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Case Analysis: A Perilous Journey
Sports has now become highly competitive and, more importantly, a commodity with money to be made, writes Dr Raju K. Parasher
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It would not be too dramatic to state that the young sport erson is under siege — sport enthusiasts as young as six years are propelled towards a perilous journey of physical as well as psychological injuries and re-injuries as soon as they are old enough to start organised sports. Participation in sports traditionally was supposed to lead to comprehensive fitness benefits — cardiovascular, cognitive, psychological, emotional, etc. It was considered important enough for parents to urge their kids to ‘go and play’ for obvious health benefits, and additionally to promote the development of life skills. The life of a young sportperson was relaxed and playful. But things have changed — sports has now become highly competitive and, more importantly, a commodity with money to be made.
This has led to alarming statistics: 90 per cent of teenage athletes report physical injury during play and 75 per cent report being psychologically traumatised as they are yelled at by either the coach, parent and/or team members. A third of these kids are 13-15 year old and half of them claim to have continued playing while injured — with or without the knowledge of their coach/parent. These athletes either ignore their pain or continue playing with the help of painkillers. And the main reason(s) they cite for doing so is — ‘I did not want to be benched’, ‘It was an important game’, ‘Could not let the team down’. What is even more surprising is that almost 50 per cent of coaches acknowledge putting an injured player back into the game due to pressures — from parents, player and/or management and the desire to win the game.
Naitik is a typical teenager with a lot of bravado and competitiveness but ignorant of the long-term results of repeated injuries and the masking effects of pain killers that lead to even more severe injuries. Even the words used by him: ‘cool’, ‘nothing serious’, ‘give me a shot, doc’, are so true. These young athletes, high on testosterone, will do anything to be back on the field and not lose their spot on the team! It is not surprising that narcotic (a strong pain killer) abuse that starts with a simple prescription has become a global problem.
Coach Elmer’s attitude contributes to the larger problem as well. His observation — that Naitik experienced excruciating pain but no discernible swelling — suggests that the injury was not severe. But clearly the injury was far worse. This reluctance to determine the injury for what it is and not taking a tough decision to ‘bench’ the player — is a mindset that contributes significantly to the problem. The competitiveness, the need for winning at all costs, the need for the best players playing the full 90 minutes, the pressures and expectations of the school, league, parents — compels the coach not to take the tough decision.
Injuries in young sportspersons most often are musculoskeletal. Take soccer, it has the largest number of ankle and knee injuries — usually ligament sprains. Ligaments — tensile band-like structures along with musculo-tendinous structures — are responsible for the integrity and proper functioning of joints. These structures are injured in two ways:
(1) An excessive force that moves a joint beyond its normal range, or (2) Sub-maximal repetitive force that causes multiple micro-injuries.
Regardless of mode, injuries need time to heal and be rehabilitated in preparation for return to play. Generally, a ligament sprain, depending upon the severity of the injury, will require approximately 2-3 weeks of rest and another 3-6 weeks of rehab in the least! Injuries are additionally impacted upon by previous injuries and gender — females sufferg a greater number of and more severe injuries. The developing tissue biology of the young athlete further impacts the type and severity of injury — for example, the bone growth plates are more prone to injury.
The impact of injury is immediate — both at the level of the body as well as the brain. At first, the injured part ‘shuts down’ as a protective response. Second, there is an overuse of the uninjured body parts and the body weight shifts over to the uninjured side. This leads to an automatic reorganisation of the brain areas responsible for the control of the injured and uninjured limbs. Accordingly, rehabilitation needs to be geared towards a reorganisation of the neural system to pre-injury status.
Pain is a natural response to injury. Its primary function is to serve as a warning signal and initiate the body’s healing mechanisms. Rest and/or immobilising the part is a key step in this process. It allows the healing processes to be initiated at a tissue and molecular level. Torn tissue is repaired by the laying down of fibres — this process is critical to the long-term recovery and integrity of the healed tissue — particularly (for example, ligaments) around joints. Stressing the tissue too quickly interferes with this healing process and leads to a weakened tissue and/or joint — making it vulnerable to re-injury. Thus, the suppression of pain should be done with caution. It is important to administer pain suppressing modalities — cold sprays, ice, pain killers — in order make the injured athlete comfortable — to reduce his/her suffering — but not to return them to play.
Rehab can be divided into the initial and the later phase. The treatment during these phases is dependent upon the severity of the injury. For mild to moderately severe injuries — the objectives of the first 72 hours are to rest the injured part, reduce excessive swelling and keep the patient pain free. Later movement is gradually introduced within the limits of tolerable pain as it helps in the healing process. Movement also limits the loss of strength. Immobilising joints is kept to the minimum – as there is a rapid loss of muscle tissue — necessitating a longer and more intensive rehab.
Later stages of rehab involve sport specific rehabilitation and is geared towards simulated movements that occur within the game. This is necessary to prepare the athlete to deal with natural forces that are generated within a game situation.
There are no short cuts when it comes to the healing of injured biological tissue – all stakeholders should be aware of what is involved. As professionals it is imperative that we set a goal of ZERO tolerance to sports injuries in the young athlete, as the cycle of injuries and re-injuries has significant ramifications to their quality of life as they grow older — with the early onset of degenerative changes in tendons, joints, etc.
The solution is not to stop all organised sports, but make them safer for young sportspersons. This onus is on parents, school management, coaches, etc. Additionally, the athlete has to be made stronger and equipment, playing fields, etc., should be made safer. More importantly, we need to be able to make tough decisions of benching an injured player. Coaches and medical personnel on the field should be given the freedom to make such decisions without pressure. It is important, however, that personnel on the field be adequately trained — both in the classroom and on the field.
This task is monumental for developing nations such as ours. However, before competitive sports spread to the smaller towns, we need to put in place systems that vote for a policy of zero tolerance and properly trained personnel. In urban areas, particularly schools and leagues where organised sport is already big business —we need to implement policies that protect the young athlete.
A discussion that needs to take place immediately is the problem of concussions and repetitive sub-maximal concussions that the young soccer player (also boxers) experiences as he repetitively heads the ball — more during practice than during the game. Imagine a firm gel like mass (a young brain) being repeatedly bashed against an unrelenting hard ball (our skull). The general approach to the effects of such head injuries (yes head injuries) is to ‘shake it off’. Keep in mind that these brains are still maturing. A number of studies have reported reduced reaction times and deficits in decision making following such injuries. Sending these athletes back on to the field makes them more vulnerable to severe injuries.
Is the problem confronting the young athlete alarming? Yes! Can it be addressed adequately? Yes! However, we need to have the will to act. Importantly, national and state sport authorities need to formulate and implement regulation policies to safe guard athletes as well certify coaches and medical personnel.
Case Study: A Player, A Coach, And A Physical Therapist
Read Analysis: Rahul S. Verghese
The writer is senior consultant at Physical Therapy Clinic, Delhi and director/principal at Amar Jyoti Institute of Physiotherapy. He is a doctorate in Motor Control/Learning from Columbia University, NY, and has 30 years of clinical experience
(This story was published in BW | Businessworld Issue Dated 25-01-2016)