Thoughts on Sports Medicine in 2010

17 09 2010

Getting injured, if you are either starting a gym class for the first time or preparing for a charity run, the London triathlon or even the  Olympic Games is more than literally a pain, but incredibly common. Whilst you are suffering, you may take heart from the fact that nearly 60% of runners report an injury in every season so you are in good company. In team sports injury is even more common with musculoskeletal injuries responsible for the predominance of weekend Accident and Emergency presentations. The question is why this happens? Is this because running or doing sport is bad for us, of course not, but much more likely it is because  like building a house on poor foundations, we would expect it to crumble and that is what is happening to your body.

The problem starts in schools , the decline in the robustness of physical education and the previous governments unwillingness to see competition in the curriculum means very few children break into a sweat during organised class sport. Of course there are some excellent examples of School PE with innovative lesson plans and children who are physically pushed, but all too often the showers are never used and games become not an opportunity to learn  sporting skills but an excuse to avoid them. It is great though to see hundreds of children at a weekend in parks across the country playing football and rugby and experiences in Australia where the AusKick programme sees ovals covered in children from 5 to 18  swarming over  balss and following structured learning programmes. This is reproduced here though on a lesser scale with some notable exceptions,  my local rugby club in Cobham has 6 pitches full of children all weekend in the season  coordinating over 200 kids, in organised sport and is a fantastic sight to see with the hundreds of volunteers working to keep it in motion.

The danger though is that we rely on governing bodies and their programmes which are sport specific and can avoid the fundamental building blocks which are general to all. The need to recognise in coaching junior sports, too often we are focused on short term goals such as teaching our children to win a rugby match as an 8 or 12  year old rather than concentrate on taking the essential skills of movement and building a robust  structure to make those gains at a later stage. These foundations skills are essential, the ability to develop flexibility, range of joint range of movement and more functional sports specific skills balance on one leg and hop forward a metre is tricky, go on try it, without falling over.

If we cannot balance on one leg, without wobbling, imagine what happens to our hips, knees , ankle and back when jogging in the Park, or sprinting for a ball. What happens to the control of your knee when  slowing for a low shot at the net in tennis or how your swing is affected  by balance on the 11th hole. which means we stand on one leg hundreds and thousands of time with greater forces  being transmitted then when we walk. These skills although often basic are the fundamentals  from which complex skills are learnt, they are often overlooked both in coaching and particularly in rehabilitation by those recovering from injury. It is be gained this muscle control, which takes many repetitions of training to achieve that we can condition the body correctly to withstand the demands of sport. Without them we lie mercy to injury.

In the elite sportsman and women we can use biomechanical analysis using motion capture cameras to analyse the  movements and control of our joints, to identify risks of injury. These systems such as Vicon and Qualysis,  are  only available in limited centres, usually linked with University research departments,  but allow accurate retraining and assessment of  movement patterning. In particular it can allow the understanding of causes of injury such as groin pain in sportsmen and women,which is often presumed to be a hernia or muscle strain when many differential diagnosis exist. At not quite so advanced a level, recently published studies highlight the pressure pattern the foot makes in contact with the ground can both predict injury risk but also can be used to intervene with a temporary shoe insert ‘orthotic’ designed from your running foot pattern or gait to allow the muscle of the leg, thigh and hip to relearn patterns that  should have been ingrained from an early age. Injury prevention is key as we all would prefer not to be exposed to injury in the first instance.

There have been significant advances in the management of acute and chronic injuries over recent years.  In the past doctors with an interest in looking after Sports and Exercise Medicine were mostly General Practitioners or Orthopaedic Surgeons doing so in their spare time. The Department of Health introduced Sport and Exercise Medicine as a new medical speciality  with a recognised training programme in 2005. Since then the appearance of NHS Consultants has been a slow process, but there are emerging NHS services in London , Sheffield, Leeds and Cardiff with over 30 doctors in training as specialists. This may have been prompted by the London 2012 Olympic games but should leave a more permanent legacy than many buildings.

The training programme ensures expertise in the recognition , diagnosis and treatment of all sports injuries but also in the designing and management of exercise of those with  other illnesses. The benefits of exercise in depression, cardiovascular disease and diabetes are all too well recognised but until now the advice on what type , how much and how often was difficult to come by. The injury prevention strategies and overall health promotion within the community and specialist groups, also is part of the training of this new speciality and the education of  the nations exercise professional’s, therapists and colleagues in the medical profession is important. Europe’s largest Sports and Exercise Medicine Conference, ASICS UKSEM is to be held in November at ExCeL in London and  here cutting edge innovation and education will be seen.

Recent advances in the management of soft tissue injuries such as muscle strains and ligament injuries focus the possible interventions.  Treatment of acute ankle ligament strains often frustrates Accident and Emergency departments  as in the past there was little to do to accelerate the outcome but you will read about work done in Canada in a high quality study which may be about to change all that. This study was done in the recreational athlete world and the trial was of a comparable quality to the normal standards of research in clinical medicine , often lacking in similar studies, and is the first to show real benefit of a novel intervention.

The treatment of many chronic conditions such as Plantar fasciitis and ‘Tennis Elbow’ and  Achilles tendinopathy have undergone rapid change with the development of the use of novel treatments. The understanding of these conditions  has resulted in the realoisation that they are not inflammation but degeneration and we have moved away from anti-inflammatory therapy to newer modalities. Shock wave therapy which uses the same technology that breaks up kidney stones from outside the body to shock the  injured structures to responding to treatment. Work is still going on to identify the mechanism  by which this takes effect but the  The National Institute of Clinical Excellence(NICE) recognise the work done in this area is worthy of use in many conditions including Shoulder tendinopathy and Tennis elbow.

The treatments used to get Elite athletes back on the track as rapidly as possible have started to filter down to recreational sport. Groin pain and hamstring injuries are less common in running  but certainly feature highly in team sports and the use of muscle injections has flourished in recent years. Whilst the use of homeopathic medicines, injected into the muscle injury have faded  from view ,as  the scientific evidence failed to match up to the purported benefits. New hope is offered by the use of ones own blood to accelerate the healing process. This is termed either autologous blood injection or platelet enriched plasma injection , and the process although different,  works on a similar basis, a sample of your own blood is taken and then spun down and concentrated so that the  beneficial  agents can be re-injected to the damaged area. Some encouraging results have been published both in acute injury but also in chronic injury where all else has failed. Avoiding the surgeons knife is all important in these conditions and increasing evidence supports their use.

The days of  injecting cortisone into a shoulder, knee or joint based on knowing the underlying anatomy and best guesswork are over. Modern medical imaging allows the use of small portable ultrasound machines to assess injures either pitch-side or in the clinic and most Sports Physicians will use this to guide their injections, often taking screen images of the route of the injection showing you the injured structure and the delivery of any therapeutic agent. Consultant Musculoskeletal radiologists are the experts in matching these images with the latest Magnetic Resonance imaging(MRI) scans to provide accurate and specific information of injuries and allowing the physician and therapy team to guide rehabilitation as accurately as possible, or direct the surgeon to the exact injury. Many providers are offering  reduced fees for rapid access scanning making it affordable for many even without private health insurance and a developing network of expert musculoskeletal radiologist report these images via a secure network allowing the radiologist to see and report the mages and send these to your physician who can show you them on a PC screen in their surgery or indeed on a laptop by the pitch. This allows rapid diagnosis  for the patient benefit.

Where  sports injury treatment differs form many other injuries is the need for a truly multi disciplinary team to get back to fitness is essential the integration of physician, physiotherapist, soft tissue therapist, podiatrist and fitness professional is all too important and  we still need to improve the communication between the fitness trainer and the  therapists to accelerate the rehabilitation process, the therapist will often guide the patient back to health but is the job of the trainer to bring them back to sport and this integrated approach is seen in the private sector in clinics such as Pure Sports Medicine in London but as yet does not fully integrate in the NHS and this is the challenge for the future.

Prevention is better than cure and as such this editorial focusses on many ways in which that can be achieved whether for your kids or for yourself, and when you do  suffer the setback of injury it highlights many innovate approaches currently employed by specialists to maximise your potential.

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19 09 2010
Tweets that mention Thoughts on Sports Medicine in 2010 « Sportsphysician's Blog -- Topsy.com

[…] This post was mentioned on Twitter by Karim Khan , uksem. uksem said: The full version of the Editorial for the Media Planet supplement in Guardian I wrote this week http://drp.ly/7jlQ […]

19 09 2010
Using Therapeutic Home Ultrasound To Treat Plantar Fasciitis | Yoga Beginners

[…] Thoughts on Sports Medicine in 2010 « Sportsphysician's Blog […]

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