely accepted that neuromus-
the incidence of stress fractures in female recruits cular conditioning plays a significant role in
during basic training [8]. This level 1 study sug- enhancing the shock-absorbing and energy-dissi-
gested that calcium and Vitamin D3 supplementa- pating function of muscles to the ground reaction
tion may have prevented a significant percentage forces occurring during impact loading. This
of their recruits from sustaining a stress fracture neuromuscular tone is able to decrease the
and led to a significant decrease in morbidity and amount of energy being directly absorbed by the
financial burden [8]. bones and joints [14]. Thus, as muscles fatigue,
they are less apt to dissipate the applied external
forces, allowing for more rapid accumulation of
15.2.2 The Female Athlete Triad microtrauma to the bone [3]. A recent study of
and Caloric Insufficiency female track-­and-­field/cross-country runners
indicated an increased risk of developing stress
Inadequate caloric intake may play a role in fractures if body mass index (BMI) was less than
amenorrhea, which has been linked to an increased 19. The authors of this case series found that
200 T. L. Miller and C. C. Kaeding

female athletes with BMI of 19 or lower took sig- or stress fracture [2–4]. Fatigue failure of bone
nificantly longer to return to unrestricted training has three stages: crack initiation, crack propaga-
and competition than those with a BMI above 19 tion, and complete fracture.
[15, 16]. The authors further suggested that Crack initiation typically occurs at sites of
decreased muscle mass is a risk factor for stress stress concentration during bone loading [3].
injuries and poor healing [15, 16]. Stress concentration occurs at sites of differen-
tial bone consistency such as the lacunae or can-
uliculi [3]. Initiation of the microcrack alone is
15.2.3 The Male Endurance not sufficient to cause a symptomatic fracture. It
Athlete Tetrad is the first step in bone remodeling and may
serve to increase bone density and strength.
Recent literature suggests that male runners Crack propagation occurs if loading continues at
may also be predisposed to decreased bone min- a frequency or intensity above the level at which
eral density [10]. This has been shown to be new bone can be laid down and microcracks
most notable in the lumbar spine and radius. repaired. Propagation, or extension of a micro-
The cause of this decreased density is most crack, typically occurs along the cement lines of
likely multifactorial. Inadequate caloric intake, the bone and is considered pathologic. Continued
decreased testosterone levels, and a genetic pre- loading and crack propagation allows for the
dilection are suspected to be the main culprits. coalescence of multiple cracks to the point of
Decreased energy availability may be the key becoming a clinically symptomatic stress frac-
factor for low bone mineral density, and ture [3]. If the loading episodes are not modified
decreased testosterone levels have been shown or the reparative response is not increased, crack
to be present in males who participate in pro- propagation can continue until a complete frac-
longed endurance events. To prevent severe or ture occurs [3, 20].
irreversible effects of low bone mineral density,
it is necessary to assess the nutritional behaviors
of male endurance athletes as well as their 15.4 Clinical Presentation
female counterparts.
Pain that is initially present only during activity
is common in patients presenting with a stress
15.3 Pathophysiology fracture. Symptom onset is usually insidious, and
typically patients cannot recall a specific injury
Healthy bone is constantly in balanced homeo- or trauma to the affected area. If activity level is
stasis between microcrack creation and repair. not decreased or modified, symptoms persist or
The key modifiable risk factors in the develop- worsen. Those who continue to train without
ment of overuse injuries of bone relate to the pre-­ modification of their activities may develop pain
participation condition of the bone and the with normal daily activity and potentially sustain
frequency, duration, and intensity of the causative a complete fracture [4].
activity [17]. Without preconditioning and accli- Physical examination reveals reproducible
mation to a particular activity, athletes are at sig- point tenderness with direct palpation of the
nificantly increased risk for the development of affected bone site. There may or may not be
overuse and fatigue-related injuries of bone [18, swelling or a palpable soft tissue or bone reac-
19]. Repeated episodes of bone strain can result tion. Physical examination tests commonly used
in the accumulation of enough microdamage to for assessing for stress fractures include the ful-
become a clinically symptomatic stress reaction crum test for long bones (Fig. 15.2a, b) where a
15  Stress Fractures 201

a 3-point bending moment is applied to a long bone

and the single leg stance and hop tests (Fig. 15.3)
for evaluating pelvic and lower extremity stress
injuries [7, 21]. The tuning fork test for identify-
ing sites of bone stress fractures has not been
shown to be adequately sensitive or specific and
should not be relied upon routinely [7, 22].

15.5 Radiologic Evaluation

b
15.5.1 Radiographs

Radiographs are most often negative early in the

course of a stress fracture, especially in the first
2–3 weeks [23, 24]. As healing progresses, radio-
graphic findings may be subtle and easily over-
looked if the images are not thoroughly evaluated.
Two-thirds of radiographs are initially normal,
Fig. 15.2  Fulcrum test of the long bones. (a) Femoral but about half ultimately provide evidence of a
shaft fulcrum test. (b) Tibial shaft fulcrum test bony stress injury as healing progresses

a b

Figs. 15.3 (a–c) Soccer goalie demonstrates single leg stance and hop tests
202 T. L. Miller and C. C. Kaeding

c (Fig.  15.4a) [25]. This makes plain radiographs

specific but not sensitive for identifying and cat-
egorizing stress fractures.

15.5.2 Bone Scintigraphy

Bone scintigraphy has been shown to be nearly

100% sensitive for bony stress injuries, although
it has a lower specificity than MRI [26]. It is
especially useful for identifying rib, pelvic, fem-
oral, pelvic, tibial, and tarsal stress fractures.
Bone scans are typically positive in all phases of
a triple-phase technetium scan (angiogram, blood
pool, delayed). This allows for easier differentia-
tion of stress fractures from periostitis, or medial
tibial stress syndrome (shin splints), as periostitis
is often negative in the angiogram and blood pool
phases and positive in the delayed image phase.
Medial tibial stress syndrome has also been
shown to have a more diffuse distribution along
Fig.15.3 (continued) the medial border of the tibia as opposed to a

a b

Fig. 15.4 (a) Anteroposterior radiograph of the hip in a (b) T2 coronal MRI demonstrating nondisplaced transcer-
47-year-old female marathon runner with tension side vical femoral neck stress fracture in a 47-year-old female
femoral neck stress fracture with early callus formation. marathon runner
15  Stress Fractures 203

Fig. 15.6  Coronal CT scan demonstrating sagittal dorsal

navicular stress fracture

determining if the fracture is complete or incom-

plete [29]. It is of particular use in the case of tar-
sal navicular stress fractures (Fig.  15.6) and for
stress injuries of the pars interarticularis [30].

15.5.4 Magnetic Resonance

Imaging (MRI)

In 2018, magnetic resonance imaging is the gold

Fig. 15.5  Bone scan of bilateral tibias of a 19-year-old standard for diagnosing and classifying bony
female college basketball player with multiple stress frac- stress injuries. It has demonstrated superior sen-
tures of the bilateral anterior tibial diaphyses
sitivity and specificity to bone scan and CT for
associated soft tissue abnormalities and may
focal “hotspot” indicating a stress fracture [27]. delineate injury earlier than bone scan [26].
The greatest value of bone scintigraphy is its Typical MRI findings on T2 sequences include a
ability to diagnose multiple stress injuries. Bone band of low signal corresponding to the fracture
scans will often demonstrate increased uptake in line, surrounded by diffuse high signal intensity
the affected bone 1–2 weeks before radiographic representing marrow edema (Fig. 15.4b) [31]. Its
changes occur (Fig.  15.5). However, given that sensitivity is similar to that of a bone scan, and it
uptake on bone scan requires 12–18  months to is much more precise in delineating the anatomic
normalize, bone scintigraphy is less helpful for location, acuity, and extent of a bony injury [26].
guiding return to sports participation [26]. It has additionally shown prognostic ability
regarding time to healing a stress fracture and
time to return to sports [15, 16].
15.5.3 Computed Tomography
(CT Scan)
15.5.5 Classification/Grading
In the setting of a chronic stress fracture, ­computed
tomography scan is beneficial for demonstrating Stress fractures are classified in a variety of ways
evidence of healing by clearly showing the pres- [32]. They are most commonly categorized by
ence or absence of a nonunion [28, 29]. CT scan the size of the fracture line, the anatomic site of
delineates bone well and is of high utility for injury, the biologic healing potential of the injury
204 T. L. Miller and C. C. Kaeding

Table 15.2  Kaeding-Miller stress fracture classification Table 15.3 Anatomic sites for high-risk stress
system—shown is a combined clinical and radiographic ­f ractures [6]
classification system for stress fractures that has shown • Femoral neck (tension side)
high intra- and inter-observer reliability and prognostic
• Patella (tension side)
ability for healing
• Anterior tibial cortex
Radiographic findings (CT, MRI, bone • Medial malleolus
Grade Pain scan or X-ray) • Talar neck
I − Imaging evidence of stress FX • Dorsal tarsal navicular cortex
No fracture line
• 5th metatarsal proximal metaphysis
II + Imaging evidence of stress FX
• Sesamoids of great toe
No fracture line
III + Nondisplaced fracture line
IV + Displaced fracture (>2 mm)
V + Nonunion first through fourth metatarsals, all of which have
a consistent blood supply and favorable natural
history. These sites tend to be on the compressive
location, the natural history of the particular frac- side of the bone and respond well to activity
ture, or a combination of these features [1–7, 31]. modification. Low-risk stress fractures are less
Multiple authors have advocated classifying likely to recur, develop nonunion, or have a sig-
stress fractures as either “high-risk” or “low-­ nificant complication should they progress to
risk.” [3–6] High-risk sites have at least one of complete fracture [5].
the following characteristics: relative avascular- Intermediate-risk stress fractures are those
ity with or without retrograde blood supply and that occur near a high-risk site but have a favor-
high tensile forces [7, 32]. These characteristics able healing potential and biomechanical forces
increase the risk of delayed or nonunion, refrac- acting on them. Anatomic sites included in this
ture, and significant long-term consequences if a group are the inferior surface of the femoral neck,
complete fracture occurs including avascular the proximal femoral shaft, the inferior pubic
necrosis. ramus, and the pars intra-articularis. Rarely do
In addition to determining the risk level of a these sites require surgical stabilization to allow
stress fracture, the extent of the fatigue failure or healing, but given their biomechanical features
“grade” of the injury is necessary to describe and and proximity to high-risk sites, they have an
treat it [1, 4, 31]. A combined clinical and radio- increased potential to extend into a high-risk site
graphic classification system developed by the if the fracture propagates.
authors of this chapter is shown in Table 15.2. This Table 15.3 presents a list of anatomic loca-
system has shown high inter- and intra-­observer tions considered high risk for stress fracture
reliability among sports medicine and orthopedic propagation along with their recommended treat-
clinicians [1]. Additionally, this system has been ment strategies. A delay in treatment for a high-­
shown to have high prognostic ability for time to risk site may prolong the patient’s period of
healing and return to sports participation [3, 4, 15, complete rest and potentially alter the treatment
16]. The recommended treatment algorithm strategy to include surgical fixation with or with-
included in this chapter is based on the Kaeding- out bone grafting. Due to their location on the
Miller classification system for stress fractures. tension side of their respective bones, these frac-
tures possess biomechanical properties that
­predispose them to propagation of the fracture
15.6 Risk Assessment line. In comparison to low-risk stress fractures,
high-­risk injuries are not likely to heal without
15.6.1 High-Risk, Intermediate-Risk, complete rest and surgical stabilization. With less
and Low-Risk Stress Fractures aggressive treatment, high-risk stress fractures
tend to progress to nonunion or complete frac-
Low-risk stress fractures include the distal femur, ture, require operative management, and recur in
the medial tibia, the ribs, the ulnar shaft, and the the same location [3, 4, 6].
15  Stress Fractures 205

15.6.2 Management of High-Risk

Stress Fractures

Treatment decision-making for high-risk stress

fractures should be based on radiographic find-
ings with less consideration given to symptom
severity. The immediate goal of treatment of a
high-risk stress fracture is to avoid propagation
of the fracture. Typically this requires either lim-
ited resistance, protected weight-bearing, or sur-
gical stabilization. Ideally while the fracture is
healing, a balance is maintained between the ath-
lete maintaining fitness and minimizing the risk
of fracture progression. While overtreatment of a
low-risk stress fracture may result in unnecessary
deconditioning and loss of playing time, under-
treatment of a high-risk injury puts the athlete at Fig. 15.7  Fluoroscopic radiographic image of the right
risk of significant long-term complications. hip following closed reduction and percutaneous screw
The presence of a visible fracture line on a plain fixation of a femoral neck stress fracture
radiograph in a high-risk stress fracture should
prompt serious consideration for surgical stabiliza- Decision-making should be based in part on
tion. Depending on injury severity, patients with symptom severity. Those who experience enough
stress injuries in high-risk locations may require pain to limit function should be treated with rela-
immediate immobilization and/or restriction from tive, if not complete, rest. The decision to con-
weight-bearing activities with close monitoring. If tinue activity despite the presence of a low-risk
an incomplete fracture is present on plain radio- stress fracture and titrate the volume of activity to
graphs with evidence of fracture on MRI or CT in a low but functional pain level can be made after
a high-risk location, immobilization and strict non- a discussion with the athlete. A key point in this
weight-bearing is indicated. Worsening symptoms discussion is the possibility of progression to a
or radiographic evidence of fracture progression complete fracture with this approach. If the goal
despite non-­operative treatment is an indication for is not to continue activity but to completely heal
operative treatment. All complete fractures at high- the fracture, then rest to a pain-free level is
risk sites should receive serious consideration for required before return to athletic participation.
surgical treatment. In general, a low threshold for Unless otherwise contraindicated, a patient may
surgical fixation should be maintained for high-­risk be permitted to maintain fitness by cross-training
stress fractures for several reasons. These include during this time with low-impact alternatives
expediting healing, allowing earlier return to activ- such as cycling, swimming, elliptical, antigravity
ity, and minimizing the risk of delayed union and treadmill, or aquatic running.
refracture. In the case of a tension-sided femoral
neck stress fracture (Fig. 15.4a, b), urgent surgical
intervention may be necessary to prevent a cata- 15.7 Insufficiency Fractures
strophic fracture (Fig. 15.7) [6, 7, 21].
A distinction should be made between stress
fractures and insufficiency fractures although
15.6.3 Management of Low-Risk they are not mutually exclusive. Both are the
Stress Fractures result of the loss of balance between the cre-
ation and repair of microdamage in bone.
Low-risk stress fractures may be treated most A  stress fracture is the result of high loads
often with relative rest and activity modification. placed on relatively normal bone, whereas an
206 T. L. Miller and C. C. Kaeding

i­nsufficiency fracture is the result of normal 15.9 P

 revention of Stress Injuries
loads placed on bone with decreased osseous to Bone
density or impaired healing capacity [33].
Insufficiency fractures occur most commonly in Prevention is the ideal treatment of stress injuries
elderly females but may occur in athletes with of bone and most other overuse injuries. An
malabsorption conditions of the gastrointestinal assessment of the athlete’s risk should be made at
tract. An example of a subchondral insufficiency pre-participation evaluations, especially in those
fracture of the medial femoral condyle is shown with a history of previous stress fractures women
along with an intraoperative fluoroscopic image with light or absent menses [2, 12, 21]. Correction
posttreatment with intraosseous bioplasty pro- of amenorrhea in females and calcium and
cedure (Fig. 15.8a, b). Vitamin D3 supplementation is recommended in
addition to general nutritional optimization. If
biomechanical abnormalities are encountered,
15.8 Return to Sports the use of appropriately designed orthotic devices
Participation should be considered as an initial corrective mea-
sure. However, running gait analysis (Fig. 15.9)
For most athletes, return to sports should only be and appropriate running form or technique
allowed after proper treatment and complete changes may be necessary to prevent future inju-
healing of a stress fracture. Given the heterogene- ries. Unfit or unconditioned athletes including
ity of these injuries, however, the time to return is military recruits, particularly female athletes
difficult to predict. The Kaeding-Miller classifi- with menstrual irregularities, are at peak risk for
cation system presented in Table 15.2 has shown stress injuries to bone and increased utilization of
the ability to predict the expected time to return healthcare resources [18].
to athletic activity with the average to time to
return to competitive running being 11–14 weeks
with female athletes requiring greater time to 15.10 Biologic Healing
return to sports [15, 16, 18]. Enhancement
The majority of early stress reactions at high-­
risk sites heal with non-operative management 15.10.1  Electrical Osseous
[6]. The key difference between a low-grade Stimulation
stress fracture at a high-risk location and a low-­
risk location is that with the low-risk site, the Recent technological developments have given
athlete may be allowed to continue to train, rise to the use of biologic treatment modalities for
whereas the high-risk injury requires complete stress injuries to bone. These include the use of
healing prior to return to unrestricted activity. electronic bone stimulators, pulsed p­arathyroid
Regardless of the grade and location, the risk of hormone (teriparatide), subchondroplasty, and
continued participation should be discussed concentrated bone marrow aspirate. Pulsed elec-
with each athlete, and the management of each tromagnetic fields (PEMF) and low-intensity
fracture should be individualized. Cross-training pulsed ultrasound (LIPU) are FDA-approved,
while resting from the inciting activity allows noninvasive tools which increase the production
maintenance of cardiovascular fitness while of regulatory mediators required for physiological
decreasing tensile, bending, and rotational bone healing [35]. PEMF creates a magnetic field
forces at the healing fracture site [3, 7, 21, 34]. and a secondary electric impulse activating a
Return to participation should be a joint deci- series of enzyme reactions that upregulate growth
sion between the physician, athletic trainer, factors such as bone morphogenetic proteins,
coach, and athlete. transforming growth factor-β, and calmodulin
15  Stress Fractures 207

a b

Fig. 15.8 (a) T2 coronal MRI demonstrating subchon- tibial plateau. (c) Intraosseous bioplasty performed at the
dral insufficiency fracture of the medial femoral condyle. medial proximal tibia. Mixture of demineralized bone
(b) Intraoperative fluoroscopic radiograph during intraos- matrix and concentrated bone marrow aspirate is injected
seous bioplasty of the medial femoral condyle and medial after core decompression has been completed
208 T. L. Miller and C. C. Kaeding

technique is performed by drilling into subchon-

dral bone with a cannulated guide pin. Under
fluoroscopy engineered calcium phosphate
paste is injected into subchondral bony defects
forming a macroporous scaffold for bone. Its
application includes the treatment of subchon-
dral insufficiency fractures most commonly of
the distal femur and proximal tibia (Fig. 15.8b)
[39]. Initial short-term results of the procedure
have shown that it provides significant improve-
ment in the parameters of pain and functional
capacity over the first 24 weeks following sur-
gery [40]. Intraosseous bioplasty involves per-
cutaneously performing a core decompression
Fig. 15.9  Video running gait analysis performed on a
29-year-old female runner with recurrent tibial stress of the affected metaphyseal bone site and inject-
fractures ing a mixture of bone marrow concentrate, cal-
cium chloride clot, and demineralized bone
matrix (Fig. 15.8c). Long-term results of these
leading to bone cell proliferation and fracture treatment options are currently being
healing. LIPU appears to have a direct effect on investigated.
ion channels for stimulating bone cell activity via
mechanoreceptors [36]. Bone stimulators have
been shown to be the most effective for delayed 15.10.4  B
 one Marrow Aspirate
unions of the tibial shaft and fifth metatarsal shaft. Concentrate (BMAC)

Bone marrow aspirate concentrate is a biologic

15.10.2  Parathyroid Hormone treatment employing an individual’s own stem
Stimulation cells to stimulate bony healing. Osteoblastic
progenitor cells are available in the bone mar-
The effect of teriparatide on fracture healing has row aspirate of the iliac crest, proximal aspect
been evaluated with mixed results. However, of the tibia, and calcaneus. The iliac crest pro-
teriparatide has been shown to achieve the pri- vides the highest yield of osteoblastic progeni-
mary endpoint of accelerated healing with tor cells though it can be extracted locally from
improved early fracture callus formation com- other sites including the proximal tibial metaph-
pared to placebo [37]. Preclinical studies on rat ysis (Fig. 15.10) [41]. Percutaneous screw fixa-
models have shown that supraphysiologic doses tion of proximal fifth metatarsal fractures
of parathyroid hormone have demonstrated augmented with bone marrow aspirate concen-
increased fracture site strength and callus quan- trate has been shown to provide predictable
tity, with greater mineralization at the fracture healing results while permitting athletes a return
site [37, 38]. to sports at their previous levels of competition
with few complications [42]. Autologous
BMAC combined with PRP injection has been
15.10.3  Subchondroplasty shown to improve bone healing in distraction
and Intraosseous Bioplasty osteogenesis of the tibia [43]. The local applica-
tion of BMAC in the treatment of delayed heal-
Subchondroplasty is a recently developed pro- ing is a promising alternative to autogenous
cedure for increasing the density and structural bone grafting and may help to reduce donor site
integrity of subchondral bone. This surgical morbidity [44].
15  Stress Fractures 209

s­ urgical intervention. Low-risk fractures are most

often those loaded in compression, have a better
prognosis, and are unlikely to progress to com-
plete fracture. The recommended treatment algo-
rithm stratifies these injuries based upon injury
severity and the biomechanical environment in
which they are located. In addition to the tradi-
tional treatment strategies of rest, immobiliza-
tion, and surgical stabilization, recent modalities
for enhancing healing potential have been uti-
lized with some success from further research
being required to fully confirm their efficacy.

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 Shin Pain
16
Sérgio Rocha Piedade, Luis António Mendes,
Leonardo Manoel Carvalho,
Ramon Medeiros Fagundes dos Santos,
Luis Carlos Marques, and Daniel Miranda Ferreira

16.1 Introduction

Anatomically, the leg is described as the segment

of the lower limb localized between the knee and
ankle joint. It provides part of the bone structure
of both joints and has muscles arranged in four
compartments, each one of them bound by fascia,
anterior, lateral, and posterior (superficial and
deep) compartments [1, 2] (Fig. 16.1). Due to its
anatomical location and the presence of biarticu-
lar muscles, the leg plays an essential role in
daily-activity physical tasks.
In sports, the physical demands are greater
compared to daily activity home, as they com- Fig. 16.1  Axial view of T1-weighted magnetic reso-
prise of  running, jumping/landing, changing nance image of four muscle compartments of the lower
leg (T tibia, F fibula)
direction, and acceleration/deceleration and
impose to axial, shearing, and rotational loads to
the lower limbs. Despite that, the legs are struc-
turally highly prepared to bear the load and inten- sity of regular sports training as well as to provide
body support, balance, and propulsion [3–6].
However, the ability of the lower limb to
S. R. Piedade (*) · R. M. F. dos Santos absorb stress can be reduced, and also impaired,
L. C. Marques
Department of Orthopedics and Traumatology, State by different clinical settings such as strenuous
University of Campinas—UNICAMP, Exercise and training, insufficient time of rest, inadequate
Sports Medicine, Campinas, SP, Brazil sports material (shoes), axis and postural defor-
e-mail: [email protected] mities of the knee and/or foot, as well as poor
L. A. Mendes · L. M. Carvalho athlete’s physical status. Therefore, it is easy to
State University of Campinas—UNICAMP, Exercise understand why leg pain is a common clinical
and Sports Medicine, Campinas, SP, Brazil
e-mail: [email protected] complaint in sports practice [7, 8].
“Shin” (leg) pain, “shin splints,” and medial
D. M. Ferreira
Department of Radiology, State University of tibial stress syndrome, are general terms used to
Campinas—UNICAMP, Exercise and Sports describe pain and discomfort localized on the
Medicine, Campinas, SP, Brazil front outside or medial side of the lower leg, a

© ISAKOS 2019 211

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_16
212 S. R. Piedade et al.

clinical entity that affects recreational and profes- should be investigated as they are related to
sional athletes, indiscriminately. A close relation- greater risk of developing MTSS [17, 18].
ship has been reported with distance runners, Therefore, the athletes’ complaint and also the
athletes of endurance sports, dancers, and the training program should be carefully explored
military, confirming the huge the influence of the during anamnesis, and the athlete should answer
physical demands (amount and intensity of load) the following questions:
present in these physical activities [9, 10].
Regarding risk factors, the literature has • How long have you been feeling pain and dis-
shown no influence of anthropometric character- comfort in your legs?
istics and body composition on the genesis of • Is it the first time?
shin pain, but extrinsic factors such as the amount • Can you pinpoint when it started?
of training, training surface (field), sports mate- • Are you in a regular training program?
rial (shoes), as well as intrinsic factors (athlete’s • Do you have close supervision from a coach?
phenotype and anatomy) play an essential role in • Have you changed your training program?
shin pain development and progression [11, 12]. • What do you think of your intensity of
Although shin pain has been described as an training?
exercise-related problem, i.e., overuse injury, it • What are your training shoes like?
has a broad differential diagnosis, as different • What is the training surface like?
pathologies and structures can be implicated in • How do you feel during your training?
clinical presentation. In this context, soft tissue
inflammation (tendons, muscle, and fascia), exer- All these questions are an important part of
tional compartment syndrome, vascular defi- the strategy used to formulate the diagnosis and
ciency, medial tibial stress syndrome, and stress treatment approach.
fracture can be a possible diagnosis [13–16].
The aim of this chapter is to discuss athletes’
complaints, intensity and load of sports training, 16.3 Symptoms and Complaints
physical and radiological assessment of different
clinical problems related to shin pain symptoms In general, shin pain primary clinical symptoms
(leg tendinopathies, vascular deficiency, stress are pain and discomfort. Usually, the athlete
fracture, and exertional compartment syndrome), complains about tenderness, pain, or discomfort
and treatment approach. along the inner edge of the shinbone, mainly the
two-thirds below the knee joint (Fig.  16.2).
Generally, the pain increases with sports activity
16.2 Physical Assessment and relieves with rest. Sometimes, shin pain com-
prises of redness and swelling [19, 20].
Considering that shin pain could involve several Regarding pain, it could have some particu-
conditions, the sports medicine physician should larities inherent to each clinical condition. In the
closely observe the athlete’s response to the exertional compartment syndrome, the pain starts
intensity and load of training as well as the peri- 10  min after sports, followed by sensory and
odicity of competition events, especially when motor loss, and relieves with 30  min of rest. In
he/she starts complaining about leg pain. the medial tibial stress, the pain is described as
Like any medical problem, anamnesis plays a vague and diffuse, while in the tendinopathies, it
vital role. The previous history of MTSS, running is related to tendon and its movement, where the
inexperience, inappropriate sports material Achilles tendon, tibialis posterior, and fibular
(shoes), high body mass index, smoking, and tendons are the commonly affected structures
increased external rotation of the hip in males [20].
16  Shin Pain 213

Achilles’ tendon
(medial view of the lower leg)

Fig. 16.3  Topography of Achilles tendon and its inser-

tion in the calcaneus bone

be manifested by pain, discomfort, diffuse, or

localized swelling, impairing the athlete’s sports
performance.
Undoubtedly, Achilles tendinopathy is more
prevalent than the other one, but it can also affect
the anterior tibial, posterior tibial, and peroneal
Fig. 16.2  Common shin pain sites tendons. All of them will cause lower leg pain
and discomfort according to the tendinopathy,
tendon anatomy, topography, and sports dynamic
16.4 Differential Diagnosis performed.

As pointed out above, shin pain is a clinical

symptom that could express different patholo- 16.4.2 Achilles Tendon
gies, and, therefore, it is essential to investigate
carefully differential diagnoses such as tendinitis, The Achilles tendon starts at the middle of the
stress fracture, tendonosis, chronic exertional calf and attaches the calf (gastrocnemius and
compartment syndrome, and popliteal artery plantaris) and soleus muscles to the calcaneus
entrapment syndrome [9, 12, 14, 15, 19, 20]. bone. It is the strongest and thickest tendon but
also the most often ruptured in the human body
[21].
16.4.1 Lower Leg Tendinopathy The configuration of its insertion on the calca-
neus bone helps to dissipate tendon-bone stress
Firstly, it should be emphasized that tendinopa- (Fig. 16.3). The Achilles tendinitis is commonly
thy includes pathological conditions such as ten- described as a sport-related injury, touching rec-
dinosis and peritendinitis and is commonly reational and professional athletes in more than
associated with overuse injuries. Clinically, it can two-thirds of cases.
214 S. R. Piedade et al.

posterior tibial tendon

(medial view of the lower leg)
Fig. 16.4  Sagittal view of T1-weighted magnetic reso-
nance image (MRI) of the ankle showing fusiform thick- Fig. 16.5  Medial side of the ankle and foot, showing the
ening of the Achilles tendon (tendinosis)* topography of the posterior tibial tendon and its insertion
in the navicular bone

Generally, athletes complain about pain and behind the posterior malleolus and has its inser-
tenderness on the medial and posteriormedial tion in the navicular bone (Fig. 16.5). It acts on
aspect of the distal third of the lower leg. This the inversion and plantar flexion of the foot and
pain could increase with sports practice, and dur- plays a vital role in the maintenance of the medial
ing a clinical exam, it may be observed when the arch of the foot.
athlete performs plantar flexion against resis- The onset of tendon dysfunction is gradual
tance. In chronic cases, edema, hyperemia, and and worse if the volume and intensity of sports
decreased loss of function are gradually estab- activity remain or increase, especially in running
lished. This clinical symptom is a prevalent prob- and jumping activities [25]. In general, athletes
lem in runners due to sports dynamic and effort. complain about pain along the posterior tibial
The main etiological risk factors related to tendon topography until its insertion in the medial
Achilles tendon are overuse, lower limb malalign- side of the foot.
ment (genu valgum, genu varum, pes cavus, pes In more advanced stages, the medial longitudi-
planovalgus), problems related to uneven and unsta- nal arch of the foot is attenuated progressively and
ble training surfaces, and previous injury [22–24]. can disappear causing the acquired adult flatfoot,
Ultrasound and MRI (Fig.  16.4) are com- presented by a clinical sign called "too many toes".
monly used exams in these cases as they Other clinical signs are, a decreased in the move-
allow,  more appropriately, the visualization of ments of foot supination and eversion (Fig. 16.6).
soft tissues, while X-rays can be used to rule out Radiological evaluation can show a medial
associated injuries. talar displacement and also a decrease of the
medial longitudinal arch of the foot, clinical
signs related to more advanced stages of tendon
16.4.3 Posterior Tibial Tendon dysfunction. However, MRI is the best exam to
evaluate the initial stages of posterior tendon ten-
The posterior tendon muscle is located on the dinopathy [25–27].
posterior medial side of the calf, rising from the In the early stages, conservative treatment
posterior rear of the tibia and fibula, and runs offers satisfactory outcomes for most of the
16  Shin Pain 215

Fig. 16.6 Posterior
view of the foot,
showing the foot in a
neutral (middle),
overpronated (left), and
over supinated (right)
position

too many toes

overpronation neutral over supination

(righ foot)

a­ thletes. Relief of the symptoms, physiotherapy,

shoe modifications, orthosis and exercise pro-
grams are part of the treatment approach. The use
of orthosis aims to provide hindfoot eversion and
longitudinal medial arch support and may include
a heel lift if there is a gastrocnemius contracture
[26–28]. Surgery is commonly performed in
advanced stages of tendon dysfunction.

16.4.4 Anterior Tibial Tendon

The anterior tibial muscle starts in the two-thirds

of the lateral side of the tibia and runs along to be
inserted in the first cuneiform and the first meta-
tarsal. It is responsible for foot dorsiflexion and
inversion. Its tendinopathy impairs these muscle
functions, and consequently, the athletes’ sports
performance for running, kicking, and many
other sport movements decreases.
Clinically, the athlete complains of pain and
discomfort as well as swelling on the medial side
of the leg, following the anterior tibial tendon
topography (Fig. 16.7) and can be exacerbated by
active foot dorsiflexion and inversion performed
against resistance.
Foot overpronation, overtraining, excessive
tendon stretching, and footwear are common Fig. 16.7  Topography of pain and discomfort related to
causes of anterior tibial tendinopathy. anterior tibial tendon tendinopathy
216 S. R. Piedade et al.

Ultrasonography and magnetic resonance imag-

ing are more accurate diagnostic strategies [31].

16.5.1 Treatment

As in any case of tendinopathies, with an initial

phase of decreased load, followed by eccentric
training with progressive loads. The use of ice
and analgesic medications may be necessary for
symptomatic control at the start of treatment.
Sports biomechanics management and ankle
alignment during gait and run should be consid-
ered because of the possibility of biomechanical
errors increasing the overload on these tendons.
peroneal tendons Injection of corticosteroids is not classically indi-
(lateral view of the lower leg) cated because of tendon rupture risk. In cases of
tendon instability, surgical treatment is usually
Fig. 16.8  Topography of the peroneal tendons and their necessary [29, 30].
insertions in the foot

16.4.5 Peroneal Tendons 16.5.2 Chronic Exertional

Compartment Syndrome
The peroneal tendons, brevis, and longus come
from the posterolateral aspect of the fibula and run Chronic exertional compartment syndrome
over to the fibula tip posteriorly: the former (CECS) is a relatively common condition that
inserted in the base of the fifth metatarsal (inferior could touch recreational and professional athletes
tubercle) and the latter in the plantar superface of indistinctly. The prevalence is uncertain, and most
the lateral side of the first metatarsal (Fig. 16.8). of the athletes affected are younger than 30 years
They are primary evertors and pronators of the old [32]. Although several sports can be involved,
foot and also contribute to plantar flexion and foot running is the main sports activity related to this
and ankle stabilization against sprain [29]. syndrome [1, 32]. It is defined as a recurrent and
The peroneal tendon injury is commonly seen in exercise-induced leg pain characterized by pain,
sports that impose repetitive ankle motion and also tightness, cramp, and weakness [1, 2, 32, 33].
affecting athletes with a higher foot arch. The pain is Many theories have been proposed for CECS
located on the lateral site of the lower leg. Moreover, pathophysiology. One of them is transient ischemia
swelling and warm to touch can be present. The that would be caused by a greater intercompart-
most frequent types of injuries are tendinitis, tears, ment pressure of the lower leg induced by sports
and subluxation. In case of peroneal tendon instabil- activity, impairing neuromuscular blood flow.
ity, subluxation can be elicited and observed by foot Although muscle volume could increase by
eversion and dorsiflexion maneuvers [30, 31]. 20% during physical activity, the compliance of
muscle compartment is vital to keep ICP control.
Other described theories involve muscle hyper-
16.5 R
 adiological Evaluation trophy, decreased venous return, muscular micro-
in Tendinitis of the Lower Leg trauma, and myopathies [1]. Moreover,
Edmundsson and colleagues showed that lower
In a complementary investigation, X-rays do not capillarity related to muscle fiber could be
usually add more accurate information but may be involved in CECS’s pathophysiology [34].
useful for ruling out other diagnostic ­suspicions. However, further investigation is needed to reach
16  Shin Pain 217

a consensus; the hypotheses match the patient’s If at-rest measurement or 1-min postexercise
symptoms. measurement is confirmatory, further measuring
Usually, patients/athletes do not present symp- shall not be necessary.
toms at rest, but clinical complaints arise sometimes
after physical activity and are described as full, achy
cramping or pressure in the lower leg according to 16.5.5 Therapeutic Approach
the compartment involved, but the pain and discom-
fort stop when the activity is interrupted [1, 2, 32].  Conservative management is usually chosen as the
The incidence is equal in both genres. treatment in the first moment. First, the treatment
plan could be with the cessation or reduction of
causative activity. In fact, most athletes are unwill-
16.5.3 Physical Assessment ing to avoid sport practice as CECS management
[1, 33]. Furthermore, the non-­operative treatment
Physical examination and anamnesis are funda- has included anti-­ inflammatory medication,
mental tools for CECS diagnosis. Although ath- stretching, and an alternative exercise program.
letes could not present symptoms at rest, recurring This apart, there has been a physical rehabilitation
and exercise-induced pain are clinical signs that program involving massage, gait changes, foot
require further assessment [32]. orthotics, botulinum toxin, and USG percutaneous
On the other hand, CECS could be manisfested needle fascial fenestration [2]. Adopting a forefoot
by indirect signs even at rest such as muscle hard- strike while running was shown to be an effective
ness and muscle hernias [2, 35]. Paresthesia, post- conservative treatment strategy in a runner. Usually,
effort muscle weakness, and postexercise the side effect of botulinum toxin A was a loss of
hypertrophy may also be reported. Moreover, the strength [1, 35]. If the non-operative management
absence of pain during palpation at rest has been has not worked as well, then the operative treat-
described as a signal associated with CECS. ment becomes a good option to be considered.
Currently, the open fasciotomy has been con-
sidered the gold standard treatment for CECS
16.5.4 Imaging Evaluation because of the positive outcomes related to
relieving pain and return to sport in most cases
Therapeutic approach requires imaging exams such [1, 37, 38]. Endoscopic techniques have also
as radiographs, bone scintigraphy, and MRI. If neu- shown favorable outcomes in athletes. In spite of
rological symptoms are persistent, an electroneuro- that, there are no studies comparing non-­operative
myography should be performed. Moreover, when and operative treatments. The complications
the clinical exam is compatible, and images exclude reported after surgery could include wound infec-
other causes for pain, the postexercise needle tion, peripheral nerve injury, hematoma, and
manometry features could help to confirm CECS. deep vein thrombosis. The failure of surgical
The measurement of ICP implies an exercise treatment is linked more to localized constric-
before the procedure. The exercise ought to be tions from postsurgical fibrosis than the involve-
enough for surging symptoms. The measurement is ment of the entire compartment [37]. It may be
taken in all of the leg compartments even in the related to incomplete fascial release.
absence of pain. Pedowitz and colleagues [36] have
described objective diagnostic criteria for CECS:
16.5.6 Popliteal Artery Entrapment
• A preexercise pressure greater than or equal to Syndrome
15 mmHg
• A 1-min postexercise pressure of greater than Popliteal artery entrapment syndrome (PAES) is a
or equal to 30 mmHg symptomatic compression or occlusion of the
• A 5-min postexercise pressure of greater than popliteal artery, typically manifested with claudi-
or equal to 20 mmHg cation symptoms due to a developmentally abnor-
218 S. R. Piedade et al.

Type 4—PA is located deep in the popliteal fossa

and entrapped by the popliteus muscle or
popliteal vein
fibrous bands.
Type 5—Any form of entrapment that involves
popliteal both PA and popliteal vein (PV).
artery

16.5.7 Medial Tibial Stress Syndrome

Similarly to shin pain, stress fracture can also

result from repetitive stress, an overuse injury.
The clinical complaints and site of pain can be
similar, but the physical examination performing
palpation and passive and active tibial rotation
and valgus and varus stress can clarify the diag-
nosis. An example of an elicit maneuver is the
“one-leg hop test” that can be used to distinguish
MTSS from stress fracture. An athlete with
MTSS can hop at least ten times on the affected
leg, while in the case of stress fracture, the
attempt of hopping is followed by severe pain,
preventing the athlete from continuing the test [7,
8, 42, 43].
Regarding MTSS, running/jumping activities,
elevated BMI, overtraining and inadequate rest,
training on hard and irregular surfaces, and
the  female sex are reported as risk factors in
(posterior view)
developing MTSS.
Fig. 16.9  Popliteal artery entrapment The radiological evaluation should be done to
confirm the diagnosis, and guide the therapeutic
approach, even though, in most cases, the X-ray
mal anatomic positioning of the popliteal artery examination can show no abnormality (no
(PA) in relation to its surrounding structures [39, injury). Although CT scan is not a sensitive exam
40]. Figure  16.9 shows the close relationship of for this pathology, it can show mild osteopenia
PA to the medial head of the gastrocnemius related to the early stage of cortical bone damage
(MHG). According to the different anatomical in tibial diaphysis [44–46]. Bone scintigraphy
features involving PA, five types of entrapment can also be useful to establish the diagnosis, but
are described (classification of PAES) [41]. MRI is the most sensitive radiological exam to
confirm the diagnosis.
Type 1—PA (popliteal artery) has an aberrant An MRI classification for tibial stress injuries
medial course around the medial head of gas- was developed by Fredericson et al. [47] based
trocnemius (MHG) which has a normal inser- on radiological findings such as periosteal
tion above the femoral condyle. edema, bone marrow edema, and intracortical
Type 2—MHG is inserted more laterally in the signal abnormality. This classification defines
distal femur but PA not displaced. grade 1 as isolated periosteal edema; grade 2 is
Type 3—An aberrant accessory slip of MHG outlined by T2-weighted images of visible bone
slings around and surrounds PA. marrow edema. Grade 3 shows bone marrow
16  Shin Pain 219

Fig. Normal periosteal edema marrow edema

(T2-weighted images)
16.10 Fredericson’s
classification

Grade 0 Grade 1 Grade 2

marrow edema intracortical signal changes

(T1 an T2-weighted images) multiple focal areas*

linear region

Grade 3 Grade 4a Grade 4b

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 Groin Injuries
17
Per Hölmich, Lasse Ishøi, Andreas Serner,
and Kristian Thorborg

17.1 Introduction quently should be avoided [46]. The authors of

this chapter fully support this recommendation.
In recent years, there have been great advances in Groin injuries are a common cause of sport-
our understanding of groin pain in athletes. In ing disability, particularly in football codes [9,
2015, the Doha Agreement on terminology and 42]. A recent study investigating groin problems
definitions on groin pain in athletes was pub- in football players during the preseason period
lished [46]. To keep the terminology more clear observed a weekly prevalence of 29% [9].
and support both clinical and scientific communi- Similarly, a large cross-sectional cohort study
cation, the consensus group agreed on four clini- including 695 football players found that 49%
cal entities to describe long-standing groin pain, reported hip and/or groin pain in the previous
including adductor-related, iliopsoas-related, season, and 31% of those had pain lasting more
inguinal-related, and pubic-related groin pain than 6 weeks [42]. Acute groin injuries are also
[46]. Thus, terms, such as adductor and iliopsoas frequent in multidirectional sports, and a
tendinitis or tendinopathy, athletic groin pain, 25-player football squad can expect 2–4 acute
athletic pubalgia, biomechanical groin overload, groin injuries each season [5, 23].
Gilmore’s groin, groin disruption, Hockey-goalie However, as groin pain is the cardinal symp-
syndrome, Hockey groin, osteitis pubis, sports tom in many diagnoses, the clinician should also
groin, sportsman’s groin, sports hernia, and seek to rule out other potential causes of groin
sportsman’s hernia, which have been used fre- pain such as intra-articular hip pathology or pel-
vic disorders [8, 20, 26].

P. Hölmich (*) ∙ L. Ishøi ∙ K. Thorborg

Sports Orthopedic Research Center—Copenhagen 17.2 Adductor Injuries
(SORC-C), Department of Orthopedic Surgery,
Copenhagen University Hospital, 17.2.1 Longstanding
Amager-Hvidovre, Denmark Adductor-­Related Pain
e-mail: [email protected];
[email protected];
[email protected] Adductor-related groin pain is a common cause of
A. Serner long-standing groin pain in athletes [46]. Although
Department Sports Groin Pain Center, the hip adductor complex comprises of five mus-
Aspetar Orthopaedic and Sports Medicine Hospital, cles (pectineus, gracilis, adductor brevis, adductor
Doha, Qatar
magnus, and adductor longus), the most frequent
e-mail: [email protected]

© ISAKOS 2019 223

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_17
224 P. Hölmich et al.

type of long-standing adductor-related pain without lifting the legs or pelvis. The test is posi-
involves the adductor longus muscle [11]. The tive if it reproduces pain from the insertion site of
pain is typically present during athletic activities, the adductor longus where the patient also was
such as sprinting, change of direction, and kick- tender at palpation [11, 12].
ing, and is located medially in the groin in the
region around the origin of the adductor longus 17.2.1.2 Treatment
muscle at the pubic bone. During activities such Consistent evidence suggests that athletes with
as kicking, acceleration and deceleration, and long-standing groin pain present with reduced
change of direction, the hip adductors are exposed hip adduction strength specifically when mea-
to large eccentric forces, typically in combination sured during eccentric contractions [22, 39].
with an abduction, external rotation, and exten- Consequently, the treatment is based upon active
sion movement of the femur putting further stress exercise therapy aiming to restore optimal hip
on the adductor muscle-tendon unit [3]. Although adductor muscle function and increase load
the specific etiology of long-­standing adductor- capacity [16]. In line with this, rest alone or pas-
related groin pain is unknown, repetitive micro- sive treatment modalities do not seem to resolve
trauma of the hip adductor structures may lead to symptoms effectively [16, 42].
long-standing adductor-related pain [4]. Only few high-quality studies on the treatment
of long-standing adductor-related pain exist [30],
17.2.1.1 Diagnosis with a randomized controlled trial showing exer-
According to the DOHA Agreement, long-­standing cise therapy to be highly effective in comparison
adductor-related groin pain is diagnosed as adduc- with passive treatment modalities, such as mas-
tor tenderness AND pain on resisted hip adduction sage or laser therapy [16]. It should be noted that
[46]. Furthermore, subjects with current and/or bony morphologies related to femoroacetabular
previous long-standing adductor-­ related groin impingement syndrome do not seem to prevent a
pain typically present with reduced hip adduction successful treatment outcome at long-term fol-
strength and/or reduced range of motion in passive low-­up [15]. The treatment program used in this
abduction and bent knee fallout [22]. study consists of two modules, with the first
With the patient lying supine with the hip module lasting approximately 2 weeks and aim-
flexed, abducted, and externally rotated, and the ing to teach the patient to reactivate the adductor
knee slightly flexed, the adductor longus tendon muscles using isometric and low-load exercises.
can be easily palpated. The examiner, using the The second module includes more demanding
right hand on the right leg, and the left hand on exercises targeting both the adductor muscles
the left leg, palpates the adductor longus tendon specifically and the stability of lumbopelvic
with two fingers and follows the tendon to the region. The patient and clinician should be aware
insertion at the pubic bone. The insertion area, that at least 8–12 weeks of focused exercise ther-
including the bone, is tested with firm pressure at apy are usually needed to resolve symptoms and
a radius of about 1  cm. Pain on palpation sug- allow return to previous sporting activities [16].
gests adductor-related groin pain [11]. In addition to exercise therapy, manual therapies
Pain on resisted hip adduction is examined may be used as a supplement [47]. Additionally,
using a long-lever hip adduction squeeze test, as a progressive running and change of direction
this has been shown to elicit the largest torque protocol appears beneficial [47]. Following
output, hence stressing the muscle-tendon unit of return to sport activities, maintenance of eccen-
the adductors the most [21]. The examiner stands tric hip adductor strength is considered impor-
at the end of the examination table with the hands tant. This can be secured by performing the
and lower arms between the feet placed just prox- Copenhagen Adduction exercise [17] or hip
imal to the medial malleolus. The feet of the sub- adduction with an elastic band [19]. In line with
ject are pointing straight up, and the subject this, football players with past-season groin pain
squeeze the legs together with maximal force for more than 6 weeks seem to begin the new sea-
17  Groin Injuries 225

son with hip adduction weakness, potentially extent of injuries, with MRI being slightly more
increasing the risk of a new injury/pain [7]. sensitive than ultrasound [29]. A detailed MRI
Besides focus on restoring hip adduction study of acute adductor injuries has shown that
strength, the clinician should also pay attention to there are three characteristic locations of adductor
other hip muscles such as the hip flexors and longus injuries: (1) the proximal insertion, (2) the
extensors. In an extended hip position, the adduc- musculotendinous junction (MTJ) of the proximal
tor muscles are considered important hip flexor tendon, and (3) the MTJ of the distal tendon. In the
synergists, whereas adductor magnus is an effec- MTJ injuries at both the proximal and distal inser-
tive hip extensor [24]. Thus, any impairments in tion, there is rarely any injury to the tendon struc-
hip flexor and/or extensor muscles should be ture itself, whereas at the proximal insertion, most
addressed as part of treatment for adductor-­ injuries are complete avulsions [32]. It is unknown
related groin pain, to minimize the risk of con- whether there is a difference in prognosis between
tinuously overloading the adductor muscles [24]. injuries in the different muscles and whether clini-
cal or imaging findings can improve prognostic
accuracy in individual cases.
17.2.2 Acute Adductor Injuries
17.2.2.2 Treatment
The adductors account for the majority of acute There is currently no evidence to suggest optimal
groin injuries in athletes [29], and similar to the treatment methods for acute adductor injuries.
long-standing adductor-related groin pain, the Therefore, the current treatment follows the gen-
adductor longus accounts for the majority of the eral recommendation of the POLICE acronym
injuries. About 90% of acute adductor injuries (protection, optimal loading, ice, compression,
involve the adductor longus [32]. The adductor elevation) [2], with a high focus on progressive
brevis and pectineus are injured in about a fourth loading as soon as possible. Studies from elite
of cases, often in combination with an adductor football suggest that the rehabilitation duration
longus injury, whereas obturator externus, graci- will be less than a month in 90% of acute adduc-
lis, and adductor magnus injuries are rarer causes tor injuries.
of acute groin pain [32]. Acute adductor magnus Avulsion injuries will usually require a dis-
is in our experience more likely to give pain more cussion of a surgical reattachment. Both surgi-
posteriorly on the thigh and may therefore be cal and conservative treatments for adductor
more common in athletes presenting with acute avulsion injuries are usually successful. The
posterior thigh pain. duration of conservative treatment is however
reported considerably shorter (3–15 weeks) [28,
17.2.2.1 Diagnosis 44] compared to surgical treatment (10–
The diagnosis of an acute adductor injury can be 32 weeks) [1, 28, 34].
comfortably made through a clinical examination It is important to note that for both acute groin
consisting of adductor palpation, adductor injuries in general and acute adductor injuries,
stretch, and adductor resistance tests, with simi- specifically, there is a high risk of reinjury, with
lar methods as described for long-standing 18–27% reported in football [5, 23].
adductor-related groin pain [31]. These tests have
a high accuracy, which means they can be highly
trusted to diagnose an adductor injury through 17.3 Hip Flexor Injuries
clinical examination only. Furthermore, they can
individually provide about 80% certainty of an 17.3.1 Long-Standing
adductor injury on magnetic resonance imaging Iliopsoas-­Related Pain
(MRI) [31].
Imaging will be able to provide more detailed Iliopsoas-related groin pain is considered the
information regarding the specific location and second most common source of groin pain in
226 P. Hölmich et al.

athletes, affecting between 8 and 35% presenting 17.3.1.2 Treatment

with groin pain [11, 48]. The pain is typically There is no evidence-based treatment of long-­
present during athletic activities, such as sprint- standing iliopsoas-related groin pain; however, it
ing and change of direction, and is in the anterior is advised to adopt an active exercise program
aspect of the thigh, lateral to the adductor-relatedfocusing on strengthening the iliopsoas muscle.
pain. Due to the location of pain most often being This can be done using a systematic and gradual
on the anterior thigh, iliopsoas-related pain is an strengthening program with a simple hip flexion
important differential diagnosis in subjects with exercise using an elastic band as external resis-
suspected intra-articular hip joint pathology. tance [37]. If pain hinders the ability to perform
Iliopsoas-related pain is frequently observed in the exercise program, it is our experience that an
conjunction with adductor-related groin pain [14, ultrasound-guided injection along the distal ilio-
35] and in patients presenting with intra-articular psoas tendon with cortisone sometimes can be
hip joint pathology [18]. helpful to settle pain allowing the patient to per-
form the exercises without pain. In a retrospec-
17.3.1.1 Diagnosis tive review of athletes with iliopsoas-related
According to the DOHA Agreement, long-­ groin pain without information on treatment, the
standing iliopsoas-related pain is diagnosed as mean (SD) duration to return to sport was 20
iliopsoas tenderness [46]. Furthermore, pain in (±14) weeks [43].
the iliopsoas muscle may also arise on passive
stretching of the muscle during the Thomas test
or when tested isometrically with 90° of hip flex- 17.3.2 Acute Hip Flexor Injuries
ion although these are not diagnostic criteria for
long-standing iliopsoas-related pain. In athletes, around one third of acute groin injuries
When palpating the iliopsoas muscle-tendon, affect the hip flexor muscles, with the iliopsoas
the subject is lying supine. The iliopsoas can be muscles accounting for about half of these [29].
palpated both (1) proximal to the inguinal liga- Acute iliopsoas injuries most frequently occur
ment at the level of the Anterior Auperior Iliac during change of direction and kicking [33].
Spine and (2) under the inguinal ligament, medial
to the sartorius muscle and lateral to the femoral 17.3.2.1 Diagnosis
artery. Abdominal palpation is performed with The clinical diagnosis of acute iliopsoas injuries
both hands using soft gentle fingers. The fingers can be difficult in the initial examination. There
are gently pressed posteriorly while pushing the is often a widespread pain in the area potentially
abdominal structures away to reach the iliopsoas coming from a number of muscles, which leads
muscle. The patient is then asked to elevate the to specific hip flexor tests (palpation, stretch, and
leg 5 cm, and the psoas can be felt and palpated resistance tests) often being positive without
for any pain. As this test can sometimes be pain- ­positive MRI findings in the iliopsoas [29]. This
ful in non-injured people, it is important to ask results in general poor accuracy of the clinical
the patient whether any pain is similar to their examination tests [31]. A delayed clinical exami-
injury pain. The palpation of the distal iliopsoas nation or imaging may therefore be helpful.
tendon is most easily performed by first locating When positive, an MRI can provide detailed
the proximal part of the sartorius muscle just dis- information on the location and extent of the
tal to the inguinal ligament and then moving the injury, which may be relevant as complete tears
fingers slightly medially. The patient is then are possible, although rare [33]. A detailed MRI
asked to elevate the examined leg 5 cm, and the study has shown that the iliacus muscle is more
finger position is adjusted until the tendon is frequently injured than the psoas major [33];
clearly felt under the fingers. Then, the patient however, it is still unclear whether this differen-
relaxes and the tendon can be palpated again for tiation is clinically relevant for diagnosis or
any pain [11]. prognosis.
17  Groin Injuries 227

17.3.2.2 Treatment until reaching just medial to the inguinal liga-

Like the long-standing iliopsoas-related groin ment [11]. The inguinal canal is approximately
pain, there is no evidence-based treatment of acute the size of a fingertip and can be palpated supine
iliopsoas injuries. Treatment therefore follows the or with the patient standing by invaginating the
general guidelines for acute muscle injuries, with a skin of the scrotum. During this palpation, the
main focus on early load progression. Although patient can be asked to perform the Valsalva
clinicians usually consider acute iliopsoas injuries maneuver. A palpable bulge of the posterior
as minor, there appears to be a large variation in abdominal wall may be present and/or increased
the time to return to sports with a mean duration pain, which should be similar to the patient’s
reported to be 8.6 ± 8.3 weeks [43]. injury pain.

17.4.1.2 Treatment
17.4 Abdominal Injuries There is no evidence-based treatment of long-­
standing inguinal-related groin pain using a con-
17.4.1 Long-Standing Inguinal-­ servative treatment approach [30]; however, it is
Related Groin Pain recommended to adopt an active exercise pro-
gram focusing on strengthening the abdominal
Inguinal-related groin pain is a relatively rare muscles including the muscles around the hip
diagnosis in the groin region, only affecting joint. The exercise program used for adductor-­
4–8% of all injuries to the hip and groin in male related groin pain [16] can be used as a base and
elite soccer players [23, 49]. The majority soccer be supplemented with progressive abdominal
players with inguinal-related groin pain is absent exercises such as long-lever planks and sit-ups
from soccer for more than 4 weeks [23]. lying on a Swiss ball, focusing on the deep and
Although, the exact pathophysiology remains oblique abdominal muscles. Like adductor-­
unclear, it is thought that inguinal-related groin related groin pain, treatment of inguinal-related
pain may develop as an overuse injury, due to the groin pain often lasts for at least 8–12  weeks.
accumulation of the large shear forces acting Aggravating activities stressing the inguinal area
across the pelvis, trunk, and leg during athletic such as kicking and forceful rotational move-
movements. Additionally, restricted hip range of ments of the trunk should be minimized during
motion may result in altered rotational pattern of the initial treatment period and gradually re-­
the symphysis leading to excessive stress on the introduced as the treatment progresses.
inguinal region [4]. In cases where exercise therapy fails, surgery,
Patients with inguinal-related groin pain typi- either open or laparoscopic hernia repair, should
cally complain of pain over the inguinal canal be considered as a viable option. In a systematic
and at the pubic tubercle that may radiate to the review published in 2015, 38 studies regarding
medial groin and the scrotum. surgical treatment of inguinal-related pain were
identified; however, only one study was deemed
17.4.1.1 Diagnosis high quality [30]. In that study, 60 patients were
According to the DOHA Agreement, long-­ randomized to either surgery (laparoscopic
standing inguinal-related groin pain is diagnosed totally extraperitoneal repair) or conservative
as tenderness at the insertion of the conjoined treatment consisting of exercise therapy, cortico-
tendon at the pubic tubercle and pain when pal- steroid injections, and oral anti-inflammatory
pating the inguinal canal through the scrotum analgesics [25]. Almost all athletes (97%)
with the patient standing [46]. returned to sport at 12 months following surgery
Palpation of the conjoined tendon insertion at compared to 50% of athletes treated conserva-
the pubic tubercle is performed with the subjects tively. While this study suggests that surgery is
lying supine. The examiner locates the proximal superior to conservative treatment for athletes
part of the pubic tubercle and follows the rim with inguinal-related groin pain, approximately
228 P. Hölmich et al.

one in two athletes can expect to return to sport pubic bone, and proper palpation at the distal part
following conservative exercise therapy, and thus is therefore important to decrease the risk of a
it is our opinion this should be considered the ini- false-positive test [12].
tial choice of treatment.
17.5.1.2 Treatment
There is no high-level evidence to suggest the
17.4.2 Acute Abdominal Muscle most appropriate treatment strategy for long-­
Injuries standing pubic-related groin pain. However, evi-
dence from a case series study including
Acute abdominal injury is a rare isolated cause professional Australian football players have
of acute groin pain; however, in about 10–20% reported favorable outcomes using an approach
of acute groin injuries, athletes will report pain consisting mainly of load management and pel-
in the lower abdominal area during clinical vic stability exercises. During the initial 12 weeks
examination. Positive tests are usually found in following the diagnosis, the athlete should refrain
combination with a larger injury in a different from all weight-bearing running activities,
muscle in the groin (such as adductor longus whereas stationary cycling may be introduced at
avulsions), and positive imaging findings in the week 4 given that no pain is elicited by the activ-
abdominal muscles will only be present in 1–6% ity. After 12 weeks, running activities should be
cases [29, 31]. There are currently no evidence- gradually introduced [45].
based treatment guidelines for acute abdominal
injuries.
17.5.2 Pubic Apophysitis

17.5 Pubic Symphysis Pain Pubic apophysitis is a newly described groin

entity, and very limited data exist. It should be
17.5.1 Pubic-Related Groin Pain suspected as a potential source of pain in skele-
tally immature athletes (up to 21 years old) pre-
Pubic-related groin pain is considered a rare con- senting with long-standing adductor-related
dition that remains poorly explored in the litera- groin pain. It has been hypothesized that the
ture. As such the epidemiological data related to development of pubic apophysitis may be due to
this entity is scarce; however, a recent report a combination of traction and compressive forces,
evaluating 100 athletes presenting multidisci- leading to excessive apophyseal plate stress in
plinary sports groin pain clinic showed that four young athletes with non-fusion of the secondary
athletes (4%) had pubic-related groin pain, but it ossification center of the pubic symphysis [27].
was only considered as the primary cause of pain
in one athlete [35]. 17.5.2.1 Diagnosis
The diagnosis of pubic apophysitis is based on a
17.5.1.1 Diagnosis history of increasing pain during and after even
According to the DOHA Agreement, long-­ careful adductor exercises in adolescent athletes
standing pubic-related groin pain is diagnosed as including tenderness of the adductor longus
tenderness with palpation of the pubic symphysis insertion on the pubis on palpation including
and the immediately adjacent bone [46]. radiographic confirmation, preferable using CT
Palpation of the pubic symphysis is performed scan [27].
with the subject lying supine. The examiner With the patient lying supine with the hip
locates the upper part of the pubic bone by pal- flexed, abducted, and externally rotated, and the
pating with a gentle finger followed by palpation knee slightly flexed, the adductor longus tendon
of the pubic symphysis distally. It is important to can be easily palpated. The examiner, using the
note that most athletes are tender at the top of the right hand on the right leg, and the left hand on
17  Groin Injuries 229

the left leg, palpates the adductor longus tendon 17.7 Prevention of Groin Injuries
with two fingers and follows the tendon to the
insertion at the pubic bone. The insertion area, A 2015 systematic review and meta-analysis on
including the bone, is tested with firm pressure to prevention of groin injuries noted a clinically rel-
a radius of about 1 cm [11]. evant reduction in groin injuries of 19%; how-
It has been suggested that CT scan allows for ever, few studies were specifically designed to
the best visualization of the pubic apophysis, reduce the risk of groin injuries [6]. Promising
with 1.5 T MRI adding no value to the diagnosis. effect for groin injury prevention exists for a pre-
However, 3.0 T MRI may be promising and thus vention program focused on active adductor exer-
should be considered due to no radiation [27]. cises, where a reduction of 31% has been
observed [13]. Additionally, a recent study
17.5.2.2 Treatment including an exercise program consisting of only
There is no high-level evidence to suggest the one adductor exercise (performed at three differ-
most appropriate treatment strategy for pubic ent levels) during the football season showed a
apophysitis; however, a combination of load reduction in groin problems of 41% [10].
management and gradual strengthening of the hip
adductors seems promising [27].
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42. Thorborg K, Rathleff MS, Petersen P, Branci S, Holmich 49. Werner J, Hagglund M, Walden M, Ekstrand J. UEFA
P. Prevalence and severity of hip and groin pain in sub- injury study: a prospective study of hip and groin inju-
elite male football: a cross-sectional cohort study of 695 ries in professional football over seven consecutive
players. Scand J Med Sci Sports. 2017;27:107–14. seasons. Br J Sports Med. 2009;43:1036–40.
43. Tsukada S, Niga S, Imamura S, Saito M, Hatanaka
J. Iliopsoas disorder in athletes with groin pain: preva-
 Part III
Neurological Disorders
 Epilepsy and Seizures
18
Jorge Roberto Pagura and Rudá Alessi

18.1 Introduction Epileptic seizures are only one manifestation

of neurologic or metabolic diseases, having many
Epilepsy is defined by the International League possible causes, from genetic predisposition to
Against Epilepsy as a brain disorder character- brain tumors and head trauma. The diagnosis of
ized by an enduring predisposition to generate epilepsy requires (1) at least two unprovoked sei-
epileptic seizures and by the neurobiologic, cog- zures occurring >24 h apart; (2) one unprovoked
nitive, psychological, and social consequences seizure and a probability of further seizures like
associated [1]. An epileptic seizure is a transient the general recurrence risk (at least 60%) after
occurrence of signs and/or symptoms due to two unprovoked seizures, occurring over the next
abnormal excessive or synchronous neuronal 10  years; or (3) the diagnosis of an epileptic
activity in the brain [1]. Not every patient that ­syndrome [2].
presents an epileptic seizure has epilepsy and/or As seizures are nonspecific manifestations of
must be treated to such condition, and even neurologic injury or even clinical disease, the
repeated seizures due to an acute identified etiol- prevalence of seizures is high, with lifetime like-
ogy (e.g., alcohol withdraw, hypoglycemia) are lihood of one seizure of 9%, and of receiving a
not considered epilepsy. diagnosis of epilepsy is almost 3% [3, 4]. There is
a very high incidence in the first year of life and
in early childhood, with a relative decrease in
adolescence.
Incidence is at its lowest between the ages of
J. R. Pagura (*) 20 and 40 and steadily increases after age 50, with
Neurosurgery, ABC Medical School—FMABC,
Santo André, Brazil the greatest increase seen in those over age 80 [5].
Brazilian Neurosurgical Society, Paraíso, Brazil
Medical and Antidoping control-Brazilian Soccer 18.2 Pathophysiology
Confederation (CBF), Rio de Janeiro, Brazil
e-mail: [email protected]
Although the pathophysiology of epilepsy and
R. Alessi
Neuroscience Department, ABC Medical School— seizures is diverse and still poorly understood,
FMABC, Santo André, Brazil there is an element in common across epilepsies:
Laboratory of Clinical Neurophysiology, Institute an imbalance between excitatory (via glutamater-
and Department of Psychiatry, University of Sao gic signaling) and inhibitory (via GABAergic
Paulo—USP, São Paulo, Brazil signaling) activity, leading to excessive neuronal

© ISAKOS 2019 235

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_18
236 J. R. Pagura and R. Alessi

activity. In order for a brain to become “epilep- Table 18.1  Types of seizures
tic,” there is an understanding that it must go Unknown
through a process called epileptogenesis. This Focal onset seizures Generalized onset onset
Motor onset Motor Motor
process suggests a time interval between the
 Automatisms  Tonic-clonic  
insult (e.g., a physical insult) and the resultant  Atonic  Clonic Tonic-­
epileptic condition [6].  Clonic  Tonic clonic
Considering post-traumatic epilepsy as a  Epileptic spasms  Myoclonic  Epileptic
 Hyperkinetic   spasms
model for symptomatic epilepsy, everything
 Myoclonic Myoclonic-­ Nonmotor
begins with injury, and often death, of a signifi-  Tonic tonic-­clonic  Behavior
cant of neurons. Hyperexcitability arises from Nonmotor onset   arrest
this lesion from the release of potassium [7, 8]  Autonomic Myoclonic-­
 Behavior arrest atonic
and glutamate [9] to the extracellular space,
 Cognitive  Atonic
which may be a reason to acute symptomatic sei-  Emotional  Epileptic
zures. Later, the glutamate release leads to a rise  Sensory spasms
in the influx of calcium, with subsequent dys- Aware/impaired Nonmotor
awareness (absence)
function of mitochondrial activity and release of
Focal to bilateral  Typical
cytochrome c [10]. It has been known for some tonic-clonic  Atypical
time now that traumatic insult leads later on to  Myoclonic
altered gene expression, with possible loss of  Eyelid
myoclonia
inhibitory constraints and altering synaptic and
network organization [11]. Adapted from Fisher RS, Cross JH, French JA, et  al.
Operational classification of seizure types by the
International League Against Epilepsy: Position paper of
the ILAE Commission for Classification and Terminology.
18.3 Classification of Seizures Epilepsia 2017
and Epilepsy

After the diagnosis of epilepsy is made (other Focal seizures may evolve to both sides of the
than other paroxysmal events, like psychogenic brain and are called focal to bilateral tonic-clonic
events or syncope), the physician must identify seizure.
the seizure type [12].
Seizure type is classified based on clinical
manifestation and is divided in generalized, focal, 18.4 Approach to a First Seizure
or unknown (seizure onset is missed or obscured)
(Table 18.1) [12–14]. The main objective when approaching a patient’s
Generalized seizures are further divided into first seizure is to determine whether there is a
motor and nonmotor (absence) seizures, while treatable (and potentially lethal) condition, such
focal seizures are subdivided on motor and non- as a systemic condition or an intrinsic injury of
motor and on level of awareness (perceptive or the nervous system.
disperceptive) [12, 13]. An acute symptomatic seizure is a seizure that
Generalized Tonic-Clonic seizures are those occurs at the time of a systemic insult or in close
that originate at some point within or rapidly temporal association with a brain insult (up to
engage bilaterally distributed networks, which do 1 week, if traumatic brain injury) [14].
not necessarily include the entire cortex [12, 13]. Some of these patients may develop epilepsy
Focal seizures are the ones that originate in net- in the future, but most of these patients do not
works limited to one single hemisphere [12, 13]. recur in seizures nor develop epilepsy.
Once seizure is a clinical manifestation of The causes of acute symptomatic seizures are
neuronal hyperactivity, its semiological classifi- many and vary according to the setting of the sei-
cation allows the physician to infer the anatomi- zure and the type of seizure. Medical conditions
cal site on the brain of the seizure generation. associated are listed on Table 18.2, and virtually
18  Epilepsy and Seizures 237

Table 18.2 Clinical causes of acute symptomatic seizure control in addition to producing social
seizure
integration [19].
Hyponatremia (<115 mg/dL) Some studies show the comparison between
Hypomagnesemia (<0.8 mg/dL)
matched controls and patients called “epilepsy
Hypocalcemia (<5 mg/dL)
only” in childhood [20] suggest that the sports
Hypo- (<36 mg/dL) or hyperglycemia (>450 mg/dL)
activity when practiced under control surely ben-
Adapted from Beleza P.  Acute Symptomatic Seizures.
The Neurologist 2012;18(3):109–19 efits the patient.
Despite this tendency, it is fundamental that
the person with epilepsy should be accompanied
any acute brain injury can cause a seizure (e.g., by a clinician and neurologist to perform their
TBI, acute ischemic or hemorrhagic stroke, brain activities safely.
hematomas, brain abscesses, encephalitis). Among many variables, the current neurologi-
The evaluation must begin with medical his- cal situation, adherence to treatment, and time of
tory and description of the event and include the crises control should be considered.
postictal event, any focal deficits, history of prior Another problem is the impact of stigma on
events, medications and substance in use, and exercising in epileptic people [21]. The stigma,
past and family history. Laboratory tests must unfortunately, influences the group negatively in
include electrolytes, glucose, calcium, magne- team sports.
sium, complete blood count, renal function tests, It is possible to reduce it by educating others
liver function tests, urinalysis, and toxicology about the effects of sports on epileptic athletes.
screens [15]. All the clarification on this brings positive aspects
Electroencephalography (EEG) is an essential to both the epilepsy patient and the other
tool to study and classify epileptic seizures. In participants.
patients that presented their first seizure, EEG People with epilepsy increased self-esteem,
must be performed, and the presence of epilepti- socialization, and health benefits in general
form abnormalities increases the odds of a new although they are often discouraged due to the
event, but a normal EEG does not rule out the overprotection and lack of knowledge about the
possibility of further seizures [15, 16]. subject.
Neuroimaging must be performed in all Social exclusions occur frequently in the first
patients with a first seizure and with urgency in ages when they are physically more fragile.
those with a new focal deficit or persistent altered In any case, the benefit of sports in an epilep-
mental status, fever, persistent headache, history tic person is indisputable, not only for the social
of TBI, malignancy, immunocompromised, alco- inclusion but due to improvement of the cogni-
holism, anticoagulation, or bleeding diathesis tive function with effects in the psychosocial
[15, 17, 18]. development and integration.
The consensus paper prepared by the
International League Against Epilepsy (ILAE)
18.5 Epilepsy and Sports divided the sports into three categories according
to the risk of death or serious injury if a seizure
The benefits and risks of sports practice in occurs during the practice of it [19]:
patients with epilepsy remain controversial
although most authors in the last decades have 1. Sports with no significant additional risk, like
reported more benefits than risks depending on collective sports on the ground, golf, and rac-
the type of sports being practiced. quet sports
The advocates of the benefits of sports prac- 2. Sports with moderate risk to epileptic athletes
tice in epileptic patients for the improvement of but no risks to bystanders like cycling, gym-
health and psychosocial benefits athletes cite evi- nastics, and weightlifting
dence that suggests that physical exercise and 3. Sports with major risk, like motor sports,

active participation in sports may favorably affect parachuting, rodeo, and scuba diving
238 J. R. Pagura and R. Alessi

There is no doubt that sports where the head after 1  week when it is considered to be post-­
can be reached routinely like boxing, karate, tae- traumatic seizure (PTS).
kwondo, judo, and MMA have to be avoided. Some authors considered PTS, seizures up to
One of the causes of seizures during the sports 4 weeks after the head injury [24].
is cerebral concussion, which occurs with the dis- Normally the post-traumatic epilepsy occurs
placement of the brain inside the skull by impact close to 80% in the first 2  years after the head
or external displacement forces. injury [25].
American football, rugby, hockey, and soccer There is a correlation between the severity of
with well-defined protocols are not only for with- the head trauma and the development of post-­
drawal in cases of occurrence of the but also for traumatic epilepsy. Thus, in patients with brain
the return to play. contusion, intracerebral hematoma is more likely
Most of these sports are classified in category to develop PTE, when compared with mild inju-
1 by the ILAE, and although they possibly pres- ries such as cerebral concussion.
ent concussion, they do not present absolute con- For the diagnosis of brain lesions, magnetic
traindication for the practice by athletes with resonance imaging (MRI) is the most indicated
epilepsy. neuroimaging method.
If the seizure after a cerebral concussion The utility of the electroencephalogram in dif-
occurs, the evaluation for the return to play ferentiating which patients are at an increased
should follow the specific protocols, in relation to risk of developing PTE remains unclear. However,
a non-epileptic athlete mainly in relation to the the use of prophylactic antiepileptic drugs for a
imaging and electroencephalogram examina- short time after severe head trauma is advocated
tions, besides the evaluation of the levels of med- by some authors to prevent the PTE [26].
ications previously used. The treatment of post-traumatic epilepsy fol-
These athletes should be managed on an lows the same orientation of epileptic patients.
individualized basis by a multidisciplinary
team of specialists with clinical expertise in
epilepsy [22]. 18.7 Management of Seizures
The high-performance athletes can use safely and Epilepsy
the antiepileptic drugs because they are not
included in the list of forbidden drugs by World For most patients with epilepsy, treatment does
Anti-Doping Agency (WADA). not aim to cure the condition but to control sei-
Even in high-performance sports where zures and improve quality of life, with the mini-
energy demand is much higher, and the hyper- mum of side effects possible. The choice of
ventilation can directly exacerbate the seizures, lifestyles according to the patient’s abilities is
or the exercise indirectly can alter the level of also a big factor in managing epilepsy [27].
anticonvulsants, [23] there are no clear restric- The first data taken into account when treating
tions on sports practice because the exercise ben- a patient with epilepsy is the type of epilepsy.
efits individuals with epilepsy. However Seizure types and seizure syndromes have impor-
neurological monitoring and adherence to the tant implications in the choice of antiseizure
prescribed treatment are very important. drugs. When well chosen, and in adequate dos-
age, approximately half of the patients with a
new diagnosis of epilepsy will remain s­ eizure-­free
18.6 Post-traumatic Epilepsy with the first antiseizure drugs prescribed, [28,
29] with another 10–20% of patients having a
Post-traumatic epilepsy is lifelong complications successful control with a second drug trial [30,
of traumatic brain injury. 31], with the remaining, nonseizure-free patients,
After the head injury, the seizure can occur, being called refractory [32], with low chances of
immediately related to the trauma itself or even becoming seizure-free.
18  Epilepsy and Seizures 239

Table 18.3  Antiseizure drugs according to seizure type 4. Hauser WA, Annegers JF, Kurland LT.  Incidence
of epilepsy and unprovoked seizures in Rochester,
Broad spectrum
Minnesota: 1935–1984. Epilepsia. 1993;34:453.
(used for focal Narrow spectrum Narrow
5. Everitt P, Sander JW.  Incidence of epilepsy is now
and generalized (used for focal spectrum
higher in elderly people than children. Br Med J.
onset seizures) onset seizures) (absence)
1998;316:780.
Valproate Carbamazepine Ethosuximide 6. Schwartzkroin PA.  Mechanisms of epileptogenesis
Levetiracetam Oxcarbazepine in symptomatic epilepsy. In: The causes of epilepsy.
Topiramate Eslicarbazepine Cambridge: Cambridge University Press; 2011.
Lamotrigine Gabapentin 7. Reinert M, Khaldi A, Zauner A, et  al. High level of
Brivaracetam Phenytoin extracellular potassium and its correlates after severe
Clobazam Pregabalin head injury. J Neurosurg. 2000;93:800–7.
Perampanel Lacosamide 8. Gorji A, Speckmann EJ.  Spreading depression
enhances the spontaneous epileptiform activ-
ity in human neocortical tissues. Eur J Neurosci.
Table 18.4 Antiseizure drugs with the potential to 2004;19:3371–4.
worsen generalized seizures 9. Benardo LS. Prevention of epilepsy after head trauma:
Generalized onset Carbamazepine and do we need new drugs or a new approach? Epilepsia.
tonic-clonic seizures phenytoin 2003;44(10):27–33.
Absence seizures in Carbamazepine, 10. Nizuma K, Endo H, Chan PH.  Oxidative stress and
children oxcarbazepine, mitochondrial dysfunction as determinants of isch-
phenobarbital, phenytoin, emic neuronal death and survival. J Neurochem.
tiagabine, and vigabatrin 2009;109(1):133–8.
Absence seizures, Carbamazepine, 11.
Pitkanen A, Karatishvili I, Karhunen
myoclonic seizures, and in gabapentin, lamotrigine, H. Epileptogenesis in experimental models. Epilepsia.
some cases generalized-­ oxcarbazepine, 2007;49(5):19–25.
onset tonic-clonic seizures phenytoin, tiagabine, and 12. Scheffer IE, Berkovic S, Capovilla G, et al. LAE clas-
in patients with juvenile vigabatrin sification of the epilepsies: position paper of the ILAE
myoclonic epilepsy Commission for Classification and Terminology.
Epilepsia. 2017;58(4):512–8.
Adapted from Glauser T, Ben-Menachem E, Bourgeois B, 13. Fisher RS, Cross JH, French JA. Operational classi-
et al. Updated ILAE evidence review of antiepileptic drug fication of seizure types by the International League
efficacy and effectiveness as initial monotherapy for epi- Against Epilepsy: position paper of the ILAE
leptic seizures and syndromes. Epilepsia 54:551–63; 2013 Commission for Classification and Terminology.
Epilepsia. 2017;58(4):522.
Tables 18.3 and 18.4 give a broad idea of med- 14. Beghi E, Carpio A, Forsgren L, et al. Recommendation
for a definition of acute symptomatic seizure.
ical treatment of epilepsy. Epilepsia. 2010;51(4):671.
Refractory patients should always be referred 15. Krumholz A, Wiebe S, Gronseth G, et  al. Practice
to a tertiary epilepsy center, in order to investi- parameter: evaluating an apparent unprovoked first
gate if there is an indication of surgical treatment. seizure in adults (an evidence-based review): report of
the Quality Standards Subcommittee of the American
Video-EEG and MRI are particularly important Academy of Neurology and the American Epilepsy
in this follow-up [33]. Society. Neurology. 2007;69(21):1996.
16.
van Donselaar CA, Schimsheimer RJ, Geerts
AT.  Value of the electroencephalogram in adult
patients with untreated idiopathic first seizures. Arch
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 Spine Injuries
19
Elcio Landim, Paulo Tadeu Maia Cavali,
Marcelo Italo Risso Neto,
and Mauricio Coelho Lima

19.1 Introduction ballers have shown that back injuries are

associated with the poor symmetry of shoulders
The head, the neck, and the spinal cord are the and back, as well as to scapulae abduction [1].
costliest and potentially morbid among sports There are specific lesions that are more com-
injuries. Although the practice of sports usually mon in sports practices, and these can be divided
results in well-being while it aggregates lots of into those due to direct trauma in a specific ana-
health benefits, no sport is immune to the risk of tomical structure or those due to supraphysiologi-
a spine injury. The spine may be affected during cal stress on the spine [2]. Stress lesions can take
professional and recreational sports practice, place both in the individual as in collective sports.
both in training and competitions [1]. Special attention must, therefore, be given during
The spine is very sensitive to asymmetric the training phase in order to avoid excessive
sports, which may contribute to the postural workloads in terms of intensity and frequency.
imbalance or increase of pre-existing asymme- Appropriate timing must be observed taking into
tries. For the same reason, athletes with posture account the period needed for recovery and the
deviations are more susceptible to these types of adaptation of the muscle and tendon involved; this
lesions. As an example, studies on the relation- way, this type of lesion can be avoided, as well as
ship between posture and sports injuries in foot- the pain associated with inflammatory phenom-

E. Landim (*) · M. C. Lima Department of Scoliosis, AACD (Associação de

Spine Surgery Group of the German Hospital Assistência à Criança Deficiente),
“Oswaldo Cruz”, São Paulo, SP, Brazil São Paulo, SP, Brazil
Department of Scoliosis, AACD (Associação de Brazilian Society of Orthopedics and Traumatology,
Assistência à Criança Deficiente), and the Brazilian Spine Society, São Paulo, SP, Brazil
São Paulo, SP, Brazil e-mail: [email protected]
Spine Surgery Division of Orthopedics and M. I. Risso Neto
Traumatology Department, State University of Spine Surgery Group of the German Hospital
Campinas—UNICAMP, Campinas, SP, Brazil “Oswaldo Cruz”, São Paulo, SP, Brazil
Brazilian Society of Orthopedics and Traumatology, Spine Surgery Division of Orthopedics and
and the Brazilian Spine Society, São Paulo, SP, Brazil Traumatology Department, State University of
e-mail: [email protected] Campinas—UNICAMP, Campinas, SP, Brazil
P. T. M. Cavali Brazilian Society of Orthopedics and Traumatology,
Spine Surgery Group of the German Hospital and the Brazilian Spine Society, São Paulo, SP, Brazil
“Oswaldo Cruz”, São Paulo, SP, Brazil e-mail: [email protected]

© ISAKOS 2019 241

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_19
242 E. Landim et al.

ena and anatomical injuries of spine structures movements or a traumatic condition. Incomplete
[3]. Traumatic lesions usually occur in speed and lesions occur due to stretches and are not associ-
contact sports, both individual and collective. ated with instability. On the other hand, complete
lesions are unstable and commonly associated
with neurological deficit [6].
19.2 A
 natomy of Spine Lesions
(Table 19.1)
19.2.4 Disc Lesions
19.2.1 Bone Lesions
This condition is related to sport intensity and its
Many types of fractures occur in sports injuries. repeated movements, as well as to a previous
The most common and frequently reported verte- degenerative disease that leads to its worsening
bral bone lesion is spondylolysis, the vertebra and becoming more frequent. A disc herniation
area that connects the upper and lower zygapoph- seldom occurs due to a traumatic event even
yseal joints. These lesions are related to repeated though it has been reported [7]. Neurological
extension movements which impact the isthmus deficits and pain may occur due to disc
on the superior facet joint of the inferior vertebra. compression.
The symptoms are back pain whether or not asso-
ciated with radiculopathy [4]. Fractures of the
vertebral body may occur due to compression 19.2.5 Joint Lesions
forces in high-energy sports accidents [5].
Low-energy traumas may cause a sprain, while
high-energy traumas may cause joint disloca-
19.2.2 Muscle Lesions tions. Chronic lesions with mild instability are
associated with synovial cysts and possible
Muscular lesions are probably the most common radiculopathy.
ones related to sports. Direct contusions,
stretches, and ruptures may be caused by diverse
mechanisms. Reflex contractions of muscles are 19.2.6 Neurological Lesions
another cause of pain, and they are usually sec-
ondary to another skeletal lesion. Neurological spine lesions are among the worst
and most devastating lesions in sports. They
affect the spinal cord and/or spinal nerve roots,
19.2.3 Ligament Lesions with different presentations and levels of severity.
Contact sports are among the riskiest for these
This type of lesion on the spine is related to lesions. Many publications report severe spine
hyperextension or hyperflexion in repeated lesions in ice hockey, rugby, and football [8–12].
Degenerative disease and congenital stenosis
reduce available space in the vertebral canal of
Table 19.1  Anatomical lesions on the spine the spinal cord; there are findings concerning the
Contusion, stretch, total or partial risk of developing neurological injury in the
Muscle rupture practice of sports.
Ligaments Stretch, total or partial rupture
Disc Disc rupture, protrusion, extrusion
Bone Fractures (compression, traction,
rotations, and avulsion)
Joints Sprain and dislocation Contact sports present the highest rates of
Neurological Nerve root and spinal cord (partial or severe injuries.
complete)
19  Spine Injuries 243

19.3 C
 ervical Spine Lesions 19.3.1 Cervical Peripheral Nerve
in Sport Injuries

Cervical spine injuries are common in sports. 19.3.1.1 Burners

Most injuries result from low-energy trauma “Burners” (also known as “stingers”) are tempo-
causing sprains, which, in turn, lead to complete rary symptoms of burn, pain, or sensitive and/or
rehabilitation without sequelae. Although rare, motor loss that happens involving the upper
cervical spine injuries involving the spinal cord limbs [14]. They usually occur after a trauma to
and nerve roots can lead to potentially serious the brachial plexus or the exiting nerve roots in
sequelae such as tetraplegia. The severity and the cervical spine [15]. They frequently happen
extent of the injury depend fundamentally on the in contact sports, such as football and rugby. A
kinetics of trauma and is related to the type of high number of football players, most commonly
sport and the technical level of the athlete. Contact defensive players, present burner symptoms at
sports, especially rugby; high-speed sports, such least once during their careers [16].
as skiing; and motorized sports have a greater risk Burners can be caused by compression, dis-
of developing serious injuries [8–11]. traction, or direct blow mechanisms. If an asym-
metrical axial trauma to the neck causes a
compression in the neuroforamen, it can damage
the peripheral nerve root. Also, if the player falls
In general, lumbar injuries are the most
on the shoulder and his head is distracted from
common, but the cervical spine is subject
the upper limb, traction is applied to the nerve
to the most severe lesions.
root and the brachial plexus. Finally, when the
cervical spine receives a force in hyperextension,
hyperflexion, or lateral flexion to the opposite
The presence of previous lesions, such as con- side, the distance and the angle between the
genital or acquired spinal canal stenosis, increases shoulder and neck are excessively increased, thus
the risk of neurological damage and should be stretching the brachial plexus. Compression
considered and evaluated before sports practices combined with extension is the most common
that expose the cervical spine to risk. Trauma in mechanism [17].
hyperextension of the cervical spine can cause a Symptoms of burners are usually severe pain
medullary contusion with the possibility of tran- in the shoulder and arm, with a loss of the sense
sient or permanent symptoms. of touch and weakness of the arm. The deltoid
Cervical neurological lesions in the athlete are (C5), biceps (C5,6), and spinatus muscles (C5,6)
classified in three categories [13]: are most commonly involved, and the symptoms
typically last only a few seconds or minutes.
• Type I—Permanent spinal cord injury. Shoulder abduction may cause less pain, and the
• Type II—Transient medullary or root neuro- doctor can ask the player to place a hand on the
logical deficit, with regression in a few min- top of the head. The Spurling maneuver repro-
utes or hours. duces the mechanism of the injury, and burning
• Type III—Post-traumatic lesion with purely or pain is reported by the player when this
radiological findings, without clinical ­movement is performed [16, 18] The symptoms
correspondence. can be presented in different degrees of severity
ranging from a transient nerve irritation without
In addition to acute traumas, repetitive traumatic residual damage (most common) to a complete
injuries can cause or accelerate degenerative pro- avulsion of the nerve root from the spinal cord
cesses leading to lesions that may have clinical pre- with permanent deficit (very rare) [17].
sentations ranging from asymptomatic to chronic To prevent burners the player needs to wear
axial pain and neurological root or spinal deficits. appropriate protection equipment and to learn the
244 E. Landim et al.

correct way to block and to tackle during the 19.4 Thoracolumbar Lesions
practice, using only the shoulder, and never the in Sports
head while keeping the head down [17].
Initial treatment involves removing the player The thoracolumbar lesions are more frequent
from the game and allowing him/her to rest; this than the cervical ones, and they represent 10% of
is followed by strengthening exercises of the the injuries caused by sports. Likewise, there is a
neck and restoration of the range of motion. broad clinical presentation spectrum ranging
These injuries are classified using the Seddon from non-specific low back pain to paraplegia
classification of neurapraxia. Athletes with more [33, 34].
severe lesions may require a longer period for The different types of sports and mechanisms
recovery lasting from a few hours to a few weeks of thoracolumbar injury are related to the clinical
when the athlete will be away from the game findings. The lesions that occur in extension
[19–26]. expose the risk of fracture of the pars or facet
joints, and gymnasts are among the most affected
19.3.1.2 Cervical Stenosis athletes [35]; torsional injuries affect discs and
Congenital cervical stenosis is a risk factor for facets and occur more often in sports such as golf
cervical spine injuries [27]. Burners are more and tennis; compression/flexion lesions expose
common in players with spinal stenosis as defined the intervertebral disc to greater risk of damage;
by the Torg ratio, which is defined as the ratio of injury by fall or secondary to an external agent
the spinal canal width to the width of the verte- can cause unexpected and potentially more seri-
bral body at the same level; the narrowest is at ous damages depending on the intensity and
C7. A Torg ratio of 0.7 to 0.8, or lower, is high energy of the trauma [36].
risk. For players with cervical stenosis, the risk of The way energy is applied to the trauma can
burners and other neurological complications lead to different lesions and in different tissues:
during sports practice is three times as high as for example, lesions occurring at high speed can
players without stenosis, and this ratio is usually affect the vertebrae and cause fractures by abrupt
used as a screening for football and rugby players deceleration, while the application of progressive
to prevent neurological complications in those and repetitive energy favors disc and ligament
sports [20–31]. degeneration.

19.3.1.3 T  ransient Spinal Cord

Compression 19.4.1 Spondylolysis
Torg and colleagues [32] related the syndrome
of transient quadriplegia, which represents a Spondylolysis is a stress fracture of the pars
“neuropraxia of the cervical spinal cord.” The interarticularis. It is generally considered to be a
syndrome is characterized by bilateral upper low-risk fracture that occurs most frequently at
and lower limbs’ neurological involvement L5, followed by L4 and L3. The mean rate of
without any fracture or dislocation associated; spondylolysis is 5–6% in the general population,
in most cases, the problem is solved in 36 hours. [37] and, in general, it is asymptomatic. Repetitive
There is a strong association between transient stress generally produces fatigue fracture. These
quadriplegia and developmental spinal stenosis; fractures may consolidate but develop fibrous
according to the current literature, all patients nonunion or heal in an elongated state [38].
who presented transient quadriparesis had a The incidence of pars defects is greater in ath-
diagnosis of spinal stenosis. However, there is letes than in the nonathletic population, and it is a
no evidence that the occurrence of transient clinical problem for these patients [39]. Sports
quadriplegia predisposes to permanent neuro- that require hyperextension associated with rota-
logical injury [17, 32]. tional movements such as gymnastics, wrestling,
19  Spine Injuries 245

and weightlifting are associated with a stress The lateral X-ray of the lumbar spine confirms
fracture of the pars interarticularis. Some specific the diagnostic, and the degree of the slip is graded
sports, such as diving, weightlifting, wrestling, according to the Meyerding classification. There
and gymnastics, have extraordinarily high rates is a consensus that kyphosis is a more important
of this injury [40]. Many studies suggest that a sign of severity measure of the deformity than
variety of sports, such as soccer, volleyball, and displacement [45].
baseball, increase the risk of spondylolysis [41].
Spondylolysis is a bone injury that, in most
cases, does not produce neurological symptoms. 19.4.3 Apophyseal Ring Fracture
Any nerve root signs would suggest an alterna-
tive diagnostic [37]. This injury is characterized by bone fragments at
the posterior vertebral endplate and is also known
as limbus fracture or fracture of the vertebral rim,
19.4.2 Spondylolisthesis ring, or endplate [46]. This lesion is exclusive of
adolescents [47] and was reported by Skobowytsh-­
Spondylolisthesis occurs when there is a bilateral Okolot in 1962 [48, 49]. There is an overall prev-
lesion in the pars interarticularis, and the verte- alence of only 0.07%; there is also an 85%
bral body slips forward over the lower vertebra. predominance in males; 66% have an association
The incidence of spondylolisthesis in athletes is with a traumatic event, such as weightlifting or
the same as in the general population [37]. sports injury [46–49]. This is, also, associated
In the current literature, there are no criteria with Scheuermann disease [50] and lumbar disc
available for predicting which cases of spondy- herniations [51].
lolysis will progressively slip, resulting in spon- Both hyperextension of the lumbar spine [52]
dylolisthesis. Most cases of spondylolisthesis are and acute flexion associated with axial compres-
low grade and unlikely to progress. With mild sion to the lumbar spine, such as it occurs with
spondylolisthesis, there is no reason to forbid the weightlifting, are the proposed mechanisms of
athlete from participating in sports [37]. this injury [47, 48, 53]. Symptoms of an apophy-
Isthmic spondylolisthesis is the most common seal ring fracture are similar to Disc Herniation -
type found in young athletes. Bilateral stress pain in the back and buttock which gets worse
fractures of the pars are the distinguishing pathol- after coughing, sports and sitting [48]. Pain may
ogy of spondylolisthesis. The main risk factor, radiate down one or both legs. The straight-leg-­
other than a familial predisposition for this injury, raise test is positive, and contralateral straight-leg
is hyperextension mechanism [37]. raise is frequently positive. Paraspinal muscle
Symptoms of spondylolisthesis are low back spasm, lumbar tenderness, scoliosis, intermittent
pain worsened during activity, especially those claudication, paraparesis, and cauda equina syn-
that involve hyperextension and rotation. Sports drome have been reported [47, 48].
with rotation and extension under load repeated a
lot of times during practice such as gymnastics,
football, wrestling, hockey, pole vaulting, diving, 19.4.4 Disc Herniation
and throwing sports are related as causal factors in
many reports [42, 43]. Typically for mechanical-­ Disc herniation or Herniated Nucleus Pulposus is
type pain, rest tends to alleviate the pain [37]. an injury related to sports, and surgeries for these
During the investigation, it was found that, if conditions in athletes are performed many times
radiculopathy is present, the L5 root is most com- during a sports season. High-risk activities include
monly involved [44, 45]. Cases with neurological weightlifting and collision sports, such as football
symptoms must be differentiated from disc [48], and also basketball, baseball, and wrestling
herniation. [50]. The incidence is 95% of herniations
246 E. Landim et al.

o­ ccurring from L4 to S1 and is fairly evenly dis- There are a high number of severe injuries dur-
tributed between L4–L5 and L5–S1. The L3–L4 ing football practice [4]; because of this, there are
herniation is present in 5% of patients [54]. probably only a few studies that have demon-
The symptoms of HNP are leg pain with or strated data on fewer incapacitating injuries in
without neurological issues. Rehabilitation is football [58]. These include back contusions, lum-
demanded as soon as the symptoms appear, and bar back pain, back cramp/spasm, back muscle
the return to sports is related to the severity of strain, back degeneration, and intervertebral disc
them and the moment of disappearance of these disorders [56]. Disc herniations have accounted
symptoms. for 13% of all injuries affecting the entire spine
MRI is the gold standard, and the conservative and, more specifically, represented 28% of lumbar
treatment is effective in most cases, while sur- spine injuries, 6% of cervical spine injuries, and
gery is reserved for the cauda equina syndrome, 5% of thoracic spine injuries [59].
progressive motor deficits, or failure of the con- Spondylolysis occurs most frequently among
servative care [37]. adolescents, with high rates of incidence among
athletes, especially football players [60]. Also,
the incidence of degenerative disc disease and
19.5 C
 ommon Spine Injuries facet degeneration is higher among the football
in Sports population than in the general population [61].
Having spondylolysis is a very important risk
19.5.1 Football factor when analyzing football athletes with low
back pain [62]. The higher incidence of spine
In the United States, football is a very popular sport issues in football players is caused by the exces-
and leads all other sports in the number of injuries sive compressive, torsional, and shearing forces
[55]. The football lesion rates are figured from produced in the spine during practice.
600,000 to 1.2 million injuries of the entire body The cervical spine is the most affected ana-
every year in the United States [56]. As the number tomic location of the spine during football, and it
of football players continues to increase around the is also where the most severe lesions occur [2]. In
globe, the analysis of prevalent lesions in profes- order of incidence, the lesions in the cervical
sional football is necessary in order to help health spine are presented as follows: nerve root or bra-
professionals to understand the risks that the ath- chial plexus neurapraxia (burners), cervical
letes are exposed to during their practice [57]. strains (muscular injury), disc injury with neck
Using a National Football League (NFL) pain only, cervical sprains (ligament injury), disc
injury database, recorded from years 2000 to herniation with radicular symptoms, transient
2010, Mall et al. [56] have identified 2208 axial spinal cord compression secondary to stenosis,
skeleton lesions, including spinal injuries. This and cervical fractures [32, 63–65].
study demonstrates that injuries to the spine Analyzing average time missed after an injury
accounted for 7% of the lesions in the National during the football practice, cervical fractures are
Football League (NFL). The number of spinal responsible for the highest mean number of days
injuries varied between 152 and 256 per year, missed during a season, among all injuries sus-
during this 10-year follow-up, while 987 (44.7%) tained in the National Football League (NFL)
of these lesions were cervical injuries which [56]. Their accounting for 120  days per injury
account for the most frequently injured location and disc degeneration/ herniation was responsi-
of the axial skeleton during football practice. The ble for a mean time loss of 85  days per injury,
lumbar spine was affected in 30.9% of the cases, while spinal cord injury responded for 77  days
the thoracic spine and ribs in 3.9%, and the per injury [66].
sacrum, coccyx, and pelvis in 10.1% and the spi- Tackling is the football movement most
nal cord was responsible for 0.6% of the related to cervical spine lesions, while blocking
injuries. produces most of the lumbar spine injuries.
19  Spine Injuries 247

This injury mechanism suggests the reason why leagues [75, 76] noted structural abnormalities in
defensive players present a higher rate of spine 74% of the rugby players assessed in the study.
injuries than their offensive teammates. Recent Severe lesions are rare in the lumbar spine, and
data suggest that these lesions are found not only disc herniation is the condition that most needs
among professional athletes but also among non- an intervention such as surgery or steroid injec-
professional players [57]. tions [77, 78].
American football players present a high risk Despite all the concerns about the cervical
for severe trauma, including spinal cord injury spine during the rugby practice, Hind et al. showed
[67]. The incidence of serious cervical spine inju- that rugby players also had a higher risk for thora-
ries was highest in early times but declined dur- columbar fractures, presenting greater rates of this
ing the 1970s with the banning of head-down kind of fracture than the previously reported prev-
“spear tackling” as shown by Torg et al. [32, 62, alence rates for the general population [79].
68]. The National Football League (NFL) began Injuries to the cervical spine are the most seri-
its efforts to address SRC (sport-related concus- ous injuries during rugby practice. From the 1970s
sion) with the establishment of the Mild to the middle of the 1980s, an increase was found
Traumatic Brain Injury Committee in 1994 [63]. in the rates of rugby-related spinal lesions in coun-
In 2010 the committee was reconstituted as the tries where rugby was commonly played all over
Head, Neck and Spine (HN&S) Committee [69], the globe. Many injury prevention measures were
which defines protocols and guidelines for the implemented worldwide by the International
management and prevention of these important Rugby Board (IRB) aiming the alterations of the
lesions and also contributes for a safer practice of rules of the game and educational measures of the
this sport around the world. players searching for safer techniques in the game.
The scrum was the part of the game most associ-
ated with spinal lesions until 1990; after the rule
changed, the rates of spinal lesions occurring dur-
The education of the athletes, coaches, and ing tackle became higher [80].
referees was responsible for the decrease of The most common cervical spine injuries in
the serious cervical injuries in contact rugby were facet dislocations. The injury often
sports, especially football and rugby. affects C4/C5 and C5/C6 levels. Hyperflexion of
the neck was hypothesized to be the primary
mechanism for cervical spine injury in rugby [17,
81–85], but recent studies have identified tackle as
19.5.2 Rugby the moment of highest occurrence of the cervical
injuries and buckling as the main ­biomechanical
Rugby is one of the most popular sports around mechanism of cervical spine injury during rugby
the world [70] and the most popular collision practice [17].
sport. Rugby is a physical contact sport that pres-
ents a high risk for traumatic injury and the use of
little or no body padding. This risk has increased 19.5.3 Tennis
with the professionalization of the sport, which
stimulated players to become larger and stronger Tennis athletes experience few severe injuries on
[71]. Rugby presents one of the highest overall average. Tennis lesions are due to repetitive over-
injury rates of all team sports [72]. load and related with the increasing years of
Epidemiological studies demonstrated that the training. Although ankle and knee lesions are
most common injuries to the spine during rugby more common in tennis practice, lumbar spine
practice are less severe lesions to the lumbar lesions are more recurrent than others [86].
spine as back pain, back muscle strain, and lum- There is a paucity of published data in relation
bar disc disorders [10, 73, 74]. Iwamoto and col- to elite athletes, with considerable variability in
248 E. Landim et al.

the reported incidence of lesions, ranging from lesions usually occur between levels C5 and C7,
0.04 to 3.0 injuries per 1000 playing hours, not caused by head impact against the boards, sus-
related to gender. Lumbar lesions account for taining an axial compression on the cervical
around 12–13% and head and neck around 3% of spine [93].
all musculoskeletal lesions [87]. Regarding male
athletes, the lumbar region is the third anatomical
site of injury, and to female athletes, it is the fifth. 19.5.5 Volleyball
This finding is due to the repetitive trunk move-
ments required in tennis practice, especially Volleyball and beach volleyball are intensive
hyperextension and rapid rotation of the lumbar sports, associated with high impact and repetition
spine during training and playing a match; this of similar movements that may cause spine
supports the frequent findings of low back pain in injuries.
tennis athletes and its correlation with radiologi- Volleyball is associated with a predominant
cal abnormalities in this population [88, 89]. As a forward bending and extension posture, which
reference, the lumbar region undergoes substan- may cause changes in lumbar lordosis and sagit-
tial loading during the kick and flat tennis serves, tal imbalance. Lumbar lordosis flattening is asso-
including lateral flexion forces approximately ciated with pelvic retroversion due to increased
eight times those experienced during running. use of abdominal and gluteal muscles. The find-
A study that describes lumbar MRI findings in ing of a decrease of lumbar lordosis is associated
asymptomatic young elite tennis players con- with the increase of thoracic kyphosis.
cluded that any abnormalities occurred with These changes in lumbar lordosis may be
84.8% of these players almost exclusively on associated with the findings of a higher incidence
L4 L5 and L5S1 levels, with facet joint arthropa- of low back pain and with a higher prevalence of
thy, pars, and intervertebral disc injuries [89, 90]. degenerative findings on MRI, including disc
degeneration and spondylolisthesis [94]. In pro-
fessional volleyball players, the prevalence of
19.5.4 Winter Sports disc degeneration is up to three times as high
when compared to the normal population.
Sports requiring ice or snow as a playing surface Considering MRI findings in professional beach
are called winter sports. Most of these sports are volleyball players, the prevalence of disc degen-
associated with high speed, thus susceptible to eration is 79%, and spondylosis is 21%. Despite
spine traumas. these data, MRI findings do not correlate with
After the head and the chest, spine injuries are back pain symptoms [95].
the most common among these sports. Due to the Traumatic lesions may occur due to repetitive
association with high speed and high energy, the stress, as well as impact or sudden and severe
majority of these lesions is caused because of contraction of the muscles. The literature on vol-
falls and collision against natural objects [91]. leyball practice reports few cases such as stable
The literature contains a wide range of statis- fractures in lower cervical spinous processes,
tics related to lesions due to snow sports, espe- called Clay shoveler’s fracture [96], myelopathy
cially depending on the age group, location, and due to acute disc herniation, and vertebral artery
the specific sport. Injuries associated with neuro- dissection [97].
logical deficit accounts for 42%, and males are
more frequently injured [92, 93]. The most fre- Case 1
quent lesions from skiing and snowboard are tho- A 34-year-old female professional volleyball ath-
racolumbar junction fractures. Ice hockey lete in the national league refers to sudden neck
presents an equal number of cervical and thora- pain during training, associated with right arm
columbar fractures since two thirds of them are pain and weakness. She came to specialized eval-
associated with neurological deficit. These uation after 2 days of conservative treatment with
19  Spine Injuries 249

analgesics and physiotherapy. She complained of injury rates with 0.69 injuries per boxer per year
neck pain irradiating to the right arm on the C6 and 2.0 injuries per 1000 h of training [102, 103].
and C7 dermatomes, weakness of wrist and Boxing athletes most often present head, upper
elbow extension, hyperreflexia, and clonus on limbs, and overall injuries; these injuries resulted
upper and lower limbs. MRI of cervical spine in an average of 10.5 lost days [104].
showed a disc herniation at C5C6 level with Cervical spine injuries represent around
medullar compression and hypersignal in the 10–20% of the injuries found in boxing athletes.
sagittal and axial views (Fig. 19.1a, b). Ten days In the cervical spine, severe injuries as fractures
after this injury, the patient was submitted to or spinal cord injuries are described as rare ones,
decompression and arthrodesis on C5/C6 levels but contusions and muscular lesions are the main
with autologous iliac graft (Fig.  19.2a, b). The cervical injuries related to this sport [104, 105].
complete weakness she experienced improved, The lumbar spine is less affected, and the
and she returned to play 3 months after the sur- number of injuries is around 8%, while the low
gery when fusion occurred and was confirmed back accounts for the highest number of lesions.
with CT scan (Fig. 19.3). Disc herniations can also occur, but the mean
number of lesions is around 0.5%. Lumbar spine
injuries during boxing are classified as less severe
19.5.6 Boxing injuries and are related to a low rate of lost days
of practice [104, 105].
Boxing is an Olympic sport [98–100]; however, it
is classified as a dangerous sport by presenting
severe neurological complications of head lesions 19.5.7 Baseball
which have been discussed in several studies
[101, 102]. Spinal injuries are relatively rare in sports with
Many studies show a small number of severe less contact between the players such as in base-
injuries, but this modality is related to dangerous ball; yet, there are a reasonable number of writ-
injuries, especially head and brain lesions. ings on the possibility of baseball players having
Previous studies on boxing practice showed low spinal lesions in the entire extension of the

a b

Fig. 19.1 (a and b) Cervical sagittal (a) and axial (b) MRI views of disc herniation at C5C6 level with medullar com-
pression and hypersignal
250 E. Landim et al.

a b

Fig. 19.2 (a and b) Decompression and arthrodesis on levels C5/C6 with autologous iliac graft 10 days after lesion,
anteroposterior (a) and lateral (b) radiographic views

v­ ertebral spine [106]. Spinal injuries during base- begins in the lower limbs; then it raises to the pel-
ball practice are mostly found in the lumbar vis, creating a hyperextension of the lumbar spine
spine, and the correct diagnosis and treatment are and a torsional movement of the thoracic spine,
necessary to allow the player to return to the sport which produce the energy necessary for the upper
as soon as possible [107]. limbs to perform the throw of the ball. This
Among baseball players, the injuries to the sequence of complex movements requires a
spine and core musculature respond with 11.7% higher strain on the facet joints [107, 110].
of all sports injuries [108]. Lumbar disc hernia- In spondylolysis and spondylolisthesis, the
tion, spondylolysis, and spondylolisthesis are the stress to the pars can lead to simple injuries as
most frequent injuries, while lumbar back pain is the local inflammatory response or to more
the main issue of the players [106, 107, severe lesions as fractures and dislocations.
109–112]. The pitchers present lumbar back pain in 15%
of the cases during their careers, while around
19.5.7.1 Biomechanics of Baseball 9% of them present spondylolisthesis [109,
Injuries 111, 112].
Spinal stability depends on the structure of the The treatment of the lumbar conditions in
bones and soft tissues and is achieved by the baseball players is widely discussed [113–116].
important role of the muscles that create dynamic Low back pain has to be investigated, and other
and active support for the spine, allowing com- important diagnostics are excluded. The rehabili-
plex moves of torsion and extension of the trunk tation of low back pain without other lesions is
which are necessary for playing baseball. based on core fortification of the muscles, train-
The pitchers are the most commonly injured ing on stabilizers, and progressive stretching of
players. During a pitch, the torsion of the body lumbar and hamstrings [110].
19  Spine Injuries 251

ance during the practice [117]. In a physical con-

tact sport, such as soccer, decreased core stability
is associated with a higher incidence of low back
pain.
Talib et  al. collected prospective injury data
for players of all 41 English professional soccer
youth academies for 5  years, totalizing 12,306
academy players. These players presented 10,225
musculoskeletal injuries, resulting in 310 (4%) of
lumbar spine injuries, and most of them was low
back pain (49%), with strains being second (15%)
and spondylolysis being third (4%). They also
reported that there is an increased risk of lower
back injury, according to the players’ age and the
contact mechanism, in the second part of the first
half of competitive matches (a risk that was
maintained throughout the second half), which
was responsible for the majority of the lesions
[118].
Back pain is the spinal symptom most fre-
quently reported by the soccer players. The
chronic lower back pain results in a time loss of
7–30 days of practice [119]. Longer training ses-
sions, especially on artificial turf, are risk factors
to develop back pain [120], and smoking and
Fig. 19.3  Computed tomography showing evidence of thigh muscle imbalance are reported with even
bone marking and signs of consolidation at 3  months
worse symptoms [121, 122]. Early diagnosis
postoperative
allows appropriate management; the radiological
investigation is indicated when this group of
Spondylolysis and spondylolisthesis treat- players presents back pain lasting longer than
ment for baseball players follows the same prin- 3 weeks [119].
ciples of the guidelines of non-player patients. Rassi et al. (2005) [119] observed that 43% of
The choice between a surgical or conservative the patients felt pain during the kicking
treatment is controversial, and most studies indi- ­movement, which is the most common moment
cate surgery only after the failure of conservative to perceive pain. Sakai et al. (2010) [123] found
treatment. Also, the average recovery time after that the incidence of spondylolysis was at 30% in
surgery is longer (about 7 months) [114–116]. the soccer-playing population. Most soccer play-
ers with spondylolysis had good or even excel-
lent results after non-operative treatment.
19.5.8 Soccer Cessation of sports for a period of 2–3  months
can optimize the clinical outcome and is a strong
Spinal injuries in soccer are not exclusive among predictor of a favorable return to sports. Similarly,
elite or semiprofessional players; they have been Sys et al. (2001) [124] reported that early diagno-
reported in all ages and from amateurs to profes- sis of a fatigue fracture of the pars interarticularis
sional players [107]. Reducing injuries and is important because non-operative treatment of
improving the performance in soccer are directly active spondylolysis leads to excellent results and
related to neuromuscular control, which is sports resumption may be possible within
defined as a dynamic process of maintaining bal- 6 months for the majority of athletes.
252 E. Landim et al.

19.6 Management of Sports should be placed and not removed, and the ath-
Lesions lete must be immobilized before taken anywhere.
Persistent or severe pain means that the player
19.6.1 Lumbar Injuries needs immediate radiologic evaluation. Returning
to practice will occur when the symptoms have
When pain is severe, rest may be necessary for a disappeared, and the image exams do not show
couple of days for initial pain management. A any injury [125].
longer time of rest can start to cause muscular
loss and is not recommended. The sooner the
player starts some minor and tolerated activity, 19.7 Return to Play
the quicker and more effective recovery is [125].
Anti-inflammatories and muscle relaxants are The return to the sport is very controversial, and
recommended for the maximum of 7–10  days, there are many conflicting guidelines for each
not more than that. Opioid administration can be modality and injury. In general terms, for lumbar
used for a few days. Local anesthetic injections injuries, the athlete can return to play when there
into the facet joints or into trigger points can be is no pain specifically related to the activity of the
used and may help to establish a diagnostic while sport, and when the full range of motion is recov-
finding different causes for the symptoms [125]. ered. There is no definitive test to define when
Different modalities of physical therapy as this point is reached. Gradual relief in pain and
ice, tens, massage, or heat can be used in initial improvement in performance are predictive of a
treatment, but the player has to start active reha- good prognosis.
bilitation and strengthening as soon as possible; The return to play after cervical spine trauma
bracing should be avoided or minimized [125]. is based on guidelines which recommend waiting
for the symptoms to disappear and for the player
to have recovered the full range of motion and
19.6.2 Cervical Injuries complete strength [125, 126]. Some studies rec-
ommend that the return to sport should be based
During the sports practice, management of the on normal radiological exams as well [125, 127].
injuries starting from the initial moment of the Less complex lesions, such as spinous process
trauma may reduce long-term risk to the players fractures, should have the treatment based on
and improve the return to playing [58]. If a cervi- immobilization and return to activities only after
cal spine injury is suspected, the physician should healing. Patients with more than three burners in
investigate any spinal pain, search for the altered the same season should be clinically evaluated as
perception of touch, and interrogate numbness, well as with imaging, to make sure that there is
weakness, or difficulty moving the extremities. no spinal stenosis or severe injury before return-
Any player with these signs during an on-field ing to the sport. A single-level fusion, or one of
examination should not participate in the game or two levels, may enable the return after healing.
training any longer, and cervical injuries need to With three or more level fusions, the return to
be investigated [62]. play is contraindicated [125, 128] (Table 19.2).
When examining ambulatory athletes after a
cervical trauma, the examiner should evaluate
neck range of motion, and perform a motor and Return to play is based on the type of
sensory examination of the extremities. injury, the relief of symptoms, and the
Alterations observed during the exam mean that recovery of the range of motion, but each
the athlete must be removed from competition case has to be analyzed for each sport and
and immobilized in a cervical collar. If the player for each patient, also taking into account
is unconscious, it means that the physician should previous spine injuries, congenital stenosis,
presume that a cervical spine injury exists, and and surgeries for spinal conditions
the neck needs to be immobilized. A helmet
19  Spine Injuries 253

Table 19.2  Traumatic and ligamentous injuries of the cervical spine: contraindication to return to play
No contraindications Relative contraindications Absolute contraindications
Neuropraxia or other neurological Healed nondisplaced Jefferson fractures in Injuries of C1-C2 that
symptoms of spinal cord without patients who are also pain-free, have full involve fracture or
radiological alterations and after range of cervical motion, and have no ligamentous laxity
complete resolution evidence of neurological injury
<3.5 mm of horizontal displacement of either >3.5 mm of horizontal
vertebra in relation to the other and depending displacement of either
on the patient’s level of performances, vertebra in relation to the
physical habits, and position played other
<11° of rotation of either adjacent vertebra >11° of rotation of either
and depending on the patient’s level of adjacent vertebra
performance, physical habits, and position
played
Adapted from Torg JS. Cervical spine injuries and the return to football. Sports Health. 2009;1(5):376–83 [129]

RETURN TO PLAY IN

STENOSIS OF THE CERVICAL SPINAL CANAL

(1 OR MORE VERTEBRAE WITH A CANAL VERTEBRAL BODY RATIO <0.8)

• documented episode of cervical cord neurapraxia

No symptom motor/sensory manifestations of cord
neuropraxia associated with ligamentous instability

• MRI evidence of neurologic damage

• symptoms lasting longer than 36 hours

• multiple recurrences of symptoms

NO RELATIVE ABSOLUTE

contraindication contraindication contraindication

Fig. 19.4  Recommendations on return to play in stenosis of the cervical spinal canal

The suspicion, correct diagnosis, and treat- Contact sports and those with the risk of colli-
ment are the key to avoid permanent lesions and, sions like rugby, football, hockey, and other snow
in some cases, allow the athlete to return to ama- sports expose the athlete to a higher risk of
teur or professional sports practice. Prevention of lesions. The association of a previous condition
lesions must be advised especially for those who of the spine with the practice of a risk sport to
are under risk due to pathological or congenital spine lesion is what should be avoided, or, at
conditions, who are under risk for spine lesions least, the athlete should be warned about the
and for the practice of sports that expose the potentiality of sequels.
spine to dangerous lesions.
The sports medicine physician must be aware Take-Home Messages
of congenital stenosis, congenital intervertebral • Spine injuries are not only related to profes-
instability, congenital spondylolisthesis, disc her- sional sports but also to recreational ones and
niation, spondylosis, degenerative stenosis, pre- can occur during competitions and training.
vious spine surgery, and antecedent spine lesion • The direct trauma and, also, supraphysiologi-
with temporary or definitive neurological sequel cal stress on the spine are the most common
when conducting an initial or periodical evalua- mechanisms of spine injury in sports
tion regarding sports practice (Fig. 19.4). practice.
254 E. Landim et al.

• Although most of these injuries are related to tained in Argentina (1991-1997). Br J Sports Med.
2000;34:94–7.
minor impairment to the athlete, such as lum- 9. McCoy GF, Piggot J, Macafee AL, AdairI V. Injuries
bago, contusion, and paravertebral muscle of the cervical spine in schoolboy rugby football. J
contracture, the sports physician should keep Bone Joint Surg. 1984;66:500–3.
in mind that devastating damage to spinal cord 10. Scher AT. Catastrophic rugby injuries of the spinal
cord: changing patterns of injury. Br J Sports Med.
can occur in cases of high-energy trauma as 1991;25:57–60.
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• The knowledge of sports biomechanics helps chez le rugbyman. Sports Med. 1997;92:36–9.
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AS. Occurrence of cervical spine injuries during the
at higher risk to spinal cord injury and, there- rugby scrum. Am J Sports Med. 1998;26:177–80.
fore, define a more accurate approach to an 13. Warren WL, Baisel JE. On the field evaluation of ath-
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 Part IV
Sports Trauma
 Facial Trauma
20
Sérgio Rocha Piedade, Leonardo Manoel Carvalho,
Luis António Mendes, Milton Possedente,
and Daniel Miranda Ferreira

20.1 Introduction and player-to-player contact. In boxing, tae-

kwondo, karate, and other martial arts, facial
The facial skeleton is made up of 14 bones, which trauma is a common event, while in soccer, rugby,
contain essential structures and sensory organs of and basketball, it is a result of the direct trauma
the body responsible for sight, smell, hearing, taste, from the opponent’s head, elbow, knee, or even
mastication, and teeth and oral cavity. Its bone the ball [2, 3].
architecture is well-organized with vertical and The magnitude of the injury is directed related
horizontal bone walls that allow protection to soft to the trauma mechanism and energy as well as
tissues and resistance against regular external and the type and size of sports material (ball, stick,
internal forces applied to the face. Besides that, it is racquet) involved [4]. In this context, small balls
one of the most vascularized regions in the body, such as those used in squash or baseball concen-
where bleeding is a common clinical event, rein- trate kinetic energy when hitting the human body,
forcing the importance of the use of gloves and potentializing tissue damage [5]. Therefore, the
glasses when approaching these sports injuries. protective equipment plays a vital role in reduc-
In sports, the face is widely exposed and sub- ing the risk of facial injuries in sports. Although
ject to traumas as it is located in the frontal region in some sports modalities the use of a mouth-
of the head [1]. In general, sports involve twisting guard, eye protection, helmets, and headgear is
movements, racing with acceleration and decel- recommended, educational interventions are still
eration, ball launches, direct hits with the ball, needed to raise the athletes’ awareness and moti-
vation of its use [6, 7].
S. R. Piedade (*) Considering that the mechanisms of sports
Department of Orthopedics and Traumatology, State trauma to the face, head, and cervical spine have
University of Campinas—UNICAMP, Exercise and similarities between them, the managing of facial
Sports Medicine, Campinas, SP, Brazil injuries should involve a careful assessment of
e-mail: [email protected]
the head and cervical spine status. This chapter
L. M. Carvalho · L. A. Mendes · M. Possedente aims to discuss and present the most common
State University of Campinas—UNICAMP, Exercise
and Sports Medicine, Campinas, SP, Brazil injuries reported on facial trauma in sports as
e-mail: [email protected]; well as the initial management of these injuries in
[email protected] the field or sports arena, minimizing the occur-
D. M. Ferreira rence of significant injuries, establishing the ade-
Department of Radiology, State University of quate strategy according to the facial injury, and
Campinas—UNICAMP, Exercise and Sports
preventing injury.
Medicine, Campinas, SP, Brazil

© ISAKOS 2019 261

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_20
262 S. R. Piedade et al.

20.2 Facial Trauma Assessment the sports injuries to facial bones, teeth, eyes, and
in Sports ears, separately.

According to the mechanism of sports injury, part

of the trauma energy is absorbed by the cervical 20.3 Facial Bone Fractures
spine or by the head. In such sports (motorcycle
races, MMA), the higher trauma energy could Facial bone fractures may be manifested by
produce substantial soft tissue and bone damage asymmetry, irregularity, instability, and defor-
and critical bleeding and, thus, cause mechanical mity of bone edges detected during the physical
problems to the athlete’s airway, especially when assessment (inspection and palpation).
the athlete presents some neurological deficits or Considering the complex facial bone anatomy,
is in unconsciousness status [8]. CT scanning is the imaging modality of choice as
In the field of play, the initial assessment starts it offers images in tridimensional view of osseous
with airway, breathing, circulation, and disabil- structures and allows to rule out associated inju-
ity, but with particular attention to the need for ries (intracranial injuries), while X-ray can be
prior cervical spine stabilization and neurological inconclusive.
status when managing the facial trauma [9]. In
most instances, the soft tissue bleeding is well-­
controlled by direct pressure with a sterile gauze, 20.4 Orbital Fractures
while ice is directly applied to minimize the tis-
sue edema and swelling when the athlete is Orbital fractures result from direct traumas to the
removed from the field [10]. periorbital regions due to a wrist, or ball, a list, or
In general, minor traumas present no obstacle even player-to-player contact. The floor and the
to the athlete’s prompt return to the game, medial wall of the orbit are less thick and resis-
whereas higher traumas require an accurate clini- tant and, therefore, more prone to fracture.
cal evaluation, making the athlete leave the game. Herniation of the orbit contents could happen
When the athlete is out of the game, the soft tis- through the fracture site causing functional defi-
sue damage can be assessed under adequate light cit resulting in diplopia and loss of ocular motric-
and also under local anesthesia if necessary. Skin ity due to the entrapment of periocular muscles,
lacerations, deep abrasions, areas of active bleed- mainly the rectus muscles. It could also be asso-
ing, or bruising can be well analyzed and ciated with a critical periorbital lesion, edema,
approached, debrided, and sutured under sterile ecchymosis, and crepitus. Paresthesia in the
conditions. This apart, palpation allows precise cheeks may indicate the involvement of the infra-
information of the tissue consistency such as orbital nerve, and a radiological assessment by
edema, hematomas, presence of bone crepitus, or bird-eye plain radiography or CT should be
depression that could suggest a bone fracture and ordered. An often-neglected orientation is that
the need for radiological evaluation (X-rays, CT, these athletes should not blow their nose because
or MRI) [11]. of the risk of nasal content herniation to the orbit
The function of the temporomandibular joint, [12, 13]. An orbital fracture should be promptly
as well as the facial muscle activity, can be evalu- referred to an ophthalmologist’s assessment, par-
ated by asking the athlete to open and close his ticularly in the presence of muscle entrapment or
mouth and eyes actively, where the symmetry of persistent oculocardiac reflex (vomiting, brady-
muscle actions confirms its regular status. cardia, and hypotension).
Considering that the most frequent orofacial The sports medicine physician in youth acad-
lesions are dental ones and lacerations of soft tis- emies (i.e., with children) should be aware of a
sues, the facial assessment involves an oral evalu- rare orbital fracture presentation consisting of a
ation to identify internal and external injuries of greenstick fracture that has spontaneously reduced
the mouth. The following sections will approach but has caused a periorbital muscle entrapment
20  Facial Trauma 263

[14]. The patient may present with no apparent their surroundings, and from falls and from direct
signs of injury, but ocular mobility dysfunction blow. This type of fracture has been decreasing over
and persistent oculocardiac reflex are observed. time due to better preventive measures and equip-
ment. The condyles and mandibular angle are the
most common sites of fractures (Figs.  20.2a and
20.5 Maxillary Fractures 20.4b). Non-displaced fractures can be managed
conservatively with analgesia, and displaced frac-
Maxillary fractures usually result from blunt tures need closed reduction and fixation.
trauma. An accurate reduction of the bone frac-
ture is crucial for both function and facial aes-
thetics re-establishment. Maxillary fractures are 20.7 Nasal Fractures
often accompanied by cranial damage, nasal air-
way obstruction, soft palate edema, hemorrhage The nasal bones are at high risk of injury in any
into the sinuses, disturbance of the orbit contents, sports practice, and they are the most fractured
cerebrospinal fluid rhinorrhea, and reduced sen- facial bones, resulting in a common sequela of
sation in the infraorbital region [15]. Maxillary sports injuries (Fig.  20.3). Clinically, it is often
fractures are classified as Le Fort I, II, and III manifested by heavy bleeding, and, therefore, the
(Fig. 20.1a, b). initial management in the field is controlling the
nasal hemorrhage [10]. In such cases, epistaxis
control or septal hematoma drainage are needed to
20.6 Mandible Fractures avoid nasal obstruction or severe pain. Nasal frac-
tures can often be addressed with closed reduction
Sports-related accidents are the third major cause of techniques if nasal obstruction or ­cosmetic defor-
maxilla and mandible fractures. Fractures can occur mity is present. In the setting of complex nasal
from contact between athletes, between athletes and trauma, an open approach may be indicated.

a b

Fig. 20.1 (a) Axial CT scan. Fracture of the anterior wall arrow) of orbit, with herniation of the intra-orbital fat and
of the maxillary sinus (white arrow). (b) Coronal CT medial rectus and inferior rectus muscles. Two cases
scan—fracture of medial wall (white arrow) and floor (red
264 S. R. Piedade et al.

a b

Fig. 20.2 (a) Coronal CT scan. Bicondylar fracture of the mandible (white arrows) with medial displacement of con-
dyles (asterisk). (b) 3D CT reconstruction. Non-displaced complete fracture of the left mandible angle (red arrow)

20.8 B
 asilar Skull and Temporal
Bone Fractures

These kinds of fractures result from direct trauma

to the occipital skull and temporal bone. According
to the fracture line toward the long axis of the
bone, temporal fractures are classified as longitu-
dinal, transversal, and oblique (Fig. 20.4).
Athletes involved in sports such as motorcy-
cling, skateboarding, and bicycling have at higher
risk than others are [16]. Usually, the most com-
mon symptoms are dizziness, vertigo, loss of
consciousness, hemotympanum, and TM rupture.
Signals of ecchymosis like Battle sign and rac-
coon eye can be present in the clinical evaluation
(Fig. 20.5). This apart, cerebrospinal fluid rhinor-
rhea can also occur from fracture, and there is a
higher risk of meningitis development. High-­
resolution head CT is the gold standard for diag-
nosis. MRI can be useful for defining vascular
damaged.
The treatment depends on the clinical evalu-
Fig. 20.3  Comminuted fracture of the nasal bone (white
arrows), without the involvement of nasal septum (axial ation; if the athlete has a stable neurological
CT scan view) state, an observation can be an option. The
20  Facial Trauma 265

a b c

Fig. 20.4  Temporal bone fractures (axial CT scan view): (a) fracture of squamous portion of temporal bone (white
arrow) and (b, c) fracture of petrous portion of temporal bone (red arrows in magnified image)

Fig. 20.5  Battle sign and raccoon eyes

athlete should be referred to a specialist for Athletes who have sustained a temporal frac-
evaluation and discuss a surgical option In ture must discuss with the surgeon an individu-
cases of brain herniation, intracranial bleeding, alized approach about when to return to play.
hearing loss and persistent cerebrospinal fluid Bearing in mind, the athlete should not return
(CSF) leak for more than two weeks [16]. to sports practice until the fracture has healed.
266 S. R. Piedade et al.

a b

Fig. 20.6 (a,b) Intracranial hematomas

20.9 Intracranial Hematomas 42 countries. Prior dental trauma was reported in

49.6%, and most of these injuries had happened
Facial traumas are often associated with intracra- during training or games (63.5%), where wres-
nial injuries [17]. Epidural hematoma, subdural tling, boxing, and basketball were the sports that
hematoma, subarachnoid hematoma, and intrace- had the highest injury prevalence. The most
rebral hematoma are types of blood collection affected tooth was the upper central incisor, and
inside the skull. Subgaleal hematomas are blood more than 80% of the athletes have reported no
collations in the small parts of the skull use of mouthguard.
(Fig. 20.6a, b).

20.11 Diagnosis
20.10 Tooth Injuries
Trauma to face, jaw, or, even, any part of head or
It should be considered that there is a close rela- neck followed by ecchymosis, bruising, facial
tionship between traumatic tooth injuries and swelling, mouth bleeding, and pain could pres-
sports activity, mainly, in the child and adolescent ent indirect clinical signs, and the presence of
populations where the number of sports practitio- tooth injuries should be carefully investigated.
ners has increased. Tooth injuries are commonly In clinical practice, dental injuries may be pre-
seen in contact sports, comprising falls and colli- sented as dentoalveolar, tooth fracture, displace-
sions. Basketball has shown a considerable tooth ment, or even tooth avulsion and fracture of the
injury rate, because the high speed of the game, alveolar process (Fig. 20.7), which impacts neg-
jumping and landing, and turns which predispose atively on the athletes’ sports activity as it
to the player-to-player collision. Moreover, soc- impairs the oral function. Due to their anatomi-
cer, rugby, wrestling, boxing, and martial arts also cal localization, the superior central incisor
have higher-risk factors of dental injuries. During teeth are commonly affected by sports trauma.
the Pan American Games held in Rio de Janeiro In most instances, a dental surgeon is not avail-
2017 [18], a cross-sectional epidemiological sur- able in the field or sports arena, and therefore,
vey was conducted to evaluate the prevalence of the sports medicine physician should approach
dental trauma in high-performance athletes from these injuries.
20  Facial Trauma 267

Fig. 20.7  Tooth fracture and tooth avulson

s­ ignificantly reduces the frequency and severity

20.12 Managing Tooth Avulsion of orofacial injuries in sports, but their use is not
in the Field or Sports Arena uniform or mandatory in most modalities of
sports. The use of a custom-made oral protector
Tooth avulsion is a critical dental injury where should be encouraged as it ensures a better fit and
the prognosis is strictly related to an adequate comfort, protecting and facilitating speech and
first aid. In these cases, the sports medicine phy- breathing which has a direct impact on the ath-
sician should deal with it following some rules: lete’s sports performance.
The mouthguards are classified as stock
• After making the diagnosis of tooth avulsion mouthguard, mouth-formed protectors, and
and finding the tooth, keep it and mobilize it custom-­made mouthguards.
by its crown avoiding touching the root. Stock mouthguards have the advantages of oral
• When the tooth is dirty, it should be carefully adjustment and low cost, but the disadvantages are
cleaned with cold water. that they work only with closed mouth (there is no
• If possible, the tooth should be repositioned into retention) and could also cause difficulties in
its natural site (alveolar process), with no friction speaking, breathing, and athlete’s concentration.
or resistance during the repositioning attempt. Mouth-formed protectors are prefabricated
• In cases where tooth repositioning is not possi- protectors plasticized in hot water and molded in
ble, the tooth should be stored in a recipient with the mouth by the user. They are commercially
milk or patient’s saliva (dry storage should be available, but their quality and cost vary. Moreover,
avoided), and the dentist’s assessment should be although they are the most used ones, they are not
performed during the first 30 min after trauma. recommended for all sports because they have lit-
tle retention, and there is the possibility of dislodg-
ing during sports activity and airway blockage.
20.13 Prevention Measures Custom-made mouthguards are made accord-
ing to the patient’s personal measurements and
The protective equipment plays a vital role in customized in a dental office, using individual
reducing the risk of facial injuries in sports. In molding. They offer better protection, retention,
this context, an oral protector (mouthguards) comfort, fitting, speaking, and breathing easily
268 S. R. Piedade et al.

sclera In the United States, it is estimated that about

retina 40% of eye injuries admitted to the hospital care
choroid were sports related, and 13% of them were pen-
etrating ocular injuries. The majority (72%) of
fovea these lesions occur in young people under
vitreous chamber 25 years old. The most cited sports involved are
vitreous humor lens cornea
baseball, basketball, hockey, soccer, and racquet
e sports [4, 19–22].
erv
ic n
opt
suspensory ligaments

anterior chamber 20.16 Ocular Evaluation

aqueous humor

Regarding eye trauma, the sports medicine physi-

Fig. 20.8  Schematic drawing of eye anatomy cian should be able to identify and rule out clini-
cal findings and symptoms such as tearing and
ocular fluid drainage, photophobia, blurred
according to the sports. When evaluated in elite vision, diplopia, pain, nausea, scotomas, and
taekwondo athletes, they did not cause negative flashes of light. Therefore, an ophthalmoscope
effects on the aerobic performance capacity. They and a slit lamp should be part of the equipment in
are recommended for the successful prevention of sports medical bags, particularly in sports where
tooth lesions, but their cost is higher. these injuries are commonly seen. Visual acuity
should be checked using the Snellen chart or
written texts, and the visual field status, pupil
20.14 Eye Injuries symmetry and reflex, conjunctiva, cornea, and
eyelids should be examined. Special attention
The eye is composed of three spherical tunics, should be given to the possibility of foreign bod-
fibrous, vascular, and internal (Fig.  20.8). In the ies and any macroscopic evidence of bleeding in
fibrous tunic there is the sclera, which is the exter- the anterior chamber. Whenever a possibility
nal fibrous component of the bulb of the eyes, exists, fluoroscopy should be performed, and, in
responsible for the eyes’ shape and resistance due case of doubtful physical examination or insecu-
to the periocular muscle attachment, while the cor- rity of the professional, the athlete should be
nea is the transparent portion that covers the ante- referred to an ophthalmologist.
rior chamber. The vascular tunic involves the
choroid, ciliary body, and iris. The choroid is a vas-
cular layer that is continuous with the ciliary body, 20.17 Common Ophthalmologic
joining the choroid to the iris and acting on the fixa- Injuries
tion and adjustment of the focus of the lens, where
the iris is positioned anterior to the lens, a contrac- 20.17.1 Eyelid Injuries
tile diaphragm with a central opening, the pupil.
The inner tunic is composed of the retina which is Direct trauma to the ocular region and also indi-
responsible for the luminous stimulus capture. rect trauma by means of a pair of broken glasses
can cause lesions to the eyelids. Closed lesions
should be treated with ice and analgesia, not for-
20.15 Epidemiology getting to rule out possible associated with orbit
fracture [23, 24]. Lacerations of the eyelids
Although eye injuries are relatively rare in sports, should be carefully evaluated, mainly when they
they cannot be neglected because of their poten- occur in the medial region, due to the risk of
tial to cause a significant functional impairment. injury to the lacrimal drainage system [25].
20  Facial Trauma 269

Lesions involving the tear duct, orbital fat expo- due to a foreign body, conjunctival laceration,
sure, and complete lacerations or involving the ocular penetration, and orbital fracture.
margin of the eyelid should be referred to evalua- The presence of associated conjunctival lac-
tion by an ophthalmologist. erations requires the use of topical antibiotics and
an overnight pressure patch. The athlete should
return to training when there is evidence of re-­
20.17.2 F
 oreign Bodies and Corneal epithelization. Lacerations larger than 1 cm may
Injuries need to be sutured by an ophthalmologist.

Foreign bodies are the most common sports-­

related eye injuries. In outdoor sports, the eyes 20.17.4 Hyphema
have a higher risk of damage by exposition to for-
eign bodies produced by dust and debris. The ath- It consists of bleeding in the anterior chamber
lete could present an acute complaint of pain and due to a rupture of iris vessels. Heavy bleeding
sensation of “sand in the eye” associated with can be easily observed at clinical evaluation,
conjunctival hyperemia. The eye should be care- while the slit lamp plays an essential role in
fully evaluated, everting the eyelid to find the for- detecting smaller volumes of blood. The athlete
eign body. Removal can be performed with a should be referred for daily ophthalmological
swab soaked in saline solution. However, if the evaluation, due to needing to monitor intraocular
removal attempt is not successful, the athlete pressure. Anti-inflammatory drugs are not indi-
should be referred to an ophthalmologist [26]. cated, and topical corticosteroid is not efficient
In this context, corneal abrasions are one of [33]. The athlete should not return to sports prac-
the complications of foreign bodies resulting in tice until resolution [34].
pain, photophobia, tearing, and foreign body sen-
sation [27]. An evaluation with cobalt blue light
and fluorescein is recommended to identify the 20.17.5 Traumatic Iris
extent of the injury. The athlete should use a topi-
cal antibiotic and stay away from the sports activ- It is an inflammatory reaction of the anterior
ity until resolution (3–5 days) [28, 29]. Patching chamber that occurs days or weeks after ocular
is currently avoided because it may not improve trauma, manifested by eye pain, photophobia,
healing or reduce pain [30]. and tearing. The use of slit lamp confirms the
diagnosis, but an ophthalmologic evaluation is
recommended. The treatment is done with topical
20.17.3 S
 ubconjunctival Hemorrhage corticosteroids, and return to sports is allowed
and Conjunctival Lacerations when the athlete is asymptomatic.

The onset of this clinical symptom is quite com-

mon after blunt trauma, manifesting as a reddish 20.17.6 Traumatic Iridodialysis
region limited to a white portion of the sclera, not
invading the cornea [31]. When isolated, this is It is the detachment of the iris from the ciliary
not clinically significant; however, if there is no insertion, where small displacements may be
history of trauma, it is prudent to check blood asymptomatic and do not require treatment, while
pressure and investigate a history of excessive larger dialysis could result in monopolar diplopia
bleeding [32]. and photophobia. A flattening of the outer iris cir-
In the presence of subconjunctival hemor- cumference can be observed. An ophthalmologic
rhages, careful inspection of the eyeball should evaluation is mandatory, and surgical correction
be performed to rule out other serious injuries may be necessary [35].
270 S. R. Piedade et al.

20.17.7 Lens Dislocation because these injuries could result in some vital
function impairment to the athlete such as hear-
Blunt trauma can cause tearing of the suspensory ing and balance [39, 40]. The knowledge on its
ligament of the lens. This injury could lead to a par- diagnosis, treatment, and prevention plays a vital
tial dislocation may cause few symptoms or a com- role for the sports medicine physician not only in
plete dislocation into the anterior chamber causing the field of play or sports arena, but also in his
a permanently blurred vision. The complications of office. Therefore, the sports medicine physician
this pathology include secondary glaucoma, retinal should be prepared to manage these injuries,
detachment, cataract, and vision loss. Surgical making a careful clinical evaluation and avoiding
repair is often the treatment of choice [36]. bodily damages.

20.17.8 Retinal Detachment 20.17.11 Anatomy

It can be caused due to trauma to the eye and pos- The ear has three compartments: the external ear
terior trauma to the head or reported by intense involves the pinna, the external auditory canal
Valsalva maneuvers, occurring hours or days after that is responsible for collecting sound, and the
the trauma, manifested by blurred vision, flashes tympanic membrane (or eardrum), which divides
of light, and peripheral vision loss. Clinical causes the external ear and the middle ear.
include diabetes, sickle cell disease, and central Behind the tympanic membrane, the middle ear
retinal vein occlusion, and athletes with significant is in the petrous portion of the temporal bone and
myopia are at higher risk as well as those with a consists of an auditory ossicle (malleus, incus, and
positive family history and prior ocular surgeries. staples) that helps to transmit wave sounds in the
The diagnosis is based on fundoscopy but may be internal ear through the oval window. The internal
inaccurate in the initial setting. The treatment may ear comprises of the cochlea (sensorial hearing)
be conservative or surgical, according to the extent and the labyrinth which is responsible for detect-
of the injury [37], and requires withdrawal from ing linear and angular acceleration.
the sports until ophthalmologic release. Due to these anatomical particularities, tem-
poral bone fractures could produce lacerations
and perforations of the tympanic membrane,
20.17.9 Penetrating Injuries and they could also impair the communication
and Ruptured Globe with the nasopharynx named Eustachian (audi-
tory) tube, which equilizes the environmental
The presence of a flat chamber, black tissue air and medial air, affecting hearing and
exposure on the outer surface of the globe, sub- balance.
conjunctival hemorrhage of the entire globe, or
drainage of gel or fluid may be signs of penetrat-
ing injuries and ruptured globe. In these cases, 20.17.12 Auricular Hematoma
pressure on the eye and removal of penetrating
foreign bodies should be avoided due to the risk Considering that the external ear has thin skin
of eye collapse. The athlete should be urgently and minimal subcutaneous tissue, blunt and
forwarded to the hospital and be seen by an oph- repeated traumas (shearing forces) applied
thalmologist to verify the need for surgery [38]. directly to it could disrupt the connections
between the perichondrium and the cartilage,
causing blood to accumulate in the subperichon-
20.17.10 Ear Injuries dral space and, consequently, resulting in an
auricular hematoma. It is commonly seen in con-
Although ear injuries are not common in sports, tact sports such as judo, jiu-jitsu, wrestling, box-
the sports physician must not be negligent ing, rugby, and even water polo [40].
20  Facial Trauma 271

The most prevalent clinical signs and symp- 1  week, and the athlete should be away from
toms are swelling, pain, and pressure. The best sports practice until the end of the treatment. In
approach for early drainage should be done the literature, prevention is still controversial,
within 1 or 2  days; however, this could also be although swimmers have the best barrier to pro-
possible 1  week later [40, 41]. Return to play tect themselves when they wear a swim cap [39].
after drainage can be immediate, and athletes at
higher risk should wear protector gear to mini-
mize the chance of an auricular hematoma [41]. 20.17.15 T
 ympanic Membrane (TM)
Eventually, chronic swelling could be developed Perforation
in cauliflower ear resulted from new fibrous car-
tilage and necrosis. Barotrauma, acoustic trauma, temporal bone
fracture, and penetrating trauma are possible
causes of tympanic membrane perforation.
20.17.13 Ear Laceration Therefore, this kind of injury is most related to
scuba diving, surfing, boxing, mixed martial arts,
Ear laceration repair may be complicated due to and diving. The athlete can complain of sudden
its thin skin, although the auricle has good blood hearing loss at first, and dizziness, pain, nausea,
supply with low risk of infection. Primary repair and tinnitus can also be associated with it. The
is considered for smaller-than-2  cm laceration, sports medicine physician should be attentive to a
while for bigger-than-3  cm lacerations, a graft Battle sign, a bruise behind the ear, which may
could be necessary to close the wound. occur 2–6  h after injury, indicating a possible
Complications involve chondrites, failure to skull fracture [41] (Fig. 20.4).
cover cartilage with skin and blood loss as a Most times, this lesion heals itself without
result of significant lacerations. intervention. The treatment initially comprises of
Return to play depends on the size of the ear pain management such as dry warm surround-
laceration. Good repair and homeostasis of small ings, and a­nalgesics (e.g., acetaminophen).
lacerations allow a prompt return to sports activ- However, NSAID should be avoided due to a
ity, while massive ear lacerations and avulsions higher risk of intracranial bleeding. To prevent
will need soft tissue healing before returning to further infection, the following measures should
play. Athletes may wear adequate protection to be taken; ear protection when showering, no
minimize the risk of infection [41]. swimming until the tympanic membrane is com-
pletely healed, the wearing of headgear in high
risk sports, and earplugs in certain sports.
20.17.14 Otitis Externa Adopted infection prevention measures are ear
protection when showering, swimming prohibi-
It is the inflammation or infection of the external tion until the complete healing of the tympanic
auditory canal. It could occur due to the disrup- membrane, and wearing of headgear in higher-
tion of the cerumen (the natural first line of canal risk sports and earplugs in sports event such as
protection), water (aquatic) sports, high environ- hunting. In case of a contained wound, ofloxacin
mental temperatures, cotton tip applicators, and otic drops can be used for 3 to 5 days.
foreign objects such as earplugs [40, 41]. An otolaryngologist evaluation should be
Discharged otalgia and otorrhea are common asked in case of:
clinical symptoms. The discharge can be seen in
varying colors between gray to green under an • Hearing loss greater than 40 dB in an audiom-
otoscopic exam. The treatment has the focus on etry testing or subjective decreased perception
external canal hygiene, topical antibiotics, and of speech, marked asymmetry in hearing or
corticosteroid and pain control (NAISD). persisting feelings of ear fullness
Fluoroquinolones and steroids cover most of the • Vestibular symptoms, such as nausea, vomit-
common pathogens. Usually, the treatment lasts ing, nystagmus, and ataxia
272 S. R. Piedade et al.

• Otorrhea been healed. The surgeon should be consulted in

• Rhinorrhea case of postsurgical event (i.e., myringoplasty).
• Facial nerve paralysis/paresis
Take-Home Messages
Swimmers, divers, and surfers cannot return • Knowledge of the dynamics of sports modal-
until the healing of TM, which heals in 4–8 weeks ity is helpful to identify the mechanism of
[40]. If the athlete has a temporal bone fracture or facial trauma and associated injuries.
hearing loss, return to sports practice should be • Airway status, breathing, circulation, and care
individualized. of cervical spine stabilization and neurologi-
cal status comprise the initial assessment to
facial trauma.
20.17.16 D
 iving and Ear Barotrauma • Signs and symptoms for a referral to an
and Eustachian Tube ophthalmologist:
Dysfunction
Altered Hyphema Penetrating Severe
fundoscopy foreign body eye pain
These are the most common complications related Blurred Irregular Perforated Visual
to scuba diving and flying (during descent espe- vision pupil globe field loss
cially) [16, 40–43], where quick changes of the (persistent)
pressure cause ear pain and traumatic injury. Diplopia Laceration Photophobia
medial/ (persistent)
Usually, the pressure between the middle ear and margin
the external environment should be equalized, but eyelid
when the equilibrium is not kept, inflammation and
rupture of the tympanic membrane could occur. • Tooth avulsion is a critical dental injury where
The patient can complain of pain or pressure, the prognosis is strictly related to an adequate
vertigo, tinnitus, and hearing loss, and blood can first aid—“don’t touch the root!”
be observed in the otoscopic evaluation if the • Keep eyes open to indirect signs of basilar
tympanic membrane is perforated. The injury skull and temporal bone fractures such as rac-
classification should be defined toward treatment coon eyes and Battle sign.
and prognosis [43] (Table  20.1). Grade 0 and 1 • Auricular hematoma is best approached for
could be treated with education and medical ther- early drainage within the first 2  days after
apy, for example, an oral or nasal decongestant. trauma.
Grade 2 should be referred to an otolaryngologist • The protective equipment plays a vital role in
for further evaluation. reducing the risk of facial injuries in sports.
When there are symptoms of nasal congestion,
ear infection, or Eustachian tube dysfunction, air
travel and diving should be avoided to prevent ear
barotrauma. The athlete is allowed to return to References
sports practice when the tympanic membrane has
1. Murphy C, O’Connell JE, Kearns G, Stassen
Table 20.1  Classification and clinical findings L.  Sports-related maxillofacial injuries. J Craniofac
Surg. 2015;26(7):2120–3.
Classification Clinical findings 2. Black AM, Eliason PH, Patton DA, Emery
Grade 0 Symptoms with no otologic signs of CA.  Epidemiology of facial injuries in sport. Clin
trauma Sports Med. 2017;36(2):237–55.
Grade 1 Any increased redness of TM when 3. Farrington T, Onambele-Pearson G, Taylor RL, Earl
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 Thoracic
21
Ivan Felizardo Contrera Toro
and Ricardo Kalaf Mussi

21.1 Background tion, circulatory, and hemodynamic status; and

level of consciousness. After initial care and
21.1.1 Sports Activities Related appropriate resuscitation of vital organ functions
to Thoracic Trauma when necessary, a second more detailed survey is
required for planning definitive care. In cases of
Sports-related chest trauma most frequently greater severity, practitioners should be diligent
affects osteomuscular structures of the thoracic and prepared to manage cardiac emergencies
cage, such as rib fractures associated or not with with the use of automated external defibrillators,
flail chest and sternum and fractures of the clavi- subsequently referring the patient to emergency
cle, sternum-clavicular joints, and sternal manu- units with more resources. Hypoxia is the most
brium, aimed at protecting intrathoracic organs important factor in chest injuries. Therefore, this
against more severe injuries. Injuries to structures disturbance should be rapidly identified, provid-
that constitute the thoracic wall may be extremely ing adequate supplementation according to the
painful and lead to morbidity, when not recog- severity and circumstances.
nized and appropriately managed. In blunt high-­ Every medical practitioner or paramedic
energy trauma or even perforating trauma, involved in amateur or professional sports should
intrathoracic structures may be affected. Despite be familiar with the initial evaluation and man-
the lower rate of these injuries, they may lead to agement of the main thoracic occurrences during
fatal outcome. Surgical interventions in blunt sporting activities. It is fundamental to distin-
thoracic trauma are required in less than 10% and guish less severe injuries from those that pose an
in penetrating wounds 15–30%, according to the imminent risk of death, including tension pneu-
ATLS 9th edition. mothorax, open pneumothorax, airway obstruc-
When the event occurs in the prehospital set- tions and injuries, flail chest, blunt cardiac
ting, the athlete sustaining chest injury should be injuries (commotio cordis), cardiac tamponade,
transferred as rapidly as possible to a trauma and massive hemothorax.
referral center where recognition of these injuries Blunt chest trauma in sporting activities occur
should include primarily the mechanism of most frequently during sports on wheels, such as
injury; initial evaluation of the airway, ventila- ice skates, roller skates, bicycles, motorcycles,
and automobiles. Regarding winter sports, skiers,
I. F. C. Toro · R. Kalaf Mussi (*) snowboarders, and particularly ice hockey ath-
Thoracic Surgery Division, State University letes are the most frequently affected.
of Campinas—UNICAMP, Campinas, SP, Brazil
e-mail: [email protected]

© ISAKOS 2019 275

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_21
276 I. F. C. Toro and R. Kalaf Mussi

Sports with more intense individual physical

contact that can cause a higher number of chest
traumas are styles of wrestling, while team sports
that can cause chest trauma include handball,
basketball, football, and rugby.

21.2 C
 lavicle Fractures, Rib
Fractures, and Flail Chest

Rib fractures may occur by forceful impact on

the thoracic wall, such as a blow with a hockey
stick during a hockey game in the grass, or result
from a more generalized anteroposterior com-
pression of the thoracic cage during sudden inter-
ruption of kinetics in a high-speed motor vehicle
accident against a fixed fence. Rib fractures usu-
ally are single events but may be associated with Fig. 21.1  CT scan shows various rib fractures on the
other complicating factors of moderate to high right side of a woman after a fall during horseback riding
risk, such as hemothorax, pneumothorax, and
pulmonary contusion in the acute phase or with nance imaging is the method of choice in injuries
bronchopneumonic processes in the subacute where there is a suspicion of soft tissue injuries.
phase. Blunt chest trauma of the first rib requires
The first three costal cartilages are relatively evaluation with angio-CT of the chest for a better
protected by the scapula, clavicle, and soft parts, investigation of suspected vascular injuries.
while the lower ribs are relatively mobile. Blunt
chest trauma of the first rib in general related to
impact with great kinetic forces may be associ- 21.2.1 Treatment (Stable X Unstable
ated with potentially severe injuries to the subcla- Patient)
vian artery, aorta, and pulmonary parenchyma.
The most common fractures occur from the Analgesia is the main treatment of rib fractures
fourth to ninth ribs as we can in. without other comorbid conditions. In addition to
Anteroposterior compression of the cavity greater comfort, it reduces the time to return to
may cause fracture in the outer middle third of physical and work activities. There are a growing
the chest cavity, while local force applied directly number of articles in the medical literature in the
tends to direct bony fragments inside the thorax last years and various prospective and retrospec-
predisposing to pneumo- and/or hemothorax. tive ongoing clinical studies listed in
Clinical features (and findings): In general, ClinicalTrials.gov evaluating surgical treatment
intense chest pain with local hypersensitivity and in rib fractures. Surgical fixation with plates has
crepitus are the most frequent findings. In cases been recommended in patients sustaining five or
of multiple fractures, chest deformity may occur. more fractures with flail chest, in incomplete
Exams: Chest radiograph should be the initial bone repair, or marked fracture dislocation dur-
imaging test. When clinical findings are very sug- ing thoracotomy. Furthermore, surgery should be
gestive of fracture and the x-ray failed to show considered when three or more fractures occur in
fractures, the specific rib view or ultrasound may patients under mechanical ventilation or there is
be used, exceptionally complemented by com- intense fracture dislocation [3].
puted tomography, which is the gold standard in The clavicle connects the axial skeleton to the
bone injuries (Fig. 21.1). Nuclear magnetic reso- upper extremity. It contributes to movement and
21 Thoracic 277

Table 21.1  Main indications for surgical treatment of

clavicle fractures
Absolute Relative
•  Open fractures • Shortening of clavicle
fracture >1.5 cm
•  Marked angulation •  Comminuted fracture
• Separation with risk of •  Floating shoulder
skin perforation
• Neurovascular • Deviation with
compromise cosmetic compromise
• Partial symptomatic
consolidation

Fig. 21.2  CT scan shows a clavicle fracture in middle

third on the right side

stability of the upper limbs and promotes protec-

tion of underlying neurovascular structures. The
clavicle is the most commonly broken bone, and
fractures occur in up to 15% of both children and
adults [6] and account for up to 10% of all sports-
related fractures.
Sporting activities with or without direct con-
tact between athletes are the main cause of clavicle
fractures, in around 45.3%, and bicycle activities
correspond to 16% of cases and American football Fig. 21.3  CT scan shows a scapular fracture on the right
12% and soccer 6%. The majority of fractures are side of a man after mountain biking fall
located in the middle third (81%) (Fig. 21.2), lat-
eral (17%), and medial (2%). injuries and infection. The most adequate surgi-
Approximately 85% of clavicle fractures that cal technique has still not been well-established.
occur in the pediatric age group are related to The main absolute and relative indications for
sports or recreational activities. Nonsurgical surgical treatment of clavicle fractures are listed
treatment with a sling or figure-of-eight bandage on Table 21.1.
is appropriate for this age group, since it is asso- Complications related to surgical treatment of
ciated with excellent remodeling and bone repair. the clavicle include infection which may range
Several studies have compared surgical and (0–18%) and nonunion (2–15%), neurovascular
nonsurgical treatments in clavicle fractures in injury (0–5%), adhesive capsulitis (0–7%),
adult athletes with significant advantages in early refracture after removal of the plate (0–8%).
return to competitions and a lower rate of refrac- There are various methods for fracture fixa-
ture. Although a moderate reduction in shoulder tion selected by the nature and location of the
function may be well tolerated, early return to injury. For middle-third clavicle fractures, tech-
sports activities even with compromised function niques include plate and intramedullary nail fixa-
is of great importance to athletes. It prevents the tion. Lateral fractures are managed with
loss of training periods for both amateur and pro- techniques that involve acromioclavicular joint
fessional athletes [6]. Nevertheless, it is funda- hooks (ACJ spanning hook), coracoclavicular
mental that patients be aware of the potential suture, and screw fixation [18]. Sternal and scap-
risks of complications, including neurovascular ular fractures (Fig. 21.3) are generally the results
278 I. F. C. Toro and R. Kalaf Mussi

of a direct impact with high kinetic energy, and

its repair occasionally is indicated.

21.2.2 Flail Chest

Flail chest occurs when three or more consecu-

tive ribs are fractured in two or more locations,
creating an independent segment of the chest
wall that moves paradoxically. This may cause
intense acute pain, pulmonary atelectasis, and
alveolar collapse, with repercussions on ventila-
tion and gas exchange. Furthermore, loss of chest
wall integrity predisposes the patient to adult
respiratory distress syndrome, which may require
and/or prolong the need for mechanical ventila-
tion. Mortality rates may range from 20 to 42%. Fig. 21.4  CT scan shows a pulmonary contusion (blue
Conservative treatment is based on effective arrow) and pneumothorax (yellow arrow) of a woman
after fall during horseback riding
analgesia and mechanical ventilatory assistance
to establish chest wall integrity. However, surgi-
cal management with rib fixation has become a hemorrhage, interstitial edema, and alveolar col-
more common option, and a number of system- lapse which may impair respiratory function. It is
atic reviews have described better outcomes [14]. rarely reported in association with sports, but
When isolated, this condition does not result some cases in the literature are related to injuries
in any major ventilatory or oxygenation disorder. in football players.
Definitive treatment is vigorous opioid analgesia Physical examination (look, feel, listen, per-
possibly using epidural blockade, fluidification cuss): Clinical and radiological manifestations
of secretions, and physical therapy. Nevertheless, may occur immediately or later. Typical findings
since it is mostly associated with some degree of are dyspnea, hypoxia, tachypnea, blood-tinged
underlying pulmonary contusion, severe hypoxia sputum, and chest pain. Auscultation may reveal
may occur requiring supplemental oxygen and crackles or reduced breath sounds.
even mechanical ventilation. Volume replace- Exams: The initial exam is the chest radiograph.
ment with crystalloids may aggravate respiratory However, this exam frequently underestimates find-
distress and warrants special attention. ings which may be absent in 10–36% of the cases.
Diagnosis is made by physical examination of Focal or diffuse opacity affecting segments or even
the chest wall associated with adequate chest lobes may develop within 48 h. Computed tomog-
radiograph. raphy of the chest offers a greater sensitivity
(Fig. 21.4), and it is the imaging method of choice
for the evaluation of pulmonary contusion.
21.3 Pulmonary Contusion
and Respiratory Distress
Syndrome 21.3.1 Treatment (Stable X Unstable
Patient)
Clinical features (and findings): It is the most
common complication in blunt force trauma, typ- It depends directly on the extension of the injury.
ically resulting from trauma with elevated kinetic Management in minor sports-related injuries
energy that may occur in motor vehicle accidents most frequently is supportive and includes
and falls. It is characterized by intraparenchymal ­oxygen supplementation, analgesia, pulmonary
21 Thoracic 279

toilet, and judicious administration of endove- Clinical features (and findings): Irrespective
nous fluids to avoid worsening of pulmonary of the mechanism, pneumothorax resulting from
edema that was initially developed. Orotracheal sporting activities must have an adequate initial
intubation with mechanical ventilation may be evaluation since it may progress to situations of
considered in cases of severe hypoxemia greater risk.
PaO2 < 65 mmHg or SaO2 < 90. Diagnosis is commonly made by history and
Complications of pulmonary contusion may physical examination. Dyspnea, chest pain, and
range from pneumonia to adult respiratory dis- tachypnea are the most common clinical findings,
tress syndrome and are related to greater severity eventually associated with subcutaneous emphy-
and mortality higher than 20%. It is worth men- sema. In more severe cases, tachypnea, anxiety,
tioning that pulmonary contusions in athletes and loss of consciousness may occur. Eventually,
occur at a low rate in healthy young individuals traumatic pneumothorax may be asymptomatic
and are usually not associated with mortality. and found on chest radiograph.
We should never underestimate the severity of Physical examination (look, feel, listen, per-
blunt lung injury, since there may be a broad cuss): The most common findings in the physical
range of clinical signs that do not always corre- examination are subcutaneous emphysema, crep-
late with radiologic findings. When a contusion itus, and hyperresonance with fremitus to
occurs without other complications, return to percussion.
activities is usually after 7 days [7]. Exams: Whenever pneumothorax is suspected
in an individual participating in a sporting event
who sustains chest trauma, a chest radiograph
21.4 Pneumothorax should be ordered. In certain cases, small vol-
and/or Hemothorax, umes of pneumothorax may not be seen in the
Pneumomediastinum imaging test with the athlete supine. We should
bear in mind that athletes usually have a greater
21.4.1 Pneumothorax respiratory capacity and the adrenaline surge of
competition that may mask intrathoracic injuries
Pneumothorax is the result of air entry into the for prolonged periods due to minimization of
pleural cavity due to both blunt and penetrating their symptoms.
lung trauma. In sports-related chest trauma, colli-
sions, falls, or frequently both are involved. Three
mechanisms may cause pneumothorax in blunt 21.4.2 Hemothorax
lung trauma: spontaneous, barotrauma, or
mechanical trauma. Pulmonary laceration with Hemothorax in blunt chest trauma generally is
air leak is the most common cause of closed related to contusion and laceration of the paren-
pneumothorax due to rib fracture during sporting chyma and visceral pleura with bleeding into the
activities. Although less frequent, these occur- pleural cavity. Penetrating wounds or multiple rib
rences are more commonly related to contact and fractures may be associated with injuries to the
collision sports such as ice hockey, soccer, rugby, intercostal or internal thoracic arteries. In situa-
and American football. Other sports that involve tions that involve greater kinetic energy, aortic
high kinetic energy such as snowboarding, horse- rupture should be considered. The most common
back riding, or skiing may also be associated site for aortic injuries is the isthmus (90%),
with barotrauma. Barotrauma is more commonly ascending aorta (5–10%), and descending aorta
related to diving and powerlifting. Spontaneous at the level of the diaphragm (1–3%). In practice,
pneumothorax may occur in any circumstance around 50% of cases die at the scene of trauma.
independent of sporting activity, but there are In general, these emergencies are related to sports
reports in athletes during racing, tennis, golf, with high kinetic energy and also after falls from
cycling, wrestling, and rowing [11, 22]. considerable heights. When aortic rupture is
280 I. F. C. Toro and R. Kalaf Mussi

s­ uspected during clinical examination, diagnostic and consequently leading to obstructive circula-
confirmation should be obtained by angiotomog- tory shock. This condition is characterized by the
raphy of the chest and immediate surgery [19]. presence of some or all of the following signs or
symptoms: chest pain, respiratory distress, tachy-
cardia, hypotension, tracheal deviation contralat-
21.4.3 Treatment (Stable X Unstable eral to the injured site, absence of vesicular
Patient) murmur, thoracic hyperinflation without move-
ment, neck distension, and cyanosis. Signs of ten-
In the majority of cases, pneumothorax and sion pneumothorax must be differentiated from
hemothorax are present simultaneously and in cardiac tamponade, since the latter does not pres-
distinct volumes in patients with blunt thoracic ent with tracheal deviation, absence of vesicular
trauma. Management in blunt trauma is based on murmur, and hyperresonance to percussion.
the magnitude of its components, in addition to This condition causes imminent death risk and
clinical and hemodynamic aspects. should be treated immediately with cavity
In cases of hemodynamically stable patients decompression by a large-bore needle of suffi-
without respiratory distress, conservative man- cient length (e.g., >8 cm) to reach the pleural cav-
agement may be adopted in the presence of a ity. Initial management (needle decompression)
small volume of hemothorax and/or pneumotho- is followed by chest tube drainage at the nipple
rax. It is worth mentioning that when conserva- level in the midaxillary line.
tive treatment is the option, periodic clinical and Open pneumothorax is a condition in which
radiologic observation is mandatory until dis- there was a significant loss of tissue with a great
charge from outpatient facility. defect in the thoracic wall that causes increased
In moderate or large volumes of hemothorax intrathoracic pressure to levels of atmospheric
or pneumothorax, hemodynamic instability, or pressure. If the defect of the thoracic wall is
respiratory distress, underwater seal tube chest greater than or equal to 2/3 of the diameter of the
drainage is indicated at the level of the nipple trachea, the air passes inside the cavity causing
region (fifth intercostal space) in the midaxillary pulmonary collapse with ventilatory compro-
line using a 36 or 38 French chest tube. mise, resulting in hypoxia and hypercapnia.
After chest drainage, initial blood loss that is Initial treatment consists of sterile dressing (plas-
higher than 1500 mL of blood or 1/3 or more of tic or gauze) that is applied to occlude the entire
total blood volume of the patient or even a vol- extension of the chest wall defect. Three of the four
ume lower than 1.5 L but blood loss of more than angles must be fixed as a flap valve system to allow
200  mL/h for a period of 2–4  h characterizes air to escape from the cavity through a free angle
massive hemothorax. In these cases, rigorous during expiration. Meanwhile, during inspiration,
attention is required with volume replacement the dressing will provide occlusion and not allow air
and use of autotransfusion, when possible. These to enter the thoracic cavity. Immediately afterward, a
patients usually sustain injuries to systemic or conventional chest tube drainage is performed until
hilar vessels. Exploratory thoracotomy is indi- the defect in the thoracic wall is adequately cor-
cated for effective bleeding control. rected and also to prevent tension pneumothorax
Tension pneumothorax is a condition in determined by the occlusive dressing.
which lung injury may cause airflow into the pleu-
ral cavity. In addition to causing pneumothorax,
this flow may lead to total collapse of the homo- 21.5 Tracheobronchial Rupture
lateral lung. Continuous airflow without adequate
drainage may progress to a condition of elevated Main causes of airway injuries in sports are
intrathoracic pressure, shifting the mediastinum related to automobile accidents and sports that
to the contralateral side, reducing venous return, involve intense physical contact or high velocity
21 Thoracic 281

with the possibility of abrupt thoracic compres- 21.5.1 Treatment (Stable X Unstable
sion, such as skiing, skating, car racing, cycling, Patient)
etc. Other sports where darts, weights, and discs
are thrown may be a risk for third parties (refer- Initial treatment goal is to maintain life, primarily
ees, aides, assistants, or the public) who are not with oxygen supplementation and general mea-
minimally protected against these objects. sures [17]. Chest drainage is mandatory in cases
Professionals involved with the health and of pneumothorax, in an attempt to expand the
well-being of athletes must understand the mean- lung, increasing areas of gas exchange. However,
ing and potential severity of this type of injury, adequate lung expansion may not occur due to
particularly to the larynx and trachea, since these the size of the injury to the tracheobronchial tree,
are potentially major causes of death in trauma and sometimes more than one chest tube is
(80% at the scene of the accident) [1]. Early diag- necessary.
nosis may ensure effective management in these When immediate obstruction is present, a
potentially fatal cases and reduce late complica- fiber-optic bronchoscope is the gold standard for
tions. The majority of tracheobronchial injuries intubation (Fig.  21.5) [17]. Cricothyroidostomy
occur inside the thorax and most commonly in is rarely indicated, since the injury may be located
the distal third of the trachea. below the tip of the cannula. When necessary, tra-
Three mechanisms are responsible for tra- cheostomy should be performed at the site of the
cheothoracic trauma: (1) anteroposterior com- hissing wound in the trachea, if existent.
pression of the thoracic cavity and/or neck, (2) Definitive procedures for specific injuries may
deceleration or abrupt acceleration, and (3) vary from clinical observation to surgical repair
increased intrathoracic pressure with closed of the injury, mobilization, and/or resection of
vocal cords [17, 20]. segments, lobes, or even the lung, in cases of
Clinical features (and findings): The main injury to the main bronchus without the possibil-
physical signs of airway injury are respiratory ity of correction of the injuries and/or even
failure, hoarseness, cervical crepitus, increased ­application of ortheses for variable periods of
neck diameter, and subcutaneous emphysema. time [15, 17, 21].
All patients with these symptoms must undergo
bronchofibroscopy or CT with virtual bronchos-
copy [15, 16]. Over time small lesions may lead
to mediastinal infection or stricture of the tra-
chea/affected bronchus [21]. Signs that may sug-
gest greater severity include progressive edema,
audible stridor with hemoptysis, dyspnea with
change in position of the ictus cordis (tension
pneumothorax), and hypoxia with a significant
decrease in oxygen saturation. In a patient with
tube drainage, escape of a large amount of air,
without lung expansion, should alert to the pos-
sibility of injury to the trachea and/or bronchus.
Whenever possible, diagnostic confirmation is
obtained by bronchoscopy.
Due to the severity of the injuries, the majority
Fig. 21.5  Injury to the trachea with total separation from
of cases die at the scene of the accident, and diag-
the larynx and inside orotracheal tube (blue arrow) (cour-
nosis is confirmed at autopsy. tesy Fraga, G)
282 I. F. C. Toro and R. Kalaf Mussi

21.5.2 Prevention Traumatic injury to the aorta occurs mainly

(63%) in the aortic isthmus (Fig. 21.8), at 1 cm
Improvement in protective gear in sports that below the site where the left subclavian artery
generate high kinetic velocity, such as cervical exits and the aorta remains fixed at the ligamen-
protectors, safety belts, and chest protection tum arteriosum. Injuries to the ascending or low
shirts, may reduce the chance of injuries. Other descending aorta are usually caused by bone
effective measures to decrease the risk of tra- fractures, primarily of the ribs or vertebrae.
cheobronchial injuries might improve isolation All sports involved with the mechanism of
of areas of potential risk in sports where darts, velocity and abrupt deceleration may cause com-
discs, and weights are thrown, etc. However, only plete or partial rupture of the aorta. Automobile
training paramedical and medical teams to sus- racing, motorcycling, cycling, horseback riding,
pect and identify possible victims of these inju- mountaineering, parachute jumping, skiing
ries can reduce sequelae and mortality [5]. (water or snow), jet skiing, snowboarding, and
pole vaulting are the main examples. In pole
vaulting, injury may occur when the athlete falls
21.6 Blunt Aortic Injury outside the protector landing mat.
The mechanism of injury is linked to stretch-
In all accidents with blunt chest trauma, around ing and torsion of the aorta in the zone of the isth-
1/6 are caused by aortic rupture. Calculating all mus, due to movement of the heart and ascending
deaths from accidents involving vascular injury, aorta, in addition to a phenomenon termed “water
aortic injury accounts for 90%. hammer effect.” This effect results from increased
The mechanism of trauma in this type of injury hydrostatic pressure in blood vessels, due to tho-
was first described in 1557 by Andres Vesalius racic compression. The aortic arch is elevated
while studying the autopsy of an individual with with partial obstruction of the descending aorta at
sudden death after falling from a horse. the passage of the diaphragmatic hiatus, increas-
With a high mortality at the scene of the acci- ing pressure dramatically and producing fluid
dent, survivors can also die after hospital admission, pressure waves.
if aortic injury is not immediately recognized and Clinical features (and findings): To reduce
investigated. Hospital death is due to rupture of the mortality due to this injury, all accidents involv-
pseudoaneurysm, formed when bleeding is con- ing blunt chest trauma which are related to accel-
tained by the thoracic fascia and pleura (Fig. 21.6). eration and deceleration must arouse suspicion
and be investigated.
There are no specific signs and symptoms.
However, interscapular pain, dyspnea, and
hoarseness (injury to the left recurrent nerve that
bypasses the aortic arch) may occur. It is impor-
tant to bear in mind that the majority of patients
sustain other associated injuries, e.g., cranioce-
phalic, chest, or pelvic fractures, etc., which may
mask symptoms.
Physical examination (look, feel, listen, per-
cuss): On physical examination, the imprint of
the steering wheel or sports-related object on the
chest, heart murmurs that were nonexistent,
interscapular murmur, extensive hemothorax,
progressive supraclavicular hematoma, absence
Fig. 21.6  Complete injury to the aorta. Note two stumps
of retracted aorta (yellow arrows) and a large hematoma in of left radial pulse, and paraplegia are alert signs
the mediastinum (blue arrow) (courtesy Fraga, G) for aortic injury.
21 Thoracic 283

Fig. 21.8 Aneurysm in the isthmus region (courtesy

Fig. 21.7  Mediastinal widening (yellow arrow) (cour- Menezes, F)
tesy Fraga, G)

21.6.2 Aortography
Exams: Imaging tests are crucial for diagnos-
tic confirmation and assist in the search for other Although it is not the gold standard for definition
concomitant injuries [10]. The main imaging of aortic injury, aortography with catheter inser-
methods that may aide in the diagnosis of aortic tion through the femoral artery has lost ground
rupture are discussed, as follows: for multichannel CT.  The technique has a mor-
Plain AP x-ray: The x-ray is part of standardized bidity rate of 1% and mortality rate of 0.003%,
care in the chest trauma patient and is performed in which are much higher than those for CT scan. It
the emergency room. It has a good sensitivity (62– is a more expensive imaging test. However, in
90%) but low specificity. The main signs are medi- large centers it permits endovascular intervention
astinal widening (Fig. 21.7), blurring of the aortic (Fig. 21.8) with placement of prostheses and may
knob, tracheal deviation to the right, left apical sometimes substitute for open surgery, which has
hematoma, elevation of the left main bronchus, and higher morbidity and mortality rates [16].
extensive pleural effusion. All these signs are non- Transesophageal echocardiogram: The use of
specific and must be confirmed by other diagnostic transesophageal echocardiogram (TE) has lim-
methods. It is important to bear in mind that up to ited indication in some unstable patients with
7% of patients that sustain aortic injury may have a suspected aortic injury on chest radiograph who
normal plain chest x-ray [8]. should not be transported to the Radiology
Division. Another indication is due to the current
worldwide epidemic of obesity. It may be indi-
21.6.1 Computed Tomography cated in the morbidly obese patient who may not
fit into a conventional tomography scanner [16].
CT is currently the most widely used imaging test Assessment at the bedside, it takes advantage
for the diagnosis of mediastinal trauma, such as of the proximity of the esophagus to the aorta at
injury to the aorta. The new generation multi- the area of highest incidence of injuries. It has a
channel CT technology through vascular recon- sensitivity of 86% and specificity of 92% and
struction can locate the injury in a matter of permits detection and location of the lesion. The
minutes. Its sensitivity and negative predictive method is operator-dependent and requires a
value are nearly 100% [8]. Helicoidal CT, more trained team both in TE and trauma.
simple and rapid, with less contrast injection and There are some blind spots in TE, the area of
lower renal damage than arteriography, is the the aorta close to the carina, distal aorta, and
method of choice for rapid diagnosis and surgical branches of the aortic arch, where injuries occur
intervention in the majority of cases. in less than 10% of cases.
284 I. F. C. Toro and R. Kalaf Mussi

The main contraindications are patients with

severe craniofacial injuries and esophageal injury
due to trauma.

21.6.3 Nuclear Magnetic Resonance

Imaging

It has a role only in chronic injuries and is not

applied in the acute patient with a suspicion of
aortic lesion close to the site of traumatic injury.
Patient access to MRI is limited; the technique is
time-consuming and requires total immobility of
the patient. On initial evaluation, it has no advan- Fig. 21.9  Placement of endovascular stent during sur-
tages over computed tomography [16]. gery (courtesy Menezes, F)

change in ventilation is not necessary. Occlusion

21.6.4 Treatment (Stable X Unstable of the aorta does not occur, decreasing neurologic
Patient) injuries due to spinal ischemia and renal injuries.
Traditional surgical technique is reserved for
Although it may seem clear that aortic injury some special situations. Normally, a heart-lung
always requires correction, this is not always pos- machine is required to establish cardiopulmonary
sible or recommended. bypass and decrease the morbidity of the
Patients with minor injuries, without large procedure.
hematomas or more severe hemorrhage, should
be controlled with medication using beta-­
blockers and hypotensive agents. Treatment goal 21.6.5 Differential Diagnosis
is to decrease tension at the site of injury, main-
taining maximum arterial pressure of 100 mmHg Differential diagnosis includes trauma to other
and heart rate of 80 bpm. thoracic organs, e.g., the thyme, heart, and esoph-
Surgery should also be avoided in patients sus- agus. Aortic lesion may also be minimized in
taining other severe associated injuries such as massive hemothorax caused by pulmonary lacer-
severe traumatic brain injury, massive burns, pul- ation or rupture of vessels such as pulmonary
monary contusion with the impossibility of total artery and vein, left hemi-azygos, and splenic
pulmonary collapse during surgery, coagulopathy, rupture with injury to the diaphragm.
and lack of an experienced surgical team.
In surgical patients sustaining major abdomi-
nal bleeding with a stable aorta, it is recom- 21.6.6 Prevention
mended to perform abdominal surgery for
damage, followed by thoracotomy or placement Preventive factors are those that can decrease
of vascular endoprosthesis. chest trauma but primarily reduce abrupt deceler-
Endovascular surgery, also called minimally ation. Limiting the speed of sports on wheels, ski
invasive corrective technique, has grown substan- circuits with less ramps, and use of clothes that
tially (Fig.  21.9). When possible, it is currently can help absorb impact may play a relevant role.
the treatment of choice for aortic injuries. With It is necessary to mention that in prehospital
stent placement through an artery (mostly the treatment of a patient suspected of aortic injury,
femoral artery), blood loss is minimum, and a the use of antishock pneumatic equipment is
21 Thoracic 285

c­ontraindicated, due to increase in peripheral Chest CT scan is helpful particularly in altera-

vascular resistance and tension of the aortic wall. tions of the myocardial wall and in pericardial
effusion.

21.7 B
 lunt Myocardial Injury:
Commotio Cordis 21.7.1 Treatment (Stable X
Unstable Patient)
Myocardial contusion may be defined as impact
on the precordial region, with momentary In the majority of cases, treatment is clinical,
decrease in the anteroposterior diameter, which with control of heart rate and rhythm. Even
can lead to the formation of hematoma of the car- patients without any apparent injury on echocar-
diac wall until valvular rupture due to increased diogram must be monitored, since arrhythmia
pressure. may appear during the first 24 h.
Three mechanisms have been described for Administration of antiarrhythmic drugs and
this type of injury: direct injury with a bony frag- maintenance of homeostasis are necessary in
ment (sternum or rib), compression of the heart patients with symptomatic ventricular premature
full of blood, and increased pressure in the car- beats or those at risk of ventricular fibrillation.
diac chambers due to abdominal compression Treatment is very similar to that of acute myo-
with a closed glottis [2]. cardial infarction. Absolute rest is required, in an
The presence of heart disease, especially one attempt to decrease cardiac work.
that progresses with increasing size of the heart, In cases of rupture of the cardiac valves or sep-
may predispose to contusion. Cardiac contusion is tum, the clinical picture is dramatic, and interven-
most prevalent in sports related to wrestling, with tion of the cardiac surgeon is often necessary [9].
punches and kicks, high-velocity sports that may
cause direct trauma to the sternum, and falls [9].
Autopsy findings ranged from petechiae and 21.7.2 Prevention
hematomas to myocardial rupture with pericar-
dial tamponade. Prevention is similar to that of chest trauma in
Clinical features (and findings): Minor inju- general: decrease the velocity of sports on wheels
ries may remain undetected, and the only symp- or skis, use of protective gear to reduce trauma,
tom is cardiac arrhythmia, initiated by extranodal training of medical and paramedical teams in the
focus. In more severe cases, the clinical picture identification of cardiac contusion risk.
may simulate myocardial infarction. Patients
have continuous precordial pain with or without
irradiation. Ventricular arrhythmia and even sud- 21.8 Commotio Cordis
den death may occur [9].
Exams: The electrocardiogram is mandatory Commotio cordis is ventricular fibrillation that
for identification of myocardial ischemic zones may or not be followed by sudden death due to
and characterization of arrhythmia. cardiac arrhythmia produced by impact of an
Cardiac enzymes are normally altered, and the object against the left side of the chest, without
CK-MB curve should be measured. the occurrence of rib fracture or fracture of the
Transthoracic echocardiogram and/or trans- sternum and without direct heart damage [13].
esophageal is of great help and may show the This condition should not be confused with
location and size of the injuries, repercussions on cardiac contusions resulting from accidental
the cardiac chambers, and presence or absence of bone injury with bony fragments that damage
blood in the pericardium. the heart.
286 I. F. C. Toro and R. Kalaf Mussi

Known ever since the first reports of Chinese 21.9 Traumatic Diaphragmatic
martial arts technique, in which a blow to the left Hernia
side of the chest led to death, the first reports in
the literature emerged in the nineteenth century. Diaphragmatic injuries are uncommon and occur
It is a rare disorder. However, it is widely pub- in approximately 3% of patients with thoracoab-
licized since it affects healthy amateur or profes- dominal trauma. Usually, these injuries do not
sional athletes, without any previous heart cause acute morbidity in trauma patients and are
disease. frequently missed clinically. However, they are
The majority of victims are men (95%) and important to recognize due to the potential for
young (only 9% over age 25  years) and 75% late adverse outcomes related to hernia
occur during professional (50%) or amateur formation.
(25%) games [12]. Traumatic diaphragmatic injuries may be pen-
Most have been reported with sports that use etrating or blunt, depending on the causal factor
blunt projectiles such as balls or discs (baseball, and sporting activity. Nevertheless, it has a rela-
hockey, and lacrosse) or intense physical contact tively low rate in athletes in particular.
(American football, soccer, and hockey). Spontaneous ruptures have also been reported in
Mechanism: despite an apparent traumatic the literature and are caused by a sudden increase
cause, cardiac arrest is due to an electrical event in abdominal pressure resulting from a pressure
translated as ventricular fibrillation that occurs gradient between abdominal and thoracic pres-
immediately after impact on the left thorax. In sure through the diaphragm in very extenuating
experimental studies, several critical events must physical activities. Previous congenital lesions
occur to promote commotio cordis [13]. Two obviously cannot be ruled out in these cases.
major events are (1) location of the crash in the In general, in penetrating injuries there is early
left anterior region, in the area corresponding to suspicion and diagnosis. Nevertheless, blunt
the heart, and (2) it should occur at the peak of trauma lesions may go undetected in 10–20% of
the T wave, an event that lasts 10–20 ms [12]. cases, due to difficulty in interpretation (as in
Clinical picture and therapy: the clinical pic- cases of acute gastric dilatation after trauma,
ture is cardiac arrest with circulatory collapse. hemopneumothorax, and subpulmonary hema-
Patient outcome depends on promptness of toma) making differentiation very difficult even
resuscitation with the use of defibrillators. The with the use of computed tomography. Lesions
success rate of CPR performed within 3 min of may appear later as radiological findings or clini-
cardiac arrest was 25%. In contrast, the success cal manifestations related to alterations in intesti-
rate in CPR initiated after 3 min was 3%. Ten to nal transit time or indirect manifestations due to
15% of patients will live and receive hospital compression of the lung parenchyma. There is a
discharge [13]. greater incidence of left-sided blunt trauma,
Prevention: The use of protective gear for the probably due to the obliterative or protective
left thoracic region is necessary, particularly in effect of the liver.
young individuals aged 25 or less who participate Upon diagnostic suspicion of left-sided injury
in the sports mentioned above [4]. Among the which occurs in up to 90% of cases, a nasogastric
protective measures are the use of softer balls in tube should be inserted. When the tube appears in
softball and baseball, chest protectors in contact the thoracic cavity after radiographic control,
sports and sports with projectiles, and presence there is no need for more complex contrast-­
of automated defibrillators wherever sports are enhanced imaging techniques.
played with training of technicians and other staff When suspicion still remains and imaging
members [13]. These measures may contribute to tests are not fully elucidative, invasive diagnostic
a decrease in cases and increase in survival of procedures may be required, including laparos-
patients affected by this fatality [12]. copy or thoracoscopy.
21 Thoracic 287

When acute injury has been identified, the tion in cardiac tamponade (paradoxical venous
abdominal approach for repair of the lesion is pressure).
preferable. When it is a chronic lesion due to a In massive pericardial effusions, T-wave
number of adhesions in thoracic structures, a tho- inversion may occur in the electrocardiogram.
racic approach is recommended. When there is a large intrapericardial volume,
Direct repair of the lesions with primary suture generally above 200 mL, an enlarged cardiac sil-
is the best option whenever possible. In more houette is detected on chest x-ray. Echocardiogram
chronic situations, the use of prosthetic materials has a diagnostic accuracy of up to 90–95%.
may be necessary for adequate closure of the After diagnostic confirmation, provided the
rupture. patient fails to respond to usual resuscitative
measures for hemorrhagic shock, a procedure for
adequate drainage of the pericardial content is
21.9.1 Cardiac Tamponade necessary. Subxiphoid pericardiocentesis guided
or not by echocardiography with aspiration of
Cardiac trauma is identified in less than 10% of content should be the alternative in patients with
all trauma admissions. Due to its anterior posi- severe hemodynamic instability, allowing relief
tion, the right ventricle is most easily affected, until pericardiotomy via thoracotomy is available
while the left atrium is less frequently affected. in a surgical theater for adequate evacuation of
More than 90% of cases occur in sports that blood and blood clots and effective repair of the
involve great kinetic energy and high-speed cardiac or vascular lesion.
events, including car racing and motorcycle
sports. Among winter sports, there is a high risk Take-Home Messages
for cardiac trauma in skiing and snowboarding. • Thoracic trauma most often involves bone
Cardiac tamponade is a medical emergency structures.
that is more commonly related to perforating car- • It needs an initial judicious evaluation due to
diac lesions. It is extremely rare as a result of more serious or life-threatening intrathoracic
blunt trauma and may be caused by direct injuries traumatic lesions.
to the heart, great vessels of the base of the heart, • After initial evaluation and clinical stabiliza-
or pericardial vessels. tion, the patient should be removed as soon as
Clinical course may be insidious in onset and possible to a trauma center for specific
slow or present rapid hemodynamic deteriora- advanced radiologic exams and definitive
tion. Cardiac tamponade occurs when localized therapy.
or distributed intrapericardial collection elevates
pressure inside the pericardium causing hemody-
namic impact due to restricted filling of the car-
diac chambers.
References
The three principal features of cardiac tam- 1. Al-Koudmani I, Darwish B, Al-Kateb K, Taifour
ponade (Beck’s triad) may be clinically observed: Y. Chest trauma experience over eleven-year period at
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rial blood pressure, and (3) muffling of heart a retrospective review of 888 cases. J Cardiothorac
Surg. 2012;7:35.
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 Abdomen
22
Rui Pedro Borlido Escaleira

22.1 Evaluation of the Athlete with peritonitis, and retroperitoneal bleeding or

with Abdominal Trauma: bleeding from the bony pelvis may compromise
An Overview the outcome if not diagnosed early. In the classic
study of trauma centers versus non-trauma cen-
Concerning trauma, athletes and coaches are ters in California published in 1979, West et al.
extremely focused on those injuries that may demonstrated that the majority of preventable
compromise their performance and career, and deaths resulted from unrecognized, and therefore
therefore musculoskeletal/extremity trauma is untreated, intra-abdominal hemorrhage [2].
subjectively assumed to be their principal con- According to Advanced Trauma Life Support
cern. This reality can seriously affect their per- (ATLS®) program of the American College of
ception of other symptoms and signs related to Surgeons [3], when we face an injured athlete, we
trauma, distracting them and the sports physician must proceed to a primary systematic evaluation of
that is proceeding to the primary survey from the, airway (A), breathing (B), circulation (C), dis-
eventual abdominal trauma, which elevates the ability (D), and exposure (E) in a timely fashion
possibility of misdiagnosing rare but serious (primary survey) and early identify and treat if pos-
abdominal potentially life-threatening injuries. sible (in the sideline or in the track) the life-threat-
Although abdominal muscle strains and con- ening injuries. Even if we cannot treat the injuries
tusions are the most common sports injuries and promptly, their early recognition, report, and trans-
can be treated conservatively [1], abdominal fer to the emergency team in the hospital setting
trauma evaluation can be challenging and is have a significant impact on the outcome [3–5].
extremely important in the sports trauma sce- Concerning to abdominal trauma, the early
nario, especially when significant kinetic energy assessment of “circulation” in the primary survey
is transferred to the torso from a direct blow, is mandatory because of the possibility of hemor-
deceleration, or penetration injury. rhage in the abdomen and pelvis in any athlete
Unrecognized abdominal and pelvic injuries who has sustained blunt trauma (more common
continue to be a cause of preventable death. in the sports setting) or victim of penetrating
Intraperitoneal bleeding from a solid organ or a torso wounds between the nipple and perineum
mesenteric laceration, a hollow viscus rupture (less common).
In most cases, the sports medicine physician is
R. P. B. Escaleira (*) the first health-care provider to arrive at the
General Surgery Department, Hospital de Santa trauma scene, and the first survey will be of his
Luzia—Alto Minho Health Care Unit, responsibility.
Viana do Castelo, Portugal

© ISAKOS 2019 289

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_22
290 R. P. B. Escaleira

There are some questions the sports medicine solid organs as the anterior, inferior, and supe-
physician may ask, and we will try to answer in rior face of the liver and the spleen.
this chapter: Problems occurring inside this cavity are
mostly associated with blunt or penetrating
1. When to suspect of abdominal trauma trauma to the anterior abdomen which is defined
injury? topographically as the area between the costal
2. Which is the initial diagnostic workflow in margins superiorly, the inguinal ligaments and
the evaluation of the athlete with abdomi- the symphysis pubis inferiorly, and the anterior
nal trauma? axillary lines laterally. It is also important to
3. Which athletes can immediately return to know that trauma involving the thoracoabdomi-
play and which athletes should be removed nal transition area (inferiorly to the trans-nipple
and transferred for further evaluation? line anteriorly) may be associated with rib frac-
4. Which diagnostic techniques are used in tures, lung and pleura lesions, and concomitant
patients with abdominal trauma? lesion of abdominal organs as the spleen (left
5. Although there are some issues regarding
subcostal area), liver (right subcostal area),
abdominal trauma that are very specific and stomach (epigastric area), and diaphragm.
from the responsibility of the trauma surgeon/ 2. The retroperitoneal space, where we can find
general surgeon and therefore will not be dis- most of the duodenum, pancreas, kidneys, and
cussed here, it is important for the sports med- ureters, the posterior aspects of the ascending
icine physician to have an overview of the and descending colon, abdominal aorta, infe-
principal blunt traumatic abdominal inju- rior vena cava, and the retroperitoneal compo-
ries, their appropriate treatment, as well as nents of the pelvic cavity.
particular concerns regarding return to Problems occurring in this space are usu-
play. ally associated with blunt or penetrating
trauma to the flank (the area between the ante-
All these issues will be discussed in this rior and posterior axillary lines from the sixth
chapter. intercostal space to the iliac crest) and to the
back (the area located posterior to the poste-
rior axillary lines from the tip of the scapula to
22.2 When to Suspect the iliac crests).
of Abdominal Trauma Injury? Chance fractures, especially in thoraco-
lumbar spine vertebra, may also be associated
To answer this question, it is important to inte- with retroperitoneal and abdominal visceral
grate the basic knowledge of the anatomy of the injuries.
abdomen, mechanism of injury, and physical As we will see later in this chapter, it is
examination of the patient. usually difficult to diagnose injuries in the ret-
roperitoneal visceral structures earlier. The
physical examination of this area has low sen-
22.2.1 Anatomy of the Abdomen sibility and specificity.
3 . The pelvic cavity is the most caudal portion of
For practical purposes as it has implications in the both peritoneal and retroperitoneal spaces and
diagnosis and treatment strategy, it is essential to is structurally dependent on the pelvic bones. It
define three abdominopelvic compartments. contains the iliac vessels, rectum, bladder, and
the internal reproductive organs in the female.
1. The peritoneal cavity that contains the If we suspect of pelvic fractures, we must
majority of the hollow viscus (distal esopha- always exclude injury of vascular, intestinal,
gus, stomach, the first portion of the duode- and genitourinary structures. Misdiagnosis
num, jejunum, ileum, transverse colon) and evolving those injuries may be problematic.
22 Abdomen 291

22.2.2 Mechanism of Injury injuries to solid and hollow organs complicated

with secondary hemorrhage, contamination with
Abdominal trauma can be divided into blunt and visceral contents, and associated peritonitis.
penetrating subtypes. Differentiating into blunt Shearing injuries are a form of crushing inju-
or penetrating trauma has practical implications ries that can be associated with acceleration/
in the diagnosis and treatment [3]. Understanding deceleration injuries in which there is a differ-
the subjacent mechanism facilitates the interpre- ential movement of fixed and nonfixed segments
tation of the initial evaluation and the stratifica- and parts of the body. Lacerations of the spleen
tion of trauma severity because it directs the and liver, at the sites of their fixed supporting
identification of the potential injuries. Globally, ligaments, and bucket handle injuries to the small
blunt trauma is the cause of more than 80% of bowel (a type of mesenteric injury) are examples.
abdominal injuries, whereas penetrating injuries The spleen is the most frequently injured
account for approximately 20% [6, 7]. Concerning abdominal organ in sports and the most common
sports injuries related to abdominal trauma, blunt cause of death due to blunt abdominal trauma
trauma is even more frequent. Although the phys- among athletes [12], followed by the liver and
ical examination is fundamental in the initial small bowel with less incidence. Retroperitoneal
evaluation of these patients, in the case of blunt hematomas must also be considered although
trauma, the definition of the volume, localization, their presentation is less conspicuous.
and extension of injury is more difficult when It is important to remember that pilot restraint
compared to penetrating trauma and is thus asso- (in the case of motorized sports) can themselves
ciated with higher morbidity and mortality due to cause blunt trauma to the liver, duodenum, and
delays in the diagnosis. Some studies have shown pancreas, and rib fractures can cause direct dam-
the sensitivity of physical examination in the age to the liver or spleen.
range of only 55–65% in the setting of blunt
abdominal trauma [8–10], and up to 20% of 22.2.2.2 Penetrating Trauma
patients with hemoperitoneum may not manifest This type of trauma is rare in a sports setting.
peritoneal signs [11]. These data support the Stab wounds transfer less kinetic energy to the
importance of a good description of the trauma surrounding tissues and cause damage by lacerat-
mechanism before starting the primary survey. ing and cutting. Unless you find an athlete with
The patient’s ability to relate the course of events evisceration, it is usually difficult to understand
may be compromised by the head or spinal cord on the sideline or track if the stab wound in the
injury, and therefore witnesses at the scene, par- anterior abdomen, flank, or back penetrates the
ticularly paramedical personnel, often provide peritoneal cavity or the peritoneum.
the most reliable data. Low-velocity gunshot wounds also induce
a lacerating and cutting pattern, although
22.2.2.1 Blunt Trauma associated with more kinetic energy transfer.
This type of trauma results from a direct blow Concerning high-velocity gunshot wounds can
into the abdomen, the situation we may find in cause increased damaged surrounding the track
contact or collision sports, such as soccer, rugby, of the projectile due to temporary cavitation.
football, hockey, boxing, and martial arts, and They also can cause additional intra-abdominal
also in noncontact sports such as bodyboarding, injuries based upon secondary bullet and bone
surfing, cycling, skiing, and snowboarding. fragmentation.
Motorized sports must also be considered as they Injuries related to stab wounds most com-
are ultimately related to accidents involving mul- monly involve the liver (40%), small bowel
tisystem injuries. (30%), diaphragm (20%), and colon (15%).
The depth and the magnitude of the injury Gunshot wounds most commonly affect the small
are proportional to the force transferred during bowel (50%), colon (40%), liver (30%), and
the trauma. We can find compression and crush abdominal vascular structures (25%) [3].
292 R. P. B. Escaleira

22.3 W
 hich Is the Initial –– The athlete with positive but equivocal find-
Diagnostic Workflow ings in the physical examination that elevate
in the Evaluation the suspicion for intra-abdominal injuries and
of the Athlete a normal hemodynamic status. These patients
with Abdominal Trauma? need to transfer to a trauma care center to con-
tinue the investigation.
The evaluation and reanimation of trauma patients –– The athlete with an evident abdominal injury
should respect the basic principles supported by that needs urgent transfer to a trauma care cen-
Advanced Trauma Life Support (ATLS®) of the ter to continue the investigation and treatment.
American College of Surgeons [3]. The hemodynamic status must always be the
According to ATLS®, we must proceed to a pacemaker of the transferring process.
primary survey in a timely fashion which implies
the evaluation and correction of the problems
encountered in the: 22.3.1 Recognition of Shock

–– Airway (A) with the protection of the cervical Recognizing (or excluding) shock must be the
spine first step when it comes to “C” evaluation, simul-
–– Breathing (B) taneously to the initiation of fluid resuscitation
–– Circulation (C) protocol with crystalloid solutions.
–– Disability (D) Although severe circulatory shock evidenced
–– Exposure (E) by inadequate perfusion of the skin, hypotension,
tachycardia, elevated respiratory rate, and confu-
The early assessment of “circulation” in the sion is easy to recognize, it is crucial to recognize
first survey is mandatory in the athlete with shock earlier. After the airway and adequate ven-
abdominal trauma as it has practical implications tilation have been ensured, proceed to a careful
in the definition of the hemodynamic status, helps evaluation of the circulatory status to identify the
the physician to suspect of an active intra-­ early manifestations of shock, especially tachy-
abdominal hemorrhage, and stratifies trauma cardia and cutaneous vasoconstriction, which are
severity and therefore the early need to transfer to typical early physiologic responses to volume
a trauma care center. At this point, the recogni- loss in most adults. Systolic blood pressure is not
tion (or exclusion) of hemorrhagic shock is a sensible indicator, and exclusive reliance on
needed, while resuscitative measures are carried this hemodynamic marker probably will result in
out. delayed recognition of the shock state, especially
The sports medicine physician must be in athletes.
able, after the integration of the mechanism of Athletes have specific physiologic responses
injury and the primary survey (focusing on to hypovolemia because training induces
hemodynamic and abdominal examination), chronic cardiovascular adaptations. Blood vol-
to identify: ume increases, cardiac output increases, stroke
volume increases, and the resting pulse can
–– The athlete suspected to have abdominal average values under 60  bpm after years of
trauma with transient complaints that present endurance training [13]. Therefore the usual
with a normal abdomen, a normal hemody- responses to hypovolemia may not be present
namic status, and no other injuries and can even when a significant amount of blood is lost
return immediately to the field or track. (compensatory mechanisms can preclude a
22 Abdomen 293

measurable fall in systolic blood pressure until utes) of immobilization and warming is consid-
up to one-third of the patient’s blood volume is ered to be in shock until proven otherwise.
lost).
In the athlete, we must look carefully to:
22.3.2 Causes of Shock: Differential
–– Pulse rate: It can be a pitfall (as an example, Diagnosis
90 bpm in an athlete with a cardiac rest rate of
40 may be a compensatory mechanism for a In trauma, the shock is classified as hemorrhagic
depressed stroke volume and effectively is an (most frequent) or nonhemorrhagic. Shock in
“abnormal finding”). acute abdominal trauma is hemorrhagic until
–– Pulse character and pulse pressure: A narrow proven otherwise. Nonetheless it is also impor-
pulse pressure, which is the difference tant to exclude nonhemorrhagic causes of shock,
between systolic and diastolic pressure, in a as tension pneumothorax, cardiac tamponade,
hypovolemic shock patient indicates a cardiogenic shock (myocardial injury), and neu-
decreasing cardiac output and an increased rogenic shock. The work-up for the identification
peripheral vascular resistance. of these causes will not be explored in this chap-
–– Respiratory rate (increased initially and ter, but it is important to know that in the case of
depressed lately). shock, multisystem trauma is not infrequent to
–– Skin circulation (compromised with vasocon- the coexistence of more than one cause of shock.
striction). Septic shock is not frequent immediately
after injury but can also be the cause of shock in
The current “gold standard” for assessment of abdominal trauma patients if there was a delay in
perfusion following injury is a measurement of the diagnosis (hours to days). In this case, hol-
the serum lactate. Elevated lactate levels indicate low viscus perforation with peritoneal or extra-
organ dysfunction and failure in severely injured peritoneal contamination must be considered,
trauma patients and therefore reflect inadequate especially but not exclusively in penetrating
perfusion and oxygenation of ischemic tissues [8, trauma.
14]. Mackersie et  al., in an evaluation of 3223
patients with blunt trauma, found that the risk of
abdominal injury was significantly increased in 22.3.3 Abdominal Examination
the presence of an arterial base deficit of
3  mmol/L or more, the presence of significant First of all…
chest trauma, the presence of pelvic fractures, or
the presence of hypotension [8]. • “Positive clinical findings may be relevant.
Be careful because the initial evaluation of the Negative ones are not! [14].”
circulatory status based on physical examination • When on the sideline or track, if the patient
and/or serum lactate may be compromised if the presents with a hemodynamic abnormality, a
athlete was performing at high levels of intensity meticulous abdominal physical examination is
before the accident, but it is expected to become not indicated. You must immediately get an IV
more reliable after a few minutes of immobiliza- access, start fluid resuscitation, and transfer
tion and external warming. the victim to a medical facility.
Concluding, any injured athlete with suspi-
cious for abdominal trauma who is cold and has In trauma, it is challenging to assess the abdo-
tachycardia after a significant period (some min- men, as the history may not be available and all
294 R. P. B. Escaleira

the available physical signs may be mislead- (Kerr’s sign). Left thoracic trauma at the level
ing. Blood is not initially a peritoneal irritant, of thoracoabdominal transition area may
and therefore it may be difficult to assess the cause splenic injury, even without rib fractures
presence or quantify the blood in the abdomen. (especially in younger athletes). Athletes with
Nevertheless, a physical examination is very a recent history of infectious mononucleosis
important to drive our investigation and should be may be at a higher risk of splenic rupture due
conducted in a systematic fashion respecting the to splenomegaly [15].
classic sequence inspection, auscultation, per- • Liver injury is usually associated with right
cussion, and palpation. We must look for direct upper quadrant pain and tenderness, referred
and/or indirect signs of anterior, flank, and back pain to the right shoulder. An ecchymosis
abdominal trauma, pelvic trauma, genitourinary around the umbilicus (Cullen’s sign) may be
trauma, as well as peritoneal signs. It is important present.
to start with a good exposition although prevent- • Kidney injury is often caused by trauma to
ing from hypothermia. the back and flank and may also be associated
Inspection: We must look for contusions and with rib fractures. Hematuria, flank ecchymo-
abrasions (especially in blunt trauma) and lac- sis (Grey Turner’s sign), and focal tenderness
erations, penetrating wounds, the evisceration may be also present.
of peritoneal contents, and impaled foreign bod-
ies in penetrating trauma. Blood at the urethral Mechanical instability of the pelvic ring
meatus, perineal hematoma, and vaginal or rec- must be tested if a pelvic fracture is suspected
tal hemorrhage are worrisome features related to [16] by manually pushing inward and outward
pelvic trauma and must be carefully investigated. the iliac crests at the level of the anterior superior
Auscultation: In trauma, the setting is diffi- iliac spine (the compression-distraction maneu-
cult to perform careful auscultation. However, ver). This procedure should be performed only
the absence of bowel sounds may be an unspe- once during the physical examination due to the
cific and late indirect sign of free peritoneal risk of aggravating ongoing pelvic hemorrhage
blood. (remember that “the first blood clot is the best
Percussion may elicit signs of peritoneal irri- clot…”). Therefore, it should not be done in
tation. If we can exclude voluntary guarding dur- patients with shock and an evident pelvic
ing abdominal palpation, involuntary guarding fracture.
must also be assumed as a sign of peritoneal irri-
tation. If they are positive, we must admit the
presence of an intraperitoneal lesion; if they are 22.4 W
 hich Athletes Can
not, we cannot exclude it. In the case of evalua- Immediately Return to Play
tion of an abdominal wall hematoma, palpation and Which Athletes Should
and percussion may help us to define its boundar- Be Removed and Transferred
ies although we cannot exclude an intraperitoneal from Competition
origin. for Further Evaluation?
There are some classic signs and symptoms
that usually elevate the suspicion for specific The following flowchart that correlates with
abdominal lesions in blunt trauma: abdominal trauma mechanism, hemodynamic
status, and physical examination was made to
• Splenic injury may cause left upper quadrant help sports medicine physician to decide rapidly
pain and referred pain to the left shoulder (in the sideline).
22 Abdomen 295

Abdominal trauma: Initial evaluation (in the Sideline)

Blunt Trauma Penetrating Trauma Multissystem Trauma

Hemodynamically Hemodynamically
Normal Abnormal

Immediate transfer to a Medical Facility

Reassess mechanism of injury

Physical Examination
Remove from competition
Suspicion for intra-abdominal injury? and observe

If assymptomatic can return

Whithout suspicion for intra-abdominal injury? to play

22.5 Which Diagnostic procedures (like diagnostic peritoneal lavage)

Procedures Are Useful directed for the detection of free fluid in the
in Patients with Abdominal abdominal cavity (blood) is mandatory in the
Trauma? emergency department.
Patients with abdominal trauma and are
The diagnostic work-up depends primarily on hemodynamically unstable, moreover, can be
the hemodynamic status of the patient, as well submitted to more accurate diagnostic proce-
on the mechanism of trauma, the abdominal dures (like computed tomography) to define the
region affected, and the type and localization best definitive treatment.
of the suspected lesions. Selection of the diag-
nostic technique procedures should respect
diagnostic accuracy and efficiency (regarding 22.5.1 Focused Assessment
invasiveness, potential harms, time consump- of Sonography for Trauma
tion, and resource use). We must remember (FAST)
that false-negative findings or delayed diagno-
ses increase the risk of severe complications, Ultrasonography performed using a four-­
so it is important to know the specificity and quadrant, focused assessment of sonography
sensibility of each type of diagnostic for trauma (FAST) is regarded as a critical
procedure. instrument for the initial assessment of patients
Patients with abdominal trauma and unsta- with suspected blunt abdominal and thoracoab-
ble hemodynamic status non-responsive to fluid dominal trauma in the emergency department
resuscitation may be (with high probability) can- setting [17–21] especially if the patient is in
didates for a resuscitative laparotomy. In this shock. FAST is a non-invasive, rapid, and inex-
case, identifying life-threatening injuries enables pensive procedure with excellent specificity but
priority-oriented management and therefore rather low sensitivity (<90%) [22] in detecting
point-of-care imaging (like FAST—focused and excluding free peritoneal blood as an indica-
assessment with sonography for trauma), or other tor of organ injury.
296 R. P. B. Escaleira

A positive FAST in the athlete with unstable 22.5.2 Diagnostic Peritoneal Lavage
hemodynamic status non-responsive to fluid
resuscitation is an indication for laparotomy. Diagnostic peritoneal lavage is an invasive pro-
A negative FAST does not exclude intra-­ cedure introduced some 50 years ago as a method
abdominal lesions (the prevalence of organ injury of evaluation of the abdomen. Its use has mark-
without accompanying free fluid ranges from 5 to edly decreased because of advances in imaging
37% [23]). In this case, if the athlete has a hemo- technology and increased non-operative manage-
dynamic status compatible with performing a CT ment after trauma. It allows investigation of the
scan, it should be done. presence of blood in the peritoneal space with
In the hands of most operators, ultrasound will high sensitivity (>97%) [14] although with lim-
detect a minimum of 200 mL of fluid in the perito- ited specificity (because of the significant false-­
neum [24]. Overall, FAST has a sensitivity between positive rate of the technique), but it does not
73 and 88% and a specificity between 98 and 100% identify the organ of injury. It also has value in
and is 96–98% accurate [21]. This level of accu- the diagnosis of a possible hollow viscus injury.
racy is independent of the practitioner performing The accuracy of DPL has been reported to be
the study. Surgeons, emergency medicine physi- between 92 and 98% [21].
cians, ultrasound technicians, and radiologists have It should be performed by a surgical team
equivalent results [21]. The experience of sports in the emergency department (not in the side-
medicine physicians with ultrasonography is line!) and is indicated in patients with hemo-
increasing, especially in the musculoskeletal exam- dynamic abnormalities who sustain blunt or
ination. It would be important to extend that experi- penetrating abdominal trauma. In this case, a
ence to FAST so that in the future this procedure positive DPL is an indication for laparotomy.
can be carried out on the sideline as an adjunct to Hemodynamically stable patients with equivocal
physical examination. Nevertheless, if the sports results are best managed by additional diagnostic
medicine physician chooses to perform FAST on testing to avoid unnecessary laparotomies.
the sideline, evaluation should not delay the trans- A DPL is generally considered as positive if:
fer of the patient to a medical facility if indicated.
Consider the advantages and disadvan- • Gross blood (>10 mL) or gastrointestinal con-
tages of FAST as follows: tents are easily aspirated from the peritoneal
cavity
Focused assessment with sonography for trauma
Advantages Disadvantages
If this condition is not achieved, lavage is per-
Is portable: Can be User dependent
done at the bedside in Unhelpful for diagnosing formed infusing saline into the peritoneum to
the emergency hollow viscus injury mix with possible blood and/or gastrointestinal
department or on the Misses diaphragm and contents and then to recover the fluid for analysis.
sideline retroperitoneal injuries
In this case, DPL is generally considered as posi-
Permits an early Obesity, subcutaneous air,
diagnosis and previous abdominal tive if:
Noninvasive, performed operations can compromise
rapidly, and the accuracy of ultrasound • Red cell count is >100,000 cells/mm3.
inexpensive Does not rule out organ injury
• White cell count is >500/mm3.
Repeatable and in the absence of
reproducible hemoperitoneum • There is amylase, bile, or gastrointestinal con-
Excellent specificity tent in the lavage return.
• Gram stain with bacteria is present.
Ultrasonography can also be used to diag-
nose post-traumatic abdominal wall hematomas Consider the advantages and disadvan-
or hernias. tages of DPL as follows:
22 Abdomen 297

Diagnostic peritoneal lavage CT scanning is adequate for evaluation of pen-

Advantages Disadvantages etrating back and flank trauma but may be inad-
Permits an early Invasive (not feasible in the equate for the diagnosis of some mesenteric
diagnosis sideline)
Performed rapidly Limited specificity
injuries and miss hollow visceral injuries. In
and inexpensive Misses injuries of the patients at high risk for mesenteric or hollow vis-
High sensitivity retroperitoneum and diaphragm ceral injury (as in penetrating trauma), DPL is
Can detect bowel False-positive results may occur generally felt to be a more appropriate test [21].
injury in the presence of pelvis fractures
CT can also miss some diaphragmatic and pan-
creatic injuries in the early phase.
Consider the advantages and disadvan-
22.5.3 Computed Tomography tages of CT as follows:

Computed tomography
Computed tomography is the gold stan-
Advantages Disadvantages
dard in the evaluation of abdominal trauma
Most specific for The patient must be
because intraperitoneal and retroperitoneal diagnosing injury hemodynamically stable
injuries can be detected, the amount of intra- (organ-specific) Need transport
abdominal blood loss can be estimated, and High sensitive Misses diaphragm, bowel,
Can detect and some pancreatic injuries
it is possible both to recognize the organ that
retroperitoneal lesions Cost and time
is injured and to grade the severity of the
injury. Nevertheless, CT is a diagnostic pro-
cedure that requires transport of the patient
to the radiology suite, administration of con- 22.5.4 Contrast Studies
trast, and scanning, which is time-­consuming.
Therefore this procedure should be used Contrast studies can be helpful in the diagnosis
only in hemodynamically stable patients. of specifically suspected injuries if the hemody-
Allergy to the contrast agent when nonionic namic status allows it:
contrast is not available and an uncooperative
patient who cannot be safely sedated are rela- • Specific upper and lower gastrointestinal
tive contraindications. contrast studies, as well as biliary-pancreatic
CT scanning has the unique ability to detect contrast-enhanced imaging, may be indicated
clinically unsuspected injuries, and therefore if a retroperitoneal-gastrointestinal structure-­
sensitivity between 92 and 97.6% and specificity isolated injury is suspected and CT scans or
as high as 98.7% have been reported in patients DPL are equivocal.
submitted to emergency CT scanning [25, 26]. • Urethrography must be performed if a ure-
When it comes to clinical decision-making in thral lesion is suspected. If we find a normal
blunt abdominal trauma, CT scanning has proved urethrogram, then we can exclude urethra dis-
to be superior to other methods in the diagnosis ruption and can proceed to the insertion of an
of injuries that require surgical intervention [27]. indwelling urinary catheter.
Negative predictive value of CT scanning in blunt • Cystography is indicated if a bladder rupture
abdominal trauma is high (99.63%), so a negative is suspected. It can be achieved with a simple
CT scan usually permits safe discharge of patients cystogram or with a more specific CT
with blunt abdominal trauma [28]. Nevertheless, cystography.
most authors still recommend admission and • Intravenous pyelography is an alternative to
observation after a negative CT scan [29, 30] if contrast-enhanced CT to evaluate suspected
the mechanism of injury is significant. urinary system injuries.
298 R. P. B. Escaleira

Images 22.1 and 22.2  Free peritoneal air

22.5.5 Routine Screening quadrant of the abdomen. The avascular suspen-

Radiographs sory ligaments of the spleen also place it at risk of
avulsion during rapid deceleration. The presence
Abdominal films specifically oriented to diag- of a splenic capsule makes it possible to occur a
nose intra-abdominal injury are not usually use- delayed splenic rupture which incidence ranges
ful. Even when it comes to looking for from 1 to 8% in adults and 0 to 7.5% in children
infradiaphragmatic free air, an erect chest radio- [12]. Therefore the spleen is one of the most fre-
graph (if possible and safe to do it) will provide quently injured abdominal organs in sports and
more information than an erect abdominal film. the most common cause of death due to blunt
Nevertheless, it is important to remember the abdominal trauma-related hemorrhagic shock
importance of obtaining an anteroposterior chest among athletes [12]. Certain diseases increase
film and a pelvic film, as preconized by Advanced the risk for complicated splenic trauma, like
Trauma Life Support (ATLS®) program of the infectious mononucleosis [15, 31, 32].
American College of Surgeons as adjuncts to the The athlete with splenic injury may present
primary survey. left upper quadrant pain and referred pain to the
left shoulder (Kerr’s sign). Peritoneal signs may
not be present. The assessment of signs of hypo-
22.6 Overview of the Principal volemia is mandatory, and the hemodynamic sta-
Blunt Traumatic Abdominal tus will be the most important prognostic
Injuries, Their Appropriate indicator when it comes to decision-making.
Treatment, as well as Special In the hemodynamically unstable patient, a
Concerns Regarding Return FAST (or DPL) during resuscitation is indicated,
to Play and if positive, operative treatment is necessary.
In the hemodynamically stable patients,
22.6.1 Splenic Injury abdominal CT is the most reliable method to iden-
tify and assess the severity of injury to the spleen
The spleen is a very vascularized and delicate (evidence level II) [32] as well as identify the
organ and can be damaged easily during blunt patients with active bleeding (presence of contrast
thoracoabdominal trauma, especially direct blush on the CT scan). With contrast enhance-
trauma to the left lower chest wall or left upper ment, a splenic laceration will be presented as an
22 Abdomen 299

irregular, linear hypodensity, whereas an intras- American Association for the Surgery of
plenic hematoma will appear as a hypodense area Trauma’s Spleen injury scale [34] is an important
in a non-perfusing region of the spleen [33]. tool for decision-making protocols:

American Association for the Surgery of Trauma’s (AAST) Spleen injury scale [34]
Gradea Injury Description of injury
type
I Hematoma Subcapsular <10% surface area
Laceration Capsular tear <1 cm parenchymal depth
II Hematoma Subcapsular, 10–50% surface area
Intraparenchymal, <5 cm in diameter
Laceration Capsular tear, 1–3 cm parenchymal depth that does not involve a trabecular vessel
III Hematoma Subcapsular, >50% surface area or expanding
Ruptured subcapsular or parenchymal hematoma
Intraparenchymal hematoma >5 cm or expanding
Laceration >3 cm parenchymal depth or involving trabecular vessels
IV Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25%
of the spleen)
V Laceration Completely shattered spleen
Vascular Hilar vascular injury with devascularized spleen
Advance one grade for multiple injuries up to grade III
a

Images 22.3 and 22.4  Splenic laceration

Management of blunt splenic injuries has pneumococcus [41]) and with other general post-
evolved during the past decade to more non-­ operative complications.
operative management due to the evolution of the Hemodynamically stable patients with AAST
critical care units, to the implementation of grade I, II, or III splenic injuries with no other
damage-­control hemostatic resuscitation proto- associated abdominal injuries requiring surgical
cols [35–39] as well as to transvascular proce- intervention and who have no comorbidities to
dures [40] to stop the parenchymal bleeding. preclude close observation are candidates for
Splenic preservation is preferred over splenec- non-operative management [42]. Given the cur-
tomy because splenectomy is associated with rent state of the interventional radiology (with the
overwhelming postsplenectomy infection (par- possibility of angiographic embolization), AAST
ticularly from encapsulated organisms such as grade IV or V splenic injuries in hemodynami-
300 R. P. B. Escaleira

cally stable patients are not absolute contraindi- injury to the liver and allows the surgeon to iden-
cations for non-operative management [42]. tify those patients who can be safely managed
Nevertheless, the risk of treatment failure is pro- non-­operatively, to assist decision-making in
portional to the injury scale grade [14]. The 2012 non-­operative management, and to act as a base-
Eastern Association for the Surgery of Trauma line for comparison in future imaging studies
(EAST) guidelines for the management of blunt [32, 42].
splenic injury suggests non-operative manage- Patient with penetrating liver trauma and
ment for the hemodynamically stable patient hemodynamically stable can also be managed
regardless of injury grade, patient age, or pres- non-operatively. Nevertheless, the risk of bile
ence of associated injuries [43]. leakage is high, so the follow-up must be made
closely.
American Association for the Surgery of
22.6.2 Hepatic Injury Trauma’s Liver injury scale [34] is an important
tool for decision-making protocols:
Like the spleen, the liver is susceptible to injury
during blunt thoracoabdominal trauma, espe-
American Association for the Surgery of Trauma’s
cially when direct compressive or shear forces (AAST) Liver injury scale [34]
are applied to the right lower chest wall or right Injury
upper quadrant of the abdomen. Consequently Gradea type Description of injury
the liver is also one of the most frequently injured I Hematoma Subcapsular <10% surface
abdominal organs in sports [44]. Although most area
Laceration Capsular tear <1 cm
injuries to the liver (like a subcapsular or intrapa- parenchymal depth
renchymal hematoma or low-grade lacerations) II Hematoma Subcapsular, 10–50% surface
do not require surgical intervention, management area
of severe hepatic lesions can be challenging and Intraparenchymal, <10 cm in
diameter
disastrous because they may involve combined
Laceration Capsular tear, 1–3 cm
parenchymal, intrahepatic vascular, and biliary parenchymal depth, <10 cm in
system injury. length
The athlete with liver injury may present III Hematoma Subcapsular, >50% surface
right upper quadrant pain and tenderness, referred area of ruptured subcapsular
or parenchymal hematoma
pain to the right shoulder. An ecchymosis around Intraparenchymal hematoma
the umbilicus (Cullen’s sign) may be present, and >10 cm or expanding
peritoneal signs may not be present. The assess- Laceration >3 cm parenchymal depth
ment of signs of hypovolemia is mandatory, and IV Laceration Parenchymal disruption
the hemodynamic status will be the most impor- involving 25–75% hepatic
lobe or 1–3 Couinaud
tant prognostic indicator when it comes to segments within a single
decision-making. lobe
In the hemodynamically unstable patient, a V Laceration Parenchymal disruption
FAST (or DPL) during resuscitation is indicated, involving >75% of a hepatic
lobe or >3 Couinaud segments
and if positive, surgical exploration is required to
within a single lobe
achieve hemostasis and exclude other sources of Vascular Juxtahepatic venous injuries,
bleeding. i.e., retrohepatic vena cava/
In the hemodynamically stable patients, central major hepatic veins
abdominal CT scanning is an invaluable diag- VI Vascular Hepatic avulsion
nostic aid to identify and assess the severity of Advance one grade for multiple injuries up to grade IV
a
22 Abdomen 301

and V) may require complex maneuvers for suc-

cessful treatment. Hepatic avulsion (grade VI) is
usually lethal [42].
The 2012 EAST guidelines for the manage-
ment of blunt hepatic injury are identical to those
for blunt splenic injuries with adjunct interven-
tions and include angiography, endoscopic retro-
grade cholangiopancreatography, endoscopy, and
laparoscopy [43].

22.6.3 Renal Injury

The kidney is the most commonly injured genito-

Image 22.5  Hepatic laceration urinary organ, occurring in 5% of all trauma cases
[45]. The sports-related blunt renal injury is often
isolated [46] and usually results from a solitary
blow to the flank sustained during sports-­related
activities, such as skiing, contact sports, or biking
[47]. Although most sports-related renal injuries
are low-grade (AAST grades I–II), isolated blows
to the flank sustained during sports-related activi-
ties can also produce high-­ grade renal injury
(AAST grades III–V) [47–50].
The athlete with kidney injury may present
hematuria (the best indicator of renal injury),
flank ecchymosis (Grey Turner’s sign), and focal
tenderness. The European Association of Urology
Image 22.6  Subcapsular hepatic hematoma
guidelines recommend imaging in all abdominal
trauma patients with the presence of hematuria
Management of blunt hepatic injuries has and shock or with major associated injuries [51].
evolved during the past decade to more non-­ The investigation of choice in an unstable patient
operative management due to the evolution of the is immediate surgery. Stable blunt abdominal
critical care units, to the implementation of trauma patients with gross hematuria generally
damage-­control hemostatic resuscitation proto- need evaluation via a CT scan. However, the
cols [35–39] as well as to transvascular proce- absence of hematuria does not preclude signifi-
dures [40] to stop the parenchymal bleeding. cant renal injury [52], and injuries such as renal
Actually, nearly all children and 50–80% of artery laceration or avulsion may not present
adults with blunt hepatic injuries can be treated hematuria [53].
non-operatively, because most liver injuries will Contrast CT is the gold standard imaging
stop bleeding spontaneously [12]. modality. Also, to allow grading of renal injuries,
Isolated hepatic injuries that are not extensive it provides a proper evaluation of intra-­abdominal
(grades I–III) are usually managed non-­ and retroperitoneal structures, with an excellent
operatively. Extensive parenchymal injuries and sensitivity of detecting concomitant injuries. CT
those involving the juxtahepatic veins (grades IV has a negative predictive value of 99.8% [54].
302 R. P. B. Escaleira

The AAST kidney injury score [55] both aids

management and confers a prognostic element
[56]. Furthermore, AAST scoring is the most
important variable predicting the need for kidney
repair or nephrectomy [57].

American Association for the Surgery of Trauma’s

(AAST) Kidney injury scale [55]
Injury
Gradea type Description of injury
I Contusion Microscopic or gross
hematuria
Hematoma Subcapsular, non-expanding
without parenchymal
laceration Image 22.8  Subcapsular hepatic hematoma and subcap-
II Hematoma Non-expanding perirenal sular renal hematoma in a splenectomized patient
hematoma confined to renal
retroperitoneum The management of renal trauma can be
Laceration <1 cm parenchymal depth of divided into conservative, radiological (angio-
renal cortex without urinary embolization), and surgical. Conservative man-
extravasation agement has become the preferred strategy in the
III Laceration >1 cm parenchymal depth of
renal cortex without
acute management of renal trauma, consisting in
collecting system rupture or admission with strict bed rest, clinical monitor-
urinary extravasation ing and serial examination, hematological and
IV Laceration Parenchymal laceration serological monitoring, and imaging assess-
extending through the renal ment “on demand” until resolution of hematuria.
cortex, medulla, collecting
system Radiological approach (angiography and selec-
Vascular Main renal artery or vein tive embolization) has been successful (83%
injury with contained success rates) for management of grade IV and
hemorrhage V renal injuries with vascular complications
V Laceration Completely shattered kidney
[58]. Surgical exploration is reserved for those
Vascular Avulsion of renal hilum
which non-vascularized patients presenting with significant renal trauma
kidney with associated hemodynamic instability [59].
a
Advance one grade for multiple or bilateral injuries up to Absolute indications for laparotomy are persis-
grade III tent life-threatening hemorrhage, renal pedicle
injury, and an expanding or pulsatile retroperito-
neal hematoma (indicating a renal artery rupture).
When it comes to follow-up imaging, some
authors suggest re-imaging upon resolution of
microscopic hematuria, others before discharge,
while some repeat CT scans 6–10 weeks after ini-
tial injury. The European Association of Urology
recommends that long-term follow-up imaging
should ultimately be decided on a case-by-case
basis (level C evidence) [60].

22.6.4 Pancreatic Injury

Because of the frequently delayed diagnosis and

Image 22.7  Renal laceration the severity of pancreatic and combined pancre-
22 Abdomen 303

aticoduodenal injuries, the sports-related trau- return to exercise and competition. The athlete
matic pancreatic injury is associated with high must be also taught to monitor for red flags
morbidity and mortality [61]. Pancreatic injuries regarding signs and symptoms.
usually result from a direct epigastric blow that
compresses the organ against the vertebral col- 1. Recommendations for resuming unrestricted
umn and must be suspected in all patients with activity after splenic injury vary from
abdominal injuries, even those who initially have 3  weeks to greater than 6  months for severe
few signs. Because of pancreatic retroperitoneal injury, depending on the injury grade score
position, blunt pancreatic trauma can be subtle at [44, 63, 64]. Athletes submitted to splenec-
presentation and consequently a high level of tomy return to play much sooner [44], and
suspicion integrated with an aggressive imaging sometimes this fact is used as an indication for
study is needed to early identify an injury. Serum splenectomy in elite athletes (elective sple-
amylase levels can be elevated in many abdomi- nectomy for elite athletes in order to achieve a
nal injuries and are neither specific nor sensitive faster return to play should be reserved for
to pancreatic injury. Nevertheless, in a study by exceptional situations). Postsplenectomy vac-
Takishima, serum amylase elevated in 84% of cination with pneumococcal and meningococ-
patients with pancreatic injury at presentation: cal vaccines is recommended [65].
elevated in 76% (<3  h postinjury) and 100% 2. Literature on return to play after liver injury
(>3  h postinjury) [62]. CT is 85% accurate but is scarce, and recommendations for resuming
does not always help with the grading of the unrestricted activity after hepatic injury are
injury, and endoscopic retrograde cholangiopan- dependent on the type and severity of the
creatography (ERCP) and magnetic resonance injury. Although healing time for hepatic lac-
cholangiopancreatography (MRCP) can be help- erations is different from subcapsular hemato-
ful in selected stable patients [14]. mas [66], it is estimated that healing from a
Management of pancreatic injury is variable, laceration and subcapsular hematoma occurs
depending on the severity, the site of the injury, in 2–4  months, whereas complex injuries
and the integrity of the main pancreatic duct. In require up to 6 months [67]. Although imag-
non-complicated cases, it can be done through a ing follow-up (US or CT) of athletes with
conservative approach associated or not to simple liver injury must be guided by symptoms,
drainage procedures but in complicated cases some authors recommend return to unre-
may be necessary highly challenging surgical stricted activity only after a normal CT, usu-
procedures. ally 3–6  months after injury. This strategy
may increase unnecessary radiation exposure
on the athletes.
22.6.5 Return-to-Play Decisions After According to a review published by Juyia
Blunt Abdominal Trauma and Kerr in 2014 [44] concerning return to
play after liver and spleen trauma:
Return-to-play decisions after blunt abdomi- –– Athletes should only engage in a light
nal trauma should be individualized, and ath- activity for the first 3  months after trau-
letes must be fully nutritionally and metabolically matic liver or spleen injury and then gradu-
recovered before engaging unrestricted activity. ally return to unrestricted activity as
There is a lack of consensus on recommendations tolerated (SORT Evidence Rating C).
for resuming full activity after blunt abdominal –– Average healing times documented on CT
trauma injuries (concerning to intensity and dura- and ultrasound can be a helpful guide to the
tion of restricted activity). Whether changing to a length of activity restriction (SORT
noncontact sport or being authorized by a physi- Evidence Rating C).
cian for a contact sport, an athletic trainer or –– Follow-up imaging is not recommended
sports medicine physician should educate the unless clinically indicated (SORT Evidence
athlete to engage in a progressive and gradual Rating C).
304 R. P. B. Escaleira

3. Decision-making about return to play after • When on the sideline or track, if the patient
kidney injury is difficult due to the lack of presents with a hemodynamic abnormality, a
specific international guidelines and consen- meticulous abdominal physical examination is
sus, and therefore the decision must be not indicated. You must immediately get an IV
decided on an individual basis by the athlete access, start fluid resuscitation, and transfer
and the sports medicine physician. the victim to a medical facility.
Conservatively managed athletes with • If the athlete victim of abdominal trauma is
renal contusions should be observed until hemodynamically unstable, point-of-care
hematuria clears and should be excluded from imaging (like FAST—focused assessment
contact sports for 6 weeks. More severe inju- with sonography for trauma) or other proce-
ries may take 6–8 weeks to heal, and in this dures (like diagnostic peritoneal lavage)
case, the athlete may have to wait for directed for the detection of free fluid in the
6–12 months before a safe return to contact/ abdominal cavity (blood) are mandatory in the
collision sports [56, 68]. emergency department.
The athlete with the solitary kidney • If the athlete victim of abdominal trauma is
appears to have a low risk for kidney loss with hemodynamically stable, we can proceed to
participation in both contact and noncontact more accurate diagnostic procedures (like
sports, but it remains a controversial issue that computed tomography) to define the best
requires patient education and an individual- definitive treatment.
ized approach [56]. • Management of blunt abdominal injuries has
4. Literature on return to play after pancreatic evolved during the past decade to more non-­
injury is scarce. It depends on the resolution operative management.
of the disease process and symptoms and must • Return-to-play decisions after blunt abdominal
be decided on an individual basis by the ath- trauma should be individualized, and athletes
lete and the sports medicine physician. must be fully nutritionally and metabolically
recovered before engaging unrestricted activity.
• There is a lack of consensus on recommenda-
Take-Home Messages tions for resuming full activity after blunt
• Unrecognized abdominal and pelvic injuries abdominal trauma injuries (concerning to
continue to be a cause of preventable death. intensity and duration of restricted activity).
• We must exclude abdominal trauma when sig- • Sports medicine physician should educate the
nificant kinetic energy is transferred to the athlete to engage in a progressive and gradual
torso from a direct blow, deceleration, or pen- return to exercise and competition. The athlete
etration injury. must be also taught to monitor for red flags
• Blunt trauma is by far more frequent than pen- regarding signs and symptoms.
etrating trauma.
• The spleen is the most frequently injured
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 Shoulder: The Thrower’s Shoulder
23
Lukas N. Muench, Andreas B. Imhoff,
and Sebastian Siebenlist

23.1 Introduction 23.2 Evolution of the Human

Throwing Movement
Due to the specific motion pattern, overhead and
throwing sports (e.g. javelin throwing, baseball, The knowledge of the changes during the Homo
tennis or volleyball) result in high stress to the sapiens’ evolution is the base to understand the
athlete’s shoulder. Besides acute injuries (e.g. underlying pathologies. When bipedalism freed
fractures or dislocation injuries), these sports the arms enabling the upper extremity for com-
show a higher incidence of long-term overload plex and specific motion sequences, the humans’
damage of the shoulder joint. Asymptomatic unique throwing abilities were made possible.
junior overhead athletes already present struc- The position of the scapula varied to a more cau-
tural and biomechanical changes [1, 2]. dal and dorsal position resulting in a higher
In a long-term process, degenerative damage range of motion. Secondary, the glenoid level
of the shoulder joint may occur with permanently changed from a rather cranial to a more lateral
limited functionality [3]. To avoid a progression orientation. In addition, the human’s trunk flexi-
with further structural damage and to restore the bility allowed more torso rotation. Decreased
function of the shoulder joint at the same time, a humeral torsion increased the external rotation
complete evaluation of the relevant pathological of the shoulder joint. These anatomical features
factors is necessary. Moreover, the understanding make it possible to store and release more elastic
of the underlying pathology is essential to initiate energy at the shoulder. Thus, the Homo sapiens
a differentiated therapy. is able to throw projectiles with high speed and
great accuracy [4].
However, biomechanical studies show that
this unique throwing ability inevitably requires
extreme abduction and external rotation of the
glenohumeral joint, which may result in perma-
nent overloading of the capsular and musculoten-
dinous structures [5, 6].

L. N. Muench · A. B. Imhoff (*) · S. Siebenlist

Department of Orthopaedic Sports Medicine,
Technical University of Munich, Munich, Germany
e-mail: [email protected];
[email protected]; [email protected]

© ISAKOS 2019 307

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_23
308 L. N. Muench et al.

23.3 Biomechanics of the Human rotation in high abduction and appears already in

Throwing Movement early stages as a glenohumeral internal rotation
deficit (GIRD). In addition, unequal distribution
An effective throwing technique is based on the of training loads leads to weakening of the exter-
successive use of kinetic energy and is divided nal rotating muscles of the rotator cuff [12].
into six phases. The whole throwing motion usu- Repetitive distention of the anterior capsule
ally takes less than 2  s to occur. The first three with simultaneous shortening of the dorsal cap-
phases consist of wind-up, early cocking and late sular structures leads to a decentralization and
cocking. In the wind-up phase, there is a torsion posterosuperior translation of the humeral head
of the whole body from the lower extremity up to in positions of external rotation and abduction.
the shoulders. In the early-cocking phase, the ath- This probably results in an internal “impinge-
lete begins to externally rotate the upper extremity ment” in the area of the posterosuperior glenoid
with maximum external rotation of 165 ± 11° in (PSI) with contact of the articular-sided insertion
the late-cocking phase. This generates maximum of the supraspinatus and infraspinatus tendon and
preload and storage of kinetic energy. The accel- the posterosuperior glenoid rim. Finally, this cas-
eration phase transfers the kinetic energy to the cade leads to partial or complete ruptures of the
projectile followed by the final two phases of rotator cuff. In combination with labral or pulley
deceleration and follow-­through [7, 8]. lesions or detachment of the long biceps tendon
During the throwing motion, high peak loads anchor (SLAP), the thrower’s shoulder may have
are caused. The great angular velocity of the a poor prognosis [7, 12, 13].
shoulder joint of up to 7000°/s and the transfer of
kinetic energy during deceleration and follow-­
through generate an extreme joint distraction [9, 23.5 T
 he Keys for a Successful
10]. Thus, a repetitive distention of the anterior Treatment
joint capsule (increased external rotation in 90°
abduction) and a simultaneous shortening of the The mentioned theoretical models are useful to
dorsal capsular structures (decreased internal understand the underlying pathology but are only
rotation in 90° abduction) occur [7]. of limited use in clinical practice. For this reason,
The unequal distribution of training loads also it is helpful to classify the complex of problems
leads to an imbalance of the muscular force cou- of the athlete’s shoulder into five underlying
ples. This presents itself especially in the relative structures with a simple approach for a clinical
strength of external and internal rotating muscles evaluation. In addition to the clinical examina-
of the rotator cuff. Besides, the unilateral loading tion, X-rays of the shoulder and MR arthrogra-
causes a dysfunctional coordination of the scapu- phy are useful. Moreover, specific examination
lothoracic muscles (M. rhomboidei, M. trapezius using the ABER position (abduction external
and M. serratus anterior), which may interrupt rotation) proved to be of value and allows to
the kinetic chain between the scapula and trunk interpret the diagnostic findings more precisely.
(scapula dyskinesia) [11]. Based on clinical examination and imaging,
the five-point check for the athlete’s shoulder was
developed by our team including the joint cap-
23.4 Pathology of the Thrower’s sule, scapula, joint stability, rotator cuff and
Shoulder biceps tendon complex [14].

Several theories exist for the development of the

complex pathology of a thrower’s shoulder. Even 23.5.1 Joint Capsule
if there is an enormous variance regarding the
theoretical models, they can be generally com- Compared to the contralateral side, the mobility
bined to basic principles. Shortening of the dorsal of the affected shoulder has to be examined with
capsular structures results in a decreased internal special regard to a glenohumeral internal rotation
23  Shoulder: The Thrower’s Shoulder 309

a b

Fig. 23.1  Patient with GIRD. (a) The unaffected left shoulder; (b) GIRD of the right shoulder

deficit (GIRD). Burkhart et  al. [11] defined the ment. During torsion of the torso, the scapula has
“shoulder at risk” as a shoulder with a decreased to be moved dorsally in the axis between both
ability of internal rotation of 20° compared to the shoulders. In case of a scapular dyskinesia (e.g.
unaffected side. Essential for the evaluation is not due to pathological scapula protraction), the
the ability of internal rotation all alone but the development of a symptomatic posterosuperior
total arc of rotation in 90° abduction and fixed impingement (PSI) is more likely [16]. During
scapula (Fig. 23.1). clinical examination, a possible contraction of
In throwing athletes, the range of motion of the pectoralis minor muscle (leading to scapula
the shoulder is shifted into external rotation. A protraction) has to be identified. Additionally, the
deviation in rotational ability of more than 20° of amplitude of scapula movement as well as the
the 180° arc of motion in this position is patho- scapulothoracic rhythm is examined while stand-
logical. Moreover, some studies show that an ing behind the patient with the patient repetitively
increased humeral retrotorsion represents itself raising both arms. The scapula assistance test
as a risk factor for the development of a glenohu- (SAT) is also helpful to determine scapula
meral internal rotation deficit [15]. dyskinesis.
For clinical evaluation, it is very important to
examine the patient in supine position with 90°
abduction and fixed scapula to avoid a compensa- 23.5.3 Stability
tory scapula movement.
In this context, stability of the capsular structures
of the glenohumeral joint is of crucial relevance.
23.5.2 Scapula Signs of instability as defined by a positive appre-
hension or relocation test and signs of hyperlax-
Optimal glenoid position and transfer of kinetic ity (sulcus sign, Gagey’s test) have to be
energy require a precise and stable scapula align- evaluated. Supplemental MRI scans detect labral
310 L. N. Muench et al.

lesions, an extended joint capsule or signs of a lesion) or complete ruptures of the rotator cuff.
prior luxation (Hill-Sachs lesion). At the same Moreover, the ABER position allows the identifi-
time, core stability is an important factor. One-­ cation of a pathological contact with the postero-
legged squads or jumping tests are useful to superior labrum.
obtain principal orientation.

23.5.5 Biceps Tendon Complex

23.5.4 Rotator Cuff
Using specific tests for the biceps tendon complex
Due to the contact of the articular-sided supraspi- (e.g. O’Brien test, Yergason test, Speed test, crank
natus and infraspinatus tendon with the postero- test), clinical examination focuses on pulley
superior glenoid rim, the PSI leads to the lesions, tendinitis of the long biceps tendon and
development of cystic lesions at the footprint detachment of the biceps tendon anchor (SLAP
area. High-grade articular-sided partial tears of lesion) (Fig. 23.3). Especially, the O’Brien test is
the rotator cuff result in a muscular imbalance of essential to rule out biceps tendon anchor pathol-
the force couples. Therefore, an exact clinical ogy. Pulley lesions present pressure pain in the
examination including common rotator cuff tests rotator interval and increasing pain during exter-
and provocation tests as the “thrower test” (pain nal rotation of the arm. For verification of SLAP
in the posterosuperior area of the glenohumeral lesions, the MR arthrography has a high diagnos-
joint during high abduction and external rotation tic performance but is limited in the classification
against resistance in throwing direction) is impor- of different types of SLAP lesions [17].
tant (Fig.  23.2). In addition, MRI diagnostics Positioning the arm in abduction and external
may reveal articular-sided partial lesions (PASTA rotation (ABER) during MR arthrography is use-

Fig. 23.2  Thrower test

23  Shoulder: The Thrower’s Shoulder 311

Fig. 23.3  Classification of SLAP lesions (type I–V). A. B. Imhoff, M. J. Feucht Atlas sportorthopädisch-sporttrauma-
tologische Operationen. 2. Auflage; Springer. Kapitel 4: Instabilität; p. 104

ful to detect and characterize labroligamentous cal and thoracic spine as well as mobility, stabil-
lesions as well as partial tears of the rotator cuff ity, and strength of the trunk and lower extremity
undersurface [18, 19]. is necessary [23]. The athlete has to pass a
Initially, Snyder et al. identified four different graded rehabilitation programme to achieve full
types of SLAP lesions [20] (Fig.  23.3). Type I functional restoration. Based on the individual
presents fraying and degenerative appearance of athlete’s performance level, the complete kinetic
the superior labrum with an intact attachment of chain, joint mobility, strength and endurance as
the biceps tendon to the labrum. SLAP-II lesions well as neuromuscular control are trained with
show a detachment of the superior labrum and varying intensity [24]. The rehabilitation goes
biceps tendon from the supraglenoid tubercle. along with a clinical reasoning process and
Type III displays an into the joint displaceable includes sport-specific requirements and
bucket-handle tear of the superior labrum with an evidence-­based recommendations [25].
intact biceps tendon anchor. Type IV is a bucket-­ A GIRD is addressed by stretching the poste-
handle tear where the tear extends into the biceps rior capsular structures with the “cross-body
tendon. Maffet et  al. added three further sub- stretch” or the “sleeper stretch” [26]. The “corner
classes of SLAP lesions, including type V, which stretch” is used for relaxation of the pectoralis
is described as an anterior-inferior Bankart lesion minor muscle. These stretching exercises decrease
continuing superiorly to the biceps tendon [21]. the athlete’s pain and reduce the GIRD [27]. At
Currently, ten different types of SLAP lesions first, neuromuscular control of the rotator cuff is
have been described in the literature [22]. trained concomitantly, followed by a specific
strengthening of the rotator cuff muscles.
Concomitant affection of the biceps tendon
23.6 Therapy requires a dosed and adapted increase of load bear-
ing. Therefore, flexion of the shoulder in supine
23.6.1 Conservative Treatment position should be initially avoided, followed by
eccentric and plyometric exercises according to
The primary therapeutic approach is nonopera- the required sport-specific profile [28].
tive, addressing the identified functional defi- The treatment of scapular dyskinesia is essen-
cits. Initially, eccentric and concentric rotational tial for the shoulder function and is based on a
strength of the shoulder, neuromuscular control, progressive rehabilitation algorithm [29].
and functional capacity have to be analysed. Training has to be focused on the restoration of
Besides, an evaluation of the mobility of cervi- flexibility of the periscapular muscles (pectoralis
312 L. N. Muench et al.

a b

Fig. 23.4  SLAP-II lesion. (a) MRI scan; (b) arthroscopic view

minor, levator scapulae and rhomboidei muscles) different arthroscopic surgical approaches are
and elimination of scapulothoracic muscular evident. In case of a SLAP-II lesion, method of
imbalances. In this context, the centralization of choice is the refixation of the SLAP complex to
the humeral head deserves special consideration. the superior glenoid rim using suture anchors
Dynamic stabilization is trained by multidimen- (Fig.  23.4). In type III lesions, the displaced
sional concentric-eccentric and plyometric bucket-handle tear is resected. If the tear of the
motion requests to avoid an excessive cranial biceps tendon anchor is located in the vascular-
migration of the joint centre [24]. ized area next to the bone at the supraglenoid
Moreover, endurance of periscapular and rota- tubercle, a refixation of the SLAP complex with
tor cuff muscles is part of the rehabilitation pro- suture anchors can be considered. In general,
gramme. During fatigue conditions, glenohumeral type IV lesions require biceps tenodesis. In
and scapulothoracic control is maintained and SLAP-V lesions, an arthroscopic refixation of the
thus stabilizes the glenoid position and central- SLAP complex together with the anterior
ization of the humeral head. In addition, strength, capsule-­labrum complex is mandatory. If there is
stability and neuromuscular control of the trunk a concomitant pulley lesion with a resulting
and lower extremity are essential for an optimal instability of the biceps tendon, a biceps tenode-
throwing technique and therefore should be sis is needed. In case of SLAP-III, SLAP-IV and
improved [30]. SLAP-V lesions, a biceps tenodesis always
Following a multistage model, the decision to should be considered because of inconsistent
return to play or not is made. According to this clinical results after SLAP repair described in the
model, health status, participation risk, and deci- literature [32–35].
sion modifiers are considered [31]. Over the past 10  years, the total number of
biceps tenodeses has increased, whereas the
number and relative percentage of SLAP repairs
23.6.2 Surgical Treatment have decreased. Especially in overhead athletes
and patients over 35 years of age, a biceps teno-
Overhead athletes often present pathologies of desis should be preferred. Chalmers et al. found
the biceps tendon anchor (SLAP lesions) without that pitchers who underwent a SLAP repair had
any responsiveness to physiotherapeutic treat- altered patterns of thoracic rotation compared to
ment. According to the existing type of lesion, the controls and pitchers who had undergone a
23  Shoulder: The Thrower’s Shoulder 313

biceps tenodesis [34]. Laughlin et al. found defi- of articular-sided partial-thickness rotator cuff
ciencies in pitching biomechanics in collegiate tears, the two techniques show no significant dif-
and professional pitchers who underwent SLAP ference. Of the patients treated with the transten-
repair [36]. Even in SLAP-II lesions, only 50% dinous technique, 75% returned to the same level
of the overhead athletes return to pre-injury level of sport, compared to 67% of the patients who
of play [37]. Therefore, biceps tenodesis is a reli- underwent a full-thickness conversion and repair
able option compared to SLAP repair [35]. [43]. Two recent reviews show an overall rate of
After cutting the long head of the biceps ten- return to sport of 79–84.7%, including 60.5–
don at its attachment, there is the possibility to 65.9% at an equivalent level of play. Nevertheless,
perform either an intraarticular or subpectoral only 49.9–54.5% of the professional athletes
tenodesis. The intraarticular tenodesis is carried reached their pre-injury level [44, 45]. There is
out entirely arthroscopically with tendon fixation only a slight difference in the return-to-sport rate
right at the entry point to the sulcus bicipitalis. between debridement (53.7%) and repair (47.5%)
The disadvantage of this procedure may be sul- [45]. The mean time for returning to sport follow-
cus bicipitalis-related pain due to remaining pain ing surgery was 8.3 months [45].
receptors. In case of a subpectoral tenodesis, the
tendon is fixed at the distal part of the sulcus
bicipitalis, 2 cm proximal to the caudal margin of
the pectoralis major muscle. Therefore, an addi- Fact Box 1: Pathology of the Thrower’s
tional incision of 1.5–3  cm length is necessary Shoulder
[38, 39]. • Shortening of the dorsal capsular struc-
Author’s preferred procedure represents the tures results in GIRD.
subpectoral tenodesis using all-suture soft • Repetitive distention of the anterior
anchors via a limited minimally invasive approach capsule.
as shown in Fig. 23.5 [38, 40]. • Decentralization and posterosuperior
Nevertheless, overhead athletes often suffer translation of the humeral head leads to
from articular-sided partial lesions of the PSI.
­supraspinatus tendon. If an appropriate and com- • Finally, lesions of the rotator cuff,
plete rehabilitation has failed, indication for sur- biceps anchor complex and pulley
gical approach is given. The size of the tear is system.
essential for the kind of operative treatment. If
over 50% of the supraspinatus tendon is ruptured,
authors favour the completion of the rupture and
refixation to the original footprint. In contrast to Fact Box 2: Therapy Essentials
the transtendinous technique, the completion of • Graded rehabilitation programme to
the rupture minimizes the risk of a too medial achieve full functional restoration.
refixation of the articular-sided tendon tissue. • Training of complete kinetic chain, joint
Especially in overhead athletes, this should be mobility, strength, endurance and neu-
avoided because of the required range of motion. romuscular control.
In case of lesions of under 50% of tendon thick- • Addressing GIRD and scapula dyskine-
ness, a debridement is recommended [41]. sia by stretching and strengthening of
Concerning return-to-play rates, the results of periscapular muscles.
surgical treatment of partial-thickness rotator • Surgical treatment of SLAP lesions with
cuff tears are poor. In professional throwers, SLAP repair or subpectoral biceps
debridement shows inconsistent return-to-play tenodesis.
rates from 16 to 76% [42]. Regarding the repair
314 L. N. Muench et al.

a b

c d

Fig. 23.5  Subpectoral biceps tenodesis. (a) Marking of ing out the long-head biceps tendon. (c) Insertion of the
the caudal margin of the pectoralis major muscle and all-suture soft anchor over the target device. (d) Stitching
1.5–3 cm-long incision in the course of the axillary fold. of the tendon at the myotendinous junction. Subsequently,
(b) Identification of the myotendinous junction after pull- tendon shortening and pulling in using the free suture limb
23  Shoulder: The Thrower’s Shoulder 315

Take-Home Messages 3. Schmitt H, Hansmann HJ, Brocai DR, Loew M. Long

term changes of the throwing arm of former elite jav-
• Due to the specific motion pattern, overhead elin throwers. Int J Sports Med. 2001;22(4):275–9.
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• Understanding the pathology of the thrower’s 5. Burkhart SS, Morgan CD, Kibler WB. The disabled
shoulder, several aspects have to be consid- throwing shoulder: spectrum of pathology. Part II:
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tures results in a GIRD. In combination with a Arthroscopy. 2003;19(5):531–9.
6. Wilk KE, Meister K, Andrews JR.  Current concepts
repetitive distention of the anterior capsule, in the rehabilitation of the overhead throwing athlete.
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perior translation of the humeral head. Due to 7. Braun S, Kokmeyer D, Millett PJ.  Shoulder inju-
the contact of the articular-sided insertion of ries in the throwing athlete. J Bone Joint Surg Am.
2009;91(4):966–78.
the supraspinatus and infraspinatus tendon 8. Fleisig GS, Andrews JR, Dillman CJ, Escamilla
and the posterosuperior glenoid rim, a PSI RF.  Kinetics of baseball pitching with implica-
develops. Finally, rotator cuff tears as well as tions about injury mechanisms. Am J Sports Med.
lesions of the biceps anchor complex and pul- 1995;23(2):233–9.
9. Fleisig GS, Barrentine SW, Escamilla RF, Andrews
ley system occur. JR.  Biomechanics of overhand throwing with impli-
• Based on clinical examination and imaging, cations for injuries. Sports Med. 1996;21(6):421–37.
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was developed including the joint capsule, skeletally immature throwers: review and current
thoughts. Br J Sports Med. 2010;44(5):306–10.
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tendon complex. throwing shoulder: spectrum of pathology Part III: the
• Conservative therapy is based on a graded SICK scapula, scapular dyskinesis, the kinetic chain,
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12. Burkhart SS, Morgan CD, Kibler WB. The disabled
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strength, endurance and neuromuscular con- pathoanatomy and biomechanics. Arthroscopy.
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 Sports Trauma: Elbow
24
Sebastian Siebenlist, Lucca Lacheta,
Christine L. Redmond, and Gregory I. Bain

24.1 A
 cute Elbow Injury: Simple locations are rare, and their occurrence is limited
Dislocation to pediatric cases or with concomitant fractures.
The exact injury mechanism is still subject of cur-
24.1.1 Introduction rent debates in literature. O’Driscoll proposed the
theory of the posterolateral ­ rotation—so-called
By definition the simple elbow dislocation is Horii circle—with soft tissue disruption from the
described as one without concomitant fractures lateral side to medial side caused by a fall on the
with the exception of small avulsions of less than outstretched forearm. This hypothesis is currently
2 mm [1, 2]. The incidence for simple elbow dis- most cited and accepted trauma mechanism [5, 6].
location ranges from 3 to 9 per 100,000 individu-
als through different periods of life with male
adults at highest risk especially following sports or 24.1.2 Clinical Findings
accidents [1–4]. Up to date, no validated classifi-
cation exists for simple elbow dislocations. A con- The key to diagnosis is in taking the history as
sensus to descriptively grade the injury according precisely as possible to get information about the
to direction of elbow dislocation exists. Posterior injury patterns and mechanism with special
and posterolateral dislocations are most com- respect to arm position at the time of impact. In
monly observed, while anterior and divergent dis- the absence of deformity, some patients report
spontaneous or self-reduction, while others just
complain of pain and swelling. These patients
S. Siebenlist · L. Lacheta have to be asked about additional clicking events,
Department of Orthopaedic Sports Medicine, feelings of instability, or deformity at the time of
Technical University of Munich, Munich, Germany
e-mail: [email protected]; injury. An accurate physical examination and
[email protected] focused neurovascular evaluation should be per-
C. L. Redmond formed. The patient should be instructed to
RAP Division, SALHN, SA Health, actively move his injured elbow to grossly verify
University of South Australia, Adelaide, SA, the muscular joint stabilization. During the first
Australia days after reduction, medial and/or lateral bruises
G. I. Bain (*) can occur as a sign of soft tissue disruption
Department of Orthopaedic Surgery, Flinders including the muscular fascia.
University, Flinders Medical Centre,
Adelaide, SA, Australia Anteroposterior and lateral radiographs are
e-mail: [email protected] obligatory to confirm dislocation and ­direction

© ISAKOS 2019 317

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_24
318 S. Siebenlist et al.

as well as to determine or exclude associated 24.1.4 Rehabilitation

­fractures even in patients with already self- or
spontaneous reduced elbow joint. Ligament Most simple elbow dislocation injuries are stable
integrity can be assessed by taking an X-ray postreduction, and patients may return to sport in
while stress testing but is often difficult due to a hinged brace approximately within the first
pain. Anteroposterior and lateral radiographs 2–4 weeks after injury. The criterion for return to
should be repeated within the first week after sport is that the athlete has to demonstrate pain-­
reduction to rule out secondary decentration with free range of motion without neurologic dysfunc-
persistent drop sign (ulnohumeral ­ distancetion. There is a need for research on the optimal
>3–4 mm) as a sign for persistence instability [7].period of immobilization, but our protocol is that
To achieve a better overview of involved soft the brace protects the healing of soft tissue injury
tissue structures and grade of injury, MRI exami- and has to be worn for at least 8  weeks for all
nation is recommended (ideally within the first athletic activities.
week post-injury). The MRI can illustrate the In the first few days postoperatively, the
continuity of the static ligamentous constraints patient has a splint to protect the repair as swell-
and the dynamic muscular stabilizers. To assess ing subsides. After the first week, the athlete
joint congruity, MRI should be performed with will be fitted with a hinged brace. Early goals
extended elbow (if possible). Radiocapitellar and are to manage pain and inflammation and regain
axial ulnohumeral incongruity in patients with active elbow movement. Initially, range of
posterolateral rotatory instability can be detectedmotion is limited but is gradually increased over
by the use of specified cutoff points as described 3–6 weeks to full arc of motion. Strengthening
by Hackl et al. [8]. of the shoulder, wrist, and hand can be initiated
Ultrasound examination can help to assess the with isometric exercises through multiple joint
collateral ligaments and the common flexor and angles. As pain and inflammation settle, goals
extensor origins by dynamic testing. However, in are to restore pain-free movement and strengthen
the acute injury, this examination is limited by the upper limb to return to pre-injury function.
patient compliance, pain, swelling, and investiga- Therapists should be aware of heterotopic ossi-
tor’s experience. fication as a possible complication, if there are
increasing pain and loss of movement of the
elbow joint [9]. Most athletes return to sports in
24.1.3 Treatment Options a brace within 3–6  weeks postoperatively and
continue activities in a brace until 3–4 months,
Most patients can be treated with non-operative depending on surgical procedure, strength, and
management following closed reduction. Early function.
mobilization does not increase the risk of re-­ The literature demonstrates clearly that con-
dislocation and leads to improved functional out- servative treatment for management of simple
comes. A rehabilitation program including elbow dislocations leads to favorable outcomes
active-assisted and active exercises is crucial to [4, 10–14]. There is evidence that prolonged
maintain concentric reduction while injured soft immobilization has detrimental effects, so cast
tissues are healing. immobilization should not exceed 2 weeks (flex-
Operative management is indicated if a closed ion contractures of 20–30° seen in patients with
reduction is not possible or in case of open dislo- immobilization beyond 3–4  weeks). There are
cations and vascular injuries and when recurrent benefits to early mobilization, and patients have
instability occurs when the elbow is flexed to less returned to work and daily activities earlier, com-
than 30°. pared to cast immobilization, when managed
24  Sports Trauma: Elbow 319

with sling immobilization for 2 weeks and active are compared to the uninjured contralateral
range of motion within the first week—using an elbow, to rule out generalized laxity.
overhead motion protocol [11, 14]. Plain radiographs are indicated and may iden-
tify intra-articular lesions, such as loose bodies or
osteophytes. A dynamic X-ray examination can
24.2 Valgus Instability be performed to confirm the clinical diagnosis. A
in Throwing Athletes MRI scan can identify tendinosis, partial and
complete rupture of the MUCL, as well as osteo-
24.2.1 Introduction chondral defects in the lateral compartment. A
CT scan can identify loose bodies and impinge-
Valgus injury is an uncommon injury that has been ment due to osteophytes.
identified in athletes that throw repeatedly, espe-
cially baseball pitchers. It has also been identified
in javelin throwers and tennis players and follow- 24.2.3 Treatment Options
ing trauma. Valgus instability develops from the
tensile forces on the medial compartment and Conservative treatment is indicated for MUCL
compression to the lateral compartment. The ten- strains and partial ruptures and where there are
sile forces are applied to the medial stabilizers, no intra-articular lesions. The initial management
consisting of the medial ulnar collateral ligament is rest from sport and pain management. A struc-
(MUCL) and the common flexor origin (CFO). tured rehabilitation and return to sport program
Compression and shear forces are applied to the can be started when the symptoms have settled.
radial head and capitellum. An elbow orthosis may be prescribed to reduce
The MUCL is protected by the stabilizing valgus stress [14].
effects of the flexor and pronator muscles during Surgical MUCL repair is indicated for acute
the throwing action. When these muscles MUCL rupture, within 3 weeks of injury. MUCL
become fatigued from overtraining, the forces reconstruction is indicated for late presentations
generated during throwing can exceed the maxi- of MUCL rupture or chronic persistent strained
mum load capacity of the MUCL.  Repeated MUCL that has failed conservative treatment
microtrauma to the medial elbow compartment (Fig. 24.1). The reconstruction involves inserting
can result in elongation and structural weakness
of the MUCL [15].

24.2.2 Clinical Findings

The diagnosis of valgus instability is primarily

made by clinical findings. Range of motion may ulna
be increased in the throwing arm due to an elon- humeral
gated MCL.  Pain is provoked by palpating the
sublime tubercle or the medial epicondyle.
Increased gapping of the joint can be observed
when manual valgus stress is applied in 0° and
15° [15]. The milking maneuver test applies
­valgus stress especially to the anterior MUCL
bundle and results in pain and/or gapping in Fig. 24.1  Shuttled graft (yellow arrow) through the ulnar
patients with severe valgus instability. All tests bone tunnels
320 S. Siebenlist et al.

a tendon graft, such as the palmaris longus, ham- original level of sports in 81–92% of cases
string, or allograft. [21–23].

24.2.4 Rehabilitation 24.3 Capitellar Osteochondritis

Dissecans
The initial management for strains and partial
ruptures is to moderate pain and modify activities, 24.3.1 Introduction
including resting from sport. When symptoms
settle, physical conditioning and coaching the The capitellum begins ossification at the age of
proper mechanics for the throwing action are part 1–2 years, and the process is completed between
of a structured rehabilitation program. Guidelines the ages of 14 and 17. Growing, young bones,
on returning to sport and resuming throwing have which are highly vasculated, are thought not to
been developed [16]. Strengthening, flexibility, resist compression well and can develop com-
dynamic stabilization, and plyometric exercises pression fractures. These subchondral compres-
are used to retrain the throwing action, which sion (micro-)fractures present with bone edema
involves the transfer of forces from the legs and on MRI, which compromises circulation, leading
trunk to the throwing arm, in a sequence of accel- to avascular necrosis (AVN) and subsequent
erating and decelerating movements. loose body formation. The AVN is characterized
Postoperative rehabilitation programs after as posttraumatic and therefore is a different entity
ligament and tendon reconstruction are based on compared to the juvenile osteochondrosis of the
the intraoperative findings and the stages of tis- capitellum, which has an atraumatic, asymptom-
sue healing which predict the strength of atic onset in children under the age of 10 years.
repaired structures. Goals are established that
are tailored to the symptoms and demands of the
patient. 24.3.2 Clinical Findings
Rehabilitation commences after a period of
immobilization. Following ligament or tendon The major complain in patients with OCD is lat-
reconstruction, a posterior cast is applied at 90° eral elbow pain while throwing, which may persist
flexion for 3–4  days, followed by a removable at rest. During physical examination, the radio-
elbow orthosis for 6  weeks. For MCL recon- capitellar joint can be tender to palpation. Chronic
struction, motion in the orthosis is limited to OCD, with loose body formation, can present with
20–60° for the first 2  weeks, then 10–110° at loss of motion, pain aggravated by flexion, flexion
3–4  weeks, and full range by 6  weeks. Active contracture, and possible occasional snapping.
motion is performed within these limited arcs of Simple radiographs can show osteopenia and
motion. The supine, overhead motion protocol chronic OCD changes, such as loose bodies. MRI
allows gravity and the triceps action to act as can be used to stage the lesion and helps to decide
joint stabilizers [14]. Muscle strengthening starts whether to proceed with conservative or surgical
when protected movement finishes and the ath- treatment.
lete may be ready to return to sport from
12 weeks postoperatively.
24.3.3 Treatment Options

24.2.5 Clinical Outcome Stable lesions (MRI grade 1 or 2) can be treated

conservatively with relative rest. Healing might
The success rate of the currently most common take up to 12 months. If symptoms do not change
surgical procedures for MUCL reconstruction is over this long period, drilling of the capitellum to
up to 93% [17–20]. Athletes return to their stimulate healing can be discussed with the patient.
24  Sports Trauma: Elbow 321

Our approach is to surgically debride the

capitellar footprint, if the fragment is sur-
rounded by fluid, and refix the fragment with
screws or pins. Loose bodies are removed in
chronic injuries.

24.3.4 Rehabilitation

Conservative treatment initially consists of a

lengthy period of rest and avoiding the aggravat-
ing activity in sport. When the symptoms have
settled, which is more likely in an early lesion,
active therapy can commence. Rehabilitation
progresses through restoring elbow range of
motion and strength and undertaking an interval
throwing program prior to returning to sport.

24.4 Valgus Extension Overload

Valgus extension overload (VEO) is a syndrome

of symptoms and physical findings associated Fig. 24.2  Valgus extension overload (VEO) syndrome:
overuse of the medial ligamentous stabilizers with
with throwing activities and usually accompanied increased compression load to the posterolateral part of
by valgus instability [24]. The ulnar collateral the elbow from [24]
ligament (UCL) experiences an average of 64 Nm
of valgus stress with each overhead throw, of
which approximately 50% has to be taken by the sports) and start specific exercises to increase the
UCL [25]. The ulnar collateral ligament (UCL) is flexor pronator strength and rotator cuff strength.
the main ligamentous stabilizer to the medial part Nonsteroidal anti-inflammatory medication may
of the elbow. Repetitive overuse that increases also be used in the acute stage for a short period.
UCL laxity will also result in increased compres-
sion to the lateral articular part of the elbow and
the fossa olecrani (Fig. 24.2). Over time, degen- 24.5 Little Leaguer’s Elbow
erative changes such as osteophytes rise slowly in
the posterolateral compartment [26]. The diagno- “Little leaguer’s elbow” summarizes all possible
sis of VEO can typically be made by a thorough overuse elbow injuries in young athletes and was
history and physical examination. Additionally, first described by Brogan and Crow who reported
simple radiographs or MRI can confirm degen- radiographic changes occurring in young throw-
erative changes. Typical complaints for VEO are ers’ elbows. The most common injuries include
medial pain at the onset of arm acceleration medial epicondyle apophysitis, capitellar osteo-
(UCL) and posterior pain at ball release when the chondritis dissecans, radial head deformation,
elbow reaches full extension (posterolateral flexion contracture, and olecranon injury. Triceps
structures). Athletes with isolated VEO without apophysitis, posterior impingement, radiocapi-
structural UCL issues should be treated with tellar meniscoid lesions, loose body formation,
active rest from throwing (approximately ulnar collateral ligament attenuation, and nerve
10–14  days; in athletes with prolonged symp- disorders may also result from extensive
toms, 4–6  weeks; afterward, gradual return to throwing.
322 S. Siebenlist et al.

24.6 Distal Biceps Tendon In these cases, we consider that the tendon is
Rupture palpable, but will yield to pressure when per-
forming the hook test [32] (Table 24.2).
24.6.1 Introduction

An acute distal biceps tendon rupture is an injury 24.6.2 Clinical Findings

that has been associated with weight lifting,
smoking, or anabolic steroid abuse. The mecha- The distal biceps tendon rupture is primarily a
nism of injury is usually a sudden eccentric force clinical diagnosis. The athlete will report sudden
applied against the flexing elbow. Men in their pain and loss of flexion and supination strength,
middle decades (40–60 years) and the dominant sometimes accompanied by an audible “pop”
arm are at higher risk for distal biceps tendon while the flexed elbow is eccentrically loaded.
ruptures [27, 28]. With a complete rupture, the muscle belly will
In contrast to acute distal biceps tendon rup- displace proximally, giving the appearance of a
tures, partial ruptures, chronic tendonopathies, “pop-eyed” deformity. The hook test can confirm
and bicipitoradial bursitis are less common and the discontinuity of the tendon in the antecubital
associated with activities requiring repetitive fossa in case of complete ruptures [27].
movements, which occur without a traumatic MRI using the FABS view will allow assess-
event [29, 30]. ment of the biceps tendon and its attachment
The distal biceps tendon has an area of rela- [34]. Complete tears with retraction are usually
tively poor vascularity, between the proximal easily identified with loss of continuity of the ten-
supply by the brachial artery and the distal supply don to the radial tuberosity. Partial tears may
by the posterior recurrent artery. This hypo-­ have more subtle changes, including tendonitis,
vascularized zone may predispose the distal bursal effusion, and signal changes near the distal
biceps tendon to rupture [31]. The distal biceps attachment. The partial ruptures can be graded
tendon can also be subjected to mechanical (more or less than 50%) [35].
impingement from the ulna shaft during forearm
rotation, which may predispose the tendon to
degeneration, prior to rupture [31]. 24.6.3 Treatment Options
Several clinical tests that aid in the diagnosis
of complete rupture have been described. The recommended treatment will depend upon the
O’Driscoll described the hook sign (Table 24.1), grade of biceps tear as defined by the clinical assess-
where the patient actively supinates and flexes ment, MRI, and operative findings. Tables  24.1 and
the elbow to 90°. The examiner finger is hooked 24.2 provide an assessment and algorithm.
under the distal biceps tendon from the lateral Conservative treatment is indicated for partial
side. In the complete tear, the hook test is consid- tears and complete tears in low-demand individu-
ered the best test in making the diagnosis [27]. als. Some athletes may elect to delay surgery
However, there are a number of cases where it until the end of the playing season; however, this
can be difficult to interpret. These include pre-
sentations where: Table 24.1  Hook test: clinical assessment and interpre-
tation (Modified from [32])
1. The biceps sheath remains attached distally Hook test Grade Tendon
despite tendon retraction. Normal N Taut, unyielding, symmetrical
2. A pseudotendon bridges the gap in a chronic Yielding A1 Taut, but yielding, asymmetrical
tear [33]. Lax A2 Complete tear
3. The partial or single head ruptures. Absent A3 Tendon retracted
24  Sports Trauma: Elbow 323

Table 24.2  Distal biceps pathologies: classification, assessment, and management (Modified from [32])
Hook
Grade Injury Clinical test MRI Management
0 Tendinosis, bursitis Atraumatic, tender, N Bursitis, effusion, Non-operative,
swollen tendinosis bursectomy, biopsy
1A Low-grade partial tear Pain, weakness N, A1 Bursitis, effusion, Endoscopic
(<50% footprint) against resistance footprint irregularity debridement
1B Isolated head rupture Pain, weakness A1 Isolated head avulsion Repair isolated head
against resistance
1C High-grade partial tear Pain and weakness A1 Incomplete footprint Complete tear and
(>50% footprint) detachment repair
2 Complete tendon Tendon medialized by A2 Detached tendon within Repair
rupture, lacertus intact lacertus, weak sheath
3 Tendon and lacertus Retracted muscle, A3 Retracted tendon and Repair
rupture retracted marked weakness muscle
4A Chronic rupture, Marked weakness A1, A2 Pseudotendon to Repair
lacertus intact footprint (A1)
Contracted tendon in
sheath (A2)
4B Chronic tendon and Retracted muscle, A3 Retracted tendon within Repair in flexion or
lacertus rupture marked weakness fibrous cocoon use tendon graft

increases the risk of surgical complications and

the need for a tendon graft [36].
For complete acute tears, the natural history is
to continue to have weakness [37]. This reduces
the ability to sustain supination power and pres-
ents as fatigue weakness, cramps, and pain with
repetitive activities. Therefore for acute complete
tears, early surgery is recommended, to restore
strength and prevent these symptoms. Ideally, the
procedure is done within 3  weeks to avoid scar
formation [38].
Several fixation techniques are available for
repair: extracortical button, intramedullary but-
Fig. 24.3  Postoperative X-ray after distal biceps tendon
ton, interference screw, and suture anchor [39– repair with the double intramedullary button technique
42]. There is a trend toward a two-point fixation, [42, 44]
as there are two functional tendon bundles [43].
The single-incision approach is more commonly
used now as there is less risk of synostosis and Partial distal biceps tendon repairs are an area
loss of forearm rotation (Fig. 24.3). of interest. They can occur in the patient who has
Schmitt has highlighted the importance of an eccentric load to the biceps, as seen in the com-
anatomic repairs of the distal biceps tendon [45]. plete tears. Repetitive activities can also cause
For this reason, newer methods have been aimed bursitis and partial tear as the tendon impinges
at performing a true anatomic repair [46–49]. between the radius and ulna. Examination find-
Comparative studies have demonstrated superior ings can be subtle, and as such, the diagnosis is
supination and flexion strength when an anatomi- often missed. Clinical findings of partial distal
cal repair is performed [49]. biceps tendon tears and bursitis include [32]:
324 S. Siebenlist et al.

1. Biceps muscle pistoning. During active fore- 24.7 Lateral Epicondylitis

arm rotation, the biceps musculotendinous
junction will normally migrate proximally 24.7.1 Introduction
and distally. In the complete tear, the muscle
will retract and budge. In the partial tear, the Symptoms of lateral epicondylitis usually
muscle may be flatter due to atrophy and develop from activities that involve repetitive
translate less. motions and overuse of the wrist extensors or
2. Passive pronation is restricted and painful.
supinator muscles. The most common affected
There may also be crepitus. muscle is the extensor carpi radialis brevis. Over
3. Localized discomfort and tenderness over the time, a chronic tendonosis develops, and
radial tuberosity with 90° flexion and full increased cross-linkage and collagen deposition
supination against resistance. can be seen within the tendon. Ongoing accumu-
4. Yielding hook test. lation of load may then lead to structural failure
5. Weakness of supination in maximal elbow
of the tendon with partial or complete rupture.
flexion.

Diagnostic endoscopy provides visualization 24.7.2 Clinical Findings

of the tendon, bursa, and radial tuberosity [46,
47]. Therapeutic endoscopy includes bursec- Patients typically complain pain around the lat-
tomy; release of the tendon and repair can be per- eral epicondyle that radiates into the common
formed [46, 47, 49]. extensor muscles of the forearm. Pain scale can
vary from mild to severe with affection of daily
activities. Tenderness is more likely to be found
24.6.4 Rehabilitation on palpation at the insertion site of the extensor
carpi radialis brevis just anterior to the lateral
A posterior cast is applied at 90° flexion for epicondyle. A number of tests have been
3–4 days, and then an elbow orthosis is worn for described to reproduce the pain. They all actively
6 weeks. In the first 2–4 weeks of rehabilitation, contract the wrist extensor muscle group against
movement into the last 20° of extension is resistance to recreate the pain.
restricted, in order to protect the repair. Active
supination is restricted by the orthosis for the first
6  weeks. Resistance training can start after the 24.7.3 Treatment
orthosis is removed and full active movement is
achieved. Strengthening is progressed with func- First-line treatment is non-operative treatment
tional training directed to the specific sport, and consisting of rest, avoidance of aggravating activ-
the athlete may be ready to return to sports at ities, and modification of behavior during work,
12 weeks. sport, and daily life accompanied by anti-­
inflammatory medication in the acute period.
This should lead to a remission of the symptoms.
Bisset et al. showed that non-operative treatment
24.6.5 Clinical Outcome leads to similar results after 52 weeks compared
to corticosteroid injections. Bisset et al. described
Clinical outcomes are generally good following a positive effect of physical therapy in reducing
surgical repair of distal biceps tendons (Redmond, pain with focus on preserving range of motion
2016 #382) [17, 18, 21–23, 50]. Anatomic repairs and eccentric strengthening exercises. This treat-
have been demonstrated to have better strength ment was found to be superior to conservative
[51]. treatment alone at 6 weeks.
24  Sports Trauma: Elbow 325

Epicondylar counterforce braces lead to a

reduction of tension in the forearm extensors.
Several studies have shown a positive effect on
pain relief compared to placebo orthosis; however,
meta-analysis did not find one type of brace to be
better than others.
Surgery is preserved for patients who failed
non-operative treatment or with complete tear of
the common extensor origin.

24.8 D
 istal Triceps Tendon
Rupture Fig. 24.4  Common bony distal triceps avulsion (“flake
of bone”) (orange circle)
24.8.1 Introduction
Plain radiographs are needed to rule out com-
The distal triceps tendon rupture is a rare injury mon bony avulsion (“flake of bone”) of the inser-
that has been reported in professional football tion (Fig. 24.4).
players [52]. It can occur from a fall on the out- To grade partial or total rupture and assess
stretched hand or direct trauma [53]. An eccentric retraction, an MRI scan or ultrasound examina-
loading of the contracting triceps muscle pro- tion should be performed. Especially in chronic
duces osseous avulsions of the bony insertion at cases, the MRI should be used to judge tendon
the olecranon or occasionally at the musculoten- retraction and muscle quality.
dinous junction [54–56].
Spontaneous ruptures have also been reported
in weight lifters and following elbow arthroplasty 24.8.3 Treatment Options
[57, 58]. They have been associated with corti-
sone and steroid abuse and some systemic dis- Conservative management is indicated for partial
eases [30, 59]. distal triceps rupture (<50%), where some exten-
sion strength is maintained, and for musculoten-
dinous ruptures [60]. Immobilization in a cast or
24.8.2 Clinical Findings orthosis with flexion is restricted to 30° for
4–6 weeks. Full motion may recover by 12 weeks
The diagnosis of a distal triceps tendon rupture and full extension strength by 6–9 months [60].
can be made clinically. The tendon gap at the dis- Surgery is indicated for complete ruptures and
tal triceps may be difficult to palpate due to soft performed within 3 weeks to minimize scar for-
tissue swelling. Triceps strength can be tested mation. Techniques include transosseous cruciate
against gravity by asking the patient to extend the repair technique [61], knotless suture-bridge
elbow, with the arm overhead and the elbow at repair technique [62], and V-shaped double-row
90° of flexion. In case of partial ruptures, an repair technique [63] (Fig. 24.5).
active extension can be possible but with
decreased strength compared to the uninjured
contralateral site. Additionally, in complete rup- 24.8.4 Rehabilitation
tures, a manually applied compression of the
muscle belly does not lead to elbow extension There is insufficient evidence to determine the
(equivalent to Thompson test for Achilles optimal position in which the elbow is immobi-
tendon). lized, in order to protect the triceps repair.
326 S. Siebenlist et al.

Fig. 24.5  Postoperative X-ray, two proximal suture anchors and one distal unicortical button (left); cadaver demonstra-
tion, V-shaped distal triceps reconstruction with intramedullary placed distal button (right)

A ­posterior cast is applied (in 90° flexion or near 24.8.5 Clinical Outcome
full extension, depending on surgeon preference)
for 3–4  days, followed by a removable elbow Surgical repairs have good functional outcomes
orthosis for 6 weeks. Passive- and active-assisted with minimal re-ruptures [64] and high patient
therapy commences once the cast is removed. satisfaction [65].
Active motion is limited to 0–60° of flexion for
the first 6 weeks. Rehabilitation starts by control-
ling pain and swelling and gently moving the 24.9 Olecranon Stress Fracture
elbow through the available range. Active exten-
sion against resistance is then introduced when 24.9.1 Introduction
the orthosis is removed. A structured approach to
strengthening the arm and returning to functional Olecranon stress fractures are due to repetitive
activities is advised, as the triceps muscle tends tensile forces generated by the triceps tendon or
to be weaker than the biceps. Return to sports mechanical impingement. They are rare and usu-
may be possible at week 12, if the athlete has ally in baseball pitchers, javelin throwers, weight
recovered full strength. lifters, or gymnasts [66–68].
24  Sports Trauma: Elbow 327

24.9.2 Diagnosis 6. O’Driscoll SW, Bell DF, Morrey BF.  Posterolateral

rotatory instability of the elbow. J Bone Joint Surg
Am. 1991;73(3):440–6.
Athletes report a long-standing history of pos- 7. Pipicelli JG, Chinchalkar SJ, Grewal R, King
terolateral elbow pain, aggravated by throwing. GJ.  Therapeutic implications of the radiographic
The clinical examination and plain radiographs “drop sign” following elbow dislocation. J Hand
Ther. 2012;25(3):346–53; quiz 354. https://doi.
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or CT scans usually demonstrate the stress 8. Hackl M, Wegmann K, Ries C, Leschinger T, Burkhart
fracture. KJ, Muller LP.  Reliability of magnetic resonance
imaging signs of posterolateral rotatory instability
of the elbow. J Hand Surg Am. 2015;40(7):1428–33.
https://doi.org/10.1016/j.jhsa.2015.04.029.
24.9.3 Treatment 9. Winkler S, Wagner F, Weber M, Matussek J, Craiovan
B, Heers G, Springorum HR, Grifka J, Renkawitz
Initial management is to avoid the aggravating T.  Current therapeutic strategies of heterotopic ossi-
fication—a survey amongst orthopaedic and trauma
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Ross G, McDevitt ER, Chronister R, Ove
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 Sports Trauma: Wrist and Hand
25
Margaret W. M. Fok, Christine L. Redmond,
and Gregory I. Bain

25.1 Introduction When the athlete “hangs up their boots,” it is

these hand and wrist injuries that continue to
Wrist and hand injuries are common entities in cause them ongoing pain and disability. It is com-
many contact and ball sports [1, 2]. Wrist injuries mon for the following conditions to present late:
often occur from a fall, and the finger can be
injured attempting to catch a ball or from being • Wrist—scaphoid fractures, scapholunate (SL)
caught in clothing. Early assessment and man- instability, and TFCC tears
agement provide the best outcome. But, referral • Hand—PIP joint dislocations, FDP tendon
to an experienced orthopedic hand surgeon is fre- ruptures, and skier’s thumb
quently delayed. The athlete continues to com-
pete with a painful wrist or swollen finger, which The role of the hand therapist is critical in
can lead to further injury of the secondary stabi- rehabilitation following injury and surgery. They
lizers and articular surfaces. It is common for the provide valuable education, splints, edema con-
athlete to present 6 months after a fall with a stiff, trol, and exercises. The exercises are directed
painful, unstable joint with degenerative arthritis. toward tendon guiding, joint mobility, strength,
Unfortunately, these late presentations are a and sports-specific training drills.
much greater challenge to manage. It is too late to
simply reduce the joint or the fracture, so a sal-
vage procedure such as a fusion may be required. 25.2 Acute Wrist Injury

For the acute wrist injury, our clinical decisions

are based on an algorithm (Fig.  25.1). When
M. W. M. Fok
Department of Orthopaedics and Traumatology, assessing a wrist, we start with a general history
Queen Mary Hospital, The University of Hong Kong, and examination. The swelling and tenderness on
Hong Kong, China palpation can help localize injured structures.
C. L. Redmond Physical examination can suggest whether the
Flinders Medical Centre, Adelaide, SA, Australia injury is a fracture or a soft tissue sprain. For
e-mail: [email protected] example, displaced distal radius fracture and
G. I. Bain (*) perilunate dislocation usually present with dif-
Department of Orthopaedic Surgery, fuse swelling, pain, and limited range of move-
Flinders University, Flinders Medical Centre,
Adelaide, SA, Australia ment of the wrist. As there are many structures in
e-mail: [email protected] the wrist that can be injured, it is common to

© ISAKOS 2019 331

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_25
332 M. W. M. Fok et al.

Fig. 25.1  Algorithm in Elevation, Ice,

managing acute wrist First Aid Splint,
injuries Immobilization
Location of swelling,
Physical
tenderness,
Examination
neurovascular integrity
Fracture, Carpal
X ray stability

Fracture No fracture / Carpal

Instability

Fracture
MRI Bruising, Fracture,
CT pattern
AVN, Ligament Injury

Unstable Stable
Fracture Bone Bruising Carpal
Fracture / Fracture Instability

Splint or Surgery Surgery or

Surgery in High Demand Splint

c­ ategorize presentations as either radial- or ulnar-­

sided disorders of the wrist.

25.2.1 Imaging

Standard radiographs (AP and lateral views) of

the wrist are performed. Scaphoid radiological
views are indicated if there is tenderness in the
anatomic snuff box. In cases of suspected scaph-
olunate instability and perilunate dislocation, the
identification of a break in the Gilula lines [3] is
helpful for diagnosis on an AP view of the wrist
(Fig. 25.2). Lateral view is also used to assess the
position of the lunate in cases of suspected carpal
instability. Dorsal intercalated segmental insta-
bility (DISI), where the lunate tilts dorsally with
respect to the axis of the radius and makes a
scapholunate angle of >60°, suggests scapholu-
nate dissociation. In contrast, volar intercalated
segmental instability (VISI), where the lunate
flexes with respect to the axis of the radius and
makes a scapholunate angle of <30°, suggests an Fig. 25.2  AP radiograph wrist showing that the Gilula
injury to the lunotriquetral ligament. lines are broken
25  Sports Trauma: Wrist and Hand 333

Further imaging includes computer tomogra- t­ ubercle while bringing wrist from ulnar deviation
phy (CT), which allows better understanding of to radial deviation) imply SL instability [8].
the osseous structures, and MRI which is useful
for the soft tissues, especially the scapholunate 25.2.3.1 Scaphoid Fracture
ligament and the triangular fibrocartilage com- Scaphoid fractures can be problematic as they
plex (TFCC). can be difficult to diagnosis and are prone to mal-
Third-line investigations include a SPECT union and non-union. If the scaphoid heals with a
scan [4], which is a hybrid of bone scan and CT “humpback deformity,” then it will affect the
scan. It provides the very high specificity of the kinematics of the wrist. A delay in diagnosis
bone scan and the anatomic localization of the increases the risk of scaphoid non-union, which
CT scan. The 4D CT scan is useful to assess the predisposes the wrist to degenerative arthritis in
dynamic component of carpal instability [4]. the following 10–20 years [9]. Surgical manage-
ment of non-union of the scaphoid, with wrist
immobilization for 6–10  weeks, has about 85%
25.2.2 Acute Carpal Tunnel success. Limited and full wrist fusions are indi-
Syndrome cated for patients with arthritis and for the non-­
unions which fail to heal with surgery.
Acute carpal tunnel syndrome can be a complica- Plain radiographs of the wrist (AP, lateral, and
tion of a wrist injury [5, 6]. Symptoms include scaphoid views) are the initial imaging. In cases
severe pain and paresthesia in the radial 3½ dig- where an undisplaced fracture of the scaphoid is
its. This complication has been associated with suspected, yet with a normal X-ray, a CT or MRI
distal radius fracture or perilunate dislocation scan may be useful for diagnosis [10, 11]. If scans
and requires urgent surgery, to decompress the are not readily available, a short arm cast (includ-
median nerve. ing thumb immobilization of suspected scaphoid
Depending on the expertise of the surgeon, fracture) is applied for 2  weeks for temporary
one-stage (e.g., fracture and joint fixation and immobilization. An undisplaced fracture can be
open carpal tunnel release) or two-stage opera- more readily seen on reassessment radiograph
tions (e.g., open carpal tunnel release and exter- due to the bone resorption at the fracture site.
nal fixator followed by internal fixation when the Undisplaced fractures can be managed with
swelling has subsided) are indicated [1, 5, 7]. cast immobilization for 8  weeks, and 90% will
unite [12]. Early mobilization can be permitted if
internal fixation is performed [13–15]. Internal
25.2.3 Radial Wrist Pain fixation is usually recommended for fractures in
the proximal pole of the scaphoid, as they are asso-
For acute radial wrist pain and swelling, scaphoid ciated with a non-union rate of 50% [16]. Displaced
fracture is the most common condition [1], fol- scaphoid should be managed with internal fixation
lowed by radial styloid fracture and scapholunate to prevent non-union and deformity.
dissociation. A careful palpation to feel the exact
location of tenderness, and knowing the underly- 25.2.3.2 Radial Styloid Fractures
ing anatomical structures, assists in the diagnosis. For radial styloid fracture, it is important to look
(e.g., tenderness anatomical snuff box—scaphoid for associated scapholunate dissociation and
fracture). Dynamic tests of instability can provide more importantly perilunate dissociation [17].
additional information that may be missed by pal- Surgical intervention with joint reduction and
pation alone. Pain and instability elicited on fracture fixation is indicated when carpal insta-
Watson test (i.e., compressing the scaphoid bility is part of the presentation.
334 M. W. M. Fok et al.

25.2.3.3 Scapholunate Instability on palpating the SL junction but no obvious

Scapholunate (SL) instability is less commonly increase in SL gap is noted on radiograph, tem-
seen than scaphoid fracture but is often missed. porary immobilization with a removal wrist
The pain and swelling are usually less severe than splint may be given for 2–3 weeks, before reas-
the scaphoid fracture and are located more dif- sessing the wrist. For dynamic instability, both
fusely over the scapholunate region, rather than wrist immobilization of at least 8  weeks with
at the anatomical snuffbox. Static SL instability splint and surgical repair or debridement are
can be seen on AP or lateral views of the wrist. SL acceptable treatment options [19]. Exercises to
dissociation is diagnosed if SL gap is ≥3 mm on strengthen the wrist that use a strong grip are
the AP view [18], and dorsal intercalated seg- not permitted for at least 12 weeks, as making a
ment instability (DISI) is diagnosed when the fist is the classic stress test for SL ligament
scapholunate angle is greater than 60° on the lat- tears.
eral view of MRI (Fig. 25.3) [18]. Dynamic insta-
bility of the SL joint can be seen with clenched
fist AP radiograph of the wrist (SL gap of ≥3 mm) 25.2.4 Ulnar Wrist Pain
[18, 19]. Magnetic resonance imaging
(MRI) ± arthrogram or diagnostic wrist arthros- The common causes of acute ulnar wrist pain
copy can also be performed to assess the integrity from a traumatic injury include the following:
of the SL ligament. distal radioulnar joint subluxation/dislocation,
Surgical treatment for scapholunate dissocia- ECU subluxation/dislocation, and hook of
tion is achieved by ligament repair or debride- hamate fracture. It can be difficult to differentiate
ment, Kirschner wires, or a temporary SL screw, which structures are injured, but careful physical
followed by joint immobilization of at least examination and imaging help in making the cor-
8–12 weeks [10, 19, 20]. If tenderness is elicited rect diagnosis.

a b

Lunate
Capitate

SL

C
L CL

Radius

Scaphoid

Fig. 25.3  Schematic drawing (a) and lateral radiograph wrist (b) on how to measure scapholunate angle to determine
SL dissociation
25  Sports Trauma: Wrist and Hand 335

25.2.4.1 D  istal Radioulnar Joint and stabilize the ECU tendon is recommended
Instability [29, 30].
Distal radioulnar joint (DRUJ) subluxation or dis-
location can be the result of a fall on an out- 25.2.4.3 Hook of Hamate Fracture
stretched hand in athletes, such as gymnasts, Hook of hamate fracture can occur from the sud-
racquet players, hockey players, skiers, and pole den impact when the golf club hits the ground or
vaulters [1]. In some instances, a “pop” may have the baseball hits the very end of the bat [10].
been heard at the time of the injury. The joint may There is pain and localized tenderness over the
be dislocated or have spontaneously reduced. If hook of the hamate. It is easily missed, as it may
the joint is dislocated, reduction is warranted not be evident on plain radiographs. It is more
under anesthesia. easily seen in a carpal tunnel view or in the
The ballottement test can be used to elicit DRUJ ­supinated oblique view (hook of hamate view).
instability. In this test, the amount of displacement CT scan is preferred as it provided an excellent
of the ulnar head in supination, neutral, and prona- image of the fracture [10] (Fig.  25.4). Hook of
tion is compared to the contralateral wrist. hamate fracture can be managed conservatively,
Distal radius fractures and basal ulnar styloid but it can remain painful, as there is a 50% rate of
fractures are often associated with DRUJ insta- non-­union [31, 32]. They can be internally fixed,
bility [21–23]. DRUJ subluxation/dislocation is but excision is usually preferred [32].
usually a result of a triangular fibrocartilage com-
plex (TFCC) tear.
Conservative therapy with an above-elbow 25.3 Chronic Wrist Pain
brace to keep the forearm in supination or prona-
tion (depending on whether the DRUJ is stable at Chronic wrist pain in sport can develop from a
supination or pronation) for 6  weeks is well past acute injury that may not have been investi-
accepted [24]. Surgical repair or reconstruction gated at the time or may develop through over-
with either arthroscopic or open technique is usu- use. It can be classified by location similarly to
ally reserved when conservative therapy fails and acute wrist pain.
instability persists [25, 26].

25.2.4.2 E  xtensor Carpi Ulnaris 25.3.1 Radial Wrist Pain

Subluxation/Dislocation
ECU subluxation/dislocation is a result of the Athletes may have persistent pain from missed
disruption of its own fibro-osseous tunnel that scaphoid fracture or scapholunate dissociation.
lies over the distal ulna. A classic example is Patterns of posttraumatic wrist arthrosis may
when a rugby player attempts to grip the ball have developed, such as scaphoid non-union
tightly, with the wrist flexed and supinated, and advanced collapse (SNAC) and scapholunate
the ECU tendon subluxates from the sudden advanced collapse (SLAC) wrist. Imaging and
increase in the isometric force [27]. The athlete wrist arthroscopy are useful to diagnose these
would present with painful snapping or clicking conditions and to perform debridement of associ-
sensation of the tendon during pronation and ated synovitis. Reconstructive wrist surgery or
supination movements [25]. Ultrasound and even limited wrist fusion may be required in
MRI may be performed to support the diagnosis advanced cases.
but is usually not necessary. Early diagnosis of
ECU tendon subluxation can be treated with a 25.3.1.1 de Quervain’s Disease
short arm cast or split for 1–3 months [10, 28]. de Quervain’s disease, stenosing tenosynovitis of
However, for cases with delayed presentation, the first extensor compartment, is caused by
surgical intervention to reconstruct the sheath repeated movement of the thumb and wrist in
336 M. W. M. Fok et al.

a b

Fig. 25.4  Hook of hamate fracture: (a) AP radiograph wrist showing no obvious fracture of the carpal bone, (b) MRI
axial cut of carpal bones showing hook of hamate fracture

racquet sports, rowing and golf [28]. There are symptoms, and their comparative prevalence in
pain and tenderness along the first extensor com- sports, it can be a diagnostic challenge. The other
partment of the wrist. Finkelstein’s test is positive less common but frequently missed conditions
when pain is elicited by ulnar deviating a fisted are ulnar nerve irritation and ulnar artery
wrist, with the thumb in the palm [33]. This diag- thrombosis.
nosis can be further confirmed when the test is Like radial wrist pain, clinical assessment uti-
negative with the thumb out of the fist. It is a lizes identification of localized tenderness. On
clinical diagnosis, based on history and examina- examination, palpate for tenderness over the
tion. Imaging is only used to rule out other diag- ulnar styloid, TFC, ulnar head, lunotriquetral
nosis, e.g., missed scaphoid fracture or first ligament, and hook of hamate. Additional investi-
carpal-metacarpal joint degeneration. gation like X-ray, CT, MRI, or nerve conduction
Treatment includes rest, NSAIDs, and study may be necessary.
forearm-­based thumb splint [34]. Corticosteroid
injection into the tendon sheath is often success- 25.3.2.1 E  xtensor Carpi Ulnaris
ful [35–37]. Surgical release is performed if non-­ Tendinopathy
operative treatment fails. ECU tendinopathy is a condition that results from
chronic loading of the tendon, due to repetitive
flexion and extension of the wrist, particularly in
25.3.2 Ulnar Wrist Pain supination. This is most frequently seen in tennis
players and golfers [10]. There will be swelling
ECU tendinopathy and TFCC tear resulting in and a constant dull ache on the dorso-ulnar aspect
DRUJ instability are the most common causes for of the wrist and sudden searing pain felt along the
ulnar wrist pain in athletes, especially for those ECU tendon on active contraction of the muscle.
playing golf, tennis, football, baseball, rugby, The ECU synergy test is a sensitive and specific
hockey, and basketball. Due to their similarity in test for ECU tendinitis [38]. This test is per-
25  Sports Trauma: Wrist and Hand 337

formed with the wrist in supination and neutral ered. Six weeks of immobilization is recom-
flexion/extension. Pain is felt over the ECU ten- mended postoperatively. Rehabilitation starts
don when the adducted and extended index and after this period, with the aim to return to sports
middle fingers are resisted. Ultrasound and MRI after 3–6 months.
show a thickened tendon with increased fluid in
the surrounding sheath [25]. Management is usu- 25.3.2.3 Ulnar Nerve Irritation
ally conservative with NSAIDs and a short arm Ulnar nerve irritation at the wrist can be a result
splint to maintain the wrist at 30° extension and of hook of hamate fracture non-union, causing
ulnar deviation for 3 weeks [10]. A corticosteroid repetitive trauma to the nerve, or chronic pressure
injection may be given if conservative therapies applied to the area of Guyon’s canal, typically
fail. Surgical debridement of the tendon and seen in cyclists with sustained gripping of the
release of the compartment are usually not handlebars. Symptoms include pain felt in the
necessary. hypothenar area and numbness of the ring and
little finger, sparing the dorsum of the hand [40].
25.3.2.2 Triangular Fibrocartilage In chronic cases, weakness of the intrinsic mus-
Complex Tear and Distal cle of the hand may be observed. While the diag-
Radioulnar Joint Instability nosis is mainly clinical, nerve conduction test can
For TFCC tear with DRUJ instability, patient be used to confirm and to differentiate the diag-
usually complains of ulnar wrist pain following a nosis from cubital tunnel syndrome. Treatment is
fall. Pain may be precipitated by activities which often conservative. Making recommendations to
require forceful wrist flexion and rotation (e.g., change hand positions on the handlebars and
golf, racket sports, wringing dry a towel, or open- wearing cycling gloves with protective gel pad-
ing a jar). DRUJ ballottement test, ulnocarpal ding are strategies to reduce the chronic pressure.
stress test, and press test are some of the common In some cases, a rest from cycling, prescribing
maneuvers to elicit DRUJ joint instability [25]. nonsteroidal anti-inflammatory medication, and a
The movements need to be compared with the period in a wrist splint may be appropriate. In
unaffected side to differentiate normal from path- cases of hook of hamate non-union, surgical exci-
ological laxity. sion of the hook of hamate may be performed if
First-line imaging are plain radiographs. conservative therapy fails.
Radiographs will identify fractures and positive
ulnar variance (predisposes for ulnar impaction 25.3.2.4 Ulnar Artery Thrombosis
syndrome and TFCC degenerative tear) [25]. For Ulnar artery thrombosis, also known as hypothe-
patients with significant injuries or persistent nar hammer syndrome, is a condition of which
pain, an MRI is commonly used to assess the results from repetitive microtrauma to the ulnar
integrity of TFCC. It has a sensitivity of 67–100% artery at the level of Guyon’s canal [41]. This can
and specificity of 71–100% [39]. MRI arthro- occur with baseball, badminton, handball, foot-
gram appears to be superior in the diagnosis but ball, hockey, karate, and golf [42]. Patient com-
is a more uncomfortable investigation. Diagnostic plains of the presence of a tender mass in the
wrist arthroscopy remains the gold standard in
the assessment of TFCC.
In the acute case, the forearm is immobilized Fact Box: Wrist Injuries
in an above-elbow splint in supination for • Often missed, produce early arthritis
6 weeks. For chronic DRUJ instability, surgery is and persistent pain and stiffness
required [10, 25]. Arthroscopic repair and recon- • Diffused wrist pain and swelling
struction have gained popularity over open sur- –– Acute: distal radius fracture and peri-
gery in recent years. In the setting of positive lunate dislocation
ulnar variance, concomitant ulnar shortening –– Chronic: wrist arthritis—posttraumatic
osteotomy or wafer procedure should be consid-
338 M. W. M. Fok et al.

injury [1]. Closed, simple extra-articular, and

• Radial wrist pain and swelling undisplaced intra-articular phalangeal fractures
–– Acute: Fracture of scaphoid or radial with no rotational deformity can be managed
styloid and SL dissociation with protected mobilization with buddy taping
–– Chronic: SLAC, SNAC, and de for 4 weeks.
Quervain’s tenosynovitis Closed fractures of the proximal 2/3 of the
• Ulnar wrist pain and swelling proximal phalanx can be unstable, due to the
–– Acute: DRUJ instability, ECU insta- intrinsic muscles flexing the proximal fragment
bility, and hook of hamate fracture and the extensor mechanism extending the distal
–– Chronic: ECU tendinopathy, TFCC fragment. After closed reduction, the MCPJ is
tear, DRUJ instability, ulnar nerve irri- splinted in 70° flexion for 4 weeks. Splinting in
tation, and ulnar artery thrombosis MCP joint flexion with PIP joint extension at rest
• Investigation allows the extension mechanism to provide a
–– X-ray first line compressive force that stabilizes the fracture [44].
• If symptoms persist, CT for bone or For fractures with rotational deformity, derotation
MRI for soft tissue taping can be used [45]. When a fifth metacarpal
fracture has involved the ulnar nerve, the malrota-
tion is reduced and then the Jahss maneuver per-
hypothenar eminence, pain in the palm, ulnar formed. The finger is taped, so that the rotation is
nerve irritation, as well as ischemic changes to maintained and then an ulnar gutter is applied
the ring finger and little finger. Ultrasound and with the MCP in flexion. If there is marked flexion
MRI/MR angiography can be used to confirm the or shortening, then internal fixation with K wires,
diagnosis [43]. Conservative management mini-screws or plates, and screws has been advo-
includes rest from aggravating activities, smok- cated [46–48]. In all cases, early mobilization is
ing cessation, and the use of vasodilators. needed to prevent finger stiffness.
Surgical management involves excising and
reconstructing the thrombosed segment with a
vein graft [42]. 25.4.2 Fractures of the 
Metacarpal Neck

25.4 Acute Hand Injury Fractures of the metacarpal neck are common
in combat sports. Boxer fracture, a fracture of
Unlike wrist injuries, where both acute and the fifth metacarpal neck, is the most prevalent
chronic injuries are common, most hand injuries of all, but it is not limited just to boxers. In fact,
in sports are caused by a single traumatic event. trained boxers typically punch with greater
However, they are commonly missed and often force at the second and third rays. When no
present late. rotational deformity is present, angulation is
usually accepted, ranging from 10° in the sec-
ond metacarpal up to 40° in the fifth ray. For the
25.4.1 Metacarpal and Phalangeal repeat offender, up to 70° of flexion can be tol-
Fracture erated in the fifth metacarpal neck [49]. In cases
of rotational deformity, closed reduction and
Metacarpal and phalangeal fractures are the derotation taping can be performed [45].
most common fractures of the upper extremity in Reduction and fixation may be required if the
athletes, especially those in contact and ball metacarpal head is flexed to the point that it is
sports. Most of these fractures are low-energy prominent in the hand and causes discomfort
trauma from a direct blow, twisting, or crush with gripping [50].
25  Sports Trauma: Wrist and Hand 339

25.4.3 Proximal Interphalangeal to confirm a congruent joint reduction. Stability

Joint Injuries and laxity should also be checked clinically.
On the lateral radiograph, the presence of dor-
Proximal interphalangeal joint (PIPJ) injuries sal displacement should be accurately assessed.
are common in ball sports, when the finger is Any dorsal subluxation of the middle phalanx on
jammed at the time of catching a ball, causing a the lateral radiograph is abnormal. If the fracture
hyperextension injury. As they are often managed is <33% of the articular surface, it is usually sta-
on field by the coach, they have been described as ble and can be treated with reduction of the dislo-
the “coach’s finger” [51]. Unfortunately, these cation and protected mobilization. Dorsal block
are often missed and can end up with a poor out- splint with the PIPJ at 20–30° of flexion is given
come [52]. This highlights the importance of pro- for 3 weeks and may be followed by a period of
fessional assessment and management of these buddy splinting [54].
injuries, of which we follow an algorithm When the avulsion fracture is >33% of the
(Fig. 25.5). articular surface, the construct is unstable because
It is critical to have good-quality AP and lat- the collateral ligament is attached to the avulsed
eral radiographs of the injured finger. Dorsal dis- fragment [55]. This large fragment usually
location is the most common and usually requires fixation to provide joint stability. If the
associated with an avulsion of the volar plate joint remains subluxated or the volar fragment is
with a fracture of the volar rim of the middle pha- comminuted, then surgical management can be
lanx (Fig. 25.6) [53]. The dislocation needs to be difficult but is usually required.
reduced in the acute setting, usually via a closed Volar dislocation of the PIP joint is uncom-
reduction under ring block. Traction together mon and has a poor prognosis as the central slip
with pressure to the dorsal aspect of the base of is usually involved [56]. Joint reduction is
the middle phalanx as the finger is brought into required, and the central slip either repaired or
flexion is recommended for reduction. allowed to heal, but with the joint stabilization
Postreduction radiograph of the finger is needed with a K wire [56].

PIPJ Dislocation
X Ray, Close Reduction

Successful Delayed in
Failed Reduction
reduction Presentation

Reotational Open Reduction Open Reduction /

Dorsal Dislocation Volar Dislcation
Dislocation and Stabilization Repair
+/- Fracture Central slip
Between Central Volar Plate Arthroplasty or
Slip and Lateral Ext Fix
Volar Fragment Volar Fragmnet Joint Stabilization Band
<1/3 Articular >1/3 Articular +/- Central Slip
Surface Surface Repair
Fracture Stable Fracture Open reduction
Unstable and Stabilization

Dorsal Block Splint Fracture Fixation

for 3/52

+/- Buddy Splint +/- Joint Stabilization

Fig. 25.5  Algorithm in managing PIPJ injuries

340 M. W. M. Fok et al.

the DIPJ.  Radiographs are required to identify

any associated fracture. A three-level classifica-
tion has prognostic value as it reflects the integ-
rity of the nutrient support of the tendon
(Fig. 25.7) [58–60]. Early surgical repair is rec-
ommended. In a delayed presentation or in a
case where the patient refuses to undergo a pro-
longed tendon rehabilitation, excision of the
stump may be performed if discomfort is experi-
enced and the patient accepts the inability of
flexing the DIPJ [28].

25.4.5 Mallet Finger

Mallet finger is the failure of the terminal exten-

sor digitorum tendon which typically presents
with a flexed DIPJ, as they are unable to actively
extend the joint. Volar subluxation of the DIPJ is
not uncommon on radiographs. The majority of
Fig. 25.6  Lateral radiograph of ring finger showing PIP mallet fingers can be satisfactorily treated with a
joint fracture dislocation short mallet splint, holding the DIPJ in full
extension all of the time for 6–8  weeks [61].
Surgical Kirchner wire or screw fixation may be
If the PIP joint is malrotated on examination or indicated if the fractures involve >30% of the
the proximal and middle phalanx appear to have articular surface and volar subluxation of the
different rotations, then there is likely to be a rota- DIPJ [28].
tory dislocation. The condyle of proximal pha-
lanx usually buttonholes between the central slip
and lateral bands. Therefore open reduction, Fact Box: Hand Injuries
repair, and Kirchner wire pinning are recom- Assessment
mended [57]. • Often misdiagnosed as just a finger
In cases of delayed presentation or failed sprain
closed reduction, surgical management including • Most can be treated conservatively with
open reduction, volar plate repair, arthroplasty, or a splint
external fixation may be required [52, 57]. • Most dislocations can be treated with
reduction and splint
• Stability must be checked post
25.4.4 Jersey Finger reduction

Jersey finger is an avulsion of the flexor digito- Indications for surgery

rum profundus tendon (FDP) from the distal • Open fractures
phalangeal joint, which usually occurs when a • Rotational deformity of the finger
player grasps an opposition player’s jersey [28]. • Joint incongruity
There will be painful “pop,” and the athlete will • Multiple fractures
present with a stiff swollen finger and can’t flex
25  Sports Trauma: Wrist and Hand 341

Fig. 25.7  Classification of jersey fingers (Copyright Dr. Margaret Fok)

25.4.6 Traumatic Subluxation There may be extensor tendon triggering, as the

of the Extensor Tendon/ extensor tendon snaps over the metacarpal head
Sagittal Band Rupture during movement from flexion to extension. In
acute (<3 weeks), a hand therapist should make a
Traumatic subluxation of the extensor tendon at custom-made splint to block MCPJ from flexion
the metacarpophalangeal joint (MCPJ) is caused while freeing PIPJ for 6–8 weeks. With a delayed
by rupture of the sagittal band (usually the radial presentation, a repair or reconstruction of the
side), which is the primary stabilizer of the exten- sagittal band is needed [28]. A splint is needed
sor tendon at the MCPJ level (Fig.  25.8) [62]. for protection for 6 weeks postoperatively.
342 M. W. M. Fok et al.

tion, i.e., after 3  months, UCL reconstruction

may be necessary [63].

25.5 Rehabilitation for Hand

and Wrist Injuries

The role of the hand therapist is critical in reha-

bilitation following wrist and hand injuries and
surgery. Hand therapists provide valuable educa-
tion, edema control, scar management, orthoses,
and exercises.
Education is a key component to managing de
Quervain’s tendinopathy, as risk factors include
poor skills in the sport, inadequate neuromuscu-
lar control, and increased time spent performing
the sport. These factors can be addressed by
patient education, skills acquisition, and activity
modification [66].
Edema routinely occurs after injury, creating
tension in tissues that can lead to predictable
deformity. Hand swelling will limit finger joint
and tendon motion, which can create permanent
Fig. 25.8  Radial sagittal band rupture causing extensor
tendon subluxation to the ulnar side (Copyright Dr. contractures and compromise function and per-
Margaret Fok) formance. Wrist injuries often develop difficulty
with supination and flexion. Finger injuries often
develop difficulty with MCP flexion and PIP and
25.4.7 Skier’s or Gamekeeper’s DIP joint extension [67]. Methods to reduce
Thumb edema include compression, elevation, exercise,
and manual edema mobilization [68].
Skier’s thumb is a rupture of the ulnar collateral Static orthotics are used to immobilize healing
ligament (UCL) of the first MCPJ. It is common in tissues, to prevent deformity and to prevent con-
recreational skiing, following a fall, and in ball tracture of soft tissue. Collateral ligament length
sports [63]. There are pain, swelling, and weak- is maintained by splinting the IP joints in exten-
ness in pinch grip due to the instability of the MCP sion and MCP joints in 70–90° of flexion [67]. A
joint.
If the MCP joint is unstable in full extension,
and in 30° flexion, then the UCL, accessory col- Fact Box: Tendon and Ligament Injuries
lateral ligaments, and the volar plate are disrupted of the Digits
[64]. Ultrasound or MRI can be performed in • Tendon/ligament injuries are often asso-
cases where complete ULC tear is suspected. A ciated with a bony avulsion.
Stener lesion occurs when the ruptured UCL is • Does the tendon/ligament avulsion
displaced and the adductor pollicis muscle affect joint stability or tendon function?
becomes interposed between the ruptured UCL • Indications for surgery
and its insertion [65]. Immobilization in a thumb –– FDP avulsion
splint for 4–6 weeks is recommended with partial –– Gamekeeper’s thumb (UCL MCP
and complete UCL tear without Stener lesion. joint)
For the Stener lesion or gross instability, surgical –– Large bony mallet finger fractures
repair is indicated. In cases of delayed presenta-
25  Sports Trauma: Wrist and Hand 343

wrist extension immobilization orthotic can be ple is an undisplaced fracture of the scaphoid,
used to treat wrist fractures and is often used for of which 90% will heal in a cast. Yet untreated
carpal instability, to relieve pain and prevent is likely to result in a non-union and then a
movements that aggravates symptoms, in con- SNAC wrist in 10–15 years.
junction with isometric exercises and advice on • Surgery is indicated for some presentations
activity modification [69]. seen in acute settings. Examples are finger
Uncertainty surrounds the optimal time frames fractures with rotational deformity, PIPJ volar
to introduce exercises and limit the period of dislocation, and Stener lesion in a skier’s
immobilization. Shorter immobilization periods, thumb.
so that exercises are started earlier, have been • Rehabilitation is an important part in the man-
found to be more effective than longer immobili- agement of many wrist and hand injuries.
zation periods for some wrist fractures [70] and Different kinds of exercise are recommended
similarly effective for boxer’s fractures [71] and in different stages of the healing process.
wrist sprains [72]. Patients and hand therapists need to work
Exercises are designed to restore passive or hand in hand to achieve the best outcomes.
active limitations to specific structures. Movement
can be isolated at specific joints, referred to as
blocking exercises. Differential tendon gliding Acknowledgment For assistance in preparation of this
exercises promote full excursion of the flexor manuscript, Kimberley Ruxton, Research Manager,
Department of Orthopaedic Surgery, Flinders University,
digitorum superficialis (FDS) and flexor digito- and Flinders Medical Centre, Adelaide, Australia; upper-
rum profundus (FDP) tendons and are important [email protected]; +61882044289.
for preventing hand or wrist stiffness. An active
limitation, or lag, due to weakness can be
addressed with place and hold exercises, which
encourage maximal contraction required to
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Br. 1998;80:1014–9. ical controlled study comparing the effect of modified
53. Chen F, Kalainov DM.  Phalanx fractures and dis- manual edema mobilization treatment with traditional
locations in athletes. Curr Rev Musculoskelet Med. edema technique in patients with a fracture of the dis-
2017;10:10–6. tal radius. J Hand Ther. 2011;24:184–94.
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interphalangeal joint. Br J Hand Ther. 2016;3:9–12. in the diagnosis and treatment of carpal instability—
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results of a survey of Australian hand therapists. J
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 Sports Trauma: The Hip
26
Molly C. Meadows and Marc R. Safran

26.1 Introduction population, leading to an increased risk of intra-

articular injury to the hip joint.
Hip injuries are common among athletes, repre- Symptoms about the hip and groin in athletes
senting approximately 6% of all sports injuries can present a diagnostic challenge, as pain can be
[1]. Furthermore, hip injuries have received referred from multiple locations including the
increased attention in recent years as a result of lumbar spine, genitourinary system, extra-­
identification of sources of non-arthritic hip pain articular musculature, and hip joint itself.
and damage, improved evaluation techniques, Understanding the diagnosis and management of
such as physical examination and imaging, as common hip injuries in athletes is essential to
well as less morbid approaches to evaluation and appropriate treatment, as well as to maximize
management of hip problems, such as hip outcomes and return to play.
arthroscopy.
The hip joint is a constrained synovial joint that
functions to support the body in static and dynamic 26.2 Muscle Strains/Sprains
activities. The fibrous capsule with ligamentous
thickenings and the acetabular labrum contribute Muscle strains are the most common type of ath-
to the inherent stability of the hip joint. Finally, the letic injury to the hip and groin region. These
multiple muscles crossing the hip joint further injuries typically occur from an eccentric con-
contribute to dynamic stability of the hip through- traction in a muscle group crossing two joints.
out the physiologic range of motion. However, While strains most frequently occur at the myo-
there is wide variability in the bony morphology of tendinous junction, they can occur anywhere
the hip, leading to predisposition to intra- and along the muscle belly. The most common mus-
extra-articular hip pathology. Furthermore, multi- cle strain injuries about the hip occur to the hip
ple studies have demonstrated an increased preva- flexors, quadriceps, hamstrings, and adductor
lence of femoroacetabular impingement (FAI) muscles [1]. These injuries can be classified as
anatomy in athletes as compared to the general grade I, II, or III depending on the severity of the
injury. Grade I strains involve tearing of a few
muscle fibers with pain but minimal loss of
M. C. Meadows · M. R. Safran (*)
Division of Sports Medicine, Department strength. Grade II injuries involve more extensive
of Orthopaedic Surgery, Stanford University, partial tearing with some strength loss. Grade III
Stanford, CA, USA injuries are complete tears with loss of function.
e-mail: [email protected]; In adolescent patients, the origin or insertion of
[email protected]

© ISAKOS 2019 347

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_26
348 M. C. Meadows and M. R. Safran

the tendon may be avulsed with a bony fragment, rior thigh, with painful and potentially weak knee
and these are classified as grade IIIB injuries [2]. extension with the hip flexed. Iliopsoas strains are
Quadriceps strains most commonly involve the also common hip flexor strains, and athletes may
rectus femoris, often in sports that emphasize complain of groin or lower abdominal pain that is
sprinting or kicking (Fig.  26.1a). These injuries worse with attempts at resisted hip flexion
typically present as pain and swelling in the ante- (Fig. 26.1b). Adductor strains result from an abduc-

a b

c d

Fig. 26.1  Muscle strains. (a) Is an acute rectus femoris Arrow points to edema within the iliopsoas. (c)
strain in an American professional football kicker seen on Demonstrates an acute adductor strain with diffuse edema
a sagittal view T2 MRI. The green line demonstrates the in a male collegiate soccer player on coronal T2-weighted
nearly 1 cm displacement of the tendon from the anterior MRI. (d) Is an axial MRI (T2 weighted) of a 28-year-old
inferior iliac spine. (b) Is a coronal T2 MRI of a profes- professional American football player’s thigh with an
sional tennis player with acute right iliopsoas strain. acute hamstring avulsion
26  Sports Trauma: The Hip 349

tion force on the thigh during an attempted adduc- strains [4]. Further studies are needed to identify
tion movement, such as with kicking a soccer ball, athletes at risk for muscle strains and to develop
but are also common during skating in ice hockey effective exercise programs to mitigate these risks.
(Fig. 26.1c). As such, these are common injuries in
American football, ice hockey, and soccer. They
present as acute onset medial groin pain that is 26.3 Hip Contusions
worse with resisted adduction [1]. Hip flexor inju-
ries are the most common injury to the hip in NFL Contusions about the hip are common in contact
players, representing 63% of all muscle strains in sports, as they typically result from a collisions or
this population. These injuries are also associated falls to the ground [3]. Contusions range from
with cutting and pivoting maneuvers in sport. superficial subcutaneous hematoma formation to
Hamstring injuries classically result from forced more severe injuries involving subperiosteal
hip flexion with the knee in extension; however, edema. An iliac crest contusion, commonly
any sport that involves rapid acceleration and referred to as a hip pointer, occurs from a direct
deceleration puts the hamstring at risk for injury blow to the iliac crest or a fall onto the anterior
(Fig. 26.1d). Patients with a hamstring injury often hip. These injuries present as acute pain over the
describe a pop associated with pain and bruising at iliac crest. Examination will often reveal an anta-
the posterior hip. In severe cases, a gap may be pal- lgic gait, tenderness to palpation, and decreased
pable at the posterior thigh. Functionally, there are strength testing in any of the muscle groups that
two common main types of hamstring injury— attach at the iliac crest [5]. Radiographs are
injuries at the muscle-tendon junction, which are obtained to rule out an iliac crest avulsion, as an
treated conservatively but have a high recurrence apophysis may persist until age 25 (Fig.  26.2).
rate, and the hamstring avulsion from the ischial Management of these injuries in the acute setting
tuberosity, which may require surgery. involves ice, compression, and a brief period of
Radiographs in the setting of a suspected mus- crutch use to reduce swelling and hematoma for-
cle strain are useful to assess for avulsion injury, mation. As pain improves and bleeding subsides,
particularly in skeletally immature patients. typically around 3 days post-injury, a rehabilita-
Additionally, MRI is a useful diagnostic and tion program can be initiated. In settings where
prognostic tool to evaluate the degree of muscle immediate return to play is important, an injec-
involvement or to distinguish a partial from a tion of local anesthetic with or without cortico-
complete tear. The majority of muscle strains are steroid can be performed to decrease pain. While
treated non-operatively with rest, NSAIDs, and a
progressive rehabilitation program. Rehabilitation
should begin with gentle range of motion exer-
cises and gradually progress to strengthening and
sport-specific activity. In cases of complete tears,
particularly of the hamstring tendon avulsion,
surgical repair is recommended to return the ath-
lete to their pre-injury level of function [1].
While typically amenable to nonsurgical man-
agement, muscle strains present a significant cause
of disability in the athletic population. Indeed,
among NFL players who sustained muscle strains,
the overall mean playing time lost was 10.2 days,
with a range of 1–197 days [3]. One study found
that in a population of professional ice hockey
players, a preseason exercise program was effec- Fig. 26.2  Iliac crest avulsion fracture in a 19-year-old
tive in reducing the incidence of adductor muscle collegiate basketball player
350 M. C. Meadows and M. R. Safran

there is no clear data to support this treatment ter of the acetabulum. The anterior labrum typi-
option, reports demonstrate that elite athletes can cally has a smooth transition to articular cartilage
often return to play immediately following injec- at the chondral edge, whereas the posterior
tion with additional padding [6]. Aspiration of labrum is often separated from the underlying
the lysed hematoma may also be attempted in cartilage by a physiologic cleft [10]. The labrum
high-level athletes to hasten return to sport. serves to deepen the acetabular socket and pro-
Quadriceps contusions are another common vide a suction seal for the hip joint, thereby add-
injury in collision sports, typically as a result of a ing stability to the joint and protecting the
kick or direct helmet blow to the thigh. These articular cartilage [11, 12]. The strain along the
injuries cause swelling and edema of the thigh acetabular labrum depends on the position of the
and limited knee range of motion as a result of lower extremity. The greatest strain at the poste-
trauma to the muscle fibers. These injuries are rior labrum results when the hip is flexed and
classified based on knee range of motion at adducted, whereas hyperextension and external
12–24  h post-injury, with greater limitations in rotation of the hip create strain at the anterior
motion correlating with more severe injuries and labrum [13].
prolonged recovery time [7]. Initial treatment Labral tears can result from an acute trau-
involves immobilizing the knee at 120 degrees of matic injury or more commonly from chronic
flexion with compression and ice for the first 24 h repetitive microtrauma secondary to FAI or
post-injury, an algorithm that has been shown to microinstability. FAI morphology includes
decrease the time to return to full athletic activity, CAM-type impingement from asphericity of the
as the knee flexion limits hematoma formation femoral head and pincer-type impingement
[8]. While rare, very severe contusions should be from acetabular over-coverage. Both types of
monitored for anterior thigh compartment syn- abnormal anatomy cause bony impingement
drome and managed accordingly. After the initial against the acetabular rim and subsequent dam-
period of immobilization, unrestricted active age to the labrum. Multiple studies have demon-
range of motion exercises are initiated. Crutches strated that participation in athletic activities is
are recommended until the athlete regains appro- a risk factor for development of FAI, leading to
priate quadriceps muscle control, and gradual increased prevalence of FAI and labral tears in
return to noncontact sport may begin when con- the athletic population [14–17]. Patients with an
trol and range of motion return. Contact is gener- acute labral tear will present with pain or catch-
ally permitted at around the 3-week time point, ing in the groin area following a pivoting or cut-
provided the athlete has regained full strength. In ting injury to the hip. However, in the setting of
collision sports, the use of a thigh pad may help FAI and chronic labral injury, patients often
reduce the risk of recurrent injury. Myositis ossi- cannot identify a specific inciting event. On
ficans is a late complication that can occur follow- physical examination, the flexion-adduction-
ing a severe contusion, with reported occurrence internal rotation maneuver, often referred to as
rates of 9–14%, but may be avoided by early use the impingement test, will elicit symptoms in
of NSAIDS (started 48  h after injury). Myositis patients with FAI.  However, while very sensi-
ossificans is self-limiting and typically does not tive, this maneuver is not specific to impinge-
require surgical treatment, but it can lead to a ment and may cause pain with any type of
period of lost playing time secondary to pain [9]. intra-articular pathology [18]. Additionally, a
dynamic labral stress test taking the hip through
a range of motion can be performed, which
26.4 Labral Tears/FAI involves rotating and axially ­loading the hip in
an impingement position, to elicit catching and
The acetabular labrum attaches to the bony rim pain from a torn labrum.
and joins with the transverse acetabular ligament Radiographs, including a high-quality antero-
inferiorly to circumferentially cover the perime- posterior pelvis film and a lateral film of the
26  Sports Trauma: The Hip 351

affected hip, are essential in the setting of a sus- articular pathology is the cause of pain, as
pected labral tear to evaluate for FAI anatomy 70–90% of asymptomatic adults have labral
(Fig. 26.3a). MRI with gadolinium can provide tears on MRI [19]. Relief with an anesthetic can
information regarding the presence of a labral often be ascertained following an MR arthrogra-
tear or other intra-articular pathology, as well as phy, as the contrast is combined with local
further detail regarding the bony morphology of anesthetic.
the hip and femur (Fig. 26.3b). While imaging is Treatment of labral tears and FAI typi-
helpful to guide treatment, a diagnostic intra-­ cally begins with conservative measures such
articular injection of local anesthetic provides as activity modification, anti-inflammatory
the most powerful tool to determine if intra- medications, and a focused physical therapy

a b

c d

Fig. 26.3  FAI and labral tears. (a) Demonstrates an AP looks homogeneous, while maintaining its triangular
pelvis radiograph of an American professional ice hockey shape, while the acetabulum is to the right. (c) Is an intra-
player with FAI. Arrows point to the cam lesion (aspheric- operative image of a collegiate basketball player with
ity of the femoral head). (b) Is a T1-weighted axial MRI FAI—shaver is at the maximal offset of the cam lesion—
of the right hip of a professional soccer player with the while (d) is the same patient after resection of the cam
arrow pointing to the labrum separated from the acetabu- lesion seen on intraoperative fluoroscopy
lum at the labral chondral junction. The labrum, to the left,
352 M. C. Meadows and M. R. Safran

program. When symptoms persist despite con- 26.5 Hip Subluxation/Dislocation

servative management, surgical management
with hip arthroscopy is appropriate. In addi- While dislocation of the hip is a rare occurrence
tion to addressing the labrum, acetabular rim in sports, this injury is associated with significant
resection, cheilectomy (femoral osteoplasty), morbidity, and timely recognition and manage-
chondroplasty, microfracture, debridement of ment is paramount. Hip dislocation is more com-
ligamentum teres tears, and capsular plication mon in high-energy activities such as football
can be performed to treat any additional pathol- [28]; however, it has been reported in a variety of
ogy (Fig. 26.3c, d). With regard to management different sports. While data regarding hip dislo-
of the labrum at the time of arthroscopy, mul- cations in athletes is limited, it has been estimated
tiple studies have demonstrated superior out- that approximately 2–5% of hip dislocations
comes following labral repair compared with occur in the athletic setting [29]. Literature sug-
debridement [20–22]. Thus, any unstable labrum gests that FAI anatomy places the hip at a higher
amenable to repair should undergo refixation to risk for traumatic dislocation and subluxation in
recreate the suction seal. Selective debridement athletes [30, 31].
is an option in patients with irreparable labral The direction of dislocation depends on the
tears and no evidence of instability. However, position of the hip at the time of impact. Posterior
active athletes with significant labral deficiency dislocations occur when a posterior force is
or an irreparable labrum may be best treated directed against a flexed knee with the hip in a
with labral reconstruction to restore stability of flexed, adducted, and internally rotated position.
the hip joint [23]. In sports, this occurs most frequently when an
Outcomes of hip arthroscopy for athletes athlete’s knee is forcefully directed against the
have been generally favorable, which high rates field during a tackle. Anterior dislocations occur
of return to play [24–26]. In a study of 98 elite- when the hip is forcefully flexed, abducted, and
level athletes, 84.2% of female athletes and externally rotated. This typically occurs in sports
83.3% of male athletes were able to return to such as gymnastics that involve split-type activi-
their presurgery level of play at a mean age of ties [32]. If hip dislocation is suspected, an on-­
8.3 months for women and 8.8 months for men. field neurovascular examination should be
A shorter duration of preoperative symptoms performed, and urgent transport to a medical
was predictive of return to baseline level of facility should be initiated. Minimizing time to
competition, suggesting that early intervention reduction is essential to decrease the risk of avas-
should be considered to optimize function and cular necrosis [33]. A single attempt at sideline
return to play [27]. reduction is appropriate, as the reduction can be
easier prior to spasm of the surrounding muscles.
Key Points However, multiple attempts should be avoided to
minimize the risk of further damage to the articu-
• Labral tears most commonly occur in the set- lar cartilage. If a sideline reduction is successful,
ting of FAI or hip instability. transfer to a medical facility is still required, as a
• FAI is significantly more common in athletes postreduction CT scan is recommended to assess
than nonathletes. for associated fracture or presence of loose bod-
• Intra-articular injection of anesthetic is a use- ies within the joint (Fig. 26.4) [29]. While there is
ful diagnostic tool. no clear consensus regarding management of
• Hip arthroscopy is an effective treatment for simple dislocations without associated fracture,
symptomatic intra-articular pathology in the some authors recommend 6–8 weeks of toe touch
athletic population. weight-bearing, with gradual progressive return
• Goals of arthroscopy should include labral to full range of motion and athletic activity [33].
repair, and management of chondral lesions, However, most high-level athletes who suffer a
impingement, or capsular laxity as needed. traumatic hip dislocation rarely return to the
26  Sports Trauma: The Hip 353

a b

c d

Fig. 26.4  Hip instability. Thirty-year-old male American that had sheared off. (c) Is a coronal MRI, T2 weighted, with
professional football player following reduction of hip dis- an arrow pointing to a ligamentum teres tear in a competi-
location. (a) Is an axial cut of a CT scan demonstrating the tive gymnast. (d) Is an arthroscopic view of a male martial
lack of concentric reduction of the femoral head within the artist with borderline dysplasia, demonstrating a ligamen-
acetabulum. There is also a small posterior wall fracture tum teres tear associated with hip instability. (e) is an
seen. (b) Is an arthroscopic view demonstration of removal arthroscopic picture from a female dancer with central fem-
of a loose fragment of the femoral head articular cartilage oral head chondromalacia as a result of microinstability
354 M. C. Meadows and M. R. Safran

same level of play. Philippon et al. performed hip • On field reduction of hip dislocations may be
arthroscopy on 14 professional athletes following attempted, but transfer to a medical facility for
hip dislocation and noted labral tears and chon- postreduction imaging is required.
dral defects in all patients, as well as loose bodies • Early reduction is the most important factor to
in 11 of 14 patients [34]. Despite these injuries, reduce the risk of osteonecrosis.
all 14 patients in this series returned to competi- • Chronic hip instability can be treated success-
tive sports at the professional level. However, fully with arthroscopic capsular plication.
these chondrolabral injuries, in addition to capsu-
lar laxity and microinstability, likely contribute
to the overall poor outcomes following hip 26.6 Chondral Injuries
dislocation.
While hip dislocation is a relatively rare Chondral injuries of the hip most commonly
injury, hip subluxation is more common and less develop as sequelae of chronic impingement or
frequently recognized. A fall onto a flexed knee instability as previously described (Fig. 26.5). In
can cause a subluxation of the femoral head to addition, Byrd et  al. described a lateral impact
the acetabular rim. Additionally, repetitive micro- injury as a mechanism of cartilage injury. He
trauma can cause injury to the soft tissue struc- reported four cases of male athletes who suffered
tures about the hip, leading to instability [35]. a fall directly onto the lateral aspect of the hip
Finally, generalized ligamentous laxity, particu- and developed persistent pain in the groin. Initial
larly when combined with athletic activities that radiographs in all cases were unremarkable. MRI
place the hip joint in supraphysiologic positions in two of the four cases was normal, in one case
such as gymnastics and dance, can predispose the revealed signal changes in the femoral head, and
hip to anterior instability. Like dislocations, sus- in the final case demonstrated an effusion of the
pected traumatic hip subluxations should be eval- hip joint. All patients ultimately underwent hip
uated with advanced imaging to rule out arthroscopy. Two of the patients were found to
intra-articular loose bodies or acetabular rim have a grade III chondral lesion of the weight-­
fractures [28] and should be managed accord- bearing portion of the acetabulum. One patient
ingly. Alternatively, chronic hip instability is ini- had two large loose bodies located just above the
tially managed non-operatively with physical fossa, as well as damage to the femoral head car-
therapy and rest from inciting activities. If symp-
toms persist despite non-operative measures, hip
arthroscopy and capsular plication are recom-
mended to stabilize the joint. Concomitant
pathology associated with hip instability, such as
chondral lesions (usually of the central femoral
head), ligamentum teres hypertrophy or tears,
and labral tears, should be addressed at the time
of arthroscopy (Fig.  26.4c, d) [35, 36]. Isolated
arthroscopic capsular plication has been shown
to improve hip pain and function at 1-year fol-
low-­up [37]; however, further data is needed to
assess the long-term results of this procedure.

Key Points

• While hip dislocations are rare injuries in

Fig. 26.5 Chondral delamination seen with FAI.
sports, hip subluxation and chronic instability Arthroscopic view of acetabular chondral delamination in
are more common entities. the basketball player seen in Fig. 26.3c, d
26  Sports Trauma: The Hip 355

tilage, thought to be secondary to third body 3. Feeley BT, Powell JW, Muller MS, Barnes RP, Warren
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 Traumatic Knee Injuries
27
Steffen Sauer and Mark Clatworthy

27.1 Patella Dislocation patella dislocations usually occur during normal

activities and are facilitated by dysplastic changes
27.1.1 Background in the patellofemoral joint [2, 3]. Habitual patella
dislocation is defined as the consistent disloca-
The patella represents the largest sesamoid bone tion of the patella whenever the knee is flexed.
of the human body and is incorporated into the Predisposing factors of patella dislocation
quadriceps tendon. Patella dislocations are a include genu valgum, patella alta, increased dis-
common sports-related knee injury and defined tance between the tibial tuberosity and the troch-
as the complete disengagement of the patella lear groove (TTTG distance), as well as increased
from the trochlear groove. According to the fre- internal rotation and anteversion of the femur [1,
quency and associated trauma mechanism, 4]. The patella usually dislocates laterally, lead-
patella dislocations may be subdivided into trau- ing to a rupture of the medial patellofemoral liga-
matic, recurrent, and habitual dislocations. ment (MPFL). Subsequently, the lack of medial
Traumatic  (inaugural/single) dislocations are retrain provided by the MPFL may lead to patel-
usually the result of a relevant trauma, typically a lar instability and recurrent dislocation, espe-
pivoting maneuver with a twisting movement cially in cases with associated bony dysplasia or
about the flexed knee [1]. Recurrent  (several) muscle weakness. Spontaneous relocation is usu-
ally seen; otherwise, emergency reduction is
required.

S. Sauer
Aarhus University Hospital / Aleris Hamlet Hospital,
Aarhus, Denmark 27.1.2 Symptoms
e-mail: [email protected]
M. Clatworthy (*) Symptoms arising from patella dislocation are
Aarhus University Hospital / Aleris Hamlet Hospital, frequently related to the traumatic event and type
Aarhus, Denmark of dislocation. Traumatic first-time patella dislo-
ACL Study Group, Auckland, New Zealand cation usually provokes medial para-patellar pain
ISAKOS Knee Sports and Preservation Committee, as a result of capsular disruption which is often
ISAKOS Arthroscopy Committee, followed by rapid onset of effusion. However,
San Ramon, CA, USA effusion may be absent, especially in recurrent
Herodicus Society, Opelousas, LA, USA dislocations where giving way and locking may
e-mail: [email protected] be the leading symptoms.

© ISAKOS 2019 357

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_27
358 S. Sauer and M. Clatworthy

27.1.3 Diagnosis

The diagnosis is typically made with the patella

reduced as the vast majority of patella dislocations
undergo spontaneous reduction. Clinical examina-
tion will usually reveal pain or a depression upon
palpation of the medial retinaculum, usually dis-
rupted during the dislocation. Pain during patello-
femoral compression or palpation of the lateral
condyle is usually present as a result of the patel-
lofemoral collision during the dislocation. A posi-
tive apprehension sign when the examiner attempts
to manually reproduce the luxation may be present
and is thought to be pathognomonic for patella dis-
location. In patients with recurrent patella luxa-
tion, patellar mal-­tracking may become evident
with a positive J-sign when the knee is extended.
Massive effusion is typically seen in association
with osteochondral lesions. Fig. 27.1  Bone bruising following patellofemoral colli-
sion during luxation

27.1.4 Imaging indicated in the setting of chondral damage or

osteochondral lesions that require re-fixation [1].
Radiographs may visualize irregularities in the In recurrent cases of patella dislocation, surgical
contour of the lateral femoral condyle and/or the stabilization of the patella by either repairing or
medial patella facet consistent with osteochon- reconstructing the MPFL is indicated. However,
dral fractures. MRI is used to determine whether there is no reliable data regarding joint stability
there are any osteochondral lesions, visualize or patient satisfaction after either conservative or
bone bruising as a result of the patellofemoral operative treatment. Procedures that aim for cor-
collision (Fig.  27.1) and identify eventual con- rection of dysplasia as trochleoplasties should be
comitant ligamentous or meniscal lesions. reserved for cases in which  initial surgery has
Furthermore, MRI is used to identify the degree failed.
of patellofemoral malalignment including the
TTTG distance which has implications for the Take-Home Message
indication of surgical realignment procedures, The majority of first-time patella dislocations can
such as tibial tubercle osteotomies. be treated conservatively. However, acute  MRI
scan is indicated in cases with massive knee effu-
sion to identify eventual osteochondral lesions
27.1.5 Treatment which are suitable for subacute re-fixation [1].

If the patella is dislocated, emergency reduction Treatment Algorithm

is indicated; the knee is hereby extended, and the
patella is reduced  by pushing the patella medi- • First-time patella dislocation →  conservative
ally. Following spontaneous or manual reduction treatment
of first-time patella dislocation, a conservative • Recurrent patella dislocation  → MPFL
treatment approach is indicated [4]. This may reconstruction
entail RICE (rest, ice, compression, elevation), • First-time patella dislocation with osteochon-
initial knee immobilization, and progressive dral lesion → osteochondral re-fixation if pos-
muscle strengthening. Knee arthroscopy may be sible and MPFL reconstruction
27  Traumatic Knee Injuries 359

Facts menisco-femoral ligaments. As the lateral menis-

• Common injury. cus can absorb up to 70% of the shock to the lat-
• The vast majority of patella dislocations relo- eral compartment of the knee, total lateral
cate spontaneously. meniscectomy is commonly associated with
• MRI may be useful to identify typical bone rapid onset of OA. Recently, the role of the lateral
bruising,  osteochondral fractures and predis- meniscus for rotational knee stability has become
posing factors. more evident which has emphasized the impor-
tance of meniscal root repairs for better ACLR
outcomes [10]. Over time, menisci become more
27.2 Meniscus Injury rigid, and the incidence of degenerative meniscal
tears increases. Especially in association with
27.2.1 Background osteoarthritis, degenerative lesions of the poste-
rior horn of the medial meniscus are frequently
Meniscal lesions are among the most common seen. There is an emerging body of literature
injuries of the knee joint and the most frequent challenging the beneficial effect of partial menis-
indication for knee arthroscopy. Meniscal lesions cectomy as a treatment strategy of these degen-
are more often degenerative than traumatic in ori- erative lesions [11, 12]. Traumatic meniscal
gin and classified after location (medial/lateral, lesions usually arise from a twisting movement
anterior/posterior) and by morphology (longitu- about the flexed knee with the ipsilateral foot
dinal, radial, horizontal, flap-tear-type, bucket-­ planted; the resulting compressive and rotational
handle-­ type). Bucket-handle tears are further forces cause the meniscus to tear. Degenerative
classified in accordance with location and associ- lesions are often not associated with a history of
ated meniscal blood supply from the geniculate trauma.
artery which has implications for healing poten-
tial (white-white zone, red-white zone, red-red
zone) [5]. Meniscal lesions of the menisco-­ 27.2.2 Symptoms
capsular junction area  (ramp lesions) and the
meniscal root area are further classified in accor- Symptoms arising from meniscal tears are fre-
dance with specific injury pattern, which has quently related to location, morphology, and ori-
implications for treatment procedures [6]. The gin of the lesion. Purely traumatic meniscal
medial meniscus is more frequently injured than lesions are associated with a sudden onset of
the lateral meniscus due to its more rigid tibial focal pain after a rotational knee trauma.
and capsular attachment [7]. However, in associ- However, the degree of instant posttraumatic
ation with ACL injures, lateral meniscal tears pain  is variable. Patients sustaining small tears
including root injuries are reported to be more without tissue displacement usually proceed with
frequent compared to medial meniscal tears [8]. sports activities. Severe tears are associated with
The latter, however, may be easily missed during more significant pain and, especially in
arthroscopy if the posterior menisco-capsular ­bucket-­handle meniscus lesions, with hemarthro-
junction area of the medial meniscus is not thor- sis and  a fixed flexion deformity with the dis-
oughly inspected [6]. The medial meniscus does placed meniscus preventing full extension.
not only account for half of the shock capacity of However, a complete bucket-handle lesion may
the medial compartment but does also restrain the be  displaced anteriorly  to the femoral condyle
tibia from anterior translation [9]. This is the rea- without compromising range of knee motion.
son why a large number of patients with ACL Other symptoms of meniscal injury include click
injuries have concomitant tears of the medial sensation, catching, and instability due to pro-
meniscus [7]. The lateral meniscus is more prioceptive misinformation caused by the  dis-
mobile compared to the medial meniscus. As the placement of meniscal tissue. Degenerative
knee moves, the lateral meniscus moves back and lesions often show a subtle debut of diffuse pain
forth across the tibia and is hereby stabilized by without preceding trauma. The ability to squat is
360 S. Sauer and M. Clatworthy

usually compromised. A serous effusion and increased signal from the center of the meniscus,
quadriceps atrophy may be encountered. is a common finding and should not be misinter-
preted as a traumatic tear.

27.2.3 Diagnosis
27.2.5 Treatment
The diagnosis of meniscal tears is based on the
history of injury followed by clinical examina- The treatment of meniscal tears should depend
tion. Partial, horizontal, and anterior meniscal on location, morphology, origin, as well as the
tears without mechanical interference may pres- correlation of meniscal injuries with clinical
ent without clinical findings. Meniscal injuries symptoms and associated lesions. Other factors
are typically associated with pain upon palpa- affecting treatment procedures include patient
tion of the joint line and may be aggravated by a age and activity level. In general, treatment of
variety of meniscal provocation tests. The accu- meniscal lesions should always aim to restore
racy of the physical examination is dependent the best possible function of the meniscus, con-
on the type of injury and the observer [13]. sequently reducing pain [9]. Bucket-handle
Among the most important tests are the lesions with high healing potential should
McMurray’s test (pain or popping sensation be repaired, regardless of patient age. Different
over the joint line during external tibial rotation methods are hereby used including all-inside,
under repeated passive flexion/extension) [13], inside-out, and outside-in suturing techniques,
the Steinmann I sign (pain during passive knee which are mostly dependent on lesion accessi-
rotation), and the Thessaly test [14]. The latter bility [16, 17]. Isolated meniscal lesions without
has recently been popularized as loading forces mechanical symptoms and chondral erosion
on the menisci are simulated; the patient stands may initially be treated conservatively. Partial
hereby on one leg with the knee flexed while meniscectomy is indicated for cases in which
actively rotating the knee and body. Pain and resection of dysfunctional meniscal tissue is
locking constitute a positive test. As no isolated believed to optimize meniscal pressure distribu-
test is highly conclusive, a combination of tion by restoring a sharp meniscal rim, e.g., in
meniscal provocation tests is recommended, and flap-tear lesions or radial tears. However, it must
multiple positive findings with a history of rele- be kept in mind that the loss of functional menis-
vant trauma suggest a meniscal injury. A nega- cal tissue may enhance chondral degeneration
tive test does not exclude a meniscal lesion. [18, 19]. Unstable meniscal lesions that affect
Hemarthrosis and reduced range of motion are the meniscal root or ramp areas should be
commonly seen in association with displaced addressed, especially in the setting of concomi-
meniscal tears. tant ACL injury. Meniscal root avulsions should
be reattached through a transtibial tunnel [20,
21]. Unstable meniscal ramp lesions are best
27.2.4 Imaging addressed with an all-inside or inside-out sutur-
ing technique through an additional posterome-
MRI represents the main imaging modality for dial portal [22]. In contrast, degenerative lesions
the diagnosis of meniscal tears and shows high with underlying OA without meniscal displace-
sensitivity and specificity. Especially when range ment and mechanical symptoms should be
of knee motion is compromised, MRI should be treated conservatively as no evidence is support-
performed to visualize meniscal injuries that ing the beneficial effects of partial meniscec-
require immediate attention [15]. Generally, tomy [5, 23–26]. Meniscus allograft
however, MRI findings need to be interpreted in transplantation is an option for  young patients
relation to clinical findings. Mucoid degeneration with extensive meniscal loss with pain and or
of the meniscus, which is associated with an early chondral loss.
27  Traumatic Knee Injuries 361

a b

Fig. 27.2 Acute bucket-handle meniscus lesion. (a) fering meniscal tissue lying between the femur and tibia
(Left): a small meniscal rim can be seen where the menis- may cause an extension deficit
cus has been detached from the capsule. (b) (right): inter-

Diagnosis Algorithm for Acute Meniscal

Injuries
• Hemarthrosis and reduced range of knee
motion  → MRI to exclude fracture, patella
dislocation, ligament lesions, and bucket-­
handle meniscus injury
• Normal range of motion without instability →
RICE and reevaluation after 2–3 weeks

Diagnosis Algorithm for Chronic Meniscal

Injuries
• Plain radiographs showing OA →  conserva-
tive treatment
• Plain radiographs without OA → MRI to visu-
alize meniscal injuries suitable for surgery

Fig. 27.3  Complex lateral meniscus injury. The central

Treatment Algorithm
part of the meniscus lies between the femur and tibia as
the bucket-handle part of the injury. The peripheral part of • Degenerative meniscal lesions → conservative
the meniscus is torn transversally leaving a lower and treatment
upper meniscal portion • Degenerative meniscal lesions with locking/
catching → arthroscopy and partial meniscec-
tomy where indicated
Take-Home Message • Bucket-handle meniscal lesions   →  subacute
Patients presenting with the inability to fully arthroscopy and meniscal repair
extend the knee after a relevant trauma should • RAMP lesions →  Repair:  Inside-out or all-­
undergo subacute MRI to identify meniscal inju- inside suture where indicated
ries that require immediate attention such as • Root lesions  → Repair:  Transtibial root
bucket-handle lesions. re-fixation
362 S. Sauer and M. Clatworthy

Facts tendon grafts has not emerged a specific superior

• The meniscus should always be preserved if graft [33–40]. The reconstruction of both ACL
possible. bundles (double-bundle ACLR) has been pro-
• Meniscal surgery is specialist surgery demand- posed by some authors [41, 42]. However, its
ing special techniques, especially for root and necessity has been challenged as the procedure
ramp lesions. is technically more demanding without clearly
• There is no evidence supporting the beneficial improving patient outcomes [43, 44]. In single-­
effect of partial meniscectomy for undisplaced bundle ACLR, graft positioning has been a mat-
tears in patients with underlying OA. ter of debate, especially after the transportal
ACLR technique has been established as the
gold standard [45–47]. Patients with high-grade
27.3 ACL Injury pivot-shift and habitual ligament laxity have
shown higher ACL failure rates. In these patients,
27.3.1 Background additional extra-articular stabilizing procedures
such as the lateral tenodesis or anterior lateral
The anterior cruciate ligament (ACL) enables ligament (ALL) reconstruction have currently
stable knee kinematics by limiting internal tibial been popularized and thought to lower ACLR
rotation and anterior tibial translation. As the failure and revision rates [48–51]. In general, the
ACL has migrated anteriorly during embryo- susceptibility of ACL lesions is higher among
logic development to its central position, it has women compared to men engaged in the same
preserved synovial coverage. The ACL has been pivoting sports [52–54]. Physiological factors
thought to be comprised of two distinguishable such as neuromuscular control and quadriceps-
bundles: an anteromedial and a posterolateral dominant deceleration, the geometrical shape of
bundle. Recent anatomical studies, however, the knee joint, and hormonal factors are thought
have emphasized the ribbonlike structure of the to be the explanation of this disparity [46, 47,
ACL [27]; rather than bundles the ACL is com- 55–60].
posed of direct and  indirect fibers according to
their  insertional morphology [28]. Acute ACL
ruptures are predominantly the result of a non- 27.3.2 Symptoms
contact rotational or hyperextensional trauma
[29, 30]. Altered biomechanics of the ACL- Symptoms associated with ACL injury include
deficient knee may cause symptoms of instabil- a  audible  pop at the time of injury followed
ity, subsequent meniscal and chondral injury, as by intense pain, rapid onset of knee effusion and
well as osteoarthritis [31, 32]. ACL reconstruc- a subsequent inability to continue with sports
tion (ACLR) is preformed to improve knee sta- activity. Other symptoms including reduced
bility and shows overall satisfactory results and range of knee motion may be present and are usu-
low revision rates. The therapeutic approach to ally aggravated by concomitant meniscal inju-
ACL injuries has historically been a dynamic ries. Subjective instability with or without giving
process, entailing repair procedures, augmenta- way phenomenon is usually reported. However,
tions, open and arthroscopic reconstructions, as subjective instability may first be evident when
well as a variety of graft choices. Even though pain is resolved and the knee is fully loaded.
arthroscopic procedures are currently chosen
over open approaches and reconstructions over
repair procedures, the optimal graft choice is 27.3.3 Diagnosis
still controversially discussed. Meta-analysis of
studies comparing the outcomes of ACLR Clinical assessment of the knee is best performed
depending on graft choice including auto- and shortly after ACL injury before the onset of muscu-
allografts and bone-tendon-bone versus pure lar guarding  and effusion.  The Pivot shift test is
27  Traumatic Knee Injuries 363

considered the best test to determine an ACL injury timing of eventual ACL reconstruction is depen-
as it replicates the subluxation of the ACL deficient dent on several factors such as patient age and
knee. However, in the acute setting the test may be functional level, degree of instability, the condi-
difficult to perform due to pain and muscular tion of the knee, and concomitant injuries. In gen-
guarding. In this case, the Lachman´s test is pre- eral, patients with concomitant ligament injury or
ferred [61, 62]. The knee is hereby flexed 20–30°, unstable meniscus lesions usually need surgical
and the amount of anterior tibial translation and the reconstruction due to increased instability of the
quality of the translation endpoint are evaluated by knee [67]. Furthermore, patients who experience
pulling the lower leg in a forward direction [63]. significant knee instability wishing to resume
The test usually induces less pain and muscular high-demand sports or occupation usually benefit
guarding than the anterior drawers test in which the from ACL reconstruction. Isolated ACL lesions
knee is flexed 90° or the pivot-shift test, in which a with stable meniscal lesions may be treated con-
dynamic subluxation of the tibia is induced [64]. servatively, especially if return to pivoting sports
Meta-analysis of the efficacy of these tests finds the is not desired [68]. As a general rule, ACL surgery
Lachman test to be the most useful with sensitivity is scheduled 6–8 weeks after the injury when nor-
and specificity of 85% and 94%, respectively [61]. mal range of motion is restored, swelling has gone
Especially regarding the anterior drawers test, PCL and peripheral structures including MCL lesions
injury may mimic ACL insufficiency as the poste- have healed. Injuries that need immediate surgical
rior sag will give the impression of increased ante- attention (e.g., bucket-handle injuries) should be
rior tibial translation, when in fact the knee is addressed subacutely. Even though evidence is
reduced to its neutral position. The clinical exami- inconclusive, ACL reconstruction is often post-
nation should include assessment of concomitant poned until normal range of knee motion is
injuries that require immediate attention  such as restored to avoid complications including arthro-
meniscal lesions, MCL, LCL, PCL and posterolat- fibrosis [69, 70]. However, there is no consensus
eral corner injuries as well as acute patellar disloca- among knee surgeons regarding optimal timing of
tions. Hemarthrosis may be evacuated by ACLR.  According to a systematic review of 69
percutaneous aspiration for pain relief. studies including 7556 participants, 90% of
patients undergoing ACL reconstruction achieve
normal or near-normal knee function. However,
27.3.4 Imaging only 55% of patients resume their preinjury level
of competition [71]. This suggests that psycho-
MRI is used to confirm the diagnosis and visual- logical factors like fear of reinjury may play an
ize concomitant injuries. Plain radiographs may important role in the treatment of ACL injury [71,
visualize an avulsion fracture of the lateral tibial 72]. There is no cutoff age for ACL reconstruc-
plateau referred to as the Segond fracture which tion, and based on observational studies, it shows
is usually associated with ACL injury [65, 66]. In overall satisfactory results in patients over
addition, plain radiographs may visualize  an 40 years of age [73]. Even though rigorous pro-
avulsion fracture of the tibial ACL insertion spective studies are rare, ACL deficiency is
which may be suitable for ORIF. thought to be associated with increased risk of
chondral and meniscal degeneration [74]. It
remains a matter of debate how much the initial
27.3.5 Treatment trauma itself contributes to progressive joint
degeneration and to what extent ACL reconstruc-
Acute management of ACL injury include RICE tion may modulate this risk [75–77]. In addition,
and oral analgesics. Crutches may initially be the severity of the initial trauma, extent of menis-
indicated to avoid full weight-bearing in cases of cal injury, knee biomechanics, and subsequent
severe instability  and  extensive bone bruising. patient activity level may affect the development
Further management including the necessity and of joint degeneration (Fig. 27.4).
364 S. Sauer and M. Clatworthy

27.4 PCL Injury

27.4.1 Background

The posterior cruciate ligament (PCL) is the

strongest of the  intra-capsular ligaments of the
knee and primary restrain to posterior translation
[78]. As the PCL has migrated anteriorly during
embryologic development to its more central
position, it has preserved synovial coverage. This
extra-synovial location accounts for limited effu-
sion in isolated PCL ruptures. The proximity to
the posterior capsule, however, ensures blood
supply to the PCL after complete rupture, which
allows satisfactory results of primary PCL repair
Fig. 27.4  ACL injury and conservative treatment in some cases
[79–81]. The femoral and tibial insertion sites of
Take-Home Message the PCL are approximately three times larger
A relevant knee trauma with early onset of effu- than its midportion diameter. The PCL is incon-
sion is highly suspicious for ACL injury. sistently accompanied by two ligamentous struc-
Muscular guarding may conceal instability, espe- tures that stretch between the medial condyle and
cially concerning the anterior drawers test. posterior horn of the lateral meniscus, referred to
as the Humphrey and Wrisberg ligament. PCL
Treatment Algorithm ruptures may be classified based on timing (acute
• If ACLR is indicated   →  usually 6–8  weeks versus chronic) and severity (isolated versus
after injury when range of motion is multi-­ligament). Isolated PCL ruptures are usu-
normalized ally the result of a fall onto the flexed knee or
• ACL rupture with concomitant bucket-handle forced hyperextension. PCL lesions are more
meniscal injury and fixed flexion deformity likely found in the setting of complex multi-liga-
→  Subacute meniscal suture if indicated, ment injuries after high-velocity trauma mecha-
delayed ACLR until range of motion is nisms. In these cases, thorough assessment of the
normalized knee including the neurovascular status is crucial
for satisfactory outcomes [82]. Isolated PCL
Facts lesions usually show subtle clinical appearance
• Up to  seventy-seven percent of patients pre- and may therefore go frequently undetected,
senting with traumatic knee hemarthrosis have leading to chronic insufficiency, a flexion deficit
an ACL injury. or generalized anterior knee pain [83]. The
• ACLR delay may enhance meniscus and majority of athletes with isolated PCL injuries
chondral degeneration. may continue to function at a high level [79, 80].
• ACL deficiency is associated with increased
risk of further injury (e.g., meniscal tear),
chronic pain, and decreased level of activity. 27.4.2 Symptoms
• OA may develop regardless of treatment
approach. Clinical findings of acute PCL ruptures are highly
• No graft choice has been shown to be dependent on the preceding trauma and thereof
superior. resulting concomitant injuries. Especially lesions
• Geometrical features of the knee joint affect of the posterolateral corner may severely aggra-
ACL injury and ACL graft failure risk. vate knee instability. In isolated PCL lesions,
27  Traumatic Knee Injuries 365

effusion is uncommon as the blood usually drains clinical findings including the degree of tibial
into the posterior soft tissues and lower leg. In displacement and associated functional
addition, muscle guarding may conceal mild instability.
instability. Pain in the fossa poplitea may there-
fore be the only perceptible symptom. A popping
sensation is rarely reported, and patients with iso- 27.4.5 Treatment
lated PCL lesions are usually able to instantly
resume sporting activities. In contrast, PCL Displaced avulsion fractures of the tibial inser-
lesions in the setting of multi-ligament lesions tion should undergo ORIF to prevent PCL insuf-
are usually associated with hemarthrosis, severe ficiency. Arthroscopically assisted procedures
instability, inability to bear weight, as well as and fracture fixation with suspension devices
reduced range of knee motion. Patients present- have also shown promising results. Ligamentous
ing with chronic PCL deficiency suffer from a lesions should primarily undergo conservative
fixed anterior subluxation of the medial femoral treatment including rehabilitation with a dynamic
condyle in relation to the tibia, which may cause brace that supports anterior reposition of the tibia
generalized anterior knee and symptoms related during flexion [87]. Results after conservative
to degeneration of the medial tibiofemoral joint treatment with mild instability are usually good
compartment [83, 84]. [80, 88]. PCL reconstruction (PCLR) is indicated
in cases of chronic instability [89, 90]. Surgical
results after PCLR, especially after severe insta-
27.4.3 Diagnosis bility, are worse compared to ACLR outcomes
[91–93]. PCL lesions in the setting of a multi-
Acute and especially isolated PCL lesions may ligament injury should be treated operatively
be challenging to diagnose and are frequently while addressing all injuries in a single operation
overlooked. Spontaneous posterior drawer sign is to ensure early mobilization which is thought to
rare and primarily present with concomitant be of paramount importance for satisfactory out-
injury of the posterolateral corner [85]. Anterior-­ comes [94].
posterior translation is frequently seen in the
chronic phase when muscular guarding is over- Take-Home Message
come [86]. In these cases, a positive posterior Isolated PCL lesions are easily overlooked. Pain
drawer test is typically found. Lesions of the pos- in the fossa poplitea after a relevant trauma may
terolateral corner with rotational instability are be the only symptom.
assessed with the dial test; the patient is hereby
lying prone, and both knees are externally rotated Treatment Algorithm
and compared. • Acute isolated PCL → dynamic bracing
• Chronic PCL lesions with mild instability
→physiotherapy
27.4.4 Imaging • Chronic PCL lesion with distinct instability →
PCL reconstruction
Plain radiographs may visualize posterior tibial • PCL injury in the setting of multi-ligament
displacement or an avulsion fracture of the tibial lesions (e.g., PLC) →  multi-ligament recon-
PCL insertion site. Subacute MRI is indicated struction in a single operation
when PCL lesions are suspected. However, MRI
does not reveal the functional status of the PCL Facts
and degree of instability of the lesion. In chronic
injuries the PCL may heal in a lengthened posi- • PCL lesions with spontaneous posterior
tion and appear normal on the MRI scan. drawer sign are usually associated with lesions
Treatment is therefore based on  symptoms and of the posterolateral corner (PLC) [85].
366 S. Sauer and M. Clatworthy

• Massive effusion after PCL injury is uncom- atic MCL insufficiency should undergo MCL
mon as the blood usually drains into the poste- reconstruction [102, 103]. Patients with acute
rior soft tissues and lower leg. MCL lesions in a severe multi-structural injury
• Isolated PCL lesions show good outcomes setting should undergo repair or reconstruction
when treated conservatively. to ensure early mobilization [102, 104, 105].

27.5 MCL Injury 27.5.2 Symptoms

27.5.1 Background Isolated MCL injury is usually associated with

pain and periarticular swelling along the course
The medial collateral ligament (MCL) is one of of the MCL. Joint effusion is usually absent and
the most commonly injured structures of the typically indicates concurrent intra-articular
knee joint [95, 96]. Partial or complete MCL structural injury. Concomitant ACL and meniscal
ruptures are typically the result of a direct valgus injury may aggravate instability and impair range
trauma, less frequently the result of indirect of motion.
injury mechanisms including abduction and
rotation of the lower leg [97]. MCL injuries usu-
ally carry low morbidity, in spite of the complex 27.5.3 Diagnosis
three-layered medial anatomical structure of the
knee [98–100]. The superficial MCL (sMCL) is Clinical findings are tenderness along the MCL,
located within the second layer between the deep predominantly at the femoral insertion site.
MCL and the sartorial fascia. The superficial Instability may be present in 20–30 degrees of
MCL is considered the main static retrain against flexion indicating MCL insufficiency. Instability
valgus stress and rotational forces. The deep in both 20–30 degrees of flexion and extension is
MCL lies in the third and deepest layer and usually a sign of combined MCL, posteromedial
forms the middle third of the medial capsule capsule and ACL injury.
[100]. The deep MCL is not ascribed a signifi-
cant joint stabilizing function [101]. From the
second and third layer originates a conjoint liga- 27.5.4 Imaging
mentous structure referred to as the posterior
oblique ligament (POL). The deep MCL and Plain radiographs may visualize a bony MCL
posterior oblique ligament have attachments to avulsion. In chronic cases, an osseous irregularity
the medial meniscus which explains why MCL at the femoral insertion site is seen as a result of
injuries may be associated with medial meniscal repetitive trauma, referred to as the Pellegrini-­
tears. MCL injuries are classified into minor sta- Stieda complex [66, 106]. MRI and ultrasound
ble injuries (grade I), partial injuries with mild are used to confirm the diagnosis. Stress radio-
instability (grade II), and complete tears with graphs comparing both knees where manual val-
severe instability (grade III). MCL injuries carry gus stress is applied may be used to quantify the
low morbidity and tend to heal without compli- extent of instability [107, 108].
cations undergoing the following stages: hemor-
rhage, inflammation, repair, and remodeling.
Most patients will resume preinjury level of 27.5.5 Treatment
competitive sports following conservative treat-
ment. Even though most MCL injuries occur iso- Isolated MCL sprains without valgus instability
lated, they may be associated with both ACL and may be treated conservatively after the RICE
medial meniscus injury, referred to as the principle (rest, ice, compression, and elevation)
unhappy triad. Patients with chronic symptom- [104]. Early remobilization is encouraged. Grade
27  Traumatic Knee Injuries 367

II and III lesions associated with valgus instabil- LCL lesions are present in the setting of multi-
ity require a coronal stabilizing brace for ligament injuries following high-­energy trauma
5–6  weeks; free range of motion is usually mechanisms [114]. The most commonly associ-
granted. Surgical intervention is rarely indicated ated injuries are the posterior cruciate ligament
as conservative treatment usually shows good and the popliteus tendon and the popliteo-fibu-
results [103]. However, a grade III lesion is often lar ligament [115]. The latter are referred to as
associated with multi-ligament lesions where the main static stabilizing structures of the pos-
repair procedures or reconstruction may be indi- terolateral corner (PLC) in conjunction with the
cated in a multi-ligament reconstruction setting LCL.  Other structures forming the posterolat-
[104, 109, 110]. In chronic cases with ongoing eral corner include the lateral capsule and ilio-
instability, MCL reconstruction is usually indi- tibial band, the biceps tendon and lateral head
cated [96]. of the gastrocnemius muscle, as well as vari-
able structures such as the arcuate and fabello-
Take-Home Message fibular ligament. Especially following
Even though isolated MCL injury is frequently high-energy trauma mechanisms, a fibular avul-
seen, thorough assessment of the knee is crucial sion fracture (arcuate fracture) or a common
to correctly identify concomitant meniscal or peroneal nerve injury may be present [115].
ligamentous injury.

Treatment Algorithm 27.6.2 Symptoms

• Grade I →  RICE following early
remobilization Pain and swelling along the lateral aspect of the
• Grade II → coronal stabilizing brace with free knee is usually found. Complete LCL lesions and
range of motion for 6 weeks associated ACL/PCL or PLC injuries lead to
• Grade III →  often associated with multi-­ instability near full knee extension [116], typi-
ligament lesions where repair procedures or cally compounding stair climbing and pivoting
reconstruction may be indicated maneuvers.

27.6.3 Diagnosis
27.6 LCL Injury/Posterolateral
Corner Injury Ecchymosis and lateral joint line tenderness may
be present and may be aggravated by concomi-
27.6.1 Background tant meniscal injuries. Coronal stability of the
knee is assessed in 20–30 degrees of flexion and
The lateral (fibular) collateral ligament extension. Instability in extension and 20–30
(LCL)  runs just proximal and posterior to the degrees of flexion is usually associated with inju-
lateral femoral epicondyle to the anterolateral ries of the posterior capsule and cruciate liga-
aspect of the fibular head. Due to its tubular ments. Rotational stability is assessed with the
shape and the fact that the axial rotational axis dial test; the patient is hereby lying prone, and
of the knee lies within the medial compartment both knees are externally rotated at 30 and 90
[111], complete injuries of the LCL usually degrees of flexion. The extent of external rotation
lead to significant instability and poor conser- is compared to the non-affected side. Rotational
vative healing potential. If undetected or asymmetry at 30° but not in 90° indicates an iso-
untreated, chronic instability is usually seen, lated PLC injury. Rotational asymmetry at 30 and
frequently associated with a thrust gait [112, 90° indicates a combined PLC and PCL injury.
113]. Isolated LCL lesions are rare and the Chronic instability may become evident in a
result of a direct varus trauma. Most frequently, thrust gait.
368 S. Sauer and M. Clatworthy

27.6.4 Imaging [117]. Ongoing development in the field of sports

traumatology has uncovered a much higher inci-
MRI is used to confirm the diagnosis. Plain radio- dence of multi-ligament injuries than initially
graphs may visualize a fibular avulsion fracture thought. Thorough assessment of the knee after
of the biceps tendon suitable for subacute re-­ relevant trauma is crucial to correctly identify the
fixation. Stress radiographs comparing both extent of complex multi-ligament injuries [82,
knees where manual varus stress is applied may 118]. Multi-ligament injuries are typically
be used to quantify the extent of joint opening addressed in a single operation to ensure early
and instability. mobilization which is thought to be of paramount
importance for satisfactory outcomes. In chronic
situations, malalignment of the lower limb needs
27.6.5 Treatment to be addressed before collateral ligament recon-
struction is performed. In acute initial manage-
Isolated partial LCL lesions with no varus insta- ment of multi-ligament injuries, the neurovascular
bility in full knee extension may initially be status needs to be assessed in accordance with
treated conservatively. This entails RICE (rest, ATLS principles, and CT angiography should
ice, compression, elevation) and functional always be considered in order to identify vascular
­rehabilitation with a coronal stabilizing brace for injury, especially after knee dislocation [119,
6  weeks. Conservative treatment of complete 120]. Overlooked vascular injuries are associated
LCL lesions may result in ongoing varus instabil- with high morbidity and may lead to amputation
ity. In these cases, LCL reconstruction is usually of the lower limb [121].
indicated. Patients with rotational instability
should undergo LCL/PLC reconstruction.
Patients with combined ACL/PCL and LCL/PLC 27.8 Quadriceps Tendon
insufficiency should undergo multi-ligament and Patellar Ligament
reconstruction [114]. Rupture

Take-Home Message 27.8.1 Background

LCL lesions are frequently associated with
lesions of the posterior cruciate ligament and Quadriceps tendon and patellar ligament rup-
structures of the posterolateral corner (PLC). tures may be partial or complete and commonly
affect the nondominant knee of male patients
Treatment Algorithm beyond 30 years of age. In younger patients, rup-
• Grade I and II LCL lesion → RICE and coro- tures are usually the result of a direct trauma. In
nal stabilizing brace for 6 weeks older patients, the rupture usually represents the
• Grade III LCL lesion with coronal instability final stage of prolonged underlying tendon
→ LCL reconstruction degeneration. Associated factors which are
• LCL/PLC lesion with rotational instability thought to increase the susceptibility of these
→ LCL/PLC reconstruction ruptures include diabetes, connective tissue dis-
• Multi-ligament setting → acute reconstruction orders, renal failure, and the use of intra-articu-
±(ACL/PCL/LCL/PCL) lar injections or fluoroquinolone antibiotics
[122, 123].

27.7 Multi-ligament Injury

27.8.2 Symptoms
Multi-ligament injuries are predominantly the
result of high-energy trauma mechanisms, and Patients with acute ruptures present with pain and
their management requires specialist expertise swelling at the rupture site. A popping sensation
27  Traumatic Knee Injuries 369

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 Sports Trauma: Ankle and Foot
28
Bruno Silva Pereira and C. Niek van Dijk

28.1 Sports Injuries 28.2 Epidemiology and Injuries

Healthy, pain-free foot and ankle function is both 28.2.1 All Sports
essential for participation in most sports and, sta-
tistically, is also most frequently impaired in ath- Ankle sprains are the most common of the foot
letes. As the base of the lower quarter kinetic and ankle injuries affecting athletes, accounting
chain, the foot and ankle form a cornerstone of for up to 21% of all sports injuries, with the most
lower body biomechanics, ensuring efficient sta- common mechanism being forced inversion and
bilization, movement, and power development. tearing of one or more lateral ligaments. In a
Injuries to this area must be properly managed to review of injuries treated at a multispecialty
ensure a return to pre-injury status as well as sports clinic, 25% of injuries occurring in 19 of
avoid development of secondary injuries [1]. the most popular sports involved the foot and
ankle [2].

28.2.2 Women’s Gymnastics

B. S. Pereira (*)
Kerr et  al. reported that data collected from 11
Department of Orthopedic Surgery, Hospital de
Braga, Braga, Portugal women’s college gymnastic programs show that
ankle sprains are the most common injuries and
Faculty of Medicine, University of Barcelona,
Barcelona, Spain account for large proportions of injuries across
all types of gymnastic equipment. Ankle and
Clínica do Dragão, Espregueira-Mendes Sports
Center, FIFA Medical Centre of Excellence, lower leg/Achilles tendon injuries have the high-
Porto, Portugal est rates of recurrence. Ankle injuries account for
C. N. van Dijk 17.9%, lower leg/Achilles tendon injuries
Clínica do Dragão, Espregueira-Mendes Sports account for 13.6%, and foot injuries account for
Center, FIFA Medical Centre of Excellence, 12.4% of all reported injuries. The majority of
Porto, Portugal
injuries occur in the preseason. Severe injuries—
Department Orthopedic Surgery, Academic Medical those resulting in more than 3  weeks of time
Center (AMC), Amsterdam, The Netherlands
loss—account for 12.4% of all injuries. Of these,
FIFA Medical Centre of Excellence Ripoll De Prado 53.7% are season-ending injuries for the student-­
& Van Dijk Sport Clinic, Madrid, Spain
athlete. This data represents a reduced time-loss
e-mail: [email protected]

© ISAKOS 2019 375

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_28
376 B. S. Pereira and C. N. van Dijk

injury rate compared to previous surveillance injuries. Age, weight, height, and shorter warm-­
data. Addition of safety padding and equipment ups were significantly correlated. Players who
redesign is thought to have contributed to the had sustained five or more injuries were signifi-
injury reductions [3]. cantly older, heavier, and taller than those with
fewer than five injuries. Amateur players reported
a much higher rate of foot and ankle injuries than
28.2.3 Pivotal Sports semiprofessional players, with rates of 64% and
40%, respectively. The vast majority (80%) of
In a prospective observational study, 35% of mid- foot and ankle injuries occurred while playing in
tarsal joint injuries involved sports accidents. a match. However, the position played did not
Midtarsal joint sprain (MJS), also referred to as correlate with increased foot or ankle injury
Chopart’s injury, occurs more commonly in piv- occurrence [6].
oting sports such as soccer, rugby, basketball, and
tennis. Chopart’s injury presents a diagnostic and
clinical challenge. When it occurs, it is often 28.3 Most Common Injuries
severe. Foot inversion accounted for 76% of all
cases, followed by plantar flexion in 21% [4]. 28.3.1 Ankle Instability

Definition: Chronic ankle instability (CAI) is

28.2.4 Running generally seen as having two potential etiologies:
mechanical instability and functional instability.
Most running-related injuries are associated with The term mechanical instability is often used
repetitive microtrauma and arise from a combina- synonymously with “laxity” to describe move-
tion of individual anatomical and biomechanical ment beyond the ankle’s physiologic limit.
factors, training errors, and limited running expe- However, laxity should be reserved to describe
rience. Ankle and Achilles tendon injuries are the the pathologic movement beyond the ankle’s
most prevalent injuries of the foot and ankle. A physiologic limits. This can exist with or without
survey of marathon race participants found 54% complaints. Mechanical instability should be
lifetime incidence of all running-related injuries reserved for a patient with recurrent giving way
among long-distance runners, with one-third of due to an ankle with laxity. By contrast, func-
recreational runners affected by at least one tional instability is a subjective sensation of ankle
minor injury of any kind per season. Risk factors giving way or history of recurrent ankle sprains
include male gender, short running history of arising from impaired proprioception and neuro-
approximately 1–3  years, previous injuries, and muscular function. Tenen et  al. found that high
BMI. Additionally, higher age and barefoot run- school athletes are more likely to experience
ning are risk factors for lifetime running-related chronic ankle instability than college athletes and
lower leg injuries. Training distances of 21–50 km women are more likely than men to have CAI at
per week increase a runner’s risk for lifetime both the high school and college level [7, 8].
running-­related injuries of the foot [5]. Biomechanically, the subtalar joint serves a
critical function in ankle movement by acting as
a hinge around which the leg rotates on the foot
28.2.5 Soccer during weight-bearing. The muscles around the
ankle together with the subtalar and talocrural
Foot and ankle injuries are common in both ama- joints determine the ankle’s ability to counteract
teur and semiprofessional soccer players. A torque. The muscular imbalance has been shown
newly developed standardized questionnaire to be a more significant contributing factor than
revealed that 42% of all soccer injuries occur to muscle weakness in chronic ankle instability.
the foot or ankle, with 61% of those being ankle In  particular, smaller dorsiflexion-to-inversion
28  Sports Trauma: Ankle and Foot 377

strength ratio and greater eversion-to-inversion able patient-reported outcome measure for
strength are predictors of ankle-inversion injury. assessing ankle instability. Its advantage is that it
The typical scenario in traumatic injuries is that is short and concise thereby decreasing patient
the evertor muscles are unable to counteract burden and increasing reliability. The CAIT also
external inversion torque [7]. uses a numeric measuring scale and is completed
Diagnosis: Consideration of ligament anat- for both ankles, allowing for separate assessment
omy and anatomical variants can help with the of each ankle. If the rupture is suspected, a repeat
precise diagnosis of ankle injuries. It is also the physical examination can be performed within a
most important stabilizer of the ankle joint. The few days of the first examination, to allow time
anterior talofibular ligament (ATFL), which lim- for pain, swelling, and muscle tension to subside
its anterior displacement of the talus and plantar [10–14].
ankle flexion, is the most commonly injured Treatment of acute ruptures: Rehabilitation
ankle ligament. It lies horizontal to the ankle in of athletes following lateral ankle injury should
neutral position. However, in plantar flexion, it include varied exercises emphasizing mainte-
inclines downward and is subject to strain and nance of proprioception, strength, coordination,
injury, particularly during inversion [9]. ATFL and function. The merits of cryotherapy for an
lesions can be isolated or combined with calca- acute ankle injury have not been definitively
neofibular ligament (CFL) lesions. proven, though ice in combination with exercise
Anatomic variants of the calcaneofibular liga- is more effective than heat for reducing swelling.
ment are common and should be considered in Ice combined with rest, compression, and eleva-
the diagnostic process. In 35% of the population, tion is also valuable during the acute phase.
the ligament is reinforced by the lateral talocalca- Prolonged immobilization of 4  weeks or more
neal ligament; in 23% a lateral talocalcaneal liga- has been discredited in favor of shorter, 10-day
ment is present anteriorly and is anatomically periods with early initiation of functional
distinct from the calcaneofibular ligament. The ­treatments [15].
lateral talocalcaneal ligament is absent in 42% of Interestingly, the number of ligaments injured
cases, with an anterior talocalcaneal ligament in does not seem to affect the prognosis for acute
its place. In these individuals, the calcaneofibular lateral ankle ligament injury. Acute pain and
ligament becomes more important as a stabilizer swelling can complicate the diagnostic and treat-
of the subtalar joint [9]. ment process by delaying grade (I, II, III) assign-
A multidisciplinary clinical practice guideline ment for the first 4–5 days. Three main treatment
has been proposed to improve diagnosis and modalities include surgical, conservative via
treatment of acute lateral ankle ligament injuries immobilization with cast or splint, and functional
and reduce societal costs associated with these conservative via tape or brace [15].
injuries. Ottawa ankle rules for ruling out frac- Currently, functional treatment is favored over
ture after acute ankle injury should be performed operative treatment. For athletes however opera-
as an emergency room evaluative tool. On physi- tive treatment has been shown to result in a more
cal examination, the presence of hematoma along stable ankle, while the rehab time is not longer
with local pressure pain or positive anterior when compared to functional treatment [16].
drawer test is a strong indicator of lateral ankle Outcomes: There is currently insufficient evi-
ligament rupture. Van Dijk has determined that dence in support of surgery over conservative
the delayed physical examination of the ankle treatment for acute lesions. For elite athletes sur-
4–7 days after trauma has the highest sensitivity gery, however, it should be considered since sur-
and specificity for the diagnosis of an acute lat- gery has shown to result in a more stable ankle.
eral ligament rupture [10]. This strategy was However, there is evidence supporting functional
adopted by the ISAKOS consensus statement as treatment over immobilization, with tape, semi-
the diagnostic strategy of choice. The Cumberland rigid brace, and lace-up brace producing equiva-
Ankle Instability Tool (CAIT) is a valid and reli- lent results for treating acute lateral ankle
378 B. S. Pereira and C. N. van Dijk

ligament injuries within the 6-month recovery patients with congenital ligament laxity may ben-
window. Kerkhoffs et  al. note that 60–90% of efit from performing ligament reconstruction as
athletes with acute ankle instability injuries can the primary procedure. Although isometry of the
return to sports and can perform to pre-injury lev- lateral ankle ligaments has not been proven,
els after 12 weeks [16–18]. placement of the tendon grafts at the ligaments’
Treatment of chronic instability: Before anatomical origin and insertion should be per-
conducting any surgical procedure, nonsurgical formed. The goal is to achieve good ankle stabil-
management is highly recommended for patients ity without over-constraining the ankle or subtalar
with chronic ankle instability at least over the joints. The nonanatomic positioning of the graft
first 2-month period. During the rehabilitation may alter the biomechanics of the joints resulting
stage, physiotherapy with neuromuscular and in joint loading alterations which may lead to
proprioceptive training should be provided. In joint degeneration over time [19].
case of functional instability, proprioceptive and Nonanatomic reconstructions of the lateral
neuromuscular deficits are probably important ankle ligaments have a long track record in the
cause; a minimum period of 3–6 months of phys- orthopedic literature where they have been shown
iotherapist rehabilitation, consisting of strength- historically to work well to establish a stable
ening exercises of the active stabilizers of the hindfoot for functional activities. The long-term
ankle and proprioceptive training, was recom- results in the ankle reveal an increased incidence
mended [14–17]. of degenerative changes in the hindfoot. One of
Surgical management is advised when chronic the options is by also applying a nonanatomic
ankle instability is persistent, and other options tenodesis, which is stabilizing the end of the ten-
are of no use. Operative procedures of chroni- don to a bone. Watson-Jones developed a proce-
cally unstable ankles fall into anatomic repair, dure to limit rotation and interior subluxation:
nonanatomic reconstruction, and anatomic They used peroneus brevis and routed the tendon
reconstruction. through anterior-to-posterior (distal-to-proximal)
The anatomic repair is defined as suturing of style passing through the fibula to be secured to
the torn lateral ligaments. The classic Broström the talar neck. Another option is the Chrisman-­
procedure is thus defined as a true repair of the Snook reconstruction procedure; the peroneus
lateral ligaments including the ATFL and brevis tendon is the first split and then driven into
CFL. However, it is rarely performed as a stand-­ the fibula and then into the calcaneus. This proce-
alone procedure, because it is usually augmented dure supports anatomic reconstruction, but some
with a transfer of the extensor retinaculum either patients were reported to experience nonphysio-
as a proximal advancement—the Gould proce- logical kinematics and subtalar stiffness. In our
dure. The Gould modification adds an augmenta- opinion consensus is that with modern fixation
tion with a transfer of the extensor retinaculum techniques and the known long-term degenera-
[14–17]. tive sequelae associated with nonanatomic recon-
The reconstruction refers to the replacement struction, these procedures should be avoided [7,
of the chronically deficient lateral ligaments with 10, 11, 14].
local tissues or with autograft or allograft tissue. Because intra-articular conditions such as
Reconstruction may be anatomical or impingement, talus osteochondral lesions, osteo-
nonanatomical. phytes, and chondromalacia can accompany
Anatomic reconstruction with tendon graft or chronic ankle instability and can be factored in
transfer was traditionally procedures that have dysfunction and pain, arthroscopy is ready to
been reserved for patients who have failed a prior lend a hand to diagnose and treat the ankle insta-
Broström-Gould repair. However, patients who bility [17, 18].
may stress their ankle to a greater degree than nor- In our opinion, Broström-Gould repair is still
mal, including those with high body mass index, considered the gold standard treatment in patients
heavy labor occupation, or sports requirements, or with chronic lateral ankle ligament laxity requir-
28  Sports Trauma: Ankle and Foot 379

ing surgical treatment. However, in some patients, sion of the great toe can help localize the pain of
anatomic reconstruction may be preferred. such an FHL tendinitis [20, 22].
Moreover, the use of arthroscopy to do or assist Diagnosis in anterior impingement is mainly
the surgery is mandatory. clinical, though imaging is required to rule out
other pathologies and locate osteophytes.
Anterior impingement typically presents as pain
28.3.2 Anterior and Posterior during terminal dorsiflexion. History in anterior
Impingement impingement often reveals multiple ankle sprains
or pain that worsens through a training session or
Definition: Anterior and posterior impingement performance. Palpation elicits tenderness along
syndromes may include abnormal entrapment or the anterior joint line and thickening of the
contact of structures in the anterior, anterolateral, synovium. Recognizable tenderness on palpation
anteromedial, posterior, posteromedial, postero- confirms the diagnosis. Osteophytes may be pal-
lateral, and syndesmotic structures of the ankle. pable at the anterior lateral or anterior medical
Posterior ankle impingement syndrome is a com- joint line. The classic anterior ankle impingement
mon repetitive plantarflexion injury. It often has four typical presentations: the lip of the tibia,
occurs in dancers and soccer players but can neck of the talus, both, or secondary to frank
occur in all sports. Posterior impingement most osteoarthritis [21, 23].
commonly stems from the pathology of the lat- X-ray, CT, and MRI are all useful imaging
eral process of the posterior talus or, less com- methods. An x-ray should include weight-­bearing
monly, from tibiotalar or subtalar degenerative AP, lateral, and mortise views. The lateral view
joint disease. Anterior impingement is the most should be carefully analyzed for the presence of
common chronic injury in the ankle. Chronic lat- exostoses and posterior bony anomalies. Oblique
eral ankle instability has been identified as a pos- views can help assess bony abnormalities. In the
sible contributing factor in anterior impingement, case of anteromedial recognizable tenderness on
but it can occur in any sports with recurrent palpation, one should order an anteromedial
hyperdorsiflexion. The majority of cases (63% impingement view (AMI view) like van Dijk
and above) involve synovitis in the anterior com- described in 2002 [24]. This oblique view can
partment, anterior lateral gutter, or other soft tis- help assess bony abnormalities on the medial side
sue lesions. Soft tissue hypertrophy or osteophyte of the joint. Consider MRI in case osteochondral
growth encroaches upon the space between the defects are part of the differential diagnosis. The
anterior lip of the tibia and the dorsal talar neck. posterior impingement x-ray view (PIM view)
Anterior osteophytes are common and occur in provides superior diagnostic accuracy over the
59% of dancers without impingement symptoms. lateral view for detecting os trigonum, while
Most professional soccer players have spurs at MRI can detect soft tissue anomalies, such as
the end of their career (personal observation of peroneus quartus. Soft tissue injuries associated
the senior author) [20–22]. with posterior impingement include posterior
Diagnosis: Accurate diagnosis starts with a capsuloligamentous injury or flexor hallucis lon-
thorough physical exam including neurovascular gus tendinopathy [20–22, 24].
evaluation, strength, and range of motion. Treatment: Physical therapy should focus on
Presentation in posterior impingement is gener- the entire kinetic chain. Night splint or removable
ally a pain deep to the Achilles tendon, some- walking brace can be used briefly. High-level ath-
times confused with Achilles or peroneal tendon letes may benefit from ultrasound-guided injec-
pathology. Pain is aggravated by forced plantar tions. Surgery is indicated if symptoms persist
flexion of the ankle. A negative plantarflexion test after 3 months of conservative care. Arthroscopy
does rule out posterior impingement. Posterior is advantageous for the patient regarding smaller
impingement is often combined with flexor hal- incisions and shorter recovery times. Surgery for
lucis longus tendinitis. Active flexion and exten- anterior impingement may involve resection,
380 B. S. Pereira and C. N. van Dijk

debridement, or both. Surgery for posterior the ankle, occurring in 50% of ankle sprains.
impingement involves resection of involved Shimozono et al. report the rate of occurrence in
structures [21, 22]. athletes is five to nearly ten times that of the gen-
Yasui, Hannon, et  al. describe a four-stage eral population. Etiology is controversial and
arthroscopy that allows for full assessment of all includes a diverse range of potential factors, such
posterior ankle and subtalar joint structures. The as acute or remote trauma, degenerative arthropa-
procedure involves dividing the hindfoot structures thies, repetitive microtrauma, systemic metabolic
into four regions of interest: superolateral, supero- disorders, genetic predisposition, abnormal vas-
medial, inferomedial, and inferolateral. Each culature, and systemic conditions. The talar dome
region is methodically inspected and appropriately is a common site for osteochondral lesions and is
treated. This assessment has lost its use since diag- second to the knee in frequency. Posteromedial
nosis should not depend on arthroscopy. A diagno- lesions tend to be deeper and cup-shaped, while
sis must be made before any surgery is performed. anterolateral lesions tend to be shallow and
The arthroscope is used as a tool to perform the wafer-shaped. Medial osteochondral lesions of
surgery and not as a diagnostic tool [22]. the talus occur at a higher rate than lateral lesions.
Baxter advises that exercising care while per- All lateral lesions and 36% of medial lesions are
forming incisions can help reduce the risk of inci- associated with trauma. These patients present
sional neuromas. Anterior impingement spurs on with deep ankle pain. Van Dijk published on the
the medial shoulder of the talus can be missed on cause of the pain in these lesions: that pain does
lateral x-ray and may require nonweight-bearing, not arise from the cartilage lesion but is most
oblique views. To resect this “hidden” spur probably caused by repetitive high fluid pressure
arthroscopically, the ankle must be held in dorsi- during walking, which results in stimulation of
flexion [25]. the highly innervated subchondral bone under-
Outcomes: Conservative treatment has been neath the cartilage defect [28–31].
shown to produce up to 60% success rates. Diagnosis: The most important for the diag-
Arthroscopy has resulted in high patient satisfac- nosis is the history taking. A patient with an OLT
tion rates and AOFAS scores, with low rates of has deep ankle pain. A thorough examination can
complications. Tanawat et  al. found that sometimes reveal joint swelling, crepitus,
arthroscopic bony or soft tissue debridement reduced passive and active ranges of motion, and
each provide positive long-term outcomes where palpatory tenderness. Anterior drawer and talar
there are no arthritic changes, ligament laxity, or tilt tests can assess laxity and help narrow the
chondral lesions. Open treatment for posterior diagnosis; however, there are no confirming
impingement using a lateral or medial approach physical examination tests for osteochondral
produces good results but is associated with high lesions. Physical exam signs may be absent, and
rates of complications. Posterior endoscopy has the exam is often nondiagnostic. Most patients
shown significantly faster return to sports and with an OLT will show a “normal ankle”; long-­
lower complication rates; however, the technique standing problems may involve compensatory
is technically difficult. Yasui reports very good contralateral knee, hip, and back pain [28, 32].
short-term results of the four-stage arthroscopy When symptoms persist after conservative
procedure, with low complication rates [20, 22, management, imaging studies may be necessary
23, 26, 27]. to confirm the diagnosis. X-ray is the standard
imaging method but misses up to 41% of
OLT. The x-ray also lacks the personal ability to
28.3.3 Osteochondral Lesions assess the integrity of the articular cartilage, and
of the Talus thus, its usefulness for accurately staging the
disease process is limited. X-ray imaging should
Definition: Osteochondral lesions of the talus include weight-bearing, if tolerable. Mortise
(OLT) are the most common cartilage injury of view is best for showing lateral lesions. Medial
28  Sports Trauma: Ankle and Foot 381

lesions are best viewed with anteroposterior 89% of OLT patients with nonmalignant patholo-
views. Bilateral radiographs allow comparison gies. Arthroscopy can also be used as a diagnostic
of affected and non-affected sides, though con- tool when imaging is negative, and symptoms
tralateral lesions occur in up to 25%. MRI is bet- persist after conservative management has been
ter for evaluating cartilage and is 96% sensitive tried. Arthroscopy offers the advantages of direct
and 96% specific for diagnosing OLT.  MRI is visualization and immediate treatment [36].
regarded as the gold standard for imaging pure Treatment: Surgery is indicated in the event
cartilage lesions, with 100% specificity and of failure of conservative therapy for chronic
73–95% sensitivity. However, these lesions are lesions and. Acute osteochondral fragments of
seldom pure chondral injuries. Most symptom- >12  mm in size should be fixed (Figs.  28.1,
atic patients have osteochondral lesions. MRI 28.2, and 28.3). Concerning chronic lesions
and CT scan have shown similar diagnostic curettage, drilling, or microfracture techniques
accuracy, but CT scan is preferred since it is can be used on lesions <15 mm wide and <7 mm
much better for preoperative planning since it deep (Fig.  28.4). Larger lesions are candidates
shows the exact extent and location of the lesion for fixation. Those which primary bone marrow
[28, 32–35]. stimulation surgery was tried and failed may be
SPECT/CT shows promise for improving candidates for autologous chondrocyte implan-
treatment outcomes for OLT by improving the tation (ACI), osteochondral autograft transplan-
accuracy of disease staging. Morteza, Stuart, et al. tation (OATs or mosaicplasty), osteochondral
reported that SPECT combined with multi-­slice allograft transplantation, or metal inlay implant.
low-dose CT (MslCT) added clinical value in These secondary lesions can also benefit from a

Fig. 28.1  OLT large defect

Fig. 28.2  Sequence of OLT larger lesion fixation

382 B. S. Pereira and C. N. van Dijk

sliding calcaneal osteotomy in case of larger lesions or where previous bone marrow
­malalignment [28]. stimulation techniques have failed, there is evi-
Spennacchio et  al. reported that the 70° dence supporting autogenous chondrocyte
arthroscope could provide improved capabilities implantation and osteochondral autograft or
for visualizing for certain lesions involving the allograft transplantation [29, 32].
borders of the talar dome when compared to the Microfracture arthroscopy for treatment of
30° arthroscope. This method is particularly osteochondral defects of the talus is less effective
useful for uncontained lesions as it provides for larger lesions. Tissue-engineered scaffolds
visualization of “hidden” portions of the lesions have shown promising results in a single-step
in the joint gutters. Successful treatment of a arthroscopic procedure that does not require trac-
large talar dome defect, refractory to two previ- tion, fibrin glue, or pins for scaffold stabilization.
ous arthroscopic procedures, using a novel con- This procedure is shorter in duration and simpler
toured metal implant was reported by van to perform and eliminates neurapraxia risk asso-
Bergen et  al. The technique uses an oblique ciated with traction. However, the absence of
osteotomy of the medial malleolus in order to tracks restricts access to anterior lesions from
provide adequate exposure to ensure accurate posterior portals, making the preoperative loca-
implantation [32, 37, 38]. tion of the lesion mandatory. Additionally, with-
Outcomes: Conservative treatment including out gluing or pinning, it is imperative that the
weight-bearing tolerance has been reported by patient maintains neutral ankle position meticu-
Zengerink et al. to produce successful outcomes lously for 3 weeks following surgery [39].
in 45% of patients.
The operative treatment produces good-to-­
excellent outcomes in up to 85% of patients. For 28.3.4 Achilles Tendon Injuries

Definition: The terminology of Achilles tendon

pathology has become inconsistent and confus-
ing throughout the years. We use the terminology
adapted from KSSTA: midportion Achilles tendi-
nopathy, Achilles paratendinopathy, insertional
Achilles tendinopathy retrocalcaneal bursitis,
and superficial calcaneal bursitis [39–41].
Midportion Achilles tendinopathy is a clinical
syndrome characterized by a combination of pain,
swelling, and impaired performance. It includes,
but is not limited to, the histopathological diagno-
sis of tendinosis. Achilles paratendinopathy is an
Fig. 28.3  Post-op x-ray acute or chronic inflammation and/or degenera-

Fig. 28.4  Microfracture arthroscopy for treatment of osteochondral defects of the talus
28  Sports Trauma: Ankle and Foot 383

tion of the thin membrane around the Achilles ence of inflammatory changes in the peritendi-
tendon. There are clear distinctions between acute nous connective tissue surrounding the plantaris
paratendinopathy and chronic paratendinopathy, tendon, indicating that the pathologic process
both in symptoms and in histopathology. may involve a compressive or frictional compo-
Insertional Achilles tendinopathy is located at the nent [39–46].
insertion of the Achilles tendon onto the calca- Concerning insertional Achilles tendinopathy
neus; bone spurs and calcifications in the tendon is a distinct clinical entity from midportion/non-­
proper at the insertion site may exist. insertional Achilles tendinopathy or retrocalca-
Retrocalcaneal bursitis is an inflammation of the neal bursitis. It appears in the insertion of AT
bursa in the recess between the anterior-­inferior onto the calcaneus, most often with the formation
side of the Achilles tendon and the posterosupe- of bone spurs and calcifications in the tendon
rior aspect of the calcaneus (retrocalcaneal proper at the insertion site. The patient has pain,
recess). Superficial calcaneal bursitis is an inflam- stiffness, and sometimes a (solid) swelling.
mation of the bursa located between a calcaneal Diagnosis: The condition can usually be diag-
prominence or the Achilles tendon and the skin. nosed clinically via history and presentation.
Overuse injuries of the Achilles tendon can be Tests for non-insertional Achilles tendinopathy
either insertional or non-­insertional based on ana- include palpation for thickening, crepitus, and
tomical location [31, 40–43]. pain and tendon loading tests to elicit pain on
Non-insertional Achilles tendinopathy occurs passive dorsiflexion, single heel raise, and hop-
disproportionately in athletes compared to the ping. The painful arc sign, characterized by
general population, particularly affecting middle- movement of the swollen tissue concurrently
and long-distance runners. Roche and Calder with ankle movement, can be used as an indica-
estimate that 9% of recreational athletes are tion of tendinopathy but not paratendinopathy.
affected and that chronic Achilles tendinopathy Ultrasound and MRI are of equivalent accuracy
becomes a career-ending condition for up to 5% in diagnosing this condition. Ultrasound tissue
of professional runners. Concerning the characterization and sonoelastography show
non-­
­ insertional problems, van Dijk postulated promise for improving sensitivity and accuracy.
that the pain does not originate from the tendon Bloodwork may reveal the decreased activity of
itself but from the nerves in the paratenon. The matrix metalloproteinases (MMPs), particularly
process starts within the tendon with local degen- MMP3 [39, 40, 42, 46].
eration or microrupture. Since there are hardly Treatment: Conservative management with
vessels and nerves within the tendon by means of rest, activity modification, orthotics, and eccentric
cytokines, a neurogenic response is induced with stretching is often recommended, initially. NSAIDs
neovascularization and neoinnervation in the may have detrimental effects by inhibiting tendon
paratenon. It is these neonerves which cause the cell migration and proliferation and by increasing
pain in these patients. Treatment originally leukotriene levels. Extracorporeal shockwave ther-
addressed the tendon proper itself. Van Dijk, apy (ESWT) has been used in conjunction with
however, proposed endoscopic denervation of the rehabilitative protocols [39, 40, 42, 46].
painful area with excellent results. He also postu- Injection therapies such as platelet-rich
lated the role of the plantaris tendon that may plasma are currently in wide use. Ultrasound-­
contribute to symptoms in some midportion guided dry needling combined with high-volume
Achilles tendinopathy patients. Anatomical stud- image-guided injection has also been used. Dry
ies have found firm connections between the needling involves repeated needling to the
plantaris and calcaneal tendons at the level of the affected tendon to cause localized trauma and
midportion of the Achilles tendon. Plantaris exci- induce inflammation and formation of granula-
sion has revealed the absence of tendinopathic tion tissue, which strengthens the tendon. High-­
changes; however, the majority of patients who volume image-guided injection (HVIGI) uses
clinically improve following surgery show pres- normal saline, local anesthetic, and corticoste-
384 B. S. Pereira and C. N. van Dijk

roids. A mixture of 10  mL 0.5% bupivacaine the use of tendoscopy for Achilles tendinopathy
hydrochloride and 25 mg of hydrocortisone ace- but add that the limited number of high-level
tate is injected between the anterior Achilles ten- studies speaks to the need for more studies and
don and Kager’s fat pad at the area of maximal does not equate to a recommendation against the
neovascularization. This procedure works well in use of tendoscopy [25, 48, 49].
conjunction with eccentric exercises [39, 46, 47].
Limited understanding of the pathophysiology
underlying chronic Achilles pain has resulted in a 28.3.5 Plantar Fasciitis
variety of surgical approaches. It has been postu-
lated that intratendinous degeneration is the cause Definition: A common overuse injury of the
and that performing multiple tenotomies should plantar fascia, which provides static support and
increase blood supply and speed healing. Others dynamic shock absorption to the medial longitu-
theorize that neurovascular ingrowth is responsi- dinal arch. The condition is usually a result of
ble for chronic pain in Achilles tendinopathy and repetitive microtrauma, causing microtears that
that release of the paratenon helps resolve pain by lead to degeneration and inflammation. Plantar
its denervating effects. Multiple percutaneous fasciitis affects elite as well as recreational ath-
longitudinal tenotomies using ultrasound guid- letes. It is common in runners and accounts for
ance can be performed under local anesthesia as 10% of all running-related injuries. Women are
outpatient procedures [48–50]. slightly more prone than men. Pes planus and pes
Outcomes: Roche and Calder report that non- cavus are both risk factors, as are reduced ankle
operative management is successful long term in dorsiflexion and excessive pronation [51, 52].
approximately 70% of cases. Pearce notes that Diagnosis: There is not a separate algorithm
eccentric stretching is the most effective conser- for athletes vs. nonathletes for diagnosing plantar
vative treatment. Ultrasound-guided dry needling fasciitis. Intense, acute heel pain at the anterior
combined with high-volume image-guided injec- calcaneal insertions is a cardinal sign. History
tion have produced good short- and medium-term generally reveals the onset of pain upon first
symptom relief. Platelet-rich plasma has shown walking in the morning or after rest, though pain
some improved healing in acute rupture but no can also occur after prolonged walking, standing,
improvement in symptoms over saline injection or intense training. Palpation of the medial tuber-
for chronic Achilles tendinopathy [39, 40, 47]. cle of the calcaneus and proximal plantar fascia
For recalcitrant cases, minimally invasive and assist with diagnosis. Ankle passive dorsiflexion
tendinoscopic treatments show promising results. and ankle dorsiflexion/eversion can be performed
Baxter notes that operative treatment is 70–90% to rule out tarsal tunnel syndrome. Melvin notes
successful, provided a 3- to 6-month healing period that plantar fasciitis commonly occurs
before return to athletic participation is observed. ­concurrently with heel spurs but that 50–75% of
With the exception of multiple percutaneous tenot- all heel pain patients have heel spurs, indicating
omies, minimally invasive and endoscopic proce- that heel spurs may not be a cause of pain in plan-
dures for treatment of midportion Achilles tar fasciitis [51, 52].
tendinopathy are associated with lower complica- Diagnostic imaging should be performed in
tion rates than open procedures and produce simi- persistent cases in which symptoms remain after
lar rates of patient satisfaction [25, 39, 40]. 4–6  months of conservative care or when signs
A retrospective study by Opdam, Baltes, et al. and symptoms are atypical. X-ray and bone scans
found that endoscopic treatment of midportion are used primarily to rule out a tumor or fracture.
Achilles tendinopathy using paratenon release MRI and diagnostic ultrasound can be used to
combined with plantaris tendon resection pro- evaluate plantar fascia thickness, to confirm the
duces high patient satisfaction rates and good diagnosis, and to evaluate the inflammatory pro-
functional outcomes. Cychosz, Phisitkul, et  al. cess. Petraglia notes that nerve conduction stud-
report weak evidence in the current literature for ies can be also helpful in diagnosis [52].
28  Sports Trauma: Ankle and Foot 385

Treatment: Treatment options for plantar fas- myelitis, fat pad atrophy, and plantar fascia tears.
ciitis are numerous and varied. Conservative In the chronic phases of the condition, normal
options include activity modification, night fascia is replaced by angiofibroblastic hyperplas-
splints, and NSAIDS.  Instrumental modalities tic tissue, with no inflammation present. PRP
may include laser, extracorporeal shock wave supplies cytokines and growth factors as well as
therapy, iontophoresis, ultrasound, cryoultra- anti-inflammatory components that, in combina-
sound, and low-dose radiotherapy. Physical ther- tion, initiate healing and halt degenerative
apy may include massage, manipulative therapy, changes [52, 55].
stretching, orthotic devices, low-dye taping, and Surgery is recommended after 6–12  months
kinesiotaping. Stretching exercises yield the most of failed conservative treatment. Minimally
statistically significant long-term results. invasive radiofrequency microtenotomy has
NSAIDs are not indicated as plantar fasciitis is ­produced promising results in refractory plantar
considered a degenerative and not an inflamma- fasciitis [47].
tory process. As an alternative therapy, injection
of platelet-rich plasma can be used to promote
healing. A minimally invasive surgical procedure 28.3.6 Lisfranc Sprain
called radiofrequency microtenotomy uses radio-
frequency energy to improve blood flow and pro- Definition: The Lisfranc ligament spans the
mote healing. This procedure allows more medial cuneiform and second metatarsal base.
precision while preserving the plantar aponeuro- The tarsometatarsal articulation is supported by
sis [51, 53]. the “keystone” wedging of the second metatarsal
Outcomes: Conservative therapy is success- into the cuneiform and vulnerable to injury when
ful in 90% of cases. A meta-analysis of random- stressed. Damage may involve ligaments, frac-
ized clinical trials revealed focused shock wave tures, or fracture-dislocations. Injury occurs via
(FSW) therapy to be effective for relieving pain direct force from an external source or, most
in chronic plantar fasciitis, with the advantages of commonly, indirect force, whereby the foot is
fast recovery and patient convenience. stationary, and the body exerts torque, rotation, or
Effectiveness was not confirmed for general compression. Indirect injuries occur in equestrian
extracorporeal shock wave therapy (ESWT) or sports in which the foot becomes caught in a stir-
radial shockwave (RSW) therapy. FSW concen- rup and is forced into external rotation or twist-
trates waves on the tissue, while RSW disperses ing. Soccer and rugby players experience
waves rather than concentrating them. Osman direct-force trauma from contact with another
et  al. report that pulsed radiofrequency to the athlete landing on the heel during kneeling or
medial calcaneal nerve is safe and effective for lying prone. Statistically, 87.5% of Lisfranc
reducing pain and achieves analgesia in less time ­injuries are closed and up to one-third involve
than thermal radiofrequency. The pauses between low-­energy trauma in athletes. Fracture of the
pulses allow heat to dissipate resulting in less risk base of the second metatarsal of often the only
of damage to surrounding nerves compared to positive finding. This however represents a
thermal radiofrequency [53, 54]. Lisfranc dislocation [56–59].
Among injection therapies, botulinum toxin Diagnosis: Fracture dislocations can result in
injections produce better results than corticoste- residual malunion and loss of function, making
roid injections. Corticosteroid injections pro- early diagnosis imperative. Midfoot swelling and
duce short-lasting benefits that are superior to loss of weight-bearing ability, particularly on tip-
autologous blood but with the potential risk of toe, may be the only physical exam findings.
fascia rupture and infection. PRP therapy has History will indicate injury mechanism consis-
shown superior long-term pain relief and similar tent with a Lisfranc injury. Direct palpatory pain
functional improvement compared to steroid will localize to the medial or lateral foot at the
injections, which carry the risk of abscess, osteo- tarsometatarsal area. Abduction and pronation of
386 B. S. Pereira and C. N. van Dijk

Fig. 28.5 Lisfranc
fracture right foot

the forefoot with fixed hindfoot will also elicit ing. Particularly in athletes, displacement greater
pain [56, 60]. than 2 mm may require open reduction and inter-
Plain radiographs are highly useful for diag- nal fixation to ensure good outcomes. Procedural
nosis and postoperative assessment (Fig.  28.5). preference varies, with some orthopedists prefer-
Weight-bearing dorsal anteroposterior, lateral, ring closed fixation with percutaneous K-wires
and 30° oblique views should be obtained and and others open reduction and internal fixation
will commonly reveal diastasis between the first with AO screw fixation. Precise postoperative
and second metatarsal bases. X-ray is potentially assessment allows for early intervention should
limited in precision due to swelling, projection complications arise [56, 62].
angle, or image overlap. CT offers greater detail Following open reduction and fixation, the
of small fractures and deviations but is limited in foot should be cast for 8–12  weeks. Full, non-­
postoperative assessment due to interference casted weight-bearing should be avoided until the
from metal implants. Bone scans and MRI can plates are removed at 8–12 weeks. A protective
detect occult fractures earlier than radiographs. shoe should be worn for 3  months after cast
Woodward et  al. report characteristic sono- removal [56].
graphic findings indicating Lisfranc ligament Outcomes: Incidence of acute complications
tear [58–61]. is high and results in lengthy hospitalizations.
Treatment: Stable injuries can be treated con- Three factors serve as important predictors of
servatively with a CAM boot for 6–10 weeks fol- complications: the extent of local trauma, delay
lowed by physical therapy to restore strength, in diagnosis, and degree of displacement.
balance, and ROM [56, 58]. Posttraumatic arthritis is common and usually
Treatment of fractures and fracture-­requires a subsequent arthrodesis. Li et  al.
dislocations is controversial, with some research- reported that CT imaging easier identification of
ers asserting that nonoperative management is nonanatomic reduction and poor internal fixation
ineffective due to loss of alignment during cast- compared to radiographs [56, 59–61].
28  Sports Trauma: Ankle and Foot 387

28.3.7 Stress Fractures Diagnosis: Initial diagnosis is largely clinical

and relies on history and physical examination.
Definition: Stress fractures account for 10% of Typically, patients describe the insidious initial
all sports-related injuries and occur as a result of onset of pain, associated with a recent increase in
repeated submaximal loads whereby shear forces, training intensity with pain occurring toward the
which stimulate osteoclast activity, exceed com- end of training sessions and intensifying gradu-
pressive forces, which stimulate osteoblast activ- ally over weeks to become constant. The absence
ity, ultimately exceeding the bone’s ability to of rest pain helps to differentiate stress fractures
adapt. Lower limbs are most affected, with 25% from a variety of other conditions, including
of stress fractures occurring in the tarsals and 9% inflammatory pathologies and bone tumors.
in the metatarsals. The incidence of stress frac- Usually, there is no history of trauma. Physical
tures in military recruits varies from 5 to 30% per examination reveals pain on weight-bearing or
year, being higher in female recruits. The inci- range of motion and palpatory tenderness.
dence in the nonmilitary athletic population var- Edema, ecchymosis, or a palpable callus may
ies from 1.1 to 31% per year, the highest being also be present [63, 64, 66].
the incidence noted in track and field athletes. Due to the nature of the healing process, stress
Retrospective studies in ballet dancers have fractures commonly evade x-ray diagnosis for the
shown the incidence of stress fractures to be first 2 weeks until sufficient sclerosis and callus
between 22.2 and 31.5%, the most common loca- formation occur. These statistics range from 40 to
tion being the metatarsals. In a questionnaire-­ 95% of cases, depending on location.
based survey by Pecina et  al., 21.5% of elite Cases with a high suspicion of a stress fracture
figure skaters reported a stress fracture during and negative radiographs should be evaluated by
their career; the most common site was the lum- alternative imaging techniques, such as an MRI,
bosacral spine. Gymnasts showed an incidence of which provides high sensitivity and specificity,
16% stress fractures for men and 24% stress frac- and CT, which is useful for evaluating for signs
tures for women [63–67]. of periostitis and assessing fracture union in con-
Intrinsic risk factors include lack of physical servative management [17, 63, 65–67].
activity, low body mass index, age (in males, Treatment: Management varies with the
incidence decreases after 17  years of age; in sports, severity, and athletic level. Most stress
females, it increases after menarche), decreased fractures can be treated conservatively using boot
muscle strength, and anatomical factors: low immobilization for 6–8  weeks, followed by
cross-sectional area, leg-length discrepancy, 6  weeks partial weight-bearing in a functional
menstrual dysfunction, low bone mineral density, splint, followed by gradual return to sports.
and eating disorders. Extrinsic risk factors ­Low-­impact activities can be maintained through-
include activity type, changes to training tech- out. Asano et  al. report that surgery should be
niques or intensity, improper equipment or train- considered early for elite athletes due to higher
ing surfaces, suboptimal nutrition, long-distance risk for dislocation and non-consolidation and for
runners, alcohol, smoking, and low vitamin D fractures of the navicular, which has a poor blood
levels [66]. supply, and medial malleolus, which is prone to
Locations vary by sports; runners are prone to dislocation and non-consolidation. Van den
stress fractures of the medial malleolus, distal fib- Bekerom et al. caution that, in medial malleolus
ula, calcaneus, lesser metatarsal, and medial sesa- fractures, complete rest can lead to atrophy and
moid bones. Ballet dancers, gymnasts, and tennis deconditioning and should be avoided [63, 65].
and volleyball players commonly experience frac- Outcomes: Low-risk fractures usually heal
tures of the navicular and sesamoids. Basketball within 4–8  weeks of limited activity. Surgical
players are prone to the medial malleolus, navicu- treatment in athletes is advantageous in that it
lar, and metatarsal fractures. Soccer players are speeds healing and allows a faster return to
prone to metatarsal V fractures [63, 66]. sports. For surgically treated navicular frac-
388 B. S. Pereira and C. N. van Dijk

tures, Asano et  al. report an average time of thema, swelling, and tenderness. The medial arch
4  months for full healing and return to sports. is intact, and foot alignment is normal.
For fifth metatarsal fractures, Robertson and Radiographs show normal foot and ankle align-
Wood report a minimum of 75% return times ment. MRI distinguishes normal and abnormal
within 13.8 weeks for surgical management and anatomy of the tendon sheath and provides supe-
minimum of 33% return times within 19.2 weeks rior visualization of abnormalities of the spring
for conservative management. Conservative and deltoid ligaments [69, 70, 72].
management of medial malleolus fractures has Stage 2: Irreversible tendon changes may lead
been found to take three times longer for a to rupture. Radiographs should be examined for
return to sports compared to surgical manage- talar-first metatarsal (Meary) angle, calcaneal
ment [63, 65–68]. pitch, talocalcaneal angle, and medial and lateral
column heights on lateral weight-bearing views.
Stage 3: Possibly fixed, non-flexible subtalar
28.3.8 Posterior Tibial Tendinitis joint arthropathy is evident on x-ray, along with
arthritic symptoms. Stage 4: Radiographs reveal
Definition: Posterior tibial tendinitis is progres- fixed deformity with valgus ankle, calcaneal val-
sive, beginning with tendon dysfunction and pro- gus, midfoot planus, and forefoot abduction with
gressing to ligamentous dysfunction and supination [70, 72].
ultimately leading to flatfoot deformity. The ten- Pain at the posterior margin of the medial mal-
don’s sheath is unique in that the mesotenon layer leolus without intra-articular pathology can sig-
lacks complete blood supply, particularly nify adhesions and irregularities in the tendon
between the musculotendinous and osseous-­ sliding channel [73].
tendinous junctions, and this is where most tendi- Treatment: Stage 1: Conservative treatment
nopathy occurs. Anatomically, the posterior tibial with immobilization, rest, and plaster cast or
tendon lies near the medial malleolus and beneath walker boot. Orthotics can reduce forefoot prona-
the flexor retinaculum and is vulnerable to injury tion and reduce stress on the tendon. Physiotherapy
in ankle fractures. Other risk factors include decreases acute swelling and strengthens the pos-
impingement at the fibro-osseous groove and terior tibialis muscle. Steroids should be avoided
insertion abnormalities. Posterior tibial tendinitis due to the risk of tendon rupture and fat atrophy.
is three times more common in women [69–71]. Ribbans and Garde report good results using
Primarily a soft tissue tendinopathy results in saline infiltration of the sheath combined with
altered biomechanics. Four stages are described. physiotherapy. Synovectomy should be consid-
Stages 1 and 2 involve only soft tissues. In stage ered for nonresponsive cases after 3  months.
2, permanent changes in the tendon have Wake and Martin report that endoscopy is becom-
occurred. Development of subtalar arthritis ing the standard in stages 1 and 2 [61, 69, 72].
defines stage 3. Involvement of the ankle joint Stage 2: Soft tissue reconstructive procedures
defines stage 4. Van Dijk confirmed the presence are preferable to bone or joint reconstruction
of thickened vincula following trauma that, when [49]. Return to elite sports performance is
released, provided symptom relief. Gody-Santos unlikely without surgical intervention. Surgery
et  al. report the presence of a polymorphism in should address lateral column lengthening and
the MMP-1 promoter gene, leading to degrada- stabilizing medial column fusion [72].
tion and removal of collagen from the extracel- Stages 3 and 4: Arthrodesis is usually required
lular matrix [70–72]. and may be single or multiple. Open or mini-
Diagnosis: Early diagnosis and intervention mally invasive procedures can be used. Nishimura
can help stop progression. Stage 1: Symptoms reports that ultrasonographic guidance can be
include pain over the medial foot and decreased used to assist with the insertion of an endoscope
endurance. Physical examination will reveal ery- into the tendon sheath [70, 73].
28  Sports Trauma: Ankle and Foot 389

Outcomes: Endoscopy offers shorter postop- II involves partial rupture of the plantar soft tis-
erative periods and smaller scars with equivalent sue structures. Grade III involves complete rup-
results and greater patient satisfaction compared ture and may require surgery [74, 78, 79].
to open procedures. However, there is a risk of Weight-bearing and stress AP, lateral, and axial
injury to the medial plantar nerve. Rehabilitation sesamoid radiographs should be obtained for both
is lengthy, taking at least 12 months, with a return feet. Fluoroscopy can help detect valgus instabil-
to high-impact elite sports not advised [69, 72]. ity and plantar plate integrity. Drakos et al. define
stable injuries as a change of less than 2 mm on
dorsiflexion stress radiographs in proximal retrac-
28.3.9 Turf Toe tion of the sesamoids compared with the unaf-
fected side. MRI can provide detail regarding
Definition: Turf toe was originally described as a associated osseous, intra-articular, and soft tissue
hyperextension injury to the hallux metatarso- injuries and is preferable to CT [74, 79].
phalangeal joint (MTPJ) resulting from overly Treatment: Stable injuries can be treated with
flexible shoes on insufficiently flexible artificial conservative treatment with casting or a stiff-­
turf. The condition is now recognized in a num- soled shoe, gradual weight-bearing, orthotics,
ber of sports played on artificial turf as well as in and physical therapy. Substantial but stable cap-
sports requiring repetitive loading of the hallux, sule injuries can be cast for 4–6 weeks [79].
such as wrestling, basketball, and dancing. It Grade I injuries do not require the loss of play-
encompasses a variety of injury mechanisms ing time. After the acute phase, the toe can be
affecting the hallux plantar capsule, plantar mus- taped in slight plantar flexion, and a toe separator
cles, and sesamoid complex [74–76]. can be used in medial injuries. Grade II injuries
The hallux MTPJ is inherently unstable and will require at least 2-week cessation of sports
must withstand as much as eight times body participation with a gradual progression from
weight during a running jump. The injury typi- low- to high-impact exercises. Grade III injuries
cally occurs when the foot receives an axial load may require 8 weeks of immobilization and can
while in a fixed equinus position at the ankle and take up to 6 months for resolution [78].
the great toe in extension at the MTP joint. Waldrop et al. recommend surgery for injuries
Waldrop et  al. demonstrated that an increase of involving at least three of the four ligaments in
3  mm between the sesamoids and the proximal athletes. For displaced fractures, excision of the
phalanx increases the risk for severe injury to the smaller fragment with plantar plate repair has
plantar plate, with a likelihood of involving three been done with and without augmentation. Open
ligaments [77, 78]. reduction and internal fixation can be accom-
Diagnosis: Physical examination must include plished using small screws [77, 79].
a comparison to the unaffected side. The drawer Outcomes: Accurate and early diagnosis is
test for the first MTPJ is conducted by stabilizing essential for successful outcomes and can result in
the first metatarsal superiorly and inferiorly with full recovery and return to pre-injury activity for
one hand while applying an anterior and poste- many patients, though McCormick et al. note per-
rior translational force to the proximal phalanx to sistence of residual or chronic symptoms in up to
feel for dorsal or plantar subluxation. A positive 50% of patients at 5-year follow-­up in one study
test demonstrates anteroposterior instability. and persistent loss of range of motion in other
Stress and instability testing determines the need studies. Covell et  al. report 74% return to pre-
for surgery. Plantar plate rupture can be easily injury playing level and average 3- to 4-month
overlooked during a physical examination in recovery time for surgical treatment of traumatic
severe injuries. Grade I injury involves sprain of hallux valgus. A multidisciplinary team approach
the plantar capsular ligamentous complex. Grade can help ensure optimal results [74, 76].
390 B. S. Pereira and C. N. van Dijk

28.4 Conclusion phy and sonography compared in 160 patients after

inversion trauma. https://www.ncbi.nlm.nih.gov/
pubmed/9065068.
Worldwide, sports participation has increased 11. Diagnosis, treatment and prevention of ankle sprains:
substantially over the past few decades. In addi- an evidence-based clinical guideline. http://bjsm.bmj.
tion to increasing participation among youth, par- com/content/46/12/854.
12. The Cumberland Ankle Instability Tool (CAIT) in
ticularly girls, as the global population ages, the Dutch population with and without complaints of
older adults are also continuing to be active or ankle instability. https://www.ncbi.nlm.nih.gov/pmc/
choosing to begin sports participation at advance articles/PMC5847203/.
ages. As a result, sports medicine specialists are 13. The ANKLE TRIAL (ANKLE treatment after injuries
of the ankle ligaments): what is the benefit of external
experiencing new diagnostic and treatment chal- support devices in the functional treatment of acute
lenges. To meet those challenges, orthopedists, ankle sprain?: a randomised controlled trial. https://
surgeons, and other orthopedic professionals are www.ncbi.nlm.nih.gov/pmc/articles/PMC3306273/.
responding with innovative approaches to sur- 14. Van Dijk CN. Diagnosis of ankle sprain: history and phys-
ical examination. ISAKOS—FIMS World Consensus
gery and other management techniques. In the Conference on Ankle Instability. 2005. p. 21–2.
surgical realm, arthroscopy is finding increased 15. Randomized comparison of tape versus semi-rigid
utilization, often with excellent results, though, and versus lace-up ankle support in the treatment of
in some procedures, with certain attendant risks. acute lateral ankle ligament injury. https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC4823346/.
Overall, the orthopedic professions are well-­ 16. Van Dijk CN. The athletes’ ankle: lateral ligament injury.
positioned to serve the changing needs of the Consensus Meeting ESSKA-AFAS. Warsaw; 2011.
sports community [80, 81]. 17. Arthroscopic capsular shrinkage for treatment of

chronic lateral ankle instability. https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC5794102/.
18. Arthroscopic repair of ankle instability with all-soft
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 Part V
Special Conditions
 Female Athlete Triad and RED-S
29
Samantha Tayne, Melody Hrubes,
Mark R. Hutchinson, and Margo Mountjoy

Menstrual Disturbances/Amenorrhea
29.1 Overview

The appreciation and understanding of energy

deficiency as it relates to the athlete population
have evolved over time. The Female Athlete Female
Triad was a phrase originally coined in 1993 to Athlete
describe a phenomenon noted in female athletes Triad
experiencing a metabolic energy deficit leading
to pathologic findings [1]. The Triad was
Energy Deficit
described as disordered eating, osteoporosis, and Bone Loss/Osteoporosis
Disordered Eating
amenorrhea (Fig. 29.1). As further research and
consideration were given to this diagnosis, clini- Fig. 29.1  The Female Athlete Triad
cians and researchers discovered that the original
criteria defining the Triad were too narrow. The
term was expanded and revised to low energy 29.1.1 Key Definitions
availability (with or without disordered eating),
low bone mineral density, and menstrual dys- The diagnoses of the Female Athlete Triad and
function. In 2014, the International Olympic RED-S require an understanding of several key
Committee released a consensus statement defin- definitions. Energy availability is defined as
ing a new term, Relative Energy Deficiency in energy intake minus energy expenditure during
Sport (RED-S), expanding the diagnosis beyond exercise adjusted for fat-free mass (Eq.  29.1).
just female participants to include all athletes, Low energy availability (LEA) is when the equa-
and allowing for a broader definition of energy tion falls into negative territory for an extended
deficiency in athletes that includes any physio- period of time, the absolute assessment that the
logic and pathologic effects [2]. reduction in energy availability below a specific
threshold (30 kcal/kg of fast free mass per day)
has recently been challenged. While these defini-
S. Tayne · M. Hrubes · M. R. Hutchinson (*) tions are quite specific, there is no gold standard
University of Illinois at Chicago, Chicago, IL, USA to measure energy availability, and it may be par-
e-mail: [email protected] ticularly difficult to measure in athletes with var-
M. Mountjoy ied exercise regimens. Providers may attempt to
University of Guelph, Guelph, ON, Canada measure energy availability through self-reported
e-mail: [email protected]

© ISAKOS 2019 395

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_29
396 S. Tayne et al.

food and exercises logs, or more often various rhea, and/or oligomenorrhea. Primary amenor-
tools are utilized to assess the outcomes of LEA, rhea is failure of menses to occur by age 16 years,
such as the Low Energy Availability in Females while secondary amenorrhea is a loss of menses
Questionnaire (LEAF-Q) and Female Athlete for 3 or more months. Oligomenorrhea is infre-
Screening Tool (FAST). These tools are typically quent menstruation, often going 35  days or
used to screen for LEA in athletes, but are also greater between menses. In athletes, any of these
imperfect and imprecise. Further, LEA can occur forms of amenorrhea typically are due to func-
with or without disordered eating or eating disor- tional hypothalamic amenorrhea, a disruption of
ders. Eating disorders include those with clinical pulsatile, hypothalamic gonadotropin-releasing
criteria consistent with DSM-V definitions such hormone (GnRH) secretion caused by relative
as anorexia nervosa, bulimia nervosa, and energy deficiency. Males may experience a simi-
unspecified feeding or eating disorder, while dis- lar phenomenon, known as male hypogonadism,
ordered eating includes a broader spectrum of a decrease in one or both of the functions of the
pathologic eating behaviors and weight control. testes—sperm production and testosterone for-
mation. Low energy availability may result in
EA ( kcal / kg ) = EI ( kcal ) - EEE ( kcal ) / secondary hypogonadism again due to disruption
FFM ( kg ) (29.1) of release of GnRH and may relate to symptoms

of androgen deficiency [4].
Low energy availability may result in decreased The pathophysiology of energy deficiency is
bone mineral density, more specifically defined still incompletely understood. There are many bio-
as osteoporosis and osteopenia. As defined by markers of energy deficiency, including leptin,
the World Health Organization, osteoporosis ghrelin, triiodothyronine, cortisol, insulin-like
involves a T score of −2.5 and below and osteo- growth factor-1, insulin, and glucose. Leptin and
penia a T score between −1.5 and −2.5. However, ghrelin are regulators of appetite. Triiodothyronine
the T score assesses bone density as compared to is a regulator of metabolism through the
the average healthy adult and was created to hypothalamus-­ pituitary-thyroid axis. Cortisol is
assess for risk of pathologic fracture in post- steroid hormone released in response to stress, and
menopausal women, not premenopausal female IGF-1 is a growth hormone that supports cell divi-
athletes nor young male athletes. There is no sion and growth and may also be associated with
standard to adjust bone mineral density for bone systemic inflammation. Yet the appropriate method
size, skeletal maturity, or body composition. of measuring and utilizing these biomarkers is still
Therefore, the applicability of the T score to the an area requiring further study.
athlete population is limited. A Z score, which
compares bone mineral density to the average
for age, sex, weight, and ethnicity, may provide 29.1.2 Epidemiology
a better diagnostic measure, recognizing that
elite athletes may still be inadequately measured The epidemiology of LEA in both female and
or diagnosed when comparing to the average in a male athletes has been hard to determine, espe-
general population. Studies have indicated that cially given the difficulty in assessing
athletes in weight-bearing sports typically have a LEA. However, studies have shown a higher fre-
bone mineral density Z score of 5–15% higher quency of pathologic eating behavior in athletes
than nonathletes, suggesting that a Z score of [5, 6], with 25% of female elite athletes in endur-
anything less than −1.0 in an athlete participat- ance sports, aesthetic sports, and weight-class
ing in a weight-bearing sport should prompt fur- sports showing evidence of clinical eating disor-
ther evaluation for osteopenia and energy ders compared to 9% of the general population
deficiency [3]. [7]. Another study showed eating disorders in
Menstrual dysfunction related to LEA may 31% of elite female athletes in “thin-build” sports
include primary amenorrhea, secondary amenor- compared to 5.5% of the control population [8].
29  Female Athlete Triad and RED-S 397

This issue is not limited to female athletes, as Games (776 BC) where only male athletes were
studies have demonstrated increased disordered allowed to compete, the Heraean Games were
eating in mass-dependent sports in male athletes established in the sixth century BC and involved
[6, 9, 10] and evidence of low energy availability competitions of young, unmarried women. In the
in male endurance runners, jockeys, triathletes, fourth century BC, the rules were more lenient at
and cyclists [11, 12]. the Olympic Games, and Cynisca became the
Primary amenorrhea exists in less than 1% in first female Olympic champion in the four-horse
girls over 15 years old in the United States; how- chariot race. Unfortunately, continued advance-
ever one study indicates that this prevalence ment of women’s participation in elite support
jumps to 7.4% in collegiate athletes and 22% in was delayed for centuries. Medical care of female
athletes competing in aesthetic sports [13]. The athletes has long been shrouded in the miscon-
percentage of female athletes with secondary ception that women are “more frail” and there-
amenorrhea or oligomenorrhea is even higher; fore at greater risk of injury compared to their
studies show numbers ranging from 31 to 44% in male counterparts. Indeed, this misconception
athletes, particularly those participating in lean persisted during the establishment of the modern
sports, such as dancing and long distance run- Olympic Games in 1896 as Baron de Coubertin
ning [13–15]. felt the inclusion of women was “impractical,
There is a lack of epidemiologic data relating uninteresting, unaesthetic, and incorrect.” In
bone mineral density to fractures in adolescents 1900, 22 women out of 997 athletes participated
and premenopausal women, let alone to the ath- in the Paris Olympic Games but were restricted
lete population. A systematic review that used to tennis, sailing, croquet, equestrian, and golf. It
WHO T scores found a prevalence of osteopenia was not until the 1984 Olympic Games in Los
ranging from 22% to 50% and a prevalence of Angeles that women were allowed to run the
osteoporosis ranging from 0% to 13% in female marathon.
athletes, compared to 12% and 2.3% in a normal With societal changes in the late 1960s and
population, respectively [16]. As discussed previ- early 1970s, a federal law in the United States,
ously, these numbers likely underestimate the Title IX, was established that assured equal
relative loss of bone mineral density. More access to women for all facets of education
recently, studies including male athletes involved including sports participation. Title IX led to an
in mass-dependent or endurance sports are also at expansive growth in the number of female ath-
increased risk for decreased bone mineral density letes participating in sports in the United States
[4, 9, 11, 12]. and a renewed focus on their health. As one might
Several studies have shown a prevalence of expect, early interest focused on factors that were
1.2–4.3% of the complete Female Athlete Triad uniquely female such as gynecology, hormones,
in college athletes [17–19]. However, these stud- and menstrual cycles [21–24, 41]. Subsequently,
ies have used the narrowly defined parameters of key researchers including Barbara Drinkwater
the original Female Athlete Triad. More recent began to recognize a correlation of pathologies
studies utilizing the broader definition of relative with abnormal menses related to athletic par-
energy deficiency or LEA show a much higher ticipation. Menstrual dysfunction appeared to be
prevalence, anywhere from 6 to 100% depending directly related to decreased bone mineral den-
on the sport [20]. sity in these athletes [25–27]. Pathogenic weight
control behaviors especially disordered eating
also appeared to be directly related to abnormal
29.2 Background and History menses ([28]). In response to this growing con-
cern in 1992, the American College of Sports
The tradition of female athletic competition can Medicine (ACSM) brought together a group of
trace its roots into antiquity. While ancient leading experts to discuss issues of defining the
Greece is famous for establishing the Olympic problem, create diagnostic parameters, develop
398 S. Tayne et al.

screening and prevention protocols, as well as and return to play as the authors would have
identify knowledge gaps and directions for future liked. Subsequently, these weaknesses have
research [1]. Based on their observations and been addressed via position stands and consen-
correlations of clinical findings, the group coined sus statements by the National Athletic Trainers
the term the Female Athlete Triad to define the Association [30], by the Female Athlete Triad
apparent link between disordered eating, amen- Coalition, [31], and by the International
orrhea, and osteoporosis (Fig.  29.1) that were Olympic Committee (IOC) [2]. In addition to
more common in female athletes. It is important providing guidelines regarding screening, man-
to note that this first group of experts recog- agement, and return to play, the IOC consensus
nized that poor nutritional factors, i.e., decreased statement emphasized the underlying trigger
energy intake, and the psychological and social pathophysiology of energy deficiency, by coin-
pressures of sport were the critical cause of the ing the term Relative Energy Deficiency in
subsequent symptom trilogy. Over time, contin- Sport or RED-­S.  While including the trilogy
ued study and research have led to further under- of the female athlete triad within the frame-
standing of the problem. In 1997, ACSM created work of RED-S, the expanded concept targets
a position stand on the Female Athlete Triad [29], any pathophysiology, not limited to endocrine
which was updated in 2007 [3]. The core con- and bone metabolism, regardless of gender
cepts of the interrelationship between energy bal- (Fig. 29.3).
ance, hormonal health, and bone health remain
unchanged with the key philosophical update
being that each of these facets was on a contin- 29.3 Clinical Presentation
uum from normal to pathologic that varies from and Diagnosis
individual to individual (Fig. 29.2). The updated
position statement once again emphasized that As a provider caring for the athlete population, it
the foundational trigger leading down the path- is important to recognize those at risk for relative
way to disease was poor energy availability. energy deficiency and the impact that might have
Due to guideline and page count restric- on the athlete’s performance and overall health.
tions of ACSM position statements, the 2007 There are several sports that lend themselves to
Position stand was not able to go as into as higher-risk athletes, including aesthetic, lean,
much depth regarding screening, management, and endurance sports. However, there is emerg-

Fig. 29.2 Continuum Healthy Athlete

of the Female Athlete
Triad Optimal Energy
Availability

Reduced Energy
Availability

Optimal Bone
Health Low Energy Availability
Eumenorrhea
with or without
an Eating Disorder
Osteopenia

Menstrual
Changes
Functional Osteoporosis
Hypothalamic
Amenorrhea

Female Athlete Triad

29  Female Athlete Triad and RED-S 399

Fig. 29.3 Relative
energy deficiency in
sport. The effect of
energy deficiency on Immunological
various physiological
functions. The original Gastro- Menstrual
intestinal Function
Female Triad is also
incorporated into the
RED-S framework
(Reproduced from
Mountjoy et al. [2])
Cardio- Triad Bone health
vascular

RED-S

Psychological* Endocrine

Growth +
Metabolic
development

Hematological

ing evidence that RED-S is also present in sprint for Primary Care (ESP), and Disordered Eating
and power sports [32]. Questionnaire. Similar screening tools specific to
male athletes are being developed, including the
Low Energy Availability in Males Questionnaire
While sports that emphasize aesthetic, (LEAM-Q) [35]. The pre-participation physical
leanness, and endurance are at elevated examinations are a provider’s best chance of
risk, relative energy deficiency may also be detecting a problem before the athlete develops
a problem in sprint and power sports. more severe pathology or injury or before there is
a negative impact on performance. Athletes
should be questioned regarding menses, a history
As previously mentioned, there are limitations of stress fractures, cardiac events, and a history of
in measuring energy availability and deficiency; depression or insomnia. If the provider notes one
however there are multiple screening tools avail- component of RED-S in an athlete, the provider
able, and they should be utilized during athlete should continue a further, more in-depth evalua-
pre-participation physical and annual physical tion of history, physical examination, and labora-
examinations. Examples of such screening tools tory investigations.
include Female Athlete Screening Tool (FAST) Every female athlete should be asked about
(Fig.  29.4), Brief Eating Disorder in Athletes her menstrual function. Reports of amenorrhea or
Questionnaire (BEDA-Q) (Fig.  29.5), Low oligomenorrhea require further workup to
Energy Availability in Females Questionnaire exclude other physiologic and pathologic causes
(LEAF-Q) (Fig.  29.6), Eating Disorder Screen before diagnosing functional hypothalamic
400 S. Tayne et al.

Please answer as completely as possibly: 16. I am worried that if I were to gain weight, my performance
Keya: Exercise = Physical activity ≥ 20 minutes would decrease.
Practice = Scheduled time allotted by coach to work 1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
as a team or individually in order to
improve performance. 17. I think that being thin is associated with winning.
Training = Intense physical activity. The goal is to 1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
improve fitness level in order to
perform optimally. 18. I train intensely for my sport so I will not gain weight.
1)Frequently 2)Sometimes 3)Rarely 4)Never
1. I participate in additional physical activity ≥ 20 minutes in
length on days that I have practice or competition. 19. During season, I choose to exercise on my one day off from
1)Frequently 2)Sometimes 3)Rarely 4)Never practice or competition.
1)Frequently 2)Sometimes 3)Rarely 4)Never
2. If I cannot exercise, I find myself worrying that I will
gain weight. 20. My friends tell me that I am thin but I feel fat.
1)Frequently 2)Sometimes 3)Rarely 4)Never 1)Frequently 2)Sometimes 3)Rarely 4)Never

3. I believe that most female athletes have some form of 21. I feel uncomfortable eating around others.
disordered eating habits. 1)Frequently 2)Sometimes 3)Rarely 4)Never
1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
22. I limit the amount of carbohydrates that I eat.
4. During training, I control my fat and calorie intake carefully. 1)Frequently 2)Sometimes 3)Rarely 4)Never
1)Frequently 2)Sometimes 3)Rarely 4)Never
23. I try to lose weight to please others.
5. I do not eat foods that have more than 3 grams of fat. 1)Frequently 2)Sometimes 3)Rarely 4)Never
1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
24. If I were unable to compete in my sport, I would not feel
6. My performance would improve if I lost weight. good about myself.
1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree 1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
7. If I got on the scale tomorrow and gained 2 pounds, I would 25. If I were injured and unable to exercise, I would restrict my
practice or exercise harder or longer than usual. calorie intake.
1)Frequently 2)Sometimes 3)Rarely 4)Never 1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
8. I weigh myself . 26. In the past 2 years I have been unable to compete due to
1)Daily 2)2 or more times a week an injury.
3)Weekly 4)Monthly or less 1)7 or more times 2)4 to 6 times
3)1 to 3 times 4)No significant injuries
9. If I chose to exercise on the day of competition (game/
meet), I exercise for 27. During practice I have trouble concentrating due to feelings
1)2 or more hours 2)45 minutes to 1 hour of guilt about what I have eaten that day.
3)30 to 45 minutes 4)Less than 30 minutes 1)Frequently 2)Sometimes 3)Rarely 4)Never

10. If I know that I will be consuming alcoholic beverages, 28. I feel that I have a lot of good qualities.
I will skip meals on that day or the following day. 1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
1)Frequently 2)Sometimes 3)Rarely 4)Never
29. At times I feel that I am no good at all.
11. I feel guilty if I choose fried foods for a meal. 1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
1)Frequently 2)Sometimes 3)Rarely 4)Never
30. I strive for perfection in all aspects of my life.
12. If I were to be injured, I would still exercise even if I was 1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
instructed not to do so by my athletic trainer or physician.
1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree 31. I avoid eating meat in order to stay thin.
1)Strongly Agree 2)Agree 3)Disagree 4)Strongly Disagree
13. I take dietary or herbal supplements in order to increase
my metabolism and/or to assist in burning fat. 32. I am happy with my present weight.
1)Frequently 2)Sometimes 3)Rarely 4)Never 1)Yes 2)No

14. I am concerned about my percent body fat. 33. I have done things to keep my weight down that I believe
1)Frequently 2)Sometimes 3)Rarely 4)Never are unhealthy.
1)Frequently 2)Sometimes 3)Rarely 4)Never
15. Being an athlete, I am very conscious about consuming
adequate calories and nutrients on a daily basis.
1)Frequently 2)Sometimes 3)Rarely 4)Never
FIG. Female Athlete Assessment Tool (FAST)b
a
Initial validation studies have been conducted on the FAST. Future research wilt attempt to further validate the questionnaire.
b
The key is used to quantify and define activity level for further clarification of the questions.

Fig. 29.4  Female athlete screening tool (Reproduced from McNulty et al. [33])

amenorrhea due to low energy availability. energy availability. Therefore, athlete use of
Importantly, oral contraceptive pills (OCPs) and OCPs and IUDs must also be ascertained. The
hormonal intrauterine devices (IUDs) may affect counterpart to menstrual dysfunction in male ath-
menstrual cycles such that it is no longer an letes may not be as easily recognized; however
appropriate assessment for normal menses or male athletes with low testosterone may present
29  Female Athlete Triad and RED-S 401

Fig. 29.5  Brief Eating Items

Disorder in Athletes
1
Questionnaire
I feel extremely guilty after overeating
(BEDA-Q). Positive
scores are weighted as always usually often sometimes rarely never
follows: 3, always; 2, 2
usually; 1, often; 0, I am preoccupied with the desire to be thinner
sometimes; 0, rarely; always usually often sometimes rarely never
and 0, never, and 3
reverse-scored items are I think that my stomach is too big
weighted in the opposite always usually often sometimes rarely never
manner (Reproduced 4
from Martinsen et al. I feel satisfied with the shape of my body
[34]) always usually often sometimes rarely never
5
My parents have expected excellence of me
always usually often sometimes rarely never
6
As a child, I tried very hard to avoid disappointing my parents and teachers
always usually often sometimes rarely never
7
Are you trying to lose weight now?
Yes No
8
Have you tried to lose weight?
Yes No
9
If yes, how many times have you tried to lose weight?
1–2 3–5 >5 times
Dieting (trying to lose weight now and/or tried before ≥3 times)

with symptoms of androgen deficiency w ­ arranting and orthostatic hypotension, and even an arrhyth-
further workup [42]. Symptoms of androgen defi- mia, may indicate low energy availability in ath-
ciency include lethargy, fatigue, depression, letes with a negative cardiac workup, possibly
reduced muscle mass and strength, loss of body due to an eating disorder or disordered eating. A
hair, hot flashes, increased sweating, reduced prolonged QTc on EKG can also be a result of
sexual desire, and sexual dysfunction. Workup of energy deficiency due to electrolyte imbalance.
athletes with symptoms of androgen deficiency Laboratory testing can reveal anemia, altered
may include testosterone levels drawn in the electrolytes, low vitamin B12, folate, iron, mag-
morning and evening, luteinizing hormone and nesium, phosphorus, calcium, or albumin all due
follicle-stimulating hormone levels, as well as to relative energy deficiency. Electrolyte imbal-
further evaluation of eating behaviors and psy- ances need to be corrected urgently to prevent a
chological assessment. potentially catastrophic event. Indeed, based on
During pre-participation physical examina- the recommendations of the IOC [2], clinicians
tions, athletes should also undergo a cardiovascu- should be observant of a broad differential diag-
lar examination and laboratory testing. All nosis of pathophysiologies that may be related to
athletes should be questioned about a history of low energy availability.
palpitations, lightheadedness, or dizziness occur- Many athletes first present to a physician pro-
ring during exercise or while at rest. These symp- vider or orthopedic surgeon with symptoms of a
toms may indicate bradycardia or orthostatic stress fracture, which should immediately prompt
hypotension, which certainly require further car- further evaluation for LEA, including an evalua-
diac testing to rule out a cardiac cause. However, tion for disordered eating, amenorrhea, and other
providers should also realize that bradycardia markers of RED-S.  These patients should also
402 S. Tayne et al.

Injuries
Have you had absences from your training or participation from No, not at all
competition during the last year due to injuries? Yes, once or twice
Yes, three or four times
Yes, five times or more

If yes, for how many days absence from training or 1–7 days
participation in competition due to injuries have you had in 8–14 days
the last year? 15–21 days
22 days or more
If yes, what kind of injuries have you had in the last year? Accidental
Overload

Comments or further information regarding injuries:

Illnesses
Have you had absences from your training or participation from No, not at all
competition during the last year due to illness? Yes, once or twice
Yes, three or four times
Yes, five times or more

If yes, for how many days absence from training or 1–7 days
participation in competition due to have you had in 8–14 days
the last year? 15–21 days
22 days or more
If yes, what kind of injuries have you had in the last year?

Comments or further information regarding injuries:

Dizziness
Do you experience dizziness or lightheadedness? Yes, several times a day
Yes, several times a week
Yes, once or twice a week or more seldom
Rarely or never

Cold sensitivity
Do you experience sensitivity to cold? Yes, several times a day
Yes, several times a week
Yes, once or twice a week or more seldom
Rarely or never

Gastrointestinal symptoms
Do you feel gaseous or bloated in the abdomen, also when you do Yes, several times a day
not have your period? Yes, several times a week
Yes, once or twice a week or more seldom
Rarely or never
Do you get cramps or which cannot be related to your Yes, several times a day
menstruation? Yes, several times a week
Yes, once or twice a week or more seldom
Rarely or never

Fig. 29.6  Low Energy Availability in Females Questionnaire (LEAF-Q)

29  Female Athlete Triad and RED-S 403

How often do you have bowel movements on average? Several times a day
Once a day
Every second day
Twice a week
Once a week or more rarely
How would you describe your normal stool? Normal (soft)
Diarrhea-like (watery)
Hard and dry
Comments regarding gastrointestinal function:

Contraceptives
Do you use oral contraceptives? Yes
No
If yes, why do you use oral contraceptives? Contraception
Reduce menstruation pains
Reduction of bleeding
To regulate menstrual cycle in relation
performances etc
Otherwise menstruation stops
Other
If no, have you use oral contraceptives earlier? Yes
No
If yes, when and for how long?
Do you use any other kind of hormonal contraceptives (e.g, Yes
hormonal implant or coil)? No
If yes, what kind? Hormonal patches
Hormonal ring
Hormonal coil
Hormonal implant
Other
Menstrual function
How old were you when you had your first period? 11 years or younger
12–14 years
15 years or older
I don’t remember
I have never menstruated
Did your first menstruation come naturally? Yes
No
I don’t remember
If no, what kind of treatment was used to start your menstrual Hormonal treatment
cycle? Reduced amount of exercise
Weight gain
Other
Do you have normal menstruation? Yes
No
I don’t know
When was your last period? 0–4 weeks ago
1–2 months ago
3–4 months ago
5 months ago or more
Do you have normal menstruation? Yes
No
I don’t know
When was your last period? 0–4 weeks ago
1–2 months ago
3–4 months ago
5 months ago or more
Are your periods regular? Yes, most of the time
No, mostly not

Fig. 29.6 (continued)
404 S. Tayne et al.

For how many days do you normally bleed? 1–2 days

3–4 days
5–6 days
7–8 days
9 days or more
Have you ever had problems with menstrual bleeding? Yes
No
How many periods have you had in the past year? 12 or more
9–11
6–8
3–5
0–2
Have your periods ever stopped for 3 consecutive months or longer No, never
(besides pregnancy)? Yes, it has happened before
Yes, that’s the situation now
Do you experience that your menstruation changes when you Yes
increase your exercise intensity, frequency or duration? No
If yes, how? I bleed less
I bleed more
I bleed fewer days
I bleed more days
My menstruation stops

Fig. 29.6 (continued)

undergo evaluation of bone mineral density, tial effect of LEA; those athletes with energy
specifically using the Z scores rather than T
­ deficit demonstrated a 9.8% regression in their
scores. Z scores, as discussed previously, provide 400-m swim over 12 weeks, as compared to those
a better assessment of bone mineral density in an athletes without an energy deficit who experi-
athlete population than T scores, as Z scores com- enced an 8.2% improvement [37]. These num-
pare the bone mineral density to an average for bers indicate while athlete performance is
age, sex, weight, and ethnicity. Yet even the use impacted by many variables, a decline in perfor-
of Z scores may be limited for evaluation of ath- mance should alert a coach or sport medicine/
letes, and providers should have a high suspicion sport science specialist of possible energy defi-
for low BMD even when evaluation results place ciency (Fig. 29.7).
the athlete in the normal range compared to the
general population.
Ultimately, LEA has effects on physical and Low energy availability increases recovery
mental health, as well as athlete performance. time, decreases focus, decreases judgment,
One study demonstrated that compared to ath- increases risk of depression, and reduces
letes with adequate energy availability, those performance.
with low energy availability were 2.1 times more
likely to report increased recovery time, 4.3 times
more likely to report judgment impairments, 1.6 The most recent work from the IOC [35] sug-
times more likely to report feeling uncoordinated, gests that measuring the effects of LEA may prove
and 2 times more likely to report difficulty con- to be clinically more relevant than the actual mea-
centrating [36]. Those with low energy availabil- surements of energy availability (EA) due to the
ity were further 1.6 times more likely to report considerable effort needed to accurately assess
feelings of irritability, 2.3 times more likely to EA and its frailties as a stand-alone diagnostic
report feelings of depression, and 1.5 times more tool. They strongly suggest that this is true for
likely to report a decrease in endurance during both male and female athletes. Furthermore, they
training or competition [36]. One study in junior suggest that since cultural, social, psychological,
elite female swimmers demonstrated a substan- and financial factors contribute to low energy
29  Female Athlete Triad and RED-S 405

Fig. 29.7  Effects of

LEA on athlete
performance Decreased
(Reproduced from endurance
Mountjoy et al. [2]) performance*
Decreased
muscle Increased
strength injury risk

Decreased Decreased
glycogen training
stores response

RED-S

Impaired
Depression
judgement

Decreased
Irritability
coordination
Decreased
concentration

availability, all of these would have to be addressed Initially, the appropriate setting for treatment
for a holistic approach or prevention. must be assessed. Depending on medical or psy-
chiatric stability, an inpatient setting might be
required for unstable vital signs or inability to
29.4 Therapeutic Interventions ensure safety. Most often, treatment can be initi-
ated and continued on an outpatient basis.
Recognizing athletes with an energy deficit is an Following the determination of the appropriate
important initial step toward recovery and should treatment setting, diet and/or exercise modifica-
trigger a team of medical professionals experi- tion is the next step in order to improve energy
enced in the unique demands of sport to initiate availability. This occurs via increased oral energy
appropriate treatment. The importance of early intake, decreased energy expenditure through
intervention cannot be overstated given the activity restriction, or more often a combination
potential irreversibility of some of the physio- of both. Although the immediate goal is to pre-
logic effects, such as lost opportunity for optimal vent further injury, this also serves to establish a
bone mineral density accrual during adolescence. quantifiable assessment tool that can be regularly
Once an athlete is identified as having, or at risk assessed by the athlete and members of the treat-
for having, relative energy deficiency, interven- ment team.
tions for amelioration can begin. Effective treat- A registered dietician, ideally one with experi-
ment must address both the immediate issue of ence in the unique demands of sport, should meet
relative energy deficiency and the cause, which is with the athlete to assess current nutritional sta-
often multifactorial. tus through energy intake and ­macro-/micronutri-
406 S. Tayne et al.

ent requirements based on activity level. assessed by the treating physician and advanced as
Appointments at regular intervals allow for nutri- appropriate. Establishing a treatment contract and
tion education, implementation, monitoring, and return-to-play expectations early in treatment can
adjustments of oral intake. Nutritional supple- give the athlete control and context through spe-
mentation with calcium and vitamin D for bone cific expectations for treatment and recovery while
health or protein for intense exercise [38] might establishing the goal of full return to sport.
be necessary. Progressive return to sport is an indication of a
When disordered eating behavior contributes successful treatment strategy for energy defi-
to energy deficiency, a mental health practitioner ciency. Given the multifactorial nature of energy
can address the underlying mental health disor- deficiency, many considerations should be taken
der as well as the psychiatric comorbidities com- into account when considering return to play.
monly occurring with eating disorders, including When involved with the athlete’s team, an athletic
depression, anxiety, obsessive-compulsive disor- trainer can manage return to play on day-­to-­day
der, and substance abuse [6]. Pharmacologic basis, monitor for adverse effects or non-­
therapy can be considered, discussed, and initi- compliance, and update the coaching staff as
ated if deemed appropriate. In the absence of an appropriate. Establishing the importance and
identified eating disorder, a mental health practi- necessity for adherence to the treatment plan and
tioner can help the athlete develop strategies for treatment contract (Fig.  29.8) is critical to the
healthy behavior and problem-solving in addition compliance of the athlete. For female athletes,
to addressing feelings of frustration, isolation, or resumption of menses can be a reliable sign of
depression that can come from restricted sport adequate nutrition provided the absence of OCP or
participation. IUD use, however, should not be used as a marker
A primary care provider should monitor and of time to return to play, as resumption of menses
treat other medical implications of low energy is often delayed once energy balance is achieved.
availability such as electrolyte imbalance and Return to play is a decision process with par-
low bone mineral density. Laboratory testing ticipation of healthcare providers, coaches, and
can assess for nutritional status or other etiolo- athletes based on continuous assessment of the
gies of menstrual dysfunction or amenorrhea. It athlete and the competitive environment. There
should be noted that hormone replacement ther- are several tools available for risk stratification to
apy has not been found to improve bone mineral guide safe return to sport, including a return-to-­
density, and the oral contraceptive pill can delay play model (Fig. 29.9) developed by the Female
and reduce menstrual cycle restoration [39]. The Athlete Triad Coalition [40] and a cumulative
use of bisphosphonates and selective estrogen risk assessment model (Fig. 29.10), which incor-
receptor modulators is not recommended [5]. porates evidence-based risk factors and desig-
The use of DEXA scans for the ongoing moni- nates a point value for each factor [31]. Similarly,
toring of bone mineral density is a multifactorial the IOC created a “red light, yellow light, green
consideration based on the athlete’s history and light” clinical guidelines (Fig.  29.11) that can
physical exam. Pharmacological intervention assist the clinician in determining when an ath-
for low bone mineral density should be consid- lete should be allowed to participate with or with-
ered if there is no response after 1 year of non- out restrictions [2]. Once an athlete has been
pharmacologic therapy or if new fractures occur returned to full sport, periodic weights can moni-
despite addressing energy deficiency [31]. tor for continued adequate nutritional status.
In order to achieve a healthy energy balance, More recently, the IOC has written an update on
sports participation may need to be initially RED-S [35] which continues to emphasize the
restricted in order to decrease energy expenditures. need to create a more practical tool to identify
The athlete’s level of activity should be regularly athletes at risk of relative energy deficits, the
29  Female Athlete Triad and RED-S 407

(Athlete Name)
The following items are mandatory and must be completed as prescribed. Failure to do so will result in the
consequence listed below the requirements. All benefits and consequence are subject to change at any time
and at the discretion of the Multidisciplinary Team. Multidisciplinary Team:
(Physician), (Psychotherapist), (Dietitian)

Requirements:
Meet with (therapist) 1x per week, or as recommended by therapist.
Meet with (dietitian) 1x per week, or as recommended by dietitian.
Meet with Dr. 1-2x per month, or as recommended by Dr. .
Follow daily meal plan set forth by sports dietitian.
Keep daily workout log updated with specific type, length, and effort.
Weight gain of lbs per week.
Weekly weigh-in with (name team member), or at time intervals of weeks.
Must achieve minimal acceptable body weight of lbs by (date).
After this data, must maintain weight at or above minimal acceptable body weight.
Limit of workout sessions per week with no one session being more than minutes in length.
All activity counts (e.g., biking running, weight lifing, and swimming).

Benefits:
If ALL requirements are met then clearance to participate in team activities and use of athletic facilities will:
be granted continue.

Consequences:
If ANY requirements(s) are not met then clearance to participate in team activities and use of athletic facilities
will be revoked, and re-instatement will be at the discretion of the team physician and multidisciplinary team

I, have read this contract and all of my questions were answered.

Athlete Name Athlete Signature Date

Team Physician Name Team Physician Signature Date

Fig. 29.8  Example athlete treatment contract (Reproduced from Joy et al. [6])

need for increased awareness of the broad spec- Multidisciplinary team members are required
trum of pathophysiologic impact of low energy for comprehensive treatment of energy defi-
availability regardless of gender, and the need for ciency, and communication between treating
more practical guidelines regarding return to team members is critical to athlete success.
play. When the athlete involved is an adolescent,
parental involvement is necessary. In addition to
assisting with complex treatment plan compli-
Return-to-play decisions in more severe
ance and implementation, families should be
cases are complex and require a team
encouraged to participate in family therapy if
approach that includes healthcare provid-
appropriate. Although not required, family
ers, nutritionists, coaches, and the athlete.
involvement in the treatment of energy defi-
ciency can be an option for any athlete regard-
less of age.
408 S. Tayne et al.

Patient Demographics (age, ethnicity)

Symptoms (fatigue, lightheadedness, skeletal pain, weight loss / fluctuations)
Personal Medical History (Triad risk factors - severity / chronicity,
adolescent growth phase, hospitalizations, other medical factors)
Family History/Genetics (eating disorders, other psychiatric illnesses,
menstrual dysfunction, osteoporosis, fracture history)
Step 1 Medical Signs (Physical Exam) (bradycardia, low BP / orthostatic, low BMI <17.5,
Evaluation of Factors low % body fat, lanugo, Russel’s sign)
Health Status Lab Tests/ECG/DXA (metabolic panel, CBC, hormonal work up if
oligomenorrhea and/or amenorrhea, 25(OH) Vit D if low BMD or bone stress
injury, TSH and TFTs; ECG if ED; DXA if indicated;
X-ray and imaging if suspect bone stress injury)

Risk Psychological State (depression, anxiety, OCD co-morbidities; severity of illness;

Evaluation athlete’s willingness to participate in treatment; psych testing if indicated)

Process Potential Seriousness (ED, other psych hospitalization, chronicity of each Triad
spectrum, co-morbidities, bone health evaluation/DXA)

Cumulative Risk Assessment Score (based on cumulative Triad risk stratification)

Step 2 Type of Sport (leanness vs non leanness sport, sport with subjective judging,
thin physique felt advantageous, endurance sport, weight class,
Evaluation of impact nature/bone loading)
Participation Sport Risk
Position Played (perceived advantage if lean)
Risk Modifiers
Competitive Level (Competitive vs non-competitive, high school, club,
college/intercollegiate/ division rank, elite, professional, Olympic)
Timing & Season (in season vs off season, early in season or late)
Pressure from Athlete (desire to compete and excel)
Step 3
Decision External Pressure (coach, family, friends, administration, society)
Decision
Modifiers Masking the Injury (analgesia, ignoring symptoms)
Modification
Conflict of interest (scholarship athlete, professional, Olympic athlete)

Return-to-Play Decision

Fig. 29.9  Decision-based return-to-play model from the Female Athlete Triad Coalition Statement (Reproduced from
Joy et al. [40])

29.5 Prevention energy availability and should not be dismissed.

Education regarding prevention and identifica-
Prevention of relative energy deficiency, and tion can come from the medical team caring for
the associated pathology, could be considered an athletic team, along with governing organiza-
the most effective treatment. Coaches, par- tions and federations, such as the NCAA, through
ents, athletic administrators, judges/officials, publications and conferences [3, 5, 6], or even
and t­eammates can influence an athlete and peers [43]. Primary prevention strategies include
help identify early signs of intentional or unin- educating athletes on healthy eating and the cost
tentional poor energy availability in an athlete. of poor nutrition, along with teaching teammates,
Negative comments on body size can lead to to identify warning signs of an eating disorder.
poor body image and eating disorders; therefore Teaching athletes methods to nourish their bodies
education on healthy feedback and support is correctly allows for a positive relationship with
important. Loss of menstruation is a sign of poor food, while educating about the harm to bodily
29  Female Athlete Triad and RED-S 409

a
Magnitude of Risk
Risk Factors
Low Risk = 0 points each Moderate Risk = 1 point each High Risk = 2 points each

Low EA with or without No dietary restriction Some dietary restriction §

§; Meets DSM V criteria for ED∗
DE/ED current/past history of DE;

BMI ≥ 18.5 or BMI 17.5 < 18.5 or BMI £17.5 or < 85% EW or
Low BMI ≥ 90% EW∗∗ or < 90% EW or ≥ 10% weight loss/month
weight stable 5 to < 10% weight loss/month

Delayed Menarche Menarche < 15 years Menarche 15 to < 16 years Menarche ≥16 years

Oligomenorrhea and/or
> 9 menses in 12 months∗ 6-9 menses in 12 months∗ < 6 menses in 12 months∗
Amenorrhea

Low BMD Z-score ≥ -1.0 Z-score -1.0*** < -2.0 Z-score £ -2.0

Stree Reaction/Fracture None 1 ≥ 2; ≥ 1 high risk or of

trabecular bone sites†
Cumulative Risk
(total each column, then points + points + points = Total Score
add for total score)
b
Cumulative
Low Risk Moderate Risk High Risk
Risk Score*

Full Clearance 0 – 1 point

Provisional
Provisional/Limited Clearance
2 – 5 points
Clearance
Limited Clearance

Restricted from
Training/
Restricted from Competition-Provisional
≥ 6 points
Training and
Competition Disqualified

Fig. 29.10 (a) Cumulative risk assessment tool. (b) Clearance and return to play using cumulative risk assessment
(Reproduced from DeSouza et al. [31])

health and athletic performance can provide processes involved from becoming ingrained in
motivation to achieve or maintain an adequate the athlete’s identity and approach to the sport.
nutrition status. Teaching those in authority, peers, and the ath-
Identifying the early signs of relative energy letes themselves can prevent or identify relative
deficiency can prevent harmful habits and thought energy deficiency in the early states.
410 S. Tayne et al.

a
High risk: no start red light Moderate risk: caution yellow light Low risk: green light

Anorexia nervosa and other serious eating disorders Prolonged abnormally low % body fat measured by DXA or Healthy eating habits with
Other serious medical (psychological and physiological) anthropometry using The International Society for the Advancement of appropriate energy
conditions related to low energy availability Kinanthropometry ISAK141 or non-ISAK approches142 availability

Extreme weight loss techniques leading to dehydration Substanial weight loss (5-10% body mass in 1 month)
induced haemodynamic instability and other Attenuation of expected growth and development in adolescent athlete
life-threatening conditions

Abnormal menstrual cycle: FHA amenorrhoea >6 months Normal hormonal and
Menarche >16 years metabolic function

Abnormal hormonal profile in men

Reduced BMD (either from last measurement or Z-score < –1 SD). Healthy BMD as expected for
History of 1 or more stress fractures associated with hormonal/menstrual sport, age and ethnicity
dysfunction and/or low EA Healthy musculoskeletal
system

Athletes with physical/psychological complications related to low EA/

disordered eating - ECG abnormalities- Laboratory abnormalities

Prolonged relative energy deficiency

Disordered eating behaviour negatively affecting other team members
Lack of progress in treatment and/or non-compliance

BMD, bone mineral density; DXA, dual-energy X-ray absorptiometry; EA, energy availability; FHA, functional hypothalamic amenorrhoea; ISAK, International Society for the
Advancement of Kinanthropometry

b
High risk: red light Moderate risk: yellow light Low risk: green light

No competition May compete once medically cleared under supervision Full sport participation
Supervised training allowed when medically cleared for adapted training May train as long as is following the treatment plan
Use of written contract (see supplementary appendix 1)

Fig. 29.11 (a) The Relative Energy Deficiency in Sport risk assessment model for sport participation. (b) The Relative
Energy Deficiency in Sport return-to-play model (Reproduced from Mountjoy et al. [2])

Take-Home Messages 3. Nattiv A, Loucks AB, Manore MM, et al. American

• Relative Energy Deficit Syndrome and the College of Sports Medicine position stand: the
female athlete triad. Med Sci Sports Exerc.
Female Athlete Triad are a complex group of 2007;39(10):1867–82.
pathologies usually triggered by low energy 4. Hooper DR, Kraemer WJ, Saenz C, et  al. The pres-
availability. Low energy availability can ence of symptoms of testosterone deficiency in
have negative effects on both males and the exercise-hypogonadal male condition and the
role of nutrition. Eur J Appl Physiol. 2017;117:
females. 1349–75.
• Low energy availability predisposes athletes 5. Drinkwater BL, Loucks A, Sherman RT, et  al. IOC
to possible physical injury, systemic ­pathology, medical commission position stand on the female
psychological stress, and poor athletic athlete triad. Medical and Scientific Commission,
International Olympic Committee; 2005. https://
performance. www.olympic.org/news/consensus-statement-
• Early recognition and a team-based approach adopted-on-the-female-athlete-triad. Accessed 4 Mar
are the most effective interventions to opti- 2018.
6. Joy E, Kussman A, Nattiv A. 2016 update on eat-
mize the health of the athlete and prevent
ing disorders in athletes: a comprehensive narrative
more severe complications. review with a focus on clinical assessment and man-
agement. Br J Sports Med. 2016;50:154–62.
7. Sundgot-Borgen J, Torstveit MK. Prevalence of eating
disorders in elite athletes is higher than in the general
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 Sudden Cardiac Arrest
30
Clea Simone S. S. Colombo, Michael Papadakis,
and Nabil Ghorayeb

30.1 Introduction of conditions, the majority due to primary intrin-

sic cardiac abnormalities [4].
Sudden cardiac arrest (SCA) is defined as an It is well established that regular exercise pro-
unexpected cessation or severe malfunction of motes health and prolongs life [5, 6]. Therefore,
heart function followed by loss of conscious- the athlete is considered not just a symbol
ness due to haemodynamic collapse [1, 2]. of good health but also an invulnerable hero.
Unfortunately, most SCAs progress to sudden Consequently, SCA in an athletic individual is
cardiac death (SCD) [3]. SCA is responsible for always a tragic event and devastating for their
50% of cardiovascular mortality, and it is the families and the wider society.
third leading cause of death in the United States SCA/SCD is often the first clinical manifesta-
[1]. It is the end result of a heterogeneous group tion of underlying cardiovascular disease. Most
individuals with inherited cardiac diseases are
asymptomatic, and therefore most individuals are
unaware they harbour a substrate to malignant
arrhythmias. Approximately 60% of SCDs occur
C. S. S. S. Colombo (*)
Cardiology Clinical Academic Group, St. George’s during exertion [7, 8]. The adrenergic stimulus of
University of London, London, UK exercise causes cardiovascular responses, which
Department of Ergometry, Exercise, Nuclear result to an increase of heart rate, stroke vol-
Cardiology and Cardiovascular Rehabilitation ume and blood pressure. Intense exercise during
(DERC), Brazilian Society of Cardiology (SBC), competitive sports may promote lethal arrhyth-
Rio de Janeiro, Brazil
mias in the presence of an abnormal substrate.
Cuore Dello Sport, São Paulo, Brazil Consequently, intense exercise is not the primary
M. Papadakis cause of the SCA but acts as a trigger in predis-
Cardiology Clinical Academic Group, St. George’s posed individuals [9].
University of London, London, UK
Prevention of SCA/SCD encompasses a
European Section of Sports Cardiology and Exercise number of complementary strategies including
of the EAPC, Sophia Antipolis Cedex, France
the recognition of high-risk individuals, pre-­
e-mail: [email protected]
participation cardiovascular evaluation and early
N. Ghorayeb
defibrillation. The presence of quiescent cardiac
Institute Dante Pazzanese of Cardiology—
Universidade São Paulo, São Paulo, Brazil disease has brought pre-participation cardio-
vascular evaluation of athletes at the forefront
Heart Hospital (Hospital do Coração—HCor),
São Paulo, Brazil of preventative strategies for SCD.  The aim is
e-mail: [email protected] to identify athletes at potential risk of exercise-­
© ISAKOS 2019 413
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_30
414 C. S. S. S. Colombo et al.

induced fatal arrhythmias and through a number 30.3 C

 ommon Causes of SCD
of life-style and medical interventions, including During Exercise
restriction from competition, to minimise their
risk [10, 11]. The early recognition of a SCA and 30.3.1 Noncardiac
prompt emergency care during sports activity are
essential to minimise SCD or serious brain dam- Climate conditions and poorly regulated body
age [3, 12]. Data report that there is still a lack temperature, inadequate electrolyte and fluid
of trained personnel and proper emergency action replacement or overhydration can trigger fatal
plans, causing a delay to start cardiopulmonary arrhythmias and SCA. Hyperthermia and resul-
resuscitation (CPR) and a negative impact on sur- tant rhabdomyolysis, renal failure and electro-
vival rate [13]. lyte disturbances are increasingly recognised
as an important substrate for arrhythmias.
Dehydration may also predispose to hyperka-
30.2 Epidemiology laemia and hypernatraemia which in turn may
result to SCA. Excessive water intake can cause
The incidence of SCD in athletes varies depend- significant hyponatraemia, leading to cerebral
ing on the age, gender, ethnicity, sports modal- oedema, seizures, coma and respiratory and car-
ity and the methodology used to acquire the data diac arrest.
[14]. In addition, there is lack of systematic reg- Some drugs, illicit or not, can contribute as an
istries of SCD in athletes in most countries, and arrhythmogenic substrate.
data are often based on media reports. The use of diuretics and stimulants such as
The rate of SCD among young athletes amphetamines and ephedrine is not uncom-
(<35 years) is reported as 2.1 per 100,000 athletes/ mon, predisposing to hypokalaemia and tachy-
year (a/y) in the Veneto region of Italy, approxi- cardia, especially in sports modalities where
mately 2.8-fold greater compared to nonathletes weight control is an important issue. The
(0.7 in 100,000 a/y). Women athletes are at lower chronic use of anabolic-androgenic steroids
risk with a reported ratio of female to male of 1:10 to gain muscle mass and power may increase
[9]. Black athletes seem to have a higher risk than the risk of myocardial infarction and arrhyth-
white athletes, with a reported incidence rate of mias due to electrolyte imbalance or athero-
4.7 per 100,000 a/y [15]. The sports modalities sclerosis. Other performance enhancement
with highest rates of SCD reported are basketball substances, such as recombinant human eryth-
and soccer [9, 15]. Among young athletes of the ropoietin, can predispose to thromboembolic
National Collegiate Athletic Association (NCAA) events and SCA [17]. The increasing use of
in the United States, the incidence rate of SCD supplements by both professional and recre-
was 1.9 per 100,000 a/y, but considerably higher, ational athletes poses a new challenge. Drinks
19.2/100,000 a/y, in Division I male basketball and other supplements, often considered inno-
players [15]. During long-distance running races, cent, must be evaluated carefully, as they may
the incidence of SCA is reported as 1:184,000 run- contain electrolyte concentrations or other
ners (0.54 per 100,000 runners), and the incidence substances that in predisposed individuals
is higher during marathons (1.0 per 100,000 run- may result to severe metabolic imbalance and
ners) than half-marathon (0.27 per 100,000 runners) SCA. “Contamination” of dietary supplements
whereas among triathlon participants is 1:52,630 with anabolic steroids has also been reported
participants (1.9 per 100,000 runners) [16]. [18, 19].
30  Sudden Cardiac Arrest 415

30.3.2 Cardiac lar hypertrophy (LVH), defined as a left ven-

tricular wall thickness (LVWT)  ≥  15  mm in
30.3.2.1 Inherited or Congenital one or more left ventricular myocardial seg-
ments, in the absence of abnormal loading
Structural conditions, such as hypertension or valve dis-
ease. Microvascular dysfunction, mitral valve
Hypertrophic Cardiomyopathy abnormalities and myocardial fibrosis are
Hypertrophic cardiomyopathy (HCM) has been associated with the phenotypic expression of
reported as a major cause of SCD in young ath- the disease.
letes, accounting for up to one third of deaths The ECG is abnormal in more than 90% of
in some cohorts [8]. The prevalence of HCM HCM patients and is an early marker of disease,
is reported as 1:500 young individuals. It is an often predating structural changes by many years.
inherited myocardial disorder, most frequently The most common findings are left ventricular
transmitted in an autosomal-dominant mode. hypertrophy (LVH) associated with T-wave inver-
In up to 60% of cases is caused by mutations sion (TWI) in lateral and/or inferior leads (81%),
in cardiac sarcomere protein genes, most com- ST-segment depression and pathological Q waves
monly beta-myosin heavy chain (MYH7) and (Fig. 30.1), [20]. Echocardiography can be used to
myosin-­ binding protein C (MYBPC3). It is confirm the diagnosis of HCM. Cardiac magnetic
characterised by the presence of left ventricu- resonance (CMR) imaging can better delineate

Fig. 30.1  Athlete’s ECG with HCM. LVH associated with deep anterolateral TWI, ST-segment depression
416 C. S. S. S. Colombo et al.

localised or subtle hypertrophy, can detect micro- ing in thinning of the wall and aneurysms. This
vascular disease and can identify myocardial fibro- interferes with electrical impulse conduction and
sis, which is present in 65% of patients and has leads to life-threatening arrhythmias. The risk of
been associated to an increased risk of SCD [21]. SCD is fivefold higher during competitive sports,
Athletes with HCM are more frequent in start-­ and accumulating evidence suggests that intense
stop sports modalities, such as soccer, rugby and exercise practice accelerates the progression of
basketball [22]. This occurs probably due to their the disease [7, 23, 25].
incapacity to sustain a prolonged augmentation The clinical diagnostic criteria include the
of stroke volume, being more difficult to compete presence of functional and structural changes of
in endurance sports. the right ventricle depolarisation and repolarisa-
Cardiac physiological adaptation to exercise tion ECG abnormalities and ventricular arrhyth-
poses a challenge to differentiate HCM from mias [25]. The left ventricle is also affected in
athlete’s heart in some athletes. Physiological the majority of cases, and the condition is more
LVH in athletes can overlap a mild HCM phe- appropriately referred to as arrhythmogenic car-
notype (LVWT = 13–15 mm), referred to as the diomyopathy (ACM).
“grey zone”. The diagnostic conundrum is more The ECG is abnormal in up to 80% of patients,
frequent in black males and athletes involved with TWI in the right precordial leads (V1–3),
in endurance sports. To differentiate physiol- prolonged QRS duration (>110 ms), epsilon wave
ogy from pathology, it is essential to do a com- (small amplitude potentials after QRS and before
prehensive assessment of the athlete, which in the onset of T wave), premature ventricular con-
addition to a comprehensive history may include tractions (PVC) with left bundle branch block pat-
cardiopulmonary exercise testing (CPET), ECG tern and ventricular tachycardia (VT) (Fig. 30.2).
monitoring, CMR and even familial evalua- Diastolic dilation of right ventricular outflow tract
tion. Detraining to assess resolution of the ECG (>30 mm) and wall motion abnormalities are fre-
changes and LV hypertrophy can also be of quent findings in echocardiography [26].
incremental value. Once the diagnosis of HCM is The early disease process of ARVC can also
established, expert consensus recommendations overlap with physiological cardiac adaptation
advise against participation in competitive sports, to exercise and represents another “grey zone”
with the possible exception of those of low inten- (Fig.  30.3). Recent studies have demonstrated
sity (class IA sports) [23]. that up to 30% of athletes exhibit right ventricular
cavity dimensions which overlap with the dimen-
Arrhythmogenic Right Ventricular sions suggested as part of the ARVC diagnosis
Cardiomyopathy criteria [27, 28].
Arrhythmogenic right ventricular cardiomyopa- Athletes with ARVC should be advised against
thy (ARVC) is also an important cause of SCD in participation in competitive sports (with the pos-
young athletes, accounting for 4–5% of deaths. sible exception of class IA sports). Studies indi-
The prevalence is 1:1000  in the general popu- cate that individuals with positive genotype and
lation, but can be as high as 0.4–0.8% in Italy negative phenotype can develop the disease with
(Veneto) and Greece (Naxos) [24]. It is transmit- intensive exercise; therefore, they should follow
ted as an autosomal-dominant trait with vari- the same recommendations [29].
able penetrance, caused by mutations in genes
encoding cardiac desmosomal proteins. There Congenital Coronary Artery Anomalies (CAA)
is progressive replacement of the myocardium Coronary arteries present anomalous origin from
by fibrofatty tissue, from epicardium or mid-­ sinus of Valsalva in 0.5–1.0% of individuals and
myocardium, extending to transmural, result- are reported as the second most common cause of
30  Sudden Cardiac Arrest 417

Fig. 30.2 Athlete’s ECG with ARVC.  Right precordial TWI (V1–3), isolated VE and couplets with LBBB
morphology

Fig. 30.3  Specific and

Grey Grey
overlapping features of zone LVWT = zone RV
athlete’s heart and 13-15mm dilatation
cardiomyopathies.
ARVC arrhytmogenic ATHLETE’S
right ventricular HCM HEART ARVC
cardiomyopathy; HCM physiological adaptations
hypertrophic
cardiomyopathy; IRBBB
incomplete right bundle ECG: ECG:
ECG:
branch block; LV left - Infero-lateral TWI - Isolated LVH
- ST segment - TWI beyond V2
ventricle; LVH left - TWI V1-2 (after J point
depression - VE
ventricular hypertrophy; elevation in black athletes)
- Pathological QW - NSVT
LVWT left ventricular - IRBBB
- Epsilon wave
- Isolated VE
wall thickness; NSVT ECHO:
non-sustained - LVH
ventricular tachycardia; - No LV dilatation ECHO: ECHO:
QW Q waves; RV right - Abnormal diastolic - RV dilatation
- LVH
ventricle; TWI T wave function with associated
- LV and RV dilatation
wall motion
inversion - Normal ventricular abnormalities
function and/or
Cardiopulmonar exercise test: dysfunction
peak VO2 < 50ml/kg/min
Cardiopulmonar exercise test:
peak VO2 55-70ml/kg/min
418 C. S. S. S. Colombo et al.

SCD in young athletes accounting for 17–24% of in moderate- to high-intensity isometric and iso-
deaths [8, 26]. The higher risk of SCD is in indi- tonic sports or sports with the potential for bodily
viduals with the left coronary artery origin from collision [34].
the right sinus of Valsalva, with the coronary
course between the pulmonary artery and the aorta. Bicuspid Aortic Valve, Aortic Stenosis
During intense exercise, the coronary artery may and Mitral Valve Prolapse
get compressed between the big vessels leading Bicuspid aortic valve (BAV) is a congenital valve
to myocardial ischaemia, ventricular arrhythmias abnormality that affects 1.5–2% of the popula-
and SCA. Coronary artery origin can be localised tion, with a male predominance of 3:1, and can
by echocardiography; however, the gold standard be associated with thoracic aortic dilatation in up
imaging tests are cardiac magnetic resonance to 50% of adults [35]. Commonly, degenerative
angiography or computed tomography coronary changes of the leaflets can result to aortic ste-
angiography [30]. The demonstration of exertional nosis (AS) and/or regurgitation at a young age.
ischaemia is challenging, and usual tests such as Ventricular arrhythmias and ventricular dysfunc-
exercise testing, exercise e­ chocardiography, stress tion, with inadequate cardiac output during exer-
CMR and nuclear imaging can be falsely reas- cise, can be present in athletes with severe AS,
suring. The recommendations for sports depend leading to SCA. Aortic stenosis is a cause of SCD
on the coronary artery anatomy, the presence of in 2–4% of young athletes [8].
symptoms and the presence of inducible isch- Pre-participation evaluation has an important
aemia. Usually, athletes with left coronary origin role because clinical history and physical exami-
from right sinus or anomalies traversing between nation can identify AS, usually presenting an
the great vessels should be restricted from partici- aortic systolic murmur and symptoms of dyspnea
pating in all competitive sports (with the possible and angina during exercise. Echocardiography
exception of class IA sports). After surgical repair can confirm the diagnosis and determine the
the decision depends on the results from the reas- severity of AS, and exercise testing is useful for
sessment of the athlete [31]. risk stratification [26]. Athletes with AS should
undergo regular evaluation. In the presence of
Marfan Syndrome moderate AS, they can participate in low- and
Marfan syndrome (MS) accounts for 3% of SCD moderate-intensity static or dynamic competi-
in young athletes [8]. It is an autosomal-­dominant tive sports, if asymptomatic and with normal
inherited disease of the connective tissue, caused response to exercise testing. Athletes with severe
by mutations in the fibrillin-1 (FBN1) gene with AS should not participate in competitive sports
a prevalence of 1:5000 individuals. Multiple (with the possible exception of class IA sports, if
organs are affected with skeletal, cardiovascu- they are asymptomatic) [36].
lar, ocular, skin, lungs and nerve abnormali- Mitral valve prolapse (MVP) is relatively com-
ties. Cardiovascular abnormalities include aorta mon in the general population, with a prevalence
dilatation, dissection or rupture. Intense exercise of 3–5%. Despite the association of MVP and
increases the pressure in the aorta and can accel- SCD is controversial, few cases of SCD have been
erate the progression. Tall athletes with hypermo- reported in which MVP was the only abnormal-
bility of the joints are common in some sports ity identified, including in young athletes. Some
such as volleyball and basketball and should be patients with MVP can present ventricular fibril-
evaluated carefully, especially if aortic root diam- lation (VF) leading to SCA, but rarely during
eter enlargement is present (>40  mm in males exercise [37]. MVP is considered a benign con-
and >34  mm in females) [32]. The diagnosis is dition, and competitive athletes can participate in
done based on clinical features, family history, all sports unless it is associated with significant
imaging and genetic testing, following the Ghent mitral regurgitation; with symptoms, such as
criteria [33]. Recommendations suggest that ath- severe chest pain or exertional syncope; or with
letes diagnosed with MS should not participate documented ventricular tachycardia (VT) [37].
30  Sudden Cardiac Arrest 419

Electrical Long QT Syndrome

Individuals with long QT syndrome (LQTS) pres-
Wolff-Parkinson-White Syndrome ent loss- or gain-of-function mutations in genes
Wolff-Parkinson-White (WPW) is a syndrome encoding ion channels that cause cardiac repolari-
with paroxysmal arrhythmias due to an acces- sation abnormalities and can lead to polymorphic
sory pathway in a re-entrant circuit involving VT. The estimated prevalence in the general pop-
AV node-His axis. Approximately one third of ulation is 1:2500 [8]. Most of the clinically and
the patients can develop atrial fibrillation, and genetically identified cases (up to 75% and 95%,
there is a risk of VF secondary to rapid antero- respectively) are related to mutations in three
grade conduction via the accessory pathway genes, KCNQ1, KCNH2 (potassium ion channel)
in these individuals [38]. SCD can be the first and SCN5A (sodium ion channel), determined as
manifestation in up to half of the patients, the genotypes LQT1, LQT2 and LQT3. Adrenaline
majority during exercise or stress-induced, and surges, such as during intense exercise, can trig-
it accounts for 1% of deaths in athletes [39, 40]. ger arrhythmias in LQT1 and LQT2, whereas
The prevalence in the general population is 0.1– in LQT3 SCD occurs more frequently at rest or
0.3%. The patients may present with symptoms during sleep. Swimming and diving are reported
of palpitations and/or syncope, but 65% of ado- as specific triggers for SCA in LQT1 [42], while
lescents and 40% of individuals >30 years with loud noises can trigger arrhythmias in LQT2
a typical ECG are asymptomatic. The ECG pat- patients. Symptoms include palpitations, seizures
tern includes delta wave, short P-R interval and and syncope. The diagnosis is based on a score
prolonged QRS duration (Fig.  30.4). Structural with clinical and ECG evaluation. When evalu-
cardiac diseases such as HCM and Ebstein ating the QT interval, the measurement should
anomaly can be associated with pre-excitation, use the “Teach the tangent” method and be cor-
and patients should undergo echocardiogra- rected for the respective heart rate (QTc), usu-
phy to confirm a structurally normal heart [38, ally calculated by Bazett’s formula (Fig.  30.5).
39]. An ECG monitor and exercise testing may Normal QTc values are <440  ms for males and
be helpful with risk stratification, as the pres- <460  ms for females in the general population,
ence of intermittent pre-­excitation is considered in the absence of use of QT-prolonging drugs or
a low-risk feature. The electrophysiological electrolytes imbalance. Athletes tend to exhibit
study is mandatory for symptomatic individu- longer QT intervals, and a QTc value is con-
als and advisable in asymptomatic competitive sidered abnormal when ≥  470  ms for male and
athletes to evaluate the risk of sudden death. ≥480 ms for female athletes [43]. Therapy with
Catheter ablation is the treatment of choice for beta-blockers is effective in LQT1 and LQT2 and
symptomatic athletes, athletes with documented is recommended as first-line treatment. Athletes
arrhythmias or individuals with high-risk path- with suspected/diagnosed LQTS should be
ways [41]. The procedure is curative, with a high advised to avoid QT-prolonging drugs, hyper-
success rate, and permits return to competitive thermia, dehydration and conditions predispos-
sports within 3 months. ing to electrolytes imbalance. Competitive sports
participation can be considered for asymptomatic
Channelopathies athletes in places with an emergency plan and
Inherited ion channel diseases are associated AED availability, with the exception of swim-
with life-threatening arrhythmias that can lead to ming in LQT1 [44].
SCA/SCD in a structurally normal heart, termed
sudden arrhythmic death syndrome (SADS). Brugada Syndrome
Contemporary publications from the United Brugada syndrome (BrS) is a sodium ion chan-
Kingdom, United States of America and Australia nelopathy that accounts for a large proportion
have reported SADS as the most frequent cause of SADS deaths. Its prevalence in the general
of SCD in young and athletic individuals [7]. population is estimated at 1:2000. The presumed
420 C. S. S. S. Colombo et al.

Type A – left sided accessory pathway – Delta wave and RBBB

Type B – Right sided accessory pathway – Delta wave LBBB morphology

Fig. 30.4  WPW-ECG patterns. Type A—left-sided accessory pathway—delta wave and RBBB. Type B—right-sided
accessory pathway—delta wave LBBB morphology
30  Sudden Cardiac Arrest 421

Fig. 30.5 LQTS-ECG
and QT measurement

“Teach the tangent” method

RR =
1120ms

Bazett’s Formula: QT/÷RR

QT =
620ms QTc = 585ms

Fig. 30.6  Brugada syndrome—ECG type 1 pattern

mode of transmission is autosomal dominant, ing may predispose to SCD at rest or the recov-
and the main identified gene linked to BrS is ery phase of exercise. The typical ECG (type 1)
SCN5A, accounting for only 18–30% of cases. shows a specific repolarisation pattern, charac-
Although SCD typically occurs during rest, in terised by a coved ST-segment elevation ≥2 mm
athletes with BrS, the elevation of body tempera- followed by a negative T wave in right precordial
ture caused by high-intensity effort can trigger leads (Fig. 30.6). The diagnostic pattern is typi-
arrhythmias during exercise, and the increased cally dynamic and often concealed [45]. Athletes
vagal activity secondary to athletic condition- with BrS may be considered to participate in
422 C. S. S. S. Colombo et al.

competitive sports with appropriate precaution- Myocarditis

ary measures, ­avoiding dehydration, electrolyte Myocarditis is an inflammatory cardiomyopa-
imbalance, hyperthermia and drugs that exacer- thy, secondary to infective and non-infective
bate the BrS [44]. causes. It has been reported to account for up
to 13% of SCD in young athletes [10, 49]. The
Catecholaminergic Polymorphic Ventricular most common cause is a viral infection and
Tachycardia sometimes can be subclinical [49]. Despite this,
Catecholaminergic polymorphic VT (CPVT) is a the presence of inflammatory infiltrate associ-
disease characterised by malignant arrhythmias, ated with myocyte degeneration and non-isch-
typically bidirectional or polymorphic VT, during aemic necrosis, which are its characteristics can
exercise or emotional stress. Most of the cases lead to life-threatening arrhythmias and SCA
are caused by mutations in the gene encoding [50]. Athletes are more susceptible to upper
ryanodine (RyR2) that alter calcium homeostasis respiratory infections, and it is described that
in cardiac myocytes triggering arrhythmias. The the viral replication rate, myocardial inflamma-
prevalence is estimated around 1:10,000. Usually, tion and necrosis may be increased by exercise
the symptom is stress-induced syncope starting during the early phase of myocarditis [51, 52].
in childhood, but SCD can be the first manifesta- The inflammation usually completely resolves
tion. A family history of syncope, seizures and within 6  months but, occasionally, can prog-
SCD is present in 30% of patients. The resting ress to a chronic phase, with permanent myo-
ECG is normal. Exercise stress testing can induce cardial dysfunction and arrhythmogenic scar. In
premature ventricular complexes at the beginning order to prevent SCD, the athlete should return
that increase in frequency and complexity at pro- to exercise training after complete resolution
gressive workloads. Beta-­blocker therapy reduces of the disease, confirmed by a comprehensive
VT occurrence, but 30% of patients still present medical re-evaluation [23].
with cardiac events [46, 47]. Competitive sports
are not recommended to athletes with previously Commotio Cordis
symptomatic CPVT or asymptomatic CPVT with From the Latin, “agitation of the heart”, it
documented exercise-­induced arrhythmias [44]. accounts for 2–3% of SCDs in young athletes.
It refers to blunt, non-penetrating blow to the
30.3.2.2 Acquired chest wall that causes VF and SCD and is dif-
ferent from cardiac contusion because there is
Atherosclerotic Coronary Artery Disease no myocardial injury [53]. Animal models have
(CAD) demonstrated that the trauma must occur perpen-
The major cause of SCD in older athletes dicular to the chest, over the cardiac silhouette
(>35  years) is CAD, accounting up to 80% of and during a specific 1% of the cardiac cycle,
cases [48]. Acute ischaemic events can initiate just before the T-wave peak [54]. Sports impli-
VT or VF.  Even in athletes cardiovascular risk cated include those using hard spherical objects
factors must be monitored, including periodic such as hockey, lacrosse and baseball, as well as
control of blood pressure, cholesterol and glu- sports involving body collision and martial arts.
cose levels, aiming at the prevention of athero- The most important thing is to recognise com-
sclerosis. Clinicians should maintain a high index motio cordis and initiate prompt defibrillation.
of suspicion as athletes may present with atypical Previously, survival rates among commotio cor-
or minimal symptoms of ischaemia due to condi- dis victims were low, probably due to the lack of
tioning and the presence of collateral circulation identification and late defibrillation. Fortunately,
and, in some cases, subconsciously underreport this has changed, and contemporary reports quote
their symptoms. a survival rate in excess of 50% [55].
30  Sudden Cardiac Arrest 423

Box 30.1: Causes of Sudden Cardiac Death

CAUSES OF SUDDEN CARDIAC DEATH

CARDIAC NON-CARDIAC

inherited or congenital acquired

• Inadequate fluid
structural electrical replacement
Hypertrophic • Coronary
WPW syndrome
cardiomyopathy atherosclerotic
Long QT syndrome
artery disease • Hyperthermia
Arrhythmogenic right Brugada syndrome
ventricular cardiomyopathy • Myocarditis
Catecholaminergic
Coronary artery anomalies • Commotio cordis • Electrolyte disturbances
paroxismal ventricular
Marfan syndrome tachycardia
Aortic stenosis
• Drugs (illicit or not)
Mitral prolapse valve

30.4 Prevention [11, 57, 58]. The European Society of Cardiology

(ESC), the International Olympic Committee (IOC)
30.4.1 Pre-participation and the Fédération Internationale de Football
Cardiovascular Evaluation Association (FIFA) recommend PPE with ECG for
(PPE) all athletes [59, 60]. However, the American Heart
Association supports just clinical questionnaire and
The aim of PPE is to detect athletes with quies- physical examination as a routine evaluation, due
cent cardiac disease at potential risk of SCA and to concerns relating predominantly to high false-­
SCD.  The medical evaluation includes a detailed positive rates, lack of expertise and associated costs
history including symptoms and personal and fam- [61]. Indeed, ECG interpretation can be challenging
ily history and physical examination. In Italy, where because athletes may exhibit ECG patterns caused
PPE has been mandatory for competitive athletes by physiological adaptation to exercise that can
since 1982, a 12-lead ECG is also included. The overlap with the ECG phenotypes present in car-
26-year Veneto experience reported in a study diac disease. Appropriate evaluation of the ECG by
showed a sharp decline of the incidence rate of SCD physicians trained in the field of sports cardiology
in young athletes after the introduction of system- improves the results [43, 62, 63].
atic screening [10]. Among the screened athletes,
the annual rate of death dropped from 3.6 to 0.43 per
100,000 person-­years (86%), whereas it remained 30.4.2 Emergency Care
almost the same in the unscreened nonathletic
population during the same period. A considerable A well-established emergency response plan is
proportion of the causes of SCD in athletes can be extremely important in the sports arena. Time
identified by the ECG, while history and physical response is crucial to positive results. In the pres-
examination have a very poor yield [56]. Despite ence of SCA, the ideal target is to start cardiopul-
the fact that inclusion of ECG in PPE increases monary resuscitation (CPR) in less than 1  min
more than fourfold the sensitivity of detecting car- and defibrillation by 3–5 min. For each 1 min of
diac disease, its inclusion remains controversial delay, the chance of survival decreases by 10%
424 C. S. S. S. Colombo et al.

[64]. Unfortunately, the average survival rate of to identify the heart rhythm and to deliver a shock
out-of-hospital SCA (OHCA), outside the context when indicated. The time of pause compressions
of a sports arena, is less than 10%, and it has not pre shock should be minimum, and the compres-
improved in 30 years, despite the medical advance. sions should resume immediately after shock.
The cardiac rhythm should be checked and the
30.4.2.1 Predictors of Survival procedure repeated every 2 min [66].
The survival rate after SCA to hospital admission Once a trained rescuer is present, breath res-
is 23.8% but to hospital discharge is 7.6% [13]. cue should be delivered (by mouth to mouth or
Four clinical criteria have been identified as impor- bag mask), with the ratio of 30 compressions to
tant predictors of survival from OHCA: (1) SCA 2 ventilations (breath over 1 s, 8–10/min) [66].
witnessed by a bystander or emergency services,
(2) provision of early CPR, (3) presence of shock- 30.4.2.2 Emergency Planning
able cardiac rhythm (VT or VF) and (4) return to and Practice
spontaneous circulation in the local setting [13]. The key to a good outcome is planning and
Based on this the “Chain of survival” was estab- practice.
lished which includes immediate recognition of Every venue of training and competition must
SCA, early initiation of CPR, rapid defibrillation, have a written medical action plan (MAP), avail-
effective advanced cardiac life support (ACLS) able to all staff, referees and visiting team. This is
and good integration with post-SCA care [65]. essential to guarantee the efficiency of the emer-
gency responses. The MAP should name a medical
Recognition director, who is responsible to coordinate and assign
Any athlete who collapses and is unrespon- roles. First responders should be clearly defined and
sive should be considered as SCA.  Sometimes trained. Basic life support training should be done
they can exhibit seizure-like activity and agonal for all staff (including coaches, physiotherapists,
breathing that causes confusion and delays the referees, officials and administrators) and, ide-
diagnosis of SCA. Assessment of the presence of ally, ACLS certification for at least one physician.
a pulse can also cause delay. Thus, any unher- Personnel training and practice is the most impor-
alded syncope should be assumed as SCA, call tant part of a successful plan. For rapid defibrilla-
for help and activate the emergency system. tion, the access to AED should be within 3 min from
anywhere in the arena. The number of AEDs may
Early CPR be calculated based on proposed algorithms (aver-
Chest compressions should be initiated imme- age velocity to cross a distance in the place, number
diately. The last Basic Life Support (BLS) of people) and have a mapping distribution [68, 69].
Guidelines changed the previous sequence “A-B-­ Emergency medication, oxygen and transport equip-
C” to “C-A-B” recommending chest compres- ment must be available. It is recommended that 1–2
sion before breath rescue (hands only) [66]. The physicians are present per 50,000 spectators (not
focus is on the high quality of compressions to including the team physicians) and 1 nurse and 2
guarantee coronary and brain perfusion. The emergency responders per 10,000 spectators.
compressions should have an adequate rate (100/ The collaboration with the local emergency
min) and depth (2 in or 5 cm), allowing full chest services defining the place of transportation, the
recoil in between, and must continue until the best way to go, time to arrive, number and loca-
victim becomes responsive. tion of ambulances and alertness of the nearest
hospital should be planned in detail, aiming for a
Rapid Defibrillation coordinated and integrated response. The medi-
This is a powerful predictor of success of resusci- cal director must ensure the documentation of all
tation. An automated external defibrillator (AED) emergency care provided [2, 70].
is the best strategy. High survival rate (71%) has Regular practice for the team and periodic
been demonstrated in school-based AED pro- review of the plan are parts of a good emergency
grammes in the United States [67]. AED is able response.
30  Sudden Cardiac Arrest 425

30.5 Conclusion
Box 30.2: SCD- Prevention Keys
• PRE-PARTICIPATION CARDIAC The occurrence of SCD in sports is always a
EVALUATION tragic event, with a high impact on the wider
• Investigation of individuals with cardiac society. Exercise is health, and people should
symptoms be stimulated to be physically active. However,
• FAMILY SCREENING AFTER SCD at some predisposal individuals can present life-­
a specialist centre threatening arrhythmias triggered by sports.
• ADEQUATE TREATMENT and recom- Pre-­participation cardiovascular evaluation is
mendations relating to sport participation effective to identify a great part of these indi-
• EMERGENCY response PLAN to facil- viduals and is recommended to prevent SCD in
itate EARLY CPR and defibrillation all athletes. The assessment of athletes including
clinical and family history, physical examina-
tion and 12-lead rest ECG done with expertise
30.4.2.3 Special Events and Venues is very useful. Cardiomyopathies such as HCM
Some events such as marathons and Olympic and ARVC frequently present ECG abnormalities
Games need special planning. and can be identified in the screenings. Previous
Running events in open areas should have med- syncope episodes and family history of SCD at a
ical coverage along the way; 1–5 first-aid person- young age associated with specific ECG abnor-
nel per 1000 runners is recommended and at least malities can also raise the suspicion of channelo-
1 ACLS medical provider per 2500 and 1 BLS and pathies such as LQTS and BRs.
1 ACLS ambulance per 500 runners, being most of In the presence of SCA, prompt recognition
them on the latter half of the course and near the and early CPR and defibrillation are keys to sur-
finish line. One AED should be available less than vival. An emergency plan with personal training
1 mile away from any participant [71]. and regular practice is essential to a successful
The challenge in Olympics is to coordinate outcome.
the multiple events and teamwork, providing
good communication and plan to multisport Take-Home Messages
venues. During the competition in the venue • SCD IN SPORTS is a relatively rare event but
area, the host medical staff is responsible for more frequent than previously thought with
emergency care, whereas in the training area, male athletes and athletes of African/Afro-­
visiting medical staff should assume their ath- Caribbean descent competing in high-­intensity
lete’s care [71]. start-stop sports being at increased risk.
• Most athletes (80%) are asymptomatic with
no known family history and SCA is the first
30.4.3 Family Screening After SCD clinical symptom.
• Most SCA (60–80%) occur either during or
Evaluation of the families is essential after a SCD to shortly after exertion but a significant
prevent other cases of SCD. It is reported that an ini- proportion occurs at rest, outside the sporting
tial clinical evaluation with rest ECG and echocar- arena.
diogram can identify an inherited cardiac disease in • Most conditions predisposing young (<35
22% of families [72]. A more comprehensive evalu- years) athletes to SCA are either congenital or
ation is recommended for all first-­degree relatives inherited. In contrast, coronary atherosclerosis
of victims with a normal post-mortem (SADS), predominates in the older athletes.
since over half of the evaluated families have been • PPE WITH ECG CAN PREVENT SCD IN
identified with a c­hannelopathy or cardiomyopa- ATHLETES although significant concerns
thy. The investigation may include exercise testing, remain regarding false-negative and false-pos-
24 h holter, CMR, drug provocation testing or other itive rates as well as cost implications and lack
tests, depending on the suspicion [72, 73]. of expertise.
426 C. S. S. S. Colombo et al.

• SCA RESCUE AND GOOD OUTCOME: 13. Sasson C, Rogers MAM, Dahl J, et al. Predictors of
–– IMMEDIATE initiation of CHEST survival from out-of-hospital cardiac arrest: a system-
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–– DEFIBRILLATION within 3–5min CIRCOUTCOMES.109.889576.
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trained personnel and regular practice den cardiac death: new updates for athletic depart-
ments. Sport Health. 2017 May;9(3):268–79. https://
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15. Harmon KG, Asif IM, Maleszewski JJ, et  al.

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 Concussion
31
Natalie Sherry and Michael W. Collins

31.1 Introduction were forced to rely primarily on athletes’ self-­

report of symptoms for diagnosing and managing
An estimated 1.6–3.8 million sport-related con- SRC, but there are now empirically derived tools
cussions (SRCs) occur annually in the United that can detect SRC using objective measures [6,
States [1], and there has been a rise in the number 7]. A reliance on self-reported symptoms for the
of athletes seeking treatment for this injury in diagnosis and management of SRC is now criti-
recent years [2]. A concussion is defined as a cized by the International Consensus Statements
transient neurometabolic crisis in the brain that is on Concussion in Sport [8, 9] due to the tendency
induced by a traumatic biomechanical force to for athletes to underreport their symptoms [10,
the head or body. The mechanical trauma to the 11]. The advancement of assessment tools for
brain results in a distortion and stretching of neu- evaluating SRC has led to a shift in the field in
ronal structures allowing for unregulated ionic which concussion experts now believe there are
fluctuations that initiate a series of complex neu- different subtypes or clinical profiles that occur
rometabolic events disruptive to brain function after SRC, and each athlete must be treated in an
[3, 4]. These pathophysiological changes are not individualized manner [12–14]. Given the het-
detectable with conventional neuroimaging tech- erogeneity in clinical presentations after SRC
niques (e.g., computed tomography [CT], mag- among athletes, a multimodal assessment of neu-
netic resonance imaging [MRI]) [5] but can result rological functions is warranted. Furthermore,
in a myriad of neurological signs (e.g., loss of treatment of the injury may require a multidisci-
consciousness [LOC], posttraumatic amnesia plinary approach that includes a dependence
[PTA]), symptoms (e.g., headache, blurred upon the expertise of multiple healthcare provid-
vision), and impairments (e.g., cognitive deficits, ers in order for the athlete to achieve a full recov-
oculomotor abnormalities). ery. This overview provides a framework for the
Several advancements have been made in the clinical management of SRC based on the current
clinical evaluation, management, and treatment trends in the assessment and treatment of the
of SRC. In the past, sports medicine practitioners injury.

N. Sherry · M. W. Collins (*)

Sports Medicine Concussion Program, Department of
Orthopaedic Surgery, University of Pittsburgh
Medical Center, Pittsburgh, PA, USA
e-mail: [email protected]; [email protected]

© ISAKOS 2019 429

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_31
430 N. Sherry and M. W. Collins

31.2 Clinical Management 31.2.2 Sideline Assessment

of Sport-Related Concussion and Management

Sport organizations have started to implement The goal of sideline assessment and management
standardized protocols for improving the identifi- is to properly identify when an SRC has occurred
cation and treatment of SRC.  Although each and conduct an evaluation to determine whether a
injury is managed on an individual basis, some return to play is contraindicated. When there is
organizations have implemented guidelines for any unusual neurological sign or symptom after a
assisting sports medicine physicians, particularly significant blow to the head or body, an athlete is
team physicians, in diagnosing and managing prohibited from a return to sport participation
SRC among athletes. Protocols may include within 24  h of injury [8]. Athletes suspected of
guidelines for preseason (i.e., baseline) testing, sustaining an SRC must be removed from sport
sideline assessment of SRC, specialty manage- participation immediately and avoid activities
ment of SRC, and determining return to play sta- with a risk of head injury, due to the risk of poten-
tus, as outlined in Fig. 31.1. tial catastrophic outcome should an athlete sus-
tain a second insult to the head when actively
concussed [20, 21]. Recent research indicates
31.2.1 Preseason (i.e., Baseline) that athletes who are not removed from play
Testing immediately after sustaining an SRC may double
their recovery time [22].
Prior to the beginning of the season, athletes are Detection. Detection of SRC on-field or dur-
often required to undergo a preseason physical ing sport can be difficult for the sports medicine
examination to ensure their medical readiness to physician given that not all SRCs result in observ-
play. Teams have started to utilize the preseason able signs of injury. More obvious signs of neuro-
physical examination to incorporate concussion logic injury include the presence of LOC, PTA,
assessment tools, in which athletes are tested on incoordination/imbalance, vomiting, appearing
concussion assessments when non-injured to dazed/confused, disorientation, or physical slow-
allow for later comparison should an athlete sus- ness after a blow to the head or body. However,
tain an SRC in the future. This baseline assess- many athletes who sustain an SRC will not
ment model may be especially useful for exhibit any of these acute markers of injury. For
evaluating the subtle cognitive deficits than can instance, most athletes diagnosed with an SRC
occur after SRC [15], particularly among athletes will have no accompanying LOC, and contrary to
with a history of a neurodevelopmental condition popular belief, the presence of LOC and other
(e.g., attention deficit hyperactivity disorder) [16, traditional markers of traumatic brain injury
17] or who exhibit above average intelligence (TBI) is not considered to be a reliable predictor
[18]. It is recommended that all baseline testing of the severity of SRC [23–25]. Other symptoms
utilizing functional assessment tools include that are indicative of SRC, but cannot be readily
validity indicators to prevent from attempted observed and require questioning of the athlete,
“sandbagging” (i.e., intentionally performing include complaints of headache, nausea, dizzi-
poorly) on their testing [19]. ness, tinnitus, visual disturbances, photo- and
phonophobia, mental slowness, and sense of

Preseason Specialty
Detection of Return to Play
Baseline Evaluation and
Injury Status
Testing Management

Fig. 31.1  Guidelines for the clinical management of sport-related concussion

31 Concussion 431

imbalance. Detection of the injury requires vigi- tion by a healthcare professional prior to allow-
lance of observable signs of injury as well as ing athletes to return to sport. For instance, all 50
direct questioning of the athlete. states in the United States have legislation requir-
ing that athletes participating in organized sports
must receive clearance from a designated sports
Fact Box medicine practitioner prior to being permitted to
A loss of consciousness is not required for return to full sport participation [30]. There is a
the diagnosis of concussion, and losing call to action around the world to adopt such poli-
consciousness does not predict recovery cies for management of SRC to protect the health
from or the severity of the concussion. of athletes [8].

31.2.3 Specialty Evaluation

Sideline assessment. Athletes suspected of and Management
sustaining an SRC are removed from play and of Concussion
further evaluated on the sideline. A standard side-
line evaluation includes questioning of concus- The goal of outpatient or specialty management
sion signs and symptoms, a focused neurological of SRC is to conduct a thorough assessment of
examination, and mental status testing [26]. The the injury and develop an individualized treat-
sideline evaluation should incorporate athletes’ ment plan for rehabilitation. Some deficits of
self-report of symptoms in conjunction with SRC may require formal treatment, and through a
objective tools to prevent athletes from minimiz- comprehensive, multimodal assessment, specific
ing their SRC symptoms in attempt to expedite impairments and complicating factors related to
their return to play [8, 27]. Questioning of signs the injury can be identified and addressed to
and symptoms of SRC provides information to potentially avoid the development of post-­
the sports medicine practitioner on subjective concussion syndrome (PCS). Identification of the
complaints of the athlete. A focused neurological specific impairments of the athlete [12] can assist
examination must be conducted to rule out poten- in the development of a targeted treatment plan,
tially emergent neurological sequelae (e.g., intra- rather than a one-size-fits-all approach to injury
cranial bleed, skull fracture) and evaluate management. Emerging trends in research sug-
neuromotor functions affected by SRC (e.g., ves- gest there may be distinct clinical profiles that
tibular function, oculomotor function). And occur after an SRC. Proposed clinical profiles, or
lastly, mental status testing should include ques- presentations after SRC, include posttraumatic
tions to determine if the athlete is oriented and migraine, ocular, vestibular, anxiety/mood, and
cognitive screening for testing attentional and cognitive fatigue [14]. Some athletes may exhibit
memory functions [28]. Unlike more severe signs of multiple clinical profiles, and each of
TBIs, athletes with an SRC may be able to cor- these clinical profiles may require different types
rectly answer traditional orientation questions of treatment. Concussion experts advocate for a
(i.e., person, place, and time), and therefore, comprehensive assessment [26] to elucidate the
questions of recent memory (e.g., “what is the clinical profile(s) and develop a patient-centered
score of the game?” “what is the name of the treatment plan after SRC [13, 14].
opposing team?”) may be more effective [29]. Comprehensive assessment. Traditional
Results of all sideline assessments may be imaging for detecting acquired neurological
compared with baseline testing when possible to injury (e.g., MRI, CT scan) is usually unremark-
facilitate intraindividual interpretation. Any posi- able following SRC. Structural neuroimaging is
tive finding on sideline evaluation precludes a often not sensitive to the neurometabolic cascade
return to play based on international criteria [8]. following an uncomplicated concussion [5], and
Some governing bodies require further evalua- therefore, clinicians must rely on empirically
432 N. Sherry and M. W. Collins

derived, functional assessment tools for diagno- 31.2.3.2 Symptom Inventories

sis and management of SRC. Standardized evalu- Structured questionnaires designed to evaluate
ation of SRC should include a thorough clinical the specific symptoms and functional impair-
interview, supported with information gathered ments after SRC provide an indication of the
from symptom inventories, neurocognitive test- severity and nature of the injury. Athletes can
ing, and vestibular/oculomotor screening [26], as experience a wide range of symptoms including
displayed in Fig. 31.2. physical, cognitive, mood, and sleep-related dis-
turbances. Evaluating symptoms using a struc-
31.2.3.1 Clinical Interview tured questionnaire, such as the Post-Concussion
Sports medicine physicians should aim to estab- Symptom Scale (PCSS), provides a more com-
lish a rapport with athletes through a comprehen- prehensive clinical profile than asking about
sive clinical interview that details the nature of symptoms using an open-ended interview
the injury and prior medical history. Essential approach [31]. Symptom questionnaires also
components of the clinical interview include allow for serial tracking of symptoms over time
establishing the mechanism of injury (e.g., and are useful for prognosticating recovery time.
helmet-­ to-helmet hit), identifying immediate Symptom severity at initial evaluation is a robust
signs and acute markers of injury (e.g., LOC, diz- predictor of recovery time [32–34].
ziness), identifying potential medical or psychi-
atric risk factors for complicated recovery (e.g., 31.2.3.3 Neurocognitive Testing
major depressive disorder), detailing prior treat- Standardized neurocognitive testing provides an
ments and current symptoms (e.g., medications), objective evaluation of brain impairment after
and obtaining a psychosocial history (e.g., educa- SRC.  Neurocognitive testing evaluates brain
tion level, employment) [14]. Through the clini- functions such as attention, reaction time, and
cal interview, hypotheses regarding the clinical memory that are commonly affected after
profile can be established and tested with objec- SRC. Athletes who are reportedly asymptomatic
tive assessment tools sensitive to concussion. may still demonstrate deficits on objective neuro-
cognitive testing [6, 10, 35], and performance on
neurocognitive testing can be compared to clini-
cal cutoffs to prognosticate recovery time from
the injury [32, 33]. Computerized neurocognitive
testing may be more practical in the evaluation of
SRC rather than traditional paper-and-pencil
Neuro-
cognitive
Symptom neuropsychological testing given its feasibility of
Inventories
Testing use. Specifically, computerized neurocognitive
testing allows for randomization of test stimuli to
mitigate practice effects with serial test adminis-
tration, an accurate measure of reaction time, and
Vestibular-
Oculomotor immediate scoring of performance to make expe-
Screening dited clinical decisions [36, 37]. Patterns of per-
formance on neurocognitive testing can yield
information on the type of clinical profile an ath-
lete is demonstrating and determine the ability of
an athlete to function in the school or occupa-
tional environment [14, 26]. Performance on neu-
Concussion Diagnosis and rocognitive testing can be compared to an
Conceptualization of Injury
athlete’s baseline (i.e., preseason evaluation) for
Fig. 31.2 Comprehensive evaluation of sport-related intraindividual comparison or using normative
concussion data; baseline comparison may be beneficial for
31 Concussion 433

nontraditional athletes or athletes with above/ strate an individualized constellation of different

below average intelligence [16, 18, 38]. symptoms and deficits and may require different
Performance validity indicators should addition- treatment approaches depending on the nature of
ally be utilized as part of cognitive testing to their injury [13]. Sports practitioners advocate
evaluate effort, which is important when there is for an individualized, patient-centered treatment
concern of malingering or issues of secondary approach tailored to the athlete given the hetero-
gain associated with the injury [26]. geneity of clinical presentations and outcomes
after SRC [8, 13]. Recent research indicates that
there may be distinct clinical profiles after SRC
Fact Box that are associated with specific symptoms and
Athletes who deny symptoms may still impairments [12, 14, 45]. Some athletes may be
demonstrate impairments from concussion more predisposed to a certain phenotype depend-
on objective testing. ing on risk factors in their medical history [46].
Proposed clinical profiles are displayed in
Fig.  31.3 and include posttraumatic migraine,
vestibular, ocular, anxiety/mood, and cognitive
31.2.3.4 Vestibular/Oculomotor fatigue. Cervical involvement may be considered
Screening as a separate clinical profile, as some athletes’
Focused neuromotor screening is an important symptomology (e.g., headache) may be multifac-
aspect of a multimodal evaluation of SRC [26]. torial and related to both head and neck injury
Over half of athletes will report dizziness or [14]. These clinical profiles are not considered
imbalance after an SRC [32, 39], which is sug- mutually exclusive, and athletes may exhibit
gestive of an underlying decompensation of the symptomology from more than one clinical pro-
central vestibular system. The vestibular system file. Specialty management of SRC involves a
is a multipart sensorimotor system that allows for comprehensive assessment to determine the spe-
neural control of postural stability (i.e., balance) cific clinical profile of the athlete and develop a
and stabilization of vision during movement. targeted treatment plan to promote recovery and
Balance testing is useful in the acute phase of the attempt to expedite return to play.
injury, but such vestibulospinal impairments typ-
ically resolve within the first 72 h of injury [40,
41]. In contrast, deficits in vestibular and oculo-
motor functions (e.g., vestibular-ocular reflex
Posttraumatic
[VOR], visual motion sensitivity, convergence) Migraine
after SRC may persist much longer. Recent
research indicates that a positive finding on
vestibular-­oculomotor screening [7] after SRC is Cervical Vestibular

predictive of a prolonged recovery time among

athletes [42, 43]. Incorporating vestibular-­
Concussion
oculomotor screening provides useful informa-
tion to help delineate the athlete’s clinical
presentation after injury. Deficits in vestibular Cognitive
Ocular
dysfunction can cause symptoms of motion sick- Fatigue
ness, which can become an obstacle for athletes
trying to return to sport given the demand for Anxiety/Mood
dynamic movement in physical activity [14, 44].
Clinical profiles of concussion. Leading
experts investigating concussion agree that not
all concussions are the same. Athletes demon- Fig. 31.3  Clinical profiles of sport-related concussion
434 N. Sherry and M. W. Collins

31.2.3.5 Posttraumatic Migraine injuries pharmacological intervention may be

Posttraumatic migraine is the onset of a headache warranted [54, 55].
with accompanying nausea and photosensitivity
and/or phonosensitivity [47]. Athletes demon- 31.2.3.7 Ocular
strating this clinical profile report a headache of Athletes may experience posttraumatic vision
moderate-to-severe intensity, with a pulsating changes after sustaining an SRC. Potential visual
quality that lasts hours. Most athletes report disturbances include blurred or double vision,
headaches immediately after injury [39], but the trouble focusing eyes, asthenopia or fatigue with
persistence of migraine headaches may be a risk visually demanding activities, and/or headache/
factor for a prolonged recovery [48, 49]. To eval- pressure behind the eyes [14]. The most com-
uate the presence of this clinical profile, a thor- mon oculomotor problems after SRC are related
ough interview of headache characteristics, to decompensation of convergence and accom-
symptom inventories, and performance on neuro- modative functions [59, 60]. Clinical markers of
cognitive testing should be considered. Athletes this profile include a lowered performance on
with posttraumatic migraine may perform more computerized neurocognitive testing [61, 62]
poorly on neurocognitive testing of verbal and and abnormalities on oculomotor screening of
visual memory [48]. Potential treatments for this near point of convergence, accommodation,
clinical profile include behavioral management smooth pursuits, and/or saccades [7]. There is
strategies (i.e., regulated sleep schedule, healthy limited research on the potential risk factors
diet, stress management, physical activity, and associated with this clinical profile, but perhaps
hydration) [50, 51], nutritional supplements [52, a history of developmental oculomotor abnor-
53], and/or pharmacological intervention with a malities (e.g., strabismus) may render some ath-
migraine preventative, abortive, and/or rescue letes more vulnerable to posttraumatic vision
medication [54, 55]. disturbances after SRC [14]. The presence of
oculomotor abnormalities after SRC is associ-
31.2.3.6 Vestibular ated with a prolonged recovery time [42, 63].
Vestibular dysfunction is associated with symp- Potential treatments may include vision therapy,
toms characteristic of motion sickness. vestibular-ocular therapy, and/or specialty eye-
Specifically, athletes may report sensations of glasses [64, 65].
dizziness, fogginess, unsteadiness, light-­
headedness, and nausea when engaged in head 31.2.3.8 Anxiety/Mood
and eye movements and/or when in complex/ Athletes may experience a myriad of mood and
busy environments [14, 42, 56]. Athletes with emotional changes after sustaining an SRC.  In
this clinical profile may be asymptomatic at rest addition to the psychological factors associated
but have difficulty returning to physical activity with the injury, there are several physiological
given the dynamic movement (e.g., lateral or pla- changes in limbic-cortical circuitry secondary to
nar movements) involved in sport participation. the metabolic disturbance from SRC [3, 39, 66,
Assessment of this clinical profile requires 67]. Emotional changes may include feelings of
screening of vestibular/oculomotor functions anxiety, panic attacks, sadness, ruminative think-
including smooth pursuits, saccades, vestibular-­ ing, irritability, agitation, and mood lability.
ocular reflex, and visual motion sensitivity. A Some athletes may also have accompanying sleep
preinjury history of high susceptibility toward dysregulation (e.g., trouble falling asleep) and
motion sickness is a potential risk factor for the engage in avoidant coping to prevent from emo-
development of this profile [46]. Active treatment tionally triggering stimuli [68]. To determine if
of this clinical profile involves the development anxiety or mood factors are present after SRC, a
of a structured physical therapy plan tailored to thorough clinical interview utilizing a functional
the individual athlete in order to rehabilitate the behavioral assessment approach, symptom inven-
vestibular system [43, 57, 58], and in protracted tories, and comparison of subjective complaints
31 Concussion 435

to objective test results is warranted to elucidate 1) • Symptom free at rest

if there may be a psychological basis to reported
symptoms [68]. A preinjury history of a mental 2) • Symptom free with physical activity
health condition is a risk factor for the develop-
3) • Normal clinical evaluation
ment of this clinical profile and one of the stron-
gest predictors of a prolonged recovery from Fig. 31.4  Return to play criteria based on international
SRC [69, 70]. To treat the anxiety/mood clinical guidelines
profile in the acute phase of injury, psychoeduca-
tion [71, 72] and a gradual return to functional
activities [73, 74] are recommended. Protracted symptom-free from concussion with physical
mental health complications after SRC may activity, and (3) athletes must demonstrate a nor-
require psychotherapy [75–77] and/or psychotro- mal clinical evaluation. Figure 31.4 provides an
pic medications [78, 79]. outline of criteria. Evaluation of tolerance of
physical activity should incorporate a combina-
31.2.3.9 Cognitive Fatigue tion of both aerobic activity and dynamic move-
The cognitive fatigue clinical profile is character- ment. The current international guidelines for
ized by complaints of difficulty with thinking exertion protocols after SRC do not specify the
skills (e.g., attention, processing speed, memory) necessity of incorporating dynamic movement in
and overwhelming fatigue. Functional com- return to play evaluation, but given the preva-
plaints associated with this clinical profile may lence of vestibular dysfunction after SRC, this
include feeling mentally slow, difficulty multi- may be an important assessment tool [8, 12]. If
tasking or retaining information, or exhaustion the criteria in Fig. 31.4 are not met, then the ath-
after engaging in cognitively demanding activity. lete should be held from play and receive further
Assessment of this clinical profile hinges on the treatment. Making return to play decisions should
athletes’ pattern of symptom report and perfor- always involve a multimodal assessment that
mance on objective neurocognitive testing [14]. incorporates both subjective and objective
A potential risk factor for the development of this measures.
clinical profile is a history of preinjury sleep dif-
ficulties [80]. Limited research has been con-
ducted for the treatment of this clinical profile,
Fact Box
but this is some preliminary evidence for the use
International guidelines require the follow-
of cognitive therapy [72] or pharmacological
ing criteria to be met prior to returning an
intervention [81].
athlete to full sport participation after con-
Return to play criteria. To protect the safety
cussion: (1) athletes must be symptom-free
of athletes, there are established international
from concussion at rest, (2) athletes must
guidelines standardizing the protocol for deter-
be symptom-free from concussion with
mining readiness of an athlete to return to sport
physical activity, and (3) athletes must
after sustaining an SRC [8]. When an athlete is
demonstrate a normal clinical evaluation.
suspected or diagnosed with an SRC, they are
never to returned to play on the same day as the
injury [8]. The goal of these established guide-
lines is to prevent an athlete from returning to Take-Home Message
play prematurely and suffering a second insult to Concussion is an individualized injury that
the head when actively concussed. There are requires a comprehensive assessment and tar-
three major conditions that must be met prior to geted treatment approach. A multimodal eval-
considering clearance of an athlete back to con- uation of concussion sequelae allows for the
tact sports: (1) athletes must be symptom-free determination of the clinical profile from the
from concussion at rest, (2) athletes must be injury and a treatment plan tailored to the
436 N. Sherry and M. W. Collins

individual athlete. There have been several 13. Collins MW, Kontos AP, Okonkwo DO, et  al.

Statements of agreement from the Targeted Evaluation
advancements in the tools available for evalu- and Active Management (TEAM) approaches to treat-
ating concussion, and sports medicine practi- ing concussion meeting held in Pittsburgh, October
tioners should rely on a combination of 15–16, 2015. Neurosurgery. 2016;79(6):912–29.
subjective ­ symptoms and performance on 14. Collins MW, Kontos AP, Reynolds E, Murawski

CD, Fu FH.  A comprehensive, targeted approach to
objective testing for clinical decision-making. the clinical care of athletes following sport-related
There are established international guidelines concussion. Knee Surg Sports Traumatol Arthrosc.
for returning athletes to sport participation 2014;22(2):235–46.
after sustaining a concussion. 15. Barth JT, Alves W, Ryan T, Macciocchi SN, Rimel
RW, Nelson WE.  Mild head injury in sports: neu-
ropsychological sequelae and recovery of function.
Mild head injury. New York: Oxford University Press;
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 Doping
32
Maria João Cascais

32.1 Background World Anti-Doping Code [Code]—the document

harmonizing anti-doping policies in all sports
The concept of doping is old as sport itself. In an and all countries” (https://www.wada-ama.org/
ideal world, this chapter would not be necessary, en/who-we-are).
only in the historic concept. Unfortunately, here Having this in view, the rules of what athletes
we are, providing some information for the sports can take or do about doping do not leave any
medicine clinician, hoping that this text will doubts as this cited site of WADA is available for
guide him through these always changing issues. every sport-concerned entity.
The changes are the essence of doping because The List is updated every year and has started
there are new methods and rearrangement of old with the Olympic Committee “Under the leadership
ones every day. of the International Olympic Committee, the
Doping is described at least since the Old Prohibited List [List] was first published in 1963.
Greece (Fig. 32.1) [1]; it was used by the Romans Since 2004, as mandated by the World Anti-­Doping
and the ancient tribes of Norway [2]. In the Code [Code], the World Anti-Doping Agency
explosive growing of sport in the early twentieth [WADA] is responsible for the preparation and pub-
century, all the issues came back from the past lication of the List (Fig.  32.2)” (www.usada.org/
and were enhanced with the light of science. when-was-the-first-prohibited-list-created-and-
The actual organization in terms of doping, how-does-a-substance-get-on-the-prohibited-list/).
education, and fair play is the WADA [World
Anti-Doping Agency]. “The World Anti-Doping
Agency [WADA] was established in 1999 as an
independent international agency composed and
funded equally by the sports movement and gov-
ernments of the world. The key activities include
scientific research, education, development of
anti-doping capacities, and monitoring of the

M. J. Cascais (*)
NOVA Medical School Lisbon, Lisboa, Portugal
Sports Medicine College, Medical Portuguese Order,
Lisboa, Portugal Fig. 32.1  Athletics in ancient Greece

© ISAKOS 2019 439

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_32
440 M. J. Cascais

an opportunity to make the appropriate changes

in medications.

32.2 The List: WADA

Reading the list is an important step not to be

overwhelmed by all the chemical compounds
inside it. This List has the first step to consider,
the division between substances and methods
prohibited at all times and the other refers to the
Fig. 32.2  Doping means many threats
substances and methods prohibited only in
competition. The Monitoring Program is
The First World Conference on Doping in another chapter and finally the one called The
Sport held in Lausanne, Switzerland, on February Summary of Major Modifications and
2–4, 1999, produced the Lausanne Declaration Explanatory Notes. With these tools that are
on Doping in Sport. This document provided for published every year by the WADA, all the medi-
the creation of an independent international anti-­ cal community and the athletes have a source of
doping agency to be operational for the Games of information that is the key to maintain the health
the XXVII Olympiad in Sydney in 2000 (https:// of athletes and a clean sport.
www.wada-ama.org/en/who-we-are). Having the WADA List as a starting point
As the Olympic Movement governing body, becomes easier to go through all the doping
the IOC makes the Code mandatory for the issues nowadays, keeping in mind that this List is
entire Movement. During the Olympic Games, revised every year. Each individual has different
it oversees all doping control and testing pro- genetic endowments, and this is translated in a
cesses in compliance with the Code regula- more or less performance in sports [3]. Natural
tions. However, the IOC is striving to make all genetic advantages are, for example, the eight for
these processes independent. Since the sports like basketball, the predisposition for
Olympic Games Rio 2016, sanctioning has anaerobic explosive power like the deletion of
been handled by the Court of Arbitration for alpha-actinin 3 [4], and many others that wore
Sport [CAS] and its Anti-­Doping Division. born with the athlete. In the future, modifications
The creation of an independent testing agency of genetic expression will be the ultimate goal of
is also underway (https://www.olympic.org/ doping agents.
fight-against-doping).
WADA convenes an independent panel of
international experts to consider the composi- 32.3 Prohibited Substances
tion of the List on an annual basis. A substance and Methods
or method will be considered for the List if it
meets any two of the following three criteria: it 32.3.1 Prohibited Substances
has the potential to enhance sports performance; and Methods at All Times
it represents an actual or potential health risk to
the athlete; or it violates the spirit of sport 32.3.1.1 Non-approved
(Fig. 32.2). After the List is drafted for any year, Substances: SO
it is sent to stakeholders for comment and finally In this category fall all the substances that are
approved by the WADA Executive Committee. not in the world pharmacopeia and so can
A new List is approved each October for imple- include every new drug, coming from labs as a
mentation the following January to give athletes new molecule. Before as it was not referred in
32 Doping 441

the list, athletes claimed that “what is not in the 32.3.1.3 S  2 Peptide Hormones,
List is not banned.” Growth Factors, Related
Substances, and Mimetics
32.3.1.2 S1 Anabolic Agents Under this complicated title are listed the hor-
This includes anabolic-androgen steroids, endog- mones EPO, mimetics, and receptor agonists, the
enous and exogenous, and other anabolic agents. HIF [hypoxia-inducible factor], that have in com-
The ergogenic effects of androgen steroids have mon the same goal, to raise the level of hemoglo-
been brought to light before the Second World bin by stimulating erythropoiesis. High levels of
War [5] were referred as noxious and dangerous hemoglobin are useful in aerobic endurance
but used without restrictions in the times of the sports, and it has been proved that these levels
Cold War [6]. Only in 1990, all was explained in increase maximal exercise-induced oxygen
a scientific way [7] and some people were consumption.
convinced. The HIF stabilizers and related small mole-
The anabolic-androgen steroid abuse gives an cules interfere with molecular oxygen sensing
increase in muscle mass and circulating hemo- mechanisms to simulate hypoxia leading to a
globin and has other deleterious effects like the release of red blood precursor cells [8]. Adverse
depression of spermatogenesis and fertility, effects include cardiovascular complications due
gynecomastia, and hepatotoxicity, just to cite to high blood viscosity [thromboembolism,
some (Table 32.1). They are divided into endog- hypertension, stroke, and, in the extreme, sudden
enous and exogenous and the list you can find in death] and immune reactivity to the compounds
WADA shows almost all the more used. injected [9].
Different laboratory methods are used to iso- Here in S2, we can also find hormones like
late them in the urine, and today we have the chorionic gonadotropin [CG], luteinizing hor-
Steroidal Passport that will be treated later in this mone [LH], growth hormone [GH], and cortico-
chapter. The athletes consume androgens from trophins and their releasing factors. The CG
many sources, including veterinary, counterfeit hormone binds to LH receptors and stimulates
preparations; almost all are bought in illegal web- Leydig cells to secrete testosterone simulating
sites and labs. the endogenous secretion. Side effects include
There are other types of anabolic drugs, not edema and gynecomastia.
steroidal, that you can find in the same chapter GH has been linked to athletes in sports like
but in another division, like clenbuterol. These baseball, swimming, and cycling and is used out
drugs are used for asthma and have similar effects of the sport by high school students in the USA. It
to the anabolic steroid androgens. can cause insulin resistance, hyperglycemia, dia-
betes, and premature epiphyseal closure, for
example [10].
Growth factors and growth factor modulators,
Table 32.1  Effects of the misuse of anabolic steroids like IGF-1 and VEGF [vascular endothelial
Fluid retention growth factor], affect protein synthesis, and tis-
Acne sue regeneration has been used too [11].
Increased blood pressure and cholesterol levels
Headaches
Reduced sexual functioning
32.3.1.4 S3 Beta-2 Agonists
Increase in muscle size All the medicaments for asthma with action like
Swelling of feet and ankles beta-2 agonists are prohibited except salbutamol,
Insomnia salmeterol, and formoterol in the doses indicated
Rapid weight gain in the List [see the List for exact thresholds]. The
Increased appetite asthmatic athlete is always a concern for the phy-
Improved healing
sician and coach, and all the beta-2 agonists
442 M. J. Cascais

o­ utside the three cited here need authorization for

therapeutic use.

32.3.1.5 S  4 Hormone and Metabolic

Modulators
In this chapter are listed the hormone and meta-
bolic modulators used to treat diseases like pros-
tatic cancer and breast cancer but are used by
athletes to make a sustained rise in testosterone
and hide the use of exogenous testosterone and Fig. 32.3  Mildronate (meldonium)
other steroids.
Aromatase inhibitors block the “enzyme” aro-
matase which converts androgens [e.g., testoster- regulating the cellular energy metabolism
one] into estrogens by a process called through fatty acid β-oxidation and glycolysis in
aromatization. Consequently, aromatase inhibi- the myocardium, as carnitine is the key molecule
tors lower estrogen levels in the blood or in tumor in fatty acid metabolism in mitochondrial mem-
“tissues” by preventing the formation of estradiol brane. Under aerobic conditions, carnitine
[12]. Forbidden aromatase inhibitors are, but not improves myocardial functioning through
limited to, anastrozole and letrozole. enhancement of fatty acid β-oxidation that sup-
Selective estrogen receptor modulators plies about 80% of myocardial ATP generation.
[SERMs] are compounds that bind with estrogen However, under oxygen deficiency, cytotoxic
receptors and exhibit estrogen action in some tis- intermediates can accumulate in the cell due to an
sues and antiestrogen action in other tissues. insufficient oxygen supply. Under sport-­
Forbidden SERMs are, but not limited to, raloxi- physiological aspects, reports on positive effects
fene, tamoxifen, and toremifene. The abuse is on the physical working capacity of elite athletes
just based on the suppression of biomedical side were published. Moreover, mildronate shows
effects caused by an abuse of anabolic-­androgenic mood-improving effects, as well as an increased
steroids in males [13]. learning and memory performance, which are
Myostatin or growth differentiation factor 8 is properties athletes may also benefit from [15].
a “protein” of the skeletal muscle cells regulating
the size of muscles by blocking extensive growth. 32.3.1.6 S  5 Diuretics and Masking
Agents modifying the myostatin function, espe- Agents
cially inhibiting the myostatin gene, are growth-­ These substances are used to eliminate fluid from
regulating by apparently accelerating the the body and are used by athletes for two main
development of muscle stem cells. In this con- purposes: one, to keep weight in the limits
text, the agents are forbidden, but not limited to required, for example, in Judo, and the other, to
myostatin inhibitors [14]. In metabolic modula- mask the forbidden substances that they have
tors, the list has the hormone for diabetes like been taken. The physician should be aware of the
insulin, but it includes the famous meldonium diseases, which require a diuretic because it will
that gave rise to the media case with Sharapova be necessary a TUE [Therapeutic Use
and other athletes in 2016. Exemption].
Mildronate [3-[2,2,2-trimethylhydrazinium]
propionate] (Fig. 32.3) was originally developed
in the late 1970s as a growth-promoting agent for 32.4 Prohibited Methods
animals in the Latvian Institute of Organic
Synthesis. Most of Mildronate’s clinical benefits These methods include manipulation of blood
are mediated through its modulation of the carni- and blood components, chemical and physical
tine metabolism, which is the essential factor in manipulation, and gene doping. Here are referred
32 Doping 443

the blood transfusions autologous or heterolo- The nonspecified substances include the medi-
gous, and it is set the limit of endovenous replace- caments used for ADHA [attention deficit hyper-
ment outside hospital treatment, surgical activity disorder] that had explosive growth in the
procedures, or clinical diagnostic investigations, last 5 years. Therefore they require a TUE and
in 2018 no more than 100 mL in 12-h periods. other stimulants that have been abused, for
Gene Doping improving mood and arousal and masking
“the non-therapeutic use of cells, genes, genetic fatigue.
elements, or of the modulation of gene expression,
having the capacity to enhance athletic perfor-
mance” [16]. This kind of doping is obviously a 32.5.2 S7 Narcotics
product that has to be granted to the athlete by
medical professionals.
These drugs are forbidden not because of the
There are four endurance genes that can match enhancement in performance, but because being
the needs of endurance sports: (1) erythropoietin pain killers, they would allow athletes to compete
[EPO] stimulating erythropoiesis, (2) peroxi- without an important mechanism of defense and
some proliferator-activated receptor [PPAR] survival—the pain.
encoding enzymes of fatty acid oxidation, (3) By their structure, they cause addiction and
hypoxia-inducible factors [HIF], and (4) mood alterations, and they are opioid-related
angiotensin-­converting enzyme [ACE] being a molecules.
vasoconstrictor or vasodilator.
Some muscle genes are listed too like the
myostatin, as negative muscle regulator; mech- 32.5.3 S8 Cannabinoids
ano growth factor [MGF], insulin-like growth
factor-1 [IGF-1], and insulin-like growth factor-­ They are a group of substances present in the
binding protein [IGFBP] for the control of mus- plant Cannabis sativa; THC [tetrahydrocannabi-
cle growth; and growth hormone [GH] for the nol] is the main psychoactive component and
control of muscle mass. binds to cannabinoid receptors in the brain. They
cause euphoria, relaxation, and visual and audi-
tory amplified perceptions. This THC is a social
32.5 Substances and Methods drug and should be treated like that because it has
Prohibited in Competition no improvement in performance in most of the
sports.
Additionally, to all these groups, in competition,
the following substances are prohibited.
32.5.4 S9 Glucocorticoids

32.5.1 S6 Stimulants Glucocorticoids are used to treat the inflamma-

tion process. The inflammatory process in the
In this group of drugs, there are differences body has evolved for a useful purpose, namely, as
between specified and nonspecified substances. a defensive reaction to the damage or injury of
The denomination concerns the stimulants the tissues. Inflammation is designed to isolate
that can be found in many medications for the cause of the irritation, to eradicate the pre-
upper respiratory pathologies and cough syr- sumed invader, and to repair the surrounding
ups, and so the athlete could have taken them damaged tissues, so using them in the sport with-
without the intention of doping, e.g., ephedrine out medical indication can lead to serious dam-
and methylephedrine, which are positive when age. They are prohibited in oral, intravenous,
their concentration in urine is greater than intramuscular, or rectal administration. All the
10 μg per mL. other forms of administration are allowed.
444 M. J. Cascais

They stand for a large percentage of TUEs in all forthcoming season, they would not be surprised.
countries and sports, but they are used by inhala- All the changes from the anterior list are in a spe-
tion by many asthmatic or allergic athletes which cial chapter too.
do not need authorization.

32.7 Biological Passport

32.6 Substances Prohibited
in Particular Sports The new substances available for doping that
mimic physiologic molecules produced by the
This section has only one group of substances: body itself make detection very difficult. In order
the beta-blockers. Norepinephrine is the major to keep sport clean, and to ensure the protection
neurotransmitter of the sympathetic nervous sys- of the athlete’s health, the WADA has developed
tem, and it is released into the periphery upon with the collaboration of medical specialists the
activation of the sympathetic nervous system. program of ABP [Athlete Biological Passport]
Beta-blockers are drugs that bind to beta-­ (Fig.  32.4), which uses several physiologic
adrenoceptors and thereby block the binding of results, that together in a computerized program
norepinephrine and epinephrine to these recep- [17] can produce a display of graphics and calcu-
tors. That is, beta-blockers avoid the activation of late the odds of a positive result, with a percent-
these receptors, and in consequence catechol- age of 99% of suspicion.
amines cannot carry out their function, and anxi- The action after this result can be taking other
ety is reduced. samples or calling the athlete because he can
In archery and shooting, they are prohibited in have a specific clinical situation that explains the
and out of the competition. In automobile, golf, results. Making it simpler, there are three mod-
billiards, darts, skiing/snowboard, and some ules of ABP: the Hematological, Steroidal, and
underwater sports, they are prohibited only in subsidiary to this module the Endocrinological
competition. Every year the agency releases passport [18]. The Hematological profile is aimed
another chapter that concerns the substances that to detect any form of blood doping or rEpo [19].
are not forbidden yet but are being monitored in The Steroidal module aims to detect direct and
the anti-doping labs. indirect forms of doping with anabolic agents
That group of substances could be part of the [20]. The endocrinological module doping is
List next year or not. Anyway, sports medicine used to detect growth hormone factors and insu-
doctors should be aware of this chapter, so in the lin growth factors [21].

Fig. 32.4  Some aspects of the biological passport

32 Doping 445

In the definition of WADA: “The fundamental to educate the young children in an early stage of
principle of the Athlete Biological Passport the competition, because when they arrive at a big
[ABP] is to monitor selected biological variables association, club, or federation it is already too
over time that indirectly reveal the effects of dop- late sometimes. An effort should be made by all
ing rather than attempting to detect the doping governments and each individual that deal with
substance or method itself.” sport, at all levels making prevention of misbe-
Finally, all the athletes have their data and spe- havior a very important goal to achieve.
cial ID and number in a global system of registra-
tion and identification: the ADAMS, anti-doping Take-Home Messages
administration, and management system, web-­ • Consult the list every year at January, because
based data management system developed and there are changes to be implemented and you
administered by the World Anti-Doping Agency should be acquainted with them.
[“WADA”] in its role as a central clearinghouse • Check every medication of your athletes, even
for anti-doping information. if it seems simple and comes from a respected
clinician—you are the sports medicine doctor,
it is your call.
32.8 T
 UE [Therapeutic Use • Prevention and education are the best methods
Exemptions] to achieve a sport without doping.
• Anti-doping became a specialized process
When an athlete needs to be treated for the acute that moves thousands of people all around
or chronic disease, he has the right to the treat- the world, doctors, lawyers, economists, ath-
ment, no matter if it is a prohibited substance letes, etc.
because health care comes first. Nevertheless, if
it is a lifesaving issue or has to be medicated in a
hospital or any kind of ER, the application form
that exists in WADA must be sent to de ADO of
References
the athlete, and it will be authorized retroactively. 1. Pausanias. Descriptions of Greece, a second century
If it is a condition that is part of the athlete’s life, A.D. (Translated by W.H.S. Jones). Cambridge: Loeb
like insulin for diabetes type 1, it will be sent a Classical Library; 1959.
request to the ADO, together with a small clinical 2. Voy R. Drugs, sport, and politics. Champaign: Leisure
Press; 1991 (OR by the tribes of actual Norway).
history and complimentary exams. 3. Eynon N, et al. Genes and elite athletes: a roadmap for
In any other cases, there must be submitted an future research. J Physiol. 2011;589:3063–70.
application form with all the information about 4. Berman Y, North KN. A gene for speed: the emerg-
the disease, the athlete and the physician contact, ing role of alpha-actinin-3  in muscle metabolism.
Physiology (Bethesda). 2010;25:250–9.
that will go directly to the TUE Committee 5. David K, Dingemanse E, Freud J, Laqueur
[TUEC] of each ADO. This TUEC will decide to E.  Uber krystallinisches mannliches Hormon aus
authorize or not or to ask more details to the doc- Hoden,[Testosteron], wirksamer als aus Harn oder
tor. This procedure must be completed in 21 days, aus Cholestrin bereitetes Androsteron. Hoppe Seylers
Zeischrift Physiologische Chemie. 1935;233:281–2.
but as a rule, it only takes 3–5 days. 6. Wade N.  Anabolic steroids: doctors denounce
them, but athletes aren’t listening. Science.
1972;176:1399–403.
32.9 Conclusion 7. Bhasin S, et al. The effects of supraphysiologic doses
of testosterone on muscle size and strength in normal
men. N Engl J Med. 1996;335:1–7.
All that text is based in experience and documents 8. Beuck S, Schanzer W, Thevis M.  Hypoxia-
available for every doctor. However, we must inducible factor stabilizers and other small-mole-
keep in mind that the best politics to avoid this cule erythropoiesis-­ stimulating agents in current
and preventive doping analysis. Drug Test Anal.
“disease” [doping] is prevention. In this matter, all 2012;4:830–45.
the society has a responsibility, and all that ­contact 9. Bennett CL, et  al. Venous thromboembolism and
directly or indirectly must give their ­contribution mortality associated with recombinant erythropoietin
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and darbepoetin administration for the treatment of effect. In: 5th Baltic sport science conference: cur-
cancer-associated anemia. JAMA. 2008;299:914–24. rent issues and new ideas in sports science, Kaunas,
10. Thieme D, Hemmersbach P, editors. Doping in
Lithuania, 18–19 April 2012. Lithuania: Lithuanian
sports. In: Handbook of experimental pharmacol- Academy of Physical Education; 2012. p. 59.
ogy, Vol. 195. Berlin: Springer; 2010. https://doi. 16. Pray L. Sports, gene doping, and WADA. Nature

org/10.1007/978-3-540-79088-4_8. Education. 2008;1(1):77.
11. Guha N, et  al. Biochemical markers of recombinant 17. Taroni F, Aitken C, Garbolino P, Biedermann

human insulin-like growth factor-I [rhIGF-I]/rhIGF A.  Bayesian networks and probabilistic inference in
binding protein-3 [rhIGFBP-3] misuse in athletes. forensic science. Chichester: Wiley; 2006. 372p.
Drug Test Anal. 2013;5:843–9. 18. WADA. Athlete Biological Passport operating guide-
12. Selective estrogen-receptor modulators  — mecha-
lines and compilation of required elements. Montreal:
nisms of action and application to clinical practice. N WADA; 2009.
Engl J Med. 2003;348(7):618–29. 19. Sottas PE, Robinson N, Saugy M. The athlete’s bio-
13.
Handelsman DJ.  Indirect androgen doping by logical passport and indirect markers of blood doping.
oestrogen blockade in sports. Br J Pharmacol. Handb Exp Pharmacol. 2010;195:305–26.
2008;154:598–605.. [PMC free article] 20. Sottas PE, Saugy M, Saudan C.  Endogenous ste-

14.
Yamada AK, Verlengia R, Bueno Junior roid profiling in the Athlete Biological Passport.
CR.  Myostatin: genetic variants, therapy andgene Endocrinol Metab Clin North Am. 2010;39:59–73.
doping. Braz J Pharm Sci. 2012;48(3):369–77. 21. Holt RI, Sönksen PH.  Growth hormone, IGF-I and
15. Dzintare M, Kalvins I. Mildronate increases aerobic insulin and their abuse in sport. Br J Pharmacol.
capabilities of athletes through carnitine-lowering 2008;154:542–56.
 Dermatological Injuries
33
Margarida Gonçalo and Luis Santiago

33.1 Introduction Some manifestations are common to all sports,

but some are very particular to some modalities
Sports practice can be good to your body but is (like jogger’s nipples, basketball pebble fingers,
not completely safe to your skin. As the body’s the ball site sign in table tennis [2], herpes or
first line of defence to exogenous aggressors, the tinea gladiatorum in wrestlers [3]) or acquire par-
skin can suffer acute or chronic traumatic lesions ticular aspects dependent on the sports activity
and be more prone to cutaneous infections and (different types of callosities, chilblains and other
allergic contact dermatitis due to sports equip- cold-induced skin disorders in sports on ice or
ment, and, on long term, outdoor sports activities cold water, watersports hands or aquagenic syrin-
with high sun exposure are associated with an geal acrokeratoderma [4]). Topical or systemic
increased risk of skin cancer. Although not life-­ medication used by the patient, eventually to treat
threatening, these cutaneous lesions may have a sports injuries, may also cause allergic contact or
significant impact on athletic performance, may photoallergic contact dermatitis. Moreover some
need several hours/days away from training for chronic skin diseases, e.g. atopic dermatitis or
recovery [1] and, therefore, need particular atten- psoriasis, may interfere with sports, and a special
tion by the sports medicine physician or the attention should be given to these athletes to
dermatologist. allow them enjoy the sports and achieve the best
Some cutaneous lesions are acute, often self-­ performances, but this is outside the scope of this
limiting, and the diagnosis is obvious, like in fric- chapter.
tional bullae or callosities. Others occur after
some time in practice, like allergic contact der-
matitis. Then the relation with sports may be less 33.2 Acute and Chronic Traumatic
obvious, and additional tests may be necessary to Lesions
confirm the diagnosis.
33.2.1 Skin Blisters
M. Gonçalo (*)
Clinic of Dermatology, University Hospital Repeated friction or mechanical tension can
and Faculty of Medicine, University of Coimbra, cause painful dermo-epidermal blistering partic-
Coimbra, Portugal
e-mail: [email protected] ularly when the equipment is not very well fitted
to the athlete’s body, when there is excessive
L. Santiago
Clinic of Dermatology, University Hospital, moisture or previous skin fragility (e.g. epider-
Coimbra, Portugal molysis bullosa simplex) or when the skin is not

© ISAKOS 2019 447

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_33
448 M. Gonçalo and L. Santiago

yet trained to stand this tension, namely, in young friction with the cement in the bottom or border
athletes beginning their training [5]. These serous of the swimming pool usually at the beginning of
or haemorrhagic blisters, which usually have a the swimming season [7]. “Basketball pebble fin-
competent rooftop, should be drained on the gers” present as purpura, erosions and fissures on
more dependent area by a small sterile puncture the fingertips due to rotation and contact with the
to reduce tension and pain. The blister roof pebbled surface of the basketball [8]. “Canyoning
should be kept on site, as it is the best biological hands” are characterized by fissuring and abra-
dressing that reduces pain and allows quick and sion of the fingertips and hands due to exposure
complete healing. If rupture occurs and the lesion to cold water and contact with rocks during
is painful due to dermal exposure, a simple dress- descent of the rapids [9].
ing with sterile greasy gauze or hydrocolloid Chronic repeated friction on the same area
dressing left in place for a few days will control may be responsible for friction dermatitis [10],
pain, prevent secondary infection and allow quick callosities and corns, knuckle pads or sports
resolution. Friction blisters can be prevented by ­nodules [5].
good skin hydration (applying a good emollient Friction dermatitis can present as erythem-
before sports activities), reducing skin moisture atous papules or plaques with hyperkeratosis
(use of antiperspirants or adequate clothing) and and scaling or lichenification in an area of
best adaptation of the equipment to the body, chronic friction. It has been described in sumo
especially over bony prominences or where fric- wrestlers localized to the knee/leg or the
tion is higher. knuckles [10]; in baseball pitchers in the ankle
and knee, known as “baseball pitcher’s fric-
tion dermatitis”; and in rower’s gluteal area,
33.2.2 Friction Dermatitis: Callosities known as “rower’s rump”, which is due to fric-
and Corns tion in an unpadded seat or the metal training
machines [8, 11].
Acute exposure to friction without previous skin Callosities represent an area of thickened skin,
hardening or in more fragile areas can cause ery- particularly dependent on the stratum corneum,
thema, minor erosions and fissures with pain. formed as an asymptomatic protective reaction
“Jogger’s nipples” occur after long runs or jog- pattern to chronic and repetitive friction. They
ging that present as painful erythema with fis- occur more commonly over the bony promi-
sures, erosions and crusts on the nipples due to nences of the feet, toes and hands or in weight-­
friction of the shirt [6]. “Pool toes” occur due to bearing areas (Fig. 33.1a).

a b

Fig. 33.1  Traumatic lesions due to chronic friction. Callosities in weight-bearing areas of the feet (a) and knuckle pads
in a boxer (b)
33  Dermatological Injuries 449

“Pump bumps” are particularly frequent Repeated friction, for instance, by the use of
among ice skaters who use badly fitting skates helmets, may cause mechanical acne localized to
[12]. the area of contact. Acne in sports has also been
Corns can be clinically similar to callosities, associated with the high consumption of anabolic
but they are painful and can become inflamma- steroids, but more recently the use of milk-­
tory, and they are associated with a small, derived products and whey protein, particularly
1–2 mm translucent central core within the base in body building sports, has been associated with
of the lesion, which is easily observed after curet- more severe acne [13].
tage of the superficial keratosis. These corns need
to be distinguished from plantar warts (no pin-
point black dots and persistence of dermato- 33.2.3 Cutaneous Haemorrhage
glyphics), and treatment is required as they may
limit sports activities. Warm soaking baths, curet- Abrupt tension or strong contact with the work-
tage and keratolytics (urea, salicylic acid, reti- ing surface or the equipment can cause superfi-
noids) or more aggressive measures may be cial dermal haemorrhage, but red blood cells may
needed along with protection from friction. further progress to the epidermis where they will
Due to friction and pressure, some athletes persist until full epidermal renewal. Petechiae or
also develop benign, asymptomatic, well-­ a black macule on the plantar or posterolateral
circumscribed, smooth, firm, skin-colour pap- aspect of the heel, also known as “black heel” or
ules, nodules or plaques over the dorsal aspect of “talon noir”, is seen mostly in young athletic
the proximal interphalangeal joints of the fingers individuals who practice sports associated with
or the dorsal aspects of the foot over joints, quick starts and stops, particularly in harder sur-
known as “knuckle pads” or sports-associated faces, such as tennis, squash, football, ice skaters
pads (Fig.  33.1b). They can be related to shoes or gymnastics [14]. Similar lesions occur less fre-
but seem to be more frequent in the fingers, quently in the palms, particularly in the thenar
namely, in boxers [5]. Similar nodular lesions on eminence, namely, in weightlifters, gymnasts,
chronic frictional areas—athlete’s nodules— golfers, tennis players, skiers and mountain
commonly observed in similar locations in surf- climbers, as these athletes apply pressure to their
ers, boxers, skaters and football and hockey hands (Fig.  33.2a) [5]. Although asymptomatic,
players, are also associated with epidermal thick- these lesions may last for more than a month,
ening, but increased dermal collagen bundles or especially in the feet and palms where the epider-
granulomatous reactions from exogenous mate- mis and stratum corneum are thicker, and they
rial can co-exist [5]. may be confused with pigmented lesions.

a b

Fig. 33.2  Cutaneous haemorrhage on the thenar region of a tennis player (a), with the typical dermatoscopic aspect,
showing blood within the stratum corneum (b)
450 M. Gonçalo and L. Santiago

Dermatoscopy allows a correct distinction In sports that involve high velocity balls, the
between skin haemorrhage and melanoma or unexpected impact of the ball on the skin—a
other pigmented lesion due to the “red-wine” paintball, a ping pong ball, a racquetball or a
colour of the blood and absence of the pigmented squash ball—may result either in erythema or
network (Fig. 33.2b) [15]. Moreover, skin curet- petechial purpura or both. Lesions typically
tage removes the pigmented stratum corneum, appear as a round or mostly as an annular ring of
immediately confirms the diagnosis and resolves erythema or petechiae with or without accompa-
the “black heel”. nying ecchymosis and a clear centre, forming a
When similar tension affects the toenails, par- targetoid lesion, known as the “ball site sign” or
ticularly the hallux, subungueal and periungueal ball sports-induced targetoid erythema [2].
haematoma can occur. It is frequently associated After a marathon, especially in hot tempera-
with badly fitting shoes during long walks, tures, oedema of the lower limbs and feet can
namely, in marathon runners, or in sports associ- occur and be associated with petechial or more
ated with quick starts and stops [16]. An acute palpable purpura due to venous insufficiency and
traumatic subungueal hematoma can be painful inflammatory capillaritis [16].
due to high tension under the nail plate. Immediate
drainage by a small hole in the nail plate, per-
formed, for instance, with a 2-mm biopsy punch 33.2.4 Onychocryptosis, Retronychia
before the hematoma gets organized, is advised. and Distrophic Toenails
A smaller subungueal haematoma or chronic and
repetitive haemorrhage into the nail apparatus Trauma, ill-fitting footwear, incorrect toenail
with incorporation of the blood in the nail plate trimming and malalignment of the toenail are
can be asymptomatic and go unnoticed concurrent factors for ingrown toenails (ony-
(Fig.  33.3), but the dark colour that persists for chocryptosis), a painful disorder that may have a
months may be mistaken for subungueal mela- negative impact on athlete’s performance. As the
noma. Dermatoscopy with the red/violet colour nail plate penetrates the dermis on the lateral
of the blood within the nail plate or nail bed may nailfold, there is inflammation, often associated
allow a correct distinction. Distal progression of with bacterial infection and purulent discharge,
the coloured lesion accompanying nail growth, granulation tissue and persistent oedema of the
which is nevertheless slow (>6 months in the hal- lateral nailfolds, which further predisposes to
lux), also supports the diagnosis, but in case of onychocryptosis (Fig.  33.4a). It affects mostly
doubt, a skin biopsy can establish the correct the inner lateral nailfold but can affect both nail-
diagnosis. folds and both toes. If onychocryptosis does not
resolve with simple measures like antiseptics,
topical antibiotics and corticosteroids and cor-
rect nail trimming (strait cutting of the distal nail
border), partial chemical or surgical matricec-
tomy to reduce the width of the nail plate is
advised.
Following trauma, mainly in runners or ballet
dancers, painful retronychia can occur espe-
cially in the great toe (Fig. 33.4b). This situation
that is often under-diagnosed consists on embed-
ding of the nail plate into the proximal nailfold
with separation from the nail matrix, followed
by inflammation and pain of the proximal nail-
Fig. 33.3  Chronic subungueal haemorrhage at the mid-
dle portion of the nail, as it progressed distally with nail fold and the formation of a new nail plate under
growth the detached one. The “old” nail plate will stop
33  Dermatological Injuries 451

a b

Fig. 33.4  Nail disorders in athletes. Ingrown toenails mation and haemorrhage on the proximal nailfold in a
(onychocryptosis) with inflammation and granulation tis- ballet dancer (b)
sue on the lateral nailfold (a) and retronychia, with inflam-

or reduce growing and detaches from the nail long-distance runners, bilateral and multiple
bed, and a new nail plate will form under it often wrist and palmar papules can also be observed in
in association with granulation tissue. Surgical sports where constant pressure around the hand
nail ­avulsion confirms the diagnosis and is may cause subdermal fat herniation, such as box-
­therapeutic [17]. ing or gymnastics [5].
Iterative trauma on the nail plate may favour
distal and/or lateral onycholysis (detachment of
the nail plate from the nail bed, with loss of trans- 33.3 Environment-Induced
parency of the nail plate). It also predisposes to Cutaneous Lesions
nail dystrophy, with hyperkeratosis, discoloura-
tion and thickening of the nail plate, which fur- Practising winter sports with inadequate protec-
ther disturbs shoe fitting, causes pain and tion or in very extreme conditions (high-­mountain
predisposes to onychomycosis. trekking, ice skaters) or watersports in cold water
may induce cold-related dermatoses, like frost-
bite, chilblains (perniosis), Raynaud phenome-
33.2.5 Piezogenic Papules non, Livedo reticularis, cold-induced urticaria or
cold panniculitis. Chilblains or frostbite affect
Piezogenic papules are multiple small subdermal mainly fingers and toes, but ears and nose can
fat herniations observed in weight-bearing areas, also suffer from cold-induced inflammation.
such as the lateral, posterior or medical surface of Chilblains and cold-induced panniculitis have
the heel. They present as small (1–5 mm), skin- also been described in external surface of the
or yellow-coloured papules that are usually pain- arms and thighs in equestrian athletes in France
less and are most noticeable after standing and [20]. Apart from adequate protection against the
prolonged exercise or when pressure is applied to cold and wet, smoking should be discouraged,
the affected area [18, 19]. Apart from the more and calcium channel blockers can be used in
frequent pedal piezogenic papules often found in more severe cases [21].
452 M. Gonçalo and L. Santiago

Heat exposure occurs mostly from hot treat- plaques, elicited after submersion in water.
ments for sports lesions and can induce acute Symptoms include a burning pain and a tighten-
burns. Erythema ab igne with the typical ing sensation in the palms, as well as hyperhidro-
­reticulate erythematous and telangiectatic or pig- sis, but symptoms resolve upon skin drying. It
mented pattern occurs in areas of chronic contact occurs mainly in females and patients with cystic
with hot compresses or other sources of heat. fibrosis, but anyone can be affected [4].
Exercising under high temperature with heavy Practising outdoor sports in areas of high
sweating can induce miliaria rubra, presenting ultraviolet (UV) radiation (beaches, sea, moun-
with asymptomatic tiny red superficial vesicles tains, snow) during long sun exposure with no
that correspond to sweat accumulation within the protection can induce an acute sunburn, with
eccrine ducts and the epidermis. Moreover, exer- well-demarcated painful erythema, eventually
cising in a hot environment may enhance cholin- with bullae. A sunburn-like reaction—phototox-
ergic urticaria, a transient but highly pruritic icity—can occur in athletes with lower photo-
reaction that impairs physical activity for a few types and with vitiligo or those exposed to plants
minutes to more than half an hour and is not often containing phototoxic chemicals (fig trees, Ruta
completely prevented by the use of oral H1-anti-­ graveolens) during outdoor activities or under
histamines (Fig. 33.5). treatment with topical or systemic phototoxic
Exposure to water in susceptible individuals drugs (tetracyclines, quinolones, amiodarone,
can induce “watersports hands” or aquagenic phenothiazines, psoralens) [22]. Moreover, ath-
syringeal acrokeratoderma. This condition affects letes can become sensitized and develop eczema-
the palms and soles and is characterized by tous lesions as a manifestation of systemic
hyperkeratotic hypopigmented papules and photoallergy from drugs with known photosensi-
tizing potential (piroxicam, fenofibrate, fluoro-
quinolones, thiazides) or photoallergic contact
dermatitis, mostly from non-steroidal anti-­
inflammatory drugs (NSAID) used to treat skel-
etal/muscle pain (ketoprofen, piketoprofen,
etofenamate), H1-anti-histamines to treat reac-
tions to mosquito bites (promethazine) or even
from UV filters used for their photoprotection
(oxybenzone, octocrylene, butyl methoxydiben-
zoylmethane, cinnamates) [23, 24].
Athletes performing regular outdoor activities
under high sun exposure (cycling, marathon run-
ning, tennis, sailing) who are chronically exposed
to UV light have an increased risk of skin cancer,
mostly squamous cell carcinoma but also basal
cell carcinoma and melanoma, the latter associ-
ated with a poor prognosis. Athletes, particularly
from older age groups, repeatedly show little
knowledge on the increased skin cancer risk and,
consequently, use inadequate or incomplete sun-­
protective measures [25, 26]. Organizers of com-
petitions in many outdoor sports also demonstrate
unawareness of this risk, even in more advanced
Fig. 33.5  Cholinergic urticaria with highly pruritic con- countries, as they keep performing these activi-
fluent erythema on the trunk with many small urticarial ties at hours with high UV index, like cycling
papular lesions that develops after increased body tem- tours that usually oblige athletes to cycle at the
perature during physical training and resolves in less than
30 min
most harmful hours. Apart from avoiding the
33  Dermatological Injuries 453

hours of the day with higher UV light (11–16 h) S. aureus infections can sometimes be compli-
and favouring shaded zones, athletes should cated with furunculosis or carbuncles (agglomera-
choose adequate clothing and apply regularly tion of furuncules), which can be painful and leave
waterproof sunscreens composed mainly of pho- cutaneous depressed scars even if treated correctly
tostable filters. A single application of a sun- or progresses to cutaneous abscesses. These bacte-
screen, particularly in watersports or in situations rial infections, particularly if caused by methicil-
with heavy sweating, is certainly inadequate as lin-resistant S. aureus (MRSA), can be transferred
some of the creams will be removed with water/ to other athletes who may develop active lesions or
sweating and many filters lose their effective UV become asymptomatic MSRA carriers, harbouring
protection after some time of irradiation. the bacteria in their nares [11].
Impetigo, with weeping erosions and honey-­
coloured crusts, can also be transferred among
33.4 Skin Infections athletes in sports activities with direct skin-to-­
skin contact (wrestling, judo). Apart from local
Cutaneous infections occur in several sports antiseptics and topical antibiotics, oral antibiotics
activities, by transfer of the pathogen between as well as eradication of S. aureus from the nares
athletes by direct contact (wrestling, judo) and by with local mupirocin may be necessary. Use of
fomites (sharing equipment or facilities) or soaps with antibacterial agents, skin hydration
because the activities modify the skin environ- and breathable clothing are among preventive
ment, disturb the protective skin barrier and/or measures that can be used in recurring lesions.
change the skin microbiome favouring cutaneous Prolonged footwear occlusion in athletes with
infections (sweating, occlusion, friction, erosions hyperhidrosis can facilitate plantar skin infection
and blisters). Some bacterial, viral and particu- by Kytococcus sedentarius, formerly known as
larly cutaneous fungal infections have been Micrococcus sedentarius. This bacteria degrades
reported more frequently in athletes [1]. keratin of the thicker stratum corneum on the
Staphylococcus aureus causes infection of the weight-bearing areas of the feet causing small
hair follicles, folliculitis that occur mostly in areas whitish crater-like depressions that may coalesce
of terminal body hair, of higher sweating and forming annular lesions—pitted keratolysis or
occlusion by equipment or clothing (thighs and keratolysis plantare sulcatum (Fig. 33.6a, b). It is
buttocks in cyclists), or in athletes who perform asymptomatic but causes significant malodour.
regular shaving, therefore facilitating the penetra- Treatment includes reduction of hyperhidrosis
tion of the S. aureus into the hair follicle. Follicular (aluminium salts), topical antibacterials (benzoyl

a b

Fig. 33.6  Pitted keratolysis or keratolysis plantare sulcatum (a, b)

454 M. Gonçalo and L. Santiago

a b c

Fig. 33.7  Dermatophyte infections with lesions with an lux with the yellowish colour of the nail plate progressing
active border in the dorsum of the feet (tinea pedis) (a) from the distal to the proximal nail plate (c) and white
and groin (tinea cruris) (b) and onychomycosis of the hal- superficial onychomycosis of several toenails (d)

peroxide, erythromycin or clindamycin) and ker- s­tudies confirming inter-athlete contagious-

atolytics (urea or topical retinoids). ness, as the same fungus affects the athletes of
Superficial dermatophyte infections, namely, the same team [1, 27].
tinea pedis and tinea cruris (Fig. 33.7a, b) caused Herpes simplex virus (HSV) can cause herpes
mostly by Trichophyton rubrum and T. mentagro- gladiatorum, which develops 3–7 days after con-
phytes, are more frequent in athletes who share tact with an active lesion in another athlete.
equipment or facilities with no protection (swim- Grouped vesicles with a tendency to central
ming pools or showers with no slippers). Tinea umbilication occur on an erythematous base and
pedis presents with different aspects: interdigital progress to pustules, erosions and crusts before
tinea with maceration, erythema, scaling and fis- clearing within 10–14 days.
sures, mostly on the fourth webspace; the vesicu- HPV (human papilloma virus) can cause cuta-
lar type with pruritic erythema and vesicles in the neous lesions transmissible among athletes, par-
fingers and soles, which mimics dyshidrotic ticularly plantar warts. These lesions present as
eczema (pompholyx); and moccasin-type tinea, firm skin-coloured keratotic papules, often with a
with slight erythema and scaling in the plantar clear rim separating them from normal skin and
and lateral skin of the feet—all of them occasion- black dots that correspond to dermal vessel
ally with a typical active border on the dorsum of thrombosis within the hyperkeratotic verrucae.
the feet (Fig. 33.7a) [11]. Occlusion and sweating They may be asymptomatic, but when localized
of the feet facilitate tinea pedis and also toenail in weight-bearing areas of the body, they cause
onychomycosis (Fig. 33.7c), a situation that can pain when walking or practising sports activities.
cause severe nail dystrophy and need prolonged Treatment with curettage and topical application
oral treatment, except in the rare variant of white of salicylic acid or 5-fluorouracile under occlu-
superficial onychomycosis (Fig. 33.7d). sion or cryotherapy can resolve most situations.
Tinea gladiatorum, usually with an active Molluscum contagiosum, another viral skin
papular and squamous or vesicular border and infection, is frequently observed in atopic young
central lesional clearing, occurs in exposed swimmers as dome-shaped skin-coloured, pink
skin areas due to infection by direct contact or whitish 1–5 mm asymptomatic papules. They
among athletes. Epidemics of tinea gladiato- are more frequent in areas of atopic eczema and
rum have been described in several teams of can also aggravate eczema around them.
judo, wrestling and sumo wrestling, with Curettage or application of a caustic liquid on the
33  Dermatological Injuries 455

top of each lesion may resolve, but recurrence is piece that causes the reaction. The main allergens
frequent. are chromium from natural leather, rubber chem-
icals (thiuram, carbamates, mercapto and thio-
urea derivatives, para-phenylenediamine (PPD)
33.5 Allergic Contact Dermatitis and other para-amino compounds) or glues
(p-tertiary butyl phenol-formaldehyde resin)
Repeated contact with sports equipment (cloth- [9, 11, 29].
ing or devices) usually in association with heat Thiourea derivatives in rubber are the main
and sweating may enhance liberation of allergens allergens in neoprene-derived swimming and
from the equipment to the athlete’s skin and diving suits and other protective equipment,
induce sensitization and, on further exposure, namely, in swim goggles (Fig. 33.8). PPD deriva-
allergic contact dermatitis (ACD). tives from black rubber have been reported as a
Immediate reactions with urticaria or angio- cause of ACD in hand grips in cycling [30] and
edema have been described, mostly related with swim fins [31]. In these settings ACD can occa-
latex-derived equipment (rubber suits, elastic sionally be followed by long-lasting leukoderma,
bandages) [28], but most cases of ACD are due to simulating vitiligo [32].
T-cell-mediated reactions to small chemicals Recently a new allergen—acetophenone
(nickel, rubber chemicals, resins, fragrances, pre- azine—has been identified in shin guards causing
servatives, etc.). ACD does not occur on first ACD in the anterior shins mainly of young foot-
exposure, as previous sensitization to the chemi- ball players (Fig. 33.9b) [33]. In occasional situ-
cal is necessary to generate enough specific T ations these athletes have experienced also
cells that recognize the chemical. In sensitized footwear and widespread dermatitis and leuko-
individuals, it takes several hours or days after derma [34].
contact with the culprit until lesions become clin- Colophony, previously used in the powder/
ically visible. The allergen has to penetrate the chalk for improving the grip in the gymnasium,
skin to be presented by skin epidermal and der- was a cause of hand dermatitis and airborne
mal dendritic cells to the specific T cells that will
migrate to the skin and cause dermal and epider-
mal inflammation.
ACD presents as an acute or subacute eczema-
tous reaction, with pruritic erythema and vesicles
or desquamation or with chronic eczema and
lichenification in cases of repeated exposure. It is
localized in the area of skin contact with the cul-
prit and can even have the form of the contacting
object. Acute lesions may resolve within days
after eviction of the causative allergen, but topi-
cal or systemic steroids are frequently necessary
to clear the reaction. ACD can significantly
impair sports performance; therefore, it is impor-
tant to determine the causative allergen and
explain how to avoid it, which is the only curative
treatment for ACD.
Footwear can be a frequent cause of ACD pre-
senting with lesions that localize mostly on the
soles or the dorsum of the feet and spare inter-
Fig. 33.8  Dermatitis with erythema and inflammation in
digital spaces (Fig. 33.6a) but can have particular the areas of contact with the rubber part of the swim
distribution depending on the special footwear goggles
456 M. Gonçalo and L. Santiago

a b

Fig. 33.9  Allergic contact dermatitis from tennis shoes, football player localized in the shins and with the format
with chronic eczema involving the dorsum of the feet but of the shin guards responsible for the lesions (b)
sparing the digital webspaces (a) and eczema in a young

eczema in gymnastics. Epoxy resin, used in the ments of the equipment or products to which the
manufacture of tennis rackets and as a varnish athlete has been exposed [29], as new allergens
protection in a billiard cue, was occasionally may be involved, as recently shown in the case of
reported as a cause of hand ACD [35]. Nickel, a shin guard dermatitis [33].
very frequent allergen in most populations, was
recently found in many tools in the gym, and dur-
ing 1-h training, it was shown that nickel can 33.6 Conclusion
accumulate in the skin in amounts able to induce
hand eczema [36]. Nickel and other metals have Acute dermatological injuries and sports-related
been reported as a cause of ACD particularly in cutaneous diseases need to be prevented, prop-
weightlifters, with lesions localized also on the erly recognized and treated in order to prevent
shoulders, arms and neck [11]. impairing athlete’s performance. Often a clinical
Topical drugs, namely, NSAIDs, antibiotics and dermatological observation is enough for the cor-
antiseptics used to treat skin or muscle-­skeletal rect diagnosis, but additional studies, like patch
injuries or skin care products used during sports testing, may be necessary to establish a correct
activities, can also cause ACD by direct application diagnosis and therapy.
on the skin, exposure to contaminated clothing or The sports medicine doctor/dermatologist
contact with the treated skin of a c­ olleague [9]. should be able to diagnose lesions resulting from
Patch testing with delayed reading the direct effect of sports activities to which the
(Fig. 33.10a, b) using the baseline and additional athlete is exposed, but the doctor should be aware
series of allergens (rubber chemicals, footwear, of the drugs used for other diseases, therapies
topical drugs, sunscreens, cosmetics or fra- used for sports injuries and special diets that may
grances), chosen according to the individual’s cause or favour skin diseases and could easily go
exposure history, is the mainstay for the etiologic unnoticed (e.g. drug photosensitivity or acne
diagnosis of ACD.  In many cases, it is very from whey protein). Special attention should be
important to patch test additionally with frag- paid to differential diagnosis of sports-induced
33  Dermatological Injuries 457

48
h

Fig. 33.10  Patch testing technique and a delayed (48 h) positive reaction with erythema, infiltration and papules (++)
from diethylthiourea present in a neoprene swimsuit

inflammatory conditions, and exacerbations of

pigmented cutaneous lesions, namely, the “black pre-existing conditions. J Clin Aesthet Dermatol.
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7. Cohen P.  Pool toes: a sports-related dermatosis of
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taken into account to advise the patients concern- 8. Veien N. Clinical features  In: Johansen J, Frosch P,
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General doctors, dermatologists and sports Berlin: Springer; 2011. p. 255–303.
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ognize and treat sports-related/aggravated skin 10. Inui S, Itami S. 2 Cases of sumo wrestlers’ friction
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 Oral Health
34
Silvia Maria Rocha Piedade Damasceno,
Marly Kimie Sonohara Gonzalez,
Renata Bastos Del Hoyo Fernandes,
and Vera Lucia Gramuglia

34.1 Background mostly observed in main sports events [2].

Although oral problems are still part of elite ath-
For many years in sports, oral cavity care was letes’ reality, in amateur sports [3], this health
limited to the prevention of traumatic lesions. condition tends to be even worse, partially due to
The first records of actions involving odontologi- the athlete’s lack of orientation and lower eco-
cal practice and sports date back to 1891 when nomic condition.
mouthguards were utilized to protect British box- During the 30th Olympic Games in London,
ers’ teeth [1]. in 2012, odontological care represented 30% of
Over the years, knowledge on the close rela- the total treatments in the health area, and it was
tionship between oral health and general health only lower than the percentage of treatments
has changed the focus and attention given to the related to the musculoskeletal system [4]. The
oral cavity and its clinical manifestations. Besides athletes presented low oral health levels mainly
contributing to an athlete’s well-being, life qual- related to periodontal diseases (gingivitis 76%
ity, and self-esteem, a healthy mouth is essential and periodontitis 15%), dental caries (55%), den-
to ensure efficient mastication and the ideal use tal erosion (45%), pain and discomfort in the oral
of nutrients, resulting in energy to supply the mucosa (12%), and pericoronitis (9.9%), besides
high demands of trainings and competitions, pos- orofacial traumas (18%). These rates resulted in a
itively reflecting on athletic performance. negative impact on the athletes’ quality of life
Since the 19th Olympic Games in Mexico, in (28%) and training or performance (18%).
1968, it has been reported that elite athletes pres- In the 31st Olympiads in Rio de Janeiro, in
ent poor oral health conditions. Unfortunately, 2016, a record of 1600 odontological treatments,
this clinical condition is still true nowadays, and besides 600 image exams and the making of
a rising increase in the amount of dental care is 350 mouthguards [5], was reported. One impor-
tant consideration is that the treatment of oral
diseases and alterations is costly and a lot of
S. M. R. P. Damasceno (*) times it is not affordable to a great number of
Odontology Center, Maringá, Parana, Brazil athletes. Therefore, many of them take the
M. K. S. Gonzalez opportunity to assess their oral health and treat
Odontology Center, Rosario, Santa Fe, Argentina preexisting oral problems using the facilities of
R. B. Del Hoyo Fernandes . V. L. Gramuglia the Olympic Games and other major sports
Odontology Center, Botucatu, Sao Paulo, Brazil events.

© ISAKOS 2019 459

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_34
460 S. M. R. P. Damasceno et al.

Considering that dental caries and periodontal oral region (1st), lips (2nd), teeth (3rd), gingiva
diseases are preventable and that certain oral (gums) (4th), tongue and oropharynx (5th), other
manifestations may be related to systemic dis- mucosae (6th), and saliva (7th).
eases and conditions, the importance of the ath-
letes’ periodical oral health assessment is
undeniable. 34.2.1 Extra Oral Region
(First OHAPA)

34.2 S
 even Oral Health 34.2.1.1 Face and Neck
Assessment Points When examining the extra oral region, the pres-
in Athletes (7 OHAPA) ence of an increased volume in the medium and/
or inferior third of the face can be related to dif-
In athletes, the oral health assessment periodicity ferent clinical disorders involving teeth, salivary
is flexible according to the intensity of the train- glands, and lymph nodes.
ing and competition schedule because it helps Acute infectious dental abscess can evolve to
monitor an athlete’s global health. Thus, for elite other areas and result in posterior facial edema.
athletes, the oral health assessment must be car- Alterations of greater salivary glands (SG)
ried out every 3 months or anticipated when it is can have inflammatory, infectious, obstructive,
necessary. or neoplastic nature. The infectious processes
It is important to point out that the system- of SG are frequently caused by bacteria and
atic assessment of an athlete’s oral health viruses; present quick volumetric increase,
allows uniformity and reproducibility to the pain, and salivary secretion reduction; and most
process. In our clinical practice, we consider of the times affect the parotid gland. Malignant
Seven Oral Health Assessment Points in tumors of SG represent only 3% of head and
Athletes (7 OHAPA), because they cover the neck tumors, but 95% of palpable nodes in the
entire oral cavity topography (Fig. 34.1): extra parotid region have tumoral o­ rigin [6].
The examination and palpation of parotid,
sublingual, submandibular, and cervical lymph
nodes usually make easy to tell apart an inflam-
matory/infectious process (pain, heat, elasticity,
and preservation of the shape with hyperemia on
the skin) from a neoplastic one (painless, asym-
metric shape, and loss of e­ lasticity). In infectious
processes of the oral cavity, the submandibular
and sublingual chains are the most impaired
(Fig. 34.2).

34.2.1.2 Temporomandibular Joint

A practical and functional assessment of tem-
poromandibular joints (TMJs) can be done by
placing two folded fingers (index and medium)
at the proximal interphalangeal joints in the
mouth. If there is a limitation to mouth open-
ing, an athlete will not be able to perform this
test [7] (Fig. 34.3). The limitation and devia-
tion of mandibular movement as well as pain
Fig. 34.1  Oral cavity topography, showing the structures in TMJ may be a signal of temporomandibular
of points 2–6 disorders (TMDs).
34  Oral Health 461

Fig. 34.2  Examination and palpation of submandibular Fig. 34.4  Facial effort expression during weightlifting
and sublingual lymph nodes

Another clinical picture that involves TMDs is

the facial effort expression. Under this condition,
athletes increase the frequency of involuntary
mandibular clenching during vigorous physical
exercising which involves muscles from the legs,
arms, and back [11]. This involuntary masseter
contraction has a positive correlation with car-
diac frequency [12] (Fig. 34.4). In weightlifting,
it is also observed that voluntary mandibular
clenching increases body stability [13].

34.2.1.3 Breathing Pattern

Oral breathing (OB) pattern has been associated
Fig. 34.3  Joint movement test showing an athlete’s nor-
with posture alterations. Forward head posture in
mal mouth opening
relation to shoulders, associated with elongated
face, dark undereye circles, and lack of labial
Athletes belong to the risk group for the devel- sealing, is a characteristic observed in individuals
opment of TMDs because they are likely to have that use the oral cavity as their main respiratory
physical traumas in the middle third and inferior route.
part of the face, and often live in situations When OB is established, the most common
involving anxiety, depression, or stress, which oral alterations are malocclusion (posterior cross-
are common to the competitive environment, bite and anterior open bite), xerostomia, and gin-
mainly when an athlete is recovering from lesions givitis in upper anterior teeth as well as a greater
(convalescence) [8]. In this context, bruxism is risk of dental caries. Besides altering posture, OB
one of the most frequently observed clinical reduces the diaphragmatic work, limits thoracic
problems. It is characterized by repetitive non- expansion, and decreases pulmonary ventilation,
functional mandibular movements, mainly regu- negatively impacting on oxygen absorption
lated by the central nervous system [9] and capacity and intake to produce energy during
influenced by factors such as stress, anxiety, and physical exercises [14]. Early treatment is funda-
traumas, besides drugs and diseases [10]. mental especially for younger athletes, because it
Bruxism causes microtraumas that can result in allows to easily establish physiological breathing
abrasion, cracks, and fractures of teeth and fill- through the nose as well as the harmonious facial
ings besides muscular discomfort. growth, free from physiological and psychosocial
462 S. M. R. P. Damasceno et al.

discomfort of OB. On the other hand, in an adult 34.2.2.1 Cheilitis

athlete, a multidisciplinary approach is needed Angular cheilitis is a unilateral or bilateral chronic
for the oral breather syndrome. lesion with painful fissures in labial commissure
and can be associated with atrophy, ulceration,
candidiasis, and bacterial infection (Fig. 34.5a, b).
34.2.2 Lips (Second OHAPA) Nutritional deficiencies, lip biting or lip licking
habits, and loss of the vertical dimension of occlu-
Color alteration in lips can signal nutritional defi- sion, which predisposes to saliva accumulation in
ciencies, anemia or low blood pressure (pale), labial commissures, are common risk factors for
heart and lung diseases or hypothermia (purple), the development of angular cheilitis.
and liver disease (yellowish). In red lips—as well Actinic cheilitis is a potentially malignant
as in the palate, gingiva, and other mucosae— condition in which lip redness, mainly in the
hyperpigmented lesions are generally benign inferior one, presents atrophy, pale areas, ulcer-
(e.g., physiological melanoplasia) and can be ations, or crusting with characteristic blur
related to diseases (e.g., Addison’s disease) and demarcation of the lip, with or without pain. In
use of medications (e.g., ketoconazole), or can be sports in which there is chronic exposure to
neoplastic (e.g., malignant melanoma), to name sunlight, pale-­ skin athletes are more predis-
but a few [15]. posed to it [16].

a c

Fig. 34.5  Right unilateral angular cheilitis (a) with proximal view (b). Recurrent herpes simplex with vesicle and
beginning of crust formation (c) on the border between lower lip and skin
34  Oral Health 463

34.2.2.2 Ulcers 34.2.2.6 Labial Edema

Ulcers are the most common lesions of the oral Labial edema can be a result of immunological
mucosa. Painful ulcers are generally associated mechanisms (hereditary angioedema) and non-­
with mechanical, chemical, or thermal trauma. immunological ones (allergy), among others
[23]. In cases of anaphylaxis, immediate thera-
34.2.2.3 Aphthous Ulcer peutic intervention is necessary.
Recurrent aphthous ulcer (RAS), with an incidence Benign labial lesions may cause a dryness
of 20–60% [17], is among the most common non- sensation, pain, itching, and others. On the other
traumatic ulcers in the oral cavity. It is character- hand, neoplastic processes may be asymptomatic
ized by the emergence of one or more small and with discrete alterations. Labial lesions, includ-
very painful shallow ulcers in the nonkeratinized ing the malignant ones, are treatable when diag-
mucosa of the lips (also in the tongue, jugal mucosa, nosed early.
and mouth floor) and is frequently white or yellow
with reddish borders and oval shape. They heal
themselves spontaneously after some days and are 34.2.3 Teeth (Third OHAPA)
recurrent. The bigger lesions reach up to 3 cm and
are less prevalent and more persistent. The predis- During tooth examination, it is essential to
posing factors are deficiency of iron, vitamin B12, observe alterations in their integrity, biofilm stag-
and folic acid; and the triggering factors are hor- nation (bacterial plaque), presence of calculus
monal alterations, psychological stress, and (tartar), and dental losses while evaluating the
immune system depression [18]. level of an athlete’s awareness on the importance
of oral health hygiene and maintenance.
34.2.2.4 Painless Ulcers
Painless ulcers can indicate chronic trauma (e.g., 34.2.3.1 Oral Hygiene
parafunctional habits or poorly adapted prosthe- and Carbohydrate Intake
sis), syphilitic cancer, oral squamous cell carci- Poor oral hygiene combined with high carbohy-
noma (OSCC), and non-Hodgkin lymphoma, drate intake, which is commonly associated to
among others [19]. OSCC represents 90% of athletes’ nutrition, causes the proliferation of car-
malignant oral neoplasias, and the lower lip is iogenic microorganisms and formation of dental
one of the most affected areas [20]. This kind of caries (Fig.  34.6a). During their progression,
ulcer is painless, hard, and white or red, does not provoked pain (by hot, cold, sweet, and acid
­
heal [21], and is frequently associated with foods) may occur and evolve to spontaneous pain
actinic cheilitis [20]. (pulpitis) and pulp necrosis, resulting in chronic
or acute infections. In chronic infections, the for-
34.2.2.5 Herpes Simplex mation of fistula in the region of the alveolar
Vesicles in the lip vermilion and the border with mucosa is usually observed, whereas in acute
the skin frequently show recurrent herpes sim- infections periapical abscess and posterior edema
plex (Fig.  34.5c), also frequent in the gingiva in the medium and/or inferior third of the face are
and palate. The primary infection by herpes formed. In the long run, the lack of dental caries
simplex virus type 1 (HSV-1) usually occurs treatment makes mastication and the ideal utiliza-
during childhood, followed by a latent period. tion of nutrients difficult by the athlete, increasing
In an athlete, the exposure to sunlight, wind, the risk of dental losses, occlusal maladjustments,
cold, physical or mental stress, and anxiety are and functional, aesthetic, and psychological dam-
factors associated with HSV-1 reactivation. ages, besides being a risk factor for systemic
Vesicles break up forming crusts that spontane- diseases.
ously heal from 7 to 14 days without leaving
scars. Recurrences happen once or twice a year 34.2.3.2 Sports Drinks
and are more frequent and serious in AIDS due Commercially available sports drinks have pH
to immunosuppression [22]. lower than the one considered critical (5.2–5.5)
464 S. M. R. P. Damasceno et al.

a present pale pink color, scalloped contour, and

absence of bleeding, whereas in periodontal dis-
eases (gingivitis and periodontitis), a chronic
bacterial inflammatory process in the tissues that
surround the teeth is observed as a response to
biofilm accumulation (bacterial plaque) [28].
If poor oral hygiene conditions persist, chronic
gingivitis can evolve to periodontitis which is an
infectious disease associated with predominantly
gram-negative bacteria, mainly in the presence of
a susceptible host (Fig. 34.7a). In the periodontal
disease, the accumulation of suppuration may
b lead the formation of abscesses that cause gingi-
val edema, pain, and dental mobility [29]
(Fig. 34.7b). When a periodontal abscess occurs
during competitions, it may affect the athlete’s
concentration and performance [30].

34.2.4.2 Pericoronaritis
Pericoronaritis is an acute infection around the
Fig. 34.6  Dental caries in upper lateral incisor and bio- crown of the third molars (Fig. 34.7c). It is char-
film stagnation associated with chronic gingivitis (a).
Dental corrosion in vestibular surface of upper central
acterized by pain, edema, and abscesses in the
incisors due to consumption of sports drinks (b) retromolar region and, in more severe cases, tris-
mus, fever, and dysphagia with mastication diffi-
culty. It is highly prevalent in young athletes from
for dental enamel and can have a corrosive effect 17 to 26 years old [31] and represented 9.9% of
(erosion) on this surface [24] (Fig.  34.6b). A the odontological treatments carried out during
study carried out with college athletes in Ohio, the 30th Olympic Games in London, in 2012 [4].
USA [25], reported that 36.5% of the athletes
presented dental corrosion and that 91.8% of the 34.2.4.3 Necrotizing Ulcerative
athletes with corrosion used to drink sports Gingivitis
drinks. The dental corrosion risk is likely to be Necrotizing ulcerative gingivitis (NUG) is a spe-
greater when associated with salivary flow reduc- cific acute periodontal disease, commonly
tion, observed after long exercising [26], due to observed in younger athletes [28]. It presents
the limitation of lubricant protective functions of papillae necrosis, pain, bleeding, and halitosis
saliva. In water sports, dental corrosion can be associated with predisposing factors that alter the
related to the frequent long activity in pools with individual’s response such as stress, nutritional
chlorine water when pH monitoring is not ade- deficiencies, and immunological system disor-
quate [27]. ders, particularly HIV infection [32], smoking,
preexisting gingivitis, and trauma [33].

34.2.4 Gingiva (Fourth OHAPA) 34.2.4.4 Hyperplasia and Bleeding

Gingival hyperplasia and bleeding are fre-
34.2.4.1 Gingivitis quently observed as local inflammatory response
Chronic gingivitis affects more than 90% of the to the presence of biofilm (periodontal disease).
population, is painless with red swollen appear- When these alterations occur in the absence of
ance, and presents gingival bleeding during den- biofilm, associated with petechiae and ulcer-
tal brushing. In an examination, normal gingiva ations, they may represent the first signs of leu-
34  Oral Health 465

a c

Fig. 34.7  Chronic periodontitis in the anterior region with the presence of calculus and biofilm (a). Acute periodontal abscess
between lower left lateral incisor and canine (b). Pericoronitis in the region of the lower right and left third molars (c)

kemia [34]. The early leukemia diagnosis is and that may result in heart valve lesions, mainly
important because it determines favorable in children and teenagers. This sequela is a risk
prognostics. factor for infectious endocarditis in the occur-
rence of bacteremias that can come from oral
infection focus, invasive odontological proce-
34.2.5 Tongue and Oropharynx dures, or recurrent pharyngotonsillitis, among
(Fifth OHAPA) others. Therefore, a detailed anamnesis has an
important role in the treatment because it may
The examination of the tongue includes the signal the need of preventive measures, such as
­dorsum, ventral surface, and lateral edges. When antibiotic therapy, in patients with a history of
the tongue is sticking out, other parts of the repeated throat infections who are submitted to
­oropharynx (soft palate, uvula, tonsils, and lateral odontological procedures.
and posterior part of the throat) can be The tongue ventral surface and the mouth
examined. floor can be examined when the tip of the tongue
The presence of pus in the tonsils and oro- is raised toward the palate, whereas the tongue
pharynx associated with palpable painful cervical root and lateral edges are examined with right-to-­
lymph nodes indicates bacterial pharyngotonsil- left sideways movement.
litis. It is important to point out that rheumatic A scalloped tongue presents tooth marks on
fever is a complication of pharyngotonsillitis the edges and may indicate parafunctional habits
caused by Group A beta hemolytic streptococcus (e.g., clenching bruxism).
466 S. M. R. P. Damasceno et al.

Halitosis and keratin accumulation on the Crohn’s disease has specific oral manifesta-
tongue dorsum are generally associated with tions such as cobblestone mucosa (rigid plaques
poor oral hygiene, xerostomia, and others. with hyperplastic, swollen, and cracked appear-
Clinically, keratin accumulation looks like a ance) in the oral and palate mucosae [36]; hard-
white-yellowish plaque (coated tongue—Fig. ened lesions like tag, generally in the labial
34.8a), and when hyperplasia of filiform papillae vestibule and retromolar region; deep linear
occurs (hairy tongue—Fig. 34.8b), the plaque ulcerations; mucogingivitis; edema; and labial
becomes brown or black, and it is commonly fissures, besides other non-specific lesions such
associated with smoking. as RAS, which is its most common oral manifes-
Color variations from pale to intense red, tation. Oral lesions in Crohn’s disease have a
almost purple, with papillae atrophy, sensitivity prevalence of 0.5–20% [37]. The oral symptoms
increase, and taste alteration can be related to precede the intestinal ones in 60% of the indi-
nutritional deficiencies, anemias, and immuno- viduals [38].
suppression. In these cases, the development of Squamous cell papilloma, condylomata acum-
oral candidiasis, an opportunistic fungal infec- inata, and oral verrucas are the most prevalent
tion, usually occurs. Oral candidiasis is also com- lesions caused by human papilloma virus (HPV)
monly associated with other debilitating diseases in individuals with HIV/AIDS [39]. They are
such as AIDS. painless, exophytic, white, and rigid lesions with
Benign migratory glossitis is a common lesion well-defined borders [40] and similar clinical
among non-smoking allergic youngsters with appearance. They occur in any region of the
unknown etiology. It presents atrophic reddish mucosa, preferably where epithelium keratiniza-
areas and white edges that migrate to the dorsum tion looks like the skin (e.g., hard palate and
or the lateral region of the tongue and is asymp- gingiva).
tomatic or eventually painful [19] (Fig. 34.8c). Kaposi’s sarcoma corresponds to a malig-
Hairy leukoplakia, related to the presence of nant vascular neoplasia represented by maculae
Epstein-Barr virus (EBV), is a benign, usually or nodes that vary from red to blue and mostly
asymptomatic lesion and more frequently occurs frequently observed on the palate, gingiva, and
in the tongue edge, unilaterally or bilaterally. It tongue dorsum [41]. It occurs in approximately
looks like a white non-scrapable plaque with ver- 8% of individuals infected by HIV [35] and is
tical rugged hyperplastic pattern and well-defined considered the neoplasia that defines AIDS
edges. It is almost exclusively related to HIV [18].
infection and observed in 16% of the infected Non-Hodgkin lymphoma is heterogeneous
individuals [35]. with tissue masses with or without ulceration and
Idiopathic leukoplakia presents white, asymp- tissue necrosis in which immunodeficiency is an
tomatic, non-scrapable plaque and is the most important risk factor. The most affected regions
common potentially malignant lesion in the oral are tonsils, palate, and gingiva [19]. It is the sec-
cavity (potential of malignant transformation of ond most frequent neoplasia (4%) in individuals
5–10%) [19] (Fig. 34.8d). with HIV/AIDS [35], and its occurrence indi-
cates a late complication of the disease.

34.2.6 Other Mucosae (Sixth OHAPA)

34.2.7 Saliva (Seventh OHAPA)
Besides the lips, gingiva, retromolar area, tongue,
oropharynx, and mouth floor, the examination of Saliva is a biological fluid of compounds produced
oral mucosae also includes the alveolar and jugal in the salivary glands (alpha amylase and immuno-
mucosae and hard palate, which can reveal many globulin A [IgA-s]) and compounds disseminated
other alterations besides the ones described in the plasma (water, metabolites, hormones, elec-
before. trolytes, and proteins); its production and compo-
34  Oral Health 467

a b

c d

Fig. 34.8  Alterations in the tongue dorsum: coated tongue (a), hairy tongue (b), and benign migratory glossitis (c).
Idiopathic leukoplakia on the lateral edge of the tongue with carcinoma diagnosis in situ (d)
468 S. M. R. P. Damasceno et al.

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health-related quality of life. J Oral Maxillofac Surg. Leonardi MFP. Sports dentistry – an innovative pro-
2008;66:2482–7. posal. Rev Bras Med Esporte. 2017;23:147–51.
 Traveling Management
35
Steven R. Joseph

35.1 Introduction port structures and a planning framework. Once a

chief medical officer (CMO) or medical director
Providing medical support to a traveling sports is appointed, they can provide input and direc-
team offers an exciting but often challenging tion. There may exist a formula for the number
opportunity [1]. Depending on the sport and and type of practitioners required to care for a
travel destination, astute management is required specific number of athletes and team officials.
for the athletes to perform to their potential. Common practitioners include athletic therapists,
Variables such as climate (heat, cold, humid- physiotherapists, sport medicine physicians, and
ity), altitude, time zone changes, and travel time orthopedic surgeons. The national organizations
may offer significant obstacles to sport perfor- for each sport should provide input for selection
mance [2]. Sound strategies to minimize the as relevant.
impact on performance are necessary. Also, dif- Many recreational and sub-elite athletes are
ferences in culture including food, laws, and lan- pursuing international competition and training
guage may pose a challenge. without pre-existing support frameworks or
The role, type, scope, and number of medical national organizations. In these cases, a solo
practitioners will vary depending on overall team practitioner may have to take responsibility for
size, type of sport, available resources, and medi- all medical support and administration.
cal services provided by the host country or city. Regardless of scope, preparation is the key to
While multiday and multisport games such as the successful traveling management and athlete per-
Olympics or FIFA World Cup require significant formance, and it is the focus of our overview.
preparation, the same principles apply to single-­
day or single-event games and competitions.
Ideally, a sports governing body (i.e., a 35.2 Preparation
National Olympic Committee) will provide sup-
35.2.1 Location
S. R. Joseph (*)
Department of Family Medicine, Western University, If possible, advanced scouting of the location or
London, ON, Canada obtaining information from those who have been
Fowler Kennedy Sports Medicine Clinic, there prior is recommended. A site visit well in
London, ON, Canada advance of the event is fruitful for the CMO. This
Roth McFarlane Hand and Upper Limb Centre visit may or may not be in conjunction with
(HULC), London, ON, Canada administrative staff visits. Visits to local medical
e-mail: [email protected]

© ISAKOS 2019 471

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_35
472 S. R. Joseph

facilities, athletes’ accommodations, and training Table 35.1  General guidelines to reduce the risk of
foodborne illness
and competition venues should be arranged.
Meeting any local organizing personal can pro- • Refrigerate or freeze Avoid
raw/cooked perishable • Drinking tap water,
vide insight into potential challenges. Any foods promptly using tap water to
advanced information will give the practitioner • Fruits and vegetables brush their teeth, or
time to address nutrition, training, and local med- should be washed under using ice made from
ical coverage concerns before team arrival or the running water before tap water
eating, cutting, or • Drinking
start of the event. cooking unpasteurized milk or
• Raw meat, poultry, milk products
35.2.1.1  Food seafood, and their juices • Eating raw fruits and
Proper nutrition is vital to athlete training and should be kept away vegetables, including
from other foods lettuce and fruit
performance. Practitioners should identify local • People should wash salads, unless they
food sources and availability where possible [3]. their hands for at least peel the fruits or
Are there contamination concerns? Is high-­ 20 s with warm, soapy vegetables themselves
quality nutritious food that meets the athlete’s water before and after • Eating raw or rare
handling raw meat, meat and fish
needs and performance regimen part of the local poultry, fish, shellfish, • Eating meat or
cuisine and food customs? Is the local water sup- produce, or eggs shellfish that is not
ply safe? If not is bottled water easily hot when served
attainable? • Eating food from
street vendors
If there are food and water concerns, athletes
and the team may consider supplying their own.
This can include at destination and during travel be familiar with related health issues and ill-
itself. Quality food choices are not generally nesses associated with extreme heat, cold,
numerous in airports or on planes [4]. Bringing humidity, and altitude [6, 7]. Destination envi-
food and nutritional supplements can be helpful ronment factors should be considered when
but potentially problematic. Always ensure there identifying experienced support staff and medi-
are no concerns importing these items into a cal kit selection.
country. Customs and immigration websites Consider training at the altitude and climate
should be referenced prior to travel. conditions similar to event conditions to reduce
Athletes and support staff should be educated the environmental health risks of athletes [8]. If
on the risks of foodborne illnesses including food unable to train in venue climate conditions,
intoxication, hepatitis, and traveler’s diarrhea. arranging to arrive early to acclimatize is a con-
Many foodborne illnesses can be prevented by sideration. Identify athletes who have disease
properly storing, cooking, cleaning, and handling concerns specific to extreme climate conditions
foods [5]. General guidelines are outlined in (i.e., sickle cell disease and altitude), and ensure
Table  35.1. Hepatitis (vaccinations) and travel- medical staff are aware of initial symptoms and
er’s diarrhea will be covered in more detail later management.
in the chapter. For severe heat and humidity, athletes’ instruc-
tions include limiting exposure and proper hydra-
35.2.1.2  Climate/Altitude tion. This includes arranging for access to water
One must study the predicted weather patterns and electrolytes at accommodation, training, and
for the competition time frame. Many athletes competition sites. Proper cold weather clothing
are exposed to significant temperature and alti- and training gear during winter exposure are
tude extremes. The World Cup in 2022 is being required [9]. Teaching athletes’ signs of frostbite
played in Qatar, where the average temperature is also appropriate. A summary of climate- and
will be between 25 and 30  °C despite being altitude-specific considerations outlined above
scheduled over the winter (average daily temp should be disseminated to the team as part of the
over the summer is 42 °C!). Practitioners should safety brief.
35  Traveling Management 473

35.2.1.3  Local Medical Coverage requirements, and ensure suitable medical staff
One should obtain knowledge of the local medical with appropriate qualifications are available.
coverage at competition venues, athletic village,
and local hospital and emergency facilities. Local 35.2.2.1  Medical Records
medical authorities should be aware of the event Ensure up-to-date medical records are available
(generally not an issue for major games) and be prior to and during the event. If not the normal
involved in the planning as necessary. Depending team medical practitioner contacts coaches, offi-
on the size of the event, the local medical cover- cials, and team medical staff to identify any ath-
age planning piece will be to simply be aware of letes that may have significant or ongoing medical
the games, organizing body’s medical support. concerns. It is important to address injuries prior
Local resource availability will directly impact to departure if possible. Some athletes will be
composition of the supporting medical kit and any undergoing specific rehab or therapy; if this
necessary portable equipment. Where serious ill- should be continued during travel communica-
ness or injuries should be treated should be dis- tion with rehabilitation staff who may not be trav-
cussed pending local support. Are there concerns eling with the team is necessary. Often team
with time-sensitive repatriation planning? Further officials and coaches can cause anxiety for the
details will be discussed in emergency action plan traveling practitioner due to underlying medical
(EAP) development. Important local medical con- conditions such as coronary artery disease [10].
tact numbers and addresses should be communi- Records are to be kept secure. This may lead to
cated to the team as required. additional travel challenges as electronic and
mobile records are beginning to replace hard
35.2.1.4  Accommodations charts. There is ongoing concern with hacking
There are many facets to consider when finding into private medical files. The World Anti-Doping
or reviewing athlete accommodations. Are they Agency (WADA) confirmed a cyber espionage
in a safe area of the city? Proximity to venues? group illegally gained access to confidential
Is it difficult to find adequate transportation? medical files in 2016 [11].
Food, climate, and exposure risks discussed in
prior sections also apply to accommodation 35.2.2.2  PPE (Pre-participation
selection and planning. It is ideal to have a dedi- Examination)
cated medical room for athlete privacy and con- The pre-participation examination (assessment)
fidentiality. Long beds for tall athletes and was covered in Chap. 2. Most teams and athletes
accessible rooms for disabled athletes are con- will have some form of a PPE as part of their own
siderations that should not be overlooked. program’s medical requirements before training.
Isolation rooms for sick athletes can reduce There is ongoing research and debate to the effec-
cross infection rates between teammates. If part tiveness of a PPE [12]. Regardless, it is reason-
of an athlete’s village, ensure you have the able for the medical practitioner to attend
appropriate contact and administration informa- pre-travel/competition camps to perform their
tion if there are concerns. own comprehensive medical assessments. Ensure
there are no specific PPE requirements for the
competition/event; if so be sure to allocate
35.2.2 Personnel enough time and resources to complete.

Personnel planning involves medical records, 35.2.2.3  Travel Documents

administration, travel documents, travel insur- Obtaining and confirming travel documents such
ance, and drug testing considerations. Don’t for- as visas and passports is generally not the respon-
get to include coaching, medical, and other sibility of the medical staff. However, this may be
support personnel when reviewing travel docu- an additional administrative role depending on
ments and administration. Review medical team size and scope. Having this part of your
474 S. R. Joseph

checklist is never a poor idea (redundancy in quate medical staff. This includes qualifications
travel preparation is not a concern). Some practi- and number of personnel. Small teams traveling
tioners include this as part of the vaccination and to a well-supported event may only require a
medical record checklist. Travel insurance qualified athletic therapist for medical support.
including medical coverage should be arranged Larger teams or less supported events may
for the team and support staff. Inquire early if this require multiple providers including athletic ther-
is part of the medical staff responsibility. apists, physiotherapists, nutritionists, sport med
physicians, and orthopedic surgeons.
35.2.2.4  Drug Testing
This function is administrative and educational
and can be taxing for both athletes and medical 35.2.3 Equipment
practitioners. Drug testing is undertaken at many
international competitions; athletes and medical Timely availability of proper medical equipment
staff must be reminded about common over-the-­ is an essential component of medical care while
counter (OTC) medications that are on the pro- traveling. Equipment includes personal and team
hibited list. Providing a short reference sheet that medications, clinician medical kit, and event cov-
lists these to athletes can be helpful though the erage medical bag and supplies.
best advice is to ensure athletes don’t take any
medication without reviewing with a qualified 35.2.3.1  Medications
clinician. Ensure athlete’s required medications are con-
If an athlete is required to take a medication firmed and transported. In some cases, the athlete
to treat an illness or condition that happens to themselves will pack it; other times it may be more
fall under the WADA prohibited list, a feasible to keep the team medications together.
Therapeutic Use Exemption (TUE) may give General medications to bring can vary, and a rea-
that athlete the authorization to take the needed sonable starting point is included in Table  35.2.
medicine [13]. TUEs should be completed at The quality of local pharmacies and availability of
least 30 days prior to an athlete’s next competi- reputable medications will factor into medication
tion for in-­ competition prohibited substances; planning. It is a good practice to bring all the medi-
applications are required as soon as possible if cations you anticipate the team will need. Contact
the medical condition diagnosed requires a sub- airlines or other travel providers beforehand to
stance that is prohibited at all times [14]. ensure appropriate documentation is prepared for
Communicate with officials, athletes, and team
staff to determine existing TUEs and any
required TUEs not in place. Table 35.2  Common travel medications
There are many resources that are helpful in navi- • Analgesics • NSAIDS (ibuprofen,
gating drug testing, prohibited medications, (acetaminophen) naproxen)
• Antibiotics • Topical (antibiotic
methods, and supplements. A great place to start (amoxicillin, ointment, antifungal,
is the World Anti-Doping Agency website doxycycline, Keflex, steroid,
(https://www.wada-ama.org/). It includes the ciprofloxacin) anti-inflammatory)
prohibited list and TUE application process and • Epinephrine/EpiPen •  Antiemetic (Gravol)
• Antidiarrheal • Antihistamines
identifies anti-doping organizations by country. (loperamide) (Benadryl, second
Other initial resources to consider are the IOC • Antacid (Tums/ generation)
Anti-Doping Rules and GlobalDRO (https://glo- Rolaids) • Bronchodilators
baldro.com/Home). • Eye/ear drops (tears, (salbutamol,
antibiotic) beclomethasone,
•  Glucose tabs Atrovent)
35.2.2.5  Medical Staff • ASA •  Nitro spray
Depending on team composition, size, and local •  Throat lozenges • Sedatives (zopiclone,
and event medical support, ensure you have ade- zolpidem)
35  Traveling Management 475

transport of medications if required. This is often to transit through a country while traveling; ensure
applied to syringes, needles, and controlled sub- these issues are identified well in advance. The
stances such as narcotics and benzodiazepines Centers for Disease Control and Prevention travel
(these medications should rarely be included). website (https://wwwnc.cdc.gov/travel) and
World Health Organization (http://www.who.int/)
35.2.3.2  Medical Kit are sites to bookmark for related information.
Each clinician should carry a small kit while trav- Other vaccines that may be considered or required
eling to attend to common and minor medical include Japanese encephalitis, rabies, typhoid,
issues that may occur. This should include Band-­ cholera, and yellow fever.
Aids, athletic tape, eye drops, antibiotic oint-
ment, acetaminophen, ibuprofen, throat lozenges, 35.2.4.2  Malaria
dimenhydrinate, antihistamines, and gauze Insect-borne diseases are common in many
among others [1, 15]. parts of the world and have impacted large ath-
letic events in the past. The most recent is the
35.2.3.3  Event Medical Bag Zika virus and the 2016 Rio Summer Olympics
and Supplies [16, 17]. Mosquitos are the best-known disease
In addition to the medications and clinician med- vector and can transmit chikungunya, dengue
ical kit discussed above, an event medical bag fever, and malaria among others [18].
and other supplies are often required. In practice Preventive measures for insect-borne diseases
medications and clinician medical kit are often include limiting outside exposure, using nets,
included within the medical bag. While the con- wearing protective clothing, and using repel-
tents will vary depending on local resources, lant. Review signs and symptoms of relevant
common supplies include laceration equipment insect-borne diseases with the team and medi-
(sutures, Steri-Strips, lidocaine, instruments), cal staff.
SAM splints, tensor bandages, BP cuff, portable Malaria, which is endemic in parts of Africa,
O2 monitor, AED, airway equipment, pocket Southeast Asia, and South America, can result in
masks, stethoscope, ophthalmoscope, otoscope, significant morbidity and mortality. Unlike den-
penlight, scalpel, wound dressings, gloves, and a gue and chikungunya, there are prophylactic
portable examining table. medications available when traveling. Websites
such as the CDC or WHO can assist with identi-
fying endemic areas and recommend specific
35.2.4 Preventive Medicine prophylactic medications.
Interestingly, there are no consistent studies on
Health and safety concerns are not always related ability to work, athletic performance, and chemo-
to specific injury risks involved in a sport.
Communicable disease, insect-borne illnesses, and Table 35.3  Common vaccinations
cultural-related incidents can also prove dangerous • Hepatitis A
to the health and safety of the traveling team. • Hepatitis B
• Measles, mumps, rubella
35.2.4.1  Vaccines • Diphtheria
Common vaccines for athletes and staff are out- • Tetanus
• Pertussis
lined in Table  35.3. Most of these vaccines are
• Haemophilus influenza type B
recommended as part of the public healthcare • Human papillomavirus (HPV)
plans in some countries. If athletes are not up-to-­ • Influenza
date, these routine vaccinations are the recom- • Pneumococcal
mended minimum. Depending on the location • Meningococcal
(host country) of the event, other vaccinations • Varicella
may be required. Some vaccines are even required • Polio
476 S. R. Joseph

prophylaxis [19]. If choosing to use prophylactic can occur. Recent examples include (1) the death
medications, consider taking the medicine before of Bahman Golbarnezhad, a paralympic athlete
starting extensive training and competition to who died during a cycling event at the 2016
identify any difficulties. Common side effects of Summer Olympics in Rio De Janeiro, and (2)
the medication should factor into chemoprophy- Nodar Kumaritashvii who died during luge prac-
laxis decisions (i.e., doxycycline and photosensi- tice and the 2010 Winter Olympics in Vancouver.
tivity not ideal for summer events). Timing of However, in most cases advanced emergency
medication can be scheduled (i.e., weekly dosed planning can reduce morbidity and mortality dur-
medications can be planned around events—take ing athletic events. Specific considerations are
as far away as actual event as possible). outlined below.

35.2.4.3  Safety Brief 35.2.5.1  Emergency Action Plan (EAP)

Prepare a safety brief to be given to the athletes A predetermined emergency action plan (EAP)
and staff just prior to travel or at arrival. The safety allows for the proper assessment and care of ath-
brief includes team rules and regulations govern- letes who have suffered injury or sudden illness
ing the event. Unsafe areas, times of day, and [20]. An EAP should provide a team- and venue-­
transportation routes should be reviewed. Specific specific framework outlining personnel roles and
laws or bylaws that are not common to the ath- responsibilities in case of a significant medical
letes’ home country or unique to the destination event. These can be developed by the advanced
are to be outlined. The brief should include food medical scouting team if there is one. Depending
safety, the use and dangers of alcohol and illicit on the structure of the event or games, EAPs may
drugs, and caution with sexual activity. Sexually have been developed by the overarching organi-
transmitted infections such as gonorrhea, chla- zation (i.e., IOC) or local medical support.
mydia, HIV, syphilis, and hepatitis are concerns Obtaining and understanding any EAPs is a
and should be discussed. Condoms should be responsibility for the medical, admin, and coach-
readily available although abstinence is the ideal ing staff.
preventive measure. A buddy system or call out list
can be developed to assist with safety and team 35.2.5.2  Repatriation
communication. The safety brief can be published It is unlikely that there will be inadequate local
on a team dedicated website if available. resources to provide the required level of care for
medical emergencies and critical illness.
35.2.4.4  Culture Brief However, if local resources are not adequate,
Similar in nature to the structure of the safety adequate medical facilities and appropriate trans-
brief, the culture brief is to review specific cul- portation should be located. A plan should be in
tural norms and practices at destination. This place for transportation home of injured or ill ath-
includes language, greetings, physical contact, letes for medical care as required (during or after
and customs. Review common local food, the competition). Medical practitioners that are
emphasize food safety, and be wary of food familiar with aeromedical transportation consid-
intoxication if local cuisine is not familiar. If pos- erations are an asset [21, 22]. Some relative con-
sible, the brief should be given by someone local traindications for air travel include an athlete
to the area upon arrival. with a pneumothorax, recent eye surgery, or frac-
tures with circumferential casting.

35.2.5 Emergency Planning 35.2.5.3  Emergency Contacts

Emergency contacts for the team and local
Although true sports emergencies are rare, it is resources should be included and dispersed to the
essential to be prepared for the worst-case sce- medical staff, coaches, athletes, and administra-
nario. Despite proper planning, tragic outcomes tors. This should include local medical facilities,
35  Traveling Management 477

police, fire, ambulance, and national team or water during a 10-h flight. These losses can be
games liaisons depending on the athletic event. further exacerbated with consumption of alco-
It should also include national team personnel holic beverages on the plane or during layovers.
and/or games personnel depending on the athletic Adequate hydration in hot climates is important;
event. Each member of the team should have an arriving with a fluid deficit from travel can
emergency home contact number available increase the risks of heat-related illness unless
beforehand. This information can be complied by careful rehydration strategies are incorporated
the medical or admin staff. [28, 29].

35.2.6.4  Strategies
35.2.6 Travel Fatigue Speeding up the athletes’ biological clock adap-
tation to the new time zone can reduce symptoms
It is well documented that travel of any kind can of travel fatigue and jet lag [30]. There are a vari-
affect natural circadian rhythm and athlete per- ety of strategies to consider if planned length of
formance [23]. Considerable research is being stay is more than 5 days and at least three times
undertaken to develop strategies to mitigate per- zones away. A practical recommendation is to
formance deficits in athlete populations that are arrive 96 h before competition especially if trav-
required to travel prior to competitions. eling east [25]. This of course is not always
feasible.
35.2.6.1  Time Zone An alternate strategy is to adjust the sleep
Time zone changes can affect athletes’ perfor- schedule gradually to the next time zone prior to
mance [24]. Eastward travel affects athletes more departure. This should occur over a minimum of
than westward [25]. A general rule of thumb is to 2 days, more depending on how many time
allow one whole day of adjustment per hour of zones are to be crossed. If possible, the adjusted
time zone change, although westward travel sleep schedule should match the destination
adjustment may be 1.5–2  h per day [10]. schedule; however, even partial adjustment can
Recognizing time zone differences (especially help with adaptation at destination. Traveling
multiple changes during an event or season) is eastward requires advancing the athlete’s circa-
important for medical planning. There are a vari- dian clock (i.e., going to sleep earlier); west-
ety of strategies to address this, and they will be ward requires circadian clock delay (going to
discussed later in the section. sleep later).
Other strategies to assist in adaptation include
35.2.6.2  Sleep the use of light exposure and exogenous melato-
Sleep can affect athlete performance in many nin (pills). Scheduled bright light in the early
domains [26]. Recent studies show that athletes morning (i.e., using a light visor) to simulate an
do not get enough sleep or overrepresent the eastward destination wake-up time can assist
amount of quality sleep they achieve [27]. This is with advancing a circadian clock; using sun-
compounded during travel, especially travel that glasses or dark rooms to avoid bright light in the
includes multiple time zone changes. Given the afternoon can do the same. Melatonin pills sig-
relationship of sleep and performance, significant nal darkness and can advance the circadian
attention needs to be given to travel fatigue clock, promoting earlier sleep onset and morn-
management. ing awakening [31]. To be effective light expo-
sure and melatonin strategies should be gradual
35.2.6.3  Hydration and specific. It is recommended someone on the
Maintaining proper hydration during air travel is support team with appropriate experience and
an often-overlooked aspect of travel fatigue and knowledge assist in planning any related sleep
athletic performance [4]. Aviation guidelines strategies. Combining light exposure and mela-
suggest people can lose 2–4% of total body tonin strategies with pre-travel sleep scheduling
478 S. R. Joseph

offers a synergistic and efficient approach to ­ithout loperamide [34]. Fluoroquinolones

w
reducing the effects of travel fatigue. remain the antibiotic class of choice although
If length of stay is short or there are minimal azithromycin is a strong alternative if there are
changes in time zone (1 or 2 h), short-term strate- concerns with resistance [34, 35]. Colitis-like
gies can be used in lieu of the comprehensive symptoms or persistent diarrhea should not be
strategies above. This can include ensuring ade- ignored; the patient should be referred to an
quate sleep the week before departure, avoiding appropriate specialist [2].
work during destination sleep times, and schedul-
ing important activities in the daytime of the
home time zone. Light exposure strategies should 35.3.2 Upper Respiratory Tract
be used on the airplane as warranted. Sleeping on Illness
flights is reasonable if it is during the night
according to destination time; otherwise, it The incidence of upper respiratory tract illness
should be avoided [32]. (URTI) is higher in elite athletes during training
and competitions [36]. URTIs are also common
in air travelers [37]. Athletes and staff should be
35.3 Event/Onsite reminded about handwashing, care handling bot-
tles and towels, adequate sleep, and maintaining
While preparation before traveling is the key to hydration. A team member with respiratory
successful travel management, onsite medical symptoms should notify the medical staff imme-
considerations and treatment plans for travel-­ diately to address possible treatment and isola-
related illness, symptoms, and environmental tion. Care should be taken in treating URTI
challenges are important aspects to consider once symptoms as many over-the-counter medications
on the ground. contain banned substances. Athletes with pro-
longed symptoms, fever, or productive cough
may benefit from antibiotic intervention.
35.3.1 Traveler’s Diarrhea

Quality and availability of water supplies will 35.3.3 Jet Lag

have been covered in the preparatory stage; how-
ever, it is a good practice to remind all athletes Individual biological clock adaptation can vary
and support staff to avoid tap water and ice if widely, so despite adequate planning and pre-­
there are any quality or source concerns. Always travel sleep practices, some athletes will undoubt-
be prepared for last minute changes in plans or edly have symptoms of jet lag post arrival.
incorrect advanced planning information. Symptoms can include poor sleep, daytime
Guidelines outlined in Table 35.1 above are help- fatigue, impaired concentration, general malaise,
ful for reducing the risk of traveler’s diarrhea. headache, and poor performance.
Traveler’s diarrhea is the most common illness Treatment considerations for those experienc-
to affect the traveling athlete [33]. It is frequently ing the effects of jet lag can include caffeine and
caused by exposure to Escherichia coli, although hypnotics such as zolpidem (to address daytime
Salmonella, Campylobacter, Shigella, or Giardia function and insomnia, respectively). Other stim-
are common. Although antimicrobial prophylaxis ulants and sleep aids should be avoided in ath-
can be very effective, recent guidelines recom- letes as most of these substances are banned in
mend leaving this approach on the sidelines. This competition. These alternate substances such as
recommendation is due to increasing antibiotic modafinil (to address daytime somnolence) can
resistance and the rapid improvement of symp- be considered for coaching or support staff trav-
toms when treated with antibiotics with or eling with the team [38].
35  Traveling Management 479

35.3.4 Environment that could or should have been prevented? Any

pattern that was surprising or unexpected?
35.3.4.1  Insects Consider creating a database to document injury
Review timing and dose of any required prophy- patterns.
lactic medications for vector-borne illness.
Remind the team about proper personal protec-
tive equipment (netting, long clothes, repellant), 35.4.2 Review
exposure risks, and symptoms of insect-related
illness [39]. Advise athletes to avoid or protect An after-action review should be completed with
themselves during peak biting periods. For exam- medical staff, coaching staff, and sport officials
ple, mosquito vectors of malaria are most active as appropriate post travel and competition. Are
at dawn and dusk; mosquito vectors of Zika, den- there lessons to be learned related to communi-
gue fever, and chikungunya are most active dur- cable disease, environmental factors, travel, or
ing the day. performance? Was communication between the
medical team, athletes, and staff effective?
35.3.4.2  Climate/Exposure Lessons learned related to travel, performance, or
Climate-related illness and risks are further out- location can be collated and kept in a running file.
lined in Chaps. 36 and 40. Upon arrival at desti- This information can be used for future traveling
nation, identify any further athletes at increased management by medical practitioners and
risk due to travel-related difficulties or illness. administrators.
Take the opportunity to debrief the team if there
are unexpected weather or venue changes that
could lead to increased risk factors. Have team References
members and staff check gear and related perfor-
mance equipment to identify any shortfalls prior 1. Kary JM, Lavallee M. Travel medicine and the inter-
national athlete. Clin Sports Med. 2007;26:489–503.
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J Sport Med. 2011;21:62–6.
3. Reilly T, Waterhouse J, Burke LM, Alonso JM, et al.
35.4 Post Nutrition for travel. J Sports Sci. 2007;25(Suppl
1):S125–34.
4. British Journal of Sports Medicine (UK). How to
Congratulations, you’ve had a successful trip and keep athletes healthy when travelling [podcast on the
have made it home with hopefully no major med- internet]. Br J Sports Med. 2017 [cited 2018 Jun 18].
ical concerns or issues. https://soundcloud.com/bmjpodcasts/sets/bjsm-1.
5. National Institute of Diabetes and Digestive
It is prudent to remind athletes and team mem- and Kidney Diseases (US). Foodborne illnesses
bers that travel-related fatigue and illness are rel- [Internet]. US Department of Health and Human
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returning to work and training should include niddk.nih.gov/health-information/digestive-diseases/
foodborne-illnesses.
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Wingfield K, Matheson GO, Meeuwisse sleep to maximize performance: implications and
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what-we-do/the-prohibited-list. challenges and opportunities. J Sports Sci.
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2004;22:917–27.
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 Sports Under Extreme Conditions
36
Helge Krusemark and Annika Hackemann

36.1 Sports in the Heat order to maintain the temperature equilibrium

(temperature homeostasis). The heat emission
36.1.1 Overview can be made by several mechanisms: convection,
conduction, evaporation, and radiation [2].
At high temperatures, a physical activity is a spe- At rest, the radiation ensures the majority of
cial physical stress for athletes. The loss of fluids heat emission. In convection, heat is emitted by
and minerals due to increased sweating results in flowing liquids such as blood or gases (air, respi-
a limited performance. Acutely, the plasma vol- ration). Conduction means the transfer of heat
ume decreases, and the concentration of the elec- energy through direct contact with another solid
trolytes in the plasma changes. The heat also or liquid medium. Evaporation (in the form of
leads to an increased anaerobic energy produc- sweat production) represents the main part of the
tion with accelerated depletion of glycogen stor- heat release under physical stress. However, as
age. Clinical signs, starting from a fluid loss of the outside temperature increases, this mecha-
2% of body weight, are weakness, headache, and nism gets exhausted, causing an increased risk of
tachycardia to confusion symptoms [1]. overheating dependent on temperature and
humidity [2, 3].
In order to achieve physiological adaptation,
36.1.2 Regulation of Temperature regular physical stress under appropriate climatic
conditions is required. For a complete adaptation,
The body’s own thermoregulation is subject to up to 14  days are necessary. An increased con-
only slight fluctuations and ensures a largely con- centration of plasma proteins initially leads to an
stant body temperature in a range of 36.5– increase in plasma volume, because the osmotic
37.5  °C.  This is achieved through a complex pressure of the proteins leads to an increased
system of thermoreceptors in the central nervous amount of fluid being transferred from the tissue
system, visceral organs, musculature, and skin. into the vascular system. The increased blood
When the body temperature increases, for exam- volume reduces the heart rate required to main-
ple, more heat is released into the environment in tain cardiac output. Furthermore, the quality of
sweating is adjusted. The concentration of elec-
H. Krusemark (*) · A. Hackemann trolytes of the sweat is reduced in order to pre-
Department of Prevention and Sports Medicine, vent excessive electrolyte loss. These adaptions
Technical University Munich, Munich, Germany result in improved physical performance under
e-mail: [email protected]; these temperature conditions [4].
[email protected]

© ISAKOS 2019 481

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_36
482 H. Krusemark and A. Hackemann

The following recommendations can be afferent activity of muscle spindles with

derived from these findings. Before sports com- reduced inhibitory afferent activity of Golgi
petitions, a sufficiently long stay in appropriate tendon organs, both together cause an
climate is recommended. In addition, care should increased excitability of the muscle cell
be taken to ensure a sufficient supply of fluids membrane and muscle cramps [6]. The
and electrolytes and also carbohydrate intake if administration of saline-enriched liquid usu-
the exercise lasts longer than 1 h. It is also impor- ally leads quickly to an improvement of these
tant to have adequate sun protection through symptoms.
appropriate, light, and bright clothing, headgear, 4 . Heat Collapse
and sun cream [4]. The heat collapse is usually triggered by stand-
ing for a long time in a hot environment after
increased peripheral vasodilatation and an
36.1.3 Risks of Physical Exertion orthostatic shift of the blood into the legs have
in the Heat led to a reduced cerebral blood flow. However,
heat collapse can also occur after physical
There are six different types of heat damage. exertion such as a marathon run. Therapy is
similar to heat exhaustion (point 1) [7].
1. Heat Exhaustion 5. Sunstroke
The increased fluid loss under heat conditions The sunstroke is caused by direct sunlight on
leads to dehydration with fatigue, dizziness, the head and neck area, which leads to irrita-
headache, and increased thirst. The body tem- tion of the meninges. It manifests in dizzi-
perature can still be normal. The athlete ness, nausea, vomiting, headache, ear noises,
should be carried to a cool place and lie flat or disturbances of consciousness, stiff neck up
with slightly raised legs in case of circulatory to cramps, and coma. Worth mentioning is the
instability. Tight-fitting clothes should be frequent delay between sun exposure and the
opened or removed and cool air supplied to appearance of symptoms. Depending on the
the body if possible. Furthermore, sufficient severity of symptoms, treatment measures are
hydration should be achieved (referable by similar to the measures at heat exhaustion (in
ingestion of sodium-containing drinks) [5]. addition, attention should be paid to slight
2. Heat Stroke lifting of the head), or a drug therapy should
A heat stroke is a life-threatening form of heat be administered. This includes the treatment
exhaustion with body temperature rising to with electrolyte drinks or in severe cases with
over 40 °C. Additionally severe neurological an infusion (Ringer solution, about 500–
and cardiovascular symptoms such as dizzi- 1000 mL) [8].
ness, cramps, cardiovascular instability, vom- 6. Hyponatremia
iting, or even coma can occur. In addition to In association with long time exercising,
the measures of heat exhaustion, medication excessive intake fluids low in electrolytes (and
has to be intervened in most cases in the sense hereby especially sodium) and/or increased
of shock therapy. The fluid intake is usually loss of sweat, thus electrolyte, can result in an
intravenous [5]. imbalance of sodium-deficient electrolytes.
3. Heat Cramps The symptoms are weakness, nausea with
They occur mainly in heavy physical stress vomiting, muscle spasms, disorientation, and
combined with a greatly increased loss of swollen extremities. In severe cases, it can
sweat. Due to the liquid and electrolyte shift, lead to brain or pulmonary edema. The ther-
there is an impairment of the membrane sta- apy is carried out with medication through
bility of the cells, and this leads to muscle careful fluid administration and further in
cramps. New explanations suggest that mus- the  hospital, because of potential serious
cle fatigue is a reason for the onset of muscle complications. It is important that the hypona-
cramps. This fatigue results in increased tremia is treated slowly and in a controlled
36  Sports Under Extreme Conditions 483

manner. In case of hyponatremia with moder- (including analgesics, antibiotics) or surgical

ate symptoms, causes are medicated; in severe therapy may also be necessary [8].
symptoms, an infusion of 150  mL of 3%
saline solution should be administered over
20 min [9]. 36.2.2 Hypothermia

Hypothermia occurs when the body temperature

36.2 Sports in the Cold falls below 35  °C.  When practicing sports, par-
ticularly swimmers, tired endurance athletes, and
Physical activity at low temperatures also repre- athletes under alpine conditions have a high risk
sents a particular stress for the athlete, as pro- of hypothermia. There are four stages of hypo-
cesses that consume a lot of energy and can thermia [10]:
severely restrict performance are necessary to
maintain heat. Extreme cold leads to an increased • Stage I (mild hypothermia): Core temperature
release of stress hormones. These cause among 35–32 °C. Symptoms: shivering.
other things a constriction of the vessels (vaso- • Stage II (moderate hypothermia): Core tem-
constriction) and muscle tremors [2]. Due to the perature 32–28 °C. Symptoms: no more shiv-
reduced blood circulation of the muscles, there is ering; the consciousness is increasingly
a faster consumption of energy sources (glucose clouded.
and glycogen) and consecutively increased lac- • Stage III (severe hypothermia): Core tempera-
tate production. At the heart, extreme cold leads ture 28–24  °C.  Symptoms: no or only weak
to a peripheral vasoconstriction and thus to an vital signs, cardiac arrest or minimal circula-
increase in cardiac preload, stroke volume, and tion, and unconsciousness.
cardiac output. The stimulation of stretch recep- • Stage IV: Core temperature <15 °C. Symptoms:
tors located in the atrium leads to the release of a death.
diuresis-promoting hormone (ANP). With regard
to breathing, there is an increased respiratory rate In mild and moderate hypothermia, passive
and increased oxygen uptake. Furthermore, the reheating measures (wrapping in warm blankets)
thickness of the subcutaneous fatty tissue and the should be carried out. In addition, an improve-
influence of wind and humidity are decisive for ment in environmental conditions must be consid-
the perception of cold. When moving in cold ered (placing the supercooled person in a warm,
water, considerably more heat energy is lost than wind-protected environment, taking off wet cloth-
when moving in air at the same temperature. For ing). In severe hypothermia, there is an increased
the exercise in cold weather, it is important to do risk that the cold blood from the body periphery
a sufficiently long warm-up and wear appropriate will be mobilized into the core of the body through
clothing in order to avoid strong energy-consuming movement during the rescue of the unconscious
shivering and thus ultimately a drop in core body patient. This can lead immediately to cardiac
temperature [2]. arrhythmia which is difficult to treat and possibly
even fatal (afterdrop) [10]. This is because a hypo-
thermic heart has a lower fibrillation threshold,
36.2.1 Cold Damage which means that cold blood can be a stimulus to
trigger ventricular fibrillation (when warm and
Skin temperatures in the range of 0 °C may result cold blood mix). Therefore, a very careful rescue
in a local frostbite of exposed skin areas on the in a horizontal position is important. Reheating
body. There are three different stages: superficial then takes place in the ambulance or hospital.
frostbite, blistering, and necrosis. For treatment If this is not possible, a combination of internal
the damaged areas should be warmed up, e.g., by (warm infusion solutions and warm peritoneal
a water bath with increasing temperatures. lavage) and external (warm air blankets)
Depending on the degree of severity, drug reheating has to be carried out [11]. With regard
484 H. Krusemark and A. Hackemann

to resuscitation measures, it must be taken into composition of the gas components in the air
account that severe hypothermia significantly (Dalton’s law), this corresponds to an increas-
reduces metabolic activity, especially in the brain, ingly reduced oxygen partial pressure. This
so that a longer circulatory arrest can be more means that the oxygen content in the inhaled air
likely to be survived than at normal temperatures. and, thus, also in the blood is reduced. This leads
Thus, the brain can endure a ten times longer car- to different adaptive reactions in the organism.
diac arrest at 18 °C than at 37 °C. Resuscitation Acutely, there is an increase in heart rate, blood
should not be stopped until a body temperature of pressure, and increase in respiratory activity. In
at least 36 °C is reached (“Nobody is dead until he addition, due to the drop in oxygen partial pres-
is warm and dead”) [11]. sure, hyperventilation occurs which leads to
respiratory alkalosis. The alkalosis causes a left
shift of the oxygen binding curve, which leads to
36.3 Sports at Altitude an improved oxygen uptake in the lung and a
poorer delivery into peripheral tissues. This
When staying at altitude, the organism must increases the affinity of hemoglobin for oxygen
adapt to many different environmental conditions and reduces physical performance [12].
compared to staying at normal altitudes. The Even after a few days, there is no complete
increased radiation intensity and the reduced out- adaptation of the cardiac-circulatory system.
side temperature require, in particular with regard The performance and the oxygen saturation at
to the equipment, adequate clothing and corre- rest and under load remain below the initial val-
spondingly a high sun protection factor [12]. ues at sea level. The heart rate at rest and during
With increasing altitude, the air pressure exercise is also higher than at the sea level
drops. However, with a constant percentage (Fig. 36.1) [13].

Cognitive Performance
100
154
Resting SaO2
Physical and Cognitive Performances (%)

80
Exercise SaO2 147
SaO2 (%), AMS incidence (%),

Exercise Heart Rate (beats/min)

(144 watts)

60 Physical Performance 140

Exercise Heart Rate 133

40 (144 watts)

126

20
119
AMS Incidence
0
112

Sea Level 1 2 3 4 5 6 7 8 9 10
Days at Pikes Peak (4300 m)

Fig. 36.1  Representative time course for altitude acclimatization of low-altitude residents directly ascending to
4300 m (Muza, Beidlemann et al. 2010) [13]
36  Sports Under Extreme Conditions 485

Oxygen deficiency leads to a stimulation of severe headache can occur. An immediate descent
the hormone erythropoietin (EPO), which is pre- of at least 1000 m is recommended, possibly with
dominantly produced in the kidney, and conse- oxygen intake. A further medicinal and deconges-
quently to an increased and accelerated formation tant therapy is also necessary. In severe AMS or
of new erythrocytes. Thus, the oxygen transport incipient HACE, an intake of 8 mg of dexametha-
can be further improved. sone, followed by 4 mg every 6 h, is recommended
[8]. If it is left untreated, the increased brain swell-
ing can lead to a coma or death.
36.3.1 Altitude Sickness
36.3.1.3 High-Altitude Pulmonary
The changes mentioned under altitude conditions Edema (HAPE)
can lead to so-called altitude sickness. There are When a HAPE occurs, it comes to a dry cough,
three different forms which occur individually or dyspnea already at rest, and possibly rattling
in combination and can typically manifest at a sounds in the lungs with bloody-foamy phlegm.
height of 3000–4500  m, but occasionally at a An immediate descent of at least 1000 m is rec-
height of 2500 m: ommended, as well as the administration of oxy-
gen and other drugs that reduce the pulmonary
1 . Acute mountain sickness (AMS) hypertension. To reduce pulmonary pressure,
2. High-altitude cerebral edema (HACE) 10–20 mg nifedipine and 2 × 50 mg sildenafil are
3. High-altitude pulmonary edema (HAPE) prescribed [8].

For the prevention of altitude sickness, it is

advised that an ascent from 2500 m should not be 36.4 Diving
higher than 400 m per day. In addition, acetazol-
amide (at least 250 mg/day) can be taken to pre- Diving has become increasingly popular.
vent altitude sickness [14]. However, not only healthy persons but also per-
sons with, e.g., determined cardiovascular dis-
36.3.1.1 A  cute Mountain Sickness eases can participate in this sport under certain
(AMS) conditions. Therefore, certain physical parame-
Typical symptoms include headache, nausea/ ters must be taken into account, and any risks
vomiting, loss of appetite, weakness, dizziness, must be clarified by a medical eligibility test for
and sleep disturbances. The symptoms often diving.
appear only a few hours after the start of the stay The law of Dalton states that the total pressure
in the altitude and can increase to even higher of a gas is composed of the partial pressures of all
amounts on further ascent. If the above symp- gases contained in the gas mixture. Therefore,
toms did not improve, the affected person should not the percentage of the gas but its partial pres-
descend 500–1000  m. Patients suffering from sure is crucial. Under physiological conditions,
AMS are typically treated by halting ascent and the percentage, thus, remains the same, but the
using nonsteroidal anti-inflammatory drugs such level of the ambient pressure has a significant
as acetaminophen or aspirin for headache and, in influence on the partial pressure. When diving the
some cases, antiemetic drugs for nausea [8]. ambient pressure increases with increasing depth
of water and thus the partial pressure of the indi-
36.3.1.2 High-Altitude Cerebral vidual gases. In general, the total pressure
Edema (HACE) increases by 1 bar per 10 m depth. Dives deeper
The symptoms are similar to those of AMS, but also than 40  m are the absolute limit for the scuba
consciousness and balance disorders and particularly diver [15].
486 H. Krusemark and A. Hackemann

36.4.1 Diving Conditions rapid emergence while holding one’s breath.

There is a significant increased pressure within
The increase in the oxygen partial pressure can the lungs, which can lead to a rupture of the tis-
lead to a toxic effect of the oxygen at very great sue and vessels and also to the passage of gas
depths (Paul-Bert effect). However, larger prob- bubbles into the bloodstream (gas embolism).
lems are caused by the increase in nitrogen par- Typical symptoms of pneumothorax include
tial pressure. When diving with so-called coughing and dyspnea. The particularly severe
compressed air, i.e., using a breathing mixture form, the tension pneumothorax, can quickly
which has the same composition as the ambient lead to a life-threatening situation with circula-
air, there is a particularly strong increase in nitro- tory failure. An immediate medical therapy is
gen partial pressure, as nitrogen physiologically necessary. Depending on its location in the vas-
has a proportion of 79% of the respiratory cular system, gas embolism can cause various
mixture. mild neurological as well as life-threatening
Therefore, gas mixtures are used for diving symptoms. The first-line therapy is the adminis-
which have an altered percentage of the individ- tration of oxygen and when necessary also in a
ual gases. In these gas mixtures, the oxygen con- pressure chamber (hyperbaric therapy) [15].
tent is increased and the nitrogen content reduced.
This may reduce the incidence of decompression
sickness (see below), but it also carries the risk of 36.4.4 Decompression Sickness
increased oxygen toxicity. Hence, meticulous
calculations are necessary to plan a dive. Under the increased ambient pressure during
diving, the respiratory gases in the lungs
increasingly dissolve into solution and accu-
36.4.2 Nitrogen Intoxication mulate in the tissue. When the ambient pres-
(Rapture of the Deep) sure is reduced, i.e., when emerging, the
opposite happens: dissolved gases coming out
An increased ambient pressure may lead to an of solution. This can result in damage to vari-
intoxication with nitrogen, also called a rapture ous tissues. Frequently affected are the mus-
of the deep. Depending on depth and nitrogen culoskeletal system (muscle and bone pain),
pressure, symptoms range from mild euphoria to the skin (itching), and the nervous system
severe dysregulation with hallucinations and (numbness, balance disorders). Severe courses
coma to death. If the first symptoms of nitrogen with circulatory disorders, pulmonary embo-
intoxication occur, the partial pressure must be lism, and neurological deficits are also possi-
reduced by emerging slowly [15]. ble. A medical therapy is immediately
necessary. For this purpose, the patient must
be placed in a pressure chamber. There, the
36.4.3 Barotrauma patient is first exposed to a pressure corre-
sponding to diving, and then a slow decom-
Due to the strong pressure fluctuations during pression is started [8].
diving, injuries can occur to air-filled cavities
that are connected to the surrounding atmo-
sphere (middle ear, paranasal sinuses, lungs). References
This can happen both during the dive and reap-
pearance. Barotrauma of the ear, nose, and throat 1. Dickhuth H-H.  Einführung in die Sport- und
can cause hearing loss, nausea, vomiting, dizzi- Leistungsmedizin. Schorndorf: Hofmann; 2016.
2. Birnesser H, et  al. Praxiswissen Sportmedizin.
ness, nosebleeds, and pain. The treatment is usu- Münster: Philippka-Sportverlag; 2008.
ally symptomatic. Pneumothorax is a severe 3. Raschka C, Nitsche L.  Praktische Sportmedizin.
form of barotrauma. This can evolve during Köln: Georg Thieme Verlag KG; 2016.
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4. Racinais S, et  al. Consensus recommendations on Kurkowski E, editors. Kompendium der Sportmedizin.
training and competing in the heat. Scand J Med Sci Wien: Springer; 2017.
Sports. 2015;25:6–19. 11. Resuscitation G. Reanimation 2015. Leitlinien kom-
5. Wonisch M, et  al. Kompendium der Sportmedizin. pakt. A. Ulm; 2015.
Wien: Springer; 2017. 12. Luks AM, et  al. Acute high-altitude sickness. Eur
6. Qiu J, Kang J. Exercise associated muscle cramps— Respir Rev. 2017;26(143):160096.
a current perspective. Sci Page Sports Med. 13. Muza SR, et  al. Altitude preexposure recommenda-
2017;1(1):3–14. tions for inducing acclimatization. High Alt Med
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Heitkamp H-C, Tetzlaff K.  Sportmedizinische
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der Praxis. 2016;43(4):7. F, Röcker K, Berg A, editors. Sportmedizin für Ärzte.
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Wonisch M, Hofmann P, Förster H, Hörtnagl H, Ledl-
 Sports After Knee Arthroplasty
37
Bujar Shabani, Dafina Bytyqi, Cécile Batailler,
Elvire Servien, and Sébastien Lustig

37.1 Introduction According to AJRR (American Joint

Replacement Registry), 480,581 primary total
Life expectancy changed because people changed knee arthroplasty were performed during 2017.
the way they lived.
Lauren Carstensen, PhD.
In addition, in the United States, the demand for
primary total knee arthroplasty is estimated to
People wish to stay more and more active, and grow by 673% from 2005 to 2030, leading to 3.5
as a consequence physical activity can ameliorate million annual procedures [4], while UKA is
affluence-related chronic disease such as cardio- approximately 5% of all knee arthroplasty in
vascular disease, diabetes mellitus, and cancer [1]. AJRR.
On the other hand, the prevalence of osteoar- The aim of this chapter is to discuss the key
thritis affecting the knee is rising. Consequently, points about returning to sports after TKA and
individuals with osteoarthritis have lower physi- UKA.
cal activity comparing their fellows [2]. In a
national US survey, 44% of persons with arthritis
were classified as inactive compared to 36% of 37.2 Patient Expectations
adults without arthritis [3].
But, is the joint replacement a solution for Patients’ expectations are particularly important
this? because they are linked to request for elective and
possibly costly treatments and are strongly
Illustrations by Rosa Ballis related to patients’ assessments of outcome [5].
B. Shabani Moreover, the patient expectations are strongly
Heimerer College, Prishtinë, Kosovo associated with patient satisfaction. The more
Orthopedic Department, University Clinical Center exigent the patients, the greater is the risk of dis-
of Kosovo, Prishtinë, Kosovo satisfaction after surgery. Therefore, it is crucial
D. Bytyqi for surgeons to thoroughly explain to patients not
Orthopedic Department, University Clinical Center only the benefits but also the risks and limitations
of Kosovo, Prishtinë, Kosovo
of the total knee arthroplasty.
C. Batailler · E. Servien · S. Lustig (*) The primary goals of knee arthroplasty have
Albert Trillat Center, Lyon University Hospital, Lyon,
traditionally been pain relief, regain range of
France
e-mail: [email protected]; motion, and restoration of daily living activities,
[email protected] with patients commonly discouraged from

© ISAKOS 2019 489

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_37
490 B. Shabani et al.

p­ articipating in high-activity athletics. However, been inactive in the year before surgery [10].
nowadays patients’ expectations regarding the Naal et  al. demonstrated that patients treated
procedure have increased; they expect to restore with UKA are generally very active before the
their “before osteoarthritis” activities including operation. The proportion of patients able to
athletic activity. return to sports was 95% following UKA and
De Achaval et al. found that not all patients 34–88% following TKA [11].
have similar expectations [6]. Patients’ expec- Identification and selection of patient are very
tations are formed by many factors, including important, especially for UKA. Geller et al. have
their personality characteristics, social class, shown that proper selection in accordance with
interactions with health professionals, and the indications and contraindications for UKA is
information obtained through their individual the important factors for the success of UKA in
research [7]. In addition, a multicenter cohort regard to returning to sport [12].
study found that younger patients, male What is considered “safe” athletic activity and
patients, and those with better preoperative what constitutes “excessive” and therefore dan-
health status had higher expectations regarding gerous athletic activity that may threaten the
postoperative outcomes [8]. Older age, being integrity of the implant?
female, and worse pain predicted longer recov- Swanson et  al. have shown that physical
ery expectations [6]. activity helps patients after total joint arthro-
plasty (TJA) enhance the quality of the interface
between the bone and prosthesis [13]. On the
• Explain thoroughly to patients the ben- other hand, the surgeon concerns that participa-
efits but also the risks of surgery. tion in sporting activities following TJA
• More exigent the patients the greater is increased joint load and consequently higher
the risk of dissatisfaction. joint load can result in increased implant wear,
• Older age, being female, and worse pain periprosthetic osteolysis, and eventual prosthetic
predicted longer recovery expectations. failure [14, 15].
Huch et  al. in their study advise against
high-­impact sports activities after total joint
replacement, in order to protect the life span of
37.3 Return to Sports the prostheses [16]. In contrast, because of
increasing patient desires to engage in a highly
Due to the improvement of surgical technique active lifestyle, especially young patients,
and design of the implants, surgeons may now many surgeons now promote a more liberal
recommend participation in more demanding level of athletic activity after TJA. Survey data
physical activities. However, the level of physi- from Knee Society found that the number of
cal activity can be influenced by multiple fac- “not recommended” sports decreased from
tors including sociodemographic characteristics, 1999 to 2005 while activities that were
postoperative pain, and functional status [9]. In “allowed with experienced” or “allowed”
addition, being active before operation plays a increased [7, 17].
very important role. Sixty-five percent of While sport activities after total joint replace-
patients participated in sports before surgery, ment remain a debated topic, surgeons should
respectively, and 77% who had participated in give to patients the best postoperative instruc-
regular exercise in the year before surgery tions on returning to sports based on existing evi-
returned to sports, compared to 35% who had dence, and not based on patient desires [17].
37  Sports After Knee Arthroplasty 491

37.5 Biomechanical
• Being active before surgery plays a very Consideration
important role.
• Physical activity enhances the quality of Knee forces across the knee are very important
the interface between the bone and after knee arthroplasty because unlike biological
prosthesis. tissues, the material used in knee replacement do
• From 1999 to 2005 sports that were not regenerate or remodel [25].
“allowed” or “allowed with experienced” In a study, Argenson et al. have found that
increased. subjects with UKA experienced kinematic
patterns similar to those of the normal knee
[26]. On the other hand, other studies con-
37.4 H
 ow Long Does It Take clude that despite improvements, the knee
to Return to Sports? kinematics in TKA group differed from
healthy control group. TKA group had a
Patients after joint replacement want to go back lower extension and lower range of axial
to sports as soon as possible. Concerning the rotation and an increased tibial posterior dis-
timing, UKA is superior to TKA. Lombardi et al. placement [27]. Also, many TKA exhibit a
suggested that minimally invasive UKA using a mismatch between the femoral and tibial
rapid recovery protocol allows patients a faster radius with high peak pressures on the poly-
return to a more functional level than TKA [18]. ethylene inlay [28].
Munk et al. have shown that leg extension power There is a correlation between the angle of
reached preoperative levels after 1  month [19]. the load on the knee joint and polyethylene
Similarly, DeClaire proved that most patients wear. Kuster et  al. demonstrated that jogging
will return to normal daily activities within and downhill walking produced large areas of
10–14  days and can be relatively active within overload polyethylene. Most knee implants
4–6 weeks after surgery [20]. have a higher congruency near extension,
Patients also seem to be able to maintain these which decreases with increasing flexion, lead-
activity levels. Walton noted that 67% of their ing to a smaller contact area between femoral
patients returned to and maintained the same or and tibial component. Therefore, activities
an increased level of activity at a minimum fol- with peak loads near extension, such as walk-
low-­up of 12 months after UKA [21]. In addition, ing (20°), produce less stress on the polyethyl-
Canetti et  al. reported that robotic-assisted sur- ene than activities with peak loads in more
gery for lateral UKA reduces the time to return to flexion, such as jogging (60°). A patient after
sports at a patient’s pre-symptomatic level. This TKA participated in a marathon run despite
robotic tool permits surgeons to be less invasive being discouraged by the surgeon. The poly-
regarding soft tissues and bony resection, which ethylene inlay broke at the 35-km mark due to
may lead to a shorter recovery [21]. severe delamination and destruction.
On the other hand, return time to sport after Differently, cycling and power walking seem
TKA is longer. A study by Argenson et  al. has to be suitable activities while mountain hiking;
shown that patients after TKA need 6 months to patients are advised to avoid descents or at
return to mainly low-impact sports [22]. Hopper least use ski poles and walk slowly downhill to
and Leach reported a mean time of 4.1 months to reduce the load on the knee joint. So, it is very
return to low-impact sports [23], while Bock et al. important to consider both the load and the
reported an overall mean time of 4–7 months to knee flexion regarding recommendation suit-
return to both low- and higher-impact sports [24]. able for physical activities [28, 29].
492 B. Shabani et al.

37.6 Sports Recommendations low-impact aerobics are recommended to

patients with experience in these sports in
Waldstein et  al. demonstrated in a systematic order to minimize risk of injury and acceler-
review that 8 out of 17 studies showed a signifi- ated implant wear.
cant decrease returning in high-impact activi- –– Very high-impact activities like racquetball,
ties and a significant increase in low-impact running, high-impact aerobics, most ball
activities [30]. sports, martial arts, and rock climbing should
A guideline developed by Clifford and Mallon be discouraged because of higher-risk injury.
recommends [31]:
Vogel et al. in their study have more or less the
–– Low-impact activities like golf, swimming, same recommendations (Table 37.1) [17].
walking, stationary bike, treadmill, and ellipti- Golf is very popular among older adults, but
cal machines are recommended activities to loss of motion in arthritic knee makes it difficult
all patients. to play. So, many golfers see the TKA as a solu-
–– Potentially low activities like bicycling, speed tion in order to be able to continue playing golf.
walking, cross-country skiing, dancing, Mallon and Callaghan reported on the largest
Pilates, and rowing are recommended to group of patients undergoing TKA in active play-
patients with good balance and propriocep- ers and defined playing golf as greater than three
tion. In addition, these patients should be times per week. Eighty-four percent of the golf-
monitored by their surgeon regularly. ers reported no knee pain during the activity,
–– Intermediate-impact activities like tennis, hik- while 62% reported no pain and 35% reported
ing, downhill skiing and snowboarding, mild knee pain after the activity [32]. This pain is
weightlifting, ice skating, rollerblading, and more common in the leading knee and has been
37  Sports After Knee Arthroplasty 493

Table 37.1  Activity recommendations after TKA [17]

Recommended Recommended with experience Not recommended
Low-impact aerobics Cycling Racquetball/squash
Bowling Hiking Contact sports (football, hockey, soccer)
Golf Rowing Rock climbing
Dancing Cross-country skiing Jogging/running
Walking Stationary skiing Single tennis
Swimming Speed walking Waterskiing
Doubles tennis Baseball/softball
Ice skating Handball
Martial arts

attributed to increased torque. In addition, Judo is a contact sport, in which opponents

D’Lima et al. demonstrated that increased load- use balance and body weight, with minimal phys-
ing in the leading knee during golf swing may ical effort, to throw or pin each other down or
also be a contributing factor of pain [32, 33]. hold each other in a lock.
Moreover, the length of the drive was reduced by Lefevre et  al. have shown that 62.5% of
12 yd following knee replacement [32]. patients return to practice noncompetitive judo,
Regarding if the golf is recommended or not, 5.2  months (mean) after total knee replacement
a 2009 survey of members of the American [34]. It is important to note that this was not the
Association of Hip and Knee Surgeons found that recommendation of the surgeons. This was the
over 95% of members do not restrict patients desire of the patients, because it is difficult for a
undergoing TKA from playing golf [13]. judoka to give up practicing this sport because
Furthermore, golf is part of the recommended/ Judo is also a life philosophy [34]. However,
allowed sports after TKA. patients must be informed of the higher risk of
complication if they practice intensively.
It should be considered that in our knowl-
edge, this is the only study about “Judo after
TKA” and this study has a selection bias because
it only included subjects practicing high-level
judo who were still licensed at the French Judo
Federation [34].
Tennis has a long history, and nowadays more
and more people are choosing it as a way to
maintain their fitness. Playing tennis can vary
from high-impacted singles play to low-impacted
social doubles play. Vogel et  al. in their study
have included doubles tennis as recommended
with experience [17]. Playing doubles than sin-
gles is recommended, since it gives you a smaller
court area to cover and is less physically demand-
ing. It is also recommended a clay court surface,
since it is softer and slower than hard courts.
Also, wet surfaces should be avoided.
Mont et al. have shown that competitive tennis
players were able to perform at a high level in
their tennis activity after total knee arthroplasty
as they were in their preoperative state. These
494 B. Shabani et al.

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 Ringside Medicine
38
Joseph John Estwanik

38.1 Background 4. Innumerable disciplines to include judo, jiu-

jitsu, tae kwon do, and so many others
Ringside Medicine has now approached the dis- 5. Wrestling
tinction of becoming a subspecialty within medi- 6. Men/women
cine! OK, sub subspecialty. The physician 7. Youth/adult
attending to these dedicated athletes within the 8. Diverse venues: indoors, outdoors, large, and
combat arts provides an array of services that small
blend expertise within many medical subspecial- 9. The “alphabet soup” of various ruling bod-
ties for this subset of athletes [1]. We as physicians ies, state/federal oversight, and sanctioning
are obligated to create safety for those dedicated bodies
athletes who train and compete within their sport. 10. Multiple countries of origin with their cul-
They have earned the right to equal application of tural traditions
sports medicine technology and standards of care.
The awareness of distinct mechanisms of injury Virtually every country for many centuries has
allows predictive and then accurate diagnoses [2]. evolved their uniquely named and highly specific
The demands of these combat sports (more than a martial arts style: Kung Fu, China; Muay Thai,
contact sport) must be grasped so as to provide Thailand; Arnis, the Philippines; etc.
sports-specific rehabilitation and safely efficient Boxing has become the adopted style for the
return to play expectations. Ringside Medicine [3] United States. An awareness of customs goes a
provides a broad expanse of responsibility as its long way in developing rapport and trust within
physicians must be knowledgeable and then this community. Fellowship, mutual respect, and
respected by those competing within: an understanding of rules, regulations, and proto-
col are critical. Period!!!
1. Amateur boxing When a fighter suddenly goes down, ringside
2. Pro boxing duties do not fall under “first aid” but truly
3. Mixed martial arts “immediate” aid, with many people watching.
There is no locker room present for privacy, no
team of athletes to shield one by other activities,
J. J. Estwanik (*)
USA Boxing, US Olympic Training Center, no half times, no braces, and no substitutions.
Colorado Springs, CO, USA The clock is often still running.
Metrolina Orthopedic and SportsMedicine Clinic, In reality, the physician for large pay-per-
Cornelius, NC, USA view televised events as well as small local

© ISAKOS 2019 497

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_38
498 J. J. Estwanik

shows must be proactive and realize that he too 2. Perform physicals. Important questions to ask
is a member of a team with the obligation to for predicting fitness and preparation are:
manage his doctorly duties just as others profes- • What is your fight record?
sionally allow “the show to go on!” Just as the • How many miles/week do you run?
sound, lighting, TV, and all other technical • How many weeks of training for this event?
aspects are professional and highly synchro- • How much weight did you lose?
nized, the ringside doctor assumes the role of 3. Utilize the pre-printed forms for the history,
the physician producer. Success measured in physical exam, and injury reports.
safety outcomes doesn’t just happen, and a 4. Perform a facility walk-thru:
Ringside Physician should create an agenda for • Meet the referee.
success. You cannot just show up at your seat as • Claim your location at ringside.
the bell rings and the show goes live. Nor can • Meet security, introduce yourself, and plan
you exit as the lights dim with last bout! There ingress/egress and crowd control.
are multiple segments for a Ringside Physician • Find the treatment rooms.
agenda and checklist [3]. • Find all of the athlete locker rooms label-
ing each athlete’s name on the doors.
• Examine the ring for cleanliness, ropes,
38.2 Early apron size, and ring ties (2/each side of
ring ropes).
1. Review and discuss your expected and con- • Evaluate lighting and obstructions for
tractual obligations regarding salary and vision or entry.
arrival dates/times for the various functions • Timekeeper’s location to possibly commu-
including physicals. nicate a rapid time-out.
2. Analyze the credibility/reputation of the
• Exact rescue squad location and introduce
promoter. yourself with proper protocol.
3. Confirm the promoter’s duties to obtain sup-
port services such as a dedicated ambulance,
oxygen, stretcher, and cervical collar. 38.4 Intrabout
4. Know the calculated distance/transport time
to emergency rooms with neurosurgery 1. Review Dr E’s ten rules for ringside

services. observation.
5. Walk the facility and be sure that there is tele- 2. Basic tools of the trade: gloves, sponges,

phone or cellular signal. flashlight (torch), and oral airway.
6. Confirm the presence of proper support staff
based on the event size and magnitude. A
“team” approach with assisting medics, 38.5 Ring Responses
nurses, and physician assistants creates effi-
ciencies. Create teams A and B to simulta- 38.5.1 Short of a Knockout
neously cover the ring as well as locker
rooms. The referee, the “third man” in the ring, usually
and customarily stops a bout. The boxer is depen-
dent upon intervention by a neutral party, the ref-
38.3 Prebout eree. In case you are summoned by the referee to
evaluate a fighter, ascend the steps or have the
1. Hand out the history questionnaires. Preferred cage door opened near your seat [1, 2].
are those created by the Association of Actually, your seating for a MMA event should
Ringside Physicians available within their be very close to the door so that you may respond
website. to emergencies or enter for your opinion. In the
38  Ringside Medicine 499

majority of cases, your evaluation and grasp of the tinue, do so with authority. If you end a bout, do
ongoing scenario are not a surprise. By alertly so with authority. Do not leave room for ongoing
observing the circumstances within each round, scrutiny or it will go on and on. But, if allowed by
your analysis is in evolution at all times, and your your commission, answer questions based on
response and decision are anticipated rather than a medical science. No one knows more about
surprise. I highly prefer that the doctors, if two, are sports medicine than an ARP-certified Ringside
seated together rather than opposing corners. Physician. Simply explain the science without
Separating the physician robs the advantage of emotion. The undisputed fact is when a boxer is
scholarly discussion and shared opinion. Most usu- no longer able to defend himself, the bout must
ally, assigned Ringside Physicians are of differing end. An early fight physician, Dr. McGown,
subspecialties. The ability to learn from each other states, “A bout must be stopped minutes early,
and share input always benefits those athletes com- rather than seconds late.” Remember: the rules,
peting! Have your “tools of the trade” already open tradition, and protocol do not provide a mech-
and avoid wasting time. Hygienic gloves, sponges, anism to “quit” in traditional boxing or mar-
and a flashlight should be ready to go. tial arts. Mixed martial arts does uniquely
Once requested, enter the ring with compo- employ the “tap out” as a safety mechanism, if
sure. The referee will usually bring the athlete to the competitor wisely opts to do so. If, upon
you if possible, or you may need to travel to a examining an athlete either during the physicals
more compromised or fallen athlete. So many or within the heat of a bout, you sense their bro-
times, your opinion as to a cut, eye poke, or sore ken spirit, you must be the one who provides
rib pertains to your monitoring, not necessarily an their honorable way out. Accept this gift and
emergency. The ref just wants your input as a situ- responsibility to represent your patient. You can
ation is evolving. At this time, take your time. be the bad guy! You take the blame. This has hap-
Speaking to the athlete, more closely evaluating a pened to me on many occasions. Once I have for-
cut, checking vision, or palpating tender ribs can mally advised the bout to cease, with the athlete
be performed in an unstressed manner. Just non-verbally or verbally asking me quietly to
remember, during a bout, the doctor is not allowed stop the bout, they will often put on a show com-
to treat an injury. You are simply assessing for the plaining of the decision. They have to save face.
ability for this one athlete to safely continue. To Most usually, latter during the show, he/she
be fair, there is another athlete standing across the returns and sincerely thanks me for helping and
ring. Therefore, a lengthy and inefficient exam protecting them. That’s our job.
disadvantages the opponent unfairly. You can
always be called to reevaluate this same athlete in
question later within this round or in a subsequent 38.6 T
 he Sliding Scale
round. In my past, as I allowed a fight to continue of Tolerance
based on a cut, a second inter-fight viewing that
confirmed lengthening or deepening of a cut or Just this year during a presentation to the World
progressive decline of skills or alertness prompts Boxing Association international meeting [1, 2],
my advice to stop the bout based on accumulating I mentioned that I make different decisions dur-
evidence. If you do decide that a bout must end, ing amateur, pro, and championship events.
do so with decisive authority and self-confidence. Remarks emanating from an individual within
A wishy-­washy demeanor lacking confidence will the audience focused upon a doctor’s adherence
only invite questions and second guessing. A firm to the Hippocratic Oath and rendering equal
non-­subtle waving an end to the bout makes your treatment to all. My precipitated remarks cen-
life so much easier. tered upon the topic of cuts and other injuries in
One of my professors from London once general. Be it a facial cut, a bloody nose, a hand
quoted “Decisive hesitation is far preferred to injury, fatigue, and others, yes, I let the pro fight
hesitative indecision.” If you OK a bout to con- go longer than the amateur.
500 J. J. Estwanik

Within an entire career of practicing medi-

cine, we advise individuals differently based
upon circumstances. I actually used the knee
example of a torn anterior cruciate ligament.
In patient A who is a healthy athletic 25-year-
old, I would repair/reconstruct. In patient B
who is a wheelchair-­ bound 80-year-old, I
would not. A story was shared with me in my
early residency days by a mentor, Art Steffie,
MD.  He, of spinal Steffie plate fame, was
given advice in his early training days by
George Phalen, MD, of the carpal tunnel Fig. 38.1  A knockout in boxing
Phalen’s sign fame, “Art, I can teach you HOW
to do surgery and WHY to do surgery, but I 1. Continue protecting the cervical spine.
can never teach you WHEN to do surgery.” 2. Control random movements with the help
This wisdom applies to Ringside Medicine. from docs, referee, or EMTs.
There are absolutes but there also exists a slid- 3. Don’t get punched. I often kneel on the clos-
ing scale of tolerance for circumstances and est arm while ready to block a blow.
wise decision-making. This defines the 4. Reassure the awakening and often disori-
SCIENCE of medicine balanced with the ART ented fighter.
of medicine. By gaining experience within this 5. Provide commands to test awareness.
sport and subculture of combat sports, an abil- 6. Allow sitting on the canvas.
ity to properly navigate among science and 7. Allow sitting on a stool.
rules/regulations will allow proper decisions 8. Allow standing.
to prevail [3]. 9. Accompany the fighter to her corner.
10. Resume a more complete examination in the
privacy of a locker room.
38.6.1 Full Knockout 11. Report findings, diagnoses, and follow-up

needs to the coach and family.
1. Observe how he falls: from an accumulation
of blows, fatigue, or one solid punch? Severe acute brain injury can create a subdural
2. Where did the blow land: head or body? hematoma related to athletic injury. These brain
3. Was there a second injury mechanism of the compressing bleeds are the most common form
head hitting the canvas or the neck in ropes? of catastrophic brain injury within boxing and
martial arts. Epidural bleeds are far less common.
If a knockout (Fig. 38.1): Rapid recognition and urgent transfer efficiency
to emergency facilities equipped for neurotrauma
• Maintain the airway. are paramount to successful outcome! As we
• Protect the neck and assume a fracture until know in all sports, brain acceleration and decel-
proven otherwise. eration create the resultant forces. In boxing, the
• Do not remove mouthpiece unless grossly uppercut vertically and the cross punch horizon-
obstructing; it can be useful. tally form the coup and contrecoup pathology in
• Initiate verbal questions and commands. addition to the other expected multi-axis forces
• A flashlight exam may or may not be useful involved (Fig.  38.2a–c). Subdural hematomas
but displays concern and buys time. can viciously and rapidly occur but may also
• Look busy and concerned. more subtly and stealthfully expand into increas-
• Be time efficient but do not showboat. ingly recognizable symptoms. Within the ring,
“COMING AROUND” STAGE recognize degrading skills unrelated to e­ xhaustion
38  Ringside Medicine 501

a b

Fig. 38.2  Boxing blows: uppercut (a), punches (b), and contrecoup (c)

or dehydration. After a bout, instruct the athlete g­athered history during the physical exams
in question (and his coach) that they return to required by all participants in the combat arts is
your position at ringside at stated intervals for the of paramount importance. Remember, within
duration of the event so that you can monitor. You boxing and martial arts, each athlete must be
do not want to lose track of questionable but cur- examined every day before every bout [2, 3].
rently safe athletes. In impacted athletes who are
properly recovering with normal exams but wit-
nessed “tough bouts,” discuss with athlete, fam- 38.7 Postbout
ily, friends, or coach their responsibility for
monitoring that night and that limited sparring 1. Examine ALL fighters. Repeat evaluations as
and alcohol are common sense. In questionable needed throughout the event either as they
circumstances, send them to the hospital. Any return to the ring for a quick check-in or more
criticism for an ambulance request will be weak formally in the locker room.
and easily argued. Second-impact syndrome 2. Complete all injury forms.
occurs soon after a seemingly minor head injury 3. The doctor is the LAST to leave. Perform a
is suffered by an individual who is still experi- final “sweep” of all locker rooms.
encing symptoms from a prior concussion. This
syndrome, which involves rapid swelling of the In serving as a Ringside Physician, the good
brain, has a 50% fatality rate. Younger individu- news is that you possess the best location in the
als seem more exposed. Thus, our honestly house with unobstructed view and rapid access to
502 J. J. Estwanik

the excitement. The bad news is that this privi- access. As a unified and bonded group of friends,
lege carries with it the significant responsibility! we took seats with the audience. As the TV cam-
You are sitting in the “hot seat.” eras were about to go live, a loudspeaker
I will have to admit that when at ringside, I announcement sought our attention. Our group
wish for a boring fight although as a fan, I want waving from this remote location caught their
action and excitement. The goal of a Ringside attention and rapid relocation ensued. I guess
Physician is really not to be seen or needed. In this is termed “stand your ground” for athlete
reality, the embellished duties of ringside have safety. On many occasions, signage, advertis-
been inflated by a description often utilized ing, and photographers can obstruct your criti-
within the specialty of anesthesia—“hours of cal view (Fig. 38.4).
boredom, and moments of terror.” A fight doc Polite request for their relocation routinely
must demand the optimal visibility or leave the allows cooperation in the name of athlete
event. Be sure that access includes availability to health. When at cage side or within a high-
rapidly ascend the steps to enter the ring and mat intensity crowded event, it is so helpful to intro-
or open your Octagon gates (see diagram of ring duce yourself as the Doc to the security staff
setup, Fig. 38.3). who control access. The team concept
On one occasion, despite arriving early and immensely enhances all agendas and efficien-
“claiming” my seat for optimal visual surveil- cies. While at ringside, do not use your cell
lance and rapid access to the fighters, upon phone. A prominent fatality included audience
return, three ring girls had been placed in these video of the “unconcerned, inattentive”
doctor seats by the promoter. It was only when assigned physician constantly on the phone,
he understood that I was leaving for home and ignoring the final round and collapse of the
these three would now serve as his doctors; the staggering athlete. Even after the unconscious
seats were returned. On another occasion while fall to the canvas, the phone calls remained a
serving with four or five international physi- priority. Yes, this is on YouTube. If it is very
cians for an Olympic Qualifying America’s important to use my phone, I step away from
tournament finals, our immediate ringside seats, ringside, while a fellow physician takes over.
from this week-long tournament, were suddenly Or, I will wait until between bouts and step
delegated to the international press and VIPs. away, while an associate covers you. I never
We, docs, were allocated seats several rows dis- want to be witnessed with the phone near the
tant and remote from rapid response, vision, and active competition.

Fig. 38.3  Diagram of availability to rapidly ascend the Fig. 38.4  Obstruction of the Ringside Physician’s criti-
steps to enter the ring, mat, or open your Octagon gates cal view by press photographers
38  Ringside Medicine 503

38.7.1 The Ten Rules for Ringside my mindset and is readily quoted when poten-
Observation (Monitoring tially opening myself to criticism for demand-
Safety) ing that a bout be stopped.
4. Punch count—The active and busy competi-
Many years of observing the ups and downs of tor is rarely in trouble. When a boxer is throw-
competition from ringside have allowed me to ing punches, a wrestler working for the pin, or
establish ten practical monitoring hints. All of my a martial artist creating combinations, we
comments may not be based on researched, aca- know that they remain healthy. Again, a win-
demic calculations but with real-life basics [3]. ner can be predicted merely by “Who is
throwing?” and “Who is busy?” This is not to
I Can’t See His Eyes, but I Can Watch His Feet say that the winner cannot also be hurt.
1. Stance—A confident stance directly relates to 5 . Lowered arms—Unless one possesses a very
that participant’s skill level and training unconventional style, the sign of lowered arms
efforts. Balance means everything! A flat-­ means trouble. Fatigue and accumulated body
footed, wide-based posture infers either an blows will take their toll and drop the arms,
inadequately prepared novice or an injured thus opening the athlete to dangerous head
fighter. The progression to a staggering stance blows. Boxing coaches urge patience and
denotes head injury or other major problems. instruct the following pattern of attack to their
Early in the event, a confident stance with athletes: “Go to the body and the head will
eyes on the opponent confirms skill and train- follow.” Knowledgeable audiences also under-
ing. Mid bout, stance relates to balance. Late stand the concept of “working the body” as I
within a fight, a flat-footed, wide-based, or have amusingly heard them shout “Take the
staggering stance confirms problems. tires off that truck.” Sometimes elbows are
2. Ring movement—Here’s our chance to view lowered to protect injured ribs. At times an
“poetry in motion.” The art and grace of ath- injured extremity necessitates a one-armed
letics are no more evident than the floating, contest. More than once, I have intensely fol-
skillful movements of a dominant athlete. lowed, for a round or two, a boxer who slyly
Without consulting scoreboards, computers, shields an injured shoulder, elbow, or hand as
or bout sheets, the winner can be reliably pre- he protects his lead to hang on for the win. If
dicted by who “dominates” the action. The his defense remains adequate, I’ll hang on to
“running” boxer is the defeated boxer (unless the edge of my seat with him.
far ahead on points and purposely avoiding
the taking of risks). You can just base your Fatigue Factors
score on the gross positioning of the 6. Clinches—It is no surprise that tired athletes
competitors. “tie up” an opponent to slow the flow of
action. A tired, winning wrestler will ride his
I Can’t See Her Eyes, but I Can Watch Her opponent while failing to work for additional
Hands
points or a pin. Out of interest, I have counted
3. Defense—The big “D.” This third principle the number of tie-ups or clinches within box-
actually occupies the #1 safety priority and ing events. In martial arts events, these five or
reigns supreme for safe and timely cessation ten situations per round would have provided
of competition. An effective defense is the excellent opportunities for a grappler to bring
ultimate determinate for combat safety. When the boxer to the ground and into unfamiliar
defense is absent, the bout, match, or contest territory.
must cease. A winner has already emerged. 7. “Bruise news”—accumulated trauma—If
In  1979, Dr. I.  A. McCown wisely stated, an athlete is just plainly getting “beat up” and
“A one-sided contest should be halted minutes accumulating facial swelling, small cuts,
early, rather than seconds late.” This mirrors bloody nose, etc., the writing is on the wall.
504 J. J. Estwanik

Usually, the winners stay pretty, but extremely body language. A ringside doctor must know
competitive bouts may equally dole out pun- that the 1-min “time-­out” is NOT their time-
ishment. Even the winner may appropriately out but a highly profitable and telltale 60  s
be given a suspension in some circumstances. for predictive information gathering.
8 . Number of standing “8” counts—The By understanding and utilizing my ten
“standing 8 count” is utilized in all amateur rules of ringside observation, you’ll accu-
and some professional events. Amateur box- rately predict winners, losers, and impor-
ing rules stipulate defeat when a boxer tantly injuries. By alertly following a bout, I
receives three “8s” in a single round or a total estimate a 90% plus accuracy level in pre-
of four “8s” at any time within the ensuing dicting the injuries that will be present as
rounds. This is a good rule as it forces and competitors exit from the ring. However,
ends to a noncompetitive situation. This sports and the art of medicine will be forever
ceases one-sided contests. The argument humbling. Just when you think that you
against this states that an “8 count” scenario know it all, the ever-motivated loser lands a
allows the injured boxer unfair rest advantage lucky punch and knocks out his overwhelm-
and if the bout were allowed to continue ingly superior opponent or the wrestler
slightly more, the bout would be officially quickly reverses and pins his opponent. Do
ended, thus preventing the further accumula- not forget the critical follow-up exam in the
tion of trauma to the looser. I have mixed locker room after the session or during
opinion without a firm favoring conclusion. In breaks during the event. I have picked up
the end, if the referee performs his duty for the many injuries and complaints after the action
overall safety of the boxer, then either sce- and adrenaline subside.
nario allows for this conclusion.

Extraneous Factors 38.8 Medical-Legal Implications

9. Referee level of attentiveness—If a compe- of Ringside Duties
tent referee is handling the bout, the worries
of the doctor, coach, parent, and athlete can The sobering thought for ALL doctors covering
be eased. If a skilled referee is hyperalert to ALL athlete events focuses our concentration on
one athlete, hovering close to break up the DEFENSIVE AWARENESS—yes, defense of
action, moving in tight to peer into his eyes, our athlete’s right to safe and fair competition but
watch out! If good referees are nervous, I am also the safety of our medical careers and licenses
nervous. If bad referees aren’t nervous, I am [3]. My past duties have included the comprehen-
nervous. Their level of activity and attentive sive review of multiple catastrophic or fatal com-
focus mirror the flow of action and concern. bat sports deaths. Additional to these reviews,
10. Corner activity—Nobody should know testimony on several occasions further substanti-
their athlete better than his personal coach. ate my gained perspective.
Focusing on the coach’s facial grimaces, Should an untoward event occur, are many
smiles, intense posture, or relaxed body actions triggered? What are they looking for? Legal
imaging tells the tale of the tape. If they are review and scrutiny will fully access all records of
happy, I’m usually happy. If they focus the event: pre, intra, and post. For us that translates
hyperactive attention to a cut or an extremity into prebout exams, prebout history forms, envi-
during the 1-min rest periods between ronmental conditions, ring/cage setup and lighting,
rounds, I have an insider’s hint on what stock referee duties, efficiency of response, equipment,
to buy and where the money is. I am fore- ambulance availability, and post bout exam perfor-
warned as to what area to observe during the mance (to name a few). The written interview and
next round. If you get to know the coaches, recorded records will be subpoenaed and meticu-
you will better learn to accurately read their lously dissected. Those records investigated within
38  Ringside Medicine 505

cases to which I have been authorized for review and sports-specific focuses are documented.
are of many and varied sources: The Association of Ringside Physicians and
Association of Boxing Commissions websites
1. Everyone now has a camera, video, or smart- provide these forms.
phone. These recordings by passionate family, 5. The promoter and facility contracts will be
friends, televised events, or other athletes pro- reviewed. One fatality case disclosed that no
vide undeniable fact. ambulance and oxygen source were available
The efficiency of response will be scruti- because within remote pages of the event con-
nized second by second with an “attorney-­ tract, the responsibility (and cost) was marked
grade” stopwatch and microscope. Formal out but unnoticed until the emergency
depositions will in fact check claims and opin- occurred. This unnoticed cost savings did
ions. Be sure that you as a team physician indeed not go unnoticed. The value of that ath-
attend and supervise only sanctioned events lete’s life was beyond financial. Indeed, a
whether they be within the guidelines of USA Ringside Physician must demand dedicated
Boxing as an amateur event or professional ambulance and spine board, O2, and cervical
events approved and supervised by relevant collar at ringside. Check the facility O2 canis-
state, tribal, or national government ter. I well remember being shown the “prod-
institutions. uct” but felt thankfully compelled to check it
2. Any waivers or releases signed by participants myself, and, yes, it was “dead.” The ambulance
will be reviewed for declared facts or facts company did provide a full tank at ringside.
omitted by the athlete. A physician should Extremity splints are very appropriate articles
expect accurate historical information. Athletes to be demanded when covering mixed martial
who deceive may have short and eternal conse- arts events. The splinting of extremities in a
quences for their declarations. Always require boxing competition is rare. Within a large
athletes to sign your history forms to impress venue, clearly and at all times, know the posi-
and assure full cooperation. Circumstances tion of the EMT/ambulance team. On one
and cases have shown that athletes sustain a occasion at a massive globally televised MMA
prebout head injury in the gym while sparring event, these individuals with stretcher and sup-
for the competition but have denied or failed to plies were moved from their original position.
disclose that fact. In later interviews with In an urgent injury scenario, the doctor must
teammates, the wife or family reveals head- be able to initiate quick response verbal or
ache, loss of appetite, or personality variance. visual contact with his “team.” I have very
Several personal physical exams or review of definitely delayed events until the proper com-
records have picked up recent head injury ponents are in place. Once, the event attended
mechanisms from fights at school, auto acci- by 5000 paying customers was delayed for 2 h
dents, hitting the windshield, or street fights on a Saturday night because the promoter
not recognized by the athlete as a declarable failed to make arrangements for ambulance
prebout historical event. It wasn’t in boxing, service. Despite the city mayor and sheriff in
they say! Thus, I always ask: Have you EVER attendance, the crowd was informed that
been knocked out or unconscious or had a con- fighter safety was the preeminent concern.
cussion for any reason, at any time? Actually, they understood, and it was exhibited
3 . The individual passbooks or fight records of that safety is a dominant factor in boxing.
athletes can assist in identifying the risk fac- 6. Efficiency of care is paramount. The seconds/
tors of injury pattern, inactivity, losing streaks, minutes for physician entrance, evaluation,
sanction periods, win/loss record, recent com- action, administration of oxygen, airway posi-
petitions, or outright falsification. tioning, neck positioning with cervical stabili-
4. Our physical exams should be standardized as zation, splinting, evacuation from the ring, and
an efficient checkoff form so that pertinent transport will all be mapped out and quantified.
506 J. J. Estwanik

7. Beyond your control, the emergency room, 38.10 Defensive Awareness

admission, and operating room records will be Summary
viewed. Subsequent laboratory reports have in
my reviews confirmed the existence of illicit Based upon my medical legal experiences related
drugs present during the bout and obviously to ringside tragedy, the following summary pro-
undeclared by the combatant. Neuroimaging vides previous factors of contention and medical
and X-rays could disclose unhealed fractures concern.
or unhealed brain contusions/hemorrhage.
8. Several cases have disclosed at autopsy, find-
ings of preexisting but unresolved brain bleeds Salient points:
that predisposed to the ultimate disaster of
second-impact syndrome. Imaging and 1. No oxygen at ringside or a delay in
autopsy have also shifted the neuropathology administration.
from a fatal subdural to concurrent damage 2. No ambulance on site or significant
related to anoxia and probable lack of support- delay in response to time, no
ive care at ringside and transport. prearrangement.
Ring/cage integrity and setup should be at 3. Improper ring/cage setup:
least peripherally a concern to the physician as –– Too few ropes
he evaluates the venue pre-completion. Having –– No spacer ties
the ropes tight, two properly located spacer –– Ropes too loose
ties between the ropes on all four sides of the –– Padded obstacles near ring (stage or
ring, hygienic and clean mats, safe stairs into floor—two deaths resulting)
the ring, and an adequately wide ring apron 4. Inattention to altered details in event
(the area of padding outside of the ropes) contracts.
assure improved safety. I have studied two 5. No ringside doctor in attendance.
cases in which the athlete fell outside of the 6. Physician assistant substituting for
ring sustaining catastrophic injury in part due MD/DO.
to hitting their head on hard surfaces. While 7. Second-impact syndrome due to pre-
sitting at ringside, I have witnessed my ring existing head blows sustained and
actually collapse. The slow-motion earth- unreported prior to the bout.
quake sensation of having the ring creak and 8. Undisclosed medication or illicit drug
groan as this sinking ship tipped on its side abuse.
was surreal. The athletes clung to the ropes to 9. Two fights in 1 day.
avoid shipwreck. Fortunately, no crush inju- 10. No post bout exam given.
ries were sustained. 11. Inappropriate length of rounds as sur-
To prevent disasters, ringside doctors must facing on home video evidence.
make a “sweep” of all locker rooms and ath- Straying from the rules.
lete areas before leaving the venue. An athlete 12. Failure to respond to a crisis in a

was found dead in the abandoned locker room. humanitarian, concerned manner.
13. The responsibility of all parties includ-
ing the referee will be scrutinized.
38.9 To Prevent Catastrophe

The doctor is the last to leave! Actual quotes from legal documents:
Concerned physicians should “right” the The valve for the oxygen tank at ringside did not
wrongs that can be observed at ringside. If not, work and O2 could not be administered.
litigators will “write” the wrongs they observe at “X’s girlfriend commented to numerous indi-
courtside. viduals that X had headaches since receiving a
38  Ringside Medicine 507

sanction and halted bout 2 weeks prior to his fatal The known directional forces of a punch fol-
bout.” X did not report headaches to the ringside
physician during physicals. At autopsy of a 15-year-
low three patterns (Fig. 38.5a):
old reveals a “healing subdural hematoma” from a
fight that was stopped two weeks earlier. (a) Axial compression—a direct blow.
(b) Angular forces—missed or misdirected

punches.
38.10.1 T
 he Upper Extremity (c) Excess tension—we microscopically sublux-
ated our knuckle joint at impact.
Those who compete within the combat arts are vir-
tually stripped of the protective equipment adorned
by those within the contact sports such as ice Boxers consolidate injury to:
hockey and American football. What they do uti- 1. Traumatize MCP joints of index and long
lize should be functional, certainly not hand fingers.
wraps!! A 1000-year-old Egyptian mummy gauze 2. Impact the carpal-metacarpal joints of index
wraps the “tools of the trade” while training in and long fingers to cause arthritis called
state-of-the-art supportive impact protective run- metacarpal-carpal bossing.
ning shoes created with modern biomaterials. 3. Catch the thumb in an awkward position
When interviewing as to why competitive athletes spraining the ulnar collateral ligament
and fitness exercisers still fail to protect their hands (gamekeeper’s thumb).
with modern materials, they respond, “tradition.” 4. Suffer a variety of metacarpal fractures.
Yet the foot, groin, ankles, and knees are allowed 5. Wrist sprains.
enhanced protection options. Are the hands of the 6. When not wearing a full boxing glove, as in
boxer less important than her feet? martial arts, DIP and PIP joint sprains occur
Especially if boxing serves as a fitness tool for including mallet finger.
an otherwise employed secretary, dentist, accoun- 7. Flexor and extensor tendon injuries are rare.
tant, etc.? 8. Review illustration of hand forces to view
The art of optimally wrapping a hand with the proper loading forces within the clenched
these limited materials narrows the elite crafts- fist. Each contact loading force should maxi-
men to a small number. Limited materials are fur- mize onto the index and long digits. The
ther restricted by skill and time! Wet gauze gains smaller and less stabile ring and little fingers
weight and is impossible to wash and allows were not built to absorb the brunt of these
cheating. We, as doctors, should therefore be quite large and highly repetitive punching
aware of hand and wrist injuries to susceptible forces. Thus, we practitioners often treat
anatomical structures. “boxer” fractures to the fifth metacarpal

a b

Fig. 38.5  Boxer’s knuckle: mechanism (a) and clinical appearance (b)
508 J. J. Estwanik

which would be more accurately named Acromioclavicular separations do occur as

“lousy boxer” fractures. entangled, or knocked out athletes pile drive
9. The “boxer’s knuckle” results from over- onto the affected side. Burners/stingers
loaded compressive forces destabilizing the should be suspected with transient single
extensor tendon, capsule, and sagittal bands extremity neurological complaint as cervical
of the index and long fingers (Fig.  38.5b). spine disorders such as hereditary canal ste-
Eventually after prolonged swelling and deg- nosis, or disk protrusions are investigated
radation, the extensor tendon becomes desta- also. Biceps tendinitis and labral traction
bilized and dislocates. tears (SLAP lesions) are more common in
10. Elbow injury generally results from a missed the course of training or competing.
or blocked punch leading to hyperextension.
Coaches holding focus pads/mitts in training
can absorb rotational overload injuring the 38.11 Chest and Abdomen Injury
medial ligaments of their elbow. The elbow
joint even more than other joints has a “long “Go to the body,” “work the body,” and “take the
memory” for that injury mechanism, and that tires of that truck” all refer to body blows. Direct
causative force or movement is the last activ- COMPRESSION forces from a punch or the
ity to be tolerated during a recovery (see weight of an opponent’s body will produce injury.
illustration of memory). Smart and knowl- Miraculously, despite the tonnage of forces ham-
edgeable rehab is sport specific! mered onto the torso and abdomen region, rarely
11. Within mixed martial arts and wrestling,
does a doctor have to treat. Certainly, rib frac-
elbow joint injury occurs from the hyperex- tures do occur, and the ultimate worry of a ten-
tension of a missed spinning backlist blow or sion pneumothorax must be acknowledged.
the opponent’s massive and focused forces Costochondral sprains will not show on an X-ray,
of submission elbow locks. I certainly have but their location is a giveaway and they hurt just
seen my share of significant ­ligament/capsu- as much. Occasionally the TORSIONAL forces
lar tears and frank dislocations. Be smart; tap applied to the rib cage in a wrestling or a ground
out when you are caught!!! fighting maneuver will be the causative factor for
12. Shoulder dislocations/subluxations certainly rib or cartilage stresses. Just this week, I have
do occur following missed or misdirected observed on two separate televised events, bouts
punches in boxing or the planned or ending with a vicious single left-handed punch to
unplanned contortions of mixed martial arts the flank and a single front kick to the solar
submission techniques. All combat sports plexus area of the body. This “liver shot” punch
athletes can damage their glenohumeral or and the “solar plexus” kick immediately dropped
AC joints during a fall from a slip or a knock- the opponent to the mat rendering each helpless
out. My first suspicion however when called and ending each bout. Recovery was rather rapid
into the ring for this concern centers upon a as each downed fighter stood next to the referee
prior history of instability. Usually, a preex- as the victor’s hand was raised. Locker room fol-
isting mechanism predated that episode low-­up is certainly advised for lingering compli-
within the bout. Although helpful, the bout is cations. Punches or kicks to the flank are rarely a
usually stopped due to this circumstance. cause for stoppage or trouble, but be aware that
Even if it spontaneously reduces, the very often the fighter will demonstrate some
Ringside Physician is not allowed to TREAT hematuria should urinalysis be performed.
within a competition, and the fighter’s ability The significant causative factor for renal dam-
to adequately protect themselves is compro- age or even renal failure relates to the dangerous
mised. Rotator cuff tears usually occur in the dehydration and weight loss practices tolerated
older athletes being less common at ringside. within the combat sports. Be aware that the loss is
38  Ringside Medicine 509

not isolated to just water but also electrolytes and within the temporal fossa, some of the thinnest
glucose. Starvation is also an accomplice of dehy- bone in our body. The temporal lobes of the brain
dration. Wrestling has significantly and positively sit nestled adjacent to this temporal-mandibular
improved this scourge by requiring (1) annual joint. MRIs of famously afflicted retired boxers
euhydrated percent body fat calculation and mini- demonstrate pathological changes on the inferior
mal weight category requirements so that combat- surface of this neighboring brain surface. Recall
ants cannot choose an unphysiologic, unsafe the facial distortion seen on replays of famous
lower weight class. (2) Weigh-ins are timed close knockouts and the distortion of the jaw slamming
to the competition so that unfair advantage is not either side-to-side with a cross or impacted
empowered, and each athlete competes fairly. upward with an uppercut, confirming these com-
The creation of weight categories was initi- pressive shockwave forces. Within sports medi-
ated for fairness, safety, and competitiveness. All cine, our goal is to stabilize joints. The innovative
wisdom is sacrificed as athletes truly have been thumb-attached boxing glove now stabilizes the
allowed to compete after gaining 25 lb within a thumb MCP joint virtually ending ligamentous
24-h period. So much for weight classes! Known injury. An unstable ankle is either prophylacti-
body and organ physiology confirm that redistri- cally or therapeutically stabilized by tape. An
bution of fluids, glucose, and electrolytes require anterior cruciate-deficient knee is braced. Buddy
2–3  days. No consideration for equilibration taping protects injured fingers. The very mobile
within the brain and above the blood/brain barrier jaw joint complex should likewise be stabilized
has been documented. to prevent tooth, mandible, TMJ, and brain injury.
Does a dehydrated brain fully recover on the A proper fitting mouth piece with proper
same schedule of the kidney of liver? How can a thickness can create a spacer effect so that the
valid middleweight or welterweight champion be lower jaw (mandible) is not in contact with the
declared if the actual competition occurred at two base of the skull, actually creating a spacer or
weight classes above the claimed title weight? So cushion. The teeth are also protected both from
much for safety and fairness! The sports of box- injury and preventing cuts to the wearer and the
ing and MMA must follow the leadership of opponent. A human bite can initiate a serious
wrestling. infectious condition. Some designs of mouth
pieces on X-ray review actually create a protec-
tive gap within the TMJ.  When studying the
38.12 Mouthpieces mouthpieces worn by fighters, the majority of the
wear is always posterior adjacent to the molars.
So little equipment is allowed for a boxer. Gloves, The front tooth area remains totally intact. Very
hand wraps, no foul cup, shoes, trunks, and clearly, wear signs confirm the forces delivered to
mouthpiece complete the list. Little attention, the jaw-TMJ-fossa-brain.
information, and inspection are dedicated to the What should the Ringside Physician look for
structure that guards the mouth. Actually, com- when inspecting the mouthpiece? (Fig.  38.6).
ments should not be limited to the mouth. First, I require that all fighters bring their mouth-
Mouthpieces fit over the teeth, should be form piece to the physical exam [3]. I then view it for:
fitting, can be professionally created by a dentist
or by a home-style boil-and-bite. The structure 1. Wear almost always on the posterior molar
can be single or dual arch. Noting the biome- segment. This is consistently the location
chanics resulting from a punch, an uppercut or a where they are “chewed out” with the usage
cross tends to create the most knockout accelera- by the veterans.
tion of the brain within its boney skull. The man- 2. Tooth imprints to confirm that it has been
dible loosely articulates with the skull housing properly boiled or fitted and not out of the
the brain. This articulation involves the condyle box.
510 J. J. Estwanik

a b c d

Fig. 38.6  Problems related to mouthpiece: chewed up molar (a), chopped of molar area (b), not form fitted, loose (c),
and short and with poor impressions (d)

3. Proper length and not cut off short exposing 38.12.1 Mouthpiece Menu
the most critical zone of impact absorption.
4. Hygiene. • Observe the mouthpiece outside the mouth for
5. A true suction fit within the mouth. a fitted appearance of deep tooth
indentations.
Many times, during my exams I request the • Check inside the mouth for retention and full
athlete who has inserted his mouthpiece to open coverage of the back molars.
her mouth widely. I often use my cell phone to • Use your cell phone to photograph inside the
photograph the mouthpiece within their mouth mouth for educational purpose.
and confirm with them their picture of a
“chopped off” equipment with vulnerable A survey that I recently performed with the
molars exposed. They greatly appreciate this attendees of the annual Association of Boxing
explanation. A well-­molded, tooth capturing, Commission and then the international members
suction fit defines a proper fit. The poorly of the World Boxing Association confirmed a
shaped, incompetent mouthpiece will fall down lack of organization for mouthpiece inspection.
from the upper teeth, and they quickly close In fact, there was significant disagreement about
their mouth again to replace it. This confirms an the importance of various pieces of safety equip-
incompetent useless mouthpiece. No wonder ment. Hand wraps, gloves, and mouthpieces
we see boxers “spitting” their mouthpiece when seemed to be judged equally important, but more
hit or tired. An athlete has to be able to open regulation is mandated for hand wrap and glove
their mouth to breathe at times and not loose inspection. As it is clear that no standardized pro-
the protection. A great Olympic-­ level coach tocol exists for mouthpiece safety check, the doc-
shared his mouthpiece wisdom with me. “If the tor must perform this during physicals. This
athlete can remove their mouthpiece with their sequence generally allows the competitor time to
gloves on, it is too loose. I should have to be the react and correct. Checkups by the ref entering
one who removes it.” I do prefer the two-sided the ring only prove that “something” is present.
dual arch design as it more fully stabilizes and No quality control exists for guarding the teeth,
braces the jaw while providing more shock- gums, jaw, TMJ, and brain. Yet, great pomp and
absorbing space within the TMJ.  When I dis- circumstance exist for using ancient technology
cuss price with the athlete and they prefer the on the hands. What is the “cost-benefit” analysis
low-cost option, I ask if they have a $5 or a $35 for protection of the hand vs. the brain? The cur-
brain. rent responsibility is highly confusing as there
38  Ringside Medicine 511

was no statistical conclusion in this survey sup- s­ ignals doom and gloom to them. Cuts are readily
porting whether the coach, doctor, referee, or fixable if understood properly, while head inju-
bout inspector should assume responsibility for ries are very unforgiving and dangerous. The
checking the mouthpiece. By default, I suggest Ringside Physician’s Manual by USA Boxing
that this duty defaults to the doctor. The doctor clearly classifies the cuts of a boxer (Fig. 38.7a)
has to do this! Note that this discussion applies to according to the area of involvement:
all athletes within the contact sports also to
include safety for rugby, ice hockey, American A—Rarely lead to long-term disability, do not
football, soccer, and basketball. endanger vision, nor damage significant
underlying structures.
B—(Supraorbitial nerve) or C in the area of the
38.12.2 Facial and Cuts infraorbital nerve and near the nasal lacrimal
duct strongly indicates that a bout should be
Accumulated blows to the face and orbital areas stopped in these danger zones.
can create macabre swelling for the initial day or D—In the upper eyelid can endanger the tarsal
two post bout. Most certainly, a trained Ringside plate and are also a danger zone.
Physician should be consulted to confirm that the E—(Vertical cuts) through the vermillion borders
swelling is superficial only and that no deep of the lip creates the potential for further
structures are compromised. Facial cuts are tearing, and the edges must be precisely
poorly understood by the boxing/MMA commu- sutured to prevent future disfigurement.
nity. They freak out over a cut while also stagger- F—Near the bridge of the nose requires evalua-
ing back to their corner. A boxer can be tion for an underlying open nasal fracture or
semiconscious, yet a minor facial laceration injury to the boney orbit.

a b

Fig. 38.7  Types of facial cuts (a) and type of incision (b)
512 J. J. Estwanik

Critical cuts localized near the medial aspect Daniel O’Donoghue PA-C, PhD.  It succinctly
of the eye (orbit) and near the bridge of the nose and creatively again confirms the dangerous lac-
are dangerous because they can extend into the eration zones (Fig.  38.8b) and on its flip side
lacrimal tear duct that lies close to the surface. highlights very useful pressure points to stop
This area should be only sutured by experts as a bleeding (Fig.  38.8b). If one imagines the eye
deep suture could tie off this duct requiring fur- covered by a coin or a circle, the inner 1/2
ther extensive reconstruction. nearest the nose is the danger zone. Those on
Plenty of misunderstanding of the nature of the outer half of the coin are relatively safe zones
boxing cuts exists. Cuts to the face of a combat- for the continuance of a fight based on actual
ant are not at all similar to lacerations from a size, bleeding that might interfere with vision
sharp object like a knife or surgical scalpel (hence safety) and age-/skill-appropriate “sliding
(Fig. 38.7b). The mechanics of these facial cuts scale of tolerance.”
are similar to those of a gunshot with a little The basics of repairing cuts in fighters are:
entrance wound but larger internal cavitation (see
Fig.  38.7a). The typical laceration by a sharp • Don’t freak out at a minor cut. A little red
object is an outside insult that is extended inward blood goes a long way. The face is a very vas-
to the underlying tissues. The “punched” facial cular area that heals fast.
cut represents a skin-bursting injury that begins • Recognize laceration zones that might become
with deeply damaged tissues that then extend dangerous because of their proximity to
upwards as a cut. Believe it or not, the cut actu- underlying important structures (Fig. 38.8a).
ally begins against the bone as the skin is forced • Understand that more tissue is damaged deep
against those underlying boney ridges. Boxers’ to the skin than is first evident. Understand
cuts are “inside-outside” cuts! The bones of the that deep tissues are more extensively dam-
face are the “sharp” objects that cause the skin to aged than superficial skin: inside-out injury.
finally split or explode open externally. Thus, • A sutured wound heals faster and stronger
most of the damage is truly dealt to the subcuta- than a comparable non-repaired wound.
neous tissues rather than misleadingly apparent • The application of buried subcutaneous
in the skin surface. What fans recognize as a cut sutures in combination with skin closure by
is only the tip of the iceberg. suture, glue, or tape is the superior method of
This remarkably useful pocket card available repair in deeper cuts. That regathered and
on their Association of Ringside Physician web- repaired subcutaneous tissue serves as a cush-
site was created by Doctor Larry Lovelace and ion against future impacts and serves far better

a b

Fig. 38.8  Laceration zones (a) and pressure points to stop bleeding (b)
38  Ringside Medicine 513

than “thin skin” against the future tendency to the apron to examine, I will use a sponge to wipe
“cut easily.” away blood to visualize, apply compression as I
• Wound healing times require more weeks than prepare to view, and squeeze to elicit the pain of
one would guess. It has been estimated that a fracture. Having been painted by spatters of
even if a wound is repaired, it takes 3 months blood too numerous to count, I now instruct the
just to obtain 60% of pre-injury strength. athlete to “breathe through your mouth only,” for
• Wound strength for the forces applied within my good, not theirs! Most of the bleeding arises
the fighting arts is as follows: from Kiesselbach’s plexus where vessels con-
30 days = 20% of strength verge. View the back of the throat for excessive
60 days = 50% of strength bleeding due to a posterior bleed. Most bleeding
1 year = 80% of strength from the plexus of vessels is amenable to being
compressed by the thumb and index finger during
Other frequent facial injuries to be dealt with the 1-min rest period in their corner or post bout.
include ear tympanic membrane ruptures from Often, I will allow the bout to continue, but, if
“slaps,” an open hand, or broad surface of the bleeding is not reasonably controlled then, it ends
glove that creates significant air pressure within on a reevaluation. I try to give the athlete’s corner
the ear canal as the eardrum tears from these personnel the opportunity to work on it. Dental
shock waves. Avoid water entering this defect sponges shaped like a short cigarette are inserted
when showering. Pain pills, cotton ear plug, and for compression after the bout PRN.  The usual
possibly antibiotics are used. Most small tears advice is given: tip your head forward, don’t stop
will repair on their own, but experts need to fol- squeezing your nose, and do not blow out the
low the recovery and intervene as needed. clot. Send for X-ray if suspicious.
Speaking of ears, who can’t recognize the Orbital fractures are definitely seen within
pugilist, wrestler, or judo player by their ears. the fight game. These “blowout” orbital floor
Cauliflower ear doesn’t really have to result as fractures are dangerous and must be recognized
preventative drainage, and compression will mit- and referred for definitive reconstruction. The
igate this telltale deformity. The ears and the symptoms of this defect include:
nasal septum are both stiffened by multilayers of
cartilage just as layers of mica rock form in 1 . Interference with upward gaze
nature. A shearing split between layers allows 2. Enophthalmos (the entire eyeball sinking

blood to collect and, if not depressurized, to inward toward the skull)
thicken. Under strict sterility, aspirate the hema- 3. Double vision
toma layer and compress, or it will refill. 4. Sometimes a fractured medial wall of the eth-
Punches to the nose can also tear the cartilagi- moid sinus’s (lamina papyracea), a paper-thin
nous nasal septum creating a septal hematoma, bone layer, allows air to travel to the soft tissues
a cousin of the cauliflower ear. They appear upon of the eye. Blowing the nose will force air quite
nasal inspection with a light to be a “blueberry.” disturbingly into the now bulging eye region.
These also demand mandatory drainage. If left
intact, the cartilage will erode, collapse, and cre- A broken jaw will definitely stop a bout. See
ate the “saddle nose” sunken in, collapsed nose if the competitor can open their mouth and slide
that stereotypes our image of the old-time their jaw from side-to-side. Their failure to firmly
boxers. bite down on several layers of tongue depressors
Epistaxis is so common. Rarely is a fight elicits the diagnosis. Also, view their dental
stopped due to this. But I have stopped bouts alignment. Any step off or misalignment of teeth
when severe bleeding either obstructs vision, is confirmatory also.
grotesquely damages the image of the sport, hin- I have seen the cheek bone or zygomatic arch
ders breathing, swallowing of blood compro- fractured in many ways: punches, head butts,
mises breathing, or a displaced nasal fracture is kicks, and elbow strikes. That cheek appears flat-
present. Many times, when requested to mount ter or “stove in” compared to the opposite side.
514 J. J. Estwanik

Localized pain and the inability to fully and com- If the active, non-crusted lesions of herpes
fortably open their mouth occur due to associated simplex are discovered at physical exam, they
muscles trapped under the depressed area. They cannot fight. If active viral lesions of a “cold
need to be fixed. sore” are transferred from glove to eye, blindness
Eye injury occurs from three mechanisms: can result. Bacterial IMPETIGO can spread like
wildfire through a gym or training camp and is a
• Direct contact (coup). A direct blow either disqualifying condition. HIV and active hepatitis
creates local injury such as an “eye poke” B and C disqualify. Recent technological
causing corneal abrasion, conjunctival hemor- advances for the treatment of hepatitis C cur-
rhage, hyphema (visible blood in the anterior rently have us reconsidering a lifetime ban, if
chamber), or eyelid injury. stated cure rate claims evolve.
• Contrecoup. This line of force traveling Since inclusion within the original Olympics,
through the eye with wave-like force creates boxing and wrestling have thrived from within
damage. the humblest facilities to arenas and stadiums
• Globe distortion. This distortion weakens viewed by millions. The equal application of
layers which can tear and buckle the retina, modern sports medicine advances utilized within
resulting in a retinal tear. In boxers, most of other sports must be shared with these highly
the early ones are far peripheral and only ade- motivated and dedicated athletes.
quately viewed by a dilated exam within an
ophthalmologist office setting. This is why
office screening eye exams should be periodi- References
cally required as a matter of licensing.
1. World Boxing Association. http://www.wbaboxing.
com/wba-regulations/by-laws.
2. World Boxing Federation. http://www.worldboxing-
38.12.3 Skin Lesions federation.net.
3. Association of Ringside Physicians. http://www.ring-
Any infectious skin condition disqualifies one sidearp.org.
from competing.
 Part VI
Different Scenarios in Sports
 Indoor Sports
39
Alex Behar, Mark R. Hutchinson, Aimee Bobko,
Benjamin Mayo, Garrett Schartzman,
Erwin Secretov, Matthew Steffes,
and Samantha Tayne

39.1 Introduction heat and cold illness awareness has increased.

Participating in sports in an indoor environ-
Alex Bejar and Mark R. Hutchinson ment can place unique demands and challenges
on the athlete, coaches, healthcare team, and
Although it is unknown when sports were first administration.
played indoors, we know that sports have been The goal of this chapter is to not only outline
around for over 15,000  years, with the first the epidemiology, etiology, and treatment of
documented event as a footrace between two common injuries associated with indoor sporting
cavemen. Progress in architecture and technol- activities but also address the special challenges
ogy have allowed for outdoors competition to faced by competing indoors including such envi-
transition into indoor sporting events. In modern ronmental factors as playing surface, air quality,
day, indoor sports continue to represent a high temperature, air movement, and lighting as well
proportion of athletic events as many outdoor as architectural design could influence not only
sports are being played under the confines of an actual sports performance but introduce unique
indoor facility. Indoor sports allow for a healthy safety risks into the equation. Facility design
alternative to playing outdoors all year round. may also influence emergency access within the
Participation can occur during any time of the facility and to the facility. Every event should
year and training has subsequently improved. have a defined plan of how the emergency health-
Indoor sports participation is also on the rise as care team will have access to an injured athlete,
where they will be taken on-site for triage or
A. Behar treatment, and how they might be transported
Elmhurst Neuroscience Institute, Elmhurst, IL, USA and evacuated out of the facility for more cata-
e-mail: [email protected] strophic injuries. While prevention of injury is
M. R. Hutchinson (*) the physician’s goal, this emergency plan is
University of Illinois at Chicago, Chicago, IL, USA essential to understand every time you care for
United States Olympic Committee, athletes but particularly when you are in a for-
Colorado Springs, CO, USA eign environment. As indoor sports become
e-mail: [email protected] more popular, the role of the sports medicine
A. Bobko · G. Schartzman · E. Secretov · M. Steffes physician will continue to evolve with the expec-
University of Illinois at Chicago, Chicago, IL, USA tation to continue injury prevention, diagnosis,
B. Mayo · S. Tayne and treatment.
Department of Orthopedic Surgery, University of
Illinois at Chicago, Chicago, IL, USA

© ISAKOS 2019 517

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_39
518 A. Behar et al.

39.2 Basketball injuries, while men had a higher prevalence of

fractures and contusions [3].
Erwin Secretov The National Collegiate Athletic Associated
(NCAA) injury surveillance system data has
shown that lower extremity injuries accounted
39.2.1 Introduction for 60% of all game and practice injuries in col-
legiate basketball players. Furthermore, injury
Basketball has become increasingly more popu- rates during games were two times higher than
lar over the past decade. The National Federation those in practice. Male basketball players sus-
of High Schools reports that approximately one tained more injuries than female players during
million high school student athletes participate in the game (9.9 vs. 6.75 per 1000 AE). Male bas-
basketball in the United States on a yearly basis ketball players also sustained more injuries than
[1]. Traditionally basketball has been perceived female players during practice (4.3 vs. 2.84 per
as a noncontact sport. However, the modern game 1000 AE) [4, 5].
of basketball puts great emphasis on maximizing The injury patterns at the professional level
both speed and power. With the increased impor- are similar to the collegiate rates. Lower extrem-
tance placed on strength and quickness in combi- ity injuries account for 65% of all injuries when
nation with the rising number of participants looking at professional basketball players. Lateral
globally, injuries tend to occur. ankle sprains (13.7%) account for the most com-
mon diagnosis in both the NBA and
WNBA.  Interestingly, WNBA players experi-
39.2.2 Injury Rates enced higher in-game-related injury rates com-
pared to their NBA counterparts (23.9 vs. 19.3
Research has shown that the adolescent popula- per 1000 AE) [6].
tion accounted for the majority of basketball-­ While in the ambulatory setting, the annual
related injuries (50.7%), and adolescents were visit rate for basketball-related injuries in the
three times more likely to sustain injuries to the adult population was 3.2 per 1000 patient visits.
lower extremity compared to younger children. The most common injuries reported were sprains
Younger children, 5–10  years old, were more and strains to the lower leg and ankle, as well as
likely to injure the upper extremity, sustain trau- fractures and dislocations to the wrist, hand, and
matic brain injuries, or suffer fractures. The male fingers [7].
population accounted for three-fourths of the
injuries and were more likely to sustain injuries
such as laceration, fractures, or dislocations, 39.2.3 Injury Mechanism
while females were more likely to sustain trau-
matic brain injuries and knee injuries [2]. It has been shown that the majority of basketball-­
Furthermore, reports have shown that high related injuries tend to occur to the lower extrem-
school basketball players sustain 1.94 injuries ity. The most common injuries documented in
per 1000 athlete exposures (AE). Injuries have literature are to the foot and ankle region with
also been shown to be more prevalent in games ankle sprains and muscle strains dominating the
versus practice (3.37 vs. 1.40 per 1000 AE) [3]. landscape. Lateral ankle sprains predominate
The most common injuries reported were to the when compared to medial ankle sprains [8]. The
ankle/foot (39.7%), knee (14.7), head/face lateral ankle sprain typically occurs from an
(13.6%), arm/hand (9.6%), and hip/thigh upper inversion/plantar flexion mechanism to the foot
leg (8.4%). The female high school basketball and ankle. Typically, this will occur as a player
player sustained more injuries than men (2.08 lands on another player’s foot, rolling one’s ankle
vs. 1.83 per 1000 AE). Females also accounted inward, or when the player lands awkwardly
for a greater portion of concussions and knee twisting one’s own ankle on the ground. The
39  Indoor Sports 519

most common ligament involved in an inversion patellar injuries (2.4%), upper leg contusions
mechanism would be the anterior talofibular liga- (3.9%), and concussions (3.6%) [5]. A prospec-
ment, followed by the calcaneofibular ligament. tive study spanning 10 NBA seasons found that
Eversion/external rotation mechanism of the foot ankle sprains are extremely common. The study
tends to occur at a much lower rate. These inju- demonstrates the prevalence of ankle sprains to
ries tend to affect the deltoid ligament complex, be 9.4% of all injuries [14]. In addition to acute
anterior tibiofibular ligament, and interosseous ankle injuries, overuse injuries to the foot, ankle,
membrane which may potentially disrupt the sta- and lower leg have been described. The four
bility of the ankle mortise [8, 9]. most common stress injuries that have been fre-
Anterior cruciate ligament (ACL) disrup- quently described include proximal fifth meta-
tions is one of the more devastating injuries tarsal, medial malleolus, navicular, and anterior
that a basketball player can experience, many tibia. Navicular stress fractures make up approx-
times requiring surgical reconstruction and a imately 14% of stress fractures [15]. Navicular
lengthy rehabilitation process. Unlike ACL stress fractures typically occur in sports that
tears in the game of football, ACL injuries in involve running and jumping. Patients typically
basketball are associated with a noncontact present with an insidious onset of pain, and fre-
injury. During the game of basketball, there are quently, initially radiographs will be negative.
frequent moments where a player will have to Stress fractures relating to the tibia more com-
decelerate and perform sudden stops or changes monly involve the posterior medial aspect, which
of direction which may cause abnormal rota- are relative low-risk stress injuries. However,
tion of the tibia resulting in ACL injury [10]. A anterior tibial stress fractures are high-risk inju-
study evaluating the mechanism of ACL tears ries and are slower to heal with non-operative
in basketball players with video analysis found treatment, potentially requiring prophylactic
that a majority of ACL tears occurred by a non- nailing [16]. Medial malleolus stress fractures
contact variety. In addition, female basketball are quite rare, accounting for 0.6–4.1% of stress
players were found to have a higher mean flex- fractures. The repetitive jumping and running
ion angle and were more inclined to undergo makes basketball players more prone to these
valgus knee collapse [11]. A meta-analysis injuries [17]. The Jones fracture involves the
studying the incidence of ACL tears as a func- metaphyseal and diaphyseal junction of the
tion of sport and gender found that females proximal fifth metatarsal, which is a watershed
were roughly three times more likely to sustain area of poor vascularity. These fractures are
an ACL tear in comparison to male athletes prone to non-union and will typically require
while playing basketball [12]. operative treatment in high-­ level athletes in
A study by the International Olympic order to return them to sport [18].
Committee attributed the increased risk of ACL Twelve percent of all injuries in male college
injury in female athletes to elevated risk in the athletes occur at the knee, with knee injuries
preovulatory phase of the menstrual cycle, affecting 19% of females in college sports. ACL
decreased intercondylar notch width, and a pre- injuries in basketball players show a strong
disposition to increased knee abduction on land- female tendency. A review of injuries sustained
ing in female athletes [13]. in collegiate women’s basketball players at the
University of Connecticut found that woman
experienced ACL injuries 2–4 times the rate of
39.2.4 Common Injuries their male basketball players [19]. Meniscus sur-
gery has been found to be the second most com-
In basketball, lower extremity injuries tend to mon surgery of college women basketball players
predominate. The most common injuries seen in entering the WNBA behind ACL reconstruction
Men’s Collegiate Basketball were ankle sprains [20]. Overuse injuries of the knee involve the
(26.2%), knee internal derangement (7.4%), extensor mechanisms. Patellar tendinopathy or
520 A. Behar et al.

“jumper’s knee” has been found to be a common 39.3 C

 ombat Sports: Boxing/
problem in basketball players. It has been Martial Arts/MMA
reported as high as 7% of high school players suf-
fer from patellar tendinopathy. A 10-year pro- Benjamin Mayo
spective study of injury in the NBA found that
patellofemoral inflammation accounted for 8.1%
of orthopedic injuries, second only to ankle 39.3.1 Introduction
sprains [14].
The most common upper extremity injuries Martial arts are some of the oldest sports still
that a basketball player will sustain involve the practiced today, with origins dating back as far as
wrist, hand, and fingers. Among pediatric bas- ancient Mongolia [23]. Today, as many as 6.4
ketball injuries presenting to the emergency million kids participate in martial arts in the
department, finger sprains and finger fractures United States [24]. Worldwide, the World
were the second and third most common diag- Taekwondo Federation reports as many as 120
nosis [21]. Long-term disability is a possibility million participants across 140 countries [25].
when a fracture at the PIP joint goes untreated. Boxing, though once extremely popular, has lost
X-rays should be considered when a PIP injury participation in recent years due to scrutiny from
is identified. the medical community, as there is a high injury
Back injuries and more specifically lumbar rate, but especially due to the risk of chronic
spine injuries account for 6.8% of all injuries sus- brain injury such as chronic traumatic encepha-
tained by NBA players but represent 11% of all lopathy or dementia pugilistica [26, 27]. Mixed
days missed [14]. Predominantly injuries to the martial arts, more commonly known as MMA,
back involved muscle strains and disc rupture/ has approximately 1.3 million participants in the
herniation being far less prevalent. This is a result United States [28, 29].
of the repetitive extension and hyperextension
from rebounding, shooting, or guarding the
opponent. 39.3.2 Injury Rates
Concussions account for 6.5% of the injuries
sustained during games in the WNBA [4]. There is a high overall rate of injury in combat
Concussions are less frequently reported in men’s sports, with varying risk depending on the type of
NCAA competition at 3.6% and NBA competi- rules and experience of the athlete. In large stud-
tion [5, 14]. The most likely etiology is player ies of professional boxing matches, there was an
collision, although concussions can also occur injury rate between 17.1 and 23.6/100 matches,
with direct contact with the hardwood floors. or 3.4 per 100 boxing rounds [30, 31]. A study by
Sudden cardiac death, although rare, is a risk the same group also analyzed professional mixed
when participating in sport. Basketball has been martial arts competitions and found a signifi-
found to be the highest-risk sport with an overall cantly higher rate of injury at 12.5/100 rounds
death rate of 1/11,394. Division 1 male basket- [32]. During the 2016 Rio Olympics, boxers sus-
ball players are at five and half times greater risk tained the second highest rate of injury at nearly
than female basketball players. African American 30% of athletes. This was followed closely by
basketball players are three times more at risk Taekwondo at 24% of athletes. Wrestling and
compared to white athletes [22].Hypertrocphic judo were slightly lower at 14% and 12%, respec-
cardiomyopathy (HCM) accounts for 36% of tively [33].
sudden cardiac deaths in young athletes. HCM One analysis of injury rates in combat sports
has an incidence rate of 1:500 people. A thorough at the 2008 Summer Olympics showed the high-
history and physical exam during the pre-­ est injury rate in Taekwondo, with as high as 37%
participation screening is the best method to pre- of participating athletes experiencing an injury
vent sudden death in athletes. and 16.2% missing time [34]. Boxing and judo
39  Indoor Sports 521

were the next highest with rates between 10 and that allow both striking and grappling, as well as
15% of athletes experiencing injury. A systematic mixed martial arts, there is a wide array of injury
review of combat sports in the Olympics again patterns.
demonstrated that Taekwondo had the highest Injury patterns in amateur boxing have
injury rate, with reported values between 19.09 changed secondary to rule changes by the
and 69.5 injuries per 1000 athlete exposures. Amateur International Boxing Association in
Boxing had a rate of 12.8 injuries per 1000 h in 2013 in which head guards were no longer per-
training, while judo was the lowest at 4.2/1000 h mitted, and changes were made to both glove
[35]. Other studies have reported an injury rate in specifications and the scoring system. A recent
Taekwondo as high as 139.5/1000 athlete expo- study examining fight characteristics found that
sures and 4.6 injuries per athlete annually [25]. fights were less likely to last the full time, a
One 10-year prospective study reported that par- decrease in head-to-body punch ratio, higher per-
ticipants in Taekwondo sustain 4.6 injuries annu- centage of missed punches, and more defensive
ally, for an overall injury rate of 26.1/1000 athlete tactics. They theorized that head protection actu-
exposures [36]. Karate has a reported injury rate ally made the head a larger target, limited vision,
of 5.6/100 athletes over a 1-year period [37]. and combatants were more willing to take a
Though less frequently reported on, kickboxers punch to the head due to increased perception of
have an exceptionally high injury rate as well, protection. These factors, along with an attenu-
with one large study over 16 years reporting an ated force from the padding in the headgear, may
overall injury rate of 109.7/1000 athlete expo- lead to an athlete absorbing a larger number of
sures [38]. punches over a longer period of time instead of a
Few studies have directly compared injury few heavier punches that may end the fight.
rates between types of combat events. One such However, future research on whether traumatic
study reported a slightly higher rate of injury in brain injury is more likely after receiving one
mixed martial arts compared to boxing but a heavy punch that results in a knockout, or to be
higher rate of minor injuries. Boxing had a hit with less force several times, will need to be
higher rate of loss of consciousness, as well as performed before the true benefit of these rule
longer medical suspensions by 6  days [39]. In changes can be concluded [41].
one analysis of professional mixed martial arts When comparing striking (boxing, kendo, tae-
fights, 40.3% of the time at least one athlete sus- kwondo) versus non-striking (judo, ssireum,
tained an injury [32]. Brazilian jiu-jitsu, a form wrestling) combat sports, dislocations and inju-
of mixed martial arts focused on grappling and ries to the neck, shoulder, and elbow were more
ground fighting, has a relatively low rate of common in non-striking sports, while injuries to
orthopedic injuries compared to other combat the wrist and hands are much more common in
sports, with an overall injury rate of 9.2/1000 striking sports [42]. There is a high rate of sprains
athlete exposures [40]. and strains in both (approximately 60% of all
injuries). There were similar rates of fracture
(37.7 vs. 45.3), ligament ruptures (57.1 vs. 43.7),
39.3.3 Injury Mechanism muscle rupture (26 vs. 32%), and herniated discs
(26 vs. 32%) in each group. In judo, the most
The mechanism of injury in combat sports varies common mechanism of injury has been described
based on the rules regarding striking, as well as as being thrown from a standing position, as then
grappling techniques allowed. In short, a major- in a defensive position, and may lose control of
ity of injuries are due to direct blows from the being able to land appropriately and safely [43].
opponent in striking sports, while grappling Two separate analyses of youth karate partici-
sports have a higher incidence of injuries due to pants demonstrated an overall injury incidence of
contact with the mat or pressure applied from 41.4–45.3/1000 athlete exposures [44]. However,
submission techniques. In forms of martial arts only 10% of such injuries resulted in time loss
522 A. Behar et al.

from participation. Older youth participants (12– Wrestling, discussed in a different portion of this
17  years old) were at nearly double the risk of chapter, has the highest rates of sprains and
injury compared to younger athletes, likely due strains. This is logical, as sports with a lower
to the increased strength and force of striking. emphasis on striking compared to grappling,
There is a bimodal injury rate in terms of experi- throws, and submissions are more likely to over-
ence, with the lowest belt ranks and highest belt strain a joint compared to more strike focused
ranks experiencing the highest [45]. These results sports which will have a high rate of fractures
have been corroborated in other studies, with and contusions. In striking sport such as boxing
older age and beginners being associated with a and mixed martial arts, fractures have been
higher injury risk [32, 46]. Other analyses have reported to be between 8.4 and 43.3% of all inju-
failed to find a correlation between age or weight ries [31, 47].
and a higher injury risk [30, 38, 47]. In boxing, the highest number of injuries
Many studies have analyzed other risk fac- occurs to the head, face, and hand, depending on
tors for injury. Intuitively, the loser in a fight has the skill level of the boxer. These injuries have
demonstrated to have twice the injury risk as the reported rates as high as 71% of all injuries [33,
winner. Additionally, participating in more than 35, 48, 52]. Professional boxers have a higher
three bouts per year was associated with a higher rate of head injury, with a reported 24% of fights
risk of injury [48]. Though most sports have a overall demonstrating an injury to these areas,
higher rate of injury in competition, Taekwondo though a majority were lacerations [30]. One
athletes have a relatively high percentage of analysis demonstrated that 23.6% of boxing-­
injuries sustained during training as well [33, related injuries presenting to emergency depart-
34]. In mixed martial arts, a video analysis ments are to the head and face, compared with
found common takedown moves are a high risk 11.1% of martial arts-related injuries [53]. Other
for cervical spine injuries and whiplash mecha- studies have reported that close to two-thirds of
nisms [28]. boxing injuries are to the upper extremity, while
A majority (up to 82.8%) of injuries reported only 23% are to the head and face [54]. Similarly,
in combat sports are acute versus recurrent [49]. a large analysis of kickboxing injuries reported
One study demonstrated that females are more that injuries to the head and neck were the most
likely to be injured than males at the lower weight common at over 50% of injuries [38]. In kickbox-
classes of martial arts, but at the larger weights, ing, head injuries are the second most common in
this difference disappears [36]. In youth karate both professional and amateurs rates between
tournaments, females had a lower relative risk of 31% and 4.5% [46].
injury at 0.63 [50]. In mixed martial arts, injury location has a
more equal distribution, with injuries to the head
and neck, upper extremities, and lower extremi-
39.3.4 Common Injuries ties having a much closer rate than other sports
due to the fact that there is no one particular focus
The common body locations and types of inju- or technique that can be used [45]. For head and
ries in each combat sport is variable based on the neck injuries, up to 64% of injuries have been
type of striking or grappling that is allowed. reported to be facial lacerations, while concus-
Although there is a high overall injury rate, for- sions are up to 33% of all injuries and 47% of
tunately a majority of injuries sustained in each head injuries [31, 32, 54].
of these sports are mild, with the most frequently Approximately 5–10% of injuries in boxing
reported injuries being sprains, strains, tendino- and mixed martial arts are concussions [48].
sis, and contusions with a rate of nearly 80% of Some studies have reported that martial arts has
all injuries in some studies [36, 51, 45, 47]. In significantly fewer concussions than boxing or
addition to these injuries, striking sports also wrestling, likely due to the wide variation in mar-
have a high rate of lacerations and abrasions. tial arts techniques that do not focus on head
39  Indoor Sports 523

striking [39]. A 2016 study of the World Karate common in amateurs who may have worse form,
Championships reported an overall concussion as one study demonstrated that professional
rate of 0.43/1000 athlete exposures. There are boxers had an injury rate of 347/1000 h of com-
fewer knockouts in mixed martial arts compared petition compared to <0.5 injuries/1000  h in
with boxing, likely due to the multiple ways of training [27]. In professionals, head and face
winning, whereas boxing is more focused on injuries are more common, with injuries to the
winning by knockout [53]. Despite this, the hand and wrist being second overall [49].
reported rates of head and neck injuries in martial Taekwondo has a high rate of injuries to the fin-
arts have been reported as high as 80% of all inju- gers due to a focus on grappling, with as many
ries [47]. In amateur kickboxers, nearly 31% of as 23% of injuries occurring to the hand or fin-
matches were stopped due to injury in one analy- ger [57]. Judo also has a high rate of injuries to
sis, of those, 65.2% were from traumatic brain the finger, as they can get caught in opponents
injury, while 17.4% were from musculoskeletal uniform during grappling maneuvers [43].
orthopedic trauma [55]. There is a high rate of Repeated injuries to the same joint can com-
non-specific lower back pain in martial arts com- monly lead to finger joint osteoarthritis in these
petitors. One review of judo participants reported athletes.
a rate of 35.4%, with radiologic abnormalities of Sprains and ligament injuries were the most
the spine in 81.7% [43]. common type of injury to the upper extremity
[57]. The most common of these injuries include
39.3.4.1  Upper Extremity CMC instability (21.7%), UCL injury (14.6%),
The most common injury location in nearly all and MCP sprain/extensor hood injury, also
forms of striking combat sports is to the upper known as boxer’s knuckle (15.8%), and wrist
extremity, most notably the hands and wrists. In sprains (13.5%) [49]. Hand and wrist injuries had
an analysis of emergency department visits by a high rate of serious injury; mean duration of
combat sport, upper extremity injuries account days lost was 50.7 for the hand [35].
for 63.7% of boxing visits compared to 32% of The shoulder is typically the second most
martial arts visits [53]. In Taekwondo, the over- commonly injured area of the upper extremity, at
all rate of upper extremity injuries is between up to 27% of combat sport-related injuries, fol-
11.2 and 15.1 per 1000 athlete exposures [36]. lowed closely by the elbow at 19% [33, 35, 43,
The hand and wrist is the most common location 56, 57],. Glenohumeral dislocations, AC and SC
of injury to the upper extremity with up to 53% joint separations, and clavicle fractures all have
of all upper extremity injuries [32, 48]. Mixed been reported, with the usually mechanism being
martial arts reports an overall upper extremity resisting a fall [35, 43].
injury rate between 11.8 and 22.8%, with 6–12% Judo has a relatively high rate of elbow inju-
being injuries to the hand and wrist. Most com- ries with a rate near 25% of all injuries. Elbow
monly these injuries are dislocations or sprains injuries also have a high incidence of severity
[47]. Hand and arm injuries account for nearly with up to 73% of athletes missing significant
50% of fractures, followed by the fractures of time [58]. Brazilian jiu-jitsu demonstrated the
the face between 30 and 40% of injuries [56]. highest injury rate to the elbow, as a common
One study has reported an overall hand injury submission technique is the arm bar in which the
rate of 302 injuries per 1000 training hours [39]. opponent’s elbow is forced in to hyperextension
Boxing has a high rate of hand and wrist injuries [40]. During these arm lock maneuvers, poor
incidences between 20 and 35% of all injuries in defensive technique often leads to medial collat-
amateurs [49]. Up to 70% of boxing injuries to eral ligament injuries [43]. Boxers have been
the hand and wrist were in training versus com- known to develop both anterior and posterior
petition. This may be due to the high number of elbow impingement, with the lead arm more
hours spent training and frequent contact with likely to develop the condition, and can often be
heavy bags while fatigued [33]. This is more effectively treated with debridement [49, 59].
524 A. Behar et al.

39.3.4.2  Lower Extremity mortalities over the time period. Sixty-four per-
Lower extremity injuries occur at a relatively cent of them were decided by knockout, 15% by
lower rate than injuries to the upper extremity in TKO.  The preterminal event was noticed in the
most martial arts specialties; however there is ring in 61% of such cases [60]. The rate of mor-
still a high overall injury rate. In mixed martial tality significantly decreased after 1983, likely
arts there is a comparatively higher rate of lower due to rule changes, increased medical oversight,
extremity injuries due to the variability in tech- and an overall reduction in career length and
niques used, with injuries to the lower extremities number of fights. It was noted that a higher per-
reported as high as 30% of all injuries [47]. Judo centage of mortalities were in the lower weight
also has demonstrated a high rate of lower classes [25]. Some rule changes have been made.
extremity injuries, with nearly 28% of injuries However, a recent study out of Japan examined
being sprains, strains, or contusions of the knee, mortalities before and after rule changes and
while ankle sprains occur at a slightly lower rate noted that prohibiting 6 ounce gloves and chang-
[43]. Around the knee, the MCL and ACL are the ing the weigh-in day may not result in reduced
most commonly injured ligaments [43]. mortality [60]. High rate of catastrophic head
Taekwondo has also been reported to have a high injury secondary to the force when being punched
rate of injuries to the lower extremities, with inju- is more rotational as opposed to translational
ries to the knee and ankle occurring at a rate of acceleration as seen in other sports. This is
13% and 20% overall, respectively. In a review of thought to create a higher tension on blood ves-
emergency department visits due to martial arts-­ sels and a risk of injury [61]. In martial arts,
related injuries, the lower extremity was the site nearly 70% of catastrophic injuries are to the
of injury in 41.6% of injuries, while only 32% brain and cervical spine, which are secondary to
were injuries to the upper extremity. Many of being thrown and landing incorrectly [43]. These
these injuries were sprains and strains, but nearly are more likely to occur in younger participants
25% were fractures [56]. Another large study less than 20 years old and those who are new to
reported that the knee was the most commonly the sport and practicing less than 3 years [43].
injured area at 21.3% of all taekwondo injuries,
followed by the foot at 17% [53]. Other studies
have corroborated these findings, with as high as 39.4 Diving
65.5% of reported injuries occurring to the lower
extremities in Taekwondo [36]. Samantha Tayne
Boxing logically has a low rate of lower
extremity injuries, with less than 10% of injuries
reported [53]. Conversely, kickboxing has a rela- 39.4.1 Introduction
tively high rate of injuries to the lower leg where
a majority of the striking is performed [38]. In Diving is an ancient sport with the earliest docu-
professional kickboxing, lower extremity injuries mentation found in Naples, Italy, in the Tomba
have been reported as up to 53.4% of injuries, del Tuffatore (the Tomb of the Diver). In the sev-
while this rate increases to nearly 75% for ama- enteenth century, diving began to evolve as
teurs [46]. Swedish and German gymnasts began to perform
acrobatics over water at the beach, also known as
“fancy diving.” The first modern diving competi-
39.3.5 Catastrophic Injuries tion was held in England in 1880, and in 1904 the
first men’s springboard dive competition was
Unfortunately, all combat sports have a high introduced at Olympics. Four years later, in 1908
potential for catastrophic injury. Typically this is platform diving was introduced, and in 1912
due to acute trauma to the head or spine [43]. women’s diving was added. The number of dives
Baird et al. reviewed all reported fatalities in box- and complexity of the dives has increased over
ing from 1950 to 2007, in which there were 339 the years. In the early 1900s, there were 14 plat-
39  Indoor Sports 525

form and 20 springboard dives; now there are 1000 athlete exposures for males and 2.49 inju-
close to 100 dives with vastly increased complex- ries per 1000 athlete exposures for females [63,
ity [62–65]. 67]. The majority of dive injuries, about 89%,
were found to occur during practice and the
remaining during competition [64].
39.4.2 Injury Rates

It is important to recognize the differences between 39.4.3 Common Injuries

recreational diving and competitive diving. Most
notably, recreational diving is associated with The majority of diving injuries involve the upper
much higher rates of acute spinal and catastrophic extremities, likely due to the force of impacting
injury. In fact, 10–20% of hospital admissions for the water, typically performed hands first.
a spinal cord injury are associated with recre- Additionally, the way in which divers maneuver
ational diving accidents [65]. Meanwhile there has when impacting the water to limit their splash
not been a reported acute fracture or dislocation of and improve their score, also known as a rip
the cervical spine in competitive diving [64]. And entry, can lead to injury. Importantly, there have
there have only been two fatalities noted world- been differences found between male and female
wide in competitive diving, both reported outside divers as the most common injured areas. About
of the United States. Catastrophic diving accidents 32.0% of men’s diving injuries were associated
involving the cervical spine are seen more com- with the shoulder, while hand and wrist
monly among male patients, under 25 years old, accounted for 8.0% of injuries. In women, the
diving into a shallow pool of water [65, 66]. shoulder accounted for just 5.4% of injuries,
Though competitive divers rarely suffer cervi- whereas 16.2% of injuries involved the hand and
cal spine injuries, they do demonstrate a slew of wrist [64].
other injuries. Competitive divers train on aver- The best way to evaluate injuries is by break-
age 40  h per week with one study suggesting ing down the aspects of a dive: takeoff, flight, and
about 200 dives per week [64] and another with entry. Each of these portions of a dive is associ-
an even higher estimate of 100–150 dives per day ated with various injury patterns. The takeoff
for springboard and 50–100 dives per day for involves the approach, which on a springboard
platform [63]. Injury risk has found to be includes a hurdle or an upward jump to the end of
increased for platform over springboard diving. the board, and the press or the depression of the
Haase et al. explain the increased risk of injury board leading to an upward acceleration of the
through the physics of diving, with a diver falling body. For platform dives the takeoff may begin
from a 10  m platform accelerating to about from standing or from a handstand position.
14.1  m/s or 31.5 mph before hitting the water, Common injuries during the takeoff include knee
leading to an impact force of between 2.0 and extensor mechanism injuries, including patellar
2.4 g (1 g 5 9.8 m/s2) at the surface of the water, tendon or quadriceps tendon injuries, as well as
which is a significant force [64]. Training also Achilles tendon and posterior tibial tendon inju-
occurs both in the pool and on dryland, though ries. Handstand dives may result in more wrist,
the incidence of injury during training is higher elbow, or shoulder overuse injuries [62–65].
for the pool than on land [62]. The next stage of the dive is the flight, from the
One study in the Netherlands followed divers moment of leaving the board or platform to the
prospectively for about 3  months and found an initial contact with the water, during which time
injury rate of 8.8 injuries per 1000 training hours. the diver performs a midair maneuver. To initiate
The USA Diving Injury Surveillance Program the motion in the air, the diver must throw his or
estimates an injury rate of 6.5 injuries per 100 her arms in the direction of spin, which may cause
divers per year [64]. Another study looking at the issues with shoulder instability or irritation of the
NCAA swimming and diving injuries from 2009 long head of the biceps. Additionally, the rapid
to 2014 found an injury rate of 1.94 injuries per and forced flexion of the trunk can cause increased
526 A. Behar et al.

loads in the anterior segment of the spinal col- There are two main techniques divers utilize
umn, leading to disc pathology and thoracic or to hold their hands when entering the water – the
lumbar strains. There is also the possibility of a thumb-in-fist and the flat-hand grab. The flat-­
poor takeoff leading the diver to make contact hand grab is a new technique, which creates a
with the board or platform, which could result in larger, flatter surface to enter the water [64]. The
any number of acute injuries [62–65]. deceleration forces at the water surface may
Entry, the final phase, occurs upon entry into cause forced dorsiflexion at the wrist and forced
the water. This is the phase involving the majority flexion of the elbow, leading to stress fractures,
of injuries. The diver is attempted to dissipate the sprains, and strains of the wrist and triceps strains
impact force, up to 2.4  g as mentioned previ- [62]. A case study of a 14-year-old male diver
ously, while limiting the splash, performing a rip was reported with an olecranon stress fracture
entry. Divers often hyperflex their shoulders in an [65]. Wrist injuries include carpal instability, dor-
effort to “save” a dive, leading to increased risk sal impaction syndrome, dorsal ganglion cysts,
of anterior glenohumeral subluxation. Scapular flexor carpi ulnaris tendinopathy, and scaphoid
position and motion is essential for divers to fractures. There may also be hyperextension at
achieve a well-executed entry. Malposition of the the elbow leading to injury of the medial collat-
scapula due to weakness of the serratus anterior, eral ligament and possible ulnar neuritis due to
lower trapezius, and rhomboids may impair continued instability.
energy dissipation upon water entry and therefore Divers are susceptible to several non-­orthopedic
increase the demands on the soft tissue, leading injuries that are important to mention. Perforations
to injury, to ligament laxity, and many times to of the tympanic membrane may occur from the
shoulder instability [64, 65]. A study of the pressure upon entering the water, either from land-
United States National Team in the 1990s indi- ing directly on one side of the head or even during
cated that about 80% of athletes were found to well-executed dives. More common and less severe
have had shoulder injuries kept them out of train- divers may experience otitis externa or swimmer’s
ing for at least 1 week [62]. ear. Microdefects on the corneal epithelium can
The diver requires a stable shoulder for water occur, again due to repetitive microtrauma upon
entry but also needs to maintain flexibility in the entering the water [64]. There has been a case
shoulders to minimize forces in the spine. Divers report on hemoptysis due to pulmonary contusion
often create hyperextension in their back during due to trauma from water entry [68]. And as men-
entry leading to injury of the posterior elements tioned previously, there have been two fatalities in
of the spine. However, they may also hyperflex, competitive diving, both from severe head injuries
especially at the neck. One case report illustrates after striking their head on the platform in the
a 19-year-old female collegiate diver who suf- attempt of a reverse dive [62].
fered from C5–C6 instability due to the hyper-
flexion, presenting with symptoms of neck pain
and upper extremity paresthesias. Most com- Fact Box
monly, injury involves soreness or spasm of the In competitive diving, the majority of injuries
thoracic or lumbar musculature or strains of the are due to the impact at the water’s surface
ligaments within the spine. Less commonly, and the maneuvering to “save” a dive.
there are bony injuries or apparent instability. Scapular stabilization is important in main-
Young divers are more susceptible to discogenic taining shoulder stability and flexibility.
problems and have potentially accelerated Recreational diving carries a far greater risk
degenerative process [65]. Overall, diving does of spinal or catastrophic injury than competi-
place high demands on the spinal column, but tive diving, often involving the cervical spine.
the incidence of processes such as spondyloly- In competitive divers, lumbar strains are often
sis, spondylolisthesis, and lumbar facet arthrop- self-limited in competitive diving and can be
athy have been observed less frequently than in treated with conservative measures.
gymnasts [62].
39  Indoor Sports 527

39.5 Fencing monly reported injured body part, thigh and ankle
sprains were the most frequently injured [73]. The
Alex Behar lumbar region (9.2%) and fingers (7.6%) are the
most commonly injured sites above the hips.
Interestingly, penetrating puncture wounds
39.5.1 Introduction accounted for only 2.7% of injuries with two
resulting in serious injuries (one penetrating the
Fencing is an open-skilled asymmetric combat forearm and one penetrated the lateral neck) [72].
sport. It consists of three different weapons: the
foil, the saber, and the epee. In comparison to
most other sports, direct physical contact in fenc- 39.5.5 Treatment Principles
ing is forbidden and the two athletes fight indi-
rectly using their weapons [69]. There are limited Given that fencing is an asymmetric sport, overuse
studies reporting on injuries occurring while injuries are common. Prevention strategies should
fencing, and although rare, serious injury in fenc- include appropriate warm-up, stretching, physical
ing may still occur. conditioning, and improvement in technique of the
athlete. The athlete should wear fencing protective
gear to prevent significant penetrating injuries.
39.5.2 Injury Rate Broken blades are the most common cause of seri-
ous penetrating injuries and it is mandatory for
In a 5-year prospective study, Harmer et al. looked fencers to check their weapon regularly.
at 78,223 male and female competitors ranging in
age from 8 to >70. He reported 184 time-loss inju-
ries among 78,223 competitors, 60% of which con- 39.6 Gymnastics
sisted of males and 39.3% females, for an overall
rate of 0.3 per 1000 athletic exposures (AE) [70]. Matthew Steffes
In another study involving 1356 fencers, only 3
injuries resulted in athlete withdrawal from compe-
tition [71]. Women suffered from a significantly 39.6.1 Introduction
higher risk of time-loss injury compared to men
(RR = 1.35, 95% CI = 1.01–1.81) [70]. The origin of gymnastics dates back to ancient
civilizations from the Far East and the
Mediterranean, with the word gymnastics stem-
39.5.3 Mechanism of Injuries ming from the ancient Greek word gymnaziem,
meaning “to exercise naked” [74]. Ancient forms
The majority of injuries leading to time loss in of gymnastics encompassed many different ath-
fencing are due to rapid change in direction and letic events, from track and field to wrestling. This
stop-start actions resulting in strains, sprains, and has evolved over time to encompass both artistic
ligament ruptures. Injuries from an opponent’s and rhythmic gymnastics events, in addition to
weapon are rare but may result in serious injuries. trampoline and tumbling. The artistic events cur-
Heat exhaustion has also been reported as a result rently include vault, floor exercise, balance beam,
of the heaviness protective gear’s weight and uneven bars, parallel bars, horizontal bar, pommel
material [72]. horse, and still rings. Rhythmic events include
ring, ball, ribbon, club, rope, and group. There is
much overlap in the maneuvers required for these
39.5.4 Common Injuries events, yet some involve very unique maneuvers
or use of an apparatus. Additionally, the popula-
Fencing injuries mostly occur in the lower extrem- tion participating these acrobatic events is distinct,
ity (63%). While the knee was the most com- with the overwhelming majority of athletes being
528 A. Behar et al.

adolescent females. USA Gymnastics reported and contortion of the spine to create dynamic and
67,626 female members, more than 5 times as acrobatic displays. This leads to all areas of the
many male members (12, 120), and nearly all body being affected by injury.
female members (99%) were 18 years or younger The lower extremity accounts for the majority
[75]. For these reasons, injury is frequent and of injuries in both male and female gymnast, fol-
unique injury patterns are encountered. lowed by the spine and the upper extremity [78].
This trend has been consistently demonstrated by
multiple studies [79–82]. The foot and ankle are
39.6.2 Injury Rates injured at a rate of 33.3%, the highest of all pre-
collegiate gymnastics injuries [78]. These are
Most injuries occur upon contact with the ground often inversion sprains, Achilles tendonitis, or
surface. This is best demonstrated by the 16-year stress fractures. The knee is the next most com-
review of NCAA female gymnasts by Marshall and mon area injured. The top diagnoses are patellar
associates. Floor exercise was the most common tendinosis, patellofemoral syndrome, and nonde-
event for injury at 31.1%, followed by the vault script sprains. The knee, foot, and ankle account
(27.3%), parallel bars (21.4%), and balance beam for the most injuries requiring over 10  days of
(12.1%) [76]. The floor event is associated with the missed sporting activity [83].
highest frequency of injury during international Many gymnastic events require the upper
competition [91] with the majority of all knee and extremity to bear full body weight, while others
ankle injuries occurring during this event [92]. require to maintain the body in a hanging posi-
During these events, injuries were incurred specifi- tion. This leads to many wrist injuries, with wrist
cally during floor exercise routine and upon dis- sprains leading as the most common upper
mount/landing for the vault, parallel bars, and extremity injury pattern for both genders. Chronic
balance beam. Overall injury rate was more than wrist pain affects 46–87% of young gymnast [93,
twice as frequent during competition compared 94]. Following wrist injuries, shoulder injuries
with practice (15.2 vs 6.1 injuries per 1000 expo- predominate for male gymnasts, while elbow
sure hours). Of note, however, back and upper pathology is more common among females [84].
extremity injuries were more common during prac- Given most gymnasts are skeletally immature
tice, whereas lower extremity injuries were more during prime competitive years, growth plate
frequent during competition. No difference in injury injury is of particular concern. Early and intense
rate has been demonstrated between genders [77]. gymnastics participation has long been suspected
Saluan and colleagues examined injury char- to cause damage to the distal radial physis and
acteristics among precollegiate female gymnasts positive ulnar variance. Though there seems to be
of varying competition level. The authors reported a positive correlation, no study to date shows a
elite and high-level gymnasts sustained signifi- clear causal relationship [85, 86]. A high index of
cantly higher rates of injury (2.86 and 2.82 inju- suspicion should be maintained when presented
ries per 1000 exposure hours), compared to novice with dorsal-sided wrist pain without a clear
gymnasts (0.69 injuries per 1000 exposure hours), injury. A rare type of injury, usually only
pointing toward a directly proportional relation- described in gymnastics, are clavicular stress
ship between activity time and injury risk [78]. fractures. The repetitive forces to which the upper
extremity is exposed to in tumbling and vaulting
are the cause of these stress injuries [90].
39.6.3 Common Injuries The lower back is involved in all maneuvers
and is a common source of disability. Muscular
Gymnastics is a unique sport that often requires strains, stress reactions, and spondylolysis of the
using all four extremities as weight-bearing limbs L5 vertebrae are common sources of pain, fol-
39  Indoor Sports 529

lowed by sacralization of the L5 vertebrae and at preventing injury occurrence. Joint immobili-
scoliosis [87]. The prevalence of spondylolysis is zation and bracing often restrict motions neces-
higher in gymnasts (5.9–33%) than the general sary to properly execute required event maneuvers
population (5–6%) [84]. and are rarely feasible. Therefore, preseason
Catastrophic spinal cord injuries are devas- physical conditioning programs emphasizing
tating and injuries encountered in gymnastics. joint stabilization and core stability would prove
In a case series by Schmitt and Gerner, gymnas- beneficial in prevention of common injuries
tics injuries accounted for 15.9% of all sporting about the ankle and wrist. Maintenance training
spinal cord injuries and were from neck hyper- programs would also likely be of benefit to this
flexion injuries. Forty-five percent of these were extent.
during trampoline events and led to cervical Injury incidence appears to be directly cor-
level spinal cord injuries with paraplegia [88]. related with amount of time spent in sport and
level of competition. This, combined with the
repetitive nature of gymnastics training, is
39.6.4 Injury Mechanisms likely a large contributor to chronic overuse
injuries. Periodization and increased vari-
The overwhelming majority of injuries occur as ety of training activities may also be of ben-
the gymnast contacts the hard ground surface. efit and such methods have found acceptance
This is obvious for floor exercise and rhythmic abroad [89].
events but also includes events requiring use of Additionally, Kolt and Kirkby allude to a high
an apparatus [76]. For these apparatus events, recurrence rate for gymnastics injuries [80, 84].
dismount and landing requires an abrupt halt of Whether this is truly a recurrence or merely
the body’s momentum and tremendous energy undertreatment of acute injuries, proper rest and
transfer, to either the lower or upper extremity. recovery time should be allotted to the gymnast
Kerr and colleagues reported injury mechanisms without outside pressure to return prior to satis-
among NCAA female gymnasts, noting contact factory resolution of symptoms.
with the surface was the most frequent cause of Age requirements for event participation
injury in both practice and competition, fol- have not been implemented in the United States
lowed by overuse injuries (29.8%) and direct but are a possible avenue for injury reduction.
contact with the apparatus (16.5%) [83]. This In Germany, trampoline events were eliminated
trend was re-demonstrated with no difference from grade school competition with the aim to
between practice and competition by Marshall eliminate catastrophic injuries, yet no data is
et al. [76]. currently available regarding outcome [88].
Chronic, overuse-type injuries are commonly This would be a drastic measure and would
attributed to many of the injuries seen in gymnas- need great consideration of necessity prior to
tics [86]. It has been proposed that chronic con- introduction.
centric loading through tendons and soft tissues In the event of traumatic neck and spine inju-
is the underlying cause of attritional losses, ries, proper Advanced Trauma Life Support pro-
chronic inflammatory changes, and apophysitis tocol and C-spine immobilization precautions
in the young gymnast. should be followed at all times. Coordination
with event officials and emergency medical
services prior to the start of an event is para-
39.6.5 Treatment Principles mount to avoid delays in transport to higher
levels of care. Figure 39.1 outlines ATLS guide-
Given the frequency and severity of injuries faced lines with respect to spine immobilization and
by the gymnast, much effort should be channeled examination.
530 A. Behar et al.

Fact Box

Fig. 39.1 ATLS ASSESSMENT

algorithm and spine

A I g o r i t h m
A Airway Maintenance and

T RA U M A
assessment in the trauma Unconscious
patient. Schmidt OI Cervical Spine Protection
et al. ATLS and damage

B
Chest injuries ?
control in spine trauma. Breathing and
- Ribcage
World J Emerg Surg ventilation - Bruising

T I M E
WJES. 2009;4:9.
Abdominal injury ?
C
doi:10.1186/1749- Circulation and
- Retroperitoneum
7922-­4-9 hemorrhage control - Pelvis
Normal mot./sen. Exam
Normal Reflexes
Normal Sphincter tone

S P I N E
Disability Abnorm. mot./sen. Exam
Abnorm. Reflexes
A T L S

Abnorm. Sphincter tone

Log-Roll & Spine exam

E Exposure
Posterior Processus ?
Tenderness ?
Bruising ?

Only Withdraw spinal precautions in the

alert and conscious patient

39.7 Racquet and Wall Sports by athletes competing in these sports [95, 96].
Lower extremity injuries are the most common
Garrett Schartzman encountered by these athletes. Whether it be liga-
mentous or bony in nature, these injuries are simi-
lar to any running or cutting athlete. Wall sports
39.7.1 Introduction such as squash and racquetball also encounter a
high rate of eye injuries, necessitating the use of
Indoor racquet sports are a very popular form of eye protection. A large retrospective study of
physical exercise. Sports such as badminton and patients regarding injuries during badminton and
table tennis are also commonly played in coun- squash found the incidence rates at 20% and 59%,
tries such as China and India [95]. This category respectively [96]. These were attributed to the con-
of sports also includes racquetball, handball, and stant contact with the wall and the opposing player.
squash. Given the unique aspects of these sports
such as running into a wall, projectiles coming
toward the player very quickly, and being within 39.7.3 Injury Mechanism
close proximities of another player swinging a
racquet, injuries are common. They are also at As with other cutting and running sports, indoor
times unique from other racquet sports such as racquet athletes sustain lower extremity sprains
tennis given the nature of the games. and ligamentous injuries. Appropriate shoe wear
and ankle protection can help with these injuries. A
unique aspect again is the wall encountered in
39.7.2 Injury Rates some of these sports. This creates a contact that
other racquet sports do not encounter. This has
Given the niche nature of these sports, injury data been attributed to injuries such as fractures and eye
is difficult to find. From small case studies, extrap- injuries from deflections [96, 97]. Indoor racquet
olations can be made into the injury rates sustained athletes also encounter injuries from the overhead
39  Indoor Sports 531

swinging nature of the sports and may incur rotator program that the 5-year injury rates for men and
cuff and shoulder injuries. Badminton in particular women’s swimming and diving teams are 1.54
sees a high rate of wrist injuries due to the snapping and 1.74 per 1000 AE. The majority of injuries
nature of the ­movement. Proper racquet weight for were secondary to overuse and involved the shoul-
the athlete can help to prevent this from occurring. der. The female swimmers had a 58% higher rate
of overuse injury in comparison to male swim-
mers (1.04 vs. 0.66 per 1000 AE) [100]. A sur-
39.7.4 Common Injuries vey of Division 1 NCAA competitive swimmers
showed that injury rates of 4.0 per 1000 training
Injuries among indoor racquet sport players hours for men and 3.78 per 1000 training hours
encompass the entire body. Most commonly seen for women. In addition, underclassmen were
are lower extremity injuries from cutting or lung- prone to more injuries than their upperclassmen
ing. However, in squash or racquetball, lower teammates. The survey also showed that different
extremity trauma, such as fractures or contusions, strokes contributed to the injury risk with non-
is also seen from interactions with the wall. free style specialist experiencing more injuries
Upper extremity injuries from repetitive over- with a relative risk of 1.33 [101]. During the 2013
head motion are also seen and include rotator FINA World Championships, the incidences of
cuff tears, AC impingement, De Quervain’s teno- injury were 8.3 per 100 registered aquatic ath-
synovitis, and wrist sprains. Finally, eye injuries letes [102].
are also seen in indoor racquet sports. All athletes
are highly recommended to use eye protection.
There are multiple reports of eye contusions and 39.8.3 Mechanisms of Injury
retinal damage from deflections [95–97].
The sport of swimming is specifically dependent
on the upper extremity for propulsions through
39.8 Swimming the water. The body type of a successful swim-
mer is characterized by having large upper and
Erwin Secretov middle body muscle masses. The swimmer is
also usually lean and quite tall with long limbs
and wide shoulders. This body type allows the
39.8.1 Introduction swimmer to develop significant amount of power
to drive the body forward, overcoming the resis-
Swimming is one of the most popular sports tance from water drag [103]. The majority of
around the world and is the second largest sport injuries seen in swimming have to do with over-
based on total athlete participation in the Olympic use. The shoulder is fundamentally an unstable
Games [98]. On average 27.5 million prime-time joint that requires firm scapular base and coordi-
viewers tuned into the 2016 Olympic Games with nated pattern of muscle forces to maintain stabil-
swimming being one of the marquee events [99]. ity, motion, and function. Anatomically, the
Swimming is a unique sport as it takes place in shoulder joint is stabilized by static stabilizers
the water, which results in different gravitational (labrum and capsular ligaments), as well as
and resistive forces. These forces will predispose dynamic stabilizers (rotator cuff muscles and
the aquatic athlete to primarily overuse injuries to scapular muscles). With intact shoulder kinemat-
the shoulder, knee, and lower back. ics, the humeral head should maintain balance
forces with the glenoid fossa [104]. Swimmers,
however, frequently will have increased shoul-
39.8.2 Injury Rate der laxity as their careers progress [105]. The
enhanced shoulder laxity may provide a com-
It has been reported by the National Collegiate petitive advantage by allowing swimmers to
Athletic Association (NCAA) injury surveillance achieve ideal body positions to reduce drag and
532 A. Behar et al.

generate larger stroke lengths. Consequently, the the coracoacromial arch. It can also be caused
increased shoulder laxity leaves them more by scapular dyskinesis, overuse-related fatigue,
prone to relying on the dynamic stabilizers of the and relative shoulder instability [103, 114].
shoulder to control the improper translation and Knee pain is the second most common musculo-
ultimately producing instability, impingement, skeletal injury in competitive swimmers and has
and shoulder pain [106]. The main propulsive been called “breaststroker’s knee” [109]. The
mechanism of swimming is the upper extremity, documented incidence of knee pain in Olympic
generated by powerful pectoralis major and athletes has been reported to be as high as 34%.
latissimus dorsi muscles. With the development Interestingly, non-­ breaststroking specialties
of muscle fatigue, the potential strength imbal- report 48% knee pain, while 73–86% of breast-
ance of opposing musculature is intensified, stroke swimmers reports knee pain [109, 110,
leading to further destabilization of the humeral 115]. Furthermore, groin pain is also frequently
head, scapular dyskinesis, and rotator cuff tendi- seen in the swimming populations. Hip adduc-
nopathy [106]. Scapular dyskinesis has been tors injury is common in the breaststroke spe-
thought to predispose patients to impingement cialty of swimmers. A survey of US swimmers
by placing the scapula in a relative abducted, found that groin pain affects 41% of breast-
protracted, and lateral displaced position during stroke swimmers, 21% of individual medley
activity [107]. Another common overuse injury swimmers, and only 6% of non-­breaststroke/
in swimmers is the “breaststroker’s knee” which nonindividual medley swimmers [116]. Most
causes anterior and medial knee pain. These can cases of hip adductor/flexor strain injuries occur
potentially be attributed to recurrent medial col- after repetitive hip adduction and squeezing of
lateral ligament sprains, patellofemoral pain the legs during the breaststroke kick [41]. Also,
syndrome, patellar tendinopathy, medial plica lumbar spine pain is commonly reported in the
syndrome, and pes anserine bursitis [103, 108– swimming population, affecting 33–50% of but-
110]. The mechanism of injury is thought to terfly specialist and 22–47% of breaststrokers
involve repetitive valgus load of the breaststroke [117]. Radiographic studies have shown that
kick, which causes medial distraction and lateral lumbar spine MRI in elite-level swimmers will
compression to the compartments of the knee frequently identify high grade of degenerative
[111]. In order to maintain proper streamlined disc disease, most commonly at the L5/S1 level
body position in the water, swimmers will fre- compared to controls [118]. With hyperexten-
quently be forced into a hyperextension of their sion of the lumbar spine in swimming being
lumbar spine. This position predisposes the commonplace, the stresses on the lower back,
swimmer to both lumbosacral and ligament inju- specifically in the butterfly and breaststroke, can
ries [112]. produce excessive posterior spine loads that
may eventually lead to spondylolysis and spon-
dylolisthesis [112].
39.8.4 Common Injuries

The most common complaint in competitive 39.9 Tennis

swimming is shoulder pain [101], with overuse
injuries being more common than acute injuries. Samantha Tayne
Competitive swimmers will frequently com-
plete more than 2500 shoulder revolutions and
train up to 9  miles per day [113]. The term 39.9.1 Introduction
“swimmers’ shoulder” has been described as
anterior shoulder pain that frequently will occur Tennis is a very popular recreational and com-
during or after training due to repetitive petitive sport with 17.9 million players in the
impingement of the rotator cuff tendons under United States [119] and over 75 million people
39  Indoor Sports 533

playing throughout 200 countries worldwide players; however it found that male players tend
[120]. There continues to be growth in youth to have more severe injuries, with severity
tennis, as well. Though tennis is played on var- defined as number of days off from training and/
ied surface types, indoor tennis is most often or matches. Injury incidence increased with age,
played on a hard court. This type of court has with an incidence of 2 injuries per 1000  h for
the highest coefficient of friction and lowest 13-year-olds and 2.9 injuries per 1000  h for
shock absorption. Due to the physics of playing 18-year-olds [122]. The National Collegiate
on a hard court, sliding is difficult with short Athletic Association (NCAA) had an Injury
stopping distances and therefore high peak Surveillance Program (ISP) from 2009 to 2015,
loads on the ankles and knees [119]. which found a higher injury rate of 4.9 injuries
Additionally, the high velocities with which per 1000 exposures in a sample of 19 men’s and
players hit the ball and the various positions of 25 women’s varsity tennis program. Here expo-
the racquet may cause the transfer of large sure was defined as participation in official
loads to the joints of the upper extremities. As NCAA practice or match [119, 124]. Another
racquets have evolved over the past 30  years study on NCAA athletes showed that 67% of
from heavy, wood models to the lighter graph- players had at least one musculoskeletal condi-
ite composite models, they have also been made tion during the season. Importantly, they also
to have a larger head with stiffer material [121]. found that all of the injuries sustained during
The player must make efficient use of the match play were acute, while 69.6% of injuries
kinetic chain in order to minimize the force sustained during training were gradual onset.
transferred to each joint from the racquet or the Almost one-third of the NCAA players had at
court surface. Overall, high aerobic and anaero- least one chronic condition during the season
bic demands over the course of a match on a [119, 125].
hard, indoor tennis court may lead to overuse Professional athletes were evaluated in a study
and acute traumatic injuries. analyzing injury trends from the US Open Tennis
Championships from 1994 to 2009, demonstrat-
ing a comparably very high injury rate of 48.1
39.9.2 Injury Rates injuries per 1000 match exposures. This study
also showed a significantly higher rate of acute
Several studies have been published observing injuries at 27.7 per 1000 match exposures than
the injury rate among various populations of ten- chronic overuse injuries 19.5 per 1000 match
nis players, including recreational players, exposures [119, 126]. A study performed with
juniors, college athletes, and the professional cir- participation of the Women’s Tennis Association
cuit. Most of these studies, especially among the (WTA) showed similarly high injury incidence
elite-level athletes, measure injuries as a physical rates of 56.6 per 1000 h of match play or 62.7 per
complaint during training or a match, which 1000 match exposures. Greater ranking of the
interrupts the training or match for a period of athlete typically resulted in increased number of
time. The incidence of injuries can be recorded in matches and match hours per season and was
several ways: per 1000 match hours, per 1000 associated with a greater number of injuries per
exposure hours, or simply per number of athlete season [120].
exposures (either match or training). One com- A study in the Netherlands performed via
prehensive meta-analysis by Pluim et al., which telephone survey on participation on recre-
includes all levels of players, reported an overall ational sport found an injury rate of 9.6 injuries
injury incidence of 0.04–3.0 injuries per 1000 h in 10,000 h played. This study identified tennis
of play [122]. as one that should be targeted for injury pre-
One study observing elite junior tennis play- vention for male and female recreational ath-
ers in Australia found no difference in the inci- letes, especially within the 35–54-year-old age
dence of injury between male and female group [127].
534 A. Behar et al.

39.9.3 Common Injuries force and may be related to muscle weakness or

imbalance, all the way down to the grip on the
The kinetic chain, from the feet interacting with racket.
the court surface through the trunk to the s­ houlder A study of 184 elite tennis players between
and down the arm controlling the racket, allows 11 years old and 24 years old were evaluated in
tennis players to transfer energy from the racket terms of their shoulder range of motion. This
to the ball. Any break or malfunction within this study found that reduced internal range of motion
kinetic chain may lead to injury, either acute or and increased external range of motion were
chronic. Serving is the most strenuous stroke in common in the dominant arm of these players.
tennis, with high forces generated through the Additionally, GIRD increased with age. The
trunk, shoulder, and into the forearm and wrist. players under 14 years old had significantly more
The serve is characterized similarly to pitching in internal rotation than those over 14  years old
baseball with a windup, early cocking, late cock- [129]. In SICK scapula syndrome, there is weak-
ing, acceleration, and follow through. Ground ness of the muscles stabilizing the scapula,
strokes, though they may not generate as much including the serratus anterior, infraspinatus, del-
force, also are characterized in a similar fashion toid, and lower and middle trapezius. Meanwhile
with the racket preparation, acceleration, and fol- the increased tension of opposing scapular stabi-
low through [128]. The most common chronic, lizers, which includes the levator scapulae, upper
overuse injuries are related to the repetitive trapezius, and pectoralis, leads to abnormal
motion of the upper extremities in these strokes motions of the scapula, causing increase in the
and may also lead to abdominal muscle strains, angulation of the humerus on the glenoid, and
lumbar strains, or discogenic injuries. The lower increased injury risk [130].
extremities are more susceptible to acute injuries Lateral elbow epicondylitis, also known as
such as ankle sprains, meniscal knee injuries, and tennis elbow, is commonly associated with tennis
hip injuries, during quick directional changes and injuries. The torque of the racquet as it makes
sliding on a hard court, as the body compensates contact with the ball is opposed by eccentric
for the change in direction or velocity [121]. loading of the forearm muscles, which can cause
As described previously, upper extremity inju- microtrauma and lead to tendinopathy [121].
ries tend to be less prevalent than lower extremity However, 5-year injury data from the Association
injuries; however a study of NCAA men’s and of Tennis Professionals and the WTA the world
women’s tennis injuries suggested that tennis has tour actually found that medial epicondylitis was
a higher proportion of upper extremity injuries three times more likely than lateral epicondylitis.
than other NCAA sports [128]. Maladaptive Fu et  al. comment that this may be due to the
motion of overhead athletes such as tennis play- repetitive loads of forehand groundstrokes and
ers, including glenohumeral internal rotation serve loading in modern tennis that stress the
deficit (GIRD) and SICK scapula (scapula mal- medial flexor-pronator mass [119]. Similarly,
position, inferior medial border prominence, valgus extension overload is caused by a combi-
coracoid pain and malposition, and dyskinesis of nation of valgus forces along with rapid exten-
scapular movement), may lead to further injury sion, leading to tensile forces on the medial side
[129, 130]. Such injuries may include internal of the elbow, compression on the lateral portion
impingement and superior labrum anterior-to- of the elbow, and shear forces in the posterior
posterior (SLAP) tears in the shoulder, tendinop- compartment. Valgus extension overload may
athy at the medial or lateral elbow, tendinopathy result in injury to the UCL (ulnar collateral liga-
or subluxation of the extensor carpi ulnaris ten- ment), posterior impingement of the elbow, ulnar
don at the wrist, valgus extension overload of the neuritis, or even osteochondritis dessicans [131].
elbow, and TFCC sprains. These injuries are all Acute injuries to the lower extremities are the
affected by the inefficiency of the transfer of most frequent in adult professional athletes and
39  Indoor Sports 535

NCAA athletes. Dakic studied professional relieve some of the load. Poor core strength or
women in the WTA and found that lower limb poor coordination of these muscle groups may
injuries were most common and occur twice the lead to strains or tears, which can be debilitating
rate of upper limb injuries and three times the injuries. Athletes may also suffer muscular
rate of trunk injuries [120]. It is important to strains or inflammation of structures around the
note that this study looked per match exposure, hip joint, as well as labral tears due to similar
so likely more acute injuries were taking place stresses [121]. In Gescheit’s study on elite
during a competitive match rather than chronic junior-level players, the lumbar spine was both
injuries, which may have prevented the athlete the most commonly injured and the most
from competing altogether or was adequately severely injured area, especially among
controlled and treated prior to match play. A 14–18-year-olds [123]. Another 1-year prospec-
study mentioned previously, looking at data tive study on elite junior players found that over-
from 19 men’s NCAA programs and 25 wom- use injuries made up 47% of the health problems
en’s NCAA programs, found that the lower experienced by this cohort over the year and the
extremities were the most commonly injured; lower back was a common site of injury [134].
however they did also have high rates of trunk Athletes suffering from an abdominal or lumbar
injuries, 16.6% of injuries for the men and 17.6% strain typically require at least 1–2  weeks off
for the women [124]. from any strenuous activity, and initially even
Lower extremity injuries may include a vari- walking may be difficult. Core strengthening
ety of injuries to the knee and ankle, often from may help prevent these and other injuries,
rapid change of direction on the tennis court sur- throughout the kinetic chain [121].
face. The ankle is the most common location of
acute injuries in professional and elite-level ath-
letes, specifically inversion ankle sprains, though Fact Box
knee injuries to the anterior cruciate ligament It is important to consider the equipment
and collateral ligaments are also seen [119, 121, and surface type when treating a tennis
124, 126]. In recreational tennis players, tennis injury. Acute injuries are more common in
toe and tennis leg are common lower extremity the lower extremities, while chronic, over-
injuries. Tennis toe is due to repetitive stress of use injuries tend to involve the upper
the toe against the front of the shoe, most com- extremities. Preventative measures should
monly to the big toe, leading to a subungual include evaluation of the kinetic chain and
hematoma and a painful toe. Tennis leg, first addressing any muscle imbalances.
described in 1883, has historically thought to be
related to a tear of the plantaris tendon. However,
more recently it has been shown to be a tear of
the medial head of the gastrocnemius or disrup- 39.10 Volleyball
tion of the gastrocnemius-soleus aponeurosis,
due to extension at the knee with forced dorsi- Matthew Steffes
flexion of the ankle, often in middle aged ath-
letes [132, 133].
Trunk injuries, including lumbar spine, 39.10.1  Introduction
abdominal, and groin strains, are unique to ten-
nis or overhead serving sports. The forced flex- Volleyball, originally termed mintonette, was
ion of the trunk is initiated by the rectus created by William G Morgan in a New England
abdominis and supported by the internal and YMCA in 1896. He intended to create a game
external obliques and the iliopsoas; meanwhile that incorporated elements from badminton, ten-
the gluteal muscles help drive the core and nis, handball, and the popular new game of bas-
536 A. Behar et al.

ketball. The game found new popularity abroad 39.10.3  Common Injuries
among Allied countries during World War I. This
popularity led to becoming an official Olympic Volleyball requires high demands on both the
Summer sport in 1964, while the outdoor version upper and lower extremities, in addition to the
played on sand was officially added in 1996. It is trunk and spine. At all levels of play, ankle
estimated that global volleyball participation sprains are the most prevalent injury. In a pro-
rates are second only to soccer [135]. In the spective series by Verhagen et al., ankle sprains
United States, participation rates are higher accounted for 41% of all injuries incurred during
among females and are reflected in the disparity one season among an Olympic National Team.
of varsity Division 1 collegiate volleyball pro- Additionally, ankle sprains were the most com-
grams [136]. mon injury leading to at least 10 days of missed
time from activity among collegiate athletes
[140].
39.10.2  Injury Rates The next most common acute injuries are
ACL ruptures, most prevalent among females
Several case series have been reported regarding landing from a jump. Among high school
injury incidence at various levels of competi- females, ACL ruptures are 5 times more likely
tion. Pastor et al. reported a mean of 2.58 inju- during competition compared to practice [141].
ries per player among the German Men’s Incidence of ACL ruptures has been rising
National Team over a 6-year period. These ath- among women collegiate players, with a mean
letes were 3 times more likely to sustain an 0.06 injury rate per 1000 game and practice
acute injury versus a chronic injury (3.3 vs. exposures per season [139].
1.08/1000 h) and averaged fewer injuries in the In contrast, injuries to the shoulder and lum-
second season of competition compared to first bar spine are mostly due to overuse. We also see
season (1.92 vs. 3.25 injuries/year). These inju- significant overuse injuries in the knee. Patellar
ries caused the athlete to miss on average 16.9 tendinosis, or jumper’s knee, is the most com-
participation days [137]. mon chronic injury overall, approaching nearly
The lower extremity is the most commonly 50% among high amateur athletes [142].
affected area, accounting for over 58% of all Ferretti et al. demonstrated the development of
injuries, compared to the upper extremity at patellar tendinosis is directly associated with
21%. The majority of these injuries occurred in the amount of participation and that participat-
the attack zone, which is the area nearest the net ing in practice or a game more than 4 times per
when related to the backline defensive position week for at least 2  years was the highest risk
players. Collegiate athletes showed a 6.19 injury factor [143].
rate per 1000 exposures during preseason prac- Shoulder impingement and rotator cuff ten-
tice as compared to 4.52 injury rate per 1000 donitis, suprascapular neuropathy, glenohu-
exposures during in-season competition [138]. meral internal rotation deficit, and shoulder
There is a lack of studies reporting differences instability are all common pathologies leading
in injury prevalence or incidence between gen- to shoulder pain and disability in the volleyball
ders. Agel et  al. presented 16  years of data on athlete. Among amateur and recreational ath-
female collegiate volleyball players, showing letes, shoulder impingement predominates,
similar rates of shoulder injuries incurred dur- whereas suprascapular neuropathy is the most
ing competition and practice (21.4% and common shoulder pathology seen at the elite
18.7%), whereas spine injuries were more com- level. Lumbar muscle strains and herniated lum-
mon in practice compared with competition bar discs are the most common spine injuries
(10.8 vs. 17.4%) [139]. seen, with strains more prevalent among elite-
39  Indoor Sports 537

level athletes and disc pathology higher among position and maximize the torque generated. This
amateurs [144]. produces both compressive load on the posterior
elements and stresses through the intervertebral
disc and is suspected to lead to muscle strains,
39.10.4  Injury Mechanism disc disease, pars interarticularis stress reactions,
or overt fractures.
Ankle sprains account for the majority of acute
injuries encountered and many studies have been
done involving the circumstances and mecha- 39.10.5  Treatment Principles
nism of these injuries. Bahr et  al. showed that
these injuries occur when an offensive player Injury prevention has been the focus of many
charging the net lands on a teammate’s or oppos- efforts over the last 30 years, involving changes
ing player’s foot at the centerline, inverting the to rules, rehabilitation, and training approach. A
ankle [145]. Many studies have shown fewer rule change was previously proposed to penalize
ankle sprains in beach volleyball, pointing any violation of the centerline to avoid player
toward the role the hard playing surface contrib- collisions in the attack zone. This greatly impeded
utes [146]. the game and was removed in favor of allowing
The ACL is often injured as the landing players to completely cross the line. Curiously
attacker strikes the surface with the lower this leniency did not lead to expected increase in
­extremity in a valgus and internally rotated posi- ankle sprains and has been incorporated into the
tion, placing undue stress on the ACL.  The current game regulations [149].
majorities of these injuries are noncontact inju- The use of ankle bracing was originally
ries and involve other intra-articular structures embraced as a successful method at reducing
[138]. Zahradnik et al. compared the biomechan- ankle sprains, by Pedowitz et al. showing a rate
ics of two differing methods of landing after a of 0.07 ankle sprains per 1000 exposures with use
block maneuver. By landing on both feet simulta- of a double-supported ankle brace. This was sig-
neously, each extremity is loaded evenly, as nificantly lower than the national average of 0.98
opposed to using one foot to quickly step back- sprains per 1000 exposures [150]. However,
ward in a staggered stance. The latter places an Stasinopoulos et al. showed that bracing was as
increased valgus moment at the knee causing effective as proprioceptive training and technical
increased tension of the ACL [147]. training in reducing ankle sprains [151]. While
Many volleyball-related injuries can be attrib- debate remains, this points to the importance of
uted to repetition and overuse. Kugler et  al. incorporating some modality to address ankle
reported that the elite volleyball player will per- stability prior to injury.
form 41,000 overhead spikes and serves per sea- Ankle sprains carry a significant risk of recur-
son [148]. The overhead spike, standing serve, rence, with rates approximating 42% within
and jump-serve maneuvers all require maximum 6  months of index injury [152]. Rehabilitation
abduction and external rotation of the shoulder to programs aimed at reducing this rate share many
fully “cock” the arm prior to forward acceleration similarities with preventive programs. Many dif-
and ball strike. This position may lead to stretch- ferent protocols varying in length, amount of
ing of the glenohumeral capsule in addition to guided therapy, and the use of supportive devices
inflammation or attrition of the rotator cuff have been developed, but all emphasize proprio-
muscles. ceptive training under the supervision of a physi-
The overhead spike and jump-serve maneu- cal therapist or athletic trainer. These have
vers also involve extremes of motion in the lower yielded good results at restoring general ankle
spine. During both actions the lumbar spine strength and proprioception as well as lowering
rotates and hyperextends to increase the “cocked” reinjury rate [153].
538 A. Behar et al.

Fact Box
See Table 39.1.

Table 39.1  Classification of acute lateral ankle sprains

Classification of acute lateral ankle sprains [154]
Grade Description
I The ATFL is stretched and some of the ligament fibers are torn. No frank ligamentous disruption is
present. Mild swelling, little or no ecchymosis on the lateral aspect of the ankle, point tenderness on
the ATFL, and no or mild restriction of active ROM. Difficulty with full weight bearing is sometimes
seen. No laxity on examination
II Moderate injury to the lateral ligamentous complex, frequently with a complete tear of the ATFL ±
partial tear of the CFL. Restricted ROM with localized swelling, ecchymosis, hemorrhage, and
tenderness of the anterolateral aspect of the ankle. Abnormal laxity may be mild or absent. May be
indistinguishable from a grade III injury in the acute setting.
III Complete disruption of the ATFL and the CFL ± capsular tear ± PTFL tear. Diffuse swelling,
ecchymosis on the lateral side of the ankle and heel, and tenderness over the anterolateral capsule,
ATFL, and CFL
Adapted from Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop
Surg. 2008;16 (10):608–615

documented an incidence of 67% of shoulder

39.11 Water Polo soreness or swimmer’s shoulder by the time play-
ers are at the collegiate or postcollegiate level.
Aimee Bobko The incidence of shoulder pain in water polo has
been directly correlated to the number of years a
player has participated in the sport [161]. Elite
39.11.1  Introduction women’s water polo players have been shown to
have a higher rate of shoulder soreness with
Water polo is a unique sport that combines fea- increased shooting volume [163].
tures of swimming, throwing, and wrestling
[155]. In addition to the injuries commonly seen
with swimming and overhead sports, water polo 39.11.3  Common Injuries
has a high rate of acute traumatic injuries second- and Mechanism of Injury
ary to physical contact. Water polo has the high-
est rate of injuries of aquatic sports [156]. The most common mechanism of injury results
from physical contact. The only protective equip-
ment is ear covering and mouth guards, which are
39.11.2  Injury Rate not required [159]. “Nail checks” are performed
and Epidemiology prior to each match to assess finger and toenails
of players. However, many types of lacerations
There were 15.3 injuries/100 water polo athletes including facial lacerations and corneal abrasions
in the FINA World Championships 2009/2013 still occur. Another contact injury includes con-
[157]. A majority of the injuries were the result of cussions; goalies are specifically at risk from
physical contact, including lacerations and con- other players as well as from the water polo ball
tusions [155]. The next most common are upper from shots or rebounds [160]. Another traumatic
extremity injuries, a majority involving the shoul- injury from being slapped on the side of the head
der. Reported shoulder injury rates in the sport with a cupped palm includes a tympanic mem-
vary from 24 to 51% [158]. Other reports have brane perforation (perforated eardrum). The
39  Indoor Sports 539

spine is at risk for degenerative changes due to be treated with reduction. If there is an associated
repeated rotation and extension activities with articular fracture of a greater percentage, surgical
swimming and throwing [160]. Shoulder injuries fixation may be required [161]. For a ruptured
often occur from repetitive movements and sus- tympanic membrane, players should be kept out
tained microtrauma, which include swimmer’s of the water until healed. There are options avail-
shoulder, rotator cuff injury, and labral tears able with customized ear plugs if necessary to
[160]. Shoulder dislocations are also a potential play [165]. In addition, as with all aquatic sports,
injury, especially when in possession of the water all pools should be equipped with a spine board
polo ball and being pulled by a defender [161]. A and cervical collars with a plan in place where a
result from the aquatic environment includes oti- player needs to be extracted from the water [155].
tis externa, also known as swimmer’s ear, as well
as ocular conjunctivitis. Blocking and catching
movements put players at risk for finger disloca- 39.12 Weight Lifting
tions and lacerations. The most common finger
laceration is the web space tear [161]. This injury Aimee Bobko
will occur during forced abduction with the ball
between neighboring fingers. This injury can be
superficial or complex with involvement of col- 39.12.1  Introduction
lateral ligament tears [161]. Elbow injuries can
also occur, including thrower’s elbow, ulnar col- Weight lifting as a competitive sport involves
lateral ligament injury, and osteochondritis dis- attempting to lift maximum weight loads [166].
secans of the capitellum [162]. Without the solid It’s an activity that presents extreme forces and
foundation of land to generate power from, a may produce the greatest power the human body
greater amount of force is generated from the can generate [167]. Weight lifting was included
upper extremity, placing greater tension on struc- as its own Olympic event in 1920. Current mod-
tures including the UCL [161]. ern competition consists of two exercises: the
snatch and the clean and jerk. Besides Olympic
lifting, weight lifting in the community and the
39.11.4  Treatment Principles development of activities such as CrossFit have
continued to rise in popularity and the subsequent
Education regarding injury prevention and treat- associated injuries [168].
ment is crucial. Currently, it is up to the player’s
discretion whether they wear a mouth guard. In
fact, it’s reported that only 7.7% of players wear 39.12.2  Injury Rate
mouth guards [159]. Smaller lacerations can be and Epidemiology
treated with Steri-Strips or a plastic-based water-
proof spray; larger lacerations may require An incidence of one to two injuries/lifter/year has
sutures [160]. Corneal abrasions include topical been reported [166]. Another study reports an
analgesics, topical antibiotics, and oral analge- injury incidence in weight lifting of 2.4–3.3 inju-
sics [164]. Overuse injuries can be treated by ries/1000 hours of training [169]. Prevalence var-
adjustments to swimming/throwing form, ies throughout the literature, widely from 16 to
decreased training intervals, and rest [161]. 90% of lifters sustaining injuries [166]. Shoulder
Thrower’s elbow can be treated conservatively injuries are the most prevalent, 6–36% [166].
with rest, ice, immobilization, and extension Knee injuries are the next most common with a
block splinting [161]. Web space tears range in prevalence of 10–32% [166].
severity and can be treated with simple wound Elite lifters have lower rate of injuries (3.6 vs.
care or could require surgical treatment for asso- 5.8 injuries per 1000 h) and acute injuries (50 vs.
ciated instability [161]. Finger dislocations can 72%) than novice lifters [168]. Elite lifters have
540 A. Behar et al.

more thigh injuries and less chest and shoulder Dislocations should be treated immediately as
injuries compared to novice lifters [171]. When well. Surgical fixation is recommended for many
looking at children versus adult lifters, children of the acute tendon ruptures. Chronic injuries can
are more likely to sustain accidental injuries from be first treated conservatively with training modi-
dropping or pinching weights, specifically to the fications, rest, physical therapy, and potential role
hand and foot regions [172]. of corticosteroid injections and may progress to
surgical intervention.

39.12.3  Common Injuries

and Mechanism of Injury 39.13 Wrestling

Acute injuries include spontaneous pneumotho- Benjamin Mayo

rax, myocardial infarction, fractures, disloca-
tions, tendon ruptures, meniscus tears, and acute
herniated discs [170]. Tendon ruptures most often 39.13.1  Introduction
seen in weight lifting include bicep tendon,
Achilles tendon, pec major tendon, patellar ten- Wrestling is one of the oldest known sports,
don, quadriceps tendon, and triceps tendon. with origins dating back to the ancient
Tendon ruptures are associated to occur more fre- Sumerians in 5000  BC and the first recorded
quently in those who use anabolic steroids, older wrestling competitions in 708  BC in Greece.
age, and fluoroquinolone [170]. Dislocations Rules and equipment have developed over time,
seen include glenohumeral joint, elbow joint, but the modern iteration of wrestling was noted
acromioclavicular joint, patella femoral joint, to be the Olympics in the 1896 Athens games
and ankle joint. Injuries such as these have been [174]. Today, two predominant styles prevail –
seen to occur in high rates when in the overhead Greco-Roman wrestling in which touching of
position such as in the snatch and a portion of the the lower extremities is forbidden, and free-
clean and jerk [170]. More common injuries are style, in which there are no restrictions on leg
strains, sprains, and tendinitis of the upper contact. In the United States, there are an esti-
extremity, spine, and lower extremity. Chronic mated 2.5 million participants per year, and
injuries result mainly from overuse and account wrestling was the sixth most popular high
for approximately 30% of injuries in strength school sport in 2006 [175, 176]. However, there
training [170]. Specifically patellar tendonitis is a significant risk of injury secondary to the
from deep flexion in squatting has been reported. combative nature of the sport.
Spondylolysis from excessive repetitive forces
on the lumbar spine have been seen [170].
39.13.2  Injury Rates

39.12.4  Treatment Principles There is a significant risk of injury in wrestling

that has been reported in the literature. A recent
Using equipment safely and learning proper lift- prospective study by Argarwal in 2016 demon-
ing technique can help decrease the rate or sever- strated injury rates of 5.13 injuries per 1000
ity of injuries [173]. Athletes looking to start exposures [177]. In multiple analysis of injury
using supplements or change their body weight rates among high school sports, wrestling was
should consult with a professional nutritionist, consistently second behind football with an
dietician, physician, etc. [170]. For injury man- injury rate between 7.3 and 30.7 injuries per 1000
agement, emergent treatment is warranted for athlete exposures [178–180]. Although the over-
medical conditions such as subarachnoid hemor- all injury rate is high, some studies have reported
rhage, MI, and spontaneous pneumothorax. that nearly two-thirds of injuries are deemed
39  Indoor Sports 541

minor [179]. However, a significant portion of injuries to the head and face, largely from being
wrestling injuries is severe and has been reported driven to the mat [176].
to have the highest severe injury rate in the Numerous studies have reported that a wres-
NCAA at 1.73/1000 athlete exposures [181]. tler is more likely to be injured in the defensive
Additional studies have reported that up to 37.6% position while being taken down from standing,
of injuries required at least a week off from com- and as high as 81.3% of injuries in elite athletes
petition and up to 14.8% being classified as major occurs from the standing position [180, 188,
[179–182]. Notably, more elite athletes appear to 189]. This is intuitive, as the process of being
be at higher risk of injury, as in an analysis of taken down may put the competitor in a vulner-
wrestling matches in the 2008 Olympics demon- able position and high probability to land with-
strated an injury rate of 9.3/100 athletes and 7.88 out adequately protecting them self. For
injuries per 100 matches [183]. catastrophic injuries, it has been reported as
many as 74% of occur as a result of a takedown
[185]. Similarly, a study focusing on elbow dis-
39.13.3  Injury Mechanism locations reported that 63.3% of elbow disloca-
tions occurred during takedown with the athlete
Several studies have reported on the most com- landing on an outstretched arm, while only 10%
mon injury mechanisms. As expected, most inju- occurred during an escape [190]. When analyz-
ries occur from contact with other athletes or ing emergency department visits for wrestling
with the playing surface from throws and grap- injuries, approximately 34% of injuries were
pling maneuvers. A significantly higher percent- from being struck by or against the opponent,
age of injuries occur during live competition, with another 22% as a result from a fall or take-
with as high as 93.3% of all injuries occurring down, while the remaining majority had a diag-
during matches. The reported incidence of injury nosis of overexertion [175].
during matches has been as high as 8.2/1000 ath- Few studies have attempted to analyze maneu-
lete exposures, with an odds ratio of 8.66 com- vers that may be more risky for injury and have
pared to training sessions [179, 181, 183]. had typically failed to demonstrate any pattern
Additionally, a high percentage of injuries that do leading to injury [185, 188]. However, it is con-
occur during training sessions are a result of live-­ sistently found that player contact is the most
match training. This relationship appears true for common cause in up to 56.6% of injuries, with
both minor and major injuries. Nearly 80% of contact to the surface the second most common
catastrophic injuries occurred during competition cause [181]. A majority of injuries are acute in
versus training, and the rate of elbow dislocations nature instead of chronic or recurrent injuries
was nearly three times lower in training com- [188]. In one study of Olympic athletes, only
pared to competition [185, 186]. 21.9% of all injuries were recurrent [182], while
Injuries to the legs occur more often in free- one study of high school athletes demonstrated
style, with nearly 57% of injuries occurring to that 39% were re-aggravated injuries [191].
the lower extremities [176]. Because of this,
freestyle wrestling has been reported to have a
higher overall injury rate (10.1% or 7.0 injuries 39.13.4  Common Injuries
per 1000 exposures) in Olympic athletes com-
pared to the Greco-Roman style, with knee inju- The most commonly reported injuries in the lit-
ries being four times more prevalent [176]. erature are sprains, strains, and contusions, which
Conversely, injuries to the upper extremity are account for up to 65% of injuries [179, 180, 182].
more often noted in Greco-Roman style, up to Fractures do occur, though at a lower rate than
55% of injuries to the arms, hands, or wrists soft tissue injuries. Fractures are more common in
[176, 187]. Greco-Roman has also demonstrated children under 18 years old. An analysis of emer-
to have a higher risk of concussion and other gency department visits reported fractures were
542 A. Behar et al.

the second most common diagnosis at 22.1– An increasing focus on concussion diagnosis
25.9% of injuries, led only by sprains and strains and prevention has raised the importance of
at 36.6–38.7% [175]. In more elite older athletes, understanding risks and incidence in all sports
the fracture rate has been reported to be 6.3% but particularly in sports like wrestling where the
[179]. One study of Olympic wrestlers demon- head is frequently contacted. Concussions are
strated a rate of 0.8/10,000 athlete exposures in one of the more frequent injuries of the head and
freestyle wrestlers and 0.3/10,000  in Greco-­ have been reported between 1 and 8% of all inju-
Roman [192]. ries, with a higher rate in older age groups [180,
Although all body parts are commonly injured 195]. A recent survey of NCAA wrestling
in wrestling, the knee and shoulder are the most coaches reported that their knowledge of concus-
frequently injured [180]. However, when sions was lacking, and they were more likely to
included in analysis, injuries to the skin occur at believe it was ok to keep playing after a concus-
an exceptionally high rate and should be noted. In sion in a playoff-type event compared to an early
one study, as many as 62% of reported injuries season competition. This highlights the impor-
were classified as skin abrasions or contusions tance of a need for continued concussion educa-
[187]. Though not an injury per se, skin infec- tion even at the higher levels [196].
tions are a common reason a wrestler may be Neck injuries have a reported incidence of 0.8–
held from participating in the sport. Skin infec- 14.9% of wrestling injuries, depending on the
tions in wrestlers are reported at a rate as high as level of severity recorded. Most commonly, neck
14.23/10,000 adverse events, 74% of which injuries are minor cervical strains [195, 197, 198].
caused athletes to miss more than 24 h of train- Less frequently, neuropraxias can occur typically
ing. Importantly, these infections are highly com- from a forced hyperextension mechanism while
municable and are frequently recurrent (22%), shooting in. The neck is also a potential site of
highlighting the importance of diligently disin- catastrophic injury, which will be discussed later.
fecting facilities using bleach as well as frequent
skin checks of athletes [193].
39.13.6  Upper Extremity

39.13.5  Head, Neck, and Face Upper extremity injuries are extremely common
in wrestlers, with a reported incidence between
Head and neck injuries account for 14.5% of 9.3 and 42% of all injuries [188]. The shoulder is
emergency department visits in youth wrestlers, frequently reported as the most commonly injured
with 4.5–6.2% due to traumatic brain injury part of the upper extremity and occasionally as the
[175]. The most commonly reported injury to the most common injury overall with rates as high as
head and face are minor lacerations, abrasions, 24% [175, 180]. Wrestling has also been noted to
and contusions from contact with the mat or other have the second most frequent dislocation inju-
athlete body parts, with a rate 69.9% of all inju- ries, only behind football, with 1.99/10,000 dislo-
ries when included [188]. One extremely com- cations per athlete exposures, and 7.2% of all
mon injury is perichondrial hematoma, more wresting injuries were reported as dislocation  –
commonly known as cauliflower ear in which the most commonly in the shoulder (24–54%), elbow
cartilage in the ear is damaged after trauma and (14.2%), and knee (13.5%) [180]. Recurrent
leads to deformity. In a review of the NCAA shoulder dislocations were to be at a rate of 17.3%
injury surveillance system, Chorney et  al. dem- and 12.8% eventually required surgery [199].
onstrated a maxillofacial injury rate of 7.02 inju- Elbow injuries, though less common than
ries/1000 athlete exposures. Most frequently this shoulder injuries with an incidence of 1.0–7.9%
was an injury to the nasal bone, followed by man- of injuries, are often more severe [175]. Most
dible and dental injury. However, these rarely commonly the mechanism is from a hyperexten-
needed surgery with a rate of 0.50/10,000 [194]. sion abduction motion, resulting in a sprain of the
39  Indoor Sports 543

UCL and anterior capsule. However, if continued injuries reported with an incidence near 40% and
pressure is applied, it can result in an elbow dis- fortunately are often mild. Despite being a very
location. Elbow dislocations have commonly common injury, only 6.7–8.4% of wrestling-­
been reported in the literature for wrestlers. related emergency department visits were for
Recent studies examining high school and NCAA knee complaints [175, 206]. A recent study focus-
athletes revealed that wrestling had the highest ing on knee injuries reported that 18% of all knee
rate of elbow dislocations across both age catego- injuries are strains or sprains, while another 17%
ries, with an injury rate of 6.63–10.8/100,000 were prepatellar bursitis and 24% as effusions or
athlete exposures during competition [190]. bone contusion [177]. However, when they are
Younger wrestlers are more susceptible to avul- more severe, they often require surgery and
sion fractures of the elbow including the olecra- account for up to 44% of season-ending injuries
non and medial condyle [200, 201]. in high school athletes [180]. Many of these are
Though frequently not reported due to the low for ACL injuries, which have been reported to be
severity, injuries to the wrist, hand, and fingers approximately 10% of all knee injuries. There are
are also common and account for 18.5% of mixed reports about whether the medial or lateral
wrestling-­ related emergency department visits side of the knee is more frequently injured, but
[175]. Sprains of the metacarpophalangeal and wrestling has demonstrated a relatively higher
interphalangeal joints are the most common inju- rate of lateral meniscus injuries compared to
ries to the hand [182, 188]. Less common upper other sports [178]. Although a majority of knee
extremity injuries that have also been described injuries are minor, the knee is one of the most
in the literature include ruptures of the pectoralis common sites of significant injury. One study has
major, avulsion fractures of the scapula, avul- reported that nearly 40% of significant injuries
sions of the lesser tuberosity, subscapularis inju- were of the knee, while another demonstrated
ries, and suprascapular nerve injuries [202–205]. that the knee accounted for 65% of injuries
requiring surgery [181, 206].
One unique knee injury to wrestling is prepa-
39.13.7  Torso and Spine tellar bursitis. While it is a relatively rare injury
in most sports, however, it is one of the more
Injuries to the torso are relatively common in wres- common knee injuries in wrestlers due to the
tlers, with a reported incidence between 1.2 and amount of time spent kneeling [190]. A study by
18.6% of injuries. A majority of these are rib and Mysnyk et al. reported that 21% of all new knee
chest injuries such as costochondral sprains and rib injuries were prepatellar bursitis and often would
fractures [188]. Wrestlers have also been identified reoccur [184].
as a group with a high rate of spondylosis or spon-
dylolisthesis, with as many as 25% of athletes dem- 39.13.8.1 Catastrophic Injuries
onstrating these changes on radiographs and up to Unfortunately, catastrophic injuries have been
30% of wrestlers with back pain [206, 207]. reported in the literature [208]. Though rare over-
all, with a reported rate of 0.97/100,000 in wres-
tlers, 50% of these injuries affecting the cervical
39.13.8  Lower Extremity vertebral column, head, or spinal cord resulting
from rotational or axial blows to the region [188].
Injuries to the lower extremity are extremely The other 50% are attributed to cardiac dysfunc-
common in both types of wrestling but more so in tion [188]. A large review by Boden et al. in 2002
the Greco-Roman style. The knee is often reported 54 catastrophic injuries over an 18-year
reported as the most frequently injured body period. Fifteen of such injuries were attributed to
area, with rates between 7.6 and 44% of all inju- indirect causes such as heart failure and weight
ries [188, 190]. Ligament sprains of the MCL, loss-related systemic failure. Overall there was a
LCL, ACL, and PCL are the most common knee rate of 2.11 direct catastrophic injuries per year or
544 A. Behar et al.

1/100,000 participants [185]. These included 27 39.14 Universal Challenges

cervical fractures or injury to major cervical liga- to Consider When Caring
ments, 4 spinal cord contusions w/transient for any Indoor Sport
quadriparesis, and 3 severe head injuries.
Quadriplegia was present in 11 cases, with resid- Alex Behar and Mark R. Hutchinson
ual neurologic deficits in 6 athletes and 1 death in
a head-related injury from head-to-head contact
in a practice [185]. They did determine that 11 of 39.14.1  Playing Surfaces
such injuries were preventable, as there were rules and Environment
infractions or instances of poor officiating that
resulted in a delayed call that may have stopped Playing surface is a key controllable factor when
play before injury. Other studies have reported targeting prevention of injuries in indoor sports.
wrestling as having the second highest rate of cer- Certain flooring materials such as concrete may
vical spine injuries in high school athletes, with a be more unforgiving and lead to increased risk of
rate of 7.42/100,000 athlete exposures [209]. One overuse injuries. If a more rigid surface is neces-
study of catastrophic cervical spine injuries found sary and is different than the athlete is used to,
that 50% were permanent, while 50% had full consideration of modifying shoe wear with
recovery [210]. increased shock absorption can work to balance
Non-axial catastrophic injuries have also been out the increased risk. Many events will install
reported, with an example being brachial artery some sort of temporary playing surface or court
disruption following elbow dislocation [211, made of wood or synthetic. These surfaces may
212]. Overall, it has been reported that less expe- be raised and include some additional structural
rienced athletes were more likely to experience a shock absorption. It is a good idea for the health-
catastrophic injury, as they are more likely to get care provider or athletic trainer to walk the floor
themselves in to dangerous situations [185]. before competition looking for flaws in structure
or installation that might increase the risk of ath-
lete tripping. There should be no sharp, raised
Fact Box: Medical Issues edges, gaps, valleys, or defects. The surface finish
There is a relatively high incidence of med- should be consistent so that one area does not pro-
ical issues to be aware of for wrestlers. The vide more or less traction than another. The play-
process of cutting weight can have pro- ing surface should be dry with no evidence of
foundly negative impacts on the athlete’s prior leaks. If the surface has been recently refin-
health and have deleterious effects on per- ished or treated the athletes should be allowed
formance, strength, and aerobic capacity. time to acclimate to the new playing surface to get
While maintaining a low body percentage a feel for traction and shock absorption. Certain
is expected, weight loss is often achieved playing surfaces may also introduce an increased
through unhealthy methods such as fluid risk of certain types of injuries such as rug burns,
and calorie restriction and less commonly road rash, abrasions, and splinters that the health-
diuretics and laxatives leading up to a care provider should be prepared to address.
match. Both the NCAA and NFHS have Alternative playing surfaces such as water and
placed restrictions on the amount of weight ice will introduce additional unique injury risks
loss athletes can achieve during season that should be considered and planned for. For
based on a preseason assessment and body temporary swimming events, leakages outside of
fat assessment. It is important for physi- the pool deck may increase the risk of slipping
cians to be familiar with their local proto- and all electrical devices need to be carefully
cols to ensure their athletes are eligible and grounded and kept away from standing water.
safe for participation. Indoor swimming, diving, and water polo also
introduce the presence of chlorine into the air that
39  Indoor Sports 545

may trigger bronchospasm or asthma attacks in to the facility and to the playing surface? What is
select athletes who are at risk. Optimizing venti- the quickest and safest route for emergency trans-
lation systems may minimize the risk. For indoor port to get the nearest hospital? While such emer-
ice sports such as ice hockey, figure skating, curl- gency plans are necessary for all competitions
ing, and speed skating, the potential risk of slip- whether indoors or outdoors, the unique limita-
ping on the playing surface is obvious; however, tions regarding access to an indoor venue must be
the maintenance of an indoor ice introduces accounted for.
unique risks that should be considered when car-
ing for athletes. Electrical ice resurfacing Take-Home Message
“Zamboni” machines can produce ultrafine par- The sports medicine physician covering an indoor
ticulate debris that in combination with the cold sporting event is required to know the intricacies
environment can place an athlete at risk for of such event by understanding how to prevent,
exercise-­induced bronchospasm secondary to air- diagnose, and treat injuries involved with the
way inflammation and hyperactivity. A study by sport. One must also consider the layout of the
Rundell in 2006 demonstrated an 18-fold particu- facility to develop an appropriate emergency
late matter in ice arenas, which was caused by the action plan and appropriately manage an injury.
combustion of ice resurfacing machines [213]. Performing a walk-through of the facility prior to
an event is highly recommended to prepare for
any unforeseen incidents. The goal is to limit risk
39.14.2  Structural Issues and Access and prepare for catastrophic injuries with an
appropriate emergency action plan in consider-
In addition to the playing surface, careful inspec- ation of the sporting event complex’s geographi-
tion of the venue should be done before competi- cal and architectural limitations.
tion to assure a clear field of play and that no
structural obstacles place the competitors at risk.
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 Outdoor Sports: Winter
40
R. Kyle Martin, Mitchell I. Kennedy, J. P. Begly,
Rob LaPrade, and Lars Engebretsen

40.1 Introduction Comprehensive injury surveillance systems

have been implemented across various sporting
Outdoor winter sports present unique challenges events. The goals are to identify factors associ-
for the sports medicine physician. Not only are ated with increased injury risk and subsequently
athletes pushed to their physical limits in sports to mitigate injuries through preventative mea-
that often involve high speeds, but the additional sures. The introduction of these surveillance sys-
influence of environmental factors can increase tems to the Olympic Games and the International
their injury risk and impede prompt medical care. Ski Federation (FIS) events has vastly increased
Weather can change quickly, impacting visibility, our knowledge and understanding of injuries
the frictional properties of snow and ice, and associated with winter sports [1–5]. Sport-­
jumping trajectory. Athletes that travel great dis- specific injury prevention initiatives and
tances from start to finish may experience delays improved athlete safety are the next steps, and
in receiving on-scene medical attention in the their efficacy can be monitored through ongoing
event of an injury midway through their event. surveillance. This chapter outlines the epidemiol-
Events that take place in remote locations pose a ogy, etiology, and treatment of common injuries
further challenge of achieving timely evacuation associated with alpine skiing, freestyle skiing,
to hospital in emergency situations, especially in snowboarding, ice hockey, and the sliding sports
poor weather conditions. Medical staff and event (bobsleigh, luge, and skeleton). Comprehensive
organizers must be aware of all these factors knowledge in these areas is essential for team
ahead of time in order to optimize athlete safety. physicians of winter sports athletes.

This chapter will provide clinically useful and evidence-­

based information regarding medical coverage of com-
mon outdoor winter sports.
R. K. Martin · L. Engebretsen (*) M. I. Kennedy · R. LaPrade
Department of Orthopaedic Surgery, Oslo University Steadman Philippon Research Institute,
Hospital, Oslo, Norway Vail, CO, USA
Faculty of Medicine, University of Oslo, The Steadman Clinic, Vail, CO, USA
Oslo, Norway e-mail: [email protected];
[email protected]
OSTRC, The Norwegian School of Sports Sciences,
Oslo, Norway J. P. Begly
e-mail: [email protected]; The Steadman Clinic, Vail, CO, USA
[email protected] e-mail: [email protected]

© ISAKOS 2019 553

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_40
554 R. K. Martin et al.

40.2 Alpine Skiing (Figs. 40.1 American ski resort reported an overall rate of
and 40.2) persons injured between 206.7 and 233.8 per
100,000 mountain visit [9]. The incidence of
The origins of skiing date back approximately injuries to the lower leg and ankle has decreased
5000 years, and formal alpine skiing was estab- over the past several decades; however, the rate
lished in 1767  in Norway [6]. Since this time, of injuries to the knee continues to rise [10,
alpine skiing has evolved into the most popular 11]. Ten percent of all snow-related accidents
winter sports in the world [7], attracting over 40 involve the anterior cruciate ligament (ACL),
million participants across the world [8]. Despite and 45–60% of knee injuries sustained while
significant advancements in equipment, tech- alpine skiing are ACL tears [12]. In a study of
nique, and safety protocols, alpine skiing contin- 7155 professional skiers over a 6-year period,
ues to be a pastime associated with substantial Viola and colleagues reported an ACL tear rate
injury risk. of 4.2 per 100,000 skier days in men and 4.4
per 100,000 skier days in females [13]. Pujol
et al. examined the rate of ACL injuries among
40.2.1 Injury Rates 379 athletes on elite French National ski teams.
They reported an ACL tear rate of 28.2% in
Alpine skiing carries a significant risk of males and 27.2% in females; overall, ACL tear
injury. A recent study involving a large incidence was 8.5 tears per 100 skier seasons
[7]. Reinjury incidence was 19% for the ipsi-
lateral knee, and bilateral injuries occurred in
30.5% of athletes. The level of skiing was
associated with an increased risk of injury,
because more tears were identified in skiers
ranked in the world top 30.
Bere and colleagues examined FIS ACL
injury rates over a 6-year period and found no
significant differences between genders [14].
The authors reported that the strongest risk fac-
tor for ligament injury was participation in
speed events. While there appears to be no gen-
der-related differences in tear rate among adult
Fig. 40.1  An alpine skier maintains control through a alpine skiers, Raschner et al. demonstrated that
high-speed turn
female skiers aged 14–19 are at increased risk
for injury compared to their male counterparts
[15]. In this age group, knee injuries were the
most common type of injury among ski racers,
and inadequate core strength was identified as a
significant risk factor for injury in the adoles-
cent age group.

40.2.2 Injury Mechanism

The use of video replay from event television

coverage yields valuable information for the
Fig. 40.2  The combination of high speeds, turns, jumps, study of injury mechanisms [16]. Overall, falls
and icy terrain places athletes at risk of injury account for the majority of shoulder injuries
40  Outdoor Sports: Winter 555

sustained during alpine skiing [6]. Possible 40.2.3 Common Injuries

mechanisms of upper extremity injury include
falls onto an outstretched hand, direct trauma to Upper extremity injuries are common among
the shoulder region, and eccentric forces as the alpine skiers. The true incidence of these
skier attempts to resist forced abduction. injuries is likely underreported. Shoulder
Additionally, direct collisions with other skiers injuries comprise 4–11% of all alpine skiing
and/or stationary obstacles such as trees repre- injuries and account for up to 34% of all inju-
sent additional mechanism for injury. Pole ries to the upper extremity [6]. Kocher and
planting during a fall increases external rotation colleagues examined the incidence of spe-
forces on the shoulder and upper extremity. A cific shoulder-related ski injuries and found
planted pole essentially lengthens the lever arm that rotator cuff pathology (24%), anterior
of the upper extremity and increases the risk of glenohumeral instability (22%), acromiocla-
glenohumeral instability. The use of wrist straps vicular separations (20%), and clavicle frac-
may additionally exacerbate the risk inherent tures (11%) were the most common injuries
with these mechanisms. [20]. Unlike snowboarding, there does not
Ligamentous disruption may occur via several appear to be a predominant laterality compo-
mechanisms. In elite alpine athletes skiing at nent to skiing-related upper extremity inju-
high speeds, ACL tears typically occur during ries. The most common upper extremity
jumping/landing activities [11]. As the athlete injury in skiers is a sprain of the ulnar col-
lands under significant force, a boot-induced lateral ligament of the thumb at the metacar-
anterior drawer mechanism occurs by which the pal-phalangeal joint, appropriately known as
tibia is driven anterior with respect to the femur, “skier’s thumb” [6].
increasing ACL strain that is not compensated by The majority of skiing-related injuries are
surrounding musculature. Gerritsen et  al. per- orthopedic in nature; however, injuries to the
formed video analysis of knee injuries sustained head and spinal cord are particularly danger-
during the 1994 Lillehammer Olympic downhill ous and may be life-threatening. Ackery et al.
event and identified high external rotation forces performed a systematic review of head and
on the knee during landing [17]. Gilgien and col- spinal cord injuries in 2007 and reported an
leagues compared ACL injury rates between the overall increasing incidence among skiers and
race disciplines of downhill, super-G, giant sla- snowboarders [21]. Head injury and traumatic
lom, and slalom and reported that while forces brain injury are the most common causes of
and speed differed between the disciplines, the death among skiers, highlighting the impor-
ACL injury risk was equal when injury rate was tance of helmet compliance [5, 21]. At the
corrected for race times [18]. Landing, higher World Cup level among FIS athletes, injuries
speeds, and crashes accounted for the majority of to the head and face accounted for 10–13% of
injuries in downhill and super-G, while turning all injuries [5]. Eighty-­two percent of these
speeds, turn radius, and high loading and torque injuries were concussions, and 24% of injuries
forces were associated with injury in the techni- lead to an absence from sports of over 28 days.
cal events. Recreational skiers are more likely to Steenstrup et al. performed a video analysis of
sustain an ACL tear due to valgus and internal 29 skiing-related head injuries over 10 World
rotation forces, typical of noncontact ACL inju- Cup seasons [22]. They found that alpine ski-
ries. While functional bracing has not been dem- ers were most likely to fall backward or side-
onstrated to improve long-term patient-reported ways and impact the back or side of their
outcomes following ACL reconstruction, bracing helmet respectfully. A high percentage of head
has been shown to reduce injury rates during ski- injuries occurred due to collisions with racing
ing in both ACL-deficient and ACL-reconstructed gates, and 10% of events resulted in helmet
knees [19]. ejection.
556 R. K. Martin et al.

Fact Box
Head injury is the most common cause
of death and catastrophic injury associ-
ated with alpine skiing [21]. Several
studies have demonstrated the impor-
tance of helmet use in reducing the rate
of head injuries [23–27]. While helmet
use among skiers has increased over the
past several years, approximately 30% of
adult skiers continue to ski without a
helmet [28, 29]. Sports medicine physi- Fig. 40.4  Big jumps can mean hard landings and possi-
cians can play an important role in the ble injuries
prevention of these injuries through edu-
cation and encouragement of proper hel-
met use for all ski and snowboard 40.3.1 Injury Rates
athletes.
Flørenes et al. reported injury rates for freestyle
skiers competing in the World Cup over three
winter seasons (aerials, moguls, half-pipe, and
40.3 Freestyle Skiing ski-cross). They found a high rate of injuries, and
a large proportion of these were classified as
Aerials, moguls, half-pipe, slopestyle, and ski-­ severe, defined as precluding participation in
cross are the five disciplines of freestyle skiing. training or competition for more than 28 days.
What sets them apart from other FIS events is Across all disciplines, the injury rate was 44.0
the acrobatic element that accompanies the high per 100 skiers per season. When only injuries that
speeds and big jumps (Fig. 40.3). Inherent in all resulted in 1 or more days absence from skiing
of these exciting displays of athleticism is the were considered, the incidence was 31.9 per 100
risk of injury, which can be significant skiers per season. Severe injuries accounted for
(Fig. 40.4). 44% of all time-loss injuries. Moguls had a lower
rate of total injuries than the other disciplines, but
no difference was seen in the rate of severe inju-
ries. No differences in injury rates were seen
between men’s and women’s competitions [30].
Injury surveillance studies from the 2010 and
2014 Winter Olympics also demonstrated high
overall and severe injury rates among freestyle
skiers [1, 2].

40.3.2 Injury Mechanism

The majority of injuries result from skier contact

with the ground, often when landing from a jump.
Fig. 40.3  A freestyle skier soars through the air while The most common reasons skiers experience
performing acrobatic maneuvers uncontrolled flight and an unbalanced landing are
40  Outdoor Sports: Winter 557

technical error at takeoff or contact with another

athlete in the case of ski-cross [1, 2, 31]. Over-­
rotation in the air causing a slapback episode upon
landing has been proposed as a typical mechanism
of head injury in disciplines involving aerials [5,
22]. As outdoor events, the weather conditions can
also play a factor with wind gusts and snow condi-
tions influencing skier coordination.

Fig. 40.5  Athletes compete against each other during a

40.3.3 Common Injuries snowboard cross event

The lower extremity is the most commonly

injured body region in freestyle skiing, followed In snowboarding national cup events, the overall
by the head/face. The knee is the most frequently incidence during competition is reported to range
injured body part overall, accounting for approxi- from 3.4 to 4.0 per 1000 runs. This is further
mately 25% of all injuries, of which half are clas- divided into incidences of 1.9–2.1 for half-pipe,
sified as severe. Up to 40% of freestyle skiing 2.1–5.8 for cross, and 0.6–6.6 for slalom disci-
injuries involve the anterior cruciate ligament [1, plines [32, 33]. From the 2010 to 2014 Winter
4, 30]. Freestyle skiing has been reported to have Olympic Games, there was an increase in the
the highest rate of head and face injuries of all number of athletes sustaining snowboard injuries
FIS ski events, and two of these injuries have in the slalom and half-pipe disciplines (7% to
recently resulted in fatalities [5]. Injuries to the 14% and 13% to 18%, respectively), while the
head and face account for approximately 13% of snowboard cross-discipline was unchanged (35%
all freestyle skiing injuries, of which 80% are to 34%). Slopestyle snowboarding was intro-
concussions. Up to a quarter of these are severe duced to the 2014 Winter Olympics, and an injury
injuries. There is also increasing evidence to sug- rate of 37% was reported [1, 2].
gest that women may be at higher risk for head A significant proportion of snowboarding
injuries than their male counterparts [5, 30]. injuries occur during training. In the 2010 Winter
Olympics, Engebretsen et al. reported that train-
ing injuries accounted for 75%, 89%, and 79% of
40.4 Snowboarding the total injuries in slalom, half-pipe, and snow-
board cross, respectively. Of these injuries, a
Slalom, half-pipe, snowboard cross, slopestyle, large proportion resulted in time loss from com-
and big air are the five disciplines of snowboard petition [1]. Soligard et  al. similarly reported
competition included in the Winter Olympic high rates of training injuries at the 2014 Winter
Games (Fig.  40.5). Due to the nature of these Olympics [2].
events requiring extreme acrobatic displays of
athleticism and highly difficult tricks, injuries are
common. 40.4.2 Injury Mechanism

The most common mechanism of injury is con-

40.4.1 Injury Rates tact made with the ground during a fall [2, 34].
Falls, occurring from either slopes or jumps, gen-
The incidence of injuries has been reported erate 80–90% of all snowboarding injuries.
across various snowboarding competitions. Collisions account for the rest, but relative to
558 R. K. Martin et al.

s­ kiing this is a less common mechanism of injury ­injuries [4, 34, 56]. The knee (16–18%) and back
[35–42]. Skill level also influences the incidence (13–22%) are the most commonly injured body
of injuries occurring by isolated falls or upon parts, while shoulder injuries also occur fre-
landing from jumps. Expert riders generally sus- quently (10–13%) [32, 33]. Elite athletes also
tain higher-impact injuries due to the expert-level experience a high rate of head and neck injuries
tricks they attempt during training and competi- [32, 33, 47].
tion [4, 36, 43, 44].

40.5 Ice Hockey

40.4.3 Common Injuries
Ice hockey requires high levels of athleticism, but
Injury rates of snowboarding have been reported the fast pace and aggressive nature of the sport
to be two to three times higher than that of skiing, means injuries are common. Sticks, pucks,
ranging from 1.16 to 4.20 per 1000 snowboard skates, boards, and other players are all potential
days. A large proportion of these injuries are to sources of injury, and the severity of these inju-
the upper extremities (45%), while lower extrem- ries can be variable. Healthcare providers should
ity injuries occur approximately half as often be familiar with common injury patterns, rules
(23%) [34]. The wrist is the most common area governing play, and current return-to-play proto-
affected by injury, with the head, face, and neck cols if engaged in hockey medical coverage.
also frequently injured [35–37, 40, 45–51]. In
contrast to skiing where most lower extremity
injuries are focused about the knee, snowboard- 40.5.1 Injury Rates
ing injuries more often affect the ankle. These are
most common in the form of sprains and frac- Several studies have investigated the incidence
tures [35, 37, 45, 47–50, 52, 53]. of injury among ice hockey players. Risk of
Fractures to the lateral process of the talus injury has been shown to increase with age and
(LPT), also known as “snowboarder’s fracture,” with increasing levels of competition. Emery
frequently occur from landing after jumps. The and Meeuwisse reported injury rates of 4.13
usual mechanism is sudden ankle dorsiflexion injuries per 1000 player-hours among minor
with concomitant hindfoot inversion and axial hockey players in Canada. A similar study of US
loading [54]. Treatment guidelines are tailored Junior A hockey injuries identified a rate of
according to the classification of the fracture pat- 9.4/1000 player-hours. Both of these studies
tern [55]. Type 1 fractures denote a small avul- included time spent in practice and games in the
sion without extension to the talofibular joint and rate calculations and found that injuries were far
are managed nonsurgically with a 4–6 week non-­ more likely to occur during games versus prac-
weight-­ bearing protocol and immobilization. tices [57, 58].
Type 2 fractures involve a single large fragment, Other studies have focused on the rate of inju-
which may be displaced. Non-displaced fractures ries during game competition, excluding time
are treated similarly to type 1, while displaced spent in practice. Tuominen et  al. published on
fractures >2 mm should undergo open reduction the injury rates at World Championship and
and internal fixation. A type 3 injury describes a Winter Olympic ice hockey tournaments over a
comminuted fracture and is best treated by surgi- 7-year period. Injuries at the men’s junior hockey
cal excision of the small displaced fragments. world championship tournament occurred at a
In elite snowboarding athletes, the injury dis- rate of 39.8/1000 player-game-hours. At the adult
tribution is different, with wrist injuries seen far level, injuries were more frequent with a rate of
less often (5–6%) and elevated rates of knee 52.1/1000 player-game-hours overall and
40  Outdoor Sports: Winter 559

59.6/1000 player-game-hours. International In hockey, all players must wear a helmet, but
women’s hockey had much lower rates of injury, the level of facial protection worn can vary
averaging 22.0/1000 player-game-hours over an greatly. Mandatory full facial protection is
8-year study period [59–61]. enforced for all minor and women’s hockey.
There are several explanations for the different Junior and professional men’s hockey often allow
injury rates seen at different ages and levels of players to wear half-visors that leave the lower
competition. At the minor hockey level, the initia- part of the face exposed. Several players in the
tion of body checking results in a sharp increase National Hockey League and recreational leagues
in observed injuries. Recent rule changes in North still choose to wear no facial protection attached
America have raised the age at which body check- to their helmets. The rate of head and face inju-
ing is first introduced in response to studies high- ries has been shown to be directly related to the
lighting this association [57, 62, 63]. As players amount of facial protection worn, with full facial
progress to higher levels of competition, the size shields significantly reducing the frequency of
and speed of the players also increase which can these injuries [64].
lead to more injuries during game play. Finally, The face and neck are the only fully exposed
the lack of facial protection worn by players com- parts of the body and injuries can range from
peting at the junior hockey level and higher leads simple lacerations to catastrophic airway emer-
to more injuries of the head, face, and neck [64]. gencies. Ocular and dental injuries frequently
In women’s hockey, body checking is prohibited occur, requiring prompt evaluation and access to
and players wear full facial protection, two factors specialist care. Medical personnel should be
that contribute to the lower rate of injuries among familiar with the management of these injuries
these players [61]. and have an emergency action plan should rapid
evacuation to a medical facility be required.
Concussions are the most common injury
40.5.2 Injury Mechanism reported in women’s hockey and are of increas-
ing concern for both men and women at all lev-
The most common causes of injuries to hockey els of hockey competition [66, 67]. Recognition
players are body contact (intentional or inciden- of concussion symptoms and prompt removal
tal), stick contact, or puck contact. Overuse inju- from play is the most important step in concus-
ries and fighting are other less common etiologies sion management. At the professional level,
[1, 2, 58–61, 65]. players may undergo an evaluation, and a deci-
sion can be made regarding their return to play
in the same game. For all other levels, return to
40.5.3 Common Injuries play in the same game is contraindicated, and
the general approach is: “When in doubt, sit
The most common anatomic regions affected by them out.” The Sports Concussion Assessment
injury across all levels of ice hockey are the head Tool version 5 (SCAT5) and the Child SCAT5
and face, followed by the lower extremities (knee are the most widely used sideline assessment
and hip) and upper extremities (shoulder). In tools [68, 69]. Physicians must be familiar with
men’s hockey, lacerations occur most frequently, the SCAT5, and players should be assessed
while in women’s hockey and minor hockey, promptly following a suspected concussion.
sprains, contusions, and concussions are most This should be performed in a quiet setting away
commonly encountered. Most injuries are con- from distractions. Further, vigilance on the part
sidered minor with players returning within 1 of the medical staff is imperative, as players
week, but moderate and severe injuries also regu- may under report symptoms in an attempt to
larly occur [57–61, 66]. return to competition [70–73].
560 R. K. Martin et al.

of these injuries is primarily non-operative in the

Fact Box acute setting with adductor tenotomy utilized for
Players sustaining a concussion should fol- refractory or chronic cases of adductor tendinopa-
low a graduated return-to-play protocol thy. The exception to this is the core muscle injury,
[69]. Players should be symptom-free at which has shown good results with surgical treat-
each stage for at least 24 h before progress- ment in hockey players [74–77].
ing to the next level. If symptoms reoccur, Intra-articular hip pathology includes femoroac-
players should revert back to the previous etabular impingement (FAI), labral tears, and chon-
stage until symptom-free for 24 h. Clearance dral injury. Diagnosis is based on the patient history,
from a sports medicine professional must clinical signs of impingement (in the case of FAI),
be obtained before progressing to Stage 5. and radiographic evidence of pathology. Non-
Symptoms persisting for longer than 10–14 operative treatment consists of physiotherapy, activ-
days in adults and >4 weeks in children ity modification, nonsteroidal anti-­ inflammatory
warrant referral to a specialist experienced medication, and intra-articular injection of cortico-
with sports-related concussions. steroids. If symptoms persist, surgical management
can be pursued and generally yields good outcomes
• Stage 1: No activity, complete rest with most players returning to the ice around 4
• Stage 2: Light aerobic activity such as months [73, 74, 78–80].
walking or stationary bicycle Upper extremity injuries most often involve
• Stage 3: Sports-specific training (skating) the shoulder and are usually acromioclavicular
• Stage 4: Noncontact advanced training (AC) or glenohumeral joint related. Type I–II AC
drills and progressive resistance training separations are managed non-operatively, while
• Stage 5: Full-contact training drills types IV–VI are treated surgically. Treatment of
• Stage 6: Return to full competition type III AC separations remains controversial,
but there is an increasing trend toward non-­
operative treatment of these injuries. Players who
The knee is the most common site of lower sustain one glenohumeral dislocation can often
extremity injury among hockey players. Injury to be managed with brief immobilization followed
the medial collateral ligament is the most fre- by strength rehabilitation and a gradual return to
quent diagnosis secondary to the risk of valgus play. If recurrent instability or a significant bony
force from collision with other players while the defect is present, operative stabilization is recom-
skate is caught in the ice. Meniscus and anterior mended. The timing of surgical intervention can
cruciate ligament injuries also occur but at a be individualized to each player, and the use of a
lower rate [59, 60]. brace to prevent recurrent dislocation can some-
The ankle and hip are the next most common times delay the need for surgery until the end of
lower body regions to sustain injury. High ankle the season. Injuries to the upper extremity also
sprains and Maisonneuve fractures can occur frequently affect the hand and wrist [59, 60, 73].
with rotational injuries because of the high skate
boot, and foot fractures and contusions are com-
monly the result of contact with the puck during 40.5.4 Catastrophic Injuries
shot blocking [59, 60, 73].
Injuries to the hip can be extra- or intra-­articular Catastrophic injuries can and do occur during ice
and are common in hockey players due to the hockey participation. These include but are not lim-
repetitive complex skating motion. Extra-­articular ited to airway compromise, cervical spine injury,
injuries include adductor tendon strains, flexor commotio cordis, major lacerations, and eye injury.
tendon strains, hip pointers, and core muscle inju- Upper airway injuries can result from direct
ries. History and clinical examination often clarify blows to the neck, foreign body obstruction, and
the diagnosis, and magnetic resonance imaging cervical spine injury. Advanced Trauma Life
(MRI) or ultrasound may also be useful. Treatment Support (ATLS) principles should be followed.
40  Outdoor Sports: Winter 561

Hockey Related Neck

Injury

Rapid On-Ice Assessment by

Trainer / Physician

Transport of Player to Treatment Room

(C-Spine Precautions)

Rapid Physical Examination (ABCs)

Airway Patent, No Hematoma, Stridor, Neck Hematoma,

No SOB SOB

Transfer to Definitive Care Center for

Airway Maintainable with Jaw Thrust Obstructed Airway
Evaluation and Treatment

CT Scan of Neck with IV Rapid Transport to Definitive Attempt at ETI

Contrast Care Center

Attempt at ETI by Experienced

Injury No Injury Successful Unsuccessful
Physician

Treatment Tailored to Injury Discharge Home Successful Unsuccessful Rapid Transport to Definitive Tracheostomy /
(Multi-Disciplinary) Care Center Cricothyrotomy

Post ETI Care Tracheostomy / Cricothyrotomy Rapid Transport to Definitive

Care Center

Fig. 40.6 Airway Injury Management Algorithm. Player. Clin J Sport Med. 17(1):61–67. https://journals-
Adapted with permission from: Liberman and Mulder lww-com.uml.idm.oclc.org/cjsportsmed/pages/default.
(2007). Airway Injuries in the Professional Ice Hockey aspx

A jaw-thrust or chin-lift is often sufficient to keep mechanism is a blunt trauma to the chest as
a patent airway, but endotracheal intubation or a may occur when blocking a shot with the torso.
surgical airway may be necessary. On-site medi- If the impact is timed just before the T-wave
cal personnel should be familiar with the equip- peaks, it can initiate ventricular fibrillation.
ment available and possess the skills needed to Immediate treatment consists of a precordial
secure the airway. Due to the possibility of thump or the use of an automated external
delayed airway compromise, there should be a ­defibrillator [83].
low threshold to transfer any player with a sus- The combination of high speeds, body con-
pected airway injury to a definitive care center tact, and sharp hockey skates puts players at risk
[81]. An airway management algorithm is pre- of major lacerations (Fig.  40.7). These may
sented in Fig. 40.6. involve neurovascular structures and can result in
Cervical spine injuries include fractures and the loss of a significant amount of blood in a short
dislocations. The rate of these injuries has been amount of time. Immediate care consists of direct
decreasing over the past several years, in part due pressure and emergent transfer to a definitive care
to increased awareness and preventative strate- center. A tourniquet can be used if direct control
gies. However, cervical spine injuries do still of bleeding cannot be achieved in the prehospital
occur and are frequently associated with neuro- setting.
logic injury. The most common mechanism is In leagues that allow partial or no facial pro-
headfirst contact with the boards while the torso tection, eye injuries regularly occur. These are
remains in motion. This creates an axial com- most often caused by contact with a stick or puck
pression load to the cervical spine which mani- or during a hockey fight [65]. Possible serious
fests as injury most commonly between C5 and eye injuries include corneal abrasion, traumatic
C7. Players should be immobilized on a spine hyphema, traumatic cataract, retinal detachment,
board, and prehospital ATLS care should quickly vitreous hemorrhage, open globe lacerations, and
precede transfer to hospital [82, 83]. globe ruptures. Evaluation of the injured athlete
Commotio cordis is a rare event that can involves determining the mechanism of injury,
cause sudden death in athletes. The proposed reviewing symptoms, and performing a physical
562 R. K. Martin et al.

a b

Fig. 40.7 (a) Postoperative photograph of a skate blade ferred to the hospital in unstable condition. He underwent
laceration in a professional hockey player. The femoral emergent repair, vein grafting, and fasciotomies. (b) Six
artery and vein were lacerated, and the player was trans- weeks after the injury, the player returned to light skating

Table 40.1  Symptoms and physical examination find-

ings that necessitate urgent evaluation by an ophthalmolo-
gist [84]
Symptom Examination finding
Total vision loss Asymmetric visual
acuity
Partial vision loss (visual Asymmetric pupils
field defect)
Vision changes (diplopia, Restricted extraocular
flashes, floaters) movement
Foreign body Photophobia with
penlight
Ocular pain with nausea/ Poor visualization of the Fig. 40.8  Two athletes race feet-first down the track dur-
vomiting iris ing a luge competition

examination including assessment of visual acu- injury owing to the high speeds achieved by
ity, pupils, extraocular movement, and the globe. the competitors. In bobsleigh, one, two, or
Table  40.1 highlights symptoms and physical four-person teams compete in a seated-position
examination findings that warrant urgent referral sled. Smaller sleds designed for lying flat are
to an ophthalmologist [84]. used for luge and skeleton competitions. In
luge, one or two persons lie in a supine posi-
tion and proceed down the track in a feet-first
40.6 Sliding Sports direction (Fig. 40.8). In contrast, skeleton is an
individual sport, whereby the athletes lie prone
The sliding sports include bobsleigh, luge, and and race headfirst down the track (Fig.  40.9).
skeleton. All of these events are performed on Top speeds for each of these events can exceed
an ice track and involve the risk of significant 120 km/h.
40  Outdoor Sports: Winter 563

sible for 64% of all injuries, while 24% could

not be attributed to a specific incident.
Moderate and severe injuries were usually
caused by crashes [88].

40.6.3 Common Injuries

Abrasions, contusion, strains, and lacerations are

the most common injuries sustained by sliding
Fig. 40.9  A skeleton athlete slides headfirst toward the
finish line sports athletes. Fractures and head injuries also
occur at a significant rate [87, 88].

40.6.1 Injury Rates

40.7 Treatment Principles
Injury epidemiology publications from the
Winter Olympics provide some information 40.7.1 Skiing and Snowboarding
regarding the injury incidence of the sliding
sports. At the 2002 Olympic Games in Salt Although modern orthopedic surgical techniques
Lake City, sliding sports athletes accounted for allow athletes to return to competition and func-
19.6% of all polyclinic visits [85]. At subse- tion at a high rate, continued efforts to improve
quent Olympic Games, 14.7% (Torino 2006), prevention of alpine skiing injuries are of great
11.5% (Vancouver 2010), and 13.8% (Sochi importance. Equipment characteristics such as
2014) of all registered sliding sports athletes side-cut radius, length, bindings, and stiffness all
sustained an injury. The potential for severe contribute to the risk of knee injury in skiers [89].
injury on the ice track must be acknowledged as Longer skis are more stable at higher speeds, and
there was one luge fatality at the Vancouver a small side-cut radius has been demonstrated to
Olympics following ejection from the track decrease the self-steering effect of a ski, which
during training [1, 2, 85, 86]. allows for increased ski control and subsequently
A review of injuries sustained at the Whistler less risk of aberrant rotational forces acting on
Sliding Centre over a 4-year period was per- the knee. Modern bindings feature multidirec-
formed by Stuart et al., and an incidence of 0.5% tional release characteristics which help protect
per run was reported. Severe injuries occurred at against lower extremity injuries such as tibial
a rate of 0.1% per run. The authors also reported fractures and ligamentous tears [7, 11].
an association between experience and injury Environmental conditions and skier fatigue, both
rate, finding a higher incidence of injury among physical and mental, can also contribute to injury
athletes with less experience [87]. risk [90]. Programs aimed at increasing aware-
ness regarding the risk factors surrounding alpine
skiing-related injuries have been demonstrated to
40.6.2 Injury Mechanism decrease injury risk by 62% in specific studies
[91]. More future work and effort are necessary
Despite the high incidence of injuries to slid- to continue to develop and advance both the pre-
ing sports athletes, there is a paucity of infor- vention and treatment of alpine skiing-related
mation regarding the mechanism of these injury.
injuries. Cummings et al. published a review of Injury prevention of snowboarders through
all luge injuries occurring over a 7-year period. additional protection gear is heavily advocated,
The authors reported that crashes were respon- being primarily focused on wrist guards, back
564 R. K. Martin et al.

protectors, and helmets [54]. Due to the frequent discussions about possible rule changes that
falling that snowboarders endure, this gear acts to could reduce injury incidence and/or severity.
reduce the injury occurrence resultant from These preventative strategies have proven suc-
excessive contact forces with the ground. The cessful in the past, but there is a need for more
less experienced snowboard population is at most research and science surrounding hockey injuries
risk for these types of injuries and therefore ben- in the future [62, 63, 73].
efits most from utilizing such preventative
measures.
Alpine ski, freestyle ski, and snowboarding 40.7.3 Sliding Sports
events can involve high speeds and large jumps,
which place athletes at risk for high-energy inju- Owing to the potential for severe injury, medical
ries. Physicians providing care to these athletes providers must maintain vigilance and ensure all
must be prepared for the various injuries that can medical team members are familiar with the
occur on the slopes. Following ATLS principles emergency action plan. Using an ATLS approach
will guide the prehospital care. Since these events with protection of the cervical spine is the stan-
often take place in remote locations, physicians dard. Close collaboration with track officials
must be familiar with the local emergency action regarding track conditions and design, specifi-
plan should the athlete require evacuation to the cally to avoid slider ejection from the track, is also
hospital. Prior to large events, on-site training of important to optimize the safety of the athletes.
involved medical personnel is imperative. This
may involve walk-throughs or simulation-based Take-Home Message
activities to optimize the efficiency of the team Sports medicine physicians engaged in coverage
and ensure safety for the athletes. Roles should of winter sports must be familiar with the unique
be clearly defined and the team leader(s) characteristics of each event. This includes the
identified. common injury patterns, treatment modalities,
and return-to-play guidelines. Weather and venue
location are additional variables that must be
40.7.2 Ice Hockey considered when devising event-specific emer-
gency action plans. Physicians should also take
Hockey is a contact sport and injuries occur fre- an active role in injury prevention through
quently. An understanding of the most common encouraging safe behavior and the proper use of
injuries is essential for sports medicine physi- protective equipment.
cians who care for these athletes. The vast major-
ity of hockey-related injuries are minor, and
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 Part VII
Sports Equipment
 Sports Footwear: Problems
and Advances
41
Marcelo Pires Prado and Guilherme Honda Saito

41.1 Background cian. However, the demand for the most

appropriate sports footwear is no longer restricted
During the early Greek games, athletes used to to the professional athlete. The number of the so-­
compete barefoot. As the Greek empire expanded called weekend warriors is increasing every year,
and many athletes from different regions came to and the sports professional must be capable of
compete, runners wearing sandals started to prescribing the most suitable shoe in order to pro-
appear, since it supposedly improved traction and vide comfort while preventing injuries. In this
running efficiency [1–3]. But it was not until the chapter, we summarize the main aspects of foot-
second half of the nineteenth century that specific wear anatomy and the current topics of debate in
sports footwear became available. Crocket san- the literature. Moreover, we describe the ratio-
dals made with a rubber sole, a canvas upper, and nale behind the choice of an athletic shoe.
laces were designed and became known as sneak-
ers [2]. Since then, a wide variety of specific
sports footwear for different modalities was 41.2 Athletic Shoe Anatomy
developed, culminating in the multibillion-dollar
sports shoe industry. Every year a number of To fully understand the biomechanics involved in
sports footwear with new designs and technolo- an athletic shoe, it is essential to understand its
gies are released in the market. The benefits and anatomy first. The footwear is made of two main
risks of these different footwear concepts are elements: the upper and the bottom (Fig.  41.1).
debatable, but it is undeniable that footwear inno- The bottom can be divided into three main com-
vations throughout the years allowed an inesti- ponents: outsole, midsole, and wedge [1, 2, 4].
mable development on sports, enhancing Here we will briefly describe each of these
performance both for the amateur and profes- components.
sional athlete.
The knowledge regarding sports footwear is
constantly evolving, and the amount of informa- 41.2.1 Upper
tion may be overwhelming for the general physi-
The upper covers the sides and top of the foot,
being directly exposed to dirt and water.
M. P. Prado (*) · G. H. Saito
Hospital Israelita Albert Einstein, São Paulo, Brazil Therefore, the choice of materials is important in
e-mail: [email protected] order to provide comfort and protection to the

© ISAKOS 2019 571

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_41
572 M. P. Prado and G. H. Saito

Tongue
Collar
Throat
Achilles tendon
protector Eyelet
Eyelet
stay Heel counter
Vamp (underfoxing)
Lining
Toebox
Foxing Upper
Toecap
Rearfoot
stabilizer
Sock liner
or insole
Quarter
Stabilizing
a straps
Rear
Lining stabilizer
Sock liner Midsole Bottom
or insole with wedge
Outsole
Heel
counter

c
b
Wedge Outsole Midsole Insole
board

Fig. 41.1  Illustrations of athletic shoes. (a) An overview shoe. (From LeCursi N. Sports shoes and orthoses. In:
of the external appearance. (b) Separation of shoe into its DeLee & Drez’s Orthopaedic Sports Medicine. 4th ed.
component parts. (c) A sectional view of the interior of a Saunders, 2014:1389)

foot while maintaining the material’s properties patient’s profile. Different materials with dif-
after exposure to external conditions. The upper ferent densities may be used to achieve an
should be made from a material that is breath- optimal balance.
able, washable, resistant to deformation, and yet
comfortable. Nylon is usually the material of 41.2.2.2 Outsole
choice in athletic footwear. The outsole is the part of the shoe that contacts
the ground, thus providing traction, shock absorp-
tion, and flexibility. The outsole is made from dif-
41.2.2 Bottom ferent types of rubber. Several properties are
taken into consideration when choosing the most
41.2.2.1 Midsole appropriate type of rubber for the footwear, such
The midsole is considered the most important as durability, weight, softness, and traction.
part of the shoe, located between the outsole Different types of rubber can be used at different
and the upper. The midsole provides stability, locations of the shoe according to the athlete’s
cushioning, and shock absorption. It is usually needs.
made of foam, the most common being the
ethylene-­vinyl acetate (EVA). The polyure- 41.2.2.3 Wedges
thane is more resistant and stiffer than the The wedges are located at the rear of the foot-
EVA and is also commonly used in athletic wear, between the midsole and the outsole. Its
footwear. The stiffer the midsole, the more main function is to provide medial stability
stability is provided, at the expense of cush- against overpronation. The wedges are made
ioning. Therefore, a balance must be obtained from a stiff material, capable of providing ade-
among these variables according to the quate stability and shock attenuation.
41  Sports Footwear: Problems and Advances 573

41.3 Choosing the Correct should be achieved, since these variables do not

Footwear necessarily come together. While an elite athlete
cannot afford giving up performance, a recre-
Shoes act like interfaces between the foot and ational athlete does not need a sports shoe that
ground, protecting the foot sole, providing shock provides performance at the expense of comfort
absorption against repetitive impact, stabilizing or one that puts him under the unnecessary risk of
the rear foot by protecting it from uneven ground injuries. For example, previous studies [6, 7]
and inclined surfaces. Moreover, they allow flex- have shown that climbing shoes can cause several
ibility to prevent overuse injuries related to mus- types of foot injuries. This type of shoe is
cle and tendon tension forces. The combination designed to provide an extremely close fit, which
of these properties must be balanced to provide allows the climber to stand on small holds. Some
adequate foot motion control, comfort, and phys- climbing shoes present with more aggressive
iologic function. characteristics, having a more downward point-
The choice on which sports footwear is more ing toe box. This type of footwear is usually worn
appropriate for each athlete should always be by professional climbers and conceivably leads
made on an individual basis. No footwear is suit- to higher rates of injuries and foot deformities.
able for all individuals since each person has Thereby, the amateur climber does not need it to
their own characteristics regarding foot shape, fulfill their purpose.
foot size, gait pattern, level of activity, type of Foot size, type, and function during gait
activity, and previous pathologies, among others should also be assessed. The examiner must
[2, 5]. All these variables should be analyzed by assure that the length and width of the shoe are
the professional in order to prescribe the most correct. The end of the toes should not be in con-
appropriate shoe. Still, each person and each foot tact with the toe box. Meanwhile, the footwear
is so unique that it is hard to predict whether an should be tight enough in order to prevent the
individual will adapt to a specific shoe. Ultimately, foot from sliding within the shoe. Foot type is
the athlete is the best person to evaluate the foot- also evaluated. A pes planus behaves differently
wear, according to the subjective experience from a pes cavus, thus requiring specific foot-
while wearing it. Physicians should use their best wear. When considering a certain type of foot,
judgment by analyzing the multiple factors and one must keep in mind that there are several
suggesting a shoe that will most likely suit the degrees of foot deformity. Therefore, there is no
person’s needs and expectations. recipe, and the choice of footwear should be
First, the type of activity should be taken into made on an individual basis. Insoles are useful in
consideration. Sports footwear evolved signifi- these cases and may be used as a complement to
cantly in the past decades, and now shoes for dif- make fine adjustments.
ferent modalities are completely unique. A Regarding foot type, it is important to under-
running shoe that is designed for a straightfor- stand that specific foot alignment changes foot
ward motion will have a different structure than a biomechanics and interferes with foot response
high-top basketball shoe, which is more support- to load. In the pronated foot, the mechanical axes
ive and provides additional stability for multidi- of the rearfoot (talonavicular and calcaneocuboid
rectional movements. joints) remain parallel, resulting in a more flexi-
An essential factor to be considered is the ath- ble foot. As a consequence, an increased muscle
lete’s fitness level. An elite athlete will have a dif- effort is required to maintain the same level of
ferent demand when compared to an amateur. activity compared with other types of foot. On
Their type and level of training, body structure, the contrary, the supinated foot has an oblique
body self-awareness, and muscle strength will be rearfoot joint axis alignment, resulting in a stiffer
distinct. Thus, different types of footwear will be foot [8]. Consequently, a high incidence of ankle
required for each. In addition, a balance among sprains, tendinopathies (mainly of the peroneal
performance, comfort, and injury prevention tendons), and overload lesions is observed.
574 M. P. Prado and G. H. Saito

Specific shoe design can mitigate these func- Overload lesions as sesamoiditis and stress
tional peculiarities by increasing stiffness and fractures may affect the sesamoid bones. In these
medial support for the pronated foot and flexibil- conditions, sportive shoes with midfoot support,
ity for the supinated foot. cushioning under the toes, and less flexible soles
Despite these concepts, Knapik et al. [9] pro- are recommended, in an attempt to decrease pres-
spectively compared a large group of Marine sure under these bones.
Corps recruits, who received different shoe mod- A previous study [10] showed that the use of
els depending on the shape of the foot (low, rigid rockers restricts toe dorsiflexion and
medium, or high arches, receiving, respectively, decreases plantar pressure under the lesser toe
motion control, stability, or cushioned shoes), to metatarsophalangeal joints. Higher plantar pres-
a group who received a stability shoe regardless sures on the first metatarsophalangeal joint are
of plantar shape, showing little influence on expected following the restriction of toe dorsi-
injury risk. flexion in this joint in comparison to rockers that
do not restrict this motion.

41.4 Pathologic Conditions

41.4.2 Midfoot Conditions
Foot pathologies play an important role during
footwear selection. Feet with distinct pathologies Patients with midfoot pathologies, such as
benefit from shoes with specific characteristics. arthritic conditions affecting the Lisfranc joints,
may need a rigid and supportive shoe to reduce
the load and stress in these joints, as well the use
41.4.1 Forefoot Conditions of insoles to aid treatment.

The forefoot is commonly affected by stress

lesions, mainly stress fractures, and metatarsal 41.4.3 Rearfoot Conditions
injuries. They are normally caused by an incre-
ment in mechanical demand, which is above the The rearfoot is frequently affected by overload
body ability to heal and adapt after an overload. problems. Patients with plantar fasciitis, the most
Sportive shoes proper adaptation is important to common issue affecting the rearfoot in recre-
prevent and treat these injuries. ational and professional athletes, will probably
Patients with hallux valgus should wear benefit from shoes with stiffer and cushioned
shoes with a wide toe box and more rigid soles soles.
in the forefoot in order to increase space for the Achilles tendinopathy is also common in ath-
widened foot, to decrease friction and mechani- letes. This pathology is associated with overload
cal solicitation on the metatarsophalangeal caused by rearfoot misalignments (valgus and
joint, and to protect the joint from wearing asso- varus hindfoot), muscle imbalance, and excessive
ciated with valgus misalignment. Due to the training. Patients suffering from this problem
decreased capacity to bear weight on the first may need medial supportive shoes, with eleva-
ray, lesser toe overload and deformities are tion under the rearfoot.
common in hallux valgus patients. As a conse- The posterior tibial tendon is an important
quence, lesions of the plantar plate and progres- dynamic stabilizer of the medial arch of the foot.
sive claw toe deformities may occur. Instability Tendinopathies affecting this tendon may be
of the lesser toe metatarsophalangeal joint can related to trauma, overload, and degenerative
be decreased by less flexible shoes, in order to conditions, decreasing the medial arch support
protect these joints from direct load. Toe claw power. As a consequence, overload of static sup-
deformity can be handled by the use of extra porters of the arch, such as the deltoid ligament
deep toe box shoes. and spring ligament, may occur, with subsequent
41  Sports Footwear: Problems and Advances 575

acquired flat foot deformities. In the early stages a

of the disease, athletes must be advised to
decrease the intensity of exercises and wear
medial arch supportive shoes. Peroneal tendon
issues may be associated with varus hindfoot. In
this situation, a flexible shoe without medial sup-
port is helpful.
b
41.4.3.1 Patients with Special Needs
In many cases, only footwear correction is not
enough. When an orthotic or insole is required,
it is necessary to fit them in the specific sportive
shoe. Many of sportive shoes already have
some medial arch support, which should be
taken into account during the manufacturing Fig. 41.2  Illustration of technical features designed to
prevent overpronation of the feet in runners. (a)
process. Polyurethane used in the medial side at the midsole. (b)
Injury history and previous pathologies should EVA (ethylene-vinyl acetate) foam used at the midsole.
also be discussed with the athlete, as they may (From Malisoux L et al. Injury risk in runners using
predict structures that are subject to overload. standard or motion control shoes: a randomised con-
trolled trial with participant and assessor blinding. Br
Deformities and pathologies from the back, hip, J Sports Med. 2016;50(8):481–487)
and knee must also be assessed.

tion are causally linked to overuse injuries,

41.5 Types of Running Shoes and (2) promoting limited pronation reduces
this risk [12].
Previous reports demonstrated that almost all The use of shoes that provide support and
recreational shod runners are rearfoot strikers stability to the rearfoot is supported by the fact
[11]. Based on that knowledge, during many that motion control shoes correct foot prona-
years running shoes were developed to relieve tion (Fig.  41.2) in the transverse and sagittal
rearfoot impact and decrease the chance of planes during stance when compared to neutral
lesions related to physical activities. shoes and barefoot conditions, decreasing the
incidence of injuries in recreational runners,
mainly flat feet runners [13, 14]. On the other
41.6 Regular Running Shoes hand, some studies suggest that the use of sta-
ble shoes with medial support to decrease
Regular running shoes provide shock absorption lesions in running athletes is not supported by
properties and support to rearfoot motion during the literature [15].
activities. The use of cushioning in running shoes Unstable running shoes are related to an
is based on the following assumptions: (1) impact increase in lumbar stress and incidence of low
forces while running are a significant cause of back pain in athletes because they intensify lum-
injury, (2) running on hard surfaces is a cause of bar spine muscle solicitation and lumbar spine
high impact forces, (3) a cushioned shoe can motion [16].
reduce impact forces to a less injurious level, and Another interesting topic is that shoelace
(4) the potential of the cushioning itself to cause closure techniques have been associated with
injury is minimal. an influence on plantar foot pressures and are
The protective effect of normalizing the a factor that could collaborate on forefoot
subtalar joint motion is built on the following overload problems in athletes and healthy
assumptions: (1) overpronation and supina- subjects [17].
576 M. P. Prado and G. H. Saito

41.7 Minimalist Shoes utilization of oxygen, possibly leading to

improved performance. Furthermore, previous
In recent years, the use of minimalist shoes for reports [23] demonstrated an increase in leg and
running has emerged as a topic of great interest. foot muscle volume with the use of minimalist
Esculier et  al. [18] defined minimalist shoes as shoes, which could be a protective factor against
“footwear providing minimal interference with injuries. However, some studies [24–26] associ-
the natural movement of the foot due to its high ated the use of minimalist shoes with an increased
flexibility, low heel to toe drop, weight and stack risk of injury. Firminger et al. [24] observed sig-
height, and the absence of motion control and nificant increases in metatarsal strains in recre-
stability devices.” Minimalist shoes theoretically ational runners acutely transitioning to minimalist
replicate barefoot running, which is supposedly shoes.
associated with biomechanical advantages [19– There is evidence in the literature showing
21]. However, the literature regarding this matter that both cushioned running shoes and minimal-
is controversial. istic shoes increase ground contact time during
As previously mentioned, the functional defi- walking and running, compared to barefoot con-
nition of a minimalist shoe is one that promotes ditions. However, this increase is higher with the
kinematic similarities to that of running barefoot. use of cushioned shoes when compared to mini-
A previous report [22] has determined the maxi- malist shoes [27].
mal specifications that constitute a minimalist In a previous report [28], 32% of runners
shoe (Fig. 41.3): showed a rearfoot strike pattern at the first attempt
running barefoot. This led to increased muscle
Mass: ≤200 g activation and impact accelerations and thereby
Heel stack height: ≤20 mm to a potentially higher risk of injury compared to
Heel-toe differential: ≤7 mm running shod.
Despite the controversies, most authors [25,
Therefore, only shoes with values equal to or 29–31] agree that the transition from tradi-
lower than these proposed thresholds could be tional to minimalist shoes must be done with
defined as minimalist footwear. Furthermore, a caution since runners who are not used to mini-
minimalist shoe cannot present any other device malist shoes or barefoot running are more
that is intended to control the motion of the shoe, prone to injury during this period. However,
such as medial support, a stiff carbon fiber plate, there is no standardized protocol in the litera-
or any structure that alters the interaction of the ture regarding the methods that should be
shoe with the ground. employed during the transition. Fuller et  al.
Some authors advocate that improvements in [29] suggested that runners should limit their
running economy can be achieved with the use of weekly training distance in order to prevent
minimalist shoes. Cheung et  al. [20] suggested running-related pain. Future studies should
that running in minimalist shoes requires lower look at the efficacy of minimalist shoes in pro-

Fig. 41.3 Illustration
showing the structure of
a running shoe and its
specifications. (From
Coetzee DR et al.
Conceptualizing
minimalist footwear: Heel stack
Forefoot stack
an objective definition. height
height
J Sports Sci. (HSH)
(FFSH)
2018;36(8):949–954)
Heel-toe differential (HTD) = HSH – FFSH
41  Sports Footwear: Problems and Advances 577

moting kinematic adaptations in terms of

reducing the risk of running-related injury, Fact Box 2
rather than drawing conclusions on minimalist The risks and benefits regarding minimalist
footwear by grouping runners that adapt bio- footwear are still controversial in the litera-
mechanically and those that do not [22]. The ture. When opting for a minimalist shoe,
literature regarding minimalist shoes is contro- most authors agree that the transition
versial, and there is insufficient evidence either should be made with caution, respecting
to promote or to demote its use. The physician the adaptation period.
should be cautious when prescribing minimal-
ist shoes, especially for amateur athletes who
are not well adapted.
Further studies are needed in order to clarify References
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 Part VIII
Biologics in Sports Injuries
 Biologic Treatment in Tendon
and Muscle Injuries
42
Moises Cohen, Gustavo Gonçalves Arliani,
and Camila Cohen Kaleka

42.1 Introduction 42.2 Muscle Injury

In the last decades, we have observed a great In this context, muscle injuries are among the
increase in the number of people practicing most common, accounting for approximately
sports around the world. Much of this increase is 10–55% of all sports injuries. Muscle injuries can
due to widespread media coverage of the health be caused by contusion, stretching, lacerations,
benefits of regular physical exercise, such as and other mechanisms [6]. These injuries corre-
improved quality of life and reduced risk of vari- spond to approximately 40% of all soccer inju-
ous ­diseases [1]. ries and 25% of all injury-time withdrawals. And
However, these beneficial effects must be bal- 15–20% of these muscular injuries are recur-
anced with injuries that are to some extent rences of previous injuries [7].
unavoidable [2]. The estimated number of Woods et al. have described that 12% of inju-
sports-­related injuries annually in the UK is 10 ries in professional soccer players affect ham-
million [3]. In Sweden the incidence of sports string muscles, and the financial burden of these
injuries is approximately 22.5 per 1000 inhabit- injuries is estimated at 74.7 million pounds
ants per year [4]. ­sterling [8].
These numbers show not only the enormous Despite the enormous advances in medicine in
medical but also the social and economic impor- recent decades, the treatment of muscle injuries
tance of the problem. Most of these injuries are has changed little and still consists of the use of
not serious but are usually painful and lead to a the PRICE protocol (protection, rest, ice, com-
temporary withdrawal from work and sports pression, and elevation of the affected limb),
activities [5]. medications, and physiotherapy for analgesia,
muscular stretching, and strengthening [9]. In the
M. Cohen (*) · G. G. Arliani case of mild muscle injuries, these treatment
Department of Orthopedics and Traumatology, modalities are satisfactory. However, moderate
UNIFESP, São Paulo, Brazil and severe muscle injuries usually lead to pro-
C. C. Kaleka longed absence and tend to form large areas of
Cohen Institute, São Paulo, São Paulo, Brazil fibrotic tissue at the site of the injury that can lead
Hospital Israelista Albert Einstein, São Paulo, Brazil to loss of strength and function as well as increase
e-mail: [email protected] chances of a new injury [10].

© ISAKOS 2019 581

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_42
582 M. Cohen et al.

Another key factor is that none of these treat- There are many protocols for preparation of
ments addresses the major problems of muscle platelet-rich plasma (open and closed systems,
injury that are cell loss and scar tissue formation.number of different centrifugation processes), so
In addition, routine treatments do not improve the products obtained differ in terms of cellular
the number, proliferation, and differentiation of and molecular compositions. Distinct clinical
satellite cells [11]. Therefore, the efforts to findings are attributed both to variability in PRP
develop new treatments that promote a faster and formulations and to variability in application pro-
more complete recovery after muscle injuries tocols. The perception that PRP was not a unique
with improved function and lower incidence of and similar product led some authors to classify
reinjuries are fundamental. the PRPs. The initial classification is still the eas-
In recent years, some biological treatments iest and most intuitive and divides PRPS into
have been studied with promising initial results: pure PRP (pPRP) and PRP with leukocytes
platelet-rich plasma (PRP), mesenchymal cells, (L-PRP) [16]. However, there are other widely
and losartan and gene therapy. used classifications such as PAW which is based
on absolute number of platelets (P), platelet acti-
vation (A), and the presence or absence of leuko-
42.2.1 Platelet-Rich Plasma cytes (W) [17].
Currently PRP is used in the definitive or
Platelet-rich plasma (PRP) can be defined as a coadjuvant treatment of many musculoskeletal
blood derivative with higher platelet concentra- and tendinous disorders. However, the results and
tion than blood [12]. PRP is prepared from an outcomes in the treatment of muscle injuries are
initial volume of blood of the patient that is pro- still controversial. Numerous doubts exist regard-
cessed and centrifuged to separate the various ing the best preparation, ideal concentration of
blood components [13]. This type of treatment platelets and specific growth factors, and a better
has been investigated due to promising initial time to start treatment with PRP after a muscle
results, low costs, and minimally invasive form injury.
of application. The concept of the use of this Delos et  al., in a study with rats, performed
technique in the treatment of muscular lesions is PRP applications acutely (2 h) and late (1 and 3
that after the injection of PRP in the injured days) after gastrocnemius injury. The authors did
muscle, the local development of the platelet- not find functional and histological differences
rich fibrin structure provides hemostasis and independent of the moment of application (early
allows the slow delivery of growth factors and or late) [18]. A randomized clinical trial, how-
cytokines from platelets and plasma, with anti-­ ever, showed improvement in pain and less time
inflammatory and regenerative effects. PRP was to return to sports after a single application of
effective in stimulating the proliferation and PRP (3 mL) after acute grade 2 hamstring injury
migration of mesenchymal cells in response to (<7 days). In this study, patients treated with PRP
the release of some specific growth factors by associated with rehabilitation returned to sports
platelets. Another possible action of PRP is the on average 26.7 days after injury, whereas the
stimulation of proliferation of fibroblasts in the control group treated only with physical therapy
muscle [14, 15]. However, excessive deposition took, on average, 42.5 days [19].
of type 1 collagen by fibroblasts can lead to the On the other hand, a similar study did not
formation of large areas of fibrosis. The control find differences in time for complete recovery
of this process is done by TGF-β1, which may of patients with gastrocnemius or rectus femo-
be present in great concentration in the platelet ris injury after PRP application (4–8 mL) with
α granules, and we know that the formation of drainage of the hematoma when compared to
large areas of fibrosis in the muscle can lead to the control group (isolated drainage). The
lesion recurrence as well as a decrease in func- authors also found no differences in pain
tional capacity. improvement [20].
42  Biologic Treatment in Tendon and Muscle Injuries 583

Some systematic reviews on the subject have be responsible for the secretion of cytokines and
concluded that despite the promising concept, growth factors, such as vascular endothelial
animal and clinical studies with good results, growth factor (VEGF) and hepatocyte growth
effective treatment of muscle injuries with PRP factor (HGF) [25, 26]. Andrade et  al. tested in
has not yet been confirmed by recent randomized mice the use of mesenchymal cells in the treat-
clinical trials. Therefore, there is still insufficient ment of muscle injuries and reinjuries. After 14
support in the literature for any benefit in terms and 28 days of application, the authors observed
of pain, function, return to sports, and recurrence a faster recovery and improved muscle function.
of injuries using PRP applications in the treat- However, they didn’t observe any improvement
ment of muscle injuries [21, 22]. One way for- in the scar formation tissue (fibrosis) in the
ward would be the customization and injured area [11].
individualization of PRP formulations according The application of mesenchymal cells derived
to the patient and type of lesion. In this way, we from adipose tissue accelerates muscle repair and
would guarantee the beneficial effects of PRP in improves the function of the injured muscle with
certain types of tissues avoiding their potential the promotion of angiogenesis and myogenesis
deleterious effects. and the prevention of fibrosis formation through
the secretion of growth factors. The authors also
believe that this mechanism of action is more
42.2.2 Mesenchymal cells important in faster muscle regeneration than the
proliferation and differentiation of mesenchymal
Muscle injuries and their reinjuries are a great cells injected into the tissue. Recent studies have
challenge for sports medicine, as they cause great shown that direct cell differentiation is not always
problems in sports, economic, and social areas. essential, as it is unlikely that these cells differen-
Despite the great capacity of healing and regen- tiate over such a short time in the setting of an
eration of muscles, a fully injured muscle regains acute muscle injury.
only part of its function and around 50% of its Despite the great prospect and hope in the suc-
strength [23]. The main treatments used today do cess of mesenchymal cells in the treatment of
not address the main problem of muscle injuries muscular injuries, more studies are required, with
that is the cellular loss. Mesenchymal cell trans- larger samples and longer follow-up in order to
plantation meets this requirement and has been have more safety and confidence in this treatment
tested in the treatment of muscle damage. modality [26].
Mesenchymal cells are found in large num-
bers in adipose tissue and bone marrow. The
Mesenchymal Stem Cell Committee of the 42.2.3 Losartan
International Society for Cell Therapy proposed
three criteria for defining mesenchymal cells: (1) Losartan is classically an antihypertensive drug
they should be adherent when maintained in stan- that acts by blocking the angiotensin II receptor
dard culture; (2) must express CD105, CD73, and and is used in the treatment of patients with sys-
CD90 and exhibit poor expression of CD34, temic arterial hypertension, congestive heart
CD45, CD14 or CD11b, CD79a or CD19, and failure, and sequelae of these diseases [27, 28].
HLA-DR in culture; and (3) must have the poten- The use of angiotensin-converting enzyme
tial to differentiate into osteoblasts, adipocytes, inhibitors and angiotensin II receptor blockers
and chondrocytes in vitro [24]. in patients with renal, hepatic, and pulmonary
Mesenchymal cells have multiple effects on diseases caused a decrease in fibrotic tissue for-
the body that include anti-inflammatory and mation and an improvement in the function of
immunomodulatory action. Previous studies have these organs [29, 30].
reported that mesenchymal cells contain several The development of fibrosis after muscle inju-
vascular and multipotent cells. These cells would ries is a major concern of physicians involved in
584 M. Cohen et al.

the treatment of athletes due to the increased risk However, despite promising results, quality
of reinjury and functional loss caused by scar for- studies in humans are still needed to assess the
mation in the injured muscle. The promising safety and efficacy of this medication in the mus-
results in previous research incentivated new culoskeletal system. However, these studies are
lines of research. fundamental for the development of biological
Bedair et al. [31] demonstrated a reduction in treatments that aim to accelerate and improve
fibrosis area and increase in the number of fibers muscle healing after injury.
in the gastrocnemius muscle of rats after acute
muscle injury and administration of losartan. The
authors concluded that the use of losartan is safe 42.2.4 Gene Therapy
and can aid not only in the treatment of sports-­
related injuries but also in muscular dystrophies, Another promising treatment modality for mus-
trauma, and postoperative injuries. cle injuries is gene therapy. The principle of treat-
However, the optimal timing for administra- ment is based on the transfer of genes to provide
tion of the drug is still controversial. Kobayashi genetic products at the site where the tissue dam-
et al. [32] investigated the dose and the best time age occurred [35].
to initiate treatment with losartan after acute The transfer of the genetic material is per-
muscle injury. The authors concluded that the formed by a vector that transports the genes of
standard dose of 10  mg/kg/day, used for hyper- interest to the host cells. Viruses are widely used
tensive patients, started 3 or 7 days after the as vectors because of their inherent ability to effi-
injury, led to a significant increase in muscle ciently translocate their own genetic material. In
regeneration, a decrease in  local fibrosis, and order to create a vector for gene therapy, viral
improvement of function. genome sequences that contribute to virulence
Other studies have sought to evaluate the and disease are usually removed and replaced
association of losartan with other substances with genes of interest. However, this method still
such as platelet-rich plasma and mesenchymal has some safety and cost-benefit concerns [36].
cells. The concept is to take advantage of the Some alternatives have been tested in an
strengths of PRP therapy and to use losartan attempt to improve and accelerate the process of
to inhibit TGFβ and consequently the forma- muscle healing after injury. Schertzer et al. [37]
tion of fibrosis. Combination therapy of PRP carried out the transfer of IGF-1 gene using ade-
and losartan improved muscle healing, novirus as vector to improve angiogenesis and
increasing angiogenesis and follistatin expres- muscle regeneration. The authors concluded that
sion and reducing Smad2/3 expression and gene transfer was superior to systemic adminis-
fibrosis development. These results suggest tration of IGF-1 but that both methods were
that blocking TGFβ expression with losartan effective in the treatment of muscle injuries.
improves the effect of PRP therapy on muscle Other authors promoted gene transfer of decorin
healing [33]. in order to decrease the expression of TGFβ and
A similar study was conducted in rats com- formation of fibrotic tissue [38].
paring the isolated use of mesenchymal cells Currently, there is extensive literature support-
and combined with losartan in the treatment of ing the concept of the use of gene therapy in the
muscle injuries. The simultaneous treatment of repair and regeneration of lesions of the musculo-
muscle contusions with mesenchymal cells and skeletal system; however the first clinical trials in
losartan significantly reduced fibrotic scar for- humans are still ongoing [39]. Therefore, we
mation, increased fiber numbers, and improved must await the results of the studies already in
muscle functional recovery. These effects would progress and develop new quality studies in
have been caused, at least in part, by the regula- humans in order to confirm the safety, economic
tion of Smad7 and MyoD with the inhibition of viability, and efficiency of this treatment
TGFβ [34]. modality.
42  Biologic Treatment in Tendon and Muscle Injuries 585

Best Evidence application of biologically derived materials to

–– Huard J, Lu A, Mu X, Guo P, Li Y.  Muscle stimulate the repair or regeneration of musculo-
injuries and repair: what’s new on the horizon! skeletal tissues. The orthobiologic approaches
Cells Tissues Organs. 2016;202(3–4):227–36. include the administration of hyaluronic acid or
–– Grassi A, Napoli F, Romandini I, Samuelsson biological factors, such as platelet-rich plasma
K, Zaffagnini S, Candrian C, et al. Is platelet-­ (PRP) or growth factors. With the advent of
rich plasma (PRP) effective in the treatment those, several options exist for increasing the
of acute muscle injuries? A Systematic strength and ability of the repair, as well as
review and meta-analysis. Sports Med. decreasing the length of the recovery period [42].
2018;48(4):971–89. Regenerative medicine approaches may be
–– Kobayashi M, Ota S, Terada S, Kawakami Y, indicated in the case of tissue healing signifi-
Otsuka T, Fu FH, et al. The combined use of cantly impaired due to aging, disease, or the pres-
losartan and muscle-derived stem cells sig- ence of an extended lesion [44].
nificantly improves the functional recovery
of muscle in a young mouse model of
contusion injuries. Am J Sports Med.
­ 42.3.1 Platelet-Rich Plasma (PRP)
2016;44(12):3252–61.
PRPs can be used in the management of tendi-
nopathy if we improve our understanding of
42.3 Tendon Injuries pathophysiology and to integrate molecular
knowledge about PRP participation in healing
Acute and chronic tendon injuries affect millions mechanisms [42].
of people in both occupational and athletic set- Development of PRP treatments is challeng-
tings each year. With the increasing popularity of ing because a typical group of patients with ten-
sports activities, the frequency of sports-related dinopathy does not exist, as it affects multiple
lesions, such as tendon injuries, is rapidly increas- segments of the population. Moreover, the patho-
ing [40]. Tendon problems are one of the main physiology and origin of pain are not elucidated
causes of musculoskeletal morbidity, and it has yet. Although some degree of success has been
been reported that 30–50% of all sports lesions achieved, PRP is not considered standard medi-
are painful tendon injuries [41]. Tendon lesions cal treatment, and it is largely not paid nor reim-
may be caused by traumatic events or chronic bursed by insurance companies. However, the
degenerative changes, making tendon weaker arguments for using PRP in tendinopathy are
and more prone to ruptures. increasing, and its potential to rebalance inflam-
Healing of acute injuries results in the forma- mation merits further research. Moreover, PRP
tion of scar tissue in tendons, which have inferior contains tendoinductive factors that can drive the
mechanical strength that makes them susceptible fate of stem cells. Tailoring PRPs to the specific
to reinjury. On the other hand, the current treat- needs of the host tendon has not been possible to
ment of chronic tendon injury (or tendinopathy) date, because unanswered questions remain
is largely palliative because of the incomplete about the characteristics of tendinopathy within
understanding of the tendon disorder [41]. The the different stages of progression [45].
tendon healing process is slow, and multiple There is still no consensus as to whether PRP
phases are well-defined, from inflammatory cyto- confers a beneficial effect, as not all trials have
kine recruitment to growth factors and reparative failed to demonstrate a positive benefit. Six sys-
cell involvement [42]. tematic reviews published between 2010 and
In recent years, new treatment option involv- 2014 assess the effectiveness of PRP in tendinop-
ing biologic has been used in orthopedic surgery athy [46–51]. Despite analyzing the same data,
and sports medicine to treat tendon injuries [43]. they reported contrasting conclusions, from con-
Nowadays, the aim of the treatment is the clinical cluding that PRP is efficacious to finding that
586 M. Cohen et al.

there is “strong evidence against platelet-rich injured tendons. Last, because L-PRP induces
plasma” [46–49]. The majority of comments inflammatory responses in tenocytes, its use to
stated that there is great difficulty reaching a con- treat the already-inflamed tendinopathic tendons
clusion because of the variance of the type of may only exacerbate the tendon disorder by pro-
PRP produced. In a Cochrane review of PRP in longing the inflammatory phase, thus impairing
soft tissue injuries, Moraes et  al. [51] indicated the healing process and leading to increased pain
that “there is need for standardization of PRP in patients. Caution should therefore be exercised
preparation methods.” However most of the when using PRP.
authors state that “it would be better to break out Based on the data from this study, the authors
the results by specific study design and PRP suggest the use of pure PRP to augment the repair
type” [49]. of tendinopathic tendons because of its anabolic
One critical component that affects PRP prep- properties and low inflammatory effects [40]. On
arations is the presence or absence of white blood the other hand, it is plausible that the strong ana-
cells (WBCs) or leukocytes (neutrophils, mono- bolic effects of pure PRP may cause fibrosis/scar
cytes, macrophages, and lymphocytes), which tissue formation in acutely injured tendons sim-
can be beneficial because they stimulate the ply because tenocytes differentiated from stem
immune response against infections; promote cells after pure PRP treatment produce too much
chemotaxis, proliferation, and differentiation of collagen in the wound areas. Therefore, they sug-
cells; and induce extracellular matrix production gest that whether to use L-PRP or pure PRP
and angiogenesis. Owing to these properties, depends on the type of tendon injury (acute vs.
PRP-containing leukocytes (L-PRP) are often chronic) and treatment phase (early- or late-stage
used to treat traumatic injuries [40]. healing) in clinical settings [40].
Thus, a meta-analysis was performed and
published in 2016 to assess the comparative
effectiveness of PRP types in tendinopathy [42]. 42.3.2 Mesenchymal Stem
A total of 18 studies (1066 participants) were Cells (MSC)
included, and all treatments consisted of intraten-
dinous injections with a prior administration of A growing field of research has explored tendon,
1–2 mL of local anesthetic (7 studies with autolo- bone, and cartilage regeneration using mesenchy-
gous blood injection, 10 studies with leukocyte-­ mal stem cells (MSCs), because of their multipo-
rich PRP produced from the buffy coat layer, and tency and because they are relatively easy to
1 with leukocyte-poor PRP) [42]. The meta-­ harvest. Great expectations arose from the use of
analysis showed that the outcome of PRP is dif- MSCs in regenerative medicine in the last decade,
ferent depending on the method of preparation of although both the potential and the drawbacks of
PRP and the injection technique; for that reason, this method remain under reflection [52].
both informations should always be included to Stem cells are cells with the capacity to dif-
evaluate the study results. Nevertheless, this ferentiate into multiple types of tissues and able
meta-analysis found strong evidence that to self-renew. They are able to establish daughter-­
leukocyte-­rich PRP can improve outcome in ten- cell lines for tissue generation [53]. They have
dinopathy [42]. three main characteristics: multipotency, capac-
A study conducted with tenocytes isolated ity to adhere to plastic, and the presence of stem
from patellar tendons of rabbits indicates that the cell-specific antigens on their surface with the
use of L-PRP to treat injured tendons may lead to absence of negative markers that are used to
scar formation in healing tendons [40]. Moreover, identify other cell lineages, such as hematopoi-
L-PRP induces extensive catabolic responses in etic endothelial cells (e.g., CD 14, 31, 34, and 35)
differentiated tenocytes, which may delay the [54, 55]. A common source of MSCs is the bone
repair of acutely damaged tendon matrix and new marrow, especially from the iliac crest. The cells
matrix formation, thus slowing the healing of harvested from the bone marrow are called
42  Biologic Treatment in Tendon and Muscle Injuries 587

BMDSCs. Another common source of MSCs is especially macrophages, can also respond to the
the adipose tissue. In that case, they are com- material cues and undergo phenotypical
monly called ADSCs. They have an advantage: changes, which will either facilitate or hinder
they are more readily accessible than BMDSCs. tissue regeneration. This process has been, to
The poor regenerative capacity of tendons has some extent, neglected by traditional strategies
greatly encouraged the research in finding new and may partially explain the unsatisfactory out-
ways to aid in their repair after a tear. The good comes of previous studies; thus, more research-
results found in animal models are encouraging, ers have turned their focus on developing
but there is lack of clinical studies supporting the immunoregenerative biomaterials to enhance
use of stem cells in clinical practice. So, a recom- tendon regeneration [60].
mendation for the routine use of stem cells can-
not be made as yet [55].
Further research is needed to determine 42.3.3 Growth Factors
whether MSCs are an effective treatment option
in augmentation of tendon healing. Also, the The use of growth factors for healing of muscu-
long-term safety of these cells and the best scaf- loskeletal injuries is relatively recent.
fold for their seeding and growth have to be dem- Recombinant growth factors were first consid-
onstrated with larger animal model studies and ered and proposed, but the high costs gradually
randomized clinical trials with a longer follow- reduced their use, in favor of autologous blood
­up period [56]. products. Several growth factors are expressed
Nowadays there are only a few orthopedic as tendons heal, but it remains unknown
studies that investigate the use of MSCs in the whether their combined application enhances
clinical practice. Some studies showed good the healing process. In an animal study, the
results in terms of outcome scores, ultrasound authors concluded that the implantation of a
appearance, pain, and mechanical performances GF-loaded collagen sponge at the time of sur-
in the treatment of lateral epicondylitis of the gery could provide a promising treatment,
elbow [57, 58]. A study was performed even especially in high-performance athletes and
regarding patellar tendinopathy on a population revision cases prone to re-rupture. For conser-
on 60 patients that were treated alternative with vative treatment, tiered percutaneous GF appli-
skin-derived tenocyte-like cells (N  =  33) or cation could be an option for improving clinical
plasma (N = 27) [59]. There was an improvement outcome [61].
in clinical scores in the group treated with the
stem cells (VISA score) with a concomitant sig-
nificant reduction of the thickness of the tendon. 42.3.4 Prolotherapy
Ultrasonography demonstrated improvements in
tendon hypoechogenicity and tear size in both Prolotherapy, also called proliferation therapy,
groups. is an injection-based treatment used in chronic
The progress achieved with the rapid devel- musculoskeletal conditions. It has been charac-
opment of biomaterial-based strategies for ten- terized as an alternative medicine practice [62].
don regeneration has not yielded broad benefits It consists by rehabilitation of an incompetent
to clinical patients. In addition to the interplay structure, such as ligament or tendon, by the
between stem cells and biomaterials, the innate induced proliferation of new cells. Prolotherapy
immune response to biomaterials also plays a is differentiated from other regenerative injec-
determinant role in tissue regeneration. One of tion therapies, such as platelet-rich plasma
the principles for biomaterial development in (PRP) and stem cell injection by the absence of
tendon regeneration is to stimulate tenogenic a biologic agent. The most commonly used
differentiation of stem cells. However, recent prolotherapy solution reported in current liter-
progress indicated that innate immune cells, ature is hypertonic dextrose, a simple
588 M. Cohen et al.

­onosaccharide synonymous with glucose

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 Biologic Treatment of Ligament
Injuries by the Sports Physician
43
Jonas Pogorzelski, Mitchell Kennedy,
and Robert F. LaPrade

43.1 Background struction procedures. In today’s society with a

significant commercial interest in sports, ath-
Ligament injuries are one of the most frequent letes sometimes become pressured to return to
injuries in athletes. The annual incidence of an their sports before the implanted graft has fully
injury to the anterior cruciate ligament (ACL) matured, leading to potential graft elongation
is about 0.1% in the United States, and ACL and re-rupture, which are both known to con-
reconstructions are among the most frequently tribute to persistent knee instability [12]. In
performed surgeries [9]. Although the short- fact, it is known that an implanted ACL graft is
term success rate of an ACL reconstruction is in its weakest state approximately 3–6 months
generally excellent, these calculations fail to after surgery, which often corresponds to the
account for a significant proportion of athletes time at which patients return to sporting activi-
who fail to return to their previous level of ties [17]. This disturbance has triggered the
sports and continue to show symptoms of rap- search for possible strategies of accelerating
idly progressing osteoarthritis due to persistent graft healing. Because currently accepted surgi-
instability [6, 7, 11, 12]. The vast majority of cal techniques are essentially fully developed, a
these failures in athletes occur from new inju- drastic acceleration of graft healing is an unre-
ries to ACL grafts that have not fully matured, alistic expectation due to the adjustment of the
even after technically well-performed recon- surgical technique. Thus, biologic augmenta-
tion methods have recently gained attention in
the realm of the orthopedic community, because
J. Pogorzelski they are theorized to potentially accelerate liga-
Department of Orthopaedic Sports Medicine, mentous healing.
Hospital Rechts der Isar, Technical University
of Munich, Munich, Germany The purpose of this chapter is to (1) sum-
e-mail: [email protected] marize and explain commonly used biologics
M. Kennedy and their mode of action in ligament injuries,
Steadman Philippon Research Institute, (2) present a rationale for the use of biologics
Vail, CO, USA in ligament injuries, (3) provide an overview
e-mail: [email protected] of how to use biologics in daily practice, and
R. F. LaPrade (*) (4) present published results of the use of bio-
Twin Cities Orthopaedics, Minneapolis, MN, USA logics following ligament injuries in the
e-mail: [email protected];
[email protected] literature.

© ISAKOS 2019 591

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_43
592 J. Pogorzelski et al.

43.2 B
 iologics: Growth Factor certain types of tissue regeneration—so-called
Therapy and Cell Therapy second-generation PRP [14, 23]. A typical exam-
ple for the preparation of second-generation PRP
Biologics is a widely used term for a subset of is the use of losartan, an angiotensin II receptor
endogenous substances, which have shown hypo- blocker known to prevent the action of TGF-β1
thetical therapeutic potential for modulating the and inhibit scar formation. That is why this drug
biologic microenvironment at the site of injury can be added to PRP in cases where scar forma-
[20]. In order to better categorize biologics, they tion is unintended, such as muscular injuries. On
are commonly divided into the two subgroups: the other side, TGF-β is known to be an important
growth factors and cells. growth factor in the healing process of ligament
and cartilage injuries; thus the application of
losartan should be avoided in these cases [14].
43.2.1 Growth Factor Therapy

The most commonly used growth factor therapy 43.2.2 Cell Therapy
contains the use of autologous platelet-rich
plasma (PRP), due to its easy preparation and In addition to having similar levels of growth fac-
high availability [12]. Autologous PRP consists tors to those found in PRP, bone marrow aspirate
of platelets, plasma, and varying amounts of leu- concentrate (BMAC) contains an increased
kocytes; it is made by obtaining blood from a amount of mesenchymal stem cells (MSCs) [5].
patient and processing by centrifugation into a Generally, MSCs have the ability to differentiate
concentrated platelet substance above baseline into different types of tissues such as muscle,
levels [2, 15]. In general, platelets are the first bone, cartilage, tendon, or ligament, dependent
responders to soft tissue injuries and house a on the local environment, and thus are considered
large number of alpha granules, which contain beneficial in the healing process of injuries. They
more than 1000 bioactive molecules such as can be harvested from numerous places in the
cytokines and growth factors [13]. The rationale human body, including the periosteum, bone
for the therapeutic application of PRP is based marrow, and adipose tissue (being the most com-
from delivery of supraphysiologic concentrations mon) [11]. The rationale of the transplantation of
of platelets into the injured area, with the poten- stem cells is that the delivery of the isolated
tial for improving the quality of the repair while MSCs directly into the healing zone of ACL
also reducing the time of regeneration by func- grafts or partially torn ACLs may provide a more
tioning as chemoattractants and stimulators of organized and functional transition zone—thus
cell proliferation [2, 13]. Examples of growth leading to more rapid and enhanced bony
factors that have been identified to exist in PRP ingrowth. While the theoretical advantages are
and trigger the aforementioned processes include obvious, there exist a lot of practical barriers
transforming growth factor-β (TGF-β), platelet-­ translating basic science into daily practice [12].
derived growth factors (PDGF), insulin-like In order to separate MSCs from other cell types,
growth factor-1 (IGF-1), morphogenetic proteins a laboratory culture is most commonly used.
(BMPs), matrix metalloproteinases (MMPs), Besides the high costs of such an institution, it
fibroblastic growth factor (FGF), and vascular has been reported that the cell phenotype might
endothelial growth factor (VEGF). However, temporally change during the separation process,
until today only a small subset of molecules and thus affecting cell behavior and therapeutic effi-
their mode of action are known, thus leading to a cacy [12]. In addition, the Food and Drug
change of strategy. Rather than identifying and Administration (FDA) does not allow biologics
characterizing each of the many thousands of to be manipulated and used in patients. That is
bioactive molecules, current research proposes to why most of the time whole bone marrow cell
inhibit growth factors known to be detrimental to suspensions (e.g., BMAC) or stromal vascular
43  Biologic Treatment of Ligament Injuries by the Sports Physician 593

fractions (from lipoaspirates) are directly used to In general, biologic approaches to the treat-
harness the potential of the contained stem cells ment of partial ACL injuries aim to optimize
and growth factors. However, these highly het- clinical outcomes by improving tissue healing.
erogeneous cell populations demonstrate poor More precisely, multiple recent studies suggest a
tissue formation combined with a lower regener- possibility for partial ACL tears to heal following
ative potential compared to isolated MSCs [11]. primary suture repairs augmented with the use of
More recently, flow cytometry has shown prom- biologics [7]. Therefore, biologics such as PRP,
ising results in separating MSCs from stromal may be applied directly into the torn fibers during
vascular fractions, potentially allowing for the an arthroscopic procedure, sometimes utilizing
extraction of a sufficient number of isolated stem and augmenting artificial extracellular matrix
cells without needing a laboratory culture [11]. (ECM) scaffold, which is wrapped around the
Although this facilitates the use of stem cells in ligament and soaked in PRP or a stem cell solu-
daily practice, the clinical effect of the high tion [17].
purity of MSC remains unclear. The intended goal for the use of biologics in
ACL reconstruction is more geared toward the
improvement of graft ingrowth while also min-
43.3 Ligament Healing imizing the risk of graft failure; thereby the
and Rationale for the Use graft incorporation and maturation processes
of Biologics in Ligament are of particular interest. After ACL recon-
Injuries struction, the incorporation of a soft tissue
grafts within bone tunnels takes about 12 weeks
While ligaments such as the MCL have a high or longer to complete [11, 12]. During this
healing capacity and usually do not need to be time period, a process of multiple microbio-
augmented with biologics, the ACL does not heal logic reactions involving granulation tissue,
in most cases [12]. This is even more surprising chondrogenic progenitors, and type II collagen
considering the fact that the fibroblasts of both takes place, finally ending in endochondral
ligaments show comparable rates of proliferation ossification of the graft into the bone tunnels
and collagen production [17]. Possible explana- [17]. Simultaneously, the intra-­ articular soft
tions for this poor healing response by the ACL tissue graft is gradually decellularized by mac-
may be found in the altered environments sur- rophages before the resulting ECM scaffold is
rounding the ligament. While the ACL is sur- repopulated with infiltrating progenitor cells.
rounded by synovial fluid and is poorly Activated by the progenitor cells, fibroblasts
vascularized, all extra-articular ligaments, such begin to migrate into the tendon and deposit
as the MCL, are not covered by synovial fluid and type III collagen, which is later transformed
are better vascularized, allowing a more effective into type I collagen and thus ending the matu-
healing environment [17]. More precisely, syno- ration process. In contrast to soft tissue grafts,
vial fluid prevents the two ends of the torn liga- bone-tendon-bone (BTB) grafts rely upon bony
ment to rejoin by washing out a fibrin clot that union, which only takes about 6  weeks [11].
consists of important extracellular matrix pro- However, intra-articular graft maturation
teins and cytokines. The lack of this provisional undergoes the same remodeling process as
scaffold explains why a completely torn ACL has described before, therefore it seemingly
a poor healing response, making an ACL recon- requires a similar overall length of rehabilita-
struction necessary [17]. This is contrasted by tion. There exist multiple strategies to enhance
some types of partial ACL tears. For partial and accelerate healing by the use of biologics,
femoral-­based ACL tears, if a sufficient amount including direct application into the graft and
of ACL fibers are still intact, thus a scaffold for a bone tunnels, biologics-­impregnated scaffolds
healing response exists, and an ACL reconstruc- out of ECM, silk, or poly-l-lactic acid, among
tion might not be necessary [7]. others [21].
594 J. Pogorzelski et al.

43.4 Biologics in Daily Practice trochar of the bone marrow aspiration is percu-
for Treatment of (Partial) taneously inserted until reaching the posterior
Anterior Cruciate Ligament iliac crest, followed by the manual positioning
Tears of the trochar, with pressure, upon dense corti-
cal bone; one’s aim should be directed centrally
43.4.1 Preparation and Processing between the middle of the posterior crest corti-
of PRP cal walls, with the trajectory of the needle par-
allel to the iliac crest or perpendicular to the
With a temporary elastic tourniquet used to anterior superior iliac spine or posterior supe-
accentuate the peripheral veins, approximately rior iliac spine. The trochar and needle are then
60  mL of blood is draw from the arm of the drilled into the medullary cavity of the poste-
patient. This peripheral blood is then processed rior iliac crest with the battery-powered instru-
in the laboratory, first by dividing the blood into ment. Prior to aspiration, 1  mL of heparin
two 50 mL conical tubes where they are spun at should be preloaded into the syringe (to reduce
2600 rotations per minute (rpm) for 10  min; clot formation and coagulation and maximize
before centrifugation, assure that a 1 mL sam- the potential yield). Upon completion, the aspi-
ple has undergone hematology analysis, and the ration will have yielded 60 mL of bone marrow
amounts of platelets, erythrocytes, leukocytes, using two 30  mL syringes. The bone marrow
and differentials including neutrophils, lym- aspirate is first transferred into 50  mL conical
phocytes, monocytes, eosinophils, and baso- tubes through a 200 μm mesh filter. A sample of
phils are quantified. The resultant top fraction, 1–1.5  mL of filtered bone marrow aspirate is
consisting of platelet-poor plasma (PPP), is processed for hemanalysis, and the remaining
extracted and added to a separate 50 mL conical is transferred into two 50 mL conical tubes and
tube. The remaining buffy layer (white blood centrifuged at 2400 rpm for 10 min. The buffy
cell layer) and erythrocyte layer are consoli- coat and platelet-poor plasma layers are then
dated into another 50 mL conical tube. This is extracted and discarded, leaving behind red
then centrifuged once more at 3400  rpm for blood cell layers which are combined and cen-
6  min. A final PRP product is then acquired trifuged for an additional 6  min at 3400  rpm.
once the remaining PPP layer has been extracted This yields a BMAC/white cell pellet, which is
following the final centrifugation, and 1 mL of resuspended in platelet-poor plasma, which
the final product is again analyzed for undergoes one final hemanalysis to obtain the
hematology. final product to inject.

43.4.2 Preparation and Processing 43.4.3 Application

of BMAC
The optimal timing to deliver PRP or BMAC and
Patient positioning is carried out in the prone the perfect concentration during application
position, with the resultant BMAC being har- remain largely unexplored [11]. Generally
vested under sterile conditions from the pos- speaking, biologics can be applied preopera-
terosuperior iliac crest region [3]. A bone tively, intraoperatively, or postoperatively. As
marrow aspiration kit is opened, and the BMAC platelets are released almost immediately after
aspiration device is sterilely draped. Bony land- any type of trauma to the human body (e.g., dur-
marks of the posterior iliac crest and sacroiliac ing surgery) and subsequently activate growth
joint are palpated, and 1% lidocaine without factors which only have a limited lifespan of
epinephrine is injected down to the periosteum. minutes to hours, the authors believe that the
Through the skin and subcutaneous tissue, the intraoperative application of biologics seems to
43  Biologic Treatment of Ligament Injuries by the Sports Physician 595

be the best solution [11, 12]. The optimal tech- 43.5.1 Growth Factor Therapy
nique of application also remains vague. In prin-
ciple, PRP and BMAC can either be applied As the application of isolated growth factors is so
directly into the graft or tissue and simply far not approved by national board authorities,
applied into the knee joint, or finally a scaffold most trials involving growth factor therapy deal
can be impregnated with PRP or BMAC solution with the application of PRP. In general, numerous
and subsequently wrapped around the graft or preclinical and clinical trials have been performed
partially torn ACL.  While the current literature to evaluate the impact of PRP application on his-
fails to show a superior technique, the authors tological and clinical outcomes following ACL
believe that a combination of direct application repair or reconstruction. Unfortunately, many of
and application into the joint is the most promis- them are ex vivo studies with a low level of evi-
ing technique. dence. Dallo et al. [7] summarized the results of
In summary, there exists a need for well-­ added growth factor therapy in partial ACL tears
defined studies evaluating the kinetics according in a systematic review. They reported multiple
to the activation process of cytokines or methods in vitro and animal studies using specific growth
of localization within a tissue. factors, which may demonstrate enhanced cell
proliferation and ECM synthesis. Moreover, when
taking a closer look at studies dealing with PRP
augmentation in the treatment of partial ACL
43.5 Outcomes of Biologics tears, the literature demonstrates ambiguous
in Ligament Injuries results. For example, Cheng et al. [4] reported that
there are age-dependent differences in ACL cell
In general, the current literature lacks high-level metabolism, collagen gene expression, and the
studies on the use of biologics in ligament inju- ability of the cells to respond to growth factors in
ries [11, 12]. Even more problematic is the fact PRP.  They obtained ACL cells from skeletally
that the limited number of existing studies is immature, adolescent, and adult pigs and cultured
hardly comparable among each other due to the them in a collagen type I hydrogel with or without
lack of standardized preparation of biologics [2, PRP for 14 days. As a result, the addition of PRP
16]. The only two FDA-approved biologics, to the collagen hydrogel resulted in a significantly
namely, PRP and BMAC, suffer from many increased cellular metabolic activity, reduced
inconsistencies during their harvest and prepara- apoptotic rate, and stimulation of collagen pro-
tion [2, 11, 12]. While the harvest of a sufficient duction in cells from both the immature and ado-
number of stem cells from BMAC without lescent animals (p < 0.05 for all comparisons), but
ex vivo expansion is generally difficult, the pos- the adult cells were affected less. In contrast to
sible pitfalls of PRP are more complex. It is these findings, a similar animal model by Murray
known that the growth factor concentration in et al. [18] reported on the outcome after applica-
PRP, even within the same person, is influenced tion of clotted PRP in the gap of a transected
by donor-specific factors such as age, gender, ACL. They concluded that there was no beneficial
time of day, or nutritional status [11]. Moreover, effect of adding PRP in ACL injuries. The results
different processing techniques and methods of of multiple clinical trials involving the application
delivery make PRP a highly individual product of PRP during ACL reconstruction summarized
with generally low comparability. However, even by Figueroa et al. in a recent systematic review of
though there is a need for more high-level studies the literature are equivocal [8]. While they could
in the future, there exist some studies with inter- show promising evidence that the maturation of
esting findings about biologic augmentation in the graft was enhanced and happened more
ligament injuries, which are worth being quickly by the addition of PRP, they failed to
mentioned. show superior clinical results after the use of PRP.
596 J. Pogorzelski et al.

43.5.2 Cell Therapy

There is a general paucity of trials involving the

application of BMAC following ligament injuries,
even when compared to the literature dealing with
PRP-augmented ACL reconstructions. Several
animal model studies could show beneficial
effects of the application of MSCs into a (par-
tially) torn ACL [10, 19]. Animals that were
treated with additional MSCs following a partial
ACL tear showed superior histological scores,
greater load-to-failure, and almost normal histol- Fig. 43.1  A 10–12 mL platelet-rich plasma (PRP) prod-
ogy with more mature spindle cells [10, 19]. Dallo uct is formulated from an original sample of approxi-
et  al. summarized the existing knowledge about mately 60 mL of blood, in which the platelet-poor plasma
(PPP) composition has been removed following a differ-
biologic augmentation of partial ACL tears in a entiation process of PPP and PRP via dual centrifugation.
recent systematic review [7]. They concluded that A diluted plasma releasate is then combined with inacti-
preclinical and short-term results are promising, vated PRP to activate the injected growth factors over time
but further research is required to better define the
role of biologic augmentation in partial ACL tears
for long-term settings. Concerning MSC augmen-
tation for patients that underwent ACL recon-
struction, Silva et  al. [22] compared the
radiological tendon-to-bone healing in 43 patients
with and without augmentation, finding no sig-
nificant differences between the two groups. In a
further study, Centeno et  al. [1] reported on ten
patients suffering from ACL tears with less than
1 cm retraction of the tendon stumps and treated
with an percutaneous intraligamentous injection
of BMAC.  A total of seven out of ten patients Fig. 43.2  With the patient in prone positioning, bone
marrow aspiration is performed under sterile conditions
showed improved radiological results on postop-
on the posterior superior iliac spine; the cortex is pene-
erative magnetic resonance imaging, which lead trated, and approximately 60  mL of bone marrow is
them to the conclusion that augmentation with extracted using two 30 mL syringes
BMAC is promising, but further high-level stud-
ies are required to draw final conclusions.
In summary, it appears that the translation of Take-Home Messages
basic science data into clinical application is a • Biologics can be divided into growth factor
challenging endeavor. Although promising therapy and cell therapy with PRP and BMAC
results in preclinical studies exist, there is cur- being the most commonly used. While PRP
rently insufficient evidence to suggest that bio- belongs to the growth factor therapy, BMAC
logic augmentation using any of the currently belongs to the cell therapy because it contains
available techniques provides any clinical bene- stem cells.
fit, and the ongoing efforts of basic and clinical • While the vast majority of ligaments are
research should accelerate the development of located extra-articular and have a high healing
effective biologic therapies (Figs.  43.1, 43.2, capacity and thus don’t need to be augmented
43.3, and 43.4). with biologics, the ACL does not heal in most
43  Biologic Treatment of Ligament Injuries by the Sports Physician 597

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 Biological Treatment
in Cartilage Injuries
44
Elizaveta Kon, Berardo Di Matteo,
Francesco Iacono, Filippo Vandenbulcke,
Nicolò Danilo Vitale, and Maurilio Marcacci

44.1 Background with biomechanical properties that match the

physiologic condition.
Cartilage injuries are common, and their inci- Hyaline cartilage has a complex and unique
dence is getting higher due to the greater empha- architecture allowing it to provide a low-friction
sis on physical activity with an increase in sports surface and to distribute the load. Chondrocytes
participation in all age groups [1]. Different are sparsely distributed within the surrounding
authors [2–4] found cartilage lesions in about matrix with minimal cell-to-cell contact. The
60% of the patients who undergone a knee interaction between cells, collagen framework,
arthroscopy, with defects ranging from 0.5 to aggrecan, and fluid constitutes a complex biome-
12 cm. It has also been estimated that between 5 chanical feature making hyaline cartilage diffi-
and 10% of young active subjects affected by cult to replace or reproduce [6]. Moreover, none
traumatic hemarthrosis of the knee have a focal of the inflammatory processes are available for
chondral injury [5]. its repair, and unlike other tissues chondrocytes
Although a significant number of such injuries cannot migrate to the site of injury from an intact,
may remain asymptomatic, patients frequently healthy site [7]. This poor intrinsic regenerative
present complaining of pain, recurrent effusions, capacity of articular cartilage increases the
and loss of function. importance of obtaining effective treatment
Concomitantly with the increasing incidence, options for symptomatic lesions of this tissue.
the expectations of patients about function restore Another important problem concerning carti-
have risen as well. In an attempt to fulfill patients’ lage injuries is that they represent a risk factor for
expectations and successfully treat this pathol- more extensive joint damage. Even small isolated
ogy, various techniques have been proposed over defects may cause further degeneration, due to
the years, but none has shown a tissue healing higher mechanical stress on the lesion’s edge.
Tissue near a defect experiences increased over-
all compression, and excessive strains may con-
tribute to cell death, matrix damage, or accelerated
E. Kon · B. Di Matteo · F. Iacono · F. Vandenbulcke
N. D. Vitale (*) · M. Marcacci wear. The degenerative process leading to uni-
Department of Biomedical Sciences, Humanitas compartimental osteoarthritis following an iso-
University, Milan, Italy lated critical-sized defects has been clearly
Humanitas Clinical and Research Center, Milan, Italy demonstrated in the animal model [8, 9].
e-mail: [email protected]; Several therapeutic strategies have been devel-
[email protected]; oped, both conservative and surgical.
[email protected]

© ISAKOS 2019 599

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_44
600 E. Kon et al.

The latter include simple arthroscopic debride- loproteinases, which are cartilage-matrix degrad-
ment, bone marrow stimulation techniques ing enzymes [16].
(microfractures), transplantation of autologous PRP also contains different plasma proteins,
tissue (e.g., mosaicplasty), implantation of cul- which are critical components in the healing
tured autologous cells, implantation of allograft mechanism of connective tissues [17]. In contrast
tissue, and prosthetic options. with serum, plasma contains clotting factors and
Nowadays the conservative approach is gain- fibrogen, which can be activated to form a provi-
ing constant increasing attention, and authors sional fibrin scaffold for cells to adhere, migrate,
struggle to find the better biological therapy and proliferate [18].
capable of restoring the cartilaginous tissue and Articular hyaline cartilage contains no blood
relieving clinical symptoms. vessels and is thus unable to initiate the same
Among them, infiltrative therapies, such as healing process as other tissues with good regen-
platelet-rich plasma (PRP) and mesenchymal erative potential. The three-dimensional scaffold
stem cells (MSCs), stand out as the most conser- created with the infiltration of PRP may mimic
vative and suitable for different types of cartilage the initial stage of wound healing and tissue
lesions. repair.
A more surgical biological approach is repre- Different authors demonstrated in  vitro that
sented by the bioengineered scaffold, used to PRP has a strong positive effect on chondrocyte
treat osteochondral defects. proliferation [19–24].
This is the rationale that led to the develop-
ment of several clinical studies and the subse-
44.2 Platelet-Rich Plasma (PRP) quent use of PRP as a novel biological treatment
for articular cartilage lesions.
Platelet-rich plasma (PRP) is among current bio- Some problems came out during the in  vivo
logic interventions used in medical conditions study of PRP and its effects. Firstly, many vari-
that necessitate tissue healing [10]. It is a concen- ables have to be considered when making com-
trate obtained from autologous blood containing parisons, and it is not possible to establish a
high concentrations of human platelets and univocal definition of PRP. There are several PRP
platelet-­derived growth factors. formulations, whose comparison in terms of
Inside platelets indeed lies a powerful reser- potentials and limits is very difficult to test due to
voir of factors capable of providing clinical ben- the large inter-product variability [25]. A good
efits by modulating the early healing response starting point might be to clarify what the essen-
through secretion of an array of signaling cyto- tial features are to define a blood product as
kines that influence inflammation, angiogenesis, PRP. It is generally regarded as a blood derivate
and cell migration [11–14]. with a higher concentration of platelets compared
Among them the most relevant is platelet-­ to basal level. It has been proposed that platelet
derived growth factor (PDGF), transforming concentration should be at least 200% of the
growth factor beta (TGF-beta), fibroblast growth peripheral blood PLT count [26, 27] even if in the
factor (FGF), insulin-like growth factor 1 (IGF-­ literature PRP concentrations have been reported
1), connective tissue growth factor (CTGF), epi- to range widely, up to eight times that of basal
dermal growth factor (EGF), and hepatocyte levels [26]. Therefore, just concerning the defini-
growth factor (HFG) [10, 15]. Moreover, the anti-­ tion of PRP, it is possible to understand the first
inflammatory properties of PRP have been inves- variable involved in the comparison of different
tigated as an associate effect in promoting tissue types of PRP [28]: the platelet count that can vary
repair. Lowering the inflammation in the synovial in such a significant way that the possible corre-
tissue would lead to a reduction of matrix metal- lation between platelet concentration and clinical
44  Biological Treatment in Cartilage Injuries 601

outcome could be a critical aspect. However, the accumulation of pyrogenic cytokines and
with regard to the scientific evidence available up increasing the risk of bacterial proliferation. For
to now, good clinical outcome can be obtained these reasons, some authors prefer fresh adminis-
even with lower platelet concentration. Some tration of PRP immediately after its preparation
studies also report correlations between outcome (thus requiring blood harvesting for each injec-
and platelet count [27, 29], but further investiga- tion, in case of multiple treatments) [31].
tions are needed to fully explore this topic. Another issue is the activation method. Several
The platelet count is strictly linked to the pro- options are available even in this case: from no
cedures employed: there are two main prepara- activation, counting on the in  vivo activating
tion methods used in clinical practice [28]. The effect of endogenous collagen, to the use of
first one is by using a laboratory centrifuge, and chemical agents or biomaterials or even physical
the second one a density gradient cell separator. agents. Calcium chloride and thrombin are the
In the first case several variables, such as a num- most commonly used substances, whereas
ber of centrifugations, their speed, and timing, batroxobin is less often employed. These mole-
might influence the final product in terms of con- cules contribute to PRP clot formation and
centration of different cellular types. Furthermore, increase overall GF release even if their effect on
this preparation method is more technician-­ single GF kinetic is controversial and needs fur-
dependent, and therefore its reproducibility is ther studies. In particular, thrombin, besides
biased. Concerning cell separators, they are being a strong activator of platelets, has its own
closed-circuit devices that allow PRP preparation biological properties that might influence the
without excessive manipulation of the blood. A interpretation of the effect of PRP [32].
large and constantly increasing number of these Beyond the intrinsic differences among PRP
devices are available on the market, each with its preparations due to all the aforementioned fac-
own features and specifications, so it is impossi- tors, applicative variables should also be taken
ble to obtain the same products, and again the into account. Individual authors apply their own
comparison is very difficult. therapeutic protocol: the amount of PRP used for
Furthermore, we have to consider the overall each injection, the number of the injections, and
cell types contained in PRP: even in this case, the the time intervals can vary widely, so study com-
preparation method is a key factor. In fact, some parison is even harder than just comparing prod-
PRP preparations, besides plasma and platelets, uct differences. Standardization has not yet been
also contain leukocytes and residual blood cells. proposed on this issue. Thus the different proto-
With regard to this, some disagreement has cols of each author introduce further confound-
emerged among authors. In fact, whereas the ing factors.
antimicrobial effect of leukocyte-rich PRP has Another variable regards the application of
been underlined, some authors highlight the fact PRP in the treatment of cartilage lesions. It can
that leukocytes can release matrix metallopro- be used as an augmentation procedure in differ-
teinases and reactive oxygen species capable of ent types of surgeries or alone as a conservative
damaging articular tissues and determining a method. Looking at the surgical application, it is
catabolic effect. Concerning the presence of not possible to draw definite conclusions about
residual blood cells, it has been reported in some the efficacy of this approach. It is a consequence
studies that even erythrocytes have a pro-­ of this particular kind of treatment: it is very dif-
inflammatory effect in the joint [30]. ficult to identify how much PRP might contribute
Storage procedure is also a hot topic: in fact, to determine the clinical outcome with respect to
freeze-thawing is one method, but it is thought to the surgical treatment performed alone.
impair platelet function and lifespan and alter the Comparative studies aimed at assessing the spe-
GFs’ release pattern negatively, besides favoring cific role of PRP are needed.
602 E. Kon et al.

Furthermore, in many cases, PRP is adminis- support the clinical application of PRP since each
tered together with other biological augmentation study faces an important bias related essentially
methods, such as mesenchymal stem cells [33– to the lack of a control group. All the randomized
35] or bioengineered scaffolds [36, 37], so it is controlled trials available compared the efficacy
even more difficult to determine the contribution of PRP versus HA. Actually it should be pointed
of PRP. The studies available are just case series out that each trial employed a different type of
treating disparate conditions in biomechanically PRP. Two out of three studies [39, 40] revealed
very different joints (knee and ankle). Maximum better results in the PRP group at 6  months of
follow-up evaluation is 24  months, so further follow-up. The third one [41], which had the lon-
studies are needed to determine the persistence of gest follow-up evaluation (1  year), reports no
the good clinical outcome of these particular pro- overall difference between PRP and HA in terms
cedures. In the near future, PRP will be more and of clinical outcome. Just a tendency toward better
more widely used in regenerative cartilage tech- results in patients affected by a lower degree of
niques, but, despite being safe, according to the cartilage degeneration was found. Therefore, in
present evidence, there is still no recommenda- the case of more advanced signs of OA, PRP does
tion for using PRP in such procedures. not seem to be superior to viscosupplementation,
Considering PRP as conservative manage- a conclusion that was also reached in the study by
ment, things look a bit different, especially when Sanchez et al. Surprisingly, Cerza et al. reported
treating the knee region. In fact, whereas a few significantly better results for ACP even in grade
studies have been published both on hip and III OA: worthy of consideration is the fact that
ankle cartilage lesions, several trials focus on they used a different blood-derived product with
knee treatment. As a consequence, few indica- evaluation limited up to 6 months of follow-up.
tions can be proposed for hip and talar osteo- All the randomized trials deal with the appli-
chondral lesions. For what regards talar cation of PRP in patients affected by very differ-
osteochondral lesions, only one comparative ent stages of the disease, from chondropathy to
quasi-randomized trial has been published [38]: severe OA.  Therefore no conclusions can be
despite presenting statistically superior results drawn about the possibility of applying this
for the PRP group, the low number of patients approach to a specific phase of degenerative car-
treated and the short follow-up evaluation do not tilage pathology: subgroup analysis does not
allow, even in this case, the use of PRP to be allow, in any of the trials published, sufficient sta-
endorsed. tistical strength to provide a real clinical indica-
For the knee, it is possible to have more tion. What emerges can be considered just a
detailed indications. A lot certainly still needs to suggestion to avoid the indiscriminate use of
be clarified, but the considerable amount of stud- PRP, which seems to offer a clinical benefit but
ies published allows us to draw some conclu- cannot yet be considered a first-line treatment for
sions. The first consideration regards the safety of this pathology. Moreover, its use should be lim-
the procedure, which was confirmed by all the ited to those patients who can take most advan-
different trials present in literature. They reported tage from this approach, such as young patients
only minor adverse events with just some differ- with less articular degeneration or those not
ences linked to the particular PRP formulation responsive to other more traditional treatments.
used: in fact, leukocyte-rich PRP seems to deter-
mine increased pain and swelling reaction when
compared to leukocyte-poor PRP. With regard to 44.3 Mesenchymal Stem
the clinical outcome, it can be said that this kind Cells (MSCs)
of conservative approach is time-dependent since
a gradual worsening occurs over time. Another powerful tool for cartilage repair emerg-
Analyzing efficacy, the encouraging results ing in recent years is a mesenchymal stem cell
reported in case series cannot be the backbone to (MSC). They have the marked ability to differen-
44  Biological Treatment in Cartilage Injuries 603

tiate into a variety of connective tissues including trabecular bone, infrapatellar fat pad, and muscle,
cartilage, bone, fat, tendon, ligament, marrow with similar phenotypic characteristics but differ-
stroma, and others [42]. The regenerative effects ent propensities in proliferation and differentia-
of MSCs are due to their structural contribution tion potentials [51]. Numerous studies have
to tissue repair and their immunomodulatory and described the success of different MSC applica-
anti-inflammatory action, through direct cell-cell tion modalities, through injection [52] or scaffold
interaction or secretion of bioactive factors [43]. implantation [34], involving different biomateri-
MSCs have a capacity for self-renewal, stemness als and sometimes combined with growth or tran-
maintenance, and a potential for differentiation scription factors (such as recombinant molecules
into cells forming multiple mesodermal tissues or even in the form of genetic sequences), such as
(plasticity). They can migrate toward injured tis- TGF-b, BMP-7, FGF-2, or SOX9, hyaluronic
sues (homing) where they display trophic effects acid, or magnetic devices. Some researchers have
(synthesis of proliferative, proangiogenic, and investigated the possibility of predifferentiating
regenerative molecules). Most remarkably, MSCs MSCs into the chondrogenic lineage before
exert a suppressive effect on components of the implantation [53] to provide better-targeted tis-
immune system by inhibiting T and B lympho- sue regeneration. However, the optimal strategy
cyte activation and proliferation, suppressing NK has not yet been identified. Peripheral blood is
cell activation, escaping CTL-mediated lysis, and another possible source of MSCs (PBMSCs), but
modulating the secretion profiles of dendritic current knowledge is still very limited, with poor
cells/macrophages [44]. The Mesenchymal and results, a low number of patients, and shorter
Tissue Stem Cell Committee of the International follow-up [54]. They cannot be easily isolated,
Society for Cellular Therapy has established the and their number is very low, especially in adult
following minimal set of standard criteria to pro- humans; moreover, a previous patient stimulation
vide a uniform characterization of such cells is required to increase their number, making this
[45]: (1) They must be plastic-adherent when procedure more complicated.
maintained in standard culture conditions; (2) Knowledge about the use of MSCs in the
they must express CD105, CD73, and CD90 and treatment of cartilage defects is still preliminary,
lack surface expression of CD45, CD34, CD14 as shown by the prevalence in the literature of
(or CD11b), CD79a (or CD19), and HLA-DR; preclinical studies and, among the clinical find-
(3) and they must be capable of differentiating to ings, by the presence of studies of low quality
chondrocytes, osteoblasts, and adipocytes due to weak methodology, a small number of
in vitro. MSCs were first identified by Friedenstein patients, and short-term follow-up. Nonetheless,
et  al. [46] in 1966  in bone marrow (BMSCs). the studies available suggest a potential for these
Subsequently, in 1970, Caplan’s group [47] pro- cell-based treatments to be developed and to rep-
vided the first evidence of chondrogenic, osteo- resent a promising new approach with prelimi-
genic, and muscular differentiation potential of nary interesting findings ranging from focal
these cells and introduced the term “mesenchy- chondral defects to articular OA degeneration.
mal stem cells” in the early 1990s [48]. Another However, many aspects are still controversial,
important study performed by Wakitani et al. [49] and they have to be clarified. Firstly, the optimal
first showed the efficacy of autologous MSC MSC source has not yet been identified. The
implantation in rabbit osteochondral defect heal- yield of cells obtained by extraction might also
ing, and finally, in 2001, Quarto et  al. [50] be a limiting factor and contributes to the choice
described the first successful clinical application of cell source for the clinical application. The
of cultured MSCs by focusing on bone healing in continually emerging field of experimental stem
humans. Nowadays, MSCs can be isolated from cell research and cartilage repair, particularly
human sources other than the bone marrow, such with the help of preclinical large animal models,
as adipose tissue, umbilical cord blood, synovial will provide some new solutions to this issue.
membrane, synovial fluid, periosteum, dermis, The most appropriate cell source is not the only
604 E. Kon et al.

controversial aspect. For example, many impor- lished. The current literature shows the variety in
tant biological pathways that determine the fate quantity of transplanted cells into the defect site,
of transplanted MSCs in cartilage defects, par- making clinical outcome comparison very diffi-
ticularly with the view of hypertrophic differen- cult. As the number of cells per defect volume
tiation, are unknown. Controlling the that would be required for successful articular
chondrogenesis of MSCs in this environment is cartilage regeneration remains unclear, identifi-
not understood. The interplay of MSCs with the cation of such an effective quantity of MSCs rep-
adjacent osteochondral unit has not yet been resents another key point.
­clarified. Another aspect that has to be considered
is the potential risks in MSCs use: one possibility
is, besides cancer or immunological disease, the 44.4 T
 he Osteochondral Unit
differentiation of these cells into unwanted tis- and Bioengineered Scaffolds
sue, as reported by Breitbach et  al. [55] who
described the calcification of MSCs injected into The osteochondral junction is the interface
infarcted rat hearts. For the treatment of articular between bone and cartilage, where the subchon-
cartilage defects, this implies, in theory, the risk dral bone form the layer of transition between the
of such MSC-mediated endochondral ossifica- two different histotypes [57]. Cartilage damage
tion to occur at least in some parts of the repair may lead to subchondral degeneration: in partic-
tissue, thus jeopardizing the formation of good-­ ular, certain defects, such as consequences of
quality tissue and the clinical outcome. osteochondritis dissecans (OCD), osteonecrosis,
Improvement in noninvasive imaging of the carti- and traumas, may involve primarily the subchon-
laginous repair tissue will help to detect with dral bone [58, 59].
high-resolution early signs of such unwanted Moreover, in the case of large cartilage lesions,
ossifications and to understand the real dimen- as well as untreated focal defects, the subchon-
sion of this problematic aspect. dral bone is often secondarily involved in the
Conversely, Wakitani et al. [56] demonstrated degenerative process of the articular surface.
the safeness of using BMSCs in cartilage repair Thus, the defect size can increase over time, and
in 41 patients followed up 5–137  months after concomitant changes can appear, such as osteo-
transplantation: neither tumors nor infection phytes and bone resorption [60–62].
were observed. The debate is still ongoing and The treatment of osteochondral defects is
warrants close scrutiny, since such stem cell ther- particularly challenging because of the involve-
apies are far from being accepted in the field of ment of two tissues (bone and cartilage) with a
clinical articular cartilage repair, nor has their different intrinsic regenerative potential.
long-term safety been convincingly proven. Traditional surgical techniques for such lesions
Moreover, reliable clinical data based on long-­ mainly concern an autograft or allograft implan-
term, randomized, double-blind, controlled, mul- tation of the entire osteochondral unit. Thanks
ticenter studies with systematic follow-up are to recent achievements in the field of tissue
largely lacking. Such information is needed, as it engineering, in the last years, new bioengi-
might determine the true value of MSC therapy neered scaffolds specific for these defects have
for articular cartilage defects and help to identify been developed, able to induce an in situ carti-
the best indications for it. This cell-based treat- lage regeneration.
ment for cartilage regeneration is still in its The implantation of biomaterials directly into
infancy, and many aspects remain to be clarified the lesion site aims at restoring a tissue as con-
and optimized. Among these, one of the most form as possible to the native hyaline cartilage,
clearly missing elements is the knowledge of the with physiological properties similar to those of
proper cell dosage to be administered. The dose-­ the entire osteochondral unit and durable over
response relationship of MSC transplantation for time, thus providing a valid therapeutic alterna-
clinical cartilage repair has not yet been estab- tive to the orthopedic surgeon.
44  Biological Treatment in Cartilage Injuries 605

44.4.1 Indications safe biochemical processes and adequate time

spans. Solid scaffolds have a substrate to which
• Grade III–IV chondral or osteochondral cells can adhere. Differently, gel scaffolds physi-
defects, symptomatic. cally entrap the cells. Many different scaffolds
• Etiology: Traumatic, degenerative, and osteo- have been used while trying to create new carti-
chondritis dissecans (OCD). lage tissue, from natural to synthetic, many dif-
• Defect size: Depending on the kind of scaffold ferent shapes and compositions.
applied. The most used synthetic materials are polylac-
• Age: Less than 60 years is recommended (this tides like polylactic acid (PLA) and polyglycolic
approach represents an evolution of bone mar- (PGA).
row stimulation, and, as for this latter tech- Mechanical properties and synthetic biomate-
nique, better results have been reported for rials degradation are more easily modified with
young patients, despite an established cutoff respect to natural fibers, but degradations of their
has not been defined yet). components can be harmful to the native tissue
• Body mass index (BMI): Less or equal to 30. and implanted cells.
Natural materials used to produce scaffolds
are agarose, alginate, hyaluronic acid, gel, and
44.4.2 Contraindications fibrin glue, all coming from collagen and acellu-
lar collagen matrix. Matrices that are commonly
• Medium or advanced osteoarthritis (OA). used in the clinical practice in Europe include
• Misalignment and ligamentous instability. collagen or hyaluronic acid.
The use of 3D scaffolds for cellular cultures in
Currently, different scaffolds used for osteo- open surgery allows a reduction in the time of the
chondral regeneration are commercialized for joint exposition because we can avoid the perios-
clinical application. teal patch and so the suture.
Moreover, in some scaffolds, arthroscopic
techniques for implantation have been
44.5 Matrix-Associated developed.
Chondrocyte Hyaluronan is an important component of
Transplantation (MACT) extracellular matrix [65]: it is a glycosaminogly-
can, a linear polymer made by a dimer that is
This procedure belongs to second-generation regularly repeated; it is a soluble molecule,
autologous chondrocyte implantation (ACI), and whose molecular weight varies from 4000 and
it is based on the use of temporary and biodegrad- 8000  Da; in water it forms a viscous solution.
able polymeric scaffolds as a growth site for via- This polysaccharide is not just a spacer; it has
ble cells in vitro; these cells are then implanted in many functions in determining cartilage structure
the site of the lesion. and functionality.
Chondrocytes kept in monolayer culture at Hyaluronic acid is important in maintaining
low density eventually change from a polygo- the structure of the tissue and to hydrate it, thanks
nal or round to a flattened, amoeboid-like to its hydrophilic properties; it can influence cel-
shape, and instead of cartilage collagen (type II lular movements regulating osmotic pressure.
collagen), they synthesize the genetically dif- It actively interacts with proteoglycans and
ferent type I collagen [63]; on the other side, it growth factors stimulating the production of
was demonstrated that the use of 3D scaffolds ECM and acts as a scavenger of free radicals.
favors the retainment of their original pheno- Furthermore, it was recently discovered that
type [64]. hyaluronic acid contains some receptors like
Some essential features of these scaffolds are CD-44, through which it can regulate cellular
biocompatibility and biodegradability through adhesion, growth, and differentiation.
606 E. Kon et al.

Considering all its properties, it seems the cytic phenotype even after a long period of
ideal candidate for tissue engineering in vitro expansion in monolayer culture [67].
procedures. Properties of HYAFF-11 to favor the growth
Unfortunately, its rapid water solubility and of human chondrocytes and maintain the original
the quick reabsorption make it not usable in puri- phenotype have been demonstrated in vitro, and
fied form, so it has to be processed in a different the efficacy of the cell-scaffold construct was
form. also proven by in vivo implantation in an animal
HYAFF is a scaffold derived from the total model.
esterification of sodium hyaluronate with differ- One of these studies has evaluated reparation
ent alcohol, and according to the esterification tissue in chicks: chondrocytes attached to the
percentage, we can obtain different polymers, support fibers tend to aggregate and produce
different in duration and consistency. those molecules typical of hyaline cartilage: col-
The most used is HYAFF-11, entirely based lagen type I and II and glycosaminoglycans.
on the benzylic ester of hyaluronic acid; it con- Another study based on Hyalograft C® trans-
sists of a network of 20-lm-thick fibers with plantation with human cells in athymic mice has
interstices of variable sizes and has been demon- documented the formation of a tissue similar to
strated to be an optimal physical support to allow hyaline cartilage: the implant was white, non-­
cell-cell contacts, cluster formation, and extracel- vascularized, and well attached to the articular
lular matrix deposition. It has a weight of 120 g/ surface. Histological examination showed cells
m2 and thickness of 2 mm. with round nuclei inside structures similar to
Degradation mechanism of these biomaterials lacunae and surrounded by abundant ECM whose
is very important; de-esterification in water causes composition was based on collagen and
the release of molecules that are not toxic [66]. glycosaminoglycans.
This tridimensional structure presents intersti- According to the good results, obtained
tial spaces of different dimensions that act as in  vitro and on animals, this technique seemed
physical support for cells, allowing contact promising, and study on humans started. After
among them, and cluster formation maintaining some positive results, HYAFF started to be used
phenotypical differentiation. for the treatment of symptomatic chondral
The cells harvested from the patient are lesions. Cells harvested from the patient are
expanded and then seeded onto the scaffold to expanded and then seeded on the HYAFF-11
create the tissue-engineered product Hyalograft scaffold to create Hyalograft C®.
C® (Fig. 44.1). Seeded on the scaffold, the cells At the beginning the patch was fixed at the site
are able to redifferentiate and retain a chondro- of the lesion with fibrin glue; later, it was seen
that thanks to hydrophilic properties of the
matrix, if the graft is well positioned, the tenso-­
active pression is enough to fix it.
The press-fit technique is enough because of
the shape and the properties of the graft. Another
advantage is that it can be inserted through an
arthroscopic procedure with less morbidity for
the patient, shorter surgical time, shorter stay in
the hospital, and fewer complications related to
open surgery.
Implantation arthroscopic technique was first
invented to treat localized lesions of the medial or
lateral femoral condyle. Nowadays it is used for
almost all the lesions of the femoral condyles,
Fig. 44.1  Hyalograft C® even if very big. Lesions of the patellar cartilage
44  Biological Treatment in Cartilage Injuries 607

and the tibial plate are an exception, and they Among the one-step techniques for cartilage
need open surgery. reconstruction, the use of bone marrow concen-
Sometimes, when the lesion is very big, we trate added to the scaffold instead of chondrocyte
can add fibrin glue in order to increase stability. has been introduced.
Medium-long-term results showed good Using a kit to concentrate bone marrow-­
results at 2-year follow-up and the maintenance derived cells in the operating room, collagen
of stable values at 7 years [68]. powder or hyaluronic acid membrane (as scaf-
This assumption is also reinforced by the fact folds for cell support), and platelet gel, a one-step
that second-look arthroscopy [69] and histologi- arthroscopic technique was developed by
cal [70] examination showed a normal appear- Giannini et al. [33]
ance of the newly formed cartilage in six and an The evaluation of 48 patients treated for talar
abnormal appearance in two patients. osteochondral lesions at 24 months of follow-up
In the past a study comparing microfractures documented a significant clinical improvement
and implant of autologous chondrocytes was per- and histologic and immunohistologic results
formed; it took into consideration 80 patients obtained confirmed the presence of new cartilagi-
[71] with defects grades III–IV on the femoral nous tissues with various degrees of tissue
condyle and the trochlea; these patients were remodeling toward hyaline cartilage. These data
admitted to the study and divided into two groups. suggest the one-step technique is an alternative
Both groups showed a significant improvement at for cartilage repair, permitting improved func-
5  years from surgery; however, the ACI group tional scores and overcoming the drawbacks of
showed greater improvements in the objective-­ previous techniques.
subjective scores of the International Knee Progress made in material science, cellular
Documentation Committee. biology, and nanotechnology allowed the realiza-
Even more interesting is the return to sports tion of TEC (tissue engineering constructs) for
activity; it was the same up to 2 years of follow-­up.
lesions repair. The ultimate goal is to obtain a
Later on, it remained stable in the ACI group, while complete integration of the TEC with the host tis-
it decreased in the microfractures group; this is a sue, up to the complete remodeling of the implan-
sign of the bigger reliability of the Hyalograft C®. tation site.
Musculoskeletal tissue, bone, and cartilage
are under extensive investigation in tissue engi-
44.6 New “One-Step” neering research. A number of biodegradable and
Regenerative Treatments bioresorbable materials, as well as scaffold
designs, have been experimentally and/or clini-
Recently, new solutions have been proposed in cally studied. Ideally, a scaffold should have the
order to overcome problems correlated to second-­ following characteristics such as:
generation ACI that were high costs and the two-­
step surgery, needed because of the cellular • Three-dimensional and highly porous with an
culture. interconnected pore network for cell growth
Experimental studies have demonstrated the and flow transport of nutrients and metabolic
growth and migration of chondrocytes coming waste.
from healthy cartilage of the ipsilateral knee of • Biocompatible and bioresorbable with a con-
the patient; these fragments are then put into a trollable degradation and resorption rate to
polymeric, tridimensional scaffold which is match cell/tissue growth in  vitro and/or
implanted at the site of the defect of articular in vivo.
cartilage. • Suitable surface chemistry for cell attachment,
Results demonstrate a redistribution of chon- proliferation, and differentiation and mechani-
drocytes inside the scaffold reproducing a cal properties to match those of the tissues at
hyaline-­like reparative tissue after 6 months [72]. the site of implantation.
608 E. Kon et al.

Lately, the awareness of the involvement of • Superficial (100% type I collagen): Has a smooth
the subchondral bone in many of these lesions surface to reproduce the articular surface.
resulted in the need to develop cell-free treatment • Intermediate (60% type I collagen and 40%
strategies focused on the entire osteochondral hydroxyapatite): Tidemark—Like a layer.
unit. Currently, heterogeneous scaffolds have • Lower (30% type I collagen and 70% hydroxy-
been proposed that combine distinct but inte- apatite): Reproducing the subchondral bone
grated layers corresponding to the cartilage and composition.
bone regions to regenerate both components of
the osteochondral unit to restore the articular sur- Promising results in terms of both cartilage
face [73]. and bone tissue formation have been published in
The “cell-free” osteochondral grafts have a preclinical study. Even if similar macroscopic,
been developed with the aim to give specific histological, and radiographic results are obtained
regenerative signals to mesenchymal cells com- implanting scaffold loaded with autologous chon-
ing from the bone marrow [74, 75]. drocytes or scaffold alone; given that, this scaf-
An ideal graft would be an off-the-shelf fold has been introduced into clinical practice as a
product from both a surgical and commercial cell-free approach, trying to take advantage from
standpoint, so many biomaterials have been pro- an in situ regeneration induced by stem cells com-
posed in the last years to induce cartilage ing from the surrounding bone marrow [77].
“regeneration” in situ, directly in the site of the The surgical technique needed to implant
lesion. MaioRegen® requires the following steps:
Among them MaioRegen® and, more recently,
Agili-C® have shown some of the most promising • Position: Supine position, tourniquet at the
results. proximal extremity of the lower leg.
• Access approach: Classical arthroscopic or
arthrotomic (medial or lateral) to expose
44.7 MaioRegen® lesions.
• Procedure: Identification of the lesion site and
MaioRegen® is a nanostructured biomimetic and confirmation of indications.
bioresorbable implant with a porous composite • Preparation of the defect with an adequate
structure, mimicking the whole osteochondral osteotome.
anatomy with three different layers [76] • Excision of subchondral sclerotic bone: 8 mm
(Fig. 44.2): depth.

Fig. 44.2 MaioRegen®

Chondral Layer
100% type I collagen

Tide-mark
60% collagen, 40% HA

Bone gradient
30% collagen, 70% HA
44  Biological Treatment in Cartilage Injuries 609

• Preparation of the scaffold based on the shape and 200 μm) required for vascular tissue ingrowth.
and size of the defect. These characteristics are thought to confer arago-
• Press-fit implantation, the addition of fibrin nite its osteoconductive ability and make it suit-
glue is recommended to improve the early sta- able for bone repair. The calcium carbonate
bility of the implant. structures are gradually resorbed and replaced by
• The continuous passive of motion before and functional bone tissue. Coral derivatives are com-
after tourniquet removal. monly used as a bone graft substitute and bone
void fillers.
It is important to have a well-prepared defect Agili-C™ is a porous scaffold designed for
area and stable vertical shoulders to implant scaf- the treatment of knee-joint surface lesions.
fold correctly. Agili-C™ consists of a porous, interconnected
Promising preliminary results of a pilot study calcium carbonate (aragonite) structure, derived
on 28 patients affected by chondral and osteo- from purified coral (Fig. 44.3).
chondral lesions have been recently reported. A The lower part of the implant is composed of
slower recovery was observed in older, less active inorganic aragonite, while a square grid pattern
patients who experienced adverse events or in of 2-mm deep-drilled channels are made in the
patellar lesions. However, at 2-year follow-up, top part, where HA is added (Fig. 44.4).
good results were reported in all patients with Histology performed by an independent labo-
both clinical and MRI evaluations, showing the ratory in a series of preclinical studies confirmed
potential of this osteochondral one-step proce- the regeneration of hyaline cartilage, as demon-
dure also for the treatment of complex salvage strated by the presence of collagen type II and
lesions [78]. aggrecan, and the lack of collagen type I in the
repaired tissue, alongside the reconstruction of
the subchondral bone (Fig. 44.5).
44.8 A
 gili-C™: A Novel Biphasic The basic scaffold consists of coralline arago-
Aragonite-Based Scaffold nite. Following a machining process, a square
grid pattern of 1- to 2-mm-deep-drilled channels
Agili-C™ is a coral-based scaffold; the coralline is made, in the chondral phase or the bone phase,
skeletal material is composed of calcium carbon- using Bungard CCD, a CNC drilling and routing
ate in the crystalline form of aragonite. machine, and an appropriate drill bit. This scaf-
Coral exoskeletons (aragonite) are a remarkably fold configuration is used and developed in the
similar biological material to human bone including shape of cylinders for the treatment of both chon-
its 3D structure and pore interconnections and crys-
talline form of calcium carbonate (CaCO3). These
characteristics are thought to confer its osteocon-
ductive ability and make it a suitable material for
bone repair. Corals are marine invertebrates from
the Anthozoa class that include over 7000 species
with a wide variety of skeletal topologies, different
morphologies, and crystalline structures. Corals
used for medical applications are limited to a select
number of species: Porites, Acropora, Lobophyllia,
Goniopora, Polyphyllia, and Pocillopora [79].
These biomaterials provide a three-­dimensional
(3D) structure with mechanical properties and
high interconnected macroporosity (between 100
Fig. 44.3  Porous structure of Agili-C™
610 E. Kon et al.

Fig. 44.4 Different
Cartilage Phase: Native cartilage
layers of Agili-C™
Modified Aragonite + ingrowth from
Hyaluronic Acid (HA) periphery

Cartilage

Bone

Bone marrow
Bone Phase:
cell adhesion,
Aragonite
differentiation &
proliferation

Fig. 44.5  Hystological demonstration of the cartilage regeneration process

dral and osteochondral defects in humans. It is spinal anesthesia. A pneumatic tourniquet is

10  mm high with a variable diameter available, applied at the proximal level of the thigh in
from 7.5 to 20 mm according to the lesion size. order to block the vascular supply to the lower
Recently, a tapered version of the implants, limb for a limited time span. According to the
with an angle of 2° from the longitudinal axis, size and the location of the lesion, a mini-
has been designed to improve the press-fit arthrotomy is performed using medial or lateral
implantation. After extensive purification pro- parapatellar approach in order to expose the
cesses, needed to treat and remove trapped par- lesions. The medial parapatellar incision is pre-
ticles, debris and organic remnants, the implants ferred for lesions of the MFC and the patellar
are sterilized by 25  kGy gamma radiation. cartilage, while the lateral parapatellar incision
Further modifications leads to different proto- is preferred for the lesions of the lateral
types. The implants are then impregnated with compartment.
HA homogenously in the chondral phase of the It is fundamental to have a complete vision of
implant. the lesion of the defects are exposed.
The surgical technique is carried out with the The site of the lesion is then prepared using a
patient lying in the supine position in general or proprietary surgical toolset.
44  Biological Treatment in Cartilage Injuries 611

Fig. 44.6  Surgical implant of Agili-C™ scaffold

A perpendicular aligner is positioned in the The stability of the implant is visually tested
center of the lesion upon verification that it is by cyclic bending of the knee while the graft is
perpendicular to the articular surface. The aligner under direct vision, both before and after tourni-
is used to place a K-wire, which is used to cor- quet removal.
rectly position a drill sleeve where a motorized Following promising results obtained in ani-
drill is inserted to prepare the defect up to the mal models [80], recently, clinical studies with
desired depth. A reamer is then inserted to ensure Agili-C™ have been developed. Significant
the correct depth is obtained, and a shaper is improvements at 12 months follow-up were doc-
introduced to finalize the lesion with the correct umented in all clinical scores considered after
wall inclination. the implantation of the aragonite-based scaffold
A lodge 12-mm deep with perpendicular [81]. Moreover, MRI findings revealed graft
shoulders is created to allow press-fit fixation of integration with good bone and cartilage
the implant, which is 10 mm long (Fig. 44.6). formation.
The shaper and the K-wire are removed; the
hole is appropriately cleaned with saline solution
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2001;57(3):394–403. osteochondral lesions: technique note and an early sta-
67. Marcacci M, Kon E, Zaffagnini S, Filardo G,
bility pilot clinical trial. Injury. 2010;41(7):693–701.
Delcogliano M, Neri MP, Iacono F, Hollander 77. Kon E, Delcogliano M, Filardo G, et  al. Orderly

AP. Arthroscopic second generation autologous chon- osteochondral regeneration in a sheep model using
drocyte implantation. Knee Surg Sports Traumatol a novel nano-composite multilayered biomaterial. J
Arthrosc. 2007;15(5):610–9. Orthop Res. 2010;28(1):116–24.
68. Filardo G, Kon E, Di Martino A, Iacono F, Marcacci 78. Kon E, Delcogliano M, Filardo G, Busacca M, Di
M. Arthroscopic second-generation autologous chon- Martino A, Marcacci M.  Novel nano-composite
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study. Am J Sports Med. 2011;39(10):2153–60. eration a pilot clinical trial. Am J Sports Med.
69. Podskubka A, Povysil C, Kubes R, Sprindrich J,
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Sedlacek R. Treatment of deep cartilage defects of the 79. Demers C, Hamdy C, Corsi K, Chellat F, Tabrizian
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 Part IX
Major Events in Sports
 Olympic Games: Special
Considerations—Medical Care
45
for Olympians

David J. Pohl, Garrett Schwartzman,
Mark R. Hutchinson, William Moreau, Roald Bahr,
Robert McCormack, Juan-Manuel Alonzo,
Andre Pedrenelli, and Roberto Nahon

45.1 Introduction Olympic Games and Olympic-level athletes.

Specific anatomic injuries as well as sports-
The purpose of this chapter is to present and specific injuries have been covered elsewhere
review the unique challenges that the sports in the text. Several factors make the Olympic
medicine clinician may face regarding the Games a unique event regarding sports medi-
cine care. It is not only one of the largest mass
D. J. Pohl · G. Schwartzman sporting events in the world; it often represents
University of Illinois at Chicago, Chicago, IL, USA the penultimate competition of an athlete’s
M. R. Hutchinson (*) career. Unique challenges include acclimatiza-
University of Illinois at Chicago, Chicago, IL, USA tion to a new country, travel, geography, foods,
United States Olympic Committee, and language. The athlete not only has pressure
Colorado Springs, CO, USA from their coach and the fans of that particular
e-mail: [email protected] sport but also a global audience and the pres-
W. Moreau sures coming from stress related to represent-
United States Olympic Committee, ing their country. From the medical planning
Colorado Springs, CO, USA and organization perspective, the Olympic
e-mail: [email protected]
Games is a multisport, international, and mass
R. Bahr sporting event. For the host country, the orga-
Department of Sports Medicine, Olympiatoppen,
Norwegian Olympic Training Center, Oslo, Norway nization must provide optimal communication,
e-mail: [email protected] transportation, and facilities to care for thou-
R. McCormack sands of elite-level athletes. For national orga-
Canadian Olympic Team, Toronto, ON, Canada nizations, preparations can begin years in
J.-M. Alonzo advance of the games and include planning
Qatar Olympic Team, Doha, Qatar how dependent they wish to be on the host
Past Medical Team for Spanish Olympic and Track country’s medical plan; which facilities may be
and Field Teams, Barcelona, Spain used in case of emergencies; what equipment,
e-mail: [email protected] staff, and medications will be necessary to
A. Pedrenelli retain independent care of their own athletes;
Team Physician Brazilian Olympic Team and and arranging local licensure, contacts, and
National Men’s Soccer Team, Rio de Janeiro, Brazil
training facilities for its athletes throughout the
R. Nahon course of competition.
Brazilian Olympic Medical Services,
Rio de Janeiro, Brazil

© ISAKOS 2019 617

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_45
618 D. J. Pohl et al.

45.2 Brief History Chamonix, France. During those Games 258 ath-
letes (245 men and 13 women) from 16 nations
The modern Olympic Games began in Athens, competed in 16 events across 5 sports that
Greece, in 1896, and encompassed 241 male ath- included bobsleigh, curling, ice hockey, skating,
letes competing for 14 countries across 43 events and Nordic skiing [3]. The Winter Olympics have
in 9 sports [1]. These first sports included athlet- grown in size and scope along with their Summer
ics, cycling, fencing, gymnastics, shooting, counterparts. The 2018 Winter Games in
swimming, tennis, weightlifting, and wrestling. Pyeongchang, South Korea, featured 2922 ath-
The Summer Olympics have been held in 18 dif- letes (1680 men and 1242 women) competing for
ferent countries and grown significantly since 92 nations in 102 events in 15 sports [4]
that time. During the 2016 Summer Olympic (Table 45.1).
Games, hosted in Rio de Janeiro, Brazil, over Until 1992 the Summer and Winter Olympic
11,238 athletes (6179 men and 5059 women) Games were held in the same years, after which
competed for 207 nations in 306 events in 28 the Winter Games were switched to the even
sports [2] (Fig 45.1). years between Summer Olympics to help with
While initially part of the Summer Olympics, planning the two massive events. The International
snow and ice sports split into a different Olympic Olympic Committee (IOC) is the organization
Games, forming the Olympic Winter Games. The responsible for planning and putting on the
first Winter Olympic Games were held in 1924 in Olympic Games. Established in 1894, the IOC is

Fig. 45.1 Athletes 12000

participating in Olympic
Games by year
10000

8000

6000

4000

2000

0
1890 1910 1930 1950 1970 1990 2010

Summer Athletes Winter Athletes

Table 45.1  2016–2018 Olympic sports

2016 Summer sports 2018 Winter sports
Aquatics Field hockey Shooting Alpine skiing Luge
Archery Football Table tennis Biathlon Nordic combined
Athletics Golf Taekwondo Bobsleigh Short track speed Skating
Badminton Gymnastics Tennis Cross-country skiing
Basketball Handball Triathlon Curling Skeleton
Boxing Judo Volleyball Figure skating Ski jumping
Canoeing Modern pentathlon Weightlifting Freestyle skiing Snowboarding
Cycling Rowing Wrestling Ice hockey Speed skating
Equestrian Rugby sevens
Fencing Sailing
45  Olympic Games: Special Considerations—Medical Care for Olympians 619

an international, not-for-profit organization letes, the Medical and Scientific Committee is

who’s stated goal is “to ensures the regular cele- intimately involved in detecting and preventing
bration of the Olympic Games, supports all affili- doping. The IOC has established a zero-tolerance
ated member organizations[sic] of the Olympic policy toward doping to combat cheating and
Movement and strongly encourages, by appropri- works in conjunction with the World Anti-Doping
ate means, the promotion of the Olympic values” Agency (WADA) to monitor and detect athletes
[5]. As of 2018 the IOC consisted of 100 active in violation of this policy. Further discussion of
members, 41 honorary (or past) members, and 1 WADA and doping is presented later in this
honorary president, all of who’s role is to repre- chapter.
sent and promote the interests of the IOC and of
the Olympic Movement.
Several of these members serve as chairper- 45.3 P
 athways to Serve at
sons of one of the 27 IOC commissions. One such Olympic Games
group, the Medical and Scientific Commission, is
tasked with providing “a guiding reference for all There are numerous pathways to become part of
other sports organizations on matters relating to the healthcare team at the Olympic Games, and
the protection of the health of athletes” [6]. To those paths vary from country to country and
this end, the Medical and Scientific Commission from games to games. The host country carries
has worked to increase research on, and dis- the responsibility of providing services to all resi-
semination of, relevant educational topics. Since dents of the Olympic Village, usually through
2011 the IOC has sponsored triennial meetings to establishment of a polyclinic. Each national orga-
discuss and spread information on injury preven- nization will also decide to what extent to pro-
tion. The IOC World Conference on Prevention vide their own medical care to their athletes and
of Injury and Illness in Sport focuses on the how much to rely on the host country’s services.
clinical aspects of sports and exercise medicine. Specific application processes will vary for each
These goals have also led the publication of 25 national organization, and those wishing to serve
IOC consensus statements since 2004. Topics should contact their national organization or the
are wide-ranging and have included Sudden host country’s organization committee.
Cardiovascular Death in Sport (2004), Sexual
Harassment and Abuse in Sport (2007), Asthma
in Elite Athletes (2008), Sports Nutrition (2010), 45.4 Host Country/City
Concussion in Sport (2013), Relative Energy Organizing Committee
Deficiency in Sport (2015), Sex Reassignment
and Hyperandrogenism (2015), and Dietary Planning for medical care during the Olympic
Supplements (2017). Games begins years before the opening ceremo-
Similarly, the Medical and Scientific nies. Facilities, transportation, and supplies must
Commission has published several educational be obtained to account for any potential injury or
tools available for athletes, coaches, and physi- illness that an athlete may suffer. Additionally,
cians. These tools range from articles and bro- organizers must also plan for illnesses and inju-
chures to videos to the “Get Set—Train Smarter” ries with coaches, national delegates, officials,
smartphone/tablet application, and topics include members of the media, spectators, and members
injury prevention, harassment and abuse in sport, of the Olympic workforce.
female athlete health, safeguarding athletes, and As part of a larger network of medical care,
healthy body image. As of this book’s publishing, the host country establishes one or more poly-
these resources are available on the IOC’s website clinics for athletes and their support staff. These
at https://www.olympic.org/educational-tools. centers are typically capable of managing most
As part of their commitment to promotion of medical complaints and, as the name implies,
the health of athletes and protection of clean ath- offer a variety of medical specialties including
620 D. J. Pohl et al.

primary care, sports medicine, physiotherapy, injuries or illnesses suffered by their constituent
chiropractic, podiatry, optometry, ophthalmol- athletes on standardized report forms. The same
ogy, and dentistry. There are typically additional information is also obtained from the polyclinic
specialists on call, including orthopedic surgery, and other medical facilities associated with the
cardiology, otolaryngology, obstetrics and gyne- Olympic Games and cross-referenced.
cology, dermatology, neurology, psychiatry, and The total incidence of injury in the Rio Games
gastroenterology. There is a pharmacy, labora- (8%) was the lowest reported since implementa-
tory, and advanced radiology suite including tion of the IOC surveillance system [8].
X-ray, ultrasound, and MRI scanners. The poly- Previously, the reported injury rates had been
clinics are aimed at making an accurate diagnosis above 10%, specifically 10% in Beijing 2008 [9],
quickly to allow for competent treatment of the 11% in Vancouver 2010 [10], 11% in London
athletes so that they may return to their competi- 2012 [11], and 12% in Sochi 2014 [12]. Specific
tion as soon and as safely as possible [7]. injuries, sport-specific injury rates, and severity
The polyclinics are typically located in the of injuries vary from year to year and, while
Olympic Villages where a majority of the ath- beyond the scope of this chapter, are reported and
letes stay and are staffed by a variety of expert, discussed after each Olympic Games [8–12].
yet volunteer, medical professionals including Services at the polyclinic are provided free of
physicians, nurses, physiotherapists, masseurs, charge to athletes and members of their national
technicians, and administrative staff. The poly- delegations, and many individuals seek elective
clinic runs in conjunction with the Olympic care during the Games from the expert staff and
Village: opening several days before the start utilizing the advanced healthcare technology
of the Olympic Games, operating 24 h per day, available to them [13]. For scale, the Rio 2016
and finally shutting their doors after the closing polyclinic was staffed by 180 medical profes-
ceremony. sional who covered 3500 square meters and 160
For the first time, the polyclinic at Rio 2016 rooms [7]. In total, 1015 radiologic examinations
also utilized an electronic medical record (EMR) were performed, including 607 MRI scans
during the treatment of their patients [8]. This (59.8% of total studies) [14]. The previous record
allowed for better communication among the of 650 patient consultations in 1 day during the
treatment team and also assisted with injury and London 2012 Olympic Games was easily sur-
illness data collection. Since 2008 the IOC has passed by the Rio 2016 polyclinic when it treated
sought to establish an injury and illness surveil- 900 patients in 1 day [15].
lance system to better track, study, and hopefully But polyclinics are just one part of the medical
prevent the various maladies afflicting the top ath- care offered at the Olympic Games. During the
letes in the world. The IOC used the 2008 Beijing 2016 Rio Olympic Games, over 3000 volunteers
Summer Olympics as a model. The IOC injury were utilized across all aspects of the medical
surveillance system standardized injury defini- care team [16]. The importance of early planning
tion, as well as methods and forms for reporting and effective communication among the numer-
such injuries. This system ensured the compa- ous groups and agencies involved has been well
rability of results and thereby provided impor- established [17]. First aid and appropriate medi-
tant epidemiological information, directions for cal care must be provided at the various Olympic
injury prevention, and the ability to monitor long- sites, including the training and sporting venues
term trends in the frequency and circumstances and any affiliated hotels. Specific levels of ser-
of injury [9]. This system was then expanded vices provided will vary by year and location.
in 2010 for the Vancouver Winter Olympics to Most medical needs are addressed within the
include illnesses [10]. This injury and illness sur- Olympic system and rarely result in transfer to
veillance system asks the medical teams of each outside hospitals [17]. However, consideration
National Olympic Committee (NOC) to report should be made for any medical need, from sim-
the daily occurrence (or nonoccurrence) of any ple first aid up to and including mass casualty
45  Olympic Games: Special Considerations—Medical Care for Olympians 621

incidents and emergency transfers. Organizers define expected roles and responsibilities of
should establish individualized emergency plans healthcare providers, design a health support sys-
for each specific venue based on anticipated staff tem for athletes long before the games that can
and supplies on site and proximity and transport optimize their health and performance, provide
to other resources. Organizers should therefore access to necessary therapeutic and diagnostic
coordinate with local hospitals, off-site medical equipment and treatments prior to and during the
facilities, ambulance, and emergency responders Games, and establish a chain of command that
to facilitate transfers, referrals, or other necessary optimizes communication between athletes,
services. coaches, healthcare providers, and administra-
tors. Establishing a unified system of medical
record keeping (ideally via an electronic medical
45.5 Caring for the National Team record) is essential for continuity of care, com-
munication between healthcare professionals,
In addition to providing local service during the and can be used for medical research and future
Olympic Games, the International Olympic optimization of performance.
Committee empowers each National Olympic For Team USA, the healthcare team at the
Committee to either take advantage of host coun- Olympic Games is brought together and led by a
try services or establish and develop their own chief medical officer who is formally employed
healthcare team or, more commonly, a blend of by the United States Olympic Committee and
their own team balanced with host equipment and head team physician, who is a volunteer phy-
providers. All providers are subject to the rules sician, with a long history expertise in sports
and licensure regulation of the host country medicine and established service to elite
which are usually liberalized for visiting physi- Olympic-level athletes. They, with other profes-
cians and healthcare providers during the sional staff, begin years in advance of the games
Olympic Games and restricted to the care of the to develop programming to preserve athletes’
team’s athletes and entourage. In general, you health for national-level athletes and optimiz-
have to get a temporary medical license within ing collaborative sports medicine programming
the host country to serve as a medical provider. with individual national sports governing bodies.
Approaches to creating a healthcare team vary It is their responsibility to create plans for medi-
from country to country based on a myriad of fac- cal emergency responses and review of athletes’
tors ranging from size and specific needs of del- periodic health evaluations, staff education (e.g.,
egation, past history, and organizational history anti-­doping and safe sport), staff selection, back-
of the individual national governing body, with ground checks, medical equipment, and medica-
occasional political influence. Fundamentally, tion requirements for their team at the Games.
the core goals and missions are the same regard- Team USA has several national training sites
less structure and include fielding a healthy team, where national-level athletes can receive treat-
safely optimizing athletic performance, and effi- ment, become educated about their health, and
cient and effective response to injury and illness. optimize high performance outcomes throughout
Another key factor in the success of a healthcare the Olympic quadrennium. The actual medical
team is their ability to work together across spe- team at an Olympic Games is a blend of USOC
cialties and skill sets with the singular focus on professionals, volunteer healthcare providers, and
athlete wellness and performance. nominated national governing body healthcare
Ideally organizational planning to address the providers who are credentialed with approval
core goals and missions begins years before the of the United States Olympic Committee.
Olympic Games and includes a national report- Regarding professional qualifications, the sports
ing structure that optimizes communication medicine team for Team USA at the Olympic
between healthcare professionals, athletes, and Games includes primary care physicians, ortho-
administrative leadership. Such structure can pedic surgeons, chiropractic physicians, physical
622 D. J. Pohl et al.

therapists, athletic trainers, massage therapists, Canada. It consists of a validated, OSCE-based

as well as nutritionists, exercise physiologists, examination. There are similar qualifications
and sports psychologists. The USOC leadership required for each of the other expert provider
strives to create a positive athlete-­centric envi- groups including the Diploma in Sports
ronment within the collaborative multispecialty Physiotherapy, certification by the Canadian
healthcare team that focuses on the preservation Sports Massage Therapy Association, Fellowship
of athlete health while supporting high perfor- of the Royal College Chiropractic Sports
mance outcomes. Sciences, etc. Canada brings a large team of
For Team Canada the organization is similar, health professionals to the games. This reflects
with a chief medical officer who works with a the fact that athletes have prioritized the health-
head physician and a head therapist. As noted care team to optimize their performance (rated
above planning for the games starts years in most important group after coaches). The larger
advance, and the medical team leads will perform sports will nominate their own practitioners, and
site visits to determine the needs and specific the Canadian Olympic Committee tries to ensure
challenges for the Games. Along with the continuity of care as much as possible (within the
National Sports Organizations, strategies are constraints of limited accreditation). There is also
developed to prepare the teams for optimal per- a small “core” team that supports smaller sports
formance at the Games. These plans need to and rounds out the skill set of the overall Canadian
include management of a variety of potential Health Services Team.
stressors including heat, nutrition, local health The Olympic Games present special chal-
risks, travel fatigue, and jet lag. Experts are lenges, and it is not always the best athletes that
engaged to help develop specific protocols, so wins, but the one that is best prepared to handle
recommendations can be made to the athletes, the Olympic environment. To help our health
coaches, and their support team. team prepare for this unique, high-pressure envi-
Between games, the athlete’s health is man- ronment, we organize workshops and team prep-
aged directly by the national sports organization aration seminars in the lead up to the Games. At
or through regional Canadian Sports Institutes. these sessions we not only table top scenarios but
Our goal is to have an integrated support team for also stress the importance of communication and
each sport that includes physicians, therapists, value/importance of working as one Canadian
strength and conditioning, sports scientists, nutri- team at the games. Post Games debriefs are also
tionists, and sports psychologists. This group carried out, as we constantly strive to improve
(integrated support team) is responsible for opti- our healthcare delivery and plan for the next
mization of athlete health. This includes perform- quadrennial.
ing an annual health examination, anti-doping For Team Norway, Olympiatoppen, the
education (including medication and supplement national training site, serves as the hub for all
reviews), and making sure the athletes have an athlete support, including healthcare. Although
optimized dental care, appropriate physiologic preparations for each Games are intensified
monitoring, vaccinations, baseline concussions toward the end of each Olympic cycle, the goal is
testing (high-risk sports), cardiac screening, etc. to ensure that there is continuous, optimal medi-
The goal is to not only care for injuries and ill- cal care during the 4-year period. Olympiatoppen
nesses that present but to also monitor the ath- is set up with a sports medicine department with
letes, to ensure optimal health. full- or part-time doctors and physical therapists
All physicians working with the Canadian specialized in sports medicine, orthopedics, reha-
national teams are required to hold the Diploma bilitation, psychiatry, and allergy/asthma, serv-
in Sport Medicine. The Canadian Academy of ing all types of national team athletes, senior or
Sports and Exercise Medicine developed this junior, as well as students at elite sports schools.
“certificate of qualification,” in cooperation with Day-to-day care is also provided by the medical
the Royal College of Physicians and Surgeons of teams of each national federation, in close col-
45  Olympic Games: Special Considerations—Medical Care for Olympians 623

laboration with the Olympiatoppen team. Specific sport, where the COB MD is able to optimize the
pre-Olympic preparations begin with the appoint- use and avoid waste of financial and human
ment of a chief medical officer and chief physical resources. A preselection of professionals that
therapist 2–3 years before each Olympic Games would be responsible for each sport allows the
and the formation of a large medical team con- possibility to enhance knowledge because of
sisting of all Olympiatoppen and national federa- interactions with original team staff, such as phy-
tion physicians and physical therapists engaged sicians, physiotherapists, psychologists, and
in the care of candidate athletes and their teams. coaches, making work with athletes easier and
Except for a few smaller federations with less enhancing doctor-patient relation. Furthermore,
resources, the medical teams are under contract. this improves knowledge in sports that Brazil is
At the same time, candidate athletes are offered competing in for the first time, such as in Rio the
an extensive screening examination organized by sports of badminton, golf, field hockey, and
Olympiatoppen to establish their health status and rugby, representing a total of 46 athletes. For the
develop a specific plan of preventive initiatives. Rio Games, this planning allowed thorough
The screening examination is thought to repre- assessment and planning for the largest Olympic
sent a key event, establishing a close relationship Team Brazil has ever fielded, indeed, larger than
between the athlete and his/her medical team. any other sports event. The COB supplied and
This is also the starting point for weekly, continu- staffed all official athletes in the village as well as
ous health monitoring using a smartphone app two exclusive training centers for COB athletes,
as a communication and surveillance tool for the covering over 1000 people, 465 of these being
athlete and his/her medical team. In Norway, the athletes, and 342 events, considering official
focus is less on the selection of the smaller medi- training sessions and competitions.
cal team going to the Olympic Games to provide Assessments were divided into two catego-
on-site care and more on the large team working ries: disease (26% of total assessments) and
between Games ensuring that athletes are healthy orthopedic and trauma (74% of total assess-
on the night of the opening ceremony. ments). The most common complaint for dis-
For Team Brazil, the planning of the medical eases was upper airway infection, comprising of
department of the Brazilian delegation, known 25% of complaints, and diarrhea, 7% of com-
in Brazil as Team Brazil, begins long before plaints. Among orthopedic cases, the main diag-
the Olympic year. Besides all knowledge accu- nosis was muscle soreness, comprising of 37% of
mulated in the history of the Brazilian Olympic assessments, followed by back pain with 11% of
Committee (COB) in South American, Pan-­ complaints. Several key lessons were learned in
American, and Olympic (summer and winter) medical team development for the games but par-
games, there is an effort to remodel all medical ticularly from the Rio Games. One that stands out
services during the 4-year period that preceded is the importance of previous integration with
the Games, culminating in the available ser- each sport and its multidisciplinary teams. A leg-
vice not only to athletes but also to all of those acy outcome of the Rio Games was the inaugura-
in Team Brazil (coach, technical commission, tion of the Olympic Laboratory of Brazil, where
and staff). Two main principles are used for the sports teams have direct access to lab and perfor-
medical department for the Games. First is the mance evaluations, making possible to assess
highest number of follow-ups possible of ath- health in a more individualized way related to
letes, not only during missions but for the whole high performance.
period. The second principle was to standardize For Team Qatar, the healthcare team is
assessment and team training in sports events appointed by the Qatar Olympic Committee
that preceded the Games, including briefing and among health practitioners working at Aspetar
debriefing for the events. Hospital (the national sports medicine hospital),
The entire process of planning the medical usually by choosing those professionals with
team is a result of building a risk matrix for each larger experience at previous Olympic Games.
624 D. J. Pohl et al.

The chief medical officers (CMOs) who were tions, provision of medications and medical
sports medicine physicians formally employed equipment, as well as getting the necessary permit
by Aspetar usually are appointed some months in for importing all equipment and medications. At
advance. The Qatar CMOs put together medical the Rio Olympic Games, the Spanish medical
teams of sports physicians, sports physiothera- team included 25–30 sports health practitioners to
pists, and massage therapists working with care for its Olympic team of 300–400 athletes and
national federations qualified to Olympics. The fulfilled its goal of being internally well-coordi-
Qatar CMOs were responsible to assist medical nated and communicated assuring optimized
team members to get adequate licensing and health of its athletes to provide a foundation that
accreditations, provision of medications and they could excel in performance.
medical equipment, as well as getting the neces-
sary permit for importing all equipment and med-
ication. The vision of the Qatar medical team has 45.6 Specific Lessons Learned
been to create a focused group of sports health
practitioners with good internal coordination and Each Olympic Games is a unique experience that
communication to deal with a small Olympic offers various learning points for future events.
team of 30–40 athletes. Multiple variables affect an Olympic Games.
For Team Spain, the chief medical officer is Some are more obvious, such as the host city and
appointed more than 1 year in advance by the current world events; but others are less apparent,
Spanish Olympic Committee among the members such as the climate and athlete security. By
of its Medical and Scientific Commission. The reflecting on, and learning from, previous Games’
CMO is a sport physician, orthopedic surgeon, or shortcomings, future competitions can continue
medical doctor with extended experience related to produce outstanding events.
to the Olympic Games, management of health for The first major event that provided serious les-
elite athletes, as well as appropriate language sons to future Olympic Games occurred during
skills. The Spanish CMO assembles a medical the Munich 1972 Games. On the morning of
team of sports physicians, sports physiotherapists, September 5, 1972, 8 Palestinian terrorists took
and other health allied professionals that are espe- 11 Israeli Olympic athletes and coaches hostage.
cially knowledgeable and skilled within their rel- The attack eventually ended in the death of all 11
evant national federations to accompany their Israeli Olympic athletes and 5 of the terrorists.
individual sports teams. These health profession- The security at these Games was intentionally
als know their athletes very well and take care of meant to be out of sight as a “care-free” game
their athletes’ health during the competitive and [18]. Security personnel were primarily equipped
training seasons prior to and during the Olympic to handle unarmed conflicts and not large-scale
Games. Additionally, some sports physicians and terrorist attacks. What evolved out of these events
sports physiotherapists are usually appointed to was a change in tactics into a noticeable security
support athletes from individual team sports that presence at the Olympic Games. It has now
do not meet the Olympic quota to bring health become standard protocol to make well-armed
team accompanying persons. The Spanish CMO security personnel visible to all who attend the
traditionally organizes informative workshops Games. There are also demonstrations and
and coordination meetings during the mission numerous sweeps of the venues prior to events
preparation to assure all medical team members occurring to ensure the safety of the athletes and
are aware of important logistic aspects (such spectators [18, 19]. This single event at the
required vaccinations, jet-­lag preparations, accli- Munich 1972 Games may have had the most pro-
matization camps, etc.) and to review communi- found and lasting impact on all future Olympic
cation pathways and guidelines. The Spanish Games.
CMO is responsible for assisting medical team With the continued global spread of the Games,
members to get adequate licensing and accredita- and more countries participating and hosting, new
45  Olympic Games: Special Considerations—Medical Care for Olympians 625

challenges have arisen with various Games [20– rowing and sailing. An estimated 1400 athletes
23]. An example of this is the air or water pollution came in direct contact with the contaminated
at various host cities, with the 2008 Beijing and water due to the nature of their sporting events
2016 Rio Games being prime examples. Prior to, [8]. The main issue with Rio was the failure to
and during, the Beijing Games, one of the major handle waste effectively, as most sewage in the
concerns was the air quality and pollution that ath- city was not treated. The same Associated Press
letes would be facing. Beijing has been consistently report found dangerously high viral loads
ranked as one of the cities with the worst air quality throughout the city just days before the Olympic
in the world. A number of factors contribute to this, Games began [28]. Despite efforts by the city to
including industrialization, climate, as well as improve water quality, viral and bacterial loads
geography (the mountains around Beijing help to were similar during the Games as they had been
trap the already poor air in the valley) [24]. Prior to at previous testing times. This underlines the dif-
the Olympics, organizers took numerous steps in ficulty of solving the problem. Despite the con-
order to attempt to alleviate the dense pollution, cern prior to the games, there were only a minimal
including closing factories and restricting driving. number of athletes who became sick from the
However, studies conducted during the 2008 water [29]. Given the persistent poor quality of
Games suggested that the particulate matter in the the water, these low infection rates are likely
air was still “2.9, 3.5, and 1.9 times higher than more due to awareness and preventative mea-
those in Atlanta, Sydney, and Athens” [24–26]. sures taken by individual athletes and teams than
Double the amount of pollutants in the air can have the attempted cleanup by the host country. In the
profound effects on the respiratory system. end, whether the issue is air or water pollution,
Research has shown that this amount of particulate the IOC and individual organizing committees
matter in the airways can lead to substantial inflam- must be aware of these specific challenges that
mation and smooth muscle dysfunction. Given the face a possible host city and work to correct or
extremely strenuous nature of most Olympic reduce the potential exposure to ensure the safety
events, this does not provide an ideal environment and optimal performance of the athletes.
for athletes to perform at their optimal levels [27]. Additionally, team doctor must also be aware of
Although very few negative effects were reported the potential threats from environmental pollu-
due to the poor air quality in Beijing, athletes tion and may wish to take their own measures to
should still be aware of the potential effects of pol- reduce their athletes’ exposure. In the above
lution and take appropriate steps to protect them- examples, this could include bringing bottled
selves in future Games. The steps taken by Beijing water or respirator masks for their contingents.
to decrease air pollution did have a lasting effect on Finally, given the mass numbers of people and
the host country itself. Samples taken from indi- athletes crowding into a city during the games, it
viduals following the Beijing Games continued to is inevitable that various communicable diseases
show lower levels of inflammatory markers in the should be a worry of IOC organizers and team
airways than prior to the Olympic Games [27]. physicians. The London 2012 and Rio 2016
The 2016 Rio Games presented another pollu- Games gave Olympic physicians helpful yet
tion challenge for the International Olympic hard-earned lessons to ensure that athletes stay
Committee, water pollution. The poor water healthy and are able to compete at their optimal
quality was highly publicized prior to the Rio levels. According to data collected by the IOC
games. An article published prior to the Games Injury and Illness Surveillance System, the inci-
stated that the athletes “will be swimming and dence of illness during the Rio Games (5%) was
boating in waters so contaminated with human the lowest reported since illnesses began being
faeces that they risk becoming violently ill and recorded in 2010 [8]. London 2012 and Vancouver
unable to compete” [28]. There were multiple 2010 each showed a 7% illness rate [10, 11],
reports of athletes becoming sick prior to the while Sochi 2014 reported an 8% illness rate
Games during Olympic test events, including [12]. Respiratory and gastrointestinal diseases
626 D. J. Pohl et al.

account for a majority (68–75%) of the reported Doping Agency (WADA) was not established
illnesses [8, 12, 17]. The ability to identify the until 1999 [34]. The organization’s mission is “to
most common illnesses and possible causes can lead a collaborative worldwide movement for
help keep athletes at their optimal levels in futuredoping free sport.” The organization publishes a
Games. code that 660 international sports organizations
Given the diversity of host cities around the and government bodies must adhere to when
world, it is necessary to consider the variety of competing in sanctioned sporting events. The
local infections that may not affect athletes while code provides a coordinated approach to anti-­
in their home countries. A unique infectious doping strategies and research activities for the
aspect of the Rio Games that required physician participating organizations [35].
awareness was the Zika virus outbreak. With the For the 2018 PyeongChang Games, the entire
prevalent mosquito as a vector for human trans- Russian Olympic Committee was suspended due
mission, the cases of Zika infection increased to evidence of state-sponsored doping, cover-up,
prior to the games [30]. Research into the virus and manipulation extending back to the 2014
found that it caused minimal affects in the Sochi Games. With this renewed emphasis placed
infected individual, at the most a severe upper on catching and example of punishing cheaters, it
respiratory infection, but the real concern was the is even more important for physicians to be aware
devastating birth defects, especially microceph- of, and compliant with, the rules of WADA. The
aly, found in newborns of infected mothers. This list of banned substances and methods is easily
caused grave concern among many athletes and obtainable from the WADA website as a down-
spectators, especially due to the childbearing age loadable file. An example is shown below in
of many Olympians. The world community took Fig.  45.2. It is important to note that there are
extensive action and was able to learn about the unique substances banned for each sport, as well
virus prior to the games. This information helped as for inside and outside of competition season.
with prevention techniques, especially encourag- One specific example is the prohibition of beta
ing anti-mosquito and safer sex precautions [31, blockers in shooting sports, as they help to slow
32]. As a result, there was not an increase in casesheart rate and steady the hand while shooting.
during the Games. Rio 2016 helps demonstrate WADA does offer exemptions for certain
how local disease or infections must be studied medications based on athlete medical conditions.
ahead of the Games and thus may be prevented in This is called a Therapeutic Use Exemption
the future. Team physicians should also consider (TUE) and must be applied for by the medical
specific precautions for their athletes and delega- team. The TUE is narrow and specific in scope,
tions based on the potential infections and vec- and a documented medical condition must be
tors they may encounter. With the mosquito-borne present prior to any exemption being granted.
Zika virus, physicians employed mosquito nets There are specific sets of criteria regarding diag-
and bug spray to help prevent infection. By con- nostic testing, documentation, and alternative
sidering previous examples and studying the medications that vary for each medication and
upcoming environment, team physicians can gain medical condition. These guidelines must be
the tools to handle most any future geographic ­followed to ensure the exemption is granted. It is
infectious diseases they may encounter [33]. important for the treating physician to be aware
of any chronic or acute medical condition that
may require a TUE, as failure to apply and receive
45.7 Doping an exemption can result in a positive test for the
athlete and subsequent disqualification from
Doping is an unfortunate reality that affects every competition and possible forfeiture of previous
Olympic Games. Although the first doping tests results.
were instituted at the 1968 Winter Olympic Physicians and athletes must also be compli-
Games in Grenoble, France, the World Anti-­ ant with WADA monitoring and testing policies.
45  Olympic Games: Special Considerations—Medical Care for Olympians 627

plements were contaminated with banned sub-

SUBSTANCES PROHIBITED stances, including steroids [36]. While there are
IN PARTICULAR SPORTS several third-party companies that will test and
certify supplements against WADA standards,
athletes are still ultimately responsible for every-
thing they ingest and should exercise caution
when choosing and using supplements [37, 38].
P1
BETA-BLOCKERS Overall, it is the responsibility of the physi-
Beta-blockers are prohibited In-Competition only, in cian and the athlete to have an open and candid
the following sports, and also prohibited Out-of-Competition conversation regarding doping and the rules that
where indicated.
WADA has provided. If there is any question as
• Archery (WA)* to the legality of a substance, multiple resources
• Automobile (FIA) exist to ensure that the athlete is not in violation
• Billiards (all disciplines) (WCBS) of any anti-doping rules. In the event that an
• Darts (WDF)
exemption is required, there is also a clearly
• Golf (IGF)
• Shooting (ISSF, IPC)*
defined means for providing this to the athlete.
• Skiing/Snowboarding (FIS) in ski jumping, freestyle There should be minimal hurdles or difficulty in
aerials/halfpipe and snowboard halfpipe/big air the partnership between the physician and athlete
• Underwater sports (CMAS) in constant-weight apnoea to keep Olympic sports free from doping.
with or without fins, dynamic apnoea with and without
fins, free immersion apnoea, Jump Blue apnoea,
spearfishing, static apnoea, target shooting, and variable
weight apnoea. 45.8 Caring for Olympic-Level
Athletes Outside of Olympic
*Also prohibited Out-of-Competition
Games
Including, but not limited to:
As discussed above, detecting and preventing
Acebutolol; Labetalol;
doping is a point of emphasis for the IOC and
Alprenolol; Levobunolol;
Atenolol; Metipranolol;
WADA.  It is vital that physicians working with
Betaxolol; Metoprolol; Olympic athletes know these doping rules and
Bisoprolol; Nadolol; the specific medication statutes of the athlete’s
Bunolol; Oxprenolol; sport. Physicians should also be familiar with the
Carteolol; Pindolol;
specific terminology, in-game rules, and biome-
Carvedilol; Propranolol;
Celiprolol; Sotalol;
chanical requirements of their athletes’ sports.
Esmolol; Timolol. Not only does this allow for improved communi-
cation regarding injuries, it also provides addi-
Fig. 45.2  Taken from the World Anti-Doping Code, tional credibility for the physician with the
International Standard, Prohibited List January 2018
athletes, fostering an improved doctor-patient
relationship.
This includes random and timed drug tests, both An additional, and sometimes only, opportu-
inside and outside of competition. Therefore, ath- nity to establish a doctor-patient relationship
letes and physicians must be aware of any sub- with the Olympic-level athlete is during the pre-
stances that the athlete is ingesting or utilizing, participation physical examination (PPE) or peri-
including supposedly allowed dietary supple- odic health evaluation (PHE). While not
ments such as creatine and protein. Survey data mandated by the IOC, the PHE is recommended
from 2012 to 2016 showed 57% of US high by the IOC’s 2009 consensus statement [39]. The
school teenagers used protein supplementation main purpose of the PHE is to screen for injuries
and 34% used creatine supplementation. It was or medical conditions that place the athlete at
also shown that a high percentage of these sup- higher risk during competition. Therefore, the
628 D. J. Pohl et al.

PHE should be based on scientific evidence and of the operation of the Olympic Village [16]. The
established criteria and tailored to the athlete’s licensure or accreditation will allow NOC team
specific sport, age, gender, and race when appro- doctors to treat only members of their own
priate. If a condition is detected or suspected, national delegation, unless specific permission is
additional workup and management should be granted by another national organization. The
performed as necessary. In addition to screening registration will also allow the NOC team physi-
for conditions and establishing medical care, the cians to request physiotherapy, medications,
PHE can also serve to ensure proper diagnosis imaging, or other diagnostic services from the
and management of some silent conditions that polyclinic, but not outside facilities or hospitals.
still affect performance, such as mild iron defi- Care should also be taken to ensure proper
ciency or astigmatism [39]. The PHE should be malpractice insurance, as the host country usu-
part of an ongoing process for elite athletes and ally does not provide coverage for NOC team
ideally performed far in advance of any major physicians. National team physicians should
competitions to allow for adequate treatment of inform their insurance companies of the travel
any identified conditions. abroad with a sports team and confirm that they
Throughout the years and months leading up have adequate coverage for that role. The host
to the Olympic Games, a national team physician country will provide malpractice insurance for
may be called upon to perform other preliminary the healthcare practitioners and services provided
services for the teams and athletes of their nation. under their auspices, such as those offered at the
These can range from performing the PHE to polyclinic or at specific venues.
working national competitions or Olympic Trials.
Throughout this process communication with not
only the athletes but also the training staff, 45.9.2 Language Barriers/
coaches, and national organizers is crucial to Communication
helping the Olympic athletes become or remain
healthy enough to compete at the highest level. The official languages of the IOC and thus the
Olympic Games are French and English, and all
official communications and signage must con-
45.9 U
 nique Challenges at tain both translations [41]. If different from those
Olympic Games two, the dominant language of the host country
will also be prevalent throughout each Olympic
45.9.1 Licensure and Access Games. However, with over 200 nations partici-
in Foreign Country pating in the Games, there are a myriad of other
languages spoken by athletes, national organiza-
National team physicians and other healthcare tion members, and spectators alike. As national
practitioners will need to obtain licensure or team physicians are often restricted to treating
accreditation in the host country for the duration their country’s own athletes and committee mem-
of their visit, including any time before or after bers, communication and language barriers
the Olympic Games. This process will vary based should be a relative nonissue. In the instances
on the home country’s laws and regulations but where discussion or coordination is necessary
will, at the very least, require registration of each with the host nation’s medical services, or for
national team healthcare provider with the host physicians and medical staff who will be treating
country. After registration, the process has varied patients from a variety of countries, effective
from simply allowing registrants to practice communication is paramount. Therefore, transla-
within their usual scopes of practice without fur- tion services should be made readily available to
ther licensure or certification from the host coun- facilitate accurate and timely medical care. Such
try [40] to granting accredited physicians a services can be in person, over the phone or tele-
temporary license to practice during the duration communication, or, as technology continues to
45  Olympic Games: Special Considerations—Medical Care for Olympians 629

advance, via smartphone or computer applica- 5. International Olympic Committee. The IOC—What
We Do. 2018. http://www.olympic.org/the-ioc/what-
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8. Soligard T, Steffen K, Palmer-Green D, et al. Sports
injury and illness incidence in the Rio de Janeiro 2016
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• When caring for Olympic athletes, the health- 13. Reeser JC, Willick SE, Elstad MR. Medical services
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 Paralympic Sport
46
Yetsa A. Tuakli-Wosornu, Fiona Doolan,
and Jan Lexell

Take-Home Message unwanted…with no incentive or encouragement

For 70  years, organized Para sport has offered to return to a useful life” [2].
individuals with impairment enhanced health and Toward the end of World War II, a young Jewish
improved quality of life, while the pinnacle event neurosurgeon, Dr. Ludwig Guttmann, challenged
of Para sport, the Paralympic Games, continues the prevailing notion that spinal cord injury was
to inspire and excite the world. akin to invalidism. Refuting that spinal cord injury
inevitably portended a short life with little mean-
ing, Guttmann created an intensive, dynamic clini-
46.1 History and Structure cal rehabilitation program when he became head
of the Paralympic Games of the National Spinal Injuries Unit at the Ministry
of Pensions Hospital, Stoke Mandeville, in 1943
Prior to the conclusion of World War II, even [3, 4]. Under his direction, multidisciplinary care
the most progressive clinicians viewed severe teams implemented rigorous rehabilitation pro-
spinal injuries as fatal due to the severe atten- grams, engaged patients in community recreation,
dant secondary complications such as septice- and established prevocational work programs,
mia, renal failure, major depression, and others. helping to facilitate health, happiness, confidence,
Approximately 80% of British and American spi- and independence (Fig. 46.1) [5, 6].
nally injured World War I veterans did not survive
[1], and those who did “dragged out their lives as
useless and hopeless cripples, unemployable and

Y. A. Tuakli-Wosornu (*)
Department of Chronic Disease Epidemiology, Yale
School of Public Health, New Haven, CT, USA
e-mail: [email protected]
F. Doolan
Trinity College Dublin School of Medicine,
Dublin 2, Ireland
e-mail: [email protected]
J. Lexell Fig. 46.1  “Q” Hill, Remedial Gymnast, using a medicine
Department of Neuroscience, Rehabilitation ball to strengthen a patient’s upper body at Stoke
Medicine, Uppsala University and Uppsala University Mandeville Hospital. Image reproduced with permission
Hospital, Uppsala, Sweden care of Professor Ian Brittain © International Wheelchair
e-mail: [email protected] and Amputee Sports Federation (IWAS), Aylesbury
College, Buckinghamshire, United Kingdom
© ISAKOS 2019 631
S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_46
632 Y. A. Tuakli-Wosornu et al.

Uniquely, Guttmann’s program incorporated “International Stoke Mandeville Games”)

competitive sport, one of the most social and (Fig. 46.2) [8].
spirited therapeutic modalities. He described What started as a modest contest between
sport as “the most natural form of remedial exer- Stoke Mandeville and the Star and Garter Home
cise” and saw it as a powerful tool to restore for Injured War Veterans evolved in name and
physical strength, cardiorespiratory fitness, and scope over the next 12 years, featuring an increas-
coordination while also repairing psychological ing number of sports, athletes, and nations every
health [6]. year. By 1960, the International Stoke Mandeville
Guttmann’s aim was to “not only give hope Games had evolved into the first large interna-
and a sense of self-worth to the patients, but tional Para sport festival, held in Rome, Italy,
to change the attitudes of society towards the using the same venue as the Rome Olympic
spinally injured by demonstrating to them Games [1]. The event featured 400 athletes, all of
that they could not only continue to be use- whom were spinally injured, representing 23
ful members of society, but could take part countries.
in activities and c­omplete tasks most of the Out of the spirit embodied by Guttmann’s pio-
nondisabled society would struggle with” [7]. neering sporting initiatives and transformative
Indeed, Guttmann would take patients into notions about injury and ability, the Paralympic
nondisabled community archery clubs, engag- Movement has steadily become one of the most
ing nondisabled persons in competitions with successful sporting initiatives in history. What
Stoke Mandeville teams, further eroding bar- started as a grassroots effort to restore war-­
riers between the community and paraplegic wounded citizens to physical, mental, and social
persons [7]. In 1948, Guttmann organized a health has evolved into a global campaign for
small archery competition among 16 para- unification and empowerment through sport [9].
lyzed British war veterans from two hospi- The contemporary Paralympic Movement is
tals, the Stoke Mandeville Games (later the currently enjoying unprecedented growth in both

Fig. 46.2  Archery. In Image 2, Roy Jennings (Stoke permission care of Professor Ian Brittain © International
Mandeville team) releases his arrow watched by his fian- Wheelchair and Amputee Sports Federation (IWAS),
cée, Effie Wright. “Old Bill,” the specially adapted bus, Aylesbury College, Buckinghamshire, United Kingdom
can be seen in the background. Images reproduced with
46  Paralympic Sport 633

Fig. 46.3 Two
Paralympic
ambassadors, a
wheelchair athlete and a
visually impaired
athlete, participate in the
2016 Rio Paralympic
Games torch relay in
Rio de Janeiro, Brazil.
Photo reproduced with
permission © Yetsa
A. Tuakli-Wosornu,
MD, MPH, New Haven,
Connecticut, USA

size and exposure. In 2016, the 15th meeting of 2. Group athletes into sport classes which intend
the Paralympic Games was contested in Rio de to make sure that the impact of impairment is
Janeiro, Brazil. It featured more than 4300 ath- minimized and sporting excellence decides
letes representing 160 countries including a team which athlete or team is victorious in the end
of Independent Paralympic athletes, competing
in 23 sports [10]. The 2016 Summer Games Since the early beginnings of Para sport in the
achieved a cumulative global audience of 4.1 bil- 1940s [12], several conceptual models have sup-
lion (Fig. 46.3) [10]. ported the development and subsequent progres-
sion of Para sport classification:

46.2 Classification System 1. Medical

2. Functional sport specific
The unique systems of classification used by Para 3. Evidence-based sport specific
sports carry out two very important functions to
uphold the achievement of the Paralympic vision, Classification initially appeared in the mid-­
“to enable para-athletes to achieve sporting 1950s, at which time doctors began to divide
excellence and inspire and excite the world” [11]: competitors based on high or low spinal injury
diagnosis to make wheelchair basketball “more
1. Defines who is eligible to compete in Para fair” [13]. While ostensibly during these early
sport and as a result has the opportunity to decades classification was based solely on medi-
reach the goal of becoming a Paralympic cal diagnosis, a transition was already occur-
athlete ring where athletes with spinal cord injury,
634 Y. A. Tuakli-Wosornu et al.

p­ oliomyelitis, and spina bifida competed together cation systems used in sport, such as age, body
despite having three separate medical conditions. mass, and sex. Each sport is required to identify
These conditions resulted in a common impair- the eligible impairments in that sport, to describe
ment in strength. The focus was beginning to the severity of impairment permitted, known as
shift away from medical diagnosis toward how minimum impairment criteria (MIC), to classify
much impairment impacted upon sport perfor- the impairments according to the extent of result-
mance [12]. ing sport-specific activity limitation, and to
The 1992 Barcelona Paralympic Games develop the evidence to support that the methods
advanced the use of sport-specific functional used for assigning a sport class achieved the
classification models [14]. Decisions for fewer defined purpose of Para classification [15].
classes, supported by functional classification, An athlete must have an eligible impairment
were popular with event organizers and acceler- that belongs to one of the ten eligible impair-
ated the transition to functional and sport-spe- ment types to participate. But it is not the only
cific systems, although the science to support an factor; it is the opening to the possibility to par-
objective, reliable, and valid classification sys- ticipate. Even if the athlete has one of the eligi-
tem was immature. A conceptual or theoretical ble impairments made available in that specific
model was looked for to guide classification for- sport, an athlete may still not be eligible to par-
ward [12]. ticipate if the athlete does not meet the minimum
Evidence-based sport-specific criteria sup- impairment criteria demonstrating the impair-
planted the variable methods employed by indi- ment is severe enough to affect how the athlete
vidual physicians to classify athletes by the does the fundamental activities for the sport
introduction of three primary documents by the (Fig. 46.4) [17].
International Paralympic Committee, the global The sport class an athlete is placed in for com-
governing body of the Paralympic Movement: petition has a significant effect on accomplishing
the 2003 IPC Classification Strategy, the 2007 success in Para sport. Current best practices are
IPC Classification Code, and the 2009 IPC informed by advancing research in this field [18–
Position Stand on Background and Scientific 27], but existing systems still lack evidence to
Principles of Classification [15, 16]. support the process and reliability of how athletes
The 2007 Code adopted the use of a universal are currently grouped in sport classes. To mea-
language, the International Classification of sure impairment, classifiers should have simple,
Functioning, Disability, and Health (ICF), to
interconnect with sport. Each sport governance
body was to determine which eligible impair-
ment types would be included in their respective
sport. The presence of a permanent verifiable
impairment and an underlying health condition
was mandated. And sport class decisions were to
be based on how the resulting impairment caused
activity limitation in the fundamental activities of
the sport [16]. Tweedy and Vanlandewijck pro-
vided the conceptual clarity that was lacking in
the 2007 Code with the 2009 IPC Position Stand
on Background and Scientific Principles of
Classification. Fig. 46.4  Step 1 of the athlete classification process: a
The contemporary evidence-based model, wheelchair rugby athlete and classifier are demonstrating
the assessment of impairment in motor power using man-
using a taxonomy perspective, defined the unit of ual muscle testing. Photo reproduced with permission ©
classification as impairment and aligned classifi- Lieven Coudenys, International Paralympic Committee,
cation in Para sports with other selective classifi- Bonn, Germany
46  Paralympic Sport 635

readily available, affordable, objective, valid, and lower limb is more commonly injured. Older ath-
reliable tests such as manual muscle testing to letes and athletes with spinal cord injury are par-
measure impairment in motor power [28]. ticularly at increased risk for upper limb injuries
Progress is being made all the time, but sport [35, 36]. Additionally, across all athletes, males
classification continues to have significant chal- and females have similar rates of injury [34].
lenges. By honoring all past and present contrib- Recent sport-specific sub-analysis has enabled
utors, maintaining strong links between medical a more detailed analysis of injury, noting that in
communities, and engaging scientific and the sport of track and field, wheelchair/seated
research communities, athlete classification will athletes are at higher risk of upper limb injury,
advance to be the strong cornerstone of the which is seen most commonly in the throws
Paralympic Movement into the future. events (shot put, discus, and javelin) [37].
Additionally, among ambulant track athletes,
those with cerebral palsy are at decreased risk of
46.3 Injury in Paralympic Sport lower extremity injury when compared to ampu-
tees and athletes with visual impairment [37].
In parallel with the growth of the Paralympic This may be due to increased lower extremity
movement, the field of Paralympic sports medi- muscle tone in athletes with cerebral palsy, which
cine has emerged as an exciting new frontier of may in fact be protective against injury given the
clinical care and scientific exploration [29]. lack of full, forceful eccentric muscle contraction
Sports-related injuries in Para athletes, both rec- during springs and distance running events.
reational and elite, show unique features when In the sport of Paralympic football, visually
compared to the general athlete population, and impaired athletes in five-a-side football experi-
predictably, sports medicine care for Para ath- ence a high incidence of acute injury, particularly
letes has grown to accommodate these. to the head/neck and lower limb [38]. Of interest,
Para sports injury epidemiology research is a >60% of these injuries are reported as being
growing field of sports medicine research con- attributable to foul play. In Paralympic powerlift-
tributing to quality care [30]. Earnest attempts to ing, chronic/overuse injuries are very common,
better understand injury patterns began in multi- accounting for >60% of all injuries [39]. Of
sport events in 2002 when the Paralympic Injury these, the shoulder/clavicle was most commonly
Surveillance System was implemented at the involved, and athletes in heavier weight classes
Winter Paralympic Games [31, 32]. Following on were more likely to experience injury.
this success, an advanced online injury and ill- In winter Paralympic sports, ice sledge hockey
ness surveillance system was initiated for the and alpine skiing/snowboarding demonstrate a
London 2012 Paralympic Summer Games—the high incidence of injury, while nordic skiing/
first to comprehensively capture injury patterns biathlon and wheelchair curling less so [40]. Of
across a wide range of summer Para sports as interest, sports such as nordic skiing may be
well as enable the monitoring of both injury and somewhat protective against upper limb injury,
illness [33]. Currently, many countries and sports given that the nature of propulsion heavily
federations are striving to implement similar sys- involves scapular retraction, unlike wheelchair
tems to enable prospective data collection. court sports which predominantly rely on activa-
In summer Paralympic sport, the five sports tion of the anterior chest resulting in overuse
with the highest rates of injury are five-a-side foot- injuries, particularly to the rotator cuff.
ball, powerlifting, goalball, wheelchair fencing, Additionally, concussions, fractures, and contu-
and wheelchair rugby [34]. Additionally, the upper sions are more common in winter Paralympic
extremity is most frequently injured, particularly sport, likely due to the high-speed, high-impact
involving the shoulder, elbow, and wrist/hand. nature of these events [40].
This pattern varies in comparison to similar data The importance of aforementioned injury
from an Olympic athlete population, for whom the research cannot be overstated: it is often inevita-
636 Y. A. Tuakli-Wosornu et al.

ble that athletes may incur sports-related injury. are common in Paralympians, injuries that
In Para sport, sports injuries, incurred at a young cause a neurogenic bladder and the need for
age, may result in functional decline later in life. self-catheterization.
For example, a wheelchair basketball player with When compared to the Olympic Games (6.7–
spinal cord injury may develop a rotator cuff tear 12.1%), the incidence proportion of illness was
during a game, with immediate onset of symp- higher at the Paralympic Games (14.2%) [41]. As
toms. If left untreated, this tear may progress and expected, most illnesses were due to infections,
ultimately lead to rotator cuff tear arthropathy and as much as 50% of all respiratory illnesses,
later in life. Given that the athlete uses his/her 44% of skin and subcutaneous tissue illness, and
shoulder for both sports and functional tasks such over 82% of genitourinary illnesses were caused
as wheelchair transfers and propulsion, this has by an infection. Infections involving the skin and
the potential to cause significant morbidity. Thus, subcutaneous tissue infections were most com-
injury prevention in this population is of utmost mon among athletes with spinal cord injury, those
importance. with amputation/limb deficiency and cerebral
palsy. The stump-socket interface is also a high-­
risk area in athletes with amputation. For these
46.4 Medical Illnesses conditions, high forces, hot/moist conditions,
in Paralympic Sport sweating during exercise, and possible bacterial
contamination in the sport setting are likely
With the advanced online surveillance system contributors.
implemented during the London 2012 Paralympic During the 2014 Sochi Winter Paralympic
Summer Games, our knowledge of illnesses dur- Games, a total of 547 athletes from 45 countries
ing game time has considerably increased [33]. A were monitored daily for 12 days over the Sochi
medical illness is defined as any newly acquired 2014 Winter Paralympic Games (6564 athlete
illness as well as exacerbations of pre-existing days) [40]. The illness data were obtained daily
illness that occurred during training or competi- from teams without their own medical support
tion, either during the games or immediately (13 teams, 37 athletes) and teams with their own
before. In London 2012, a total of 49,910 athlete medical support (32 teams, 510 athletes) through
days were recorded, with 10,695 athlete days electronic data capturing systems. The total num-
monitored in the pre-competition period and ber of illnesses reported was 123, with an illness
39,215 athlete days monitored during the compe- incidence rate (IR) of 18.7 per 1000 athlete days
tition period. (95% CI 15.1–23.2%). The highest IR was
During the 2012 London Games, the inci- reported for wheelchair curling (IR of 20.0 (95%
dence rate of illness was 13.2 illnesses/1000 ath- CI 10.1–39.6%)). Illnesses in the respiratory sys-
lete days [41]. The highest rates of illness were tem (IR of 5.6 (95% CI 3.8–8.0%)), eye and
found in equestrian, powerlifting, table tennis, adnexa (IR of 2.7 (95% CI 1.7–4.4%)), and
road cycling, and wheelchair tennis. The average digestive system (IR of 2.4 (95% CI 1.4–4.2%))
age of participating athletes is higher. In some of were the most common. Older athletes (35–
these sports, this may increase the risk of overall 63  years) had a significantly higher IR than
systemic illness within that sport. younger athletes (14–25 years, p = 0.049). These
The highest proportion of illness was found results confirmed that Paralympic athletes report
for the respiratory system, followed by the skin, higher illness incidence rates compared to
digestive, nervous, and genitourinary systems. Olympic athletes at similar competitions.
This is similar to the pattern of illness observed During the Rio 2016 Summer Paralympic
in Olympic athletes; illnesses involving the Games, a total of 3657 athletes from 78 coun-
genitourinary system are, however, much more tries, representing 83.5% of all athletes at the
common among Paralympic athletes. The rea- games, were monitored on the web-based injury
son is that athletes with a neurologic injury and illness surveillance system (WEB-IISS) [42].
46  Paralympic Sport 637

Illness data, based on a total of 51,198 athlete formance. An athlete with a spinal cord injury
days, were obtained daily from teams with their may, in AD, be induced, for example, by stimu-
own medical support through the WEB-IISS lating a full bladder, and experience an increase
electronic data capturing systems. The total num- in blood pressure, stroke volume, and peak heart
ber of illnesses was 511, with an illness incidence rate that can result in a 10% improvement in
rate (IR) of 10.0 per 1000 athlete days (12.4%). physical performance. This effect, referred to as
The highest IRs were reported for wheelchair “boosting,” is prohibited by the International
fencing (14.9), para swimming (12.6), and wheel- Paralympic Committee (IPC). To enhance our
chair basketball (12.5) (p  <  0.05). Female ath- knowledge about AD in Paralympic sports, the
letes and older athletes (35–75 years) were also at IPC Medical Committee has been recording
higher risk of illness (both p < 0.01). Illnesses in blood pressure in athletes susceptible to AD in
the respiratory, skin, and subcutaneous and diges- certain sports. This work, ongoing since 2008,
tive systems were the most common (IRs of 3.3, may improve how to find athletes who may be at
1.8, and 1.3, respectively). When compared with risk of developing AD and eventually lead to the
the London 2012 Summer Paralympic Games, prevention of boosting in Paralympic sports.
the rate of illness was lower. Other medical factors that need to be addressed
are hydration for training, competition, and
recovery and the impact of multi-time zone
46.5 Controversies in Paralympic travel. Traveling long distances, boarding and
Sport embarking, and many hours spent on an aircraft
can affect athletes with an impairment. Athletes
Paralympic athletes may experience various medi- with a paralysis, such as spinal cord injury, are
cal issues that can influence their sports participa- particularly susceptible. They have an increased
tion. These must be well-known to the team that risk of pressure ulcers as well as lower extremity
accompany the athletes. Thereby, they can accom- swelling causing deep venous thrombosis (DVT).
modate various preventive measures before, dur- Paralympic athletes may, due to their impair-
ing, and after any games as part of the athlete’s ment, use specific medications that are prohib-
sports preparations and medical care [43]. ited under the guidelines of the World
One such issue is autonomic dysreflexia (AD). Anti-Doping Agency (WADA) Code and the IPC
This is an acute attack of uncontrolled sympa- Anti-Doping Code. This does not exclude them
thetic activity which leads to a sudden increase in from competing at high levels, as such medica-
blood pressure that can be life-threatening. Other tion can still be used, pending a Therapeutic Use
symptoms are headache, flushing, and sweating. Exemption (TUE). Examples of such specific
It specifically occurs in persons with a spinal medications are desmopressin (antidiuretic hor-
cord injury above the sixth thoracic level. It can mone) to treat nocturnal bladder overactivity,
be triggered by a noxious stimulus below the glucocorticoids, and beta-agonists for upper
lesion, for example, a full bladder or skin wound. respiratory tract problems. Of specific concern is
Treatment can be both non-pharmacological and beta-blockers used for the treatment of hyperten-
pharmacological. A person with AD should be sion that are prohibited in precision sports, such
placed in an upright position as this will produce as archery and shooting. Finally, some
an orthostatic decrease in blood pressure. Paralympic athletes may, due to congenital
Moreover, restrictive clothing should be removed, defects, require an anabolic agent, peptide hor-
the bladder emptied by CIC and bowel by gently mone, or growth factor. After careful review, a
inserting a gloved finger. If the blood pressure TUE committee within the specific sports feder-
remains elevated (above 150 mm/Hg), oral nife- ation or IPC can grant a TUE and thereby allow
dipine, a calcium antagonist, can be used. the athlete to continue to compete at the highest
AD has also been recognized in Paralympic level, despite using potentially performance-
sports as it can be a way of enhancing sports per- enhancing medications.
638 Y. A. Tuakli-Wosornu et al.

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 FIFA World Cup
47
Andre Pedrinelli and Caio Senise Drolshagen

• Communication barriers—language, culture.

47.1 Major Events
• High visibility.
Using the example of the 2014 FIFA World Cup
There is a lack of scientific evidence for this
(held) in Brazil, we are going to discuss the medi-
emerging area; thus the majority of the informa-
cal plan of the city of São Paulo with focus to the
tion provided here is based in our and other experi-
stadium, conferences, and the logistic involved.
ences. Despite this, it is a great opportunity for the
host place to introduce some good practices and
improvements on public health, infrastructure, and
47.2 Mass-Gathering Events education, using it as a legacy for the state/country.
Mass gatherings are events attended by a suffi-
cient number of people to potentially strain the
public health resources of community, state, or 47.3 2014 FIFA World Cup
nation (WHO).
In addition to the large quantity of people The Fédération Internationale de Football
attending these events, which by this own is a Association (FIFA) World Cup is the biggest
unique challenge for the health services, there are football event in the world and the most widely
many other things that increase the complexity of viewed sport event all over the globe [1]. The
the organization: championship has been awarded every 4  years,
and in 2014 it was held in Brazil.
• Coordination and cooperation across multiple Thirty-two teams entered in the tournament
sectors. which has a duration of around 30 days. In 2014
• Some diseases can easily be introduced and this major event took place in Brazil with 12
spread. host cities, including São Paulo with the Itaquera
Stadium which hosted 6 games including the
opening match and had a capacity of over 63,000
A. Pedrinelli (*) · C. S. Drolshagen seats at the World Cup. In this chapter, we will dis-
Instituto de Ortopedia e Traumatologia—IOT, cuss the organization of the FIFA Medical Service
Faculdade de Medicina da Universidade de São
Paulo—USP, São Paulo, Brazil in São Paulo providing the structural, action plans
e-mail: [email protected] and challenges involved in that mission.

© ISAKOS 2019 641

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_47
642 A. Pedrinelli and C. S. Drolshagen

47.4 FIFA Mass-Gathering Medicine 47.6 Medical Duties

The Local Organizing Committee has started FIFA mass-gathering medicine involves pro-
the preparation of the Medical Services of vision of medical services in and around the
2014 FIFA World Cup 4  years before, in stadium and at the hotels, meetings, and offi-
South Africa (2010 FIFA World Cup). It had cial events for all persons located at the place.
included official meetings, visits to the local Ensuring the well-being of football team, staff,
infrastructure, and planning in conjunc- FIFA family, spectators, and dignitaries is the
tion with São Paulo Public Institutions with main objective.
emphasis in transports, health, and public All FWC public is divided into three groups:
security institutes.
• Group 01—Players, referees, and team staff
• Group 02—Dignitaries, FIFA managers, and
47.5 F
 IFA Medical Services: São LOC
Paulo • Group 03—Spectators, and media

The provision of medical services during the

World Cup begins with the arrival of any partici- 47.7 F
 WC Medical Services’ Main
pating team in the city for training and prepara- Sites
tion for the games.
In all places with dignitaries or teams, such as • Stadium—including 1 km perimeter outside
Hotel or Training Camp, there should be a medi- • Training sites
cal team and an ambulance (UCI equipped) for • Teams’ hotels
provision if any medical problem occurs. One of • FIFA family’s hotels
the requirements for the organization of medi- • Chiefs of government’s hotels
cal services for the World Cup was the creation • Official events
of necessary infrastructure, including number
of ambulances, medical equipment available at
the stations, and number of personnel available. 47.8 S
 tadium Medical Services:
The checklist of material available at medical Itaquera Stadium—Arena
stations was developed by LOC and is now used São Paulo
as a reference for FIFA events. In addition, an
individual medical care form has been created The arrival of the medical team to the Stadium
(Fig. 47.1). occurred 4 h before the games and finished 2 h

Operations Summary during FIFA World Cup Brasil 2014TM

Structure Equipes Operational Dates

Operational time
Facilities Unit MDs Nurses Technician Driver Start End
Hotel FIFA Staff Hotel Medical Room 1 x 1 x 24 hours 10 days before 1st game 2 days after last game
Training Camp A Ambulance 1 1 × 1 during training 1st training day last training day
Training Camp B and C Ambulance 1 1 × 1 during training 1st training day last training day
Stadium without games Medical Station 1 × 1 × Stadium operational time 14 days before 1st game 2 days after last game
Stadium Media Center Media Medical Station 1 × 1 × Media Center operational time 5 to 10 days before 1st game 2 days after last game
Players Medical Station 2 1 2 × during training Match Day - 1
Match Day - 1
Players Ambulance 1 1 × 1 during training Match Day - 1

Fig. 47.1  Medical operations summary outside games

47  FIFA World Cup 643

after the end. A debriefing was held with the Because of the efficiency, it is critical that a
coordinators. In addition to the interior of the sta- helicopter landing location is available at the sta-
dium, FIFA is responsible for dealing with medi- dium (Fig. 47.2).
cal incidents within a perimeter of 1 km outside
the stadium.
One of the biggest challenges was the logistics 47.10 Stadium Major Incident Plan
involved in the case of an ambulance removal and
assistance to multiple victims. Because of that One of main functions of the medical manage-
there were two reference hospitals equipped with ment is to ensure well-being during the events and
heliport for the rapid transportation of emergen- prepare, distribute, and train a major incident
cies. In addition, in conjunction with the Traffic plan. The objective of this plan is to make a rapid
Engineering Company (CET), the terrestrial and effective response if there is any incident that
ambulance movement was carried out. potentially can produce injury, illness, or death.
This includes an evacuation plan. Usually, it takes
8 min to empty 80% of the public from Itaquera
47.9 Location Stadium, in normal conditions (Fig. 47.3).

The geographical location of the stadium—

address and coordinates are found using Global 47.11 Staff
Positioning System (GPS). It is mandatory to list
main roads, nearby highways, and important side 47.11.1  Chief Medical Officer (CMO)
roads. During games the road access is restricted
for safety, security, and diplomatic purposes. Is the individual who has the responsibility of
Furthermore, that information will allow emer- providing appropriate medical services during
gency rescue to arrive in a short time if necessary. the World Cup.

Fig. 47.2 Itaquera
Stadium, Itaquera
Subway, FAETEC, and
nearby highways
644 A. Pedrinelli and C. S. Drolshagen

Fig. 47.3 Itaquera
Stadium map—main
exits and gates

47.11.2  Venue Medical Officer (VMO) In addition to the academics prerequi-

sites, each of them had to have knowledge in
Is responsible for providing efficient and effective emergency and football medicine. Besides
medical service in the host city, the equivalent of that, one team of fireman realized initial
the CMO regionally. Its main functions are: attendance and removal in case of structural
collapse.
• Plan and coordinate the medical service in all
locations for each FIFA group.
• Organize, in conjunction with a third-party 47.11.4  Medical Equipment
company, medical care in hotels and the provi-
sion of ambulances during events. In addition to hospital medical supplies, each
• Capture and train the health-care team during team had a backpack equipped with a first aid kit
the games. (Fig. 47.4).
• Inspect medical offices and doping control.

47.11.5  Venue Operations Centre

47.11.3  Medical Team (VOC)

Each medical team consisted of: It is the place where the coordinators stayed, with
access to the camera closed-circuit and commu-
• One doctor nicate with other members of the team, manag-
• One nurse ing attendances and hospital removals with an
• One nurse technician ambulance.
47  FIFA World Cup 645

Fig. 47.4  First aid backpack

47.12 Communication – – First choice for patient triage, treat-

ment, and transport if a major casualty
The key to successful medical management is com- occurs
munication. It is mandatory that everyone use the • Secondary medical rooms
same language. In FWC 2014, telephone, mobile –– Five stations
phone and radio with a specific channel was used –– One medical team in each one
by everyone working on the medical services. • VIP medical room
–– One doctor, one nurse, and one nurse
technician
47.13 Medical Stations • VVIP medical room
–– One doctor, one nurse, and one nurse
• Players’ medical room technician
–– One medical team of only medical doctors • Doping control center
(four) • Mobile team
• Main medical room—the largest service sta- –– Team consisted of paramedics equipped
tion destined to FIFA group 3 with a “golf car” or bicycle, a radio, first
–– Eight beds (four for critical care), five med- aid kit, and stretcher
ical doctors, five nurses, and five nurse • Volunteers
technicians
646 A. Pedrinelli and C. S. Drolshagen

–– Four volunteers who know the stadium –– One ambulance for IVIP room.
very well and were used to communicate –– Seven ambulances for the public.
with the medical teams if any problem
occurred with the radio and phone
47.15 Operational Structure
Medical team—key points
Composition
 • One MD
The schematization of a flow of service and hier-
 • One nurse archical communication was essential for the
 •  One nurse technician success of the operation. The patient arrived in
Standard uniform two ways at the medical post: through individu-
 •  Medical station—black and white als with or removed from the bleachers or con-
 •  Ambulance—white jacket venience location in the case of an emergency
 •  Field of play team—blue
call. For this, the mobile team was available to
Ambulance—12
respond quickly to calls.
 •  One for 10,000 spectators—07
 •  Two on the field of play From the medical station, the patient could have
 •  One for VIP and one for IVIP room two ways: stay in the station under the vision or be
 •  One for players’ medical room removed by an ambulance to a hospital of reference.
Otherwise, if he exceeded 20 min of observa-
tion, he was transferred to the main post. At the
main station, the maximum observation time was
47.14 Ambulances 2  h if it exceeded, he/she should be transferred
to a hospital. The ambulance coordination fol-
• An ambulance is required for every 10,000 lowed a hierarchical level too. If the head of the
fans in accordance with current legislation in medical station deemed it is necessary to remove
the city of São Paulo. a patient, he contacted the VMO who was in con-
• Twelve ambulances, six of them equipped tact with an ambulance manager located in the
with ICU. VOC who, together with the reference hospitals,
–– Two in the field with one medical team (doc- regulated the removal of the patients. This was
tor, nurse, and nursing technician) each. extremely important in order to keep all the main
–– One for players’ medical room. sites with an ambulance and to not overload the
–– One ambulance for VIP room. destination Hospital (Figs. 47.5 and 47.6).
47  FIFA World Cup 647

Patient needs
treatment

Patient is Able to Call mobile teams to

yes no
walk to medical location
centre? Use radio to
comunicate
with medical
Patient go to centre
medical centre to Mobile team analise
receive treatment the patient

Patient need Patient need

no to be transported yes to be transported
to hospital? to hospital?

Treat patient Stabilize patient

no

Request ambulance Transport patient to

medical centre

Contact
reference
hospital Treat patient

Prepare patient file

Patient is released

Fig. 47.5  Patient medical station flow

Operations Summary during FIFA World Cup Brasil 2014TM

Structure Equipes
Operational time Operational Dates
Facilities Unit MDs Nurses Technician Driver
1 × 3 × ko - 5 hours fw + 2 hours Match Days
F Field of play Team
1 × 3 × ko - 5 hours fw + 2 hours Match Days
I
F Players Medical Room 2 1 2 × ko - 5 hours fw + 2 hours Match Days
A VIP Medical Room 2 2 2 × ko - 5 hours fw + 2 hours Match Days

s VVIP Medical Room 1 1 1 × ko - 5 hours fw + 2 hours Match Days

t G × ko - 5 hours fw + 2 hours Match Days
Field of play Ambulance 1 1 1
a r
1 1 × 1 fw + 2 hours Match Days
d o Players Ambulance ko - 5 hours

i u VIP Ambulance 1 1 × 1 ko - 5 hours fw + 2 hours Match Days

u p ×
VVIP Ambulance 1 1 1 ko - 5 hours fw + 2 hours Match Days
m
Medical Room 1 3 3 6 × ko - 5 hours fw + 2 hours Match Days
Medical Room 2 2 1 2 × ko - 5 hours fw + 2 hours Match Days
m
a s Medical Room 3 2 1 2 × ko - 5 hours fw + 2 hours Match Days
t p 1 × fw + 2 hours
Medical Room 4 2 2 ko - 5 hours Match Days
c e
h c Medical Room 5 2 1 2 × ko - 5 hours fw + 2 hours Match Days
t Medical Room 6 1 × ko - 5 hours fw + 2 hours Match Days
2 2
a
d × ko - 5 hours
t Ambulance ICU 1 1 1 1 fw + 2 hours Match Days
a
o Ambulance ICU 2 × Match Days
y 1 1 1 ko - 5 hours fw + 2 hours
r
Ambulance ICU 3 1 1 × 1 ko - 5 hours fw + 2 hours Match Days
s
Ambulance ICU 4 1 1 × 1 ko - 5 hours fw + 2 hours Match Days

Ambulance ICU 5 1 1 × 1 ko - 5 hours fw + 2 hours Match Days

Ambulance ICU 6 1 1 × 1 ko - 5 hours fw + 2 hours Match Days

Fig. 47.6  Operations summary during games

648 A. Pedrinelli and C. S. Drolshagen

47.16 2
 014 FIFA Medical Services 47.16.2  During Games (Figs. 47.8,
Statistics 47.9, 47.10, 47.11, 47.12,
47.13, 47.14, 47.15,
47.16.1  FWC2014: São Paulo (Fig. 47.7) and 47.16)

Fig. 47.7  FWC medical

services general 2.800 consumed
statistics—from May 21 medical itens
to July 17
10.800
hours.resources
70 days of
13.280 liters of
Medical
solid waste
Coverage
220 FIFA
employees
1.416
appointments

29 Medical
Removals

Medical Calls
300

260
250

207
200 186

162
150 142
129 Medical Calls

100

50

0
Game 1 Game 2 Game 3 Game 4 Game 5 Game 6

Fig. 47.8  Number of medical calls during Itaquera Stadium Games

47  FIFA World Cup 649

Muscular, 2% Dehydration, 9%

Cardio, 2% Dermatologic, 2%
GIT,
Respiratory, 2%
ENT, 5% 10%
Ginecologic, 2%

Trauma, 14%

Neurologic/Headache,
52%

FIFA
Guests Media
3% 2% LOC 1%
Volunteers Players Med Mobile Team
Security 0% 6%
10% 1%
FIFA 0%
VVIP
2% VIP
8%

Employees
Employees Spectators
38% Spectator Med
38% 46% 83%

Fig. 47.9  Game 01; June 12; Brazil 3 × 1 Croatia; Spectators: 61,000, Medical Calls: 184, Hospitals Transfer: 4
650 A. Pedrinelli and C. S. Drolshagen

Dehydration, 4% Dermatologic, 3%
Back Pain, 2%

Muscular,
10%

GIT, 12% Trauma, 20%

Cardio, 7%

Neurologic/
ENT, 6%
Headache, 28%

Ginecologic, 4%

FIFA Guests Media

1% 1% Mobile Team
LOC 2% Players Med 2% 3%
Security 2%
Volunteers FIFA 2%
7%
VVIP
VIP
3%
9%

Spectators
30%
Employees
55% Spectator Med
83%

Fig. 47.10  Game 02; June 19; Uruguay 2 × 1 England; Spectators: 62,575, Medical Calls: 129, Hospitals Transfer: 2
47  FIFA World Cup 651

Muscular, 3%
Muscular, 3%

Dehydration, Dermatologic, 3%
12%

GIT, 17%
Trauma,
ENT, 7% 18%

Neurologic/
Headache, 29%
Ginecologic,
3%

Media
0% Players Med 1%
FIFA Guests 8% LOC 0% VIP 4%
Security Mobile Team 1%
Volunteers VVIP
1%
8% 1%
FIFA
1%

Spectators
Employees
44%
46% Spectator Med 93%

Fig. 47.11  Game 03; June 23; Netherlands 2 × 0 Chile; Spectators: 62,996, Medical Calls: 149, Hospitals Transfer: 2
652 A. Pedrinelli and C. S. Drolshagen

Teeth pain, 1% Dehydration,

8%
Dermatologic, 4%
Muscular,
10%
GIT,
6%
Trauma,
11%
ENT, 6%
Back pain,
3%

Neurologic/
Headache, 51%

Media
0% LOC VIP Players Med
FIFA Guests
0% 0% 0% 3%
VVIP Mobile Team
Security 0%
0% 1%
Volunteers
3% FIFA
2%

Spectators
37%

Employees Spectator
58%
Med
96%

Fig. 47.12  Game 04; June 26; South Korea 2 × 1 Belgium; Spectators: 61,397, Medical Calls: 190, Hospitals Transfer: 3
47  FIFA World Cup 653

Respiratory,
4%
ENT, 4% Dehydration,
8%
Teeth pain, 1%
Dermatologic, 6%
Muscular, 5%
Gineco, 4%

GIT, 10%

Cardio, 4% Trauma, 16%

Back pain,
7%
Neurologic/
Headache, 32%

Media Players Med

LOC VIP 4% 1%
FIFA Guests 2% 0% VVIP Mobile Team
0%
Security 1% 0%
Volunteers
1%
10%
FIFA
0%

Spectators
34%

Spectator
Employees
Med 94%
53%

Fig. 47.13  Game 05; July 1; Argentina 1 × 0 Switzerland; Spectators: 63,225, Medical Calls: 134, Hospitals Transfer: 3
654 A. Pedrinelli and C. S. Drolshagen

Respiratory, Dermatologic,
6% 3%

Teeth pain, ENT,

2% 6%
Trauma, 14%

Muscular,
10%

GIT, 11% Neurologic/

Headache, 41%

Cardio, 4%
Back pain, 3%

VIP
Media 0% Players Med
FIFA Guests LOC
2% VVIP 0%
1% 3% Mobile Team
Security 0% 0%
Volunteers 1%
FIFA
14%
0%

Spectators
32%
Employees
48% Spectator
Med 99%

Fig. 47.14  Game 06; July 9; Argentina 0 × 0 Netherlands; Spectators: 63,267, Medical Calls: 222, Hospitals Transfer: 5

12/06/2014 19/06/2014 23/06/2014 26/06/2014 01/07/2014 09/07/2014

45

40

35

30
MEDICAL CALLS

25

20

15

10

0
KO-10 KO-9 KO-8 KO-7 KO-6 KO-5 KO-4 KO-3 KO-2 KO-1 KO KO+1 KO+2 KO+3 KO+4 KO+5 KO+6 KO+7 KO+8 KO+9 KO+10
Kick off+/- 1hora

Fig. 47.15  Medical calls in each hour on match day

47  FIFA World Cup 655

Fig. 47.16 Hospital Myocardial

Transfers – TOTAL Alcoholic Intoxication Infarction (Death -
from the 06 games 5% in Hospital)
5%

Leg Pain
5%
Stroke
5%

Dehydration Trauma
5% 38%

Arrythmia
5%

Thoracic Pain
5%

Eye Foreign Body

4%
Abdominal Pain
Leg Edema 19%
4%

47.17 Outside the Game the public health resources of community,

state, or nation.
47.17.1  Medical Calls (Figs. 47.17 • The complexity of the organization involves
and 47.18) coordination and cooperation across multi-
ple sectors, some diseases that can easily be
Take-Home Message ­introduced and spread, communication bar-
• Mass gatherings are events attended by a suf- riers (language, culture), and high
ficient number of people to potentially strain visibility.
656 A. Pedrinelli and C. S. Drolshagen

Medical Calls
45

40

35
Medical Calls
30
Total: 493
25

20

15

10

0
8-May
10-May
12-May
14-May
16-May
18-May
20-May
22-May
24-May
26-May
28-May
30-May
1-Jun
3-Jun
5-Jun
7-Jun
9-Jun
11-Jun
13-Jun
15-Jun
17-Jun
19-Jun
21-Jun
23-Jun
25-Jun
27-Jun
29-Jun
1-Jul
3-Jul
5-Jul
7-Jul
9-Jul
Fig. 47.17  Medical calls outside games

Fig. 47.18 Medical Medical Complaints

complaints outside game
4%
Dehydration

11% Trauma

Neurologic/Headache
24%
12%

Ginecologic

6%
Back Pain

9% ENT

25%
Cardio

5%
GIT
4%

Reference
1. www.fifa.com.
 Extreme Sports
48
Torrey Parry, Empryss Tolliver,
and Scott C. Faucett

48.1 Introduction 48.2 Surfing

The popularity of extreme sports has grown dra- Surfing, as a sport, has grown dramatically since
matically over the past several decades, despite it began to gain widespread appeal in the 1960s.
knowledge of the higher risk of injury associated Even since the beginning of the twenty-first cen-
with such activities [1]. There is no specific defi- tury, we have seen an explosion in worldwide
nition of what categorizes something as extreme participation, with an estimated 37 million surf-
versus as a more conventional sport such as base- ers in 2013 [2], compared to 13 million in 2002
ball, basketball, or football. However, the essen- [3]. With this expansion in total number of surf-
tial aspects of extreme sports are high speed, ers, it is important for treating physicians to be
extreme height, real or perceived danger, a high aware of the types of injuries that can be expected.
level of physical exertion, and highly specialized Several factors can contribute to increasing
gear or spectacular stunts. One quality that is uni- the risk of injury during surfing. Among these are
versal across all extreme sports is the adrenaline rider experience, size of wave, maneuvers per-
rush involved by the inherent danger in the activ- formed, location of wave break, and ocean floor
ity. Whether the athlete is parachuting from the makeup [4]. Some studies have shown that the
sky, pulling a double backflip off a Moto X free- incidence of moderate to severe injuries in pro-
style jump, or attempting a frontside double cork fessional surfers is higher than in recreational
1440 in the halfpipe on a snowboard, part of the surfers—4 per 1000 surfing days compared to 3.5
appeal appears to be the fact that such activities per 1000 surfing days, respectively [5–7]. This is
are not safe. This chapter will explore specific likely related to the larger waves surfed and the
injuries and safety considerations involved in riskier maneuvers performed by elite surfers
some of the most popular extreme sports. (Fig. 48.1).
In a prospective study looking at injuries sus-
tained during competition surfing, Nathanson
et al. [8] found that knee strains and sprains were
the most common injury types in competitive
T. Parry events. This is in contrast to multiple studies find-
Department of Orthopedics, George Washington
University, Washington, DC, USA ing that lacerations are the most common injuries
in recreational athletes [3]. Knee injuries most
E. Tolliver · S. C. Faucett (*)
The Centers for Advanced Orthopaedics, commonly occur during aggressive turning and
Washington, DC, USA aerial maneuvers, which are too difficult for less

© ISAKOS 2019 657

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_48
658 T. Parry et al.

professional rugby, college football, men’s college

soccer, men’s college basketball, and snowboard-
ing, respectively [8]. It has been estimated that
there are approximately 11,000 surfing injuries
per year requiring a visit to an emergency room.
As surfing is mostly practiced in an unsupervised
environment and injuries sustained are minor, the
overall incidence of injury is likely higher than
what can be documented. Of those that are seen in
emergency rooms, 96% are treated and released,
while 4% are admitted. The most common injury
Fig. 48.1  Big Wave surfer riding a wave at the 2010 diagnosis is laceration (41%), followed by strains
Mavericks Invitational in Mavericks, California. and sprains (14%), contusions (13%), and frac-
Mavericks was the site of the deaths of two accomplished tures (12%). The most common body location
Big Wave surfers, Mark Foo and Sion Milosky
of injury is the lower extremity (26%), followed
by the face (23%), head and neck (23%), upper
experienced surfers to perform. Injuries are sig- extremity (17%), and trunk (9%). Lacerations are
nificantly more likely to occur when surfing on a most commonly located on the head, neck, and
hard bottom (e.g., rock or coral) than on a soft face (63%). Fractures most commonly involve
sandy bottom. When comparing hard to soft bot- the upper extremity (32%) and lower extrem-
tom surfing, Nathanson et al. [8] found the odds ity (31%). Strains and sprains mostly affect the
ratio for sustaining an acute injury to be 2.6. lower extremity (35%) and the neck (29%).
Similarly, the odds ratio for acute injury when Dislocations account for only 4.5% of injuries and
comparing large waves—overhead or higher—to primarily involved the upper extremity (85%), pre-
small waves was found to be 2.4. Risk of injury is dominantly the shoulder. Other reported, though
higher when surfing in  locations with shore exceedingly rare, injuries include submersion
break, where the waves break in shallow water. injuries, acute myocardial infarction, finger ampu-
This makes sense, as the shallow water provides tation, and tympanic membrane rupture. Animal
little cushion to falls compared to breaks that are attacks (e.g., shark, seal, stingray, and jellyfish) are
further out in deeper areas [4]. Performing aerial also reported as being rare, but as these encounters
maneuvers—when surfers propel themselves into are generally minor, it is likely that patients do not
the air and land back on the wave—is a signifi- seek medical attention following injury [9].
cant risk factor for a higher rate of injury. Furness While surfing does involve some risk, injuries
et al. [5] found that 48% of surfers who perform are comparatively less common and often minor.
aerial tricks sustained a major injury in a Certain practices do increase the risk of injury,
12-month period, with major injury being defined and patients should be counselled on safe behav-
as either having to take at least one day off from ior such as avoiding reefs and shore breaks,
work/surfing or requiring treatment from a health avoiding surfing on crowded waves, and knowing
professional. This was found to be the single his or her limitations when deciding which waves
greatest risk factor in that study. to surf and what maneuvers to perform.
Overall, the majority of injuries sustained
while surfing are minor and the rate of significant
injury in surfing is fairly low when compared to 48.3 Skateboarding
other sports. When looking at professional surfers,
the overall injury rate was 13 injuries per 1000 h Skateboarding is believed to have started around
surfed and only 6.6 significant injuries per 1000 h. the end of the 1940s and early 1950s when a
This is relatively low when compared to significant group of surfers began exploring ways of pursu-
injury rates of 69, 33, 18.8, 9, and 5.4 per 1000 h in ing the thrills of surfing in settings away from the
48  Extreme Sports 659

ocean. They thought of the idea of attaching and 6 times greater than surfing [16]. Given this
wheels to smaller versions of surfboards and fact, it’s not surprising that skateboarding also
“surfing” the city streets and empty pools. The has a greater risk of traumatic brain injury (TBI).
new activity was nicknamed “sidewalk surfing,” With regard to patients admitted to a hospital for
which later changed to skateboarding [10]. In the a skateboarding injury, it has been shown that
early 1960s, companies such as Larry Stevenson’s 36% have some form of TBI, with more than a
Makaha and Hobart “Hobie” Alter’s Hobie began third of these classified as severe TBI (e.g., sub-
to mass-produce the first true surfing-inspired dural/subarachnoid hemorrhage, epidural hemor-
skateboards [11]. Skateboarding quickly began rhage, or cerebral laceration/contusion). The risk
to grow in popularity. Today skateboards are used of TBI was shown to be even greater for patients
for recreation and transportation and in profes- over the age of 16, with an odds ratio of 2.53 for
sional skateboarding. In the USA alone, it is esti- sustaining severe TBI compared to their younger
mated that there are between 6 and 15 million counterparts. This is likely due to several factors
people that participate in skateboarding on some including the higher momentum of injuries from
level [12]. increased speed and body size of older riders, in
As the interest in skateboarding grew over the addition to the fact that older riders were signifi-
years, so did the risk of injury. While all extreme cantly less likely to be wearing a helmet
sports carry some level of risk, skateboarding has (Figs. 48.2 and 48.3).
been shown to be particularly dangerous.
Between 2015 and 2016, there were an estimated
121,400 skateboarding injuries in patients under
18 years of age treated in US emergency depart-
ments [13]. The rate of skateboard-associated
injuries has been reported as being 9 injuries per
1000 participants [14]. The majority of injuries
(55–63%) involve the upper extremity, followed
by the lower extremity (17–26%) and the head
(3.5–13%). Thoracoabdominal and spine injuries
make up only 1.5–3% of injuries. In children,
skateboarding is shown to be a significant source
of fractures. In a 2005 study, Zalavras et al. [15]
Fig. 48.2 A skateboarder demonstrates the acrobatic
found that 8.1% of all pediatric fractures present-
heights that put these athletes at risk for head and other
ing to a fracture clinic at a level 1 trauma center bodily injury
were attributed to skateboarding. Forearm frac-
tures made up 48% of fractures, 94% of these in
the distal third. Concerningly, 11% of forearm
fractures were open fractures, compared to 0.3%
of fractures sustained by other mechanisms of
injury [15]. Risk factors for injury that have been
described include fatigue, overuse, poor fitness,
age >16 years old, and lack of protective equip-
ment [12].
Head injury is one of the most important con-
siderations when caring for skateboard injuries.
Skateboarders were found to have by far the
highest risk of skull fractures compared with
other extreme sports—55 times greater risk than Fig. 48.3  A skateboarder performs a front side invert at
snowboarding, 28 times greater than snow skiing, an outdoor skate park
660 T. Parry et al.

Factors that were protective against TBI were new form of alpine recreation was developed
the use of a helmet and skating in a skate park, with the advent of snowboarding. Since its incep-
with odds ratios of 0.45 and 0.7, respectively tion, snowboarding has seen an incredible rise in
[17]. When major skateboarding injuries, defined popularity, now rivaling skiing in many countries
as an Injury Severity Scale (ISS) >9, were com- [19]. At present time, it is estimated that there are
pared to major injuries sustained during airborne several hundred million skiers and snowboarders
activities (e.g., hang gliding, kiting, and para- across the globe [20]. Considering this volume of
chuting) and mountain climbing, skateboarding participation, in addition to the combination of
was found to have the highest rate of loss of con- speed, obstacles (both natural and man-made),
sciousness (27%), prehospital intubation (33%), and aerial maneuvers performed while coming
and in-hospital mortality (15%) [1]. While admis- down the mountain, it is not surprising that skiing
sion rate is low in patients presenting to the ED and snowboarding are a significant source of
for skateboarding injuries (2.8%) [14], when sports trauma.
admission is required it is often due to head Although both sports take place in a similar
trauma and it is often serious. setting, different injury patterns are observed.
Skateboarding is one of the most popular Snowboarding appears to cause more frequent
extreme sports, particularly among the pediatric injuries than skiing. In a study from a base-lodge
population. While most injuries sustained are clinic in Vermont examining all snowboarder and
comparatively minor and treated in the outpatient skier injuries over the course of 18 years, Kim
setting, when hospitalization is required, injuries et  al. [19] found the mean number of days
are often severe and carry the possibility of long-­ between injury for snowboarders to be 345, ver-
standing dysfunction. Although not the most sus 400 for skiers. The most common injury type
common area of involvement, head trauma is the for snowboarders was involving the wrist—com-
most important injury consideration when bining sprains, distal radius/ulna fractures, and
­treating skateboarders. Some volume of injury is carpal fractures—whereas for skiers, the most
unavoidable, but certain precautions can mini- common injury was ACL sprain. When compar-
mize the number of injuries sustained. Patients ing the two sports, snowboarding was more likely
should be advised to always wear protective to result in wrist injury, ankle injuries, concus-
equipment including helmets, wrist guards, and sions, and clavicle fractures. Skiing, on the other
elbow and knee pads, skate in skate parks rather hand, was more likely to result in ACL sprains,
than in unregulated street environments, always MCL sprains, LCL sprains, lower extremity con-
have appropriate supervision, and receive educa- tusions, thumb metacarpophalangeal-ulnar col-
tion on proper safety techniques [17]. lateral ligament injuries, and tibia fractures.
Differences in types of injuries can be
explained by the differences in equipment.
48.4 Snow Skiing During snowboarding, both feet are strapped
and Snowboarding firmly to a single board. This limits the amount of
torsional load applied to the lower extremities, at
The practice of sliding down a snow-covered the expense of balance. Therefore, there are less
mountain with the aid of some form of board or twisting knee injuries resulting in ligamentous
ski beneath the feet is by no means a new con- injury, but more falls onto outstretched hands
cept. In fact, precursors to skis have been found resulting in wrist injury. Interestingly, if a
as far back as 2000 BCE in areas of Scandinavia ­snowboarder gets injured while one of his or her
and Siberia. Competitive skiing, however, likely feet detaches from the bindings, then knee liga-
originated in Norway in the mid-eighteenth cen- ment injury becomes much more likely to occur
tury. Acceptance slowly propagated around [19]. While relatively common in the skiing pop-
neighboring Scandinavia and, over time, to the ulation, making up 8–10% of all skiing injuries
rest of the globe [18]. In the 1960s and 1970s, a [18], thumb UCL injuries are almost nonexistent
48  Extreme Sports 661

in snowboarding. This is likely related to the dif- translate to increased safety. While it is accurate
ferent factors involved in patients landing on the that the incidence of some injuries decreases with
hand during a fall. In snowboarding, the hand is increasing skill level (such as upper extremity
free, and the thumb tends to hit the ground on the injuries, lacerations, contusions, and bruises),
radial side in an abducted and extended position. other injuries (such as those involving the trunk
This puts stress on the radial collateral ligament, and multiple body sites) tend to occur more often.
if anything. However, when the skier falls with In fact, the Injury Severity Score increases sig-
the thumb around a pole, this produces a radial nificantly with increases in skill level. This trend
directed force as the pole jams into the ulnar coincides with injury mechanism. As skill level
aspect of the thumb, leading to forced adduction increases to the intermediate and expert levels,
and extension and significant stress on the UCL rather than mostly being caused by isolated falls
[18, 19]. The differing mechanics and equipment as in novice and beginning snowboarders, inju-
involved between skiing and snowboarding ries are most commonly sustained from jumps
explain the observed differences in expected [22]. This relationship is further demonstrated
common injuries. when looking at injuries in elite snowboarders
Any sport involving high speeds and jumps that compete on the national level. Torjussen
demands special attention toward head and neck et al. [23] looked at injuries that occurred during
injuries. In the 2015 epidemiologic study of head snowboarding national cup and championship
and neck injuries in extreme sports over a 12-year events in Norway for the 2002 season. The
period [16], snowboarding was found to be the authors found that the most common injury loca-
number one cause of concussion, accounting for tions were the spine (20%) and knee (16%), both
30% of all reported concussions in that popula- body areas requiring a greater amount of energy
tion. Snow skiing followed closely behind snow- to injure. Essentially, as the rider becomes more
boarding, accounting for 25% of all concussions comfortable on the snowboard, he or she is more
in extreme sports. Even after correcting for num- likely to attempt more difficult tricks and ride
ber of athletes, snowboarding still had the highest down more difficult slopes, leading to a change in
incidence rate per person-years, with skateboard- the injury patterns observed (Fig. 48.4).
ing second and snow skiing third. It stands to rea- Skiing and snowboarding are some of the
son that with this many diagnosed concussions, a most common recreational sports in the world,
substantial number of subclinical head trauma is with millions of people on the slopes each year.
also taking place. Concussions and repeated mild However, recognition must be made of the poten-
trauma to the head have been shown to be associ- tial injuries that can occur. It is necessary for
ated with the development of chronic traumatic treating healthcare professionals to recommend
encephalopathy (CTE). Symptoms of CTE range
from headache, difficulty with concentration, and
depression all the way up to dementia, cognitive
dysfunction, and explosivity/aggression [21].
Helmet use has been associated with a 60%
reduction in the risk for head injury in skiing and
snowboarding. Unfortunately, helmet usage has
been reported as low as 20% [20]. Neck fractures
occur less commonly in skiing and snowboard-
ing. However, they cannot be discounted due to
the potential for long-term dysfunction.
In many activities, a participant’s rising skill
level is often associated with injury risk reduc-
tion. Unfortunately, in the world of snowboard- Fig. 48.4  Snowboarder performing a mute grab while
ing, increased experience does not necessarily snowboarding in Nassfeld, Austria
662 T. Parry et al.

proper safety measures including helmet use and tusions or abrasions, followed by fractures (24%)
matching slope style and tricks performed to the and dislocations/ligamentous injury (18%).
rider’s skill level. It should also be stressed, how- Fractures most frequently involve the upper
ever, that more experience does not inexorably extremity (51%), followed by the lower extrem-
result in more safety. ity (38%) and spine (6%). Interestingly, when
the lower extremity was injured, the injury
occurred on the left side 60% of the time. This
48.5 Motocross difference has been attributed to the fact that the
gear pedal is located on the left side of the bike,
The earliest form of motocross was devised in both providing less room for the foot to rest and
England in 1924, using small internal combus- increasing the time when the rider’s foot is not
tion engines attached to bicycles. As the sport has secured on the foot peg. This is coupled with the
evolved over the past century, the bikes have fact that riders often change gears during jumps,
become bigger and more powerful. Currently, leading to shifting on the foot peg right before
bikes weight up to 225 pounds and can generate landing [26].
more than 50 horsepower. While the majority of Head and neck injuries are of particular con-
race time and injuries occur at speeds around 25 cern in motocross. Although the spine is not the
miles per hour, this power enables bikes to reach most frequent location of fractures, nearly a third
top speeds over 100 miles per hour and careen of spine fractures sustained in motocross result in
more than 100 ft in the air off jumps [24]. As one permanent neurologic sequelae—paraplegia in
can imagine, this combination of speed, height, 63% and tetraplegia in 37%. Further, since the
distance, and weight of the bike can translate to initiation of indoor tracks, the likelihood of
significant injuries when do crashes occur developing permanent neurologic deficits after a
(Fig. 48.5). spine fracture has increased by 46% [26]. Sharma
Tomida et  al. [25] found the overall injury et al. [16] compared the rates of head and neck
rate for motocross to be 49.2 per 1000 h. Gobbi injuries across a variety of extreme sports, includ-
[26] reviewed all motocross injuries sustained in ing skateboarding, snowboarding, snow skiing,
the European off-road competition from 1980 to mountain biking, surfing, and snowmobiling. It
1981. From this data, the authors calculated an was found that, among these sports, motocross
overall annual injury incidence of 9.5%. When had the highest incidence of neck fractures and
separated into indoor and outdoor tracks, the the second highest amount of head fractures—
incidence was 15% and 7.6%, respectively. The skateboarding was number one. On the other
majority (58%) of injuries are classified as con- hand, when it came to concussion, motocross
ranked number four. The rate of head injury in
motocross may be higher in the pediatric popula-
tion. Daniels et al. [27] examined 298 motocross
injuries in patients under age 18 and determined
that 20% had head injury or TBI. Concerningly,
72% of these patients were wearing helmets at
the time of injury. Further, the authors com-
mented that this value likely underestimates the
total number of TBIs, as mild TBI is often over-
looked. In a prospective study surveying an entire
motocross season, 48% of riders self-reported at
least one symptom of concussion over the course
of the year [28]. With the recent focus on chronic
Fig. 48.5  Motocross rider losing control on a turn, crash- traumatic encephalopathy in other sports, these
ing into the barrier findings must raise some concerns.
48  Extreme Sports 663

A variety of mechanisms can result in differ- Riders should be approached face-on to avoid
ent injuries during a motocross event. Clavicle having them inadvertently turning their head to
fractures can occur with direct falls onto the answer questions. Helmet removal is recom-
shoulder. Scaphoid and distal radius fractures are mended for better assessment of the airway. This
more common in indoor stadiums where there must be done with great care by at least two pro-
are higher triple or double jumps and woops— viders—one stabilizes the spine from below and
steep short bumps in close proximity to one the other removes the helmet from above.
another. This allows for less time for riders to Interestingly, loss of consciousness is fairly com-
adjust and a larger chance for the front wheel to mon in motocross accidents but is not predictive
collide directly into face of the jump, driving the of significant head injury. Generally, riders that
handles into the extended wrist. Alternatively, lose consciousness recover in 1–2  min without
wrist fracture can occur in the more typical any neurologic deficit. A rapid assessment of
mechanism with falls onto outstretched wrists. whether the patient needs spinal immobilization
Metacarpal fractures can occur either indirectly, prior to leaving the track can be made using the
with forced abduction of the thumb while grip- acronym FAST—first safety, airway, spine, and
ping the handlebars, or directly, with a clenched thinking. First safety enforces the need for scene
fist ramming into the ground or an object. Tibial awareness. Airway can be assessed by asking the
plateau fractures can occur when landing hard on rider “Are you okay?” If able to answer, this con-
poorly executed jumps or by driving the foot into firms a patent and protected airway. The spine
the ground when using the leg as a pivot. can be evaluated by asking if the patient has any
Likewise, meniscal or knee collateral ligament neck pain, numbness, tingling, or weakness.
injuries can happen when using the leg as a pivot, Extra care must be taken during this step, how-
putting a large varus or valgus stress on the knee. ever, because of the short duration between time
ACL tears often result from forced hyperexten- of injury and assessment. At this point, the adren-
sion after the foot slips off the foot peg and drives aline from the crash is still high, and there has not
into the ground when landing. Thoracic spine been time for swelling to develop, so neck pain
fractures can occur with sudden and forceful for- may not be as obvious. Lastly, thinking can be
ward flexion after landing from a jump. Cervical assessed by asking the typical orientation ques-
spine fractures can result when riders somersault tions, in addition to asking the rider what hap-
over the handlebars and land directly on the head, pened during the crash. Retrograde amnesia of
causing hyperflexion [26]. This variety of injury the events of the crash has been shown to be the
patterns emphasizes the small margin of error best predictor of significant head injuries. If the
riders have when landing jumps at high speeds. rider fails any of these assessments, they should
Certain considerations need to be in effect be placed in full spinal immobilization before
when managing injuries at motocross events. being moved from the track and transported to a
Although most injuries sustained during compe- local ER or trauma center. Patients with less
tition involve the extremities, 10% are potentially emergent issues, such as extremity injuries, gen-
life-threatening injuries to the head, neck, and erally also require transport to a local hospital
other sensitive areas. Therefore, one must always unless appropriate medical staff and imaging
keep these potentially catastrophic injuries in capability is available [24].
mind when assessing the acutely injured rider. The speed and aerial spectacle that makes
The first assessment must involve scene safety. motocross exciting are the same factors that
These injuries occur on an active racetrack with make it a high-risk sport. Protective equipment
many tight corners and high jumps easily use is widespread and has been shown to
obstructing the view of other riders. Care must be decrease the injury risk. However, safety equip-
taken to extricate the injured rider as quickly as is ment cannot change the fact that motocross rac-
safely possible to avoid further injury to the vic- ing is inherently dangerous. Providing care to
tim, the treatment staff, or other competitors. motocross events requires familiarity with the
664 T. Parry et al.

spectrum of injuries that can occur—both life- design of an ATV—with its relatively high center
threatening and minor. of gravity, narrow wheelbase, and short turning
radius—confers an inherent instability that puts
the rider at risk for rollover [32]. Operating an
48.6 All-Terrain Vehicles ATV involves the rider sitting on top of the vehi-
cle, straddling it like a motorcycle, with no pro-
The first all-terrain vehicle (ATV) was created by tection in the event of collision or rollover.
John Plessinger as a graduate project in 1967 Furthermore, these vehicles are, by definition,
[29]. His design involved a rear-mounted engine used off-road on uneven terrain with frequent
with the rider sitting more within the vehicle, rapid shifts in center of gravity and potential need
providing a lower center of gravity compared to for swift course correction. Beyond the injuries
today’s models. This design was briefly manufac- sustained from simply falling off at high speeds,
tured by Sperry Rand. However, ATVs first these are relatively large vehicles with some
became widely available in 1970 with the incep- models weighing up to 600 pounds. This adds to
tion of the ATC 90 model from Honda Motor the risk for further injury if the vehicle were to
Company. Originally, the ATV was sold in both topple onto or run over the ejected rider. The
three- and four-wheel designs. combination of rollover risk, traveling speed,
Recognition of the high injury rate involving vehicle size, and operating conditions makes
ATV use became widespread in the 1980s. In ATV riding a particularly dangerous activity
1988, ATV manufacturers and dealers agreed to (Fig. 48.6) [33]
the ATV Final Consent Decree [30]. This agree- There is a significant injury risk with ATV use.
ment pushed manufacturers and dealers to pro- In 2016 alone, emergency rooms in the USA
vide sufficient safety information to consumers treated 101,200 injuries associated with ATV use.
both at the point of sale and in advertisements. Approximately 26% of these injuries occurred in
Furthermore, it enacted provisions such as elimi- children younger than 16. Between 1982 and
nating three-wheeled models, encouraging only 2016, there have been an estimated 14,653 ATV-­
single-rider use, offering free safety courses, rec- related fatalities. Of the total number of fatalities,
ommending against use of 70–90cc models to 22% occurred in children younger than 16 and
people less than 12 years of age, recommending 10% occurred in children younger than 12.
against use of models greater than 90cc by any- Injuries predominantly affect the upper extrem-
one less than 18 years of age, banning use on ity, head/neck, lower extremity, and torso—with
roads, requiring helmet use, and not allowing use
by children less than 16 without adult supervi-
sion. Results following induction of the Consent
Decree were encouraging. In 1985, prior to going
into effect, the average annual risk for injury
while riding an ATV was 2.1% [31]. Contrast this
to 1989, just one year after the Consent Decree,
when average annual risk fell to less than 1%
[32]. The Consent Decree expired in 1998 and
was replaced by the ATV Action Plan. The 2008
Consumer Product Safety Improvement Act took
regulations a step further and effected an outright
ban on importation, manufacture, or sale of three-­
wheeled models.
While it is important that safety regulations
Fig. 48.6  An ATVs due to their short turning radius, high
have been put into place, it is essential to recog- center of gravity, and narrow wheelbase are at high risk
nize the intrinsic risk in operating an ATV.  The for rollover and ejection of the rider
48  Extreme Sports 665

injury rates of 29%, 27%, 22% and 20%, respec- However, healthcare practitioners should be
tively [34]. Around 45% of injuries involve the aware of modifications that can make the activ-
musculoskeletal system. Fractures and or dislo- ity safer. The AAOS best summarized these rec-
cations account for 30% of all injuries. Pollack ommendations as:
et al determined that the most common locations
for fractures were the clavicle (24%), forearm 1. ATV drivers should be licensed, demonstrat-
(15%), and tibia/fibula (13%) [35]. ing competence and knowledge of safety
The rider’s age is a substantial risk factor for hazards.
injury. Although the group only contains 14% of 2. Riders must be at least 12 years old.
all ATV riders, children aged less than 16 years 3. Children aged 12–16 should have restrictions
old account for approximately one third of all on usage (supervision, engine size less than
injuries [32]. It has been shown that people 90cc).
between the ages of 11 and 15 are up to 10 times 4. Safety equipment must be worn (helmet,

more likely to be injured while riding than those gloves, boots).
over 40 years old [36]. It is thought that lack of 5. ATVs should only be operated during

both experience and knowledge of the intrinsic daylight.
danger of ATV riding contributes to the inflated 6. Only one person should ride at a time.
risk in this age group. Additionally, children 7. ATVs should not be operated under the influ-
under the age of 16 have not yet developed the ence of drugs and/or alcohol [33].
judgment or perceptual ability to safely operate
these vehicles. This danger is magnified as the
size of the engine and speed of the ATV increase. 48.7 Automotive Racing
Because of this, children under the age of 16
require supervision whenever riding and proper There are many different varieties of car racing,
safety training prior to use. In the same vein, chil- both on- and off-road, available to competitive
dren in this age group should not ride ATVs with drivers. Most types of automotive racing involve
greater than 90cc engines [33]. maneuvering at high speeds with multiple other
Other modifiable risk factors include riding drivers sharing the track and, therefore, risk for
with a passenger and helmet usage. Multiple high-energy collisions and rollover. Despite the
rider usage has been identified as a significant popularity of car racing, little studies have inves-
cause of morbidity and mortality. For example, in tigated the injuries sustained by drivers.
the USA, there were 1342 pediatric deaths from Stock car racing, such as NASCAR, is one of
ATV usage between 1982 and 1998. Of these the most popular varieties of car racing. On aver-
deaths, 75% were riding as a passenger [37]. It is age, NASCAR viewership is around six million
felt that adding a second passenger increases the people per race [38]. Average speeds of the win-
likelihood that the vehicle will tip or roll over ners of these races can range from 190 to 200
[33]. Wearing a helmet has been shown to signifi- miles per hour [39]. The largest study to date
cantly decrease the risk of injury to the head and examining injuries in stock car racing was per-
neck region. Given that 22% of the injuries sus- formed in 2004 by Minoyama et al. [40], looking
tained during ATV use are localized to the head at injuries that occurred at races at a single
and neck, wearing a helmet has the potential to ­speedway between 1996 and 2000. The investi-
substantially change outcomes. Despite the effec- gators separated out single-seat and saloon cars.
tiveness of helmet usage, actual utilization is Single-­seat cars are open-roofed with a much
worryingly low, with reported usage from 20 to smaller cockpit, similar to those used in Formula
37% [35, 37]. One racing. Saloon cars are the typical sedan-
Given what has been presented here, riding sized vehicles used in NASCAR. The injury rate
an ATV is an intrinsically dangerous activity in single-seat and saloon cars was found to be 1.2
with some risks that cannot be eliminated. and 0.9 injuries per 1000 competitors, respec-
666 T. Parry et al.

ronments to have a better understanding of the

true injury rate.
Despite the fact that racecar drivers travel at
higher speeds than any of the other extreme
sports discussed, it has been shown to have the
lowest incidence of injury. When injuries do
occur, they tend to be mild; however, fatalities do
occur. The limited research that does exist has
only looked at experienced professional drivers.
Likely, if novice drivers attempted to drive at the
Fig. 48.7  Crash that took place on the 11th lap of the
2011 IZOD IndyCar World Championship. This crash speeds that these athletes attain, then there would
resulted in the death of two-time Indy 500 winner Dan be substantially higher injury and mortality rates.
Wheldon. Wheldon was traveling at 220 mph just prior to Because of this, automotive racing should only
the crash be done by trained professionals in controlled
and regulated environments.
tively. The most common injuries in single-seat
cars were bruising (58%), neck sprain (34%), and
concussion (2%). There was one fatality reported 48.8 Airborne Sports
out of 1030 cars participating in 39 races. The
most common injuries in saloon cars were neck Airborne sports are all unified by the high speeds
sprain (53%), bruising (27%), fracture (8%), and and heights that participants achieve. This being
concussion (3%). It was felt that the higher rate the case, these sports are associated with more
of bruising in single-seat cars was related to the severe and, often, fatal injuries. Major injuries
limited space available in the cockpit, particu- from airborne sports trauma—defined as an
larly around the legs, with a higher chance for the Injury Severity Score >9—has been shown to be
driver’s body to crash into the sides of the car associated with the highest ISS when compared
(Fig. 48.7) to major injuries from mountain climbing, skat-
This was further evidenced by the fact that ing, and contact sports with average scores of 22,
most bruises in single-seat cars were in the lower 16, 15, and 10, respectively [1]. Because of the
extremity, while most bruises in the saloon cars small margin of error, when things go wrong in
were in the upper extremity. Neck injury was airborne sports they go very wrong.
more common in saloon cars than in single-seat Skydiving is one of the most popular airborne
cars, while head/face injury was more common sports. In the USA in the year 2000, it is esti-
in single-seat cars compared to saloon cars. This mated that 317,741 people made at least one sky-
is related to the much shorter distance between dive, adding up to 3.5 million total jumps [42].
the driver’s head and steering wheel in single-­ The injury rate in skydiving has been shown to be
seat vehicles. Because of this, the driver’s head is 1.7 injuries for every 1000 jumps. Two thirds of
more likely to crash into the steering wheel in injuries are classified as minor, with simple abra-
single-seat and, thus, cause injury to the head/ sions, contusions, and lacerations making up
face. Conversely, since the head is unlikely to 54% of all injuries. The rate of significant
contact the steering wheel in saloon cars, the injury—requiring treatment at an emergency
head/face are not injured, but the neck is free to room—is 0.6/1000 skydives. When patients do
travel through a larger range of motion and require treatment at an emergency department,
become strained. The annual rate of concussion less than one third require hospital admission.
per driver in car racing has been shown to be The most common injuries requiring emergency
from 0.67 to 1.64% [41]. This data suggests that department care were those involving the extrem-
the injury rate in professional racecar drivers is ities, making up 47%; 82% of these were to the
surprisingly low; however more research is lower extremity and 18% to the upper extremity.
needed across a broader spectrum of racing envi- The risk of mortality is fairly low, with one study
48  Extreme Sports 667

cataloguing 117,000 skydives reporting only one

fatality. Over time, the injury rate in skydiving
has been shown to decrease as equipment has
become more advanced. Innovations in skydiving
include switching from round to rectangular can-
opies, reserve static line (reserve chutes that auto-
matically deploy if the main canopy is cut away),
improved helmet design, and advances in altim-
eters. Rectangular canopies allow for better steer-
ing and braking, giving the skydiver better control
[43]. In a study looking at the injury rate in a
group of US Reserve Rescue unit skydivers, the
injury rate was found to drop from 11 injuries per
1000 jumps down to nearly 0 injuries per 1000
jumps following the switch from round to rectan-
gular parachutes [44]. Overall, the injury rate
from skydiving is quite low.
Buildings, Antennas, Spans, and Earth (BASE)
jumping is an activity where a person propels him
or herself off a fixed, elevated structure and uses a
parachute to glide down to the ground below. It has
been around for many years, but it became popu-
larized in the 1960s and 1970s by pioneers such as
Carl Boenish. Boenish helped coin the term BASE
jumping—which is an acronym for buildings, Fig. 48.8  A BASE jumper jumps off of a cliff. The low
antennas, spans (i.e., bridges), and earth (i.e., jump heights give jumpers little time to troubleshoot a
cliffs), signifying a collection of the structures complication with their parachute
from which participants jump (Fig. 48.8)
The fundamental danger of this activity is high-risk activity with significant chance of
exemplified by Boenish’s unfortunate death dur- major injury or death.
ing a jump in 1984 [45]. Because of the relatively Although the concept behind of skydiving and
low height from which jumpers take off, BASE BASE jumping is similar, the risk profile of the
jumpers do not have much time to deploy their two sports is wildly different. The added dangers
chute at a safe altitude. Not surprisingly, then, of nearby obstacles and limited time available for
BASE jumpers have been shown to have a five to course correction greatly elevate the risk posed
eight times increased risk of injury or death when by BASE jumping. In fact, the fatality rate from
compared to skydiving. Injuries have been BASE jumping is just slightly lower than the risk
reported to occur in 0.4% of all jumps. Most con- of sustaining an injury requiring treatment at an
cerningly, the rate of fatal injury has been shown emergency department while skydiving.
to be 0.4 deaths for every 1000 jumps [46].
During accidents, 72% of injuries involve the
lower extremities, 31% involve the spine, 18% 48.9 Conclusion
involve the upper extremities, and 3% involve a
head injury [47]. Typically, accidents occur when With the rising pop-culture influence of events
the chute opens facing the wrong direction, caus- like the Winter and Summer X Games, participa-
ing the jumper to collide into the object from tion in extreme sports is likely to continue to
which he or she jumped [46]. With the significant increase over the coming years. More partici-
speeds that jumpers reach and the small amount pants will certainly lead to more injuries; there-
of time for course correction, BASE jumping is a fore, physicians providing care to athletes must
668 T. Parry et al.

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 Judo, Brazilian Jiu-Jitsu, Wrestling,
and Mixed Martial Arts
49
John A. Bergfeld, Jonathan Gelber, Scott A. Lynch,
Peter H. Seidenberg, and Sérgio Rocha Piedade

49.1 Judo The milestone of judo as an Olympic sport

occurs when Dr. Jigoro Kano becomes the first
Created in 1882, in Japan, judo has in its DNA Japanese member of the International Olympic
contributions from various martial arts of samu- Committee (IOC) in 1909, bringing the philoso-
rais and feudal warriors, but mainly from its cre- phy of judo and the Olympic principles together.
ator Dr. Jigoro Kano who brought together Many years later, judo was introduced to the
concepts and techniques of traditional Japanese Olympic Program in Tokyo, Japan, in 1964, dur-
jujutsu, ancient forms of self-defense and physi- ing the XVIII Olympic Games, where judo had
cal concepts of action and reaction. Judo is a its first participation with male athletes, and then
sport based on education, hierarchy, humility, the female athletes officially joined the Program
and, mainly, respect for others, which are moral of the XXV Olympic Games in Barcelona, Spain,
values established by its maker. The philosophy in 1992.
of judo (“gentle way”) is present in most of the With every Olympic cycle, the interest and
sayings of Dr. Kano, such as “to give in to win”; strength of this sport have been increasing world-
“only those who seek it with constancy, wisdom wide [1], and this was notably evident during the
and above all great humility, comes close to XXXI Olympic Games in Rio de Janeiro, Brazil,
perfection.” in 2016, when 40 athletes from different coun-
tries were awarded medals. Even now, Japan
remains a reference in this sport, but countries
J. A. Bergfeld such as France, Russia, Brazil, Azerbaijan, the
Cleveland Clinic, Cleveland, OH, USA Netherlands, Georgia, and the USA have a fan-
e-mail: [email protected] tastic history of achievements in world
J. Gelber Championship and Olympic Games.
West Harford, CT, USA Like other martial arts, judo involves tremen-
e-mail: [email protected]
dous combat, and, therefore, it is not free from
S. A. Lynch · P. H. Seidenberg injuries [2]. The dynamics of judo takes in
Penn State University, Hershey, PA, USA
e-mail: [email protected]; throwing techniques (Nage-waza) that are per-
[email protected] formed standing and control techniques mainly
S. R. Piedade (*) done on the ground (Katame-waza). This martial
Department of Orthopedics and Traumatology, State art is practiced on a square area called dojo,
University of Campinas – UNICAMP, Exercise and which has a minimum of 64 m2 or a maximum of
Sports Medicine, Campinas, SP, Brazil
100 m2. In this space, two athletes fight, gripping
e-mail: [email protected]

© ISAKOS 2019 671

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_49
672 J. A. Bergfeld et al.

the judogui (judo uniform) to accomplish lever- Koma, known as Conde Koma, recognized
age body techniques, to change the opponent’s defender of self-defense techniques, arrived in
center of gravity, making him off balance and, Belem, state of Para, in 1914. To spread the art,
therefore, more vulnerable to fall. the master challenged fighters of different styles
Regarding the injuries, cuts and bruises usu- of martial arts around the world. His many and
ally present as minor and superficial injuries, incontestable victories aroused a great interest in
when they are deeper cuts that will need to be learning jiu-jitsu.
stitched or glued to stop blood flow, and the judo The friendship between master Maeda and a
combat may be interrupted. The acromioclavicu- member of the Gracie family, Gastao Gracie, was
lar, elbow, hand, and knee joints are commonly decisive to quickly incorporate this martial art
affected, mostly when the opponent tries to avoid into the life of the Gracie family. Over time,
his fall to account for ippon (perfect throwing Helio, Gastao’s youngest son, improved the tech-
technique) and to lose the combat. Although niques and concepts that allowed him to win
severe spine injuries are a rare clinical event, the combats against athletes physically stronger than
sports medicine physician should keep the eyes him from different fighting styles [4]. This
open to this possibility, particularly, when, during incredible trajectory was continued by his sons
the combat, the athlete falls hitting his head first and grandchildren, with remarkable achieve-
on the ground, followed by neck hyperflexion or ments and victories in the martial arts scene,
hyperextension, a potential mechanism for cervi- where many of them are referred to as a legend in
cal spine injury [3]. this sport.
A key point in the popularity of jiu-jitsu
was established by Helio Gracie’s oldest son,
49.2 Jiu-Jitsu Rorion Gracie, who created the Ultimate Fighting
Championship® (UFC), where seven great fight-
Although Japan is recognized as a stage of devel- ing athletes were reunited, including his brother,
opment and improvement of Jiu-jitsu, the precise Royce Gracie, who was physically weaker com-
origin of this martial art is not clear, as history pared to the other competitors. The tournament
records the presence of other similar martial arts was broadcast in the USA by the pay-per-view
in other places such as India, China, Egypt, and system, and basically, there were no rules, and
Persia. the fights did not have limit time, except for the
Jiu-jitsu was created to make a samurai elimination of the loser. Royce’s fantastic victory
able to skillfully defend himself from an over the other opponents further consolidated the
enemy, even when he had no weapons (sword). respect for Brazilian jiu-jitsu (Gracie’s jiu-jitsu)
Thus, this “art of self-defense without the use in the universe of fights [4], and, undoubtedly, the
of weapons” is based on the application of body event has become the embryo of the current
leverage and twisting techniques, opposing to MMA tournaments.
martial arts where weapons are used (Kenjutsu). Unlike Judo, where the throwing techniques
Over the years, new martial arts were derived are prominent in the combat (Fig. 49.1), jiu-jitsu
from the jiu-jitsu, making it temporarily distant focuses on techniques developed on the
and fragmented, until it returned in fullness with ground, such as immobilization, strangling,
the advent of the Brazilian jiu-jitsu. attacks on the joints (Fig.  49.2), which are per-
formed by body leverage, and overtaking, and
therefore, skins abrasions, cuts, and contusions to
49.2.1 Brazilian Jiu-Jitsu: Gracie the auricular and mandibular regions are com-
Family’s Contribution monly reported [5]. Joint-attack techniques can
lead to injuries such as sprains, contusions, dislo-
The pathway of jiu-jitsu in Brazil started when a cation, and fractures. Bottlenecks (mechanical
Japanese master of jiu-jitsu called Esai Maeda asphyxia) are common combat techniques, and
49  Judo, Brazilian Jiu-Jitsu, Wrestling, and Mixed Martial Arts 673

Fig. 49.1  Throwing technique: Nage-waza (Morote Seoi Nague)

OKURI ERI JIME

(Strangling)
JUJI GATAME
(arm lock)

Fig. 49.2  Control techniques (Katame-waza): Juji gatame (a and b), Okuri eri jime (c)

therefore the referee and the sports medicine staff flexibility, balance, and above all, a keen knowl-
need to closely observe the athlete’s response to edge of wrestling techniques. For high-level,
the attack and avoid the athlete’s longtime expo- equally-matched wrestlers, it becomes a physical
sition without adequate oxygenation. chess match with small adjustments that often are
unrecognized by spectators. The most popular
forms of wrestling can be divided into three
49.3 Wrestling forms. International wrestling, with its styles that
are included in the Olympic Games, consists of
Wrestling is one of the oldest known sports. It is Greco-Roman and Freestyle wrestling. The most
also among the most physically challenging of all practiced style in the USA, which is not practiced
sports. It is unique in many ways, requiring both much elsewhere, is Folkstyle—sometimes called
aerobic and anaerobic conditioning, strength, Collegiate or School Boy—wrestling. The ulti-
674 J. A. Bergfeld et al.

mate goal in all styles is to pin the opponent’s USA.  In this style, the pin occurs when both
back to the mat with both scapulae touching the scapulae are held to the mat for 1 s in collegiate
surface at the same time. Once this occurs, the wrestling and 2  s in the high school and youth
match is over, and the pinning wrestler is declared classes. The match starts with both opponents on
the winner. In each style, points are awarded for their feet; this is called the “neutral” position, and
dominating moves or penalties for illegal moves. each wrestler attempts to take the opponent to the
If no pin occurs, the wrestler with the most points mat to gain control. One main difference from
at the end of the match is declared the winner. As Greco-Roman and Freestyle rules and Folkstyle
the rules and point scoring systems of these styles rules is that once the “takedown” is awarded, the
are slightly different, some of the most common wrestling continues regardless of time, and the
injuries are also different as a reflection of the wrestler in the control position (top) tries to turn
different rules. the defensive opponent (bottom position) to their
Greco-Roman and Freestyle scoring rules are back. “Back points” are awarded for turning the
essentially the same, with the only difference opponent, with back exposure of 45° or less to
being that in Greco-Roman wrestling opponents the mat, for at least 2 s. No points are awarded for
are not permitted to attack the other wrestlers’ brief periods of exposure or for rolling across the
legs or use their legs to trip opponents. The pin back. Back points can only be earned by the
occurs when both scapulae of the shoulder touch wrestler that is in control. One other main differ-
the mat simultaneously, even for an instant. This ence is that the defensive wrestler (bottom posi-
is sometimes referred to as a “touch fall.” The tion) can earn points by either reversing control
bulk of the wrestling occurs with both opponents or getting back to the “neutral” position, where
standing on their feet, attempting to “takedown” neither wrestler is in control. Folkstyle matches
the other wrestler to the mat to gain control. are three periods in length with no rest between
Bonus points can be gained for taking the oppo- periods. Period lengths vary by age, with the col-
nent down to the mat while exposing the oppo- legiate level at 3-2-2 (in minutes) and high school
nent’s back to the mat or for high amplitude and at 2-2-2. The starting position for periods two and
arching throws to the opponent’s back. In these three are determined by the choice of each wres-
two styles, back exposure points are awarded tler. One wrestler chooses for period two and the
when the back is exposed past a 90-degree angle, other for period three. The wrestler that chooses
even for an instant. Once the “takedown” occurs, for period two is determined by coin flip.
the wrestler on top will have several seconds to Wrestlers can choose neutral, top, or bottom
attempt to turn the opponent to expose the back. position. If no pin occurs, the wrestler with the
If there is no progress toward turning the oppo- most points is declared the winner. Unlike Greco-­
nent over, the referee will stop the match and Roman and Freestyle wrestling, if the regular
return the wrestlers to the standing position for a match ends in a tie, overtime periods will con-
restart. In general, in these two styles of wres- tinue until a wrestler outscores the opponent.
tling, there is little attempt by the bottom wrestler
to get out or escape. Greco-Roman and Freestyle
have two periods of wrestling (3 min each for the 49.4 Epidemiology
higher-level competitions) with a rest between
periods (1-min rest period for higher-level com- Unfortunately, there is only limited data on wres-
petition). If no pin occurs, the wrestler with the tling injuries. The majority of published studies
most points is declared the winner. There is no come from the USA and show that injury patterns
overtime in Greco-Roman or Freestyle wrestling; and severity vary by age and style of wrestling
instead, in case of tie-on points, the winner is [6–14]. A limitation of this research is that, in the
declared by a tie-breaking criterion. USA, Greco-Roman and Freestyle participation
Folkstyle wrestling is mainly practiced by are usually limited to the more skilled group of
youth, high school, and collegiate wrestlers in the wrestlers, as nearly all novice wrestling clubs in
49  Judo, Brazilian Jiu-Jitsu, Wrestling, and Mixed Martial Arts 675

the USA begin with teaching of Folkstyle wres- the combined cohort of 1742 athletes. The most
tling. This may bias the data to a different injury common locations for injury were upper extrem-
type based on skill level or age, rather than a trueity (34%) followed by the neck and back (24%)
difference based on style. Likewise, most of the and the head and face (15%). Only 4.6% of par-
literature does not account for hours of practice ticipants had injuries that were severe enough to
and participation but usually reports the injury warrant removal from competition. Age was pos-
data from a particular competition [9, 14, 15]. A itively correlated with injury risk in the study.
few studies, which will be reviewed in more There were two significant limitations of the
detail later, encompass longer periods of time, study. First, the injuries were not differentiated
from a low of one season to a high of 11 years [7, by wrestling style, which is problematic as the
10, 11, 13, 16]. These studies are only in high rule differences may result in varying injury pat-
school and collegiate programs in US Folkstyle, terns. A second limitation is that injury rates
so its transference to other styles or age groups iscould not be calculated as the number of matches
uncertain. in which each athlete competed was not recorded.
Kordi et al. [16] reported on catastrophic inju-
ries sustained during Olympic style wresting, i.e.,
49.4.1 Greco-Roman and Freestyle Freestyle and Greco-Roman, in the county of
Iran. Wrestling is the national sport in Iran. This
Only a few studies address injury patterns for was a retrospective survey of wrestling clubs
Greco-Roman and Freestyle. Yard and Comstock throughout the country from July 1998 to June
[14] examined injuries for the pediatric age group 2005. In Iran, as with most countries outside of
(up to 20  years old) at the US National tourna- the USA, sports are not associated with schools,
ment. This tournament was the 2006 ASICS/ and athletes of all ages participate through clubs.
Vaughan Cadet and Junior National The authors identified 29 catastrophic injuries
Championships. The authors collected injury associated with wrestling (12 fatalities, 11 nonfa-
data on 3000 male wrestlers. In order to qualify tal, and 6 serious). Catastrophic injury was
for this tournament, a wrestler must place highly defined as “a sport injury that resulted in a brain
in state and/or regional qualifying tournaments. or spinal cord injury or skull or spinal fracture.”
As such, this data encompasses elite level wres- Although they do not explain well how they
tlers in the Greco-Roman and Freestyle disci- determined the number of wrestlers, the authors
plines. In addition, at this age, it is common for estimated a catastrophic injury rate of 1.99 cases
wrestlers to be entered into both styles. At the per 100,000 wrestlers per year. Most of the inju-
international level, competing in both Greco-­ ries occurred during practice during a takedown
Roman and Freestyle is extremely rare. The maneuver and were more frequent in the higher
injury rate at this tournament was 7.0 per 100 level and more experienced groups.
matches in freestyle and 4.6 per 100 matches in Shadgan et al. [15] reported on wrestling inju-
Greco-Roman. Freestyle had a higher incidence ries during the 2008 Beijing Olympic Games.
of knee injuries, while Greco-Roman had a This is one of the only studies that specifically
higher incidence of elbow and head/face/neck included elite female wrestling. At elementary
injuries. This is to be expected based on the rules and high school levels, girls will almost always be
of each discipline, since attacking the legs is not competing against boys. There are a limited num-
allowed in Greco-Roman wrestling, leading to ber of all-women collegiate programs, with the
more upper body contact and attempted throws in great majority of collegiate wrestling only includ-
Greco-Roman wrestling. ing men. At the international, including Olympic
Lorish et al. [9] prospectively examined injury levels, women and men are in separate tourna-
patterns during two youth (6–16-year-old) inter- ments that include only one sex. Women’s tourna-
national Freestyle and Greco-Roman tourna- ments are wrestled with Freestyle rules. This
ments. The overall injury incidence was 12.7% in study included a total of 343 athletes. Injuries
676 J. A. Bergfeld et al.

were only considered if they occurred during This was again a statistically significant differ-
tournament competition. Any injuries sustained ence. Impetigo, herpes simplex and ringworm
during a practice session during the tournament were the main three types of skin infections, with
were excluded. There were 32 injuries sustained herpes being more common in the college wres-
during 406 matches (9.3 injuries/100 athletes and tlers than high school wrestlers. Skin infections
7.88 injuries/100 matches). Men’s freestyle wres- accounted for 8.5% of high school and 20.9% of
tling had the highest injury rate, followed by college reported incidents, respectively. Among
Greco-Roman, with women’s wrestling having both the high school and college wrestlers, strains
the lowest rate. These rates were 10.1%, 9.3%, and sprains made up about half of all injuries.
and 7.5%, respectively. However, these were not The knee and shoulder were the two most com-
statistically significant differences. The majority mon sites of injury in both the high school and
of these injuries were minor, with skin lacerations college wrestlers. A little less than half of all
making up 59.4% of the injuries. There were no wrestlers in both high school (44.9%) and college
major or catastrophic injuries. Eighty-one percent (42.6%) missed less than 1 week of participation
of the injuries occurred in the standing position, time from wrestling. Most injuries occurred with
which is expected since the majority of the match the wrestlers in the standing position or while
is wrestled from the standing position for the executing a takedown, 54% in high school and
Freestyle and Greco-Roman disciplines. 69% in college. This is not surprising since when
the skill gap narrows, as it does in college, wres-
tlers usually spend more time in the standing
49.4.2 Folkstyle (Also Called positions because it is harder to establish domi-
Collegiate or Schoolboy) nance over the other wrestler.
Jarrett et al. [7] reported wrestling injury data
Yard et al. [13] compared high school and colle- over an 11-year period from 1985 to 1996 using
giate wrestling injury rates and patterns by col- the NCAA Injury Surveillance System (ISS).
lecting data at 74 high schools throughout the Note, that this data was collected prior to the ISS
USA and collecting data from 15 NCAA teams implementation to the online reporting system.
from all NCAA Divisions. The high school data Schools included in the ISS at that time were vol-
was collected via the High School Reporting untary contributors collected annually from 15 to
Information Online (RIO) system, and the NCAA 20% of NCAA schools that sponsor a particular
data was collected via its Injury Surveillance sport. A minimum of 15% of school participants
System (ISS). These two systems relied on each were required to come from each of the three
school’s athletic trainers to input online injury NCAA Divisions and 15% from one of each of
information. This study encompassed one season four geographic regions. The schools participat-
of competition, using the 2005–2006 academic ing in the data collection were not the same every
wrestling season data. The injury rate for high year. The average number of wrestling teams
school wrestlers was 2.33 injuries per 1000 that participated each year was 45. This repre-
athlete-­
exposures. The injury rate for college sented approximately 16% of the total number
wrestlers was 7.25 injuries per 1000 athlete-­ of schools that had wrestling during that time
exposures. This was a statistically significant dif- period. During this time, wrestlers had 873,479
ference. In addition, in both high school and athlete-­ exposures. The definition of athlete-
college wrestlers, there was a statistically signifi- exposure is one athlete participating in one team
cant higher rate of injuries during competition organized practice or competition. This defini-
than during practice. This study also collected tion can sometimes be problematic in wrestling
skin infection data. The rate of skin infections for or other individual sports, since it is common for
high school athletes was 0.22 infections per 1000 wrestlers to work out on their own or with one
athlete-exposures, and the rate for college was other wrestler. These exposures are likely not
1.91 skin infections per 1000 athlete-exposures. accounted for. Admittedly, it would be extremely
49  Judo, Brazilian Jiu-Jitsu, Wrestling, and Mixed Martial Arts 677

difficult to track those types of workouts. The rate Practice caused 63% of injuries with an injury
of injury for wrestlers was 9.6 injuries per 1000 rate of 5 per 1000 practice-exposures; however,
athlete-­
exposures. Only 37.6% missed more the injury rate was higher during competition with
than a week of time due to injury, and there was a reported rate of 9 per 1000 match-­exposures.
only one catastrophic injury, which was nonfa- The most common locations for injuries were the
tal. Similar to the Yard et al. study [13], the knee shoulder (24%) and knee (17%). Most injuries
and shoulder were the most common locations were minor with an average time missed from
for injuries, and sprains and strains made up the sport of 5 days. However, 5% of athletes suffered
highest types of injuries. For knee injuries, one of season-ending injuries, with the majority of these
the collateral ligaments was involved 30% of the due to knee trauma. The authors also reported a
time and meniscal tears accounted for 15% of the skin infection rate of 5%, with impetigo as the
knee injuries, with 6% involving the patellar and/ most common diagnosis. However, skin infec-
or patellar tendon, and 5% involving the ante- tions were not considered injuries in the study. In
rior cruciate ligament (ACL). Competition inju- this cohort, older and more experienced wrestlers
ries were more common than practice injuries at were more likely to be injured.
30.7 and 7.2 per 1000 athlete-exposures, respec-
tively. These rates were fairly stable throughout
each year of the study. Injuries that resulted in 49.4.3 Miscellaneous Issues Specific
more than 1  week of missed time included the to Wrestling
knee at 30%, the shoulder at 15%, and the ankle
at 8%. When surgery was performed, it was for Three issues are relatively unique to wrestling
the knee in 65% of the cases. Only 6.3% of inju- and other sports that have either weight cat-
ries required surgical intervention. Fifty percent egories or close one-on-one infighting, such as
of injuries occurred while in the standing posi- mixed martial arts. These include weight man-
tions or during takedowns, which is roughly agement and sometimes severe and rapid weight
similar to the Yard et  al. study [13]. Injury pat- loss and dehydration, skin infections, and auricu-
terns did not differ between practice and compe- lar hematoma.
tition or between weight classes. Skin infections Weight loss and dehydration is common in
accounted for 17.4% of incidences in this study. wrestling. Kraemer et al. [17] looked at the physi-
Otero’s group [10] retrospectively evaluated ologic effects of a simulated Freestyle wrestling
injuries in 125 NCAA Division I wrestlers from a tournament. The week prior to the tournament,
single institution over 10  years. The combined the wrestlers lost 6% of their body weight. They
practice and competition injury rate was 19.6 per then wrestled five matches over a 2-day period.
1000 exposures, with 96% of the athletes sustain- The authors found that lower body power and
ing an injury. The rate of injuries requiring sur- strength decreased significantly as the tournament
gery was 1.4 per 1000 exposures. It should be progressed. After each match, testosterone, lac-
noted that the authors considered skin infections tate levels, cortisol, norepinephrine, and plasma
as injuries, and when this was combined with lac- osmolarity significantly increased as compared to
erations, skin injury became the most common pre-match levels. Pre-match concentrations, how-
site of injury (17.5%) followed by the knee ever, serially lowered throughout the tournament,
(17.1%). There were no differences in injury so that by the end of the tournament, levels were
rates between weight classes. far below age-matched controls and were in the
Pasque and Hewett’s [11] study of injury pat- range of prepubescent boys. With such low levels,
terns in high school Folkstyle wrestling prospec- there may be compromise of testosterone’s ana-
tively examined 458 athletes over a single season. bolic properties. Whether weight loss associated
The cohort included both varsity and junior var- with wrestling is a cause of stunted growth has
sity level athletes. The injury rate was 52 per 100 been long debated, but this study might suggest
wrestlers and 6.0 injuries per 1000 exposures. that it is certainly a possibility.
678 J. A. Bergfeld et al.

The skin-to-skin contact between wrestlers The upper extremity, knee, and skin have been
increases the risk of transmitting skin infections listed as the most commonly injured body parts
as shown in some of the studies cited previously in different studies [9, 14, 15]. But it seems that
in this chapter [7, 10, 11, 13], particularly impe- lacerations, knee, and shoulder injuries make up
tigo, herpes simplex, and ringworm. Imai et  al. the bulk of the injuries, with knee injuries being
[18] showed that T-cell response to anti-CD3 more common in Freestyle than Greco-Roman
antibody was comprised, and interferon-gamma wrestling. This is to be expected since in Greco-­
production was reduced during rapid weight loss Roman wrestling, participants are not permitted
when comparing wrestlers that underwent rapid to grab the opponents’ legs or use their legs to
weight loss as compared to those that didn’t. This trip opponents. Catastrophic injuries are reported
may be a contributing factor in the high rates of by many investigators to be rare [9, 15], although
herpes viral infections and outbreaks in in Iran, the catastrophic injury rate was discov-
wrestlers. ered to be 1.99 per 100,000 wrestlers [16]. Most
Auricular hematomas, which can cause ear injuries occur when in the standing position or
deformity, often called cauliflower ear in lay- when executing a takedown [9, 14, 15, 16].
man’s terms, is common in wrestlers. In wres- Again, this is to be expected since the majority of
tling circles, it is often viewed as a badge of the match is spent with both wrestlers in the
courage and sign of brotherhood. This is a silly standing position.
concept since the ear deformity can be associated The reported injury rates in Folkstyle are
with hearing loss or increased risk of infection 2.33–6.0 injuries per 1000 exposures [11, 13] for
due to obstruction of the ear canal. After blunt high school and 9.6–19.6 for college [7, 10, 13].
trauma, blood can form in the subperichondrial Competition rates are higher than that of practice
space. This leads to formation of abnormal carti- in all styles and age groups [7, 10, 11, 13]. The
lage with fibrosis resulting in a hard and stiff most common mechanism of injury for all forms
deformed cartilage layer that permanently of wrestling is the takedown, but Folkstyle inju-
deforms the ear [19]. Treatments are designed to ries had a higher percentage of knee injuries and
try to maintain the ear’s normal shape, but these more injuries from when the wrestlers were not
are often unsuccessful. in the standing position than the international
styles [6–15]. Again, this is to be expected since
49.4.3.1 Summary Points Folkstyle rules create much more time for the
There are three styles of wrestling: Greco-­ wrestlers to be in non-standing positions.
Roman, Freestyle, and Folkstyle. The first two Skin infections are also common in wrestling
are international forms included in the Olympic with an estimated incidence of 5–17.5% and a
Games, while the third is most common in the skin infection rate of 0.22 and 1.91 per 1000
USA. Each style has different rules and, theoreti- athlete-­exposures for high school and collegiate
cally, injury patterns. In studies comparing wrestlers [10, 11, 13]. The most common of these
Freestyle to Greco-Roman wrestling, Freestyle are impetigo, herpes gladiatorum, and ringworm.
had higher injury rates with a higher percentage We have not seen rates of auricular hematoma
of knee injuries [14, 15]. In the only study to and cauliflower ear reported in the literature, but
include women’s Freestyle wrestling, women these appear to be quite high based on anecdotal
had the lowest injury rate [15]. In youth Freestyle observations [6, 8, 19].
and Greco-Roman tournaments, there was a
12.7% injury incidence during two tournaments,
though this study did not break out the two differ- 49.5 Mixed Martial Arts
ent disciplines [9].
The most common injuries reported in the lit- Mixed martial arts (MMA) is a combination of
erature on international forms vary among fighting arts including wrestling, boxing, and jiu-­
authors, making it difficult to form a consensus. jitsu and is arguably the world’s most rapidly
49  Judo, Brazilian Jiu-Jitsu, Wrestling, and Mixed Martial Arts 679

growing sport. Although the sport may seem nents into positions that will allow them to apply
foreign to some doctors and elicit an unsubstanti- a joint lock or choke hold.
ated negative response, today’s MMA competitor An example of ground work during an MMA
is a well-rounded, multidimensional athlete who bout; hyperextension injuries to elbows and
may need orthopedic care. knees, shoulder dislocations, and labral tears are
commonly sustained.
Today’s MMA athlete focuses on a wide vari-
49.5.1 Background and Evolution ety of martial arts disciplines as well as strength
and conditioning. Due to the individual nature of
Although evidence of similar forms of unarmed the sport, athletes may not have athletic trainers,
combat contests can be traced back to the original physical therapists, or team physicians, although
Olympics, today’s MMA largely evolved from some employ a nutritionist. As a result, MMA
the Brazilian tradition of Vale Tudo (or “any- athletes may seek advice from fellow fighters,
thing goes”) in the early 1900s. The Japanese boxing or jiu-jitsu coaches, or health profession-
fighting form jiu-jitsu was adapted by the Gracie als who train at the same gym.
family into a Brazilian form that stressed tech- Many MMA athletes have wrestling or other
nique over strength. These ground techniques backgrounds that rely on more “holistic”
rely on joint locks and choke holds to make an approaches to limit interventions by doctors and
opponent submit through a verbal or physical avoid surgery. As a result, many of these athletes
“tapout” [20]. shun traditional medicine in favor of Eastern
The original “Ultimate Fighting Champion- medical practitioners. Although alternative treat-
ship” (UFC) was partly an effort to market Gra- ments may have a role, team physicians need to
cie jiu-jitsu to North American audiences. In this educate MMA athletes on the value of classic
multifight, single-night tournament, practitio- sports medicine.
ners of different martial arts would face off to
prove the superiority of their fighting form. With
few rules and no time limits, rounds, or weight 49.5.2 Common Orthopedic Injuries
classes, the UFC incited a wave of criticism.
Detractors called the sport barbaric, comparing it MMA athletes are at risk for a wide variety of
to a human version of cockfighting. musculoskeletal injuries. During a fight, an
In response, the UFC—along with knowl- MMA athlete may experience lacerations, orbital
edgeable ringside physicians and referees— fractures, metacarpal fractures, or other striking-­
began to establish weight classes, rounds, and a related injuries. Because the lightweight gloves
point-based judging system. These changes are also fingerless, inadvertent eye-pokes may
enhanced fighter safety, and states began to regu- occur. Athletes have also sustained shoulder dis-
late the sport. Soon the disciplines of the fighters locations and tibial fractures [20].
began to evolve as well. Instead of training in Many joint locks require hyperextension of
only one discipline, athletes began to train in the affected joint. Such hyperextension can lead
multiple fighting forms, leading to the term to injury during training or before a referee can
“mixed martial arts” [20]. stop a fight. Elbows and knees are most at risk for
MMA involves both stand-up and ground hyperextension injuries although shoulder dislo-
work. Stand-up fighting entails punches, kicks, cation or labral tears from cranking the shoulder
knees, and elbows. (Elbows to the back of the in an awkward position are also common. In addi-
head and kicking/kneeing a downed opponent in tion, MMA athletes often sustain injuries to the
the head are illegal.) Ground work is often a com- anterior cruciate ligament (ACL) or meniscus.
bination of wrestling and jiu-jitsu or another Knee and shoulder injuries commonly occur
submission-­ based martial art. While on the during training camp or practice, because the
ground, fighters will attempt to lure their oppo- athletes are using grappling and takedown tech-
680 J. A. Bergfeld et al.

niques rather than sparring or stand-up striking. a bridge between sports medicine and MMA
These often include meniscal or ligament inju- while educating and providing better care for
ries in the knee and labral, rotator cuff, or acro- these athletes.
mioclavicular joint injuries in the shoulder.
Because many MMA athletes also lift weights
for strength and conditioning, overuse injuries 49.6 Responsibility of the Sports
may occur [20]. Physician Unique to Combat
Other injuries include hyperextension injuries Sports
of the elbow capsule and ligaments or foot sprains
from getting caught on the mat or during a scram- To adequately treat these athletes, the sports
ble. During competition or in the training camp physician must understand the culture of the
leading up to the fight, striking becomes a more sport as well as the unique medical issues.
regular training routine, and metacarpal fractures These athletes are not part of a team, they partici-
and finger dislocations tend to occur. pate as individuals. Most do not have medical
The athlete’s needs and the pressures of the insurance, and there is no off-season. The gov-
sport must be considered when recommending erning bodies are often weak and in the USA,
treatment. For example, an ACL allograft may each state has different rules of competition. An
allow a quicker rehabilitation (which the MMA athlete may suffer a concussion and be prohibited
athlete will seek) but increase the risk of re-­ from competition for 3  months in one state yet
rupture (given the intense nature of the sport and fight a week later in another state [21].
its training). Similarly, a metacarpal fracture may These athletes often have weight restrictions,
be immobilized, but the pressure to continue to and the most weigh-ins occur the day before the
train may limit the athlete’s compliance. Frank competition or often the day of competition.
discussions about treatments and options to work These athletes may also use rapid, unsafe weight
around the injury are necessary. controlling techniques resulting in significant
Treating physicians must also consider the kidney dysfunction, cardiovascular strain, and
athlete’s schedule. An athlete who misses a neurocognitive dysfunction. In the USA, the
scheduled fight will not get paid and may lose the NCAA wrestling federation recognized these
weeks of training he has invested to that point. issues and has strict rules concerning the athlete’s
After the fight, the athlete will have more time for weight competition.
possible surgery and recovery. Performance-enhancing drugs are often
Although MMA gloves are lighter, and the abused as regulation of their use is often vague in
fights are shorter than in boxing, MMA fighters different countries and in the USA by state.
are still at significant risk for concussion and long- Anabolic steroids, human growth hormones, and
term mild traumatic brain injury. In fact, most of abuse of the testosterone replacement therapy are
the accumulated brain injury may occur during significant and are a poorly controlled issue.
training for a fight. Many athletes may not even Concussion is a significant problem in com-
know that a knockout involves a concussion [20]. bat sports. A knockout or a technical knockout is
Education on the long-term risk of hard spar- the often the determining factor in winning a
ring as well as on the impact of multiple subcon- bout.
cussive episodes is important, especially for The MMA gloves are significantly light than
young athletes entering the sport. More research the classic boxing gloves, therefore able to deliver
is required to understand the effects of long-term a significant concussive blow to the head. Many
exposure in earlier generations of MMA fighters. mild concussions may occur while training for a
As MMA becomes more popular, we as sports bout where there may be unrecognized signifi-
physicians and surgeons will see more of its ath- cant cumulative mild traumatic brain injury.
letes in our practices. By understanding the ath- Being physicians to these combat athletes is
lete’s needs and the sport’s culture, we can build rewarding as there is no sport that needs well-­
49  Judo, Brazilian Jiu-Jitsu, Wrestling, and Mixed Martial Arts 681

trained culturally savvy physicians to protect the 2. Pocecco E, Ruedl G, Stankovic N, Sterkowicz S,
Del Vecchio FB, Gutiérrez-García C, et al. Injures in
athletes from significant harm yet letting them judo: a systematic literature review including sugges-
compete. tions for prevention. Br J Sports Med. 2013;47(18):
In the USA, the Association of Ringside 1139–43.
Physicians conducts an annual seminar address- 3. Čierna D, Štefanovský M, Matejová L, Lystad
RP.  Epidemiology of competition injuries in elite
ing the problems, issues, and concerns of combat European judo athletes: a prospective cohort study.
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therapists, and athletic trainers [21]. 4. Scoggin JF III, Brusovanik G, Izuka BH, Zandee van
Rilland E, Geling O, Tokumura S.  Assessment of
In association with the American College of injuries during Brazilian jiu-jitsu competition. Orthop
Sports Medicine, the Association sponsors a cer- J Sports Med. 2014;2(2):2325967114522184. https://
tification examination. More information may be doi.org/10.1177/2325967114522184. eCollection
obtained from the Association’s website—www. 2014 Feb.
5. Ingvaldsen CA, Tønseth KA.  Auricular haematoma.
ringsideARP.org. Tidsskr Nor Laegeforen. 2017;137(2):105–7. https://
It is our job not to prevent competition but to doi.org/10.4045/tidsskr.15.1279.
do all we can to allow these athletes fulfill their 6. Halloran L.  Wrestling injuries. Orthop Nurs.
dreams to compete safely. 2008;27(3):189–92; quiz 193–4. https://doi.
org/10.1097/01.NOR.0000320548.20611.16.
7. Jarrett GJ, Orwin JF, Dick RW.  Injuries in col-
Take-Home Message legiate wrestling. Am J Sports Med. 1998;26(5):
• The dynamics of judo involves throwing tech- 674–80.
niques (Nage-waza) that are performed stand- 8. Kiningham R, Monseau A. Caring for wrestlers. Curr
Sports Med Rep. 2015;14(5):404–12. https://doi.
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• Jiu-jitsu emphasizes techniques developed on SG. Injuries in adolescent and preadolescent boys at
the ground, such as immobilization, stran- two large wrestling tournaments. Am J Sports Med.
1992;20(2):199–202.
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• Wrestling has a close relationship with weight program: an epidemiological study. Iowa Orthop J.
management and sometimes severe and rapid 2017;37:65–70.
11. Pasque CB, Hewett TE.  A prospective study of

weight loss and dehydration, skin infections, high school wrestling injuries. Am J Sports Med.
and auricular hematoma. 2000;28(4):509–15.
• Today, an MMA athlete should have broad 12. Perri BR, Lynch SA.  Common injuries in the

knowledge on variety of martial arts disci- skilled wrestler. Curr Opin Orthop. 2003;14(2):
109–13.
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adequately and also preserve the athlete’s ric freestyle and Greco-Roman wrestling injuries
health in the field. sustained during a 2006 US national tournament.
­
Scand J Med Sci Sports. 2008;18(4):491–7. Epub
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Part X
PROMs
 PROMs in Sports Medicine
50
Sérgio Rocha Piedade, Mario Ferreti Filho,
Daniel Miranda Ferreira, Daniel A. Slullitel,
Sarthak Patnaik, Gonzalo Samitier,
and Nicola Maffulli

50.1 Background ness, and economic purposes and, therefore,

reflecting physically and psychologically on their
The interest in performing regular sports activ- daily living and their quality of life.
ity has been increasing every year, and, conse- Compared to the general population, athletes
quently, the number of people adopting physical have different expectations and goals that make
activity as a concept of healthy life or even as “a their lifestyle singular. Sports are not free from
kind of religion” has risen. Moreover, it is not just injuries, and consequently their practice exposes
a lifestyle for recreational athletes or professional the muscle, tendon, ligament, bone, and joint to
athletes but an activity involving happiness, fit- overload, tensile stress, and direct and indirect
trauma of high and low energy that could cause
S. R. Piedade (*) tissue damage of different patterns.
Department of Orthopedics and Traumatology, State While huge progress has come to the sports
University of Campinas—UNICAMP, Exercise and medicine area, regarding safety measures for
Sports Medicine, Campinas, Sao Paulo, Brazil
e-mail: [email protected] sports practice, protective sports equipment, rou-
tine, and periodic pre-participation evaluation
M. F. Filho
Department of Orthopedics and Traumatology, before permitting the athlete to start sports or
UNIFESP, Sao Paulo, Brazil return to sports practice, musculoskeletal injuries
D. M. Ferreira remain as “part of the game.”
Department of Radiology, State University of Without doubt, these injuries present a com-
Campinas—UNICAMP, Exercise and Sports mon clinical problem that affects the general
Medicine, Campinas, Sao Paulo, Brazil population but has a noticeable incidence in
D. A. Slullitel sports practitioners, recreational or professional
Instituto Jaime Sulllitel, Rosário, Argentina ones. Moreover, according to the modality of
S. Patnaik sports, some anatomical sites and musculoskele-
Department of Arthroscopy and Sports Surgeon, tal structures are more exposed to injury than oth-
Sunshine Hospitals, Bhubaneswar, Odisha, India
ers, for example, the shoulder in judo, the spine
G. Samitier and head in football, the ankle and knee in soccer,
Hospital General de Villalba, Madrid, Spain
and the face, hand, and elbow in martial arts.
N. Maffulli For many years, the analysis of outcomes
Department of Musculoskeletal Disorders, Faculty of
Medicine and Surgery, University of Salerno focused on different aspects of knowledge
Baronissi, Salerno, Italy regarding sports injuries, biomechanics, biologi-
e-mail: [email protected] cal behavior of living tissues, extension of tissue

© ISAKOS 2019 685

S. Rocha Piedade et al. (eds.), The Sports Medicine Physician,
https://doi.org/10.1007/978-3-030-10433-7_50
686 S. R. Piedade et al.

damage, and also in the sports physician and observed, measured with a device, or analyzed
orthopedic surgeon’s experience. However, in even by the most sophisticated imaging methods.
the last two decades, the analysis of outcomes With the use of PROMs, we can capture the
has paid more attention to patients’ perception patient’s experience. It may provide a measure-
on the whole process of treatment, medical care, ment of the outcome of an operation or provide
time of recovery, and expectation to return to clinical treatment, based on the patient’s view.
prior level of physical activity as well as their Professional athletes have different physical
understanding of the level of injury. In other and psychological overload from the general
words, outcome tools have started considering population. Not only is the athlete’s functional
the client’s point of view. recovery often important but also economic and
financial aspects are involved. Although PROMs
are considered the gold standard when evaluating
50.2 Patient-Reported Outcome outcomes in clinical or surgical treatment, in the
Measures case of high-performance athletes, they need to
evaluate each individual in a global way, taking
Patient-reported outcome measures (PROMs) are into consideration all aspects that may change
self-completed questionnaires that can measure their physical and psychological expectation.
a variety of global, disease-specific, and joint-­ PROMs have been increasingly used by clini-
specific outcomes and have become the gold stan- cians to guide and audit routine care and are
dard when quantifying a patient’s posttreatment already firmly embedded in clinical research. In
experience. In the era of patient-centered care, addition, the routine clinical use of PROMs may
there has been a dramatic increase in the num- allow to track treatment impact more effectively,
ber of PROMs within medicine and orthopedics, and, therefore, help the development of optimal
specifically. However, we have different types of management strategies.
reports focused on each of the joints, such as the The use of PROMs to measure health status in
shoulder, elbow, knee, and hip but without tak- routine practice has some distinct advantages over
ing into account the difference in the evaluation traditional research-based outcome measures.
of the overall result of the sports’ practice and The Activities Scale for Kids (ASK) is a self-­
not just of a joint [1]. Regarding the proposed report measure of childhood physical disability that
treatments, there are different psychological and has excellent reliability. The ASK is a valid and
physical outcome expectations for high-perform- responsive outcome measure designed for children
ing athletes and recreational athletes. 5–15 years of age who are experiencing limitations
Outcome measures reported by patients in physical activity due to musculoskeletal disor-
(PROMs) are used to assess satisfaction after sur- ders. The quality of this measure enables clinicians
gical or clinical treatment and reflect the patient’s and researchers to measure outcomes in a way that
perspective on their health status. The use of is relevant to patients and also in a way that is sensi-
PROMs in clinical practice helps to ensure that tive to small amounts of change [2].
the patient’s “voice” is present in all aspects of the When searching for appropriate PROMs, it is
care, which is essential to guarantee that the thera- important to ask, “what do I want to measure?
peutic management remains patient-centered. What is the reason for the assessment? At which
PROMs capture the patient’s own opinions on the level will the measurement take place (group or
impact of their condition, treatment, and life. individual)?” When aiming to benchmark the ser-
Every physical activity itself is a stressful vice performance, it is also important to ask
physical or psychological condition since it is which PROMs are recommended and being used
more dependent on the psychological condition by others [3].
of how each athlete faces adverse conditions than PROMs can assist in the clinical process for
the level of competition. Many factors that char- diagnosis and treatment, with specific focus on
acterize an athletes’ health status cannot be the patient’s perspective, identifying problems
50  PROMs in Sports Medicine 687

related to functioning and activities in daily liv- postoperative periods and monitor changes in
ing. Thus, PROMs can assist establishing treat- function status over the time.
ment objectives and monitoring treatment results. Due to the ease of collecting information, they
Despite the complexity of health measurements, are used in both research and clinical practice.
clinicians recognize that the importance of using They can be general health measures, joint-­
PROMs to improve the care process by enhanc- specific measures, or even disease-specific mea-
ing communication, improving patient’s educa- sures. Generally, they are divided into different
tion, allowing shared decision-making, and domains, such as pain, function, and satisfaction.
monitoring treatment response. However, several Each domain consists of questions which should
barriers have been identified in using PROMs, be responded by the patient. These questions
and these could lessen their usefulness in inform- should be able to capture the patient’s actual
ing important healthcare decisions: (a) the health condition.
absence of a PROM collection infrastructure and Ideally, a PROM has to be easily understood
(b) a lack of knowledge and confidence in using and answered by a patient as well as easily inter-
outcome measures [3]. preted and scored by a clinician or researcher.
These characteristics are considered important,
since they help to reduce the amount of missing
50.3 Instruments of Outcome data. The choice of the PROM should also be
Measures based on its measurement properties and target
patient (e.g., age, gender, disease).
In the literature, several outcome measure A high-quality measure instrument should be
instruments have been developed in order to reliable, valid, and responsive for the patient of
evaluate different musculoskeletal disorders and interest. Reliability refers to the precision of an
surgical treatments. Many of these are clinician- outcome measure to assess and avoid measure-
related outcome measures that evaluate from the ment error. Validity is the ability to correctly
clinician’s perspective, through a physical exam, measure what the instrument intended to. Finally,
for instance. However, the patient’s perception responsiveness is a measurement property of the
in judging the treatment efficacy has become instrument that refers to the ability to detect
increasingly more important in the orthopedic changes over time.
setting. Many of the measure instruments are only
In recent years, subjective questionnaires have validated for specific conditions, and their quality
been created with this objective as well as to eval- varies considerably. It is also important to know
uate the patient’s satisfaction. Such instruments the Minimally Important Change (MIC) of the
have important advantages over traditional PROM to be used. MIC value reflects to the
clinician-­based outcome measures. Its utilization smallest measured change score perceived by the
stimulates better communication between physi- patient as clinically important. Therefore, know-
cian and patient, besides helping patients’ educa- ing this value helps to decide whether the patient
tion regarding their health condition. The has benefited or not from a treatment.
patients’ active participation when filling out the Unfortunately, the MIC value depends on several
questionnaire helps them better understands the factors, and, therefore, they are not always
impact of the injury on their life and to be aware reported.
of their physical limitations. In order to provide Even though many PROMs commonly con-
better value in healthcare, it is mandatory to tain questions related to the impact of the injury
define what constitutes a good outcome. on sport practiced by the patient, they are gener-
PROMs are tools in the form of questionnaires ally developed for the general population. There
that evaluate results subjectively following mus- is no well-established questionnaire to evaluate
culoskeletal injury or surgical intervention. The athletes specifically. One of the main problems
questionnaires can be used to compare pre- and with PROMs used in sport-specific population is
688 S. R. Piedade et al.

that even if the patient reaches the roof of the patients of different ages are available [6]. Such
functional domain in the test, it does not mean values help researchers to interpret results and
that the athlete is ready to return to sport. compare different populations [7, 8].
Therefore, other instruments such as physical
exam, muscle reaction time, and muscle strength
should be used to decide return to sport. 50.5 Disabilities of the Arm,
Anyway, PROMs is a valuable tool to access Shoulder, and Hand (DASH)
musculoskeletal injuries and disorders and QuickDASH Outcome
approached surgically or conservatively, and the Measure
more frequently used ones in each area are listed
and discussed below. The DASH outcome measure is a self-report,
30-item questionnaire developed, and published
by the Upper Extremity Collaborative Group in
50.4 International Knee 1996 [9]. The questionnaire was designed to
Documentation Committee evaluate symptoms and physical function in
(IKDC) Subjective Knee patients with any musculoskeletal disorder in the
Evaluation Form upper extremity. In addition, it serves to capture
restrictions for both work and physical activities
The original IKDC form was published for the as well as monitoring changes in functional sta-
first time in 1993 with the purpose to be a stan- tus over time perceived by the patient [10]. A new
dard documentation system for knee ligament DASH questionnaire with only 11 items to
injuries. It is a one-page form that includes a respond to (QuickDASH) was published in 2005.
documentation section, qualification section, and The reliability, validity, and responsiveness of the
evaluation section. The form can be used not only QuickDash have been shown to be comparable to
in pre- and post-operation but also in patient’s the DASH [11].
follow-ups [4]. In 2000, a new IKDC form (IKDC The DASH questionnaire contains 30 items,
subject knee evaluation form) was published as a and its response options range from 1 to 5 (1, no
revision of the original IKDC. The IKDC subjec- difficulty; 2, mild difficulty; 3, moderate diffi-
tive knee evaluation form has been shown to be a culty; 4, severe difficulty; 5, unable). The DASH
reliable and valid tool for measurement of sub- provides a final score ranging from 0 to 100,
jective outcomes in several knee disorders, where 0 indicates no disability and 100 indi-
including ligament and meniscal injuries, carti- cates severe disability. Ideally, all questions
lage lesions, and patellofemoral conditions [5]. should be responded, and the DASH score may
The IKDC subject knee form contains 18 not be calculated if more than three items are
questions: 7 questions related to symptoms, 2 missing (QuickDASH tolerates only one miss-
questions related to general function (1 item for ing item out of 11 to be answered). An exact
sports activity and 1 item for current knee func- score in one scale does not correspond to the
tion), and 9 questions related to daily activities. same score in another scale. However, they are
The score can be calculated if there are responses probably close. The questions are about symp-
for at least 16 questions in the form. Following toms and abilities to perform daily activities
completion of the form, the scores are then trans- with the upper extremity, and they should be
formed to values in a scale that ranges from 0 to responded based on the patient’s condition in
100 [5]. A score of 100 is interpreted to mean no the previous week to the responses. There are
physical limitations and symptoms. A score of still two optional four-item modules (Work
11.5 and 20.5 points in IKDC is a more sensitive Module and Sports/Performing Arts Module) in
and specific minimum value, respectively, to both questionnaires that are calculated sepa-
detect a clinically relevant difference in a patient’s rately. The Work Module measures the ability to
status. Normative data from male and female work, and the Sports/Performing Arts Module
50  PROMs in Sports Medicine 689

measures the impact of the upper limb disorder ties for those rehabilitating from acute or chronic
on playing musical instrument or sport [9–11]. episodes of low back pain. The ODI is a valid,
reliable, and responsive condition-specific
assessment tool that is suited for use in clinical
50.6 T
 he Foot and Ankle Outcome practice. The minimum clinically important dif-
Score (FAOS) ference (MCID) has been calculated for ODI for
LBP patients, ranging from 7 to 15 [19, 20] and
The FAOS was developed to evaluate the opinion can be used as a threshold change to compare the
of patients about symptoms and physical limita- effectiveness of different surgical and nonsurgi-
tions related to foot and ankle disorders, like lateral cal procedures for a variety of conditions affect-
ankle instability, Achilles tendinosis, hallux valgus, ing the spine [21].
and hallux rigidus [12–15]. It is one of the most The ODI consists of 10 sections, with 6 state-
commonly used foot- and ankle-specific PROMs; ments in each one, scoring from 0 to 5. When
however, there is still limited evidence evaluating answering the questionnaire, patients should
its measurement properties [16, 17]. Content valid- take into account the present moment. The items
ity and reliability of the FAOS was initially con- are related to the intensity of pain, personal care
firmed in patients with lateral instability of the (washing, dressing, etc.), lifting objects, walk-
ankle, and it has been shown to be highly reproduc- ing, sitting, standing, sleeping, sexual life, social
ible both inter and intra-­investigator [12, 18]. life, and locomotion. Scores are obtained by the
FAOS is a 42-item questionnaire separated in sum of the 10 questions multiplied by 2 which
five subscales: pain (9 items), other symptoms (7 results in a percentage ranging from 0 to 20%,
items), activities of daily life (17 items), func- minimal disability; 21–40%, moderate disability;
tional sports and recreational activities (5 items), 41–60%, severe disability; 61–80%, crippled;
and foot- and ankle-related quality of life (4 and 81–100%, bed-bound [22].
items). Patients should take into account the last
week before answering the questionnaire. The
score ranges from 0 to 4 for each question, where 50.8 EQ-5D EUROQOL Health
0 indicates extreme symptoms or disability and 4 Status Questionnaire
indicates the absence of symptoms or no disabil-
ity, depending on the question. Regarding miss- The EuroQol Health Status Questionnaire (EQ-­
ing data, when up to two values are omitted, they 5D) is a measure of health-related quality of life
are substituted with the average value for that that can be used in a wide range of health condi-
subscale. If more than two items are omitted, the tions and treatments. It generates a representative
subscale is considered invalid. Each subscale is index of the health status of an individual based on
graded separately on a scale ranging from 0 to a classification system that uses five dimensions to
100, where lower scores indicate more severe describe the health state: mobility, self-­care, usual
symptoms. In the end, the subscores can be pre- activities, pain/discomfort, and anxiety/depres-
sented graphically as an FAOS profile. It takes sion. Each of these dimensions presents three
7–10 min to fill the questionnaire out and can be alternatives with associated severity levels, corre-
downloaded online [12, 13]. sponding to “no problems” (level 1), “some prob-
lems” (level 2), and “extreme problems” (level 3)
experienced or felt by the individual. The scores
50.7 O
 swestry Disability Index on these five dimensions can be presented as a
(ODI) health profile or can be converted into a single
summary index number (utility) in order to estab-
The Oswestry Disability Index (ODI) is a ques- lish comparisons between other health profiles and
tionnaire which gives a subjective percentage allow the description of a total of 243 different
score of the level of function in daily life activi- health states in evaluated individuals [23, 24].
690 S. R. Piedade et al.

50.9 S
 F-12 Short-Form-12 Quality rating of change. The LEFS is used for measuring
of Life Questionnaire lower-extremity function in a wide variety of dis-
orders and treatments [29, 30].
The SF-12 is one of the most widely used instru- The final version of the LEFS consists of 20
ments for assessing self-reported health-related items, each with a maximum score of 4. The total
quality of life. Originally developed from the possible score of 80 indicates a high functional
36-item Short-Form Health Survey SF-36, the level. The introductory statement of the question-
SF-12 covers the same eight health domains as naire states: “Today, do you or would you have
the SF-36 (General Health, Physical Functioning, any difficulty at all with:” followed by a listing of
Physical, and Body Pain, Vitality, Social functional items. Items are rated on a 5-point
Functioning, Emotional, and Mental Health) with scale, from 0 (extreme difficulty/unable to per-
substantially fewer questions, making it a more form activity) to 4 (no difficulty) [31]. Questions
practical research tool [25]. about activities vary from walking between
Twelve questions measure eight health rooms to running on uneven ground.
domains to assess physical and mental health, The scale is one page, can be filled out by most
and this instrument has been validated across a patients in less than 2 min, and is scored by tally-
number of chronic diseases and conditions [26– ing the responses for all of the items. The LEFS is
28]. Physical and mental health scores are com- easy to administer, score, and apply to a wide
puted using the scores of 12 questions and range range of disability levels and conditions and all
from 0 to 100, where a 0 score indicates the low- lower-extremity sites. A recent systematic review
est level of health measured by the scales and 100 showed that LEFS scores demonstrated excellent
indicates the highest level of health. test-retest reliability and had expected relation-
ships with measures assessing similar constructs
[32]. The LEFS can be used by clinicians as a
50.10 UCLA University of California measure of a patient’s initial function and out-
Los Angeles Activity Score come as well as to set functional goals [33].

The UCLA activity score is a simple patient-­

reported scale ranging from 1 to 10. The patient 50.12 H
 ip Sports Activity Scale
indicates their most appropriate activity level, with (HSAS)
1 defined as “no physical activity, dependent on
others” and 10 defined as “regular participation in This scale was developed in 2013  in German
impact sports.” The UCLA activity score represents and English for patients with femoroacetabular
a reliable tool for assessing the level of physical impingement (FAI). The HSAS consisted of nine
activity and the return to sport with high functional different sports activity levels ranging from 0 to 8
demand after total joint arthroplasty [27, 28]. [34]. Differences in popular sports in Europe and
the USA, as well as league specifics (e.g., col-
legiate leagues), were taken into account. This
50.11 L
 ower Extremity Functional scale does not substitute traditional self-­reported
Scale (LEFS) outcome measures, but the HSAS should be con-
sidered as an additional instrument. It can be
Created in 1999, Lower Extremity Functional considered a very useful tool for clinicians and
Scale (LEFS) was developed as a self-report researchers to evaluate sports-active FAI patients
condition-­specific measure that would validate and to better compare different treatments. HSAS
measurements and is used as clinical and research has been applied to cartilage injuries [34, 35]. In
tool. Compared at first with SF-36, LEFS proved a recent systematic review, there was insufficient
to be more sensitive to change, as indicated by evidence to recommend HSAS compared to other
higher correlations with an external prognostic hip scores [36].
50  PROMs in Sports Medicine 691

50.13 Hip Outcome Score (HOS) items). It was developed for younger or more
active patients with more demanding physical
Created in 2006 for treatment intervention for function as an extension of WOMAC. It has been
individuals with acetabular tears who may be shown as a valid, reliable, and responsive out-
functioning throughout a wide range of ability come score [40, 41].
Hip Outcome Score (HOS) consists of two scales. The five dimensions are scored separately, and
The activities of daily living (ADL), and sports a Likert scale is used, and all items have five pos-
subscales. The ADL subscale contained 19 items sible answer options scored from 0 (No Problems)
pertaining to basic daily activities, and the sports to 4 (Extreme Problems), and each of the 5 scores
subscale contained 9 items pertaining to higher-­ is calculated as the sum of the items included.
level activities, such as those required in athlet- Scores are transformed to a 0–100 scale, with
ics. In addition to the five potential responses, 100 representing no knee problems and 0 repre-
ranging from “unable to do” to “no difficulty,” a senting extreme problems [41, 42].
response of “non-applicable” is possible. This
allows subjects to elect that something other than
their hip problem limits their activity. HOS is a 50.15 Lysholm
valid measure of self-reported physical function
for individuals with acetabular labral tears who Lysholm score was developed in 1982 by
are undergoing either arthroscopic surgical treat- Lysholm and Gillquist and modified in 1985 by
ment or nonsurgical treatment [37]. Lysholm and Tegner and is used to evaluate
The HOS was found to have good psychomet- patients with knee ligament injury [43, 44].
ric properties, including a strong relationship with The score consists of the correlation of symp-
concurrent measures of physical function. It has toms and functional criteria such as limping,
high correlations with concurrent measures of instability, pain, and swelling, climbing steps,
physical function and relatively low correlations squatting, restraining, and support. For these
with concurrent measures of mental health [38]. eight questions are expressed in a final score
Since HOS is a PROM, it may be used for follow- ranging from 95 to 100 points regarded as “excel-
­up assessment when objective information is not lent”; 84 to 94 points, “good,” 65 to 83 points,
possible to differentiate individuals. Depending “fair,” and “poor” when values were equal to or
on their current activity level, surgical outcome, below 64 points.
and age at a follow-up assessment more than The Lysholm questionnaire has been shown as
3 years after surgery on average [37]. In 2008, in a valid and reliable score since the questions are
the continuous improvement of the score, the objective and easy to understand [41, 45]. Even
same authors concluded that HOS could be used though the Lysholm score was developed to
for describing outcomes of hip arthroscopy for assess patients with knee ligament injury, it has
labral pathology, femoroacetabular impingement, been used to assess other patients including TKA
chondral lesions, or capsular laxity [39]. [46].

50.14 Knee Injury 50.16 Kujala Scale

and Osteoarthritis Outcome
Score (KOOS) The Kujala scale (Scoring of Patellofemoral
Disorders) was published in 1993, and it is used
KOOS (Knee Injury and Osteoarthritis Outcome to evaluate subjective symptoms with a focus on
Score) is a functional score that evaluates the anterior knee pain. It is a 13-item screening
outcomes for Total Knee Replacement with instrument containing important questions in
regard to symptoms (7 items), pain (9 items), scoring patellofemoral disorders. The questions
daily living activities (17 items), sports and rec- are related to limping, support, walking, stairs,
reation activities (5 items), and quality of life (4 squatting, running, jumping, prolonged sitting
692 S. R. Piedade et al.

with the knees flexed, pain, swelling, abnormal important healthcare decisions: (a) the absence of
painful kneecap movements (patellar sublux- a PROM collection infrastructure and (b) a lack
ations), and atrophy of thigh, and flexion defi- of knowledge and confidence about using out-
ciency. For each multiple-choice question, the come measures.
patients should choose the answer that corre-
sponds to their symptoms. It is recommended
that the patient completes the questionnaire inde- 50.18 D
 eveloping PROMs in Sport
pendently to exclude investigator bias. The total Medicine
score is easily calculated and goes from 0
(extreme symptoms and worst function) to 100 The development of PROMs in sports medicine
(absence of symptoms) [47]. could be a practical tool to analyze the outcomes
While the Kujala has been found to be effec- of different sports injuries in regular sports prac-
tive and reliable in the adult population [48, 49], titioners, regardless of the involved anatomical
modifications may be useful to make it easier to site (the shoulder, hip, knee, foot, and ankle).
understand in the pediatric population, ensuring a This questionnaire allows a more accurate regis-
proper of functionality of the outcome measure tering of the patient’s perception of their pre-
in those patients [50, 51]. injury status of physical demand in sports, their
understanding of injury and expectations of treat-
ment, and their evaluation of received postopera-
50.17 Considerations on PROMs tive care and treatment and the “outcomes.”
in Sports Medicine As presented previously, these arguments and
stated that PROMs is a valuable tool in clinical
As observed above, all the PROMs focus on a practice. Although many questionnaires
non-specific population and were designed for approaching the knee, shoulder, hip, spine prob-
the general population. lems, and other anatomical sites have been pro-
PROMs play a more important role in the clin- posed and validated globally, the focus remains
ical reasoning process for diagnosis and treat- on the general population.
ment, with a specific focus on the patient’s Regarding this approach, the ISAKOS Sports
perspective, mainly when designed for a specific Medicine Committee has developed a systematic
population. Involving the patient in this way can review on PROMs in sports medicine that was car-
also help stimulate self-management. PROMs ried out by Piedade et al. Although the data have not
can also be used with the patient to identify the yet been published, this study has shown that there
main problems in functioning and activities in is not a clear approach regarding the subjective eval-
their daily life and, also, contribute to establish uation in sports medicine. Moreover, this systematic
treatment objectives and monitor treatment review has found out that the selected articles had
results. Those PROMs that have been developed no uniformity on the type of PROMs survey applied
for use at group level in research settings (espe- for the same joint or surgical procedure, corroborat-
cially generic tools) may be less reliable at the ing that there is a void in sports medicine area, and
individual patient level; therefore, PROM mea- it is our belief that this should be explored!
surement should always be used as an adjunct to Other points to be analyzed in this process
clinical judgment. regarding this particular population are the level
Clinicians widely recognize the potential use of physical demand (athlete’s position in the field
of PROMs for improving the process of care by of play) as well as the stress involved in sports
enhancing communication, improving patient’s practice according to competition level.
education, shared decision-making, and monitor- Consequently, these points strengthen the need to
ing response to treatment. However, several bar- consider that these individuals have singular
riers to the use of PROMs have been identified, expectations and objectives, differing from the
which could lessen their usefulness in informing general and sedentary population.
50  PROMs in Sports Medicine 693

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