Introduction. Treatment of Injuries to Athletes

Abstract

INTRODUCTION Don H. O’Donoghue (Fig 1) was born in Storm Lake, IA where he attended the local schools including Buena Vista College from which he obtained a BS degree in 1920. He studied medicine at the University of Iowa and received his medical degree in 1926. He studied orthopaedics at the University of Iowa Hospital under the aegis of Arthur Steindler. O’Donoghue spent time in the general practice of orthopaedic surgery in Oklahoma City before joining the university faculty as chief of orthopaedics. In this role, he united the free-standing orthopaedic programs in the city into one program centered at the university.Fig 1.: Dr. Don Horatio O’Donoghue. (Reprinted with permission from Clin Orthop 271:4, 1991.)Beginning in 1950, O’Donoghue began to aggressively address the problems of ligament injuries in college athletes. Instead of pursuing a conservative style of treatment consisting of prolonged immobilization in plaster dressings which was the standard of the day, he advocated early operative repair followed by a focused rehabilitation program. In addition to reporting his success in the orthopaedic journals, he summarized his ideas in a book, “Treatment of Injuries to Athletes,” which was published in 1962. 1 In the Introduction to the book, O’Donoghue expresses his philosophy regarding the treatment of athletes. O’Donoghue’s work has affected the treatment of injuries in athletes throughout the world. The results obtained by the aggressive approach to open exposure and repair of ligamentous injuries are far superior to those of the conservative approach. Don O’Donoghue truly was one of the founders and pioneers of the field of sports medicine. Leonard F. Peltier MD, PhD A book devoted entirely to injuries to a special group must have justification. Why injuries to athletes alone? Why not just injuries in general? Certainly the athlete is a human being, subject to the same frailties as the rest of the race, and one might reasonably expect him to be treated in the same manner. Could not the physician refer for guidance to one or more of the multitude of books that have been written on the subject of injury? The very fact that you are reading this book to some extent justifies it. Obviously you recognize the athletic injury as a special situation—an area in which we as physicians can render a unique service. I believe that a few paragraphs explaining our approach to this stimulating subject will give added meaning to the later sections on specific injuries. There is, indeed, real significance in the fact that a separate volume on the subject of injuries to athletes is considered to be warranted. Ten years ago this would not have been likely. Lately, however, there has been a tremendous upsurge of interest in this subject, not only among orthopedists, but among physicians in general, and indeed among the laity. An increasing number of postgraduate seminars and medical sessions have been concerned with it. At a postgraduate course on athletic injuries sponsored by the University of Colorado at Denver less than four years ago at which from 30 to 40 registrants were expected, an amazing total of almost 300 very interested and enthusiastic physicians, orthopedists, coaches and trainers appeared. In the following years the attendance was markedly increased. The injuries discussed at this and other meetings have been largely those of college athletes, but there is presently a groundswell in various parts of the country to develop these educational sessions to include secondary school and even grade school athletics. Organized athletics have been extended to involve a major segment of our youth. In many areas not only the junior high schools but the grade schools participate in competitive sports. Whether or not this is good, it must be recognized as a fait accompli which cannot be ignored. There is no present trend toward less athletics. On the contrary, the trend is toward a more inclusive program. Indeed, one of the major criticisms leveled at athletic programs has been their tendency to include the few to the neglect of the many. It should be recalled that in this country the various types of organized athletics, many of them competitive, must serve almost the whole function of physical conditioning whereas in other countries there are various health clubs, hiking clubs, ski societies, etc. Organizations of the latter type have not been popular in the United States. Our citizens are a keenly competitive group, and exercise for exercise’s sake, the calisthenic drill, the regimentation into marching clubs, has not appealed to them, one reason being the fact that in other countries these various groups have been used as springboards for political activity. Our youth have an almost paranoid dislike of anything smacking of regimentation. The effort, therefore, must be not to decry athletics and demand less participation but, on the contrary, to demand greater participation and then see to it that the whole background of organized athletics is improved. There can be no denying that competitive athletics have a great appeal to the mass of our people. However, the public is more inclined to look at the score, to observe the outstanding player, and to foster the competitive contest than to direct its attention toward those facets of the program which are best calculated to return the major good to the greatest number. Comparatively little attention outside the confines of sport itself has been paid to conditioning or to prevention of injury. An occasional blare of publicity follows a major injury to a stellar athlete or the untimely death of a budding prep school player. Occasionally this triggers a lay magazine article on the importance of equipment or the value of physical conditioning as important factors in the prevention of injury. The greater emphasis, however, is placed on the injury itself. The sport pages eagerly play up injury to the star. Wryly enough, the reporter moans that the star has been disabled by his operation rather than by his injury. In the final analysis, however, the lay public and, I fear, the majority of our medical profession have little knowledge of the actual processes of training and of the actual mechanics of injury. Competitive Athletics: Benefits and Risks Why is it important for young men to participate in athletics? Certainly, they do carry an element of risk. Perhaps the solution to the problem of athletic injuries lies in the prayer of the timorous mother that her boy not compete. Abandonment of sports would certainly be the quickest way to prevent injury to the contestant. In common with many others, I believe there are tangible benefits to be derived from athletic competition that greatly outweigh the element of risk. Certainly some of them are obvious. No one seriously doubts that the athlete does develop a stronger, healthier body. Most of the myths of catastrophic sequelae from strenuous athletic activity have been dispelled. “The athlete’s heart” is a bogyman which has finally been exorcized. The ex-athlete who “turns fat” has at least postponed his impending adiposity throughout his years of training. The trained athlete is superior to his more sedentary fellow in drive and stamina, better fitted for both work and play. I think most of us would agree that competitive athletics do have a salutary effect upon the character of the participant. This is particularly true if the programs are so managed that too much emphasis is not placed on winning and sufficient attention is given to the development of the vital ability of the athlete to value his own and respect his opponent’s capabilities. The player learns the importance of team participation, that he must sacrifice immediate gain to the final end, that desire is one of the key factors in success. The fact that the word “sportsmanship” seems trite has in no way changed its reality as a trait of character. Team effort as opposed to individual glory, ability to take a job and follow it through, the necessity to take it as well as to dish it out, are all basic measures learned by the successful athlete. There are certainly material benefits for the athlete in our present educational system that have much importance. Many a young man goes to school on his athletic ability. Much has been said about scholarships, especially by those who know the least about them. Suffice it to say that the athletic scholarship does permit many a lad to finish his education who otherwise would have dropped out of school long before. Who are we to say that the athletic scholarship is not as worthwhile as the scholarship for merit in other fields? In most of the better schools of the country the scholarship athlete maintains a scholastic average higher than the average of his school. A good estimate of the quality of the scholarship program in a given institution can be made from the proportion of the scholarship boys who go ahead to graduation. So much for the benefit of athletics to the student in school. But after graduation, what? It has been said that the athlete out of school is as a fish out of water. Not so! Many athletes make some form of physical education or a related field their career. The conditioning of our youth depends upon the organized type of athletic training which he gets in the elementary and secondary schools and such organizations as the Y.M.C.A. and Boy Scouts. Without the trained athlete to provide capable leadership these programs would be in sorry straits, indeed. We need these people. Indeed, we will find that much of the physical education of our youth is in the hands of the former athlete. On a more personal plane, many an athlete makes contacts during his school years with men who are seeking his very type of qualifications to man the leading jobs in industry. In 30 odd years of knowing athletes I have seen most of them display the same fine enthusiasm and attain the same success in life that they did in school. Certainly there are real advantages to an athletic program from many standpoints. Why then is there such bitter opposition to organized competitive athletics as such? Not because of any interference with scholastic pursuits, not because of any moral implications, not because the after-effects of training impair the physique in later life but because of one principal thing, namely, physical injuries. Do athletes get physical injuries? The answer is “Yes, they do.” Here is a very real objection to the athletic program—in fact, almost the only real objection. Our youngsters do get injured—on occasion, even seriously or fatally injured. It must be the duty of the medical profession to accept this challenge and do everything in its power to minimize those things which interfere with the goals of the athletic program. The Role of the Physician What can we as physicians do to prevent injury, to minimize temporary disability and to prevent permanent disability? Much indeed has been accomplished in the past few years toward these ends. A few years ago the trainer in the average scholastic institution was a fugitive from the supply room, having graduated into the “wrapping and taping” club largely by osmosis. He had no real knowledge of injuries and his main concern actually was to “keep ‘em rollin’.” We all remember the famous men who attained a great deal of notoriety by reason of their ability to keep the athlete in the game. Too many times this goal of immediate playing was a more vital one than the final goal of complete recovery of the patient. During this era the doctor was a necessary evil. The player felt that once he reached the doctor his days as an athlete were over. In too many instances this feeling was justified for two very pertinent reasons. First, since the doctor was the last resort, he did not see the player until long after treatment should ideally have been instituted. Second, and I think of almost equal importance, was the sad reality that it was not of any immediate concern to the doctor whether or not the player was an athlete or was able to remain one after treatment was completed. All too often the first recommendation the doctor made was “Well, give up football,” or “You must not play any more baseball.” This simply tended to confirm the conviction of the player, the coach and the public that athletes and physicians were incompatible. Also, in the past there has been a tendency on the part of the coaching staff to demand that the player continue in spite of injury or be labeled “yellow.” The trainer was urged to “tape her up” and “run him back in”—often to the detriment of the player, the team and the game. In our major institutions this is no longer true. A more enlightened approach has demonstrated that everyone is better served by having the injured player promptly and ably treated, thereby obtaining recovery before he does himself irreparable damage. The successful coach seeks to protect the player and seeks to prevent damage to either body or mind. In the well-run athletic program of today, the coach, trainer, team physician and specialist all combine in one effective unit, designed to keep the player well equipped and in ideal condition. In fact, more emphasis is placed and actually more time is spent on preparing a player to participate and on preventing his injury than is spent on treatment. The player, coach, trainer and physician are no longer working at cross purposes in most institutions. Athletic injuries are much less frequent and they are less severe than in the past. The period of disability is shorter. The degree of recovery is more complete. Many factors have combined to cause this vast improvement in the one area where it must be conceded that athletics may have a bad effect. So we find that once again the physician must become not only the doer but the teacher. The physician with an especial interest in athletes must prepare himself to handle their injuries and he must in turn pass this information on to other physicians. It must be recognized that there is one overriding difference in the management of injuries to athletes. That is, that the patient must get complete recovery from his injury or he is no longer an athlete. True enough, this axiom should apply to any injury the doctor sees but nowhere else is it dramatized quite so constantly as in the care of the athlete. Diagnostic Judgement The outstanding consideration in the treatment of athletic injury is early detection, not only of the nature of the injury but of its degree. The optimum time to examine an athlete for injury is as soon as possible after he is hurt. There must be no compromise with this statement. It may be impossible to examine the patient, or to make a complete diagnosis, at once, but if it can be done precious time has been saved. Frequently the initial examination is by the coach, the trainer or the physician on the field. Whoever this is, he must make as careful an evaluation of the injured player’s condition as he is capable of doing and must pass this information on to each succeeding link in the chain of therapy. The doctor must conscientiously and objectively examine the player. Does the injury seem serious enough that the boy should not return to the game or should he be strapped up and allowed to play? To err is human but the margin of error can be drastically reduced by comprehensive consideration of the patient’s injury. There is no place here for wishful thinking. The player is eager to continue and should not be deprived unnecessarily of this privilege. On the other hand, if continued competition adds to the hazard of injury, he should not be permitted to compete. It is, of course, always better to err on the side of conservatism. After the injury sidelines the player, what then? The prevalent habit of packing the injured part in ice and delaying examination until a convenient time the next day, or even later, is to be deplored. Your examination as a physician should be done at the earliest possible moment even at considerable inconvenience to yourself, the coach or the player. It should be obvious that the part should be undressed, all taping or strapping removed and a meticulous examination carried out. Frequently, the diagnosis, which will be easy in the early stage, becomes exceedingly difficult as pain increases apprehension and swelling, edema and hemorrhage interfere with an evaluation of the injury. with a specialist is it promptly so that the may be able to take of the optimum time for treatment. The specialist should have enough able to with the physician and the his as it in to the of the injury. This is particularly true of the on whether or not the player should be allowed to either at once or of treatment is the physician should to carry it out with the treatment is the of the team he should be permitted to it. the attention is the specialist himself should not to say The physician should be to the early and this will be done only there is good the player, the physician and the The following of treatment have to be of great complete recovery this may not be possible in any given it must always be the The athlete is in good condition and can well any if it to his for a complete the best of treatment. evaluation of the nature and extent of injury must be the in the of treatment. A will not the best you believe that one is better than you should it and then carry it out. This must be an entirely often do we the “Well, this would be better but it in a or should have the boy on but must not be permitted to outweigh medical Many factors will to the All concerned are to believe that the player is but the desire to his of his the desire to see their the that the player is not must be if the is to be must not must be for the with treatment. A as to the of treatment must be made at the earliest possible moment and then carried out. We have been able to that very often the difference success and of treatment. and not the the player, not the coach, not the but the recognize the value of competitive athletics. He must believe that to this patient it is vital that he be to competitive athletics. he in the and is The doctor who the player’s should not be such a program be but not some educational effort on the part of the He must be able to that the program is better not only for the but for the the coach and especially for the player. This will He must be interested and his program those most concerned will recognize the will observe that the to that a complete is followed by ability as opposed to an The coach will that treatment the player more and more actual playing in the long and so is better for the The player will not the doctor who has a and He that his gets He to get well and will accept the recommendation for treatment. He may some specific part of the treatment such as the of a into a but to the extent of to return or the treatment he that the doctor is to him to his ability. are not of The type of program is and has been in a number of institutions. It must be our to make it the not the is a university type training program The program does an coach and a physician who will interest himself in the problems of the athlete.

The authors' abstract, as published at the source. Clinical Orthopaedics and Related Research, 2002 · DOI ↗