Sports fractures, sprains, and so on can be acute or chronic, with the former occurring suddenly whereas the latter develop gradually over time and usually result from overuse of a body part, writes Damien O’Brien
The physical activity of sport has many health benefits associated with it, including improved cardiovascular function, improved respiratory function and improved sleep. Additionally, personal development and psychosocial benefits, including reduced stress and improved mental health, can be observed from participation in sports. However, some negative effects of sport can include burnout, eating disorders and sports injuries – which this article focuses on. The term ‘sports injury’ refers to the damage to body tissue that occurs as a result of sport or exercise. Sports injuries are divided into two broad categories: acute and chronic injuries. Acute injuries generally happen suddenly and include ligament sprains, joint dislocations and bone fractures. Chronic injuries develop gradually over time and generally result from overuse of a part of the body and includes stress fractures and tendinopathies. The accessibility and clinical knowledge of community pharmacists ensures that they are often the first port of call for a range of sports-related injuries. Therefore, pharmacists should have a thorough understanding of the risk factors of sports injuries and how to mitigate these factors. Pharmacists should also be able to identify common injuries, counsel patients on pharmacological and non-pharmacological treatment options and recognise when it is necessary to refer the patient.
Risk factors and preventative measures
Sports injuries can occur at any time and to any individual, but several factors can increase the risk of injury. Overtraining, either by training too frequently or for too long, is one of the most common reasons for injury. Other factors may include not using the correct exercise technique, changing training intensity too quickly or not wearing proper equipment. A range of preventative methods can be put in place to reduce the risk of sports injuries. Dynamic stretching, using protective equipment, performing active recovery and using appropriate training regimens that are activity-specific are all ways that can effectively reduce risk of sports injuries.
Classification of sports injuries
A wide range of sports injuries exist, which can produce different symptoms and complications. Many musculoskeletal injuries are common, which are outlined below:
Fracture – is a break in a bone that can occur from a one-time injury which is known as an acute fracture, or from repetitive impact, usually on the lower limbs, which is known as a stress fracture;
Tendonitis – is inflammation of the fibrous tissue that attaches muscle to bone. It often affects the ankle, knee, hip, elbow or shoulder and is usually as a result of repetitive actions;
Dislocation – occurs when the two bones that come together to form a joint become separated. It is common in shoulder, elbows, fingers and kneecaps;
Sprain – is a stretch/tear of the ligaments, which are connective tissue that join bone to bone. They can range from first degree (a minimal stretch) to third degree (a complete tear). Sprains are most common in the ankles, knees, wrists and fingers;
Strain – is a twist, pull or tear of a muscle or tendon. Similarly to sprains, they can range from a minor sprain to a complete tear of the muscle or tendon. This injury is most commonly observed in muscle or tendons between two joints.
Diagnosis
The diagnosis of a sports injury can be complex and require a variety of different approaches, depending on the nature of the injury. A physical examination of the injured area is required to observe bruising or inflammation. A detailed patient history may also be required to find out about the injury, how it happened, any recreational or occupational activities and if there has been a change in the intensity of these activities. Imaging techniques including magnetic resonance imaging (MRI) scans, X-rays, ultrasound and computed tomography (CT) scans can be used to evaluate soft tissue and bone.
Treatment
The treatment of sports injuries depends on several factors, including severity of injury, location and presence of inflammation. Some injuries may heal in a few days, while others may need several weeks or months to fully heal. The individual should not continue to carry out the activity if they are feeling pain. Continuing the activity may cause further harm to the individual. The treatment objectives are full recovery of the injury and prevention of future injuries. There are a number of both pharmacological and non-pharmacological treatment options outlined below.
Pharmacological treatment
Non-steroidal anti-inflammatory drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) can be effective in the treatment of symptoms of injury and generally reduce pain, decrease inflammation and improve mobility. NSAIDs can be used in a wide range of sports injuries. Pain relief should start soon after the initial dose, while full analgesia may take several days. In tendinopathies where inflammation is not the main issue, NSAIDs may not have a large influence on healing but may be useful on a short-term basis for analgesia. In muscle injuries, NSAIDs may provide pain relief and allow the patient to resume normal activity earlier. With regards to ligament sprains, strains and tears, NSAIDs can reduce pain and inflammation, while increasing the chances of the patient regaining physical functioning. Although evidence suggests that long-term use of NSAIDs may impair the bone healing process, short-term use of NSAIDs for pain and inflammation has little impact on the overall healing process.
The main mechanism of action of NSAIDs is through the inhibition of cyclooxygenase (COX) enzymes, both COX-1 and COX-2. This inhibits the synthesis of prostaglandins, which are mediators involved in inflammation and pain. NSAIDs are effective in treating mild to moderate pain and in reducing inflammation. There is no evidence that NSAIDs are effective in treating neuropathic pain, but they are effective in treating nociceptive pain – which is pain arising from tissue damaged by physical agents, including trauma.
Some injuries may heal in a few days, while others may need a number of weeks or months to heal completely
Several NSAIDs are licensed for use in Ireland. The choice of NSAID depends on a variety of factors including co-morbidities, bleeding risk, cost, availability, dosing schedule and adverse effect profile. Ibuprofen and aspirin are available over the counter in Ireland, while celecoxib, etoricoxib, diclofenac, meloxicam, naproxen, dexketoprofen, aceclofenac and mefenamic acid are among the NSAIDs available on prescription. A thorough patient history should be taken, and an individualised plan should be followed for each patient. Healthy patients that are only taking NSAIDs in the short term for their injury may not need regular monitoring. However, patients that are a higher risk and taking NSAIDs for a long-term injury may require regular full blood tests, as well as renal and hepatic tests. The cautions for use and contraindications are similar for the different NSAISDs and some of them include increasing age, history of gastrointestinal bleeds, renal disease, inflammatory bowel disease, pregnancy, breastfeeding and cardiovascular disease. Due to the adverse effect profile of NSAIDs, the lowest effective dose should be used for the shortest duration. The most common adverse effects include gastrointestinal pain, gastrointestinal haemorrhage, hepatotoxicity, reduced kidney function, hypertension and thromboembolic events.
Topical NSAIDs
Topical NSAIDs can be applied directly on unbroken skin or applied via a transdermal patch. They have been shown to be effective for treating musculoskeletal strains and sprains. This treatment option may be particularly useful if a patient can’t tolerate oral NSAIDs. Photosensitivity reactions and local adverse effects, including dermatitis, pruritis and erythema are the most common adverse effects. Systemic absorption is estimated at one to seven per cent across all topical NSAIDs at the recommended dosage, which leads to a much safer systemic adverse effect profile.
Paracetamol
Paracetamol is one of the most commonly used drugs for mild to moderate pain and can be effective in treating sports injuries. It can be used as monotherapy or in combination with other pharmacological or non-pharmacological treatment options. Paracetamol lacks the anti-inflammatory properties of NSAIDs but it is still effective in treating mild and moderate nociceptive pain. Paracetamol is a safe drug when used correctly, with a favourable adverse effect profile. The maximum recommended dose of paracetamol for adults (aged 12 years and older) is 1g every four to six hours, up to 4g per day. In children, a weight-based dosing approach is more appropriate – with 15mg/kg per dose recommended.
Opioids
Opioids are not recommended as a first-line treatment option for sports injuries. They should only be used as in cases where pain is not controlled, as a post-surgery option or if other treatment options are contraindicated or not well tolerated. There are several adverse effects associated with opioids, which limit their usefulness as an analgesic for sports injuries. Some of the important adverse effects include sedation, constipation, nausea, vomiting, respiratory depression, bradycardia, tolerance and physical dependence. Opioids should only be used if the expected benefit for both pain and function outweighs the risk of addiction, tolerance and adverse effects. Opioids should be used at the lowest effective dose and for the shortest duration possible.
Non-pharmacological treatment
Non-pharmacological treatment options are available, either as monotherapy or in combination with pharmacological treatment, for treating sports injuries. Minor sports injuries, including some strains and sprains, can be treated using the P-R-I-C-E method.
- Protect: support the injured body area from further injury;
- Rest: limit activities that involve using the injured body part in the initial phase of the injury; Avoid weight-bearing activities or using the injured body part;
- Ice: apply ice (wrapped in a towel) for about 20 minutes to the injured area up to eight times per day;
- Compression: pressure on the injured area helps to reduce inflammation;
- Elevation: keep the injured body part elevated, if possible, above the level of the heart to decrease inflammation.
Immobilisation is commonly used to limit movement in the injured body part and to allow blood to flow directly to the injury site. Immobilisation is often needed for a limited time to help reduce pain, reduce inflammation and augment the healing process. Slings, splints, braces and casts are often used to immobilise injuries, as well as offering protection and support.
Surgery is often not required in sports injuries but may be necessary in some cases to realign fractured bones or repair torn connective tissue. After the sports injury has healed, a rehabilitation programme may need to be completed before returning to activity. A physiotherapist can individualise a plan that can rebuild strength and improve the range of motion of the injured body part, as well as easing any residual pain. These exercises may be done with the physiotherapist or at home and should help the patient to return to their previous level of activity and reduce the chance of
a reoccurrence.
In most cases, concussion symptoms resolve within a couple of weeks
Concussion
Concussion, or mild traumatic brain injury (mTBI), is defined as a clinical syndrome of biomechanically induced alteration of brain function typically affecting memory and orientation, which may involve loss of consciousness. Concussion is generally caused by a bump or jolt to the head or a hit to the body that caused the head to move back and forward rapidly. The sudden impact that causes concussion can change the brain’s physiology, cause oxidative stress and damage brain cells. In most cases, concussion symptoms resolve within a couple of weeks. The most common symptoms can include dizziness, headache, nausea, vomiting, confusion and amnesia. Other symptoms that may present over the following hours and days include lethargy, mood disturbance, sleep disturbance and sensitivity to light or noise. Diagnosis involves a symptom evaluation, medical history and neurological examination, with the Glasgow Coma Scale used.
The acute management stage of concussion involves observation in the home or an acute setting for at least 24 hours due to the risk of intracranial complication. Physical and cognitive rest, with a gradual resumption of activities will improve symptoms. Paracetamol may be used to treat pain associated with concussion and is preferred over NSAIDs to reduce risk of intracranial haemorrhage. These medications can provide symptom relief but don’t necessarily reduce recovery time. There are several symptoms that warrant further medical attention if a person suffers a concussion and these include bowel/urinary incontinence, stiff neck, unsteadiness, confusion, fever, inability to wake, numbness, weakness, vision problems and seizures. Repeated concussions is linked with an increased risk of conditions including Parkinson’s disease, chronic traumatic encephalopathy and depression.
Role of pharmacist
Pharmacists can play an important role in the community for patients with sports injuries. Pharmacists are one of the most accessible healthcare providers and therefore are often the first point of access for patients experiencing an injury. Pharmacists may be able to provide first aid in the pharmacy to patients who have cuts, abrasions, bruises or other injuries. Furthermore, pharmacists can counsel patients on the use of over-the-counter medications, including paracetamol, aspirin and ibuprofen, for treating sports injuries, as well as a wide range of other analgesics available on prescription. Pharmacists can also advise patients on non-pharmacological treatment options that may aid recovery. Finally, pharmacists can identify potentially serious situations where the patient should seek urgent medical treatment.
References on request
