How to reduce the risk of injury when starting new sports

Taking up new sports can be an exciting time… new friends, new routine, fitness gains. But there can be a downside to starting a new exercise regime….injury.

Most injuries that occur when starting new sports occur due to ‘overuse’. So what is the definition of overuse?

Overuse injuries are a result of tissue damage resulting from repetitive demand over a course of time. Taking up a new sport or training schedule can make you more vulnerable to these injuries as joints and muscles are being used in a new way. The term ‘training’ is often used without us really thinking about what the term means…so what does training mean?

Training has specific goals of improving one’s capability, capacity, productivity and performance. Simply in training we are looking to improve our capacity to undertake a particular activity. This can involve improving cardiovascular fitness, strength, speed or a particular skill. The majority of sports training will involve all of the above.

Improvement in a particular facet of training requires 2 key components. Firstly we have to challenge ourselves- if we continually train in a ‘comfort zone’ then we will not achieve any improvements- we must extend ourselves. It’s important it is done in a controlled manor as if we over reach to far then we risk injury. As such the second equally important component is rest. How does rest fit in? It is during rest that our body makes the necessary adaptations from training in order to improve. As such rest is critical in minimising the risk of injury from overuse.

The term overuse often makes us think of long excessive periods of training. However in reality overuse injuries can occur over a short period of time when the body is exposed to a sudden increase in load that is new. We call this ‘acute training load’. When there is a sudden increase in ‘acute training load’ then there is an increased risk of injury. Long term training load is termed ‘chronic training load’. We know from recent research that the ratio between chronic and acute training load is key in minimising injury risk. Often we look at chronic load being anywhere between 1-3 months and acute load 1-2 weeks.

 

So you can see that starting a new sport or activity brings with it inherent risk of injury if you do not gradually increase your exposure to the activity. So how can you minimise this risk?

 

1. Make sure you have a good base fitness-this might involve some running, cycling, swimming.
2. Give yourself adequate rest periods so that you can recover from your sessions.
3. Slowly increase the time that you train and/or the intensity you train at.
4. Make sure you do some general strengthening and balance activities e.g. press ups, lunging, step ups and balancing on 1 leg.
5. Get guidance from a coach, strength & conditioning coach or physiotherapist

Olympics, Gymnastics and a Fractured French Leg

You may have recently seen our post with the unfortunate accident for the French gymnast Samir Ait Said at the Rio Olympics. It it safe to say that injury was significant enough to cause a few winces even from our office of injury veterans!

But what happens next and how does an elite athlete, or anyone, come back from such an injury?

I have watched a few videos and had a look at what the onsite medical team did, and (other then dropping him http://www.independent.co.uk/sport/olympics/rio-2016-video-paramedics-drop-stretcher-of-french-gymnast-samir-ait-said-broken-leg-a7177186.html) they did manage to evacuate the casualty quickly and get him to hospital so he could get the care he needed. However, as usual there are some things to reflect on.

In an event such as this as the first responder you have a very simple set of rules to apply. As I run to an athlete obviously you see the immediate trauma to the left leg, but you also need to see the whole picture, (it is hugely helpful to have seen the injury occur).

1. Is the environment safe to enter? (do not run across the floor and get yourself hit by another gymnast!)
2. Life threatening problems. Is there catastrophic bleeding? Is the athlete conscious? Are they breathing? (in this case the athlete is very calm and you can see him able to talk to the medical team, there is no external bleeding and the environment is relatively safe).
3. Do you have a spinal injury? Once the life threatening ABCs have been cleared a spinal injury always outweighs any arm or leg injury as the immobilisation of this has to take priority. Given this is a gymnastic event and a vault the chances of spinal injuries are very high, there are a group of questions you can ask (NEXUS) which assist your decision making. I would definitely have used these in this circumstance. There seems to have been a mixed response to his risk of spinal injury. As they actually fully immobilise his neck when removing him on the stretcher (they tape his head down and block it), yet allow him to move his head and neck around to get onto the stretcher itself, a little too late if there was an injury!
4. Once and only once I had cleared the above (this would only take a matter of minutes) then attend to the leg. With a traumatic injury such as this you need to immobilise the area safely but also deal with the systemic effects on the whole body of pain, internal bleeding and possible shock. It didn’t look like an open fracture where the bone was exposed so the risk of infection and external bleeding is low. 
5. As professionals we can use a variety of splints, some which require more time then others and some which would allow for the shape of the athletes leg! (As a physio I would not try to “pull” the leg into alignment. Most of the time this is a very risky thing to do as you may cause further damage, is the risk worth taking?). They used a SAM splint (see above photo orange and blue material around his foot and leg) in this occasion which is very quick and would allow for any shape, but definitely less secure then some of the larger splints.
6. Once immobilised, monitoring vital signs, dealing with the athletes pain and emotions, its time to safely remove them from play and get them to hospital. Most of the time you will have plenty of people willing to help. A good solid stretcher (scoop stretchers normally) and a well strapped down patient, one person takes the lead and ALWAYS go feet first, we don’t want any of this stretcher fun (https://www.youtube.com/watch?v=71zYvRfriSg.

Once in hospital investigations will be performed (X-ray etc). Which for this patient would have looked something like this as both his tibia and fibula were fractured: 

In order for the bones to heal properly the doctors have many choices depending on the degree of injury, age and other factors. Essentially they need the bone edges to be aligned to give the athlete a working leg after th
e fracture has healed, and they need the bone edges to have the right stimulation to regrow. This process will be done very quickly as the risk of blood supply compromise is high in these type of fractures. In some cases and from the pictures I have seen, the surgeons did what we call an open reduction and internal fixation (ORIF). This is where the broken bone is exposed, reduced (realigned to heal in a straight line) and held in place by metal work. The choice of this metal work depends highly on the patients needs and the type of fracture. It looked like the fracture was very close to the middle of the shin meaning a ‘intramedullary nail’ or IM nail may have been used to fix the tibia, often with the fibula being allowed to heal without needing fixation:

Post operatively the area will be held in place and the joints above and below the fracture immobilised, in this case with a normal cast. You may be surprised that in some cases the athlete may be allowed to walk on this from week 1 as this assists in bone thickness and healing (preventing an event called non-union where the bone doesn’t heal, very common in the fibula which may later mean further surgery) and also to prevent muscle wastage and joint stiffness. As a physio we are always keen for a patient to get on their feet as soon as possible!

From this stage it is all about getting the patient back to a basic level of functioning, which normally consists of learning to walk again. We will plan and make sure the patient has the required movement from the joints around the injury, sufficient strength and then balance to get this started quickly. With this level of athlete you would expect a fast recovery to this stage as his base level of function (what he can do before the injury) was very high.

Once walking, it is then a steady, gradual balancing act between moving and using (loading) the repaired area, the resultant reaction from the body and of course emotional factors such as fear. Too little load and the recovery will be slow and at risk from poor bone thickness and weak stiff joints, too much and you will cause unnecessary irritation, pain, swelling and then fear. These injuries are very difficult to manage with swelling, gravity is not your friend! The body creates excess fluid within the healing process and this will pool in the ankle. Good old elevation and movement are the best cures for this but realistically I have seen ankles still struggling with swelling 12 months afterwards. As physios there are lots of things we can also do in order to help this. We aim to manage the loading as well as is possible within daily life to prevent it occurring and use treatments such as a “game ready” (a machine that applies pressure and cools the area) as an added extra.

As you may expect from then on the way an elite athlete is dealt with vs the way the rest of us are dealt with are very different. As is nicely discussed here http://blogs.bmj.com/bjsm/2016/08/04/evidence-based-medicine-in-elite-sports-why-go-for-the-1ers/ . In the profession we call this marginal gains or the “1%ers”! Essentially this is the bells and whistles that elite sport asks for. It is areas of treatment that have little supporting research but may give you that extra 1%. They are not to be relied upon as an individual entity, but when medals are won and lost for less, 1% matters!

Within Physiokinetic we use these techniques with all of our patients. Having the knowledge from treating the elite population allows us to use those same techniques to make everyones recovery more efficient and comfortable.

If you are at all interested in another case study of another athlete with a similar injury see here, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4325293/. In this case she was allowed to start weight training again at 29 weeks post injury and went back to professional sport!