To Play or Not to Play? That Is the Question

Story by Ronald W. Lindsey, MD, of UTMB South Shore Harbour Clinic at 3023 Marina Bay Drive in League City, 281-334-0620

Sports-related injuries occur frequently.  Modern medicine has become quite adept in accurately diagnosing and effectively treating these injuries.  However, determining when an injured athlete can safely return to play (RTP) can be exceptionally difficult. 

If an athlete is prematurely cleared to resume competition at a pre-injury level, the risk for re-injury is quite high.  Often the re-injury can be even more debilitating than the initial setback.  On the other hand, an inordinate delay in RTP may not only exacerbate the athlete’s general de-conditioning but even hamper full recovery from the injury.  Moreover, a multitude of other factors (social, emotional, political, ethical, etc.) may have a profound effect on the RTP decision-making process.  Although these other influences are duly recognized, an athlete’s overall health and safety (along with the health and safety of other competitors) should be considered paramount in any decision regarding RTP.  

The principal motivation should always be the same: to restore the normal function that has been lost owing to the mishap.  This objective should apply to the highly acclaimed professional athlete as well as to the enthusiastic weekend warrior.  To achieve this, it is essential that every aspect of the RTP process include the active participation of a healthcare professional (physician, physical therapist, certified athletic trainer, etc.).  The athlete not only must be willing to comply strictly with their jointly developed recovery program, but also must have a clear appreciation of the functional targets that must be achieved prior to getting back into sports.

Although some strategies currently exist to assist with RTP decision making, no specific guidelines have been widely accepted as the standard.  It is doubtful that a routine method for addressing recovery from all athletic injuries is even feasible. Return to organized athletic play often falls under the jurisdiction of schools, organizations, communities, or local laws and their policies will likely differ. Furthermore, different injuries (by individual or by sport) will require drastically different considerations; thereby, each case warrants individual deliberation. 

There are, nonetheless, several strong recommendations that should assist in properly directing the RTP process:

•Maintain general conditioning to the extent permitted by the injury.

•Seek to return fully to the activities of normal daily life, prior to seeking to compete.

•Full clearance to play must include unrestricted practice activities.

•Consider the nature and/or extent of any special treatments, equipment, medication, or athletic activity modification that would be required to resume competition.

•Professional healthcare provider participation is fundamental at every stage of the process (even for seemingly minor injuries).  

•Major injuries (e.g., concussions, spine injuries, or adverse cardiopulmonary events) merit a second or independent medical opinion from a healthcare provider who is not typically a part of the injured athlete’s usual medical management team.  

Additional information on this topic can be obtained from the websites of the following organizations:  the American Academy of Orthopaedic Surgeons (AAOS), the American Orthopaedic Society for Sports Medicine (AOSSM), the American College of Sports Medicine (ACSM) and the American Medical Society for Sports Medicine (AMSSM).

Bone Care For Athletes

By John W. Kosty, MD of UTMB’s South Shore Harbour Clinic, 281-334-0620

The development of “stress” or fatigue fractures is a common disabling condition of athletes, and in particular, long distance runners.  Although stress fractures can occur at any age and at any level of conditioning, they are more likely to occur in poorly conditioned individuals training too rapidly, or in elite athletes who have simply overused the limb to the point of injury.  Medical studies also indicate a higher incidence of stress fractures in women than men at all ages. The exact explanation of this, however, is still unclear.  Hormonal factors such as stress-induced amenorrhea, the post-menopausal years, or nutritional factors such as inadequate calcium and vitamin D, intake inadequate exposure to sunlight or poor nutrition in general may all be causes.

The root cause of stress fractures is repetitive “loading” of the skeleton, especially in the lower extremities. Cyclic loading of a weight-bearing bone can cause microfractures which, though painful, may not be immediately obvious on x-ray examination.  

Weight-bearing stress fractures of the lower extremities most often  involve the tibia, fibula, or foot bones  Occasionally the femur, especially at the hip, can also be affected.  Children or young adults who participate in sports involving repetitive back “extension”, such as gymnastics, horseback riding, and contact sports can develop stress fractures in the lower back.  In contrast, stress fractures are extremely rare in the upper limbs or hands

Whenever an athlete begins to experience insidious onset of pain in a distinct area such as the ball of the foot, the heel, the mid leg, or lateral knee, stress reaction, or fracture, should be considered, especially if the area is tender to the touch and worsened by the athletic activity.   Though the diagnosis can usually be made by physical exam and x-ray, sometimes more advanced imaging such as a bone scan or CT scan are necessary.

Although most stress fractures will heal given an adequate period of rest (typically eight weeks), some may become troublesome. These include certain lateral foot fractures, and fractures of the posterior elements in the lower back.  Aggravation of the fracture by too early return to the activity increases the risk of prolonging the problem.

It is important to note that rest does not necessarily mean total avoidance of athletic activity, but rather, avoiding the specific activity that caused the stress fracture.  So, cross training via another pain-free, aerobic activity (such as bicycling or spinning, swimming, aqua-jogging, cross-country skiing machines or similar exercise equipment) are good alternatives. 

Here are several tips you can follow to help avoid these types of injuries:

1) When beginning a new activity, set reasonable goals.  If running, leave at least a day of rest or cross training between exercise sessions if you are increasing your mileage.

2) Use high-quality equipment.  Avoid old or worn shoes.

3) Maintain good nutrition.

4) If symptoms do occur, stop the activity immediately.  Seek medical assistance if the symptoms last more than a few days.