This article will help you classify some of the different types of injuries, some severe and others benign, that are discussed throughout the rest of the book. Various injury types are reviewed and defined, categorized by the type of tissue affected by the injury: bone, ligament, tendon, skin, or other. Although it is not possible to cover every injury in a single work, the most common sports injuries are discussed. In general, over a season, athletes spend far less time healthy than injured. That said, we must be aware that injuries can and do occur. Some injuries athletes have no control over, but with good equipment, good coaching, proper environment, and sensible exercise habits, athletes can count on being injury free most of the time.

Injuries by Structure or System

Bony injuries include various types of fractures, which are discussed in turn. An overview of injuries to ligaments and joints, muscles and tendons, skin injuries, and finally systemic disorders follows. Of all sports injuries, those to muscles, tendons, and ligaments are probably the most common. Naturally, the more physical a sport is and the more contact and high-energy collisions it involves, the greater the risk for injuries. American football and rugby are more likely to cause fractures, for instance, than tennis or basketball, in which ankle sprains tend to be more common.

Bone Injuries

One of the most common injuries that occurs to bones, particularly the longer bones of the arms and legs is a fracture, or a break in the bone. (A fractured bone and a broken bone are the same thing; one is not worse than the other.) Other common places for fractures are the bones of the wrist, ankle, and kneecap.

The many types of fractures include the following:

• Simple or nondisplaced fractures are those in which a break is noted on an X-ray, but the bone is still in perfect position. These fractures are much less likely to require surgical intervention than displaced fractures are.
• Displaced fractures usually occur in the long bones of the body and typically result in severe trauma. These fractures involve either a separation or an angulation of the fracture segments. Displaced fractures frequently require surgery and often require metal plates to be inserted to add strength and preserve the length of the bone.
• Comminuted (involving fragmentation or splintering of the bone) or impacted fractures are those in which one part of the broken bone is pushing into the other, shortening the length of the bone. This type of fracture is serious because loss of bone height can adversely affect the function of the bone. Such breaks are seen in fractures of the wrist. Wrist fractures become impacted when athletes instinctively try to break a fall with their hands. These dangerous injuries always relate to the falling action and are frequently seen in skiing, ice hockey, and in-line skating.
• Compound fractures are complicated. Such fractures include multiple fractures with displacement of bones, comminuted sections, and even bone piercing skin. These fractures are usually related to severe trauma (e.g., motorcycle crashes) but can occur in any high-impact sport. Rodeo cowboys and football and rugby players are particularly susceptible to compound fractures.
• Fracture dislocations are injuries that involve a break in a bone as well as damage to ligaments and muscles, causing the broken bone to dislocate at the joint. These types of injuries are usually caused by the type of trauma seen in auto racing or parachuting.
• Epiphyseal fractures are very serious injuries. The epiphyses, or growth centers, are seen in growing children. These growth centers are located near the ends of the long bones. The growth centers are soft and until they fuse do not have the strength of more mature bones. When fractures penetrate the growth centers, they can adversely affect future growth of the long bones. Such breaks must be handled with extreme care. Classifications of epiphyseal fractures are called Salter type I through Salter type IV, depending on the location and severity of the fracture. The Salter classification relates to how involved the growth centers are in the injury. A mild separation is a type I, and severe breaks through the growth center are categorized as types II, III, or IV, with IV being the most severe. When the fracture is extensive through the growth center, the healing process can dangerously affect the future growth of the bone. Fortunately, epiphyseal fractures in children are rare, but occasionally a child will get hit by a baseball or a bat, for example, and receive a serious injury. Stress fractures are the most intriguing of all fractures. These injuries can be caused by overuse, poor training habits, and poor environmental or practice facilities. They result from an abnormal stress being placed upon a normal bone. Often, the diagnosis is not made until after healing has taken place and new bone has been laid down. Often no treatment other than rest is necessary. If a weight-bearing bone is affected, weight should not be placed on the bone while it is healing; for a leg bone injury, the athlete must use crutches for a time (three to four weeks for an adolescent, four to six weeks for an older athlete). The amount of rest required depends on the type and degree of stress fracture. Of course no one can predict when rest alone will be sufficient, so a diagnosis and additional treatment if needed is preferable. In some cases of stress fracture, X-rays might not show a break, so a nuclear bone scan, magnetic resonance imaging (MRI), or computed tomography (CT) scan is needed for diagnosis.
• Avulsion fractures are related primarily to torn ligaments or tendons. The soft tissue trauma rather than the fracture is the focus of treatment for these injuries. Avulsion is frequently seen in injuries to fingers. Baseball catchers are notorious for avulsions in the fingers. Fractures are suspected when swelling, pain, or a history of trauma is present and can be confirmed by X-ray, bone scan, CT scan, or MRI. Typically athletes experience pain with fractures for two reasons: the periosteum (the lining of the bone where the nerve endings lie) may be disrupted, or a bone contusion or bruise (not really a fracture) may be present. A bone bruise can be extremely painful and just as disabling as a fracture, and it often takes as long as a fracture to heal. Bruised shins and hip pointers (located near the hip joint) are common in American football. Bone bruises are diagnosed by taking a careful history and possibly an X-ray. In some instances a bone scan or MRI, which may reveal increased activity within the bone, can be helpful. A fracture must always be ruled out before calling an injury a bone bruise. Other severe injuries resulting from trauma are compression injuries. Compression injuries are bone bruises with related bleeding in tight areas such as the shins or even the front of the thighs. The buildup of blood and the presence of the bone bruise can interfere with the normal blood supply, causing a breakdown of the surrounding tissue and interference with circulation.

Ligament and Joint Injuries

The area where two bones come together is called a joint. Joints are held together by tough but not very flexible tissues called ligaments. Many joints involve motion, such as the elbow, which is a hinge joint, or the shoulders and hips, which are ball and socket joints. Ligaments can surround a joint, acting as a capsule. Or they can be responsible for stability of a joint, as occurs in the cruciate ligaments of the knee. In either case, the main function of ligaments is to provide stability to a joint. At the joint, bones have surfaces covered by a very hard substance called articular cartilage. When a joint becomes arthritic, it is a breakdown of this articular cartilage that produces pain and disability. Lining the joint is the synovium, a thin tissue layer that secretes fluid which serves to lubricate the joint. The most common joint and ligament injuries result from misuse or direct trauma. Fractures to the bones at the joint are rare because severe trauma is more likely to result in the ligaments being injured. However, preadolescents have very strong ligaments relative to bone strength and thus, a traumatic injury to the joint of a young athlete may result in an avulsion. Older athletes suffering a similar injury are more likely to sustain a ligament tear than a bony avulsion because of their relatively greater bone strength and relatively weaker ligament strength. Be aware, however, that both ligament and bony avulsion injuries can occur in both age groups. When a joint, such as a finger joint, dislocates, a straining or stretching occurs at the ligaments surrounding the joint. Remember that ligament tissue is not very elastic. Fracturing of the edge of the bones might also occur. This means that unless corrective action is taken, including rehabilitation, an easy pathway will exist for further dislocations at the same joint. Ligaments can also be injured without joint involvement. The best-known injury of this type is the anterior cruciate ligament (ACL) knee injury common in so many sports. The ACL is the main stabilizer of the knee. When a running athlete suddenly stops and tries to cut, as athletes in many sports do, the force of that cut can cause the ACL to give out and tear. A very hard hit to the outside of the knee can cause the knee to cave inward, which can also strain the ACL. The majority of injuries to the ACL result from pivoting and cutting maneuvers and not from direct blows to the knee.

Ligament sprains and tears can occur anywhere in the body. Because of the inelasticity of ligaments, measures must be taken to prevent both initial and recurring injuries. Protective equipment and good body mechanics can make a significant difference. Other joint injuries include subluxation, loose bodies, osteochondritis dissecans, chondromalacia, and osteoarthritis. The patella (knee cap) is a stabilizer of the knee joint and glides through a groove created mutually by the femur and tibia. The patella is connected by the quadriceps tendon above the knee and by the patellar tendon below the knee. For various reasons the patella may sublux (that is, go to the edge of its groove) or dislocate. Probably the most common causes of these types of injury are a congenitally shallow groove for the patella to glide through and a lack of flexibility of the athlete. Osteoarthritis is a problem, especially for runners. With this condition the athlete can develop spurs and loose bodies that are painful and that limit full range of motion. Can running cause osteoarthritis? Possibly yes, if the running involves nervous running, stopping, starting, or cutting. But in flexible runners running on a good surface, osteoarthritis is unlikely to be caused simply by running. However, any direct impact on a joint can contribute to osteoarthritis. Strengthening the surrounding muscles of a joint is one of the best ways to delay the onset and reduce the severity of the symptoms of osteoarthritis.

Tendon and Muscle Injuries

Tendons are the parts of muscles that attach to bones. The muscle–tendon unit (also called the musculotendinous unit) helps to stabilize the joint. A good example is the shoulder’s rotator cuff, which actually forms a second capsule around the joint capsule. More significantly, the muscle–tendon unit is responsible for body movement and strength. The length and size of a body’s muscle–tendon units depend largely on degree of training, heredity factors, and general health of the individual. Specific training can affect the size and function of the muscle–tendon unit. Whereas stress injuries to ligaments are called sprains, injuries to tendons and the rest of the muscles are called strains. Strains to the muscles can be as minor as a mild spasm or can involve significant bleeding and swelling. Strains (also called pulled muscles) generally occur at the belly, or middle part, of a muscle and are graded on a scale of I to III based on the severity of injury to the muscle–tendon unit. In a grade I strain, a stretching and microtearing of the muscle fibers occurs, with minimal disability or loss of strength. Grade II strains result in partial tearing of the muscle–tendon unit, causing definitive functional deficits and a loss of strength. Grade III strains involve complete tearing of the muscle–tendon unit and result in severe functional deficits and significant weakness. Muscle bed injuries can involve strains, contusions, and tearing of the muscle. When a strain occurs at the origin or insertion of the muscles (at the site of the tendons, thus involving some inflammation of the tendons), the condition is called tendinitis. Tendinitis can be caused by a severe injury or can be a chronic condition. The chronic injuries—which are caused by overuse or poor body mechanics—are the most difficult to treat. A well-known sports injury, lateral epicondylitis (better known as tennis elbow, is a prime example of chronic tendinitis. As a result of overuse, playing too much tennis, or hitting with bad technique, many tennis players develop chronic tendinitis. Chronic problems of the tendons are very difficult to treat. Often the best treatments yield poor results.

Grade I: Minimal tearing of muscle fibers

(<20%), mild tenderness, no joint instability

Grade II: Moderate tearing of muscle-tendon unit (20-70%), minimal to mild tenderness, mild joint instability

Grade III: significant tearing of muscle-tendon unit (>70%), moderate tenderness, moderate joint instability Ruptured tendons can also occur and are classified in the same way muscle tears are classified.

Skin Injuries and Problems

Some serious sports-related problems can affect the skin. For example, skin infections fungal, viral, and bacterial; are common in athletics and often present in athletic training rooms. Athlete’s foot is a common fungal infection that can result from walking barefoot on dirty locker room floors or not changing socks frequently enough. It is best treated by maintaining good hygiene, keeping the feet dry, and applying appropriate powders or ointments for flares. If the nails appear eroded and are breaking down, a fungal infection of the nails may be present. This condition is more difficult to treat and may require systemic medications and removal of the affected nail(s). If symptoms of a fungal nail infection arise, professional medical care is warranted. Methicillin resistant staph aureus (MRSA) is a serious skin infection that periodically appears in and around athletic training rooms. MRSA is very difficult to treat so proper sanitizing regimes are absolutely necessary to prevent it and other skin infections. Equipment must be wiped down with proper antiseptic solutions, sharing of dirty towels must be prohibited, and personal hygiene must be stressed. Blisters a common injury typically caused by overuse, poor fitting equipment, or improper mechanics an undermine any athlete. Blisters might not look like much of a problem, but they can get infected or can get larger and become a big nuisance. The same is true of chafing injuries and abrasions. Skin irritations must be kept clean and receive proper treatment. Chafing is fairly common in long-distance runners who wear shoes that do not fit. Chafing is also common among bicyclists who wear ill-fitting biker shorts or have poorly adjusted bicycle seats. Scrapes are particularly common among skateboarders and are also seen frequently in athletes who play soccer, American football, or baseball. Many outdoor sports, including tennis, swimming, basketball, outdoor volleyball, and running, expose athletes to excess sunshine. Melanoma (a kind of skin cancer) has become more and more prevalent, especially in the Sunbelt states. Outdoor athletes must wear sunblock, shaded hats, and proper clothing for protection. Sunblock should protect against both UVA rays (which age the skin) and UVB rays (which burn the skin) and must be reapplied frequently (every two hours). When outdoors, athletes should seek shady areas when possible and drink plenty of fluids to prevent heat-related illnesses.

Other Systemic Injuries

Two injuries that can have catastrophic effects to systems throughout the body are heat injuries and sudden cardiac death. Various types of heat injuries occur and are differentiated by severity. Heat cramps (actually a form of dehydration) are probably the most painful and yet the least serious of heat-related injuries. A lack of fluids and essential minerals cause muscles, especially leg muscles, to cramp up. More serious heat exhaustion is caused by a higher degree of dehydration. Athletes with heat exhaustion become pale and lethargic and require quick treatment. The most serious kind of heat injury is heat stroke, in which the thermostat in the brain ceases to work. This is a true medical emergency and must be treated in a hospital. To avoid heat injuries, athletes’ bodies must be able to quickly and efficiently dissipate the heat generated by participating in sports. Athletes can dissipate body heat in four ways:

1. Moving to a cooler environment.
2. Moving air by moving the arms and legs. The movement of the arms and legs
3. Has a fanlike effect and prevents heat from mounting up.
4. Ingesting a cool drink (this provides only a little help).
5. Evaporation—and this is the most important. (However, evaporation can cause a loss of sodium, potassium, and fluids, which in turn can lead to dehydration and heat exhaustion.)

If these means aren’t effective enough, the athlete might need to go to the emergency room, where IV fluids, cooling blankets, and other care can be provided. Sudden cardiac death is thought to occur in 1 in 300,000 athletes. Although rare, cardiac death is obviously always tragic. About half the time, sudden death is due to a condition called hypertrophic cardiomyopathy (HCM), which is an enlarging of the heart. HCM is a congenital problem of atypical muscle that can be identified by electrocardiogram and echocardiogram. At this time it is not economically feasible to test everyone who wants to participate in sports, but the future holds promise that free clinics will spring up to screen all would-be athletes for this condition.

Injuries by Body Location

Obviously, location of an injury often depends on the sport or activity being performed. You would expect most baseball and tennis injuries to occur in the upper extremities. Conversely, basketball and track and field injuries would be more likely to involve the lower extremities.

Head and Neck Injuries

Head injuries are serious because they can cause death. The skull that houses the brain forms a hard protective capsule, but in the case of severe trauma the brain can be damaged by being shaken, or, in the event of a particularly severe blow, the skull might fracture. Although fractures of the skull do occur, the most common injuries to the brain are concussions, which are seen most often in contact sports. Being hit in the head by a hockey puck or baseball has also been known to cause severe head injury or death. With a concussion, temporary disorientation or loss of consciousness can occur. A fairly common symptom of head injuries, especially concussions, is a brief “lucid period” immediately following the injury, during which the athlete is fine for a few minutes; shortly afterward the athlete becomes disoriented. More serious than a concussion is a subdural hematoma, in which a build-up of blood compresses the brain. This condition requires immediate professional care. And, recently, a “second-impact syndrome”  has been identified as resulting in serious head injury. In this case, the individual suffers a head injury that might appear insignificant. Then later, after a week or two, another head injury occurs with disastrous results. Lacerations can occur on the face, especially in ice hockey, and these often require suturing. Some facial fractures are also worthy of mention, including nasal fractures and orbital fractures (fractures of the bones surrounding the eyes), both of which frequently require surgical intervention. Orbital fractures can be difficult to diagnose, but they need to be recognized because an untreated orbital fracture might result in a “sinking” of the involved eye with a decrease or loss of vision. Jaw fractures are not common but obviously quite painful and disabling. Other less frequent but serious injuries include nose and teeth injuries. These are less common since protective devices have been upgraded in American football and other sports. Cervical spine injuries can be classified as potentially catastrophic. These injuries are most often caused by lowering the head, which results in a straightening of the cervical spine. In such a position, if the head contacts an immovable object, such as another player or the ground, the cervical spine experiences a telescoping effect. Think of a trailer truck hitting a wall—the cab stops, the trailer continues on. Injury to the spinal cord can occur as a result of this impact, causing paralysis or even death. Cervical spine injuries are often tragic. American football and rugby players must be coached not to lower their heads during play. Other injuries to the spinal column can result in fractures, but the cervical spine injury is the most significant.

Upper Extremity Injuries

Problems in the upper extremities can occur in the shoulders, elbows, arms, hands, and wrists. Probably the most common shoulder injuries involve the rotator cuff . The rotator cuff is made up of four muscles that form a second capsule around the shoulder. Injuries to the rotator cuff range from tendinitis to muscle strains or tendon sprains. Probably the most interesting and difficult to treat rotator cuff injury is the impingement syndrome  in which muscle tendons are pinched under a bridge in the anterior shoulder area formed by ligament and bone. The coraco-acromion ligament is the only one of its type in the body. It goes between two points on the same bone. Impingement syndrome is related to overhead motion and is most common in baseball pitchers, tennis and volleyball players, and freestyle swimmers. These athletes make violent overhead maneuvers in their respective sports. Impingement syndrome can be difficult to treat. Surgery, a last resort, often does not help. Many promising careers have ended prematurely as a result of shoulder impingement syndrome. A shoulder injury often difficult to diagnose is the labrum tear. The cartilage around the cup of the shoulder joint is called the labrum. Labrum tears often produce symptoms that are identical to rotator cuff injuries and therefore sometimes cannot be identified without arthroscopic surgery. Another interesting and not uncommon overuse injury that occurs in proximity to the shoulder joints is the rupture of the tendon of the long head of the biceps, which gives the biceps a Popeye effect. When an athlete flexes the forearm, the biceps muscle balls up into what appears to resemble a big biceps muscle. Because the muscle has two tendinous attachments, functionally there is little interruption of activity. The Popeye syndrome causes very little discomfort and, because of the stronger other tendon, causes little or no disability. Traumatic elbow injuries such as fractures and dislocation can occur and frequently result in significant deformity. This is because the elbow joint is such a precise joint that any trauma can and will result in loss of range of motion, even after healing. Although functionally we can survive loss of extension or flexion or even loss of pronation (internal rotation), loss of supination (external rotation) can significantly affect a person’s everyday activities. Injuries to the elbow joint are treacherous and must be treated properly and vigorously. There are two important chronic elbow injuries. The first, known as Little League elbow occurs in youngsters whose growth centers of the bones around the elbows have not closed yet. Because of excessive throwing, primarily pitching, the ulnar (inside) or radial (outside) epiphysis closes prematurely. This condition may not cause pain, but as growth continues, the growth of the humerus is adversely affected, as is the athlete’s throw. The other chronic problem is epicondylitis, an overuse condition in which either the ulnar or, more commonly, the radial epicondyle is involved. The epicondyles are bony prominences on either side of the elbow. It is to these bony prominences that the tendons which extend and flex the forearms attach. We could very easily refer to these conditions as tendinitis because both the attachment of the tendons and the bony prominences, the epicondyles, are involved. What causes epicondylitis is that the bellies of the muscles of the forearm become spastic and shortened, which puts extra stress on the muscle tendons as they attach to the epicondyles of the humerus. This problem commonly occurs in racket sports when players hold the racket too tight and use a smaller grip than they should. When this is done repeatedly, the muscle tightens up, thus causing the problem. Epicondylitis can be very difficult to treat because not only must the irritation at the bony attachment be treated but also the tendinitis and the chronic muscle strains that tend to result from this problem. Two common wrist injuries need to be mentioned. The first is a fracture of the radius and ulna, which can occur when someone tries to break a fall with his or her hand. There is frequently deformity with these injuries, and they require surgery if the deformity cannot be corrected conservatively. A second wrist injury, a fracture to the scaphoid bone, is also significant. The scaphoid bone lies between the thumb and index finger and, when injured, might not show a fracture immediately. But if the pain persists, the possibility of fracture must be considered because an untreated scaphoid fracture can result in a “pseudojoint” or a nonunion (in which the two ends of the fractured bone fail to fuse). A nonunion can occur for several reasons but when it does occur, it can lead to chronic pain and loss of function. The pseudojoint acts like a joint, but there are no ligaments, and the edges are rough. This condition is not only painful but totally disrupts the mechanics of the affected body part. A nonunion is quite painful and ultimately requires complicated treatment, including surgery. Fractures and dislocations of the fingers are relatively common hand injuries. These injuries are sometimes belittled but in fact are every bit as significant as some larger injuries. In sports, with dislocations, there is a tendency to “bite the bullet,” reduce the dislocation (that is, correct or relocate the dislocation), and continue playing. But doing this can lead to a marked deformity called the “boutonniere” deformity, in which the joint next to the knuckle bends while the last joint of the finger remains straight. The boutonniere deformity gets its name because it looks as if the proximal finger joint (proximal interphalangeal joint, or PIP) slips through the extensor tendon as if it were a button hole. Essentially, this deformity results in the PIP joint hyperflexing, and the distal interphlanageal (DIP) joint and metacarpophalangeal (MCP) joint hyperextending. These complications illustrate why dislocations, despite any self-corrections made by the athlete, need to be followed up on and treated.

Trunk and Lower-Back Injuries

Chest injuries often occur during an impact to the chest, causing the ribs to break or the lungs to collapse. Less severe chest injuries may result in contusions or inflammation of the more superficial structures of the chest wall. For example, costochondritis, an inflammation of the area where the rib meets the breastbone, is a benign condition but causes significant discomfort especially when the upper extremities are stretched above the head. Perhaps the most unusual chest injury is commotio cordis, which occurs when an object suddenly hits a person in the chest, causing the heart to deviate from its regular rhythm, which can subsequently cause cardiac arrest and even death. This type of injury has been a factor in putting devices known as Automated External Defibrillators (AEDs) in public places and at sporting events. AEDs supply an electric shock to the heart and can save the life of a victim of cardiac arrest by shocking the heart back to a normal rhythm. Abdominal injuries are relatively uncommon in sports, but when they occur they can be serious. Causes include high-speed collisions, such as a child riding a bicycle and being thrown into the handlebars. When significant abdominal pain occurs and persists, immediate medical care should be sought. Lower-back injuries, especially herniated discs, are common among athletes. To minimize the occurrence of such injuries, athletes including weekend athletes must work to develop and then maintain their flexibility. Many times refining the technique used in sports such as swimming, racquetball, or hurdling lowers the risk of a lower-back injury.

Lower-Extremity Injuries

Problems in the lower extremities might occur in the hips, thighs, hamstrings, knees, ankles, or feet. Often young runners (in their 20s) complain of pain in their hips. Both greater trochanteric bursitis and iliopsoas tendinitis can produce such pain. A rare but significant hip problem is the coccygeal fracture, which can often be resolved without the services of an orthopedic surgeon. Of the thigh injuries, muscular injuries to the quadriceps (muscles on front of the thigh) are quite common. Because these muscles are responsible for extension (straightening the leg) in locomotion, they are among the largest and strongest muscles. They can be strained and torn and combined with contusions such injuries can be serious. When an athlete is hit hard enough in front of the thigh, bleeding within the thigh can occur. This injury is commonly experienced as a charley horse—a pain, cramping, or stiffness in the muscle as a result of a strain or bruise. However, if a second blow occurs in the same area, bleeding could become severe enough to warrant surgery. The hamstring muscles (muscles on the back of the thigh) are the flexors of the lower extremities. The hamstring muscles help to propel the body forward during locomotion. Hamstring contusions do occur, but the most common injuries to these muscles are strains. Highly trained athletes often succumb to hamstring injuries, and they take a long time to heal. When it comes to the lower extremities, the most common injuries are knee injuries; this is because the knee carries the weight of the whole body and is involved in locomotion, including running and pivoting. A common knee injury is the rupture of the anterior cruciate ligament.  Because of modern methods of surgery and rehab, an ACL injury is not the career-ender it used to be. The ACL functions to prevent the lower leg (tibia) from gliding too far forward on the upper leg (femur). Interestingly, females are much more prone to ACL injuries than males. There are many theories regarding the four- to six-fold higher incidence of ACL injuries, including female knee anatomy, hormonal influences, and other physiological differences but none has proven to be the definitive explanation. Currently one of the more widely accepted theories is that females tend to be more quadriceps dominant (as opposed to having balanced hamstrings and quadriceps), which raises the risk of an ACL strain. When quadriceps-dominant females contract their quads, they tend to put undue pressure on the front of the knee, pulling the tibia forward and causing increased stress on the ACL. In contrast, males are more hamstring dependent, so when they contract their quads, they tend to pull the tibia posteriorly, relieving pressure from the ACL. Equally as disabling as ACL tears are patella dislocations, in which the patella (kneecap), which normally glides along a groove formed by the femur (and to a lesser extent the tibia), suddenly “falls off the groove.” On either end are tendons and ligaments that stabilize the patella. In the case of a muscle imbalance the patella might not track accurately, causing the under surface to become chronically irritated. In the case of trauma, the patella might dislocate. Another injury affecting the patella is patellar tendinitis , which can produce pain during jumping, running, or stair climbing. Knee problems can also be caused by the menisci, the half-moon-shaped bits of cartilage that serve as pads or “shock absorbers” and also deepen the surface for the femur to sit on the tibia. The menisci tear rather easily, and the knee can actually lock if a piece of the meniscus gets caught in the joint. For the vast majority of athletes, a torn meniscus requires surgical attention. Fortunately, with arthroscopic surgery, meniscus injuries are not as serious as they once were. Another well-known knee injury is Osgood-Schlatter’s syndrome, which causes pain on the front of the leg bone directly below the knee. Pain is noted over the “bump” that is easily felt below the knee. This bump is called the tibial tubercle and is where the patella tendon (the area where the physician taps to elicit the knee reflex) attaches onto the tibia. Osgood-Schlatter is common in children who are active in sports at a young age. In these young athletes, the tendons and ligaments are actually stronger than the epiphyses, so they pull a small piece of bone away from the epiphysis. Later, when the growth center closes, the piece of bone that has been pulled away becomes prominent. Injuries to the lower include such acute problems as ruptured Achilles tendons as well as chronic conditions such as tendinitis, shin splints, and stress fractures. Shin splints is an injury that produces pain and tightness in the front (and sometimes the medial side) of the legs, usually caused by an inflammation of the sheath that surrounds and attaches to the bone. Shin splints is a chronic problem in running sports. Causes include poor practice habits, playing or running on improper surfaces, and what might be called “chromosomal poverty,” such as the reduced flexibility resulting from an inherited high arch that causes the impact of the foot hitting the ground to be transmitted to the legs. High-arch athletes are also more prone to Achilles tendinitis and plantar fasciitis. One of the most common injuries in sports is the sprained ankle, which occurs most frequently on the outside of the ankle. This injury is likely when athletes come down on another player’s foot or step into a divot or a hole. Sprains run from mild stretching of the ligaments (grade I) to complete rupture of the ligaments (grade IV), which requires surgery. Grade I ankle sprains are mild, stable, and without significant deformity, and may trigger mild swelling. Walking on this type of sprain as tolerated is not only okay but recommended to expedite recovery. With a more serious sprain, the ankle typically swells over the first few days, and there might be some discoloration of the foot, which usually disappears within a day or so. If the discoloration doesn’t disappear or if significant swelling, instability, or pain develops, avoid putting weight on the ankle and consult a physician. Trainers and physicians sometimes try to prevent sprained ankles by taping. Unfortunately, not everyone knows how to tape an ankle properly, but there are stocking like devices with straps available that might give adequate support and proprioceptive feedback (to improve joint stability). Injuries to the weight-bearing surface of the body, the foot, are extremely common in athletics. One of the most common conditions, plantar fasciitis, sometimes means months of disability. Whether related to body weight and habit or to biological flaws or footwear, it can be extremely painful and may severely limit athletic participation. Plantar fasciitis and other injuries to the foot such as stress fractures, neuromas, and ligament strains can be managed with subtle changes in weight bearing, specific strengthening exercises, and sometimes surgery. Unfortunately, the affected athlete must often restrict weight bearing on the injured foot to allow for healing. This can be tedious and frustrating but it does help to ensure a positive outcome.

Assessing Injuries

When assessing injuries, use your eyes and ears. Common sense will take you a long way. Obviously, a certain amount of knowledge is necessary, but many conditions or symptoms will be apparent. For instance, you can recognize a dislocated shoulder by the athlete’s obvious discomfort and deformity of the shoulder. A displaced or compound fracture of the tibia and fibula can be easily differentiated from a benign contusion. Rapid swelling of an injured part is more ominous than no swelling. Inability to bear weight on an extremity is also an ominous sign. A pale person has heat exhaustion, whereas a ruddy complexion might indicate heat stroke. An athlete who has injured a knee and mentions hearing a pop probably has a torn anterior cruciate ligament. Someone with a concussion might be fine right after the blow and five minutes later not know what day it is. Certain “red flag” signs should prompt emergency medical evaluation. These signs include disorientation following a head injury, inability to walk or move extremities following a collision or fall, inability to bear weight following a collision, and an obviously dislocated body part (e.g., shoulder, toe). Medical care should also be sought for athletes who do not improve after one to two weeks and when an injury cannot be diagnosed with certainty. Among the most helpful instruments for assessment and diagnosis, particularly for fractures and other injuries to the skeletal system, are X-rays. X-rays cannot help with soft tissue structures, such as ligaments or cartilage, but they work great for bones, with the exception of subtle fractures, such as fresh stress fractures, which might not show up well on an X-ray. X-rays do involve a minimal amount of radiation exposure, so they should be used only when necessary. They are relatively inexpensive compared to other imaging methods and are widely available. The CT or “CAT” scan is an X-ray study that, through the use of computers, is able to take “slices” of the involved areas, thus giving a more precise diagnosis. Although they require more radiation than an X-ray, CT scans are very useful in helping to diagnose questionable fractures. They can give doctors an accurate read on concussions and can help to rule out subdural hematomas. CTs are also very good in looking for chest and abdominal injuries. Compared to X-rays, CT scans entail considerable more radiation exposure and should be used only when necessary. MRI has become quite useful and popular because of its ability to identify injuries in soft tissues such as ligaments and muscles. Instead of radiation, MRI uses magnets, radio waves, and computers to produce a literal picture of the body part being looked at. No longer do athletes with possible disc problems have to go through the misery of a myelogram. MRI can gather the same information with virtually no discomfort. In sports, MRI is particularly useful in diagnosing ACL tears. But compared to X-rays and CT scans, MRI is fairly expensive. Nuclear bone scans are useful for looking at all the bones in the body. In this test, a dye is injected into the body that is picked up by metabolic activity in bones. Bone scans are particularly good for looking at inflammation and activity within bones. They can identify stress fractures even before the fractures show up on X-rays.