WHAT IS SPORTS INJURY?

According to The IOC Handbook on Sports Injuries, sports injury occurs as a result of injury to body tissues while exercising or playing sports. Sports injuries are classified as acute and overuse according to the mechanism and symptoms of the injury. Acute injuries occur suddenly, overuse injuries occur gradually. Acute injury occurs when the loading phase reaches the threshold of irreversible deformation of the tissue. Overuse injuries occur as a result of insufficient recovery time between load phases. Acute injuries are more common in team sports where speed is important, while overuse injuries are more common in aerobic sports with long and monotonous training seasons. We can also classify sports injuries as soft tissue injuries (cartilage, muscle, tendon, ligament, bursa, fascia, joint capsule) and bone tissue (fractures).

Ligaments

Ligaments are structures made of collagen tissue that connect bones together. It plays an important role in passive stabilization of joints and proprioceptive sense. It can be inside (intra-articular) or outside (extra-articular) the joint capsule. Ligament type is important for the course of healing after total rupture because the extra-articular ligaments can be fed directly from the blood and have a high healing potential. Unlike tendons, ligaments are mostly injured by acute trauma. The mechanism of injury is due to ligament stretching due to sudden loading and extreme positioning of the joint. For example, inversion trauma to the ankle injures the lateral ligaments (primarily the anterior talofibular ligament).

Grade 1: They are structural deformities at the microscopic level. The ligament is deformed, its integrity is intact. There is local tenderness but no instability. After taping, sports can be continued.
Grade 2: They are partial ruptures. Pain, tenderness and swelling are evident. Instability may develop in secondary ligament ruptures.
Grade 3: It is total rupture. Its treatment is surgery. Return to sports happens after 6-8 months.

Tendon

Tendons are structures that contain connective tissue (type 1 collagen) that connects muscle to bone. The elasticity of the tendon allows the short loading energy stored in the tendon to be released, for example, in jumping activity. The structure of the tendon is as seen in Figure 1.7. The relationship of tendons between stress and deformation is similar to ligaments.

Tendon injuries can be acute or overdose. Since the tendons are usually superficial, they can also be injured by penetrating methods. If the tendon is exposed to a force above its tolerance capacity, ruptures may occur. These are usually due to eccentric force production, partial or total, or in the form of avulsion fractures occurring at the bone-tendon junction. Tendons are the type of tissue most commonly affected by overuse injuries. Different terms are used to describe overuse injuries: tendinitis (tendon inflammation), tenosynovitis (tendon sheath inflammation), tenoperiostitis (inflammation of tendon insertions and origins), periostitis (periostitis), and bursitis/hemobursitis (bursal inflammation, possibly with bleeding).

Ligaments are structures made of collagen tissue that connect bones together. It plays an important role in passive stabilization of joints and proprioceptive sense. It can be inside (intra-articular) or outside (extra-articular) the joint capsule. Ligament type is important for the course of healing after total rupture because the extra-articular ligaments can be fed directly from the blood and have a high healing potential. Unlike tendons, ligaments are mostly injured by acute trauma. The mechanism of injury is due to ligament stretching due to sudden loading and extreme positioning of the joint. For example, inversion trauma to the ankle injures the lateral ligaments (primarily the anterior talofibular ligament).

Grade 1: They are structural deformities at the microscopic level. The ligament is deformed, its integrity is intact. There is local tenderness but no instability. After taping, sports can be continued.
Grade 2: They are partial ruptures. Pain, tenderness and swelling are evident. Instability may develop in secondary ligament ruptures.
Grade 3: It is total rupture. Its treatment is surgery. Return to sports happens after 6-8 months.

Tendon

Tendons are structures that contain connective tissue (type 1 collagen) that connects muscle to bone. The elasticity of the tendon allows the short loading energy stored in the tendon to be released, for example, in jumping activity. The structure of the tendon is as seen in Figure 1.7. The relationship of tendons between stress and deformation is similar to ligaments.

Tendon injuries can be acute or overdose. Since the tendons are usually superficial, they can also be injured by penetrating methods. If the tendon is exposed to a force above its tolerance capacity, ruptures may occur. These are usually due to eccentric force production, partial or total, or in the form of avulsion fractures occurring at the bone-tendon junction. Tendons are the type of tissue most commonly affected by overuse injuries. Different terms are used to describe overuse injuries: tendinitis (tendon inflammation), tenosynovitis (tendon sheath inflammation), tenoperiostitis (inflammation of tendon insertions and origins), periostitis (periostitis), and bursitis/hemobursitis (bursal inflammation, possibly with bleeding).

Cartilage

Cartilage tissue is a flexible and strong structure containing connective tissue, extracellular matrix, collagen 2 fibers, proteoglycan. The most important type is hyaline cartilage. Hyaline cartilage does not contain nerve, vessel or lymph drainage. It is fed by diffusion from the synovial fluid. The fibrocartilage structure is structured close to joints, tendons and ligaments and acts as a protective surface. The labrum in the shoulder or the menisci in the knee are examples. Unlike hyaline cartilage, they contain vascularization and nerves on their outer surface. For example, the nucleus pulposus is rich in nerves, and the menisci are rich in vascularity.

The healing capacity of hyaline cartilage after injuries is limited. This is due to a limited network of vessels and nerves. This regeneration failure may even lead to osteoarthritis in the future. Meniscus and labrum injuries can also occur in the fibrocartilage structure. Most injuries are acute and recovery levels depend on blood supply levels. For example, while the outside of the meniscus is in good condition in terms of blood supply, its blood supply towards the center decreases. Therefore, the healing potential of injuries occurring in the center is low.

Muscles

Muscles are structures that make up a large part of our body weight. There are myofibrils and protein filaments in the muscle structure. Capillaries surround the fibrils, thus providing nutrition.
Muscle injuries usually occur in two ways: direct traumas that result in tension ruptures (strains) and contusion (crush). In addition, sometimes some painful syndromes may occur due to overload, especially after eccentric training. This is called delayed muscle pain syndrome. They are injuries at the cellular level and cause widespread pain. It is characterized by increased tone, swelling, pain and limitation of movement.
Strains are usually caused by eccentric contractions. Injury occurs at and around the musculotendinous junction. Biarticular muscles such as the hamstrings, gastrocnemius, biceps brachii, and rectus femoris are more commonly injured.

Contusions usually occur in the quadriceps. As a result of exposure to single and high-energy traumas, tissue integrity in the muscle is impaired. This is why hematoma occurs. This hematoma may be intermuscular or intramuscular. Intramuscular hematomas are local and palpable. Healing is difficult, the vascular and nervous system may be adversely affected. In cases where the compartment pressure is more than 30mmHg, a fasciotomy is performed. If neglected, it can lead to bad pictures such as compartment syndrome or myositis ossificans. Intermuscular hematoma is bleeding that occurs within the fascia. The hematoma can be displaced by muscle movement and gravity.

Grade 1 (Mild): Few fibers are injured. There is no loss of power or ROM. Pain is localized. Edema and bleeding are minimal. There is pain with resisted movement, but stretching is painless.
Grade 2 (Moderate): Few fibers are injured. Acute and pronounced pain is accompanied by swelling. Hematoma and edema occur. Strength is reduced and movement is limited by pain.
Grade 3 (Severe): The muscle has lost its integrity. There is severe pain, swelling, and loss of function.

RESPONSE TO ACUTE INJURIES- PRICE/ POLICE/ PEACE AND LOVE PRINCIPLE

Acute injuries are injuries that occur suddenly during sports or exercise, partially or totally disrupt the tissue integrity in the body, and cause bleeding, inflammation and neurological damage. The body immediately responds to this as pain, swelling, loss of movement. The most obvious acute injuries are characterized by bleeding after trauma (whether muscle, ligament, tendon or bone). The aim of the treatment is to stop the bleeding of the soft tissue injury, reduce the pain and help the healing conditions. The method used to reduce bleeding after an acute injury is traditionally called ICE therapy. Ice (cooling), Compression (with a bandage), Elevation (injured limb). This expansion has been expanded as PRICE. P stands for Protection and R stands for Rest. Recently Rest has been updated to Optimal Loading. Because Rest means inactivity, while limited activity helps rehabilitation. Therefore, the PRICE principle has left its place to the POLICE principle. It should be known that treatment should begin as soon as possible after the injury has occurred. Cooling controls bleeding and swelling, making diagnosis easier. Treatment should continue for at least two days.

Protection and Rest / Optimal Loading

The purpose of Protection is to control bleeding and damage by minimizing the risk of extra damage. Rest is a relative concept. In acute injuries, any sudden activity can stimulate further bleeding. However, immediately after the acute stage, the goal is to start exercising at optimal intensity and regain function without tissue damage. The muscle is very vascular and contraction can accelerate further bleeding. Ligaments such as those in the ankle or knee are less vascular. Crutches can help reduce weight transfer and provide more muscle activity. Early mobilization and accelerated rehabilitation are particularly effective for ligament injuries.

Cold Treatment (Ice)

The latest high-quality evidence from systematic reviews recommends intermittent application of 10 minutes of ice (water melts at 0°C) for up to 2 hours, and this treatment is most effective within 48 hours of injury. Potential benefits include limiting bleeding by vasoconstriction, reducing swelling, limiting inflammation, slowing the metabolism of local tissues, thereby reducing hypoxic damage, reducing local anesthetic effect and pain, and inhibiting local muscle spasm. If ice is used on the playground, the effects on neuromuscular control could possibly increase the risk of further injury or re-injury. Ice should be used with caution when there is poor circulation and should not be used if there is nerve or skin damage. Ice can burn the skin if applied directly and should not be used if it increases pain.

Compression Therapy

Compression is an integral part of soft tissue injuries. It is the most important intervention that prevents the growth of hematoma. By increasing resistance, local compression reduces blood extravasation following trauma, and the absence of major blood loss can reduce bleeding and swelling. Much of the compression rationale has been drawn from research on deep vein thrombosis (DVT) prophylaxis and lymphedema management, and there is little original research. One of the few clinical studies in this area showed that compression reduces creatine kinase elevation following eccentric exercise and prevents loss of motion, reduces perceived pain, reduces swelling, and promotes recovery of strength production. Compressing dynamic joints is difficult, but more recently, specially designed compression cuffs that are molded to the shape of a joint have become available.

Elevation

Elevation is based on the principle that the effect of gravity can reduce blood flow and swelling. Elevation inevitably requires immobility and is useful only in the distal joints.

Early rehabilitation has become increasingly important in recovery from soft tissue injury and less emphasis is placed on rest. Progressive mechanical loading is more likely to restore the strength and morphological properties of collagen tissue. Indeed, after functional rehabilitation of acute ankle strain and ankle sprain, which usually includes early weight bearing with external support, early mobilization with accelerated rehabilitation is better than immobilization for most types of sprain severity. Functional rehabilitation promotes healing (a type of mechanotherapy), so that mechanical loading induces cellular responses that promote tissue structural change. The challenge is to find the balance between loading and unloading during tissue healing. Optimum Loading means early activity to promote early recovery.

Soft Tissue Injuries Need PEACE AND LOVE

PEACE AND LOVE demonstrates the importance of educating patients and addressing psychosocial factors to enhance recovery. While anti-inflammatories show benefits on pain and function, our letters mark their potentially harmful effects on optimal tissue repair.

P- Protection: Restrict or restrict movement for 1-3 days to minimize bleeding, prevent stretching of injured fibers, and reduce the risk of aggravating the injury. Rest should be minimized, as prolonged rest can compromise tissue strength and quality.
E– Elevation: Elevate the limb higher than the heart to promote interstitial fluid flow through the tissues.
A- Avoid (Avoid anti-inflammatories): Various stages of inflammation help repair damaged soft tissues. Therefore, inhibiting inflammation using drugs can adversely affect long-term tissue healing.
C- Compression: Helps limit intra-articular edema and tissue bleeding by using taping or bandaging.
E-Education: Therapists should educate patients about the benefits of an active approach to recovery.

After the first days pass, soft tissues need LOVE.

L-Load: An active approach with movement and exercise benefits most patients with musculoskeletal conditions. Mechanical stress should be added early and normal activities should be resumed as soon as symptoms allow. Optimal loading without exacerbating pain promotes repair, remodeling, strengthens tissue tolerance and capacity of tendons, muscles and ligaments through mechanotransduction.
O- Optimism: Optimistic patient expectations lead to better outcomes and prognosis. Psychological factors such as disaster, depression, and fear are barriers to recovery.
V- Vascularisation: Cardiovascular activity represents the cornerstone in the treatment of musculoskeletal injuries. While research on dosage is needed, painless aerobic exercise should be initiated several days after injury to increase motivation and increase blood flow to injured structures. Early mobilization and aerobic exercise improve physical function, promote return to work, and reduce the need for pain medication in people with musculoskeletal conditions.
E-Exercise: Exercises help restore early mobility, strength and proprioception after injury. To achieve optimal repair during the subacute phase of recovery, pain should be avoided and used as a guide for exercise progressions.