Sports injuries

How to reduce the risk of injury in sport

Physical activity of any sort does carry a risk of injury. Most people who take up regular sporting activity will only experience minor sports-related injuries. Sensible precautions can all help to reduce risks. For example:

• Warming up before exercise.

• Exercising within your capabilities.

• Increasing your exercise levels slowly.

• Cooling down exercises and stretches after sport.

There are only a few reasons why physical activity may be harmful. A common belief is that physical activity may be bad for the heart. On the contrary, physical activity is good for most people with heart disease provided they follow guidelines given by exercise specialists or health professionals. In general, if you gradually build up to do regular moderate-intensity physical activity, the potential benefits to your health will greatly outweigh the small risks involved.

Most sports injuries result from:

• Doing too much too quickly.

• Overestimating your fitness and ability.

• Lack of preparation/poor technique.

• Pushing your body too hard (over-training).

• Poor equipment, and accidents.

This leaflet looks at the common sports-related injuries seen both in non-professional and professional athletes, and how to prevent and manage them.

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Ankle injury

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by Dr Hayley Willacy, FRCGP

Are children at risk of sports injuries?

Children can also develop both sudden and overuse injuries. Children may be very competitive at their sports, desperate not to miss a race or a match. They may not be as sensible as adults when it comes to needing to rest an injury.

There are also some sports-related injuries that are particular to children, such as Osgood-Schlatter disease.

To reduce the risk of overuse injury children should be encouraged to play a variety of sports. Those who exercise regularly or compete should have their training monitored by a qualified coach.

Types of sports injuries

Depending on the type of injury, it usually involves either sudden or gradual trauma to the musculoskeletal system.

This means to the structures that hold the skeleton together and move it along.

• Muscles.

• Bones.

• Ligaments: the thick bands of tissue that connect one bone to another.

• Tendons: the tough, rubbery cords connecting muscles to bones.

• Joints: the hips, elbows, ankles and knees.

• Cartilage: tough, flexible tissue that covers the surface of joints and allows bones to slide over one another.

The nature of sports injuries

Sports injuries may be either sudden or gradual in onset.

Sudden in onset

These are often the result of a sudden impact or an awkward movement. Sprains, and sometimes more serious injuries, are a risk. Sudden injuries are accidental but are less likely to occur if you:

• Are fit.

• Know your sport.

• Wear the correct footwear and use good equipment.

• Exercise in a sensible way (for example, not running in the dark on rough ground). You can also cut down your risk of injury by warming up before any activity.

Gradual in onset

These are often the result of overusing the particular part of the body, sometimes due to poor technique. Overuse injuries are common in professional athletes because of the intense nature of their training. They are also seen in those who train regularly. For example, overuse injuries can affect those who spend long periods in a repetitive action such as marathon running. This is partly because slight problems with technique will be magnified by being repeated over and over again. It is also partly because intense and prolonged training does not allow muscles, tendons and ligaments recovery time from the minor stresses and strains of training sessions. Overuse injuries can be to any part of the musculoskeletal system, including cracks (stress fractures) in bones.

Rare serious events

In rare cases, other serious illness and even sudden death can occur in people who are taking part in physical activity. There is usually an underlying heart problem, known or unknown. It is the excess stress that is placed on the person's body during exercise that causes the sudden death. It should be stressed that, in general, regular exercise protects the heart.

What are the types of sports injuries?

The following list gives the more common types of sports injury, and links them to leaflets providing further information. The most common types of sports injuries include:

Stress fractures

• Stress fractures are common sports injuries. They are breaks in the bone but can be thought of as cracks - sometimes full-thickness cracks - rather than complete breaks in which the two parts of the bone separate.

• Stress fractures are overuse injuries. They occur when muscles are fatigued, weakened or injured, and cannot absorb added shock. Eventually the overload of force is transferred to the bone where it causes a tiny crack.

• Stress fractures tend to result from a sudden increase in training intensity or quantity, a change of sports surface or change of running shoes. Most stress fractures occur in the lower leg but they can also occur in the thigh and hip. The sports where they are most seen are track and field events, tennis and basketball. They are slightly more common in women.

• Stress fractures cause pain with activity - particularly impact. They don't always show up on X-ray, and a magnetic resonance imaging (MRI) scan may be needed to find them.

Foot and heel pain

• This often arises from the tendons in the foot and heel, which may be strained by overuse or by sudden twisting and imbalance.

• One common condition is plantar fasciitis: the plantar fascia is a thick band of tissues stretching under the foot.

• Ingrowing toenail is common in runners because the toes can become warm and swollen in tight training shoes.

• Heel pain may also be due to plantar fasciitis, or to a bruised heel, which is a bruise in the heel pad.

• Broken bones (fractures) can occur in the long bones of the feet or in the toes.
  

Ankle pain

• The Achilles tendon is a strong tendon which connects the muscles of the calf to the heel. It is a common source of pain in the back of the heel and ankle, leading to Achilles tendinopathy (often called Achilles tendonitis).

• The Achilles tendon is also the most commonly ruptured tendon: it can occur partially or completely. Achilles tendon rupture is usually caused by overstretching of the tendon.

• Ankle sprain and ankle fractures are most commonly caused by twisting injuries when running or jumping. It takes considerable force to break the ankle.

Lower leg pain

This is most commonly due to:

• Muscle strains or cramps. These are often caused by a combination of heat, lack of fluids in the body (dehydration), and inadequate warming (often with an overstretch of the muscle).

• Shin splints. This is a term for pain in the shinbone relating to exercise. It occurs when the edge of the shinbone becomes inflamed due to the muscles and tendons pulling on it during exercise. This often happens after running or jumping, or sports with sudden stops and starts, such as basketball or football. Sudden increases in running distance or pace can also trigger it. Shin splints can sometimes form mini stress fractures (surface cracks in the bone). These may occur after landing with particular force, and can be extremely painful.

• A torn calf can occur when excess strain is put on the calf. It is common in runners who have changed running shoes or who have attempted to move to barefoot or forefoot running styles without guidance. Pain is in the top of the calf, often at the outer side - and the treatment is a break from running. Physiotherapy can be very helpful.

Knee and thigh pain

Injuries to the knee and thigh are particularly common in sports such as football which involve running and twisting. This can strain the strong supporting ligaments inside the knee, leading to:

• Knee cartilage injuries.

• Knee ligament injuries.

Anterior knee pain
This means pain in the front of the knee. It is common in teenagers and young sporty adults.

• It is often called patellofemoral pain syndrome (PFPS) and is often an overuse injury. It can relate to abnormalities in the run, caused by a poor line-up of the legs when running. For example, the following can all contribute:

  • Flat feet.

  • The wrong shoes.

  • Weak ankles.

  • Weak muscles.

  • Lack of fitness.

  • Having joints which are more flexible than usual (hypermobility).

• Quadriceps strain is due to strain or injury to the bulky muscles at the front of the thigh. It can occur suddenly, in which case it is usually painful and obvious, or through overuse.

• Anterior cruciate ligament (ACL) injury. This is a sudden tear of one of the ligaments that runs across the inside of your knee. It is nearly always caused by participating in sport, caused by twisting or overextending your knee, particularly when you suddenly slow down, stop or change direction. See also the separate leaflet Knee Ligament Injuries for more information.

• Osgood-Schlatter disease is another cause of knee pain in young people (adolescents). The condition is aggravated by exercise; it causes a swelling and tenderness of the tibial tubercle, which is the bulge of bone at the front and just below the knee.

• Chondromalacia patellae also causes pain at the front of the knee in teenagers who exercise. It is also associated with hypermobility and with weakness of the quadriceps muscles. The condition is due to some slight roughening on the back of the kneecap, which causes it to irritate as it moves over the joint.

• Hypermobility can also cause anterior knee pain on its own, especially around the time when young people have increases in growth (spurts). During growth spurts, the knee joint tends to bend too much (hyperflex), straining the ligaments and tendons.

• Patellar tendonitis is due to inflammation of the tendon just below the knee. This can become sore and tender. It is an overuse injury caused by too much high-impact training. It is sometimes called jumper's knee.

Lateral and medial knee pain
Lateral knee pain means pain on the outer side of the knee. Medial knee pain means pain on the inner side of the knee. Common causes include:

• Knee cartilage injury: often due to running and twisting hard - can also cause pain at the side of the knee. In sport it tends to be a sudden injury. You will need to stop playing sports and the knee will swell immediately as the torn cartilage bleeds.

• Knee ligament injury: can be on the inner or outer side and can be sudden if the knee is pulled or twisted in a fall, leading to a ligament sprain. It can aso be gradual if the ligament is strained through poor running technique.

• Iliotibial band syndrome: inflammation of the iliotibial band occurs on the outside of the knee only. This tight band of muscle and tendon on the outside of the knee can rub against the outside of the knee joint. It's an overuse injury which is difficult to treat without physiotherapy advice.

Posterior knee pain
This means pain at the back of the knee. It is most often due to overuse. The most frequent causes in sportsmen and sportswomen are three different tendon inflammations:

• Hamstring injury: can be a persistent (chronic) injury. It usually involves the part of the hamstring called the biceps femoris and is brought on by running downhill, kicking and sprinting. It is also possible to tear the hamstring suddenly. Depending on how big the tear is, this can be very sore, cause bruising and stop you playing for several weeks.

• Popliteus tendonitis: affects the small muscle at the back of the knee, called the popliteus. It also causes pain at the back of the knee.

• Gastrocnemius tendonitis: affects the large calf muscle where it connects to the back of the knee. This is an overuse injury and usually affects the inside back of the knee joint.

Groin pain
Groin injuries can be of gradual onset or of sudden onset. The groin muscles pull the legs back towards the midline. They stabilise leg movement in running, walking, sprinting, playing football, horse riding, hurdling and any sport which requires fast changes in direction. A tear in the muscle usually occurs when sprinting, changing direction or kicking. This is especially likely if a thorough warm-up has not been undertaken first.

Bottom and hip pain

• Pain in the bottom (buttock) in runners may come from joints, ligaments, tendons and the large gluteal muscles. These may be inflamed or, in the case of the muscles, also torn. It is also possible for runners to develop small cracks (stress fractures) in the thigh bone, although this is uncommon. Injuries can be chronic or sudden, and they are common in sports involving running, twisting and kicking.

• Because there are many muscles and tendons in the thigh and buttock combining to do similar jobs it is often possible to continue to exercise with buttock and hip pain. Doing so, however, is not necessarily advisable. As self-diagnosis is not easy, if pain persists there may be a significant problem needing treatment with active rehabilitation. It is, therefore, important to seek advice.

• Pain in the buttocks can also be referred pain from the lower back.
  

Lower back pain

• Pain in the lower back is often due to underlying back problems which are made worse by sport. However, strain on the lower back is severe in those lifting weights, particularly if the technique is not excellent.

• Lumbar instability occurs when part of the lower back has too much movement. Lower back pain is very common in distance runners who lack core strength in the muscles around the trunk which support the back. Core strengthening exercises to support the back can be helpful.

Tummy pain
Tummy (abdominal) pain in sport may be due to muscular strain. Vigorous exercise may lead to pains due to stitch. Stitch is a word for pain from the muscle you breathe with (the diaphragm), particularly if you are not warmed up.

Chest pain

• Chest pain when exercising is often muscular, due to the muscles of the chest wall working hard when a person is breathing hard. In some sports such as weightlifting and rowing, pain is due to those muscles working hard due to lifting or pulling.

• Chest pain can also arise from the heart. If this is so, you are likely to feel unwell, sweaty, faint, or breathless. These are all feelings associated with sport anyway - but if they seem worse than you would normally expect, if you feel faint or if you have crushing central pains in the chest, seek urgent medical help.

Upper back and neck pain
Pains in the neck and upper back are most commonly muscular and due to poor posture.

Shoulder pain
The most common causes of shoulder pain in sports are swelling (inflammation), and pulls and tears to the muscles around the shoulder. The rotator cuff muscles are four muscles important in rotating and lifting the arm. They are prone to injury when falling or during a sudden powerful movement such as in throwing or when paddling a kayak.

• Shoulder dislocation can occur in contact sports and swimming. It causes severe shoulder pain.

• A broken collarbone or a sprain to the joint between the collarbone and the shoulder can occur if you fall on to the shoulder or an outstretched arm.

• Injuries, strains and tears to the biceps and triceps muscles can occur in those who use their arms in sport.

Elbow pain

• Pain on the outside of the elbow (lateral elbow pain) is commonly due to tennis elbow. It is an overuse injury. It is typically seen in sports (like tennis) involving repeated bending back of the wrist against resistance. Weight training can also be a cause.

• Pain on the inside of the elbow (medial elbow pain) is commonly due to golfer's elbow. This is typically caused by repeatedly bending the wrist inwards against force, such as when using a golf club.

Wrist and hand pain
Sudden wrist injuries may be fractures or sprains, or overuse injuries such as wrist tendinopathy (also called wrist tendonitis) and carpal tunnel syndrome.

Finger injuries
Finger and thumb sprains involve damage to the ligaments in the finger, often due to sudden bending back of the fingers through a fall or catching a ball badly. Finger dislocations and fractures of the bones in the hand can also occur in the same way.

How to avoid sports injuries

Not all sports injuries can be prevented, but you can reduce your risk by:

• Warming up properly before exercise; this can include stretching or rolling muscles and increasing activity levels slowly.

• Not pushing your body too hard - stay within your own fitness capability.

• Use the right equipment, such as shin guards for football, a gumshield for rugby and supportive running shoes for running.

• Receiving coaching to learn correct techniques; if you start a new sport or activity, obtain advice and training from a qualified healthcare professional or a sports coach.

People's choices and needs for running shoes vary. However, before choosing something unusual such as barefoot shoes or corrective shoes, make sure you have some advice. For example, for barefoot running you need to be taught the right technique. Break in new running shoes gradually - many injuries result from a sudden change in running shoes.

Read more information in the separate leaflets called Physical Activity for Health and Diet and Lifestyle during Pregnancy.

How to deal with a sports injury

You should always stop exercising if you feel pain, regardless of whether your sports injury happened suddenly or you've had the pain for a while.

Continuing to exercise while you're injured may cause further damage and make your recovery time even longer.

You should also consider seeking medical advice. Minor injuries may sometimes be treated at home. However, you need to be sure you know what's wrong; otherwise, you may simply repeat the problem the next time you exercise.

• If pain prevents you from resuming sport then consider seeking medical advice.

• If pain prevents you from resuming your normal day-to-day activities then seeking medical advice is recommended.

See the separate leaflet called Sprains and Strains for information on treatment of these conditions.

How should sports injuries in children be treated?

Children usually heal fast and without any problem, but they may need some guidance on rest and training. Some children are involved in very competitive sport and train very hard and long to a very high standard. This is particularly true of swimming, gymnastics and dancing. Children are still growing and their bodies are still changing, so they are at particular risk of overuse injury.

It's very important that children don't overtrain. If they do develop symptoms they should see someone other than their coach (especially if the coach is a parent). This is just to have a second opinion to make sure that the training isn't too much.

How should I treat overuse sports injuries?

You can treat most minor sports injuries yourself by resting the affected body part and using over-the-counter painkillers for pain relief. However, overuse injuries are a bit different.

If you have an overuse injury this may mean that you have been unconsciously overstraining or overusing a joint, or tendon, or group of muscles for a long time. Correcting this so that you can continue to exercise needs careful assessment and advice. If you don't do this then the moment you start exercising the injury is likely to return and may even become worse. It may be, for example, that you need to exercise particular muscle groups to strengthen them, so that your movements are properly balanced. This will help you to avoid putting extra strain on some areas.

Advice from a sports physician or a physiotherapist with an interest in sports medicine can be very useful. It can help you to:

• Recover.

• Make sure that you can exercise in the future without your injury returning.

What is active rehabilitation?

Active rehabilitation is sometimes called therapeutic exercise. It is a tailored programme which uses a variety of methods including rest, exercise and physiotherapy to speed up the return to full function and to enable sportspeople and athletes not to lose fitness whilst resting the injured part. It also educates the athlete in technique and posture for the sport, so that any mistakes which contributed to the injury are not repeated. The aims of active rehabilitation are:

• Resolving pain and inflammation.

• Getting back your full range of motion.

• Getting back your strength.

• Improving your balance and co-ordination.

• Improving your technique in your particular sport.

Typically a physiotherapist-led active rehabilitation programme would begin with an assessment of your strength, flexibility and, of course, the injury and how it happened. The programme might then involve core strengthening, postural re-education, stretching, flexibility and functional physiotherapy to correct your technique. Massage, ultrasound and other techniques may also be employed.

Sportsmen and sportswomen will work very hard to recover quickly and are often impatient. Impatience is the enemy of good recovery, as you can try to do too much too fast. It's important to take advice and follow it. Different people recover at different rates but, generally, healing is slower with older age.

How should I treat sudden sports injuries?

When you have JUST injured yourself then remember RICE. RICE stands for Resting, Icing, Compressing and Elevating the injury.

It is sometimes extended to PRICER, in which:

• P stands for protection, which may mean preventing movement of (immobilising), or adding padding to, the injured part.

• R stands for rehabilitation.

Please bear in mind that it used to be common advice to put an ice-pack on something that was injured. In fact, scientists haven't managed to prove that ice-packs make much difference and in some cases the cold ice can actually delay healing. So for now the evidence base for ice-packs in injury should be thought of as equivocal.

If a part is injured it will need to be rested. However, if you are a keen sportsperson, telling you to rest is not always realistic. If you have worked to get fit, you probably want to keep your fitness level up, so complete rest is not always the best answer. Instead you may need advice from a doctor, physiotherapist or sports injury clinic. They will provide advice on how to use exercise and movement to speed healing whilst continuing to exercise. This is called active rehabilitation.

Dr Mary Lowth is an author or the original author of this leaflet.