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INJURY Definitions of injury Any physical damage to the body caused by violence or accident or fracture etc. Means damage or harm to the physical structure of the body and those diseases or infections naturally resulting from the damage or harm. A specific impairment of body structure or function caused by an outside agent or force, which may be physical or chemical. Is physical harm or damage to the body resulting from an exchange, usually acute, of mechanical, chemical, thermal, or other environmental energy that exceeds the body’s tolerance. Harm or damage producing disturbance of structure and/or function. The term "Injury" means a physical or mental condition that is the direct or indirect result of an Accident. Physiology- Injury can result in - Cell death - Damage of fibres - Tissue damage - Alterations in interstitial fluid. Symptoms of injury - Inflammation - Pain - Swelling or edema - Redness and warmth („^ temperature) - Loss of function. Where do Injuries occur? • Bone Fracture, dislocation, contusion, periostitis. • Ligament Sprain, rupture. • Tendon Inflammation, rupture. • Muscle Cramp, Strain, fasciitis. • Skin Lesion, ecchymosis. Injury Mechanisms Understanding force is not only important in sports and fitness performance but also in various injuries. In sports and in the fitness institutions we apply forces to bats, balls, surfaces, instruments etc and absorb forces from the same. A force acting either causes- Change in velocity Deformation. The type of material that the force is acting on is important. Factors affecting whether a force will result in an injury- Size or magnitude of force - Direction of force applied - Area over which force is applied - Magnitude of stress - The amount of torque generated. Material properties of tissue and their ability to sustain strain. If a force is greater than the tissues yield point or elastic limit the structure will remain with some deformation. If greater than failure point of structure then the bone will fracture or the soft tissue will rupture. Forces that cause injury are- - Compression- shortening and widening of the structure. - Tension- lengthening and narrowing of the structure. - Shear- friction of the structure. Classification Although serious injuries are rare, acute injuries do occur, and chronic injuries are quite prevalent. Muscular strains and ligamentous sprains are the most common types of sports and gymnasium injuries. Specifically, the upper and lower trunk, as well as the shoulder seems to be the most frequently injured areas. Contributing factors that most commonly lead to injury were found to be: poor technique, lack of supervision, skeletal maturity, and steroid abuse. TYPES OF INJURIES Acute and Chronic Acute: results from macrotrauma. Strains (muscle), sprains (ligaments), fractures, ruptured discs, & nerve damage. Causes: Barbell or platform defects, improper footwear, collisions with the bar, poor technique, failure to properly warm-up, & rapid weight loss. In many cases, these types of injury occur due to a loss of concentration, performing beyond capabilities, returning to training prior to proper rehabilitation, and poor coaching. Chronic: results from microtrauma. Tendonitis, bursitis, instability, & weakness etc Causes: Poor technique, use of high volumes or high intensities for too long a period, & poor choice of exercises. Intrinsic and Extrinsic Extrinsic - Body contact - object e.g. racket, ball, barbell etc - Environmental. Intrinsic - Biomechanical gait - Muscle strength - Muscle imbalance - Training schedule. What can be used to help identify injury? Radiograph, CT Scan, MRI, Bone scan, Electromyography, Ultrasonic imaging, Palpation, Grading system of pain etc. Common Injuries 1 Shin Splints Pain felt along the front and medial side of tibia. Periosteum around the bone gets inflammed causing periostitis. Occurs due to following factor- decreased flexibility of achilles tendon, weaker calves, faulty and wornout shoes, hard surface, flat feet, overtraining and overuse etc. Further progressess to stress fracture. 2 Stress Fractures Overuse injury which cracks the periosteum around the bone (repeated stress). Common sites- metatarsals of foot, front and medial side of tibia and spine (spondylolysis). 3 Plantar fascitis Inflammation of the fascia from the sole of the foot anterior to the heel. Burning sensation during morning. Cause- Hard surface, faulty shoes. 4 Metatarsalgia Occurs due to overuse. Pain in the metatarsal heads and no pain radiating to the toes. Occurs during running and jumping. 5 Mortons Neuroma Occurs due to impingement of the nerve between 3 and 4 metatarsal. Pain occurs due to Constricting shoes and radiated to toes. Weight bearing activities should be avoided. 6 Achilles Tendinitis Achilles tendon connects the calf muscle to the heel bone. It is the inflammation of the achilles tendon. Occurs due to overuse, lack of stretching, hard surface, faulty shoes, faulty biomechanics etc. If tendon ruptures it is a medical emergency. 7 Ankle sprains It is the injury to the ligaments of the ankle. It may be an injury or a tear. Sudden twist especially the inverting movement of the foot causes it. 8 Menisci tear Menisci are the shock absorbers between femur and tibia. Menisci comprises of- Lateral menisci and medial menisci. Menisci tear occurs due to excessive twist of knee, excessive flexion and eccentric movements of knee. 9 Bursitis It is a shock absorber located at points in the body where friction is most likely to occur such as shoulder, elbow, hip and knee joints. 10 Epicondylitis Lateral- Tennis elbow (inflammation of lateral epicondyl), Medial- Golfers elbow (inflammation of medial epicondyl). Occurs due to lack of flexibility and overuse of flexor and extensor forearm muscles. 11 Rotator cuff injuries Overuse injuries. Occurs due to inflammation or tear of the SITS (supraspinatus, infraspinatus, teres minor and subscapularis) muscles. Treatment is prolonging and even surgery may be required. Overhead movements should be avoided. Tendinitis and bursitis may also be associated. 12 Iliotibial band syndrome Iliotibial band syndrome is the inflammation of the thickened fascial structure on the lateral aspect of lower thigh and knee. Occurs due to overuse and faulty biomechanics. 13 Patellar Tendinitis Called as Jumpers knee. It is the inflammation of the tendon that connects quadriceps to the tibia through the patella. Occurs due to weak quadriceps and decreased flexibility of the calf and hamstring muscles. 14 Tear of Anterior Cruciate Ligament (ACL) ACL lies deep in the center of the knee and gives stability to the knee joint. ACL gets torn in the contact sports such as football and hockey. Exercise rehabilitation / surgery provides cure. 15 Low back pain. Caused due to- Spinal deviations, faulty posture, muscular imbalance, incorrect exercise techniques, weaker back muscles, lack of muscular flexibility, restricted back movements, stress, lack of physical activity, physical injury etc. Exercises to be avoided- Dead lifts, full sit ups, double leg raises, spinal hyperextension, twisting exercises etc. Aerobics, kick boxing and tube exercises should be avoided. Cause of Injuries Overtraining Environmental Poor Technique Biomechanics Warm up/Stretching (poor flexibility) and cool down exercises Poor Fitness Poor coaching/Lack of supervision Surface Lack of Rehabilitation facilities Equipment Medical and Orthopedic problems Medical Conditions Steroid use Poor skeletal maturity Muscle imbalance Muscle strength Nutritional Factors Psychological Problems OVERTRAINING In order for training to be effective it must involve overload to elicit an adaptation. This is stressful and the body responds to stress. If the training stress is excessive and prolonged with insufficient time for recovery, then exhaustion can set in manifesting itself as the overtraining syndrome. The syndrome is probably caused by the normal adaptive neuroendocrine response to stress, mediated principally by adrenaline and cortisol, and acting principally upon the metabolism and the immune system. Measurement of endocrine, metabolic and immune system variables might be useful in the prediction of the onset of overtraining. If sufficient rest is not included in a training program then regeneration cannot occur and performance plateaus. The "overtraining syndrome" is the name given to the collection of emotional, behavioral, and physical symptoms due to overtraining that has persisted for weeks to months. Athletes and coaches also know it as "burnout" or "staleness."Overtraining is the main cause of sports as well as gymnasium injuries whether acute or chronic (overtraining related injuries). These overtraining-related injuries are the most common form of injury in both recreational and elite athletes. Recovery is the key to their prevention. To recover properly, you have to give the muscles sufficient time to recover, restore the depleted nutrients and supply the body with adequate additional nutrients for growth and adaptation. In lay terms, exercise tears your body apart so that it can get stronger. For this to happen, the body needs some time to respond. It is during this recovery period, not during the workout itself, that the positive adaptations associated with exercise, such as improved cardiovascular fitness, muscle strength and/or size, and increased flexibility take place. Signs and symptoms- Emotional signs: Incr. nervousness or depression, inability to relax, lack of desire, mental attitude of "I don't care." & drop in academic or job performance. Physiological warning signs: Extreme soreness and stiffness after training, gradual increase in soreness from session to session, deceased body weight when no effort made to lose weight, inability to complete training session that should be able to be completed, sudden increase in resting heart rate when taken at same time each day, lowered resistance to disease- colds, headaches, flu, loss of appetite, swelling of lymph nodes, constipation or diarrhea, unexplained drop in athletic performance, & decreased sex drive. Measurement- Overtraining is measured as a drop in physical performance associated with lethargy, decreased motivation and generalized fatigue. It is an indication that the training stress is in excess of the body's ability to adapt and recover. This stress factor further leads to various forms of injuries acute as well as chronic. Some invasive methods include measures of blood and urine. Non-invasive methods include monitoring body weight changes, motivation, performance, as well as other parameters. Resting heart rate is one of the vital parameters used to measure overtraining. An elevation of as little as 10 percent indicates training stress. A 20 percent increase, particularly lasting more than two days, is indicative of overtraining. Whenever your morning resting pulse is elevated by more than 10 percent, you must reduce your training overload and pay particular attention to your nutritional needs and rest. If you don't, instead of making you stronger, the physical activity will compromise your immune system. Rushing the recovery process leaves you more vulnerable to low-level infections, aches and pains, and elevates the risk of joint and muscle injuries, due to constant fatigue. Training through both fatigue and/or injuries can even lead to compensation injuries. Findings in these studies have shown decreased performance in exercise testing, decreased mood state, and, in some, increased cortisol levels -- the body's "stress" hormone. A decrease in testosterone, altered immune status, and an increase in muscular break down products have also been identified. Medically, the overtraining syndrome is classified as a neuro-endocrine disorder. Common Overtraining injuries Rotator cuff injuries, Stress fractures (tibia, femur, sacrum and toe bones in the foot), shin splints, muscle strains etc. Reiterating the fact, majority of sports and gymnasium injuries are caused due to overtraining factor, which should always be avoided to maintain performance. ENVIRONMENTAL Hot Conditions Environmental conditions play a major role in the performance of exercise. Temperature and humidity are particularly important because of their effects on 2 vital aspects of homeostasis; thermoregulation and water electrolyte balance. Both of these parameters (body temperature and body fluid volume) are tightly regulated as they have wide ranging effects on metabolism and through this on essentially all physiological systems. This is illustrated by the often-fatal effects of hyperthermia and dehydration and by the concern, particularly among endurance athletes. The circulatory requirements of thermoregulation in the heat are in conflict. In heat, maximum stroke volume decreases due to fluid deficit, reducing cardiac output and VO2 max. Cutaneous dilatation is at the expense of splanchnic and renal blood flow, which further contributes to renal and hepatic complications. Prolonged activity in the heat leads to- fatigue, glycogen depletion, reduced muscle blood flow, reduced lactate clearance, hyperthermia and dehydration, raised heart rate, Reduced VO2max etc. All these factors contribute to various injuries in the body. Heat cramps (electrolyte imbalance), heat exhaustion and heat stroke occur due to heat stress leading to deficient performance and rise in the risk of injuries. Mood disorders are also very common with heat stress. Treatment for heat cramps, heat exhaustion and heat stroke. Move victim to cool region, well ventilated place. Loosen clothing, cool gently with wet cloth and moist ice. Provide water , fluids and electrolytes. Seek medical attention. In heat stroke there is rise in BP, presence of CNS signs and seizures. Seek immediate medical attention in case of heat stroke. Cold Conditions The most important risks to athletes are hypothermia and peripheral cold injuries, such as frostnip and frostbite. Peripheral cold injuries are caused by the freezing of tissue. The ambient condition for this type of exposure is often severe, i.e., low ambient temperatures and increased wind velocity. There is little risk of frostbite above a wind-chill of -29°C (-20ÞF). Below this, the risk increases but only on exposed skin. As skeletal muscle cools, its maximum strength, muscular endurance, and aerobic capacity are all reduced. The cardiopulmonary system is also affected by exercising in the cold, as ventilation rate will increase and peripheral blood flow is reduced. It is important to remember that cold weather also depresses thirst, so athletes need to begin the workout well hydrated. Plasma glucose can become very low during long exercise sessions. Cold-weather exercise may also increase the risk of accidental injury due to impaired motor control. Groin region is also an important site for injuries in the cold climate. Flexibility is reduced which increases the risk of strain injuries. An overlooked problem of cold weather exposure is exercise-induced bronchospasm (EIB). EIB can produce decrements in pulmonary function. POOR TECHNIQUE Biomechanics- It is the study which describes the working mechanism of muscles, bones, and ligaments by which injuries can be avoided. Athletes in the western countries start working on biomechanics from the age of 13-14 and thus are injury free most of the times during their peak. Biomechanics also works on the “theory of force” for best performance and prevention of deformities. Cervical spine injuries, low back problems, stress fractures, ankle injuries, Achilles tendonitis, rotator cuff injuries are very commonly caused due to wrong biomechanics of the structure. Warm up/Stretching (poor flexibility) and cool down exercises Avoiding stretching exercises (warm up) before a high impact activity causes inflexibility at the joints due to which free range of motion is restricted. Whether hamstrings, quads or any other muscle, pulls come from not being flexible and overexerting specific muscles. Pulls are basically small muscle tears, which cause pain and stiffness restricting the intended activity. Shoulder injuries, back injuries, hamstring injuries and quadriceps injuries are very common with poor flexibility. Cool down exercises after high impact activities are essential to provide sufficient relaxation to the muscles involved in the activity. Blood supply improves and the heart rate is brought down to normal limits. Poor Fitness Poor fitness is the vital cause of sports as well as gymnasium injuries and is connected to all the other causes. Poor VO2max, high heart rate, lassitude, poor endurance and insufficient strength are the symptoms, which indicate poor fitness. Strengthening of muscles, working on flexibility and endurance techniques is a must for candidates visiting fitness institutions in the peak as well as in the off-season. Poor fitness leads to overtraining stress much earlier than expected. Poor fitness profile contributes to Muscle tears, ligament sprains, muscle strains, and stress fractures in the longer run. Immunity goes down due to which resistance capacity is hampered and the individual becomes prone to various diseases. Poor coaching/lack of supervision It is essential for the coaches in the modern world to understand fitness and biomechanics more scientifically and apply it in the day-to-day activities. Fitness testing should be done at regular intervals to mark the fitness status of an individual. This practice would help to avoid poor fitness standards and further prevent from injuries. Lack of supervision commonly results in biomechanical injuries, which turn severe in the future. Gymnasium (accident) injuries occur due to lack of attention (trainers and coaches). Surface- 35% of Knee injuries and ankle injuries occur because of hard surface. This is because; the force generated by the hard material in to the body is greater than the tissue absorbing capacity. Lack of Rehabilitation facilities In India rehabilitation facilities are quite insufficient. Rehabilitation period varies from 15-30 days and the instrumentation is very poor. Thus the injury becomes recurrent after few months. The second episode of the injury is quite severe and leads to a permanent deformity. Knee injuries, ankle ligament sprains, rotator cuff injuries are recurrent because of poor rehabilitation techniques. EQUIPMENT Maximum care should be taken by sports people as well as by the subjects regular with gymnasiums and fitness institutions while selecting their instrumentation of use. This category is further divided in to – action instrumentation and preventive instrumentation. Action instrumentation- should be accurate in size, shape and magnitude. Little changes in size or shape or the magnitude of the instrument can further lead to grievous injuries where medical/orthopedic intervention becomes a must. This is due to extra force provided by the instrument in to the body (If a force is greater than the tissues yield point or elastic limit the structure will remain with some deformation). E.g.- Rackets, Bats, Barbells, Bars, Rods, Weights etc Common injuries- Tennis elbow- occurs due to usage of tennis rackets shorter in size and having tight netting. Also can occur due to lifting of heavy object single handedly. Medial Epicondylitis (Golfers Elbow)- occurs due to mismatched golf stick. Also can occur due to lifting of heavy object single handedly with poor biomechanics. Various spine problems are very common in the fitness institutions due to wrong weight lifting procedures (heavy weights or improper barbells). Preventive Instrumentation- This includes helmets, dentures, eyeglasses, chest guard, spine belts, gloves, pads, thigh pads, kneecaps, ankle straps, perfect shoes structure with appropriate insoles etc. Lack of prevention can lead to various injuries like head injuries (hemorrhage), chest injuries (pneumothorax, fracture rib), spine injuries (low back problems, slip disc) knee problems (ligament sprains), ankle problems (ligament sprains), plantar fasciitis, Achilles tendonitis etc. Note- Maximum ankle and plantar injuries occur due to wrong footwear and this can further also lead to referred pain in the knee. MEDICAL AND ORTHOPEDIC PROBLEMS Medical Conditions Hypertension, Diabetes, Bronchial asthma and arthritis (Heredity conditions) are the medical injuries, which do not allow the athlete to perform the best. The symptoms restrict the physical activity and produce psychological ill effects simultaneously. Hypertension and diabetes patients above the age of 40 are usually found to be obese. When the body mass index scales above 25, different stages of obesity get confirmed. According to American school of sports medicine, obesity is one of the most important causes of sports and gymnasium/fitness institution injuries. Obese patients have faulty biomechanics due to which their body becomes prone to limb injuries. Knee injuries, groin injuries, ankle injuries etc are very commonly associated with obesity. Hypertension, diabetes and arthritis are the medical conditions due to obesity. Due to obesity, flexibility is reduced which is the common cause of strain injuries. Thus obesity is injurious to life. Steroid Use Steroids for temporary use provide fantastic gains but the long-term side effects are extremely dangerous. Side effects for males and females include the following: • High blood pressure and heart disease • Liver damage and cancers • Stroke and blood clots • Urinary and bowel problems, such as diarrhea • Headaches, aching joints and muscle cramps • Nausea and vomiting • Sleep problems • Increased risk of ligament and tendon injuries Other side effects in males • Reduced sperm count • Impotence • Increase in nipple and breast size (gynecomastia) Other side effects in females • Reduced breast size • Menstrual problems All the above side effects due to prolonged steroid use hampers performance and increases the susceptibility towards injury. Poor skeletal maturity Fractures caused by poor skeletal maturity are very common in fitness institutions and gymnasiums. This occurs mainly during weight training accompanied by faulty biomechanics. Muscle imbalance This is commonly associated with the hamstring and quadriceps muscle groups. The referred pain aggravates to the back due to which low back injury becomes prominent. Michael Owen from Liverpool had imbalanced hamstring muscles, which lead to severe back problems as a result of which the champion had to skip off a complete season. Muscle strength If a force is greater than the tissues yield point or elastic limit the structure will remain with some deformation. Thus muscular strength should be quite balancing and strong for the kind of activity it is accustomed to. Otherwise the structure becomes susceptible to injuries (muscle strain). Back injuries due to weight lifting and forearm injuries due to heavy bats are very common examples. Protein deficiencies also reduce the muscle strength as a result of which injuries delay the healing procedures. NUTRITIONAL FACTORS Poor nutritional status is directly proportional to injuries in various parts of the body. We all know that carbohydrates are fuel of the human body. Lack of carbohydrates or glucose depletion is a serious matter due to which human body starts using fats for provision of energy. Later comes protein for energy supply as a result of which protein content in the muscle is broken down making the body more vulnerable for injuries (muscle injuries). Thus carbohydrate loading should be done prior to any sort of high profile activity. One more point to add, glucose depletion is one of the major cause leading to poor nerve activity. Usually there is always an off-season when high profile activities are avoided to counter overtraining syndrome. Good nutrition and rest is required during this period. High protein and mineral diet is required for strength and healing tendencies. If optimal diet is not provided injuries do not tend to heal and strengthening is also avoided. Nutritional deficiencies especially calcium deficiency is the major cause of fractures and bone injuries in individuals especially females (osteoporosis). Iron deficiency also increases the risk of injuries in males as well as in females. Since iron is used to make haemoglobin, which carries oxygen in the blood, and myoglobin, which handles oxygen inside muscles, abnormally low iron levels can potentially harm endurance performance. Vitamin deficiencies and dehdration also increase the risk of injuries. PSYCHOLOGICAL PROBLEMS Prevention of Injuries 1 Warm up stretching and cool down Light exercise provides mobility to tissues and joints. Aerobic exercise increases heart rate, blood flow, respiration, warming of muscles and mobilisation of energy stores. All major muscles should be stretched with emphasis on muscles used. Each stretch should be held for 20-30 seconds. It decreases muscle stiffness as well helps in elongation of muscles,thus injuries are avoided. Joint stiffness is also reduced providing more mobility to joint to function fluently without injuries. 2 Environment Heat conditions- provide proper hydration (water and electrolyte balance). Provide appropriate clothing and appropriate ventilation. Cold conditions- Provide proper protective clothing. Provide appropriate temperature to perform. 3 Protective Equipment Helmets, Eye wear, Ear wear, Mouth guards, Throat and neck protectors, Shoulder pads, Elbow/forearm/wrist guards(pads), Thorax and abdominal protectors, gloves, Lumbar/sacral supports, Thigh pads, Knee pads/protectors, Shin guards, Appropriate shoes with right strucure and cushioning, Appropriate bats/rackets/balls, Gymnasium instruments with proper biomechanics etc. 4 Terrain Hard surfaces should be avoided. Uneven surfaces should be avoided. Ligaments injuries are common with risky terrain. Downhill running should be selective. 5 Fitness testing Essential to identify individual parameters accurately before prescribing a program. 6 Biomechanics Appropriate biomechanics and posture keeps an individual injury free. Muscle imbalance should be avoided. Muscle tightness should be cured. EMG measures the muscular imbalance. It is important to increase muscle strength with specificity and scientification. 7 Good Supervision and Coaching. 8 Identification of medical conditions. 9 Avoid Steroid use. 10 Provide scientific strengthening and rehabilitation services. 11 Overuse injuries – should be cured/avoided by rest, counselling, strengthening and proper biomechanics. 12 Nutrition Carbohydrate loading before the event. Carbohydrate and protein consumption after exercise. Importance of protein diet, mineral diet, calcium vitamin and iron diet in elite population. Management of Injuries Immediate Care PRICE- P= Protection, R= Rest, I= Icing, C= Compression, E= Elevation. NSAIDS are used after 48 hours. Assessments, Physical Examination, Investigations and Diagnosis. Assessments- History Physical Examination- Goniometer measurements, Resisted manual testing, Reflex testing and stress test. Investigations- Blood report, Urine report, X-rays, Bone scan, MRI, CT Scan, USG etc. Diagnosis- from history, physical examination and investigations. Modalities Used 1 Cryotherapy Used for 48 hours after injury. Leads to vasoconstriction. Reduces temperature of the injured site. Decreases inflammation and oedema which in turn reduces pain. Ice massage, Ice packs, Ice immersion bath, Chemical gel packs, Vapocoolant sprays, Cryocuff, Cold compression unit etc. Duration- 20-30 minutes. 2 Thermotherapy Used after 48 hours of injury. Leads to vasodilatation. Vasodilatation increases blood flow to region bringing oxygen and nutrients and removing waste products. Increases mobility and temperature of soft tissues. Hot baths, Hot packs, Whirlpool, Paraffin wax etc. 3 Ultrasound. 4 Diathermy. 5 Electrotherapy and Electrical stimulation (MS and IFT). 6 Traction. 7 Massage. Rehabilitation of injuries Goals of Rehabilitation To modulate pain, Restore ROM, Ensure flexibility, Ensure endurance, Provide co-ordination and balance, Restore power, To return a sports person to sport, pain free and fully functional activities. There 5 phases of rehabilitation. Phase 1 Controlling inflammation Ice compression, elevation, restricted activity and immobilisation, relaxation activities, remobilisation, protection and avoid detraining. Phase 2 Restoration of motion. Need to increase flexibility of muscles and also mobilisation of joints. Increase flexibility of injured area by stretching muscles within the region.Hold for 20 seconds. Open and closed kinetic chain exercises prescribed. Phase 3 Muscular strength, Muscular endurance, Muscular power (plyometrics), Core stability (for better posture and to avoid trunk injury). Phase 4 Phase 3 continued with cardiovascular fitness, balance and co-ordination. Phase 5 Sport related activities designed (balance, co-ordination, ROM, strength and CV fitness). |
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