A sporting chance for recovery

With all the health benefits associated with sport, chronic or acute injuries can be a downside, writes Damien O’Brien MPSI

Introduction

Sport has many benefits associated with it, including improving cardiovascular function, reducing the risk of type 2 diabetes, strengthening bones, and improving respiratory function. Sport also contributes to personal development and has psychosocial benefits, including reducing stress and improving mental health. However, there are negative effects of sport, and this article will focus on sports injuries.

Sports injuries refers to damage to body tissue that occurs due to sport or exercise. Sports injuries can be broadly classified into two categories — acute and chronic injuries. Acute injuries typically happen suddenly and include ligament sprains, joint dislocations, contusions and bone fractures. Chronic injuries develop gradually over time and generally result from overuse of a part of the body. Examples of chronic injuries include stress fractures and tendinopathies.

Pharmacists are accessible healthcare professionals and have the clinical knowledge to be the first port of call for a range of sports-related injuries. Pharmacists play an important role in identifying common injuries, counselling patients on pharmacological and non-pharmacological treatment options, and referring the patient if necessary.^1,2,3

Sports injuries can occur at any time to an individual, but several factors can increase the risk of injury. Overtraining, involving either training too often or for too long, is one of the most common reasons for injury. Other factors that may increase the risk of injury include not using the correct exercise technique, changing training intensity too quickly, or not wearing proper equipment.

Preventative measures can be implemented to reduce the risk of sports injuries. Dynamic stretching, using protective equipment, active recovery, and following appropriate training regimens that are activity-specific are all methods to effectively reduce risk of sports injuries.^2,3

Classification

There is a wide range of sports injuries, each with different symptoms and complications. Some common musculoskeletal injuries are outlined below:

• Fracture – A break in a bone that can occur from a one-time injury, known as an acute fracture, or from repetitive impact, known as a stress fracture. Stress fractures usually occur in weight-bearing bones in the legs. 
• Dislocation – Occurs when the two bones that come together to form a joint become separated. It is common in the shoulders, elbows, fingers and kneecaps.
• Tendonitis – Inflammation of the tissue that attaches muscle to bone. It often affects the ankle, knee, hip, elbow, or shoulder and is typically due to repetitive actions.
• Sprain – A stretch or tear of the ligaments, which are connective tissues that join bone-to-bone. Sprains can range from a minimally stretched ligament, to a complete tear. They are most common in the ankles, knees, wrists and fingers.
• Strain – A pull or tear of a muscle or tendon. They can range from a minor strain to a complete tear of the muscle or tendon.²

Diagnosis

Accurate diagnosis of sports injuries is critical for effective management. Diagnosis can be complex and may require various approaches. A detailed patient history is important to establish the mechanism of injury and any symptoms present. A physical examination of the injury helps to observe bruising and inflammation, as well as to assess functional limitations. Imaging techniques, including magnetic resonance imaging (MRI) scans, x-rays, ultrasound and computed tomography (CT) scans are used to evaluate soft tissue and bone injuries.²

Treatment

The treatment of sports injuries may depend on the severity of the injury, location, and presence of inflammation. Some injuries may heal within days, while others may take several weeks or months to fully heal. The objectives of treatment are the full recovery of the injury and the prevention of future injuries. There are several pharmacological and non-pharmacological treatment options for sports injuries.⁴

Pharmacological treatment

Paracetamol

Paracetamol is an analgesic used to treat mild-to-moderate pain and can be effective in managing sports injuries. It can be used as monotherapy or in combination with other pharmacological or non-pharmacological treatment options. While it does not have the anti-inflammatory properties that other analgesics may have, it is useful for treating mild-to-moderate nociceptive pain.

Paracetamol is safe 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 4-6 hours, up to 4g per day. In children, a weight-based dosing approach is more appropriate, with 15mg/kg per dose recommended.⁴

Opioids

Opioids are not recommended as first-line treatment for sports injuries. They should be reserved for cases where the pain is uncontrolled, such as post-surgery or a major fracture. They may also be useful if other treatment options are contraindicated or not tolerated.

Several adverse effects are associated with opioids, limiting their use as analgesics for sports injuries. Some of these adverse effects include sedation, constipation, nausea, vomiting, bradycardia, respiratory depression, tolerance, and physical dependence. Opioids should only be used for sports injuries if the expected benefit for pain relief and function outweighs the risk of adverse effects. They should be used at the lowest effective dose and for the shortest duration possible.⁴

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in treating sports injuries by reducing pain, decreasing inflammation and improving mobility. NSAIDs work by inhibiting 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 reducing pain and inflammation in sports injuries when used as monotherapy or in combination with another analgesic, such as paracetamol.

There are several NSAIDs used to treat sports injuries, and the choice may depend on a variety of factors, including comorbidities, bleeding risk, cost, availability, dosing schedule, and adverse effect profile. Aspirin and ibuprofen are available over the counter, while celecoxib, etoricoxib, diclofenac, meloxicam, naproxen, dexketoprofen and mefenamic acid are examples of NSAIDs available on prescription.

The adverse effects of NSAIDs include gastrointestinal discomfort, gastrointestinal haemorrhage, hepatotoxicity, reduced kidney function, hypertension, and thromboembolic events. Higher-risk patients and patients on long-term NSAID therapy may require monitoring, including a complete blood count, renal function and hepatic function.^4,5

NSAIDs play an important role in ligament sprains by reducing pain and inflammation, while increasing the chances of the patient regaining physical function. In muscle injuries, NSAIDs may provide pain relief and allow the patient to resume normal activity. They may not have a significant impact on tendinopathies, where inflammation is not the main issue, but they may be useful in providing analgesia.

Some evidence suggests that chronic NSAID use may impair the bone healing process, but short-term use for pain and inflammation is thought to have little impact on overall healing.³

Topical NSAIDs

Topical NSAIDs can be used in the treatment of sports injuries. They involve applying the medication directly onto unbroken skin or via a transdermal patch and are effective in musculoskeletal strains and sprains. Diclofenac and ibuprofen are available over the counter as topical preparations, while etofenamate and ketoprofen are available on prescription. Topical application may be particularly useful if a patient cannot tolerate oral NSAIDs.

Systemic absorption is estimated at 1-7% across topical NSAIDs, which leads to a much safer systemic adverse effect profile. Systemic adverse effects are rare, while local adverse effects include dermatitis and pruritis.⁵

Non-pharmacological treatment

Pharmacists can also recommend non-drug therapies, either as monotherapy or in combination with pharmacological treatment, for treating sports injuries. The P-R-I-C-E method is an approach for acute soft tissue injuries to reduce inflammation and pain:

• Protect – Support the injured body area to prevent further injury.
• Rest – Limit activities that involve using the injured body part in the initial phase of the injury. 
• Ice – Apply ice (wrapped in a towel) for approximately 20 minutes to the injured area, up to eight times per day.
• Compression – Apply pressure to the injured area to reduce inflammation.
• Elevation – Keep the injured body part elevated above the heart level, if possible, to reduce inflammation.²

Immobilising the injured area can help limit movement and allow blood to flow to the injury site. Immobilisation may be required for a limited time to help reduce pain, decrease inflammation and improve the healing process. Slings, splints, braces and casts are often used to immobilise the body part while also offering protection and support.

Surgery may be necessary in certain circumstances to realign fractured bones or repair torn connective tissue. After the healing process, a rehabilitation programme designed by a physiotherapist may help rebuild strength, improve function and ease any residual pain.⁴

Concussion management

A concussion is a type of mild traumatic brain injury (mTBI) that is common in contact sports. Concussion is defined as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, and may involve loss of consciousness.

Concussion is typically caused by a bump to the head or a hit to the body that causes the head to move back and forth rapidly. In most cases, concussion symptoms resolve within a couple of weeks. Common symptoms include dizziness, headache, nausea, vomiting, confusion and amnesia.

Other symptoms in the following hours and days may include lethargy, mood disturbance, sleep disturbance, and sensitivity to light or noise. Warning symptoms that warrant further medical attention include unsteadiness, confusion, fever, inability to wake, numbness, weakness, vision problems, and seizures. Repeated concussions are linked with an increased risk of chronic traumatic encephalopathy, Parkinson’s disease and depression.^6,7

The acute management of concussion involves observation in the home or an acute setting for at least 24 hours. Physical and cognitive rest — avoiding screens, reading, and strenuous activities — is recommended. Patients should have a gradual return to regular activities under medical guidance.

Paracetamol may be used to relieve pain associated with concussion. It is preferred over NSAIDs due to the risk of intracranial haemorrhage with NSAID use. Individuals should also be educated on proper technique and protective equipment in sports as a preventive measure.^6,7

Role of the pharmacist

Pharmacists are ideally placed to contribute to the prevention, management, and recovery from sports injuries. Pharmacists are among the most accessible healthcare providers and are often the first point of access for patients with a sports injury.

Pharmacists may provide first aid in the pharmacy to patients who have cuts, abrasions, bruises or other injuries. They also counsel patients on over-the-counter and prescription medication, advising on appropriate medication use, potential adverse effects, and interactions. Pharmacists can also refer patients to the appropriate channels if necessary. In conclusion, they play a crucial role in alleviating symptoms, ensuring medication safety and promoting recovery from sports injuries.