Sports Injuries.pdf

3/20/24, 1:58 AM Sports Injuries Sports Injuries Lily Lum, BScPharm, CSPI Date of Revision: August 8, 2019 Peer Review Date: July 1, 2019 Pathophysiology The benefits of a physically active lifestyle to promote health, well-being and quality of life is strongly advocated.​ There are physical activit...

3/20/24, 1:58 AM Sports Injuries Sports Injuries Lily Lum, BScPharm, CSPI Date of Revision: August 8, 2019 Peer Review Date: July 1, 2019 Pathophysiology The benefits of a physically active lifestyle to promote health, well-being and quality of life is strongly advocated.​ There are physical activity guidelines for all age groups (children, adolescents and adults) as part of the healthy active lifestyle movement.​ Although participation in sports and exercise is associated with health benefits, injuries can occur, especially if activities are not properly performed.​​ In healthy adults 18–64 years of age, the benefits of exercise (e.g., prevention of coronary heart disease, hypertension, osteoporosis, stroke and certain type of cancers) far outweigh the potential risks associated with physical activity.​ ​ Children and adolescents may be particularly at risk for sports injuries for several reasons. Young athletes of similar age vary greatly in size and physical maturity; they may try to perform at levels beyond their ability in order to keep up with peers. Early sport specialization in children should be avoided.​ Other factors contributing to an increased risk of sport injury include improper technique, lack of or poorly fitting protective equipment and training errors. Sports-related injuries are varied and can be caused by trauma, overuse of specific parts of the body such as muscles or joints, and environmental factors.​ Acute injuries such as ligament sprains and muscle strains are usually caused by sudden trauma and are more likely to occur in contact sports. Overuse or chronic injuries are more subtle and are most commonly associated with sports that involve repetitive movements. The 3Fs or “terrible toos”—too fast, too far and too frequent—are often used to describe the cause of overuse injuries.​ Some of the more common sportsrelated injuries such as strains and sprains, overuse injuries (e.g., Achilles tendinitis, bursitis, plantar fasciitis, shin splints and tennis elbow), and stress fractures are defined below. Sports injuries can also be caused by environmental factors, e.g., heat stroke can occur during participation in outdoor sports activities during hot temperatures.​ For further information, see Heat-Related Disorders. Common Sports Injuries Bursitis is the inflammation of a bursa. Bursae are tiny, fluid-containing, sac-like structures that are located wherever there might be friction, such as between bones and the muscles and tendons near joints (see Figure 1). When they become inflamed, movement or pressure is painful. Sports-related bursitis occurs most commonly in the elbow, knee and shoulder. Figure 1: Knee Joint—Sagital Section https://cps-pharmacists-ca.login.ezproxy.library.ualberta.ca/print/new/documents/MA_CHAPTER/en/sports_injuries_minor 1/12 3/20/24, 1:58 AM Sports Injuries A sprain is an injury to a ligament caused by overstretching or twisting. In the ankle, a common area for sprains, it is mainly the lateral ligaments of the joint that are involved. Symptoms include pain, swelling and tenderness, with subsequent bruising around the injury. Symptomatically, severe sprains may be difficult to differentiate from fractures, and an x-ray may be needed to make a firm diagnosis.​ ​ A strain is an injury to a muscle and is also referred to as a torn or pulled muscle. It is usually caused by overstretching and is characterized by pain and swelling. Muscle strains vary in severity, from damage to the fibres with the muscle sheath left intact to complete rupture of the muscle.​ ​ Plantar fasciitis is a common condition causing heel pain; it involves inflammation of the plantar fascia, the tough, fibrous band of tissue that runs along the sole of the foot. Inflammation usually occurs following increased or repetitive activity such as jogging.​ ​ Shin splints, also known as medial tibial stress syndrome, are inflammation of the muscles, tendons and periosteum (bone tissue) around the tibia or shin bone. Pain occurs along the inner edge of the tibia where the muscles attach to the bone. Shin splints are the result of repetitive activity and often occur following sudden changes in frequency, duration or intensity of physical activity. Having flat feet or exercising with inappropriate footwear can contribute to the development of shin splints.​ Stress fractures are tiny cracks in bones that often result from repeated, excessive impact. Athletes required to jump repetitively (e.g., gymnasts, basketball players) often get stress fractures.​ ​ They usually occur in the feet, ankles and legs, although any bone can suffer a stress fracture. An individual may not even notice when a stress fracture initially occurs. The pain decreases with rest and increases over time, getting worse when pressure is applied during activity. It starts progressively earlier in the workout, becoming so severe that it prohibits exercise and persists even during rest. The area may or may not show signs of tenderness and swelling. Stress fractures can be mistaken for shin splints because both can cause mid-calf discomfort. However, stress fractures are more serious than shin splints, the pain lasts longer and the injury takes longer to heal. Tendinitis refers to acute inflammation of a tendon, the thick fibrous cord that attaches muscle to bone. Two common examples of tendinitis are Achilles tendinitis and tennis elbow. Achilles tendinitis is inflammation of the Achilles tendon, which connects the heel to the calf muscle.​ A patient with Achilles tendinitis experiences pain and tenderness just above the heel. Tennis elbow, also known as lateral epicondylitis, is inflammation of the tendons attached to the outside/lateral side of the elbow at the bony prominence of the arm bone.​ It commonly occurs during racquet sports (such as tennis) and activities that require repetitive, one-sided movements. The patient experiences pain and tenderness outside of the affected area, at and below the elbow joint. With repeated overuse, degenerative microtears occur in the tendon, resulting in chronic epicondylosis. While inflammation may be present with acute tendon injuries such as tendinitis, chronic injuries are more correctly referred to as tendinosis or tendinopathy. The pathology of chronic tendinopathies is related not to inflammation but to degenerative changes occurring in the tendon over time due to microscopic tears that fail to heal properly. https://cps-pharmacists-ca.login.ezproxy.library.ualberta.ca/print/new/documents/MA_CHAPTER/en/sports_injuries_minor 2/12 3/20/24, 1:58 AM Sports Injuries Goals of Therapy Provide relief of symptoms Promote healing of the injury Prevent re-injury or aggravation of the injury Patient Assessment An assessment plan for patients suffering from musculoskeletal sports injuries is illustrated in Figure 2. Symptoms of selected non–soft tissue injuries that require immediate medical attention are described in Table 1. Table 1: Selected Injuries Requiring Immediate Medical Attention​ Injury Symptoms that Warrant Immediate Medical Attention Eye injury​ Blurred vision, loss of vision, moderate to severe eye discomfort or pain Head injury, e.g., concussion​ Confusion, amnesia, headache, loss of consciousness after injury, tinnitus, drowsiness, dizziness, nausea, vomiting, seizures, unusual eye movements, slurred speech Nosebleed​ Bleeding lasting longer than 20 min Tympanic membrane perforation (ruptured eardrum)​ Earache, partial hearing loss, slight bleeding or discharge from ear Prevention Proper conditioning and training prevent many sports-related injuries. Muscle pain and stiffness commonly occur 24 hours after unaccustomed intense physical activity.​ Appropriate warm-up exercises, stretching and cooling down (gradually slowing down before stopping the exercise) should be routinely performed. Warmed-up muscles are more pliable and less likely to tear. Stretching allows the muscles to lengthen so that they can contract and perform more effectively. Cooling down can prevent dizziness and fainting. In a person who exercises vigorously and suddenly stops, blood can pool in the dilated leg veins, causing dizziness and fainting. Cooling down maintains increased circulation and helps clear the build-up of lactic acid in the bloodstream.​ A gradual increase in the intensity and duration of workouts and adequate fluid replacement are also important preventive measures. For more information on hydration in the athlete, see Sports Nutrition. Warning signs of impending injury include extreme fatigue, pain and lack of enthusiasm for training.​ Protective equipment (e.g., helmet, eye protection, mouth guard, knee and wrist pads) and proper footwear are essential for those participating in sports with a high risk of falls (e.g., in-line skating) or those requiring direct contact with playing equipment or other players (e.g., boxing, football).​ ​ Note that eyeglasses or sunglasses do not provide adequate eye protection unless they are specifically designed for use in sporting activities. Nonpharmacologic Therapy The 4 essentials of early management of soft-tissue injuries can be remembered using the acronym RICE: Rest, Ice, Compression, Elevation (see Table 2).​ ​ ​ https://cps-pharmacists-ca.login.ezproxy.library.ualberta.ca/print/new/documents/MA_CHAPTER/en/sports_injuries_minor 3/12 3/20/24, 1:58 AM Sports Injuries After 48 hours have passed and the initial swelling has subsided, the RICE regimen can be replaced by heat, early mobilization, massage and/or rehabilitation with physical therapy if necessary.​ Table 2: RICE Regimen Rest Immobilization is recommended for at least the first 24 h to avoid aggravation of the injury. If long-term rest is indicated, the unaffected joint(s) should be exercised to prevent tissue atrophy and loss of coordination. Rest for a prolonged period of time is usually discouraged for muscle injuries. Ice The application of cold to an injury reduces local blood flow by constricting blood vessels and limiting the swelling. Apply cold therapy at regular intervals, allowing a few hours between treatments. Compression An elasticized bandage applied to an injured area for at least the first 24 h can reduce swelling, support a weak joint or provide a protective layer for wounds. Elevation The injured area should be raised above the level of the heart to help drain fluid and reduce swelling. Heat versus Cold Therapy Should patients apply heat or cold therapy to a sports injury? As a general rule, the application of cold is the preferred immediate treatment (first 24–48 h) for most acute musculoskeletal injuries.​ Sources of cold therapy include ice bags (putting crushed ice in a thick plastic bag), commercial cold gel packs, or bags of frozen peas or corn.​ Recommendations for duration and frequency of cold therapy application vary considerably.​ The application time varies depending on the body part and comfort but usually ranges from 10–30 minutes. Apply cold at regular intervals throughout the waking hours of the day, allowing a few hours between treatments. Areas with little body fat (bony areas such as the knee, ankle and elbow) do not tolerate cold as well as fatty areas (such as thighs and buttocks). For bony areas, keep application time to the lower end of the range (10 min); double the time when applying to fatty areas. Applying ice directly to the skin or for too long can cause frostbite and tissue damage. A thin towel can be placed between the ice bag and skin to prevent frostbite. Use cold therapy with caution in patients with poor circulation, such as those with diabetes or Raynaud disease, since these patients already have reduced local blood flow.​ Heat therapy (thermotherapy) is recommended after the first 48 hours when the swelling has subsided, and during the chronic rehabilitative phases of the injury.​ Local heat produces analgesia by affecting free nerve endings, decreases the incidence of painful muscle spasms by relaxing muscles, and reduces joint stiffness by decreasing synovial fluid viscosity. Heat causes vasodilation, producing increased blood flow, which in turn helps provide a greater local supply of nutrients, oxygen, antibodies, leukocytes and enzymes to the injured area. Waste products from the inflammatory process are transported away with the increased blood circulation.​ Heat may be applied for 20–30 minutes every 2–4 hours, as needed. Contraindications to the use of local heat therapy include patients who are unconscious and those with impaired skin sensitivity, poor circulation or open wounds.​ ​ Sources of local heat therapy include hot water bottles, electric heating pads, commercial heat packs and infrared heat lamps.​ Patients must take care to avoid burns from the use of heat therapy products. Hot water bottles and heat packs should be wrapped with a towel or cloth for comfort and safety. Heating pads and heat lamps should be kept on low to moderate settings.​ Pharmacologic Therapy Therapies used to treat minor sports injuries are listed in Table 4. https://cps-pharmacists-ca.login.ezproxy.library.ualberta.ca/print/new/documents/MA_CHAPTER/en/sports_injuries_minor 4/12 3/20/24, 1:58 AM Sports Injuries For more information on pharmacologic therapy for sports injuries, consult the Compendium of Therapeutic Choices: Sports Injuries. For comparative ingredients of nonprescription products, consult the Compendium of Products for Minor Ailments— Analgesic Products: External Analgesics, Internal Analgesics and Antipyretics. Oral Analgesics Oral analgesics such as acetaminophen and NSAIDs can provide effective relief of musculoskeletal pain.​ ​ ​ ​ They may be useful for acute as well as chronic injuries. Advise patients to take the lowest effective dose to relieve their pain and inflammation. Codeine can be found in combination products for the treatment of moderate to moderately severe pain. Opioids are often drugs of choice in severe acute pain or cancer pain but have limited use for most sports injuries. Opioid therapy should be considered only if expected benefits for pain and function are anticipated to outweigh risks to the patient.​ For injuries such as bone fractures, which are often extremely painful, short-term use of acetaminophen plus codeine combinations may be warranted.​ In patients with concussion, avoid opioids so that clouding of the patient's mental status on neurologic exam does not occur.​ Muscle Relaxants Muscle relaxants (e.g., methocarbamol, chlorzoxazone) are generally intended to provide pain relief when muscle spasm is a component of an acute injury. However, muscle relaxants are not routinely recommended and are not considered first-line therapy in acute musculoskeletal injuries because of their limited effectiveness in providing pain relief.​ Fatal hepatotoxicity has been reported with chlorzoxazone use.​ External Analgesics External analgesics (e.g., methyl salicylate, menthol, camphor, capsaicin) are traditional remedies for the treatment of general aches and pains. Their value is limited but they may be useful during rehabilitation as cooling or heating rubs or as accompaniments to massage therapy.​ ​ Although not often prescribed, patients frequently purchase these products for self-treatment.​ Herbal products have been promoted to provide pain relief of injuries such as sprains.​ ​ Arnica montana is used to reduce bruising. There is limited evidence to support the use of such products.​ The use of external analgesics may cause skin reactions such as a rash or blisters or, rarely, serious burns.​ ​ Post-marketing reports have identified some cases of severe burns that occurred within 24–48 hours of application of products containing menthol either alone or in combination with methyl salicylate. While there are no reports of severe burns with the use of products containing capsaicin or methyl salicylate alone, caution is still warranted.​​ External analgesics should not be applied to acute injuries if there is bleeding or if the wounds are open or covered by dressings, since this can further irritate the wound area.​ They should not be used more than 3 or 4 times a day. External analgesics should not be used concurrently with thermotherapy devices, as burns may result.​ ​ Advise patients to stop using the product and seek immediate medical attention if they experience pain, swelling or burning after applying an external analgesic.​ Topical NSAIDs Although oral NSAIDs play a well-established role in reducing pain, swelling and inflammation resulting from sports injuries, the use of topical NSAIDs is less well entrenched.​ ​ ​ It is theorized that topical application minimizes the risk of side effects associated with systemic therapy (e.g., gastrointestinal toxicity). A meta-analysis of 86 randomized, placebo-controlled trials of transdermal NSAIDs involving 10160 patients concluded that topical NSAIDs are effective in relieving pain in acute and chronic conditions.​ Another metahttps://cps-pharmacists-ca.login.ezproxy.library.ualberta.ca/print/new/documents/MA_CHAPTER/en/sports_injuries_minor 5/12 3/20/24, 1:58 AM Sports Injuries analysis of 47 randomized, double-blind, active or placebo-controlled trials involving 3455 patients concluded that topical NSAIDs were effective and safe in treating acute pain in musculoskeletal conditions.​ Topical diclofenac is available as a 1.5% solution, which is indicated for osteoarthritis of the knee, and as a 1.16% or 2.32% gel indicated for the treatment of acute pain caused by injury to joints or muscles.​ Pharmacists can also extemporaneously compound topical NSAID products. Special commercial bases (e.g., Phlojel, Diffusimax) are available for compounding of topical NSAIDs. NSAIDs commonly incorporated into topical formulations include diclofenac, ibuprofen and ketoprofen.​ ​ ​ ​ Corticosteroid Injections Local corticosteroid injection therapy has been used to treat painful conditions involving tendinitis, despite limited evidence of effectiveness. The number of local corticosteroid injections is usually limited to 3 per year due to risk of atrophy, tendon rupture and osteoporosis. Corticosteroid injections should be avoided in Achilles tendonitis, where risk of rupture is highest. Other complications of local corticosteroid injections include temporary flare of pain and inflammation, joint infection, nerve damage and loss of skin pigmentation around the injection site.​ ​ ​ Miscellaneous Some topical anesthetic preparations, known as vapocoolants or refrigerants (e.g., ethyl chloride, Spray and Stretch), may be useful when applied topically to control the pain associated with injuries such as sprained ankles and bursitis. Side effects appear to be minimal, although cutaneous sensitization may occur. Spray and Stretch (pentafluoropropane 95%/tetrafluoroethane 5%) is used with the “spray and stretch” technique: the product is sprayed onto the injured area, blocking pain impulses so the muscle can be stretched to its normal length in a painfree state.​ ​ NSAIDs can be used for short-term pain relief of tendinopathies. Other therapeutic modalities such as the use of topical nitroglycerin including the patch have been studied but their role in treating tendinopathy is not clearly defined.​ Monitoring of Therapy Table 3 provides a monitoring plan framework for soft tissue sports injuries, which should be individualized. Table 3: Monitoring of Therapy for Soft Tissue Sports Injuries Symptoms Monitoring Endpoint of Therapy Actions Pain and swelling from muscle sprain or strain and overuse injuries Patient: daily Decrease in pain and swelling over a 14-day period. The injured area can gradually be used with minimal discomfort, and daily activities can eventually be performed without pain. If pain symptoms have not improved after 14 days of self-care, patient requires referral to an appropriate health-care practitioner for further assessment. If pain is worsening despite drug therapy, patient requires immediate referral to an appropriate health-care practitioner. Health-care practitioner: after 14 days of therapy Algorithms https://cps-pharmacists-ca.login.ezproxy.library.ualberta.ca/print/new/documents/MA_CHAPTER/en/sports_injuries_minor 6/12 3/20/24, 1:58 AM Sports Injuries Figure 2: Assessment of Patients with Musculoskeletal Sports Injuries Abbreviations: RICE = Rest, Ice, Compression, Elevation Drug Table Table 4: Selected Drug Therapies for Sports Injuries Drug/​Cost[a] Dosage Adverse Effects Drug Interactions Comments Hepatotoxicity associated with chronic use, especially at high doses. Isoniazid, phenytoin may decrease acetaminophen effect and increase hepatotoxicity; decreased effect of zidovudine. Increased risk of hepatotoxicity with chronic alcohol intake. Drug Class: Analgesics, oral acetaminophen 325–500 mg Q3H PRN PO Atasol Preparations, Tylenol, generics or 325–650 mg Q4H PRN PO