• Acute care of the injury involves the principles of PRICE ⁶ for several days after the injury—protection, rest, ice, compression and elevation of the affected area.

• Ice (wrapped in a cloth or a towel; do not apply ice directly to the skin)—reduces pain, bleeding and inflammation.

• Analgesia may be required, particularly for more severe injuries.

• Short-term walking cast immobilisation may be necessary, particularly in severe grades of tears or where there is an associated avulsion fracture ⁷; followed by functional bracing.

• Taping—the use of an elastic bandage has fewer complications than taping (especially skin irritation), but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support.⁸

• Proprioceptive balance training ¹¹ in pre-season preparation and in-season training programs. This may be taught to individuals by a sports physiotherapist.

• Avoid over-training fatigued muscles.

KNEE INJURIES

Knee injuries are common in many sports, with surgical procedures performed on the knee joint more commonly than on virtually any other structure in the body. The combination of increasing average life expectancy and increasing body mass index means that most of the population will suffer from a knee complaint at some time during their life.

Although knee MRI is more sensitive than clinical examination for certain conditions, because the knee is an accessible peripheral joint it is generally possible for an experienced clinician to make an accurate diagnosis of many knee injuries using history and clinical examination. For a GP assessing a knee injury it is most important to recognise the diagnostic possibilities from the history (Table 44.1) and to be aware of which clinical diagnoses can be made without the need for imaging or specialist assessment.

TABLE 44.1 Diagnosing the major knee injuries (clinical and imaging)

Diagnosis	Clinical diagnosis	Investigations
Anterior cruciate ligament (ACL) tear	History of suddenly giving way. Experienced examiners can confirm with Lachman’s and pivot shift tests in most cases	MRI useful for high-level athletes with haemarthrosis when early diagnosis is required
Posterior cruciate ligament tear	Contact injury to the ground (on a flexed knee) or clash of knees (AFL ruckmen). Positive posterior drawer	Usually not necessary
Medial collateral ligament tear	Contact valgus injury, increased valgus stress	Usually not necessary
Tibio-fibular sprains/posterolateral complex injuries	Generally hyperextension mechanism (rare injury)	MRI to assess severity and whether surgery may be required (only required in severe cases)
Meniscal tears	Combination of medial or lateral pain and joint-line tenderness, mechanical symptoms, effusion and positive McMurray’s test	MRI scanning useful for confirming that surgery is indicated
Articular cartilage injuries	Knee effusion and history of locking or catching may indicate a significant lesion	X-ray to assess overall state of knee degeneration. MRI for pinpointing specific lesions, but X-ray is more likely than MRI to alter management
Knee inflammatory or infective conditions	Knee effusion, pain, fever, no history of trauma (or history of invasive procedure, e.g. injection or arthroscopy)	X-ray and pathology tests indicated (FBC, ESR, C-reactive protein, uric acid)
Patellar tendinopathy (or Osgood-Schlatter syndrome in adolescents)	History of sporting activity, gradual onset of pain, tenderness at either end of the patellar tendon	Ultrasound or MRI may assist with prognosis but do not generally alter management. Use X-ray instead in adolescents
Patellar tendon rupture	Sudden-onset injury, inability to support weight	Investigations indicated before surgery (ultrasound or MRI)
Hamstring insertional tendinopathy	Tenderness on medial side below joint line	Usually not necessary
Iliotibial band syndrome	History of running (or cycling), pain on slow running. Tenderness on lateral side above joint line	Usually not necessary
Patellofemoral pain	Pain with the knee bent (sitting or squatting)	Usually not necessary
Prepatellar bursitis	History of kneeling or landing on kneecap. Swelling cannot be balloted underneath the patella	Usually not necessary
Patellofemoral instability	Patellofemoral apprehension, history of dislocations	X-ray (with skyline view of patellofemoral joint) helpful

Clinical diagnosis of some injuries such as those to the anterior cruciate ligament (ACL) can be difficult for examiners who lack regular exposure to managing such injuries. However, a GP with a special interest in sports injuries and who is confident with using the Lachman (Fig 44.1) and pivot shift tests can often make this diagnosis. It is equally appropriate, when this diagnosis is suspected, to refer for MRI or specialist assessment when the diagnosis is in doubt. Although modern radiological techniques such as MRI can assist in the diagnosis of knee injuries, there is a tendency for overuse of investigations in cases where the diagnosis can be clearly established using clinical examination alone.⁵ It is important to remember that a high incidence of abnormality in normal asymptomatic knees is detected on knee MRI.¹² In general the attitude towards investigation of knee injuries should fall somewhere between the potential mismanagement in an emergency department when a normal knee X-ray is used to declare that the injury is ‘minor’, and the modern (equally inappropriate) tendency to use MRI scanning to confirm every clinical diagnosis.

FIGURE 44.1 Lachman test

KNEE MENISCAL TEARS AND ARTICULAR CARTILAGE LESIONS

Meniscal lesions are extremely common and can often be found on MRI in asymptomatic individuals. Although MRI has assisted with greater accuracy in diagnosis, the decision to undergo surgery should be made on clinical grounds. Traditionally these are:

• mechanical symptoms (catching and/or locking)

• restrictions in range of movement (in the extremes of flexion or extension)

• positive McMurray’s test, being a feeling of pain and/or catching when the examiner rotates the tibia with the knee close to full flexion

• recurrent knee joint effusions.

These indications should not be altered by the presence of in-substance signal change in the meniscus on an MRI scan. The information gained from MRI can be useful to avoid or delay surgery in a patient with knee pain due to low-grade articular cartilage degeneration. A recent controversial but landmark randomised controlled trial cast serious doubt on the value of knee ‘chondroplasty’ (smoothing of roughened areas of degenerate chondral surfaces) for mild–moderate degenerative articular cartilage change, showing no improvement with chondroplasty compared with placebo surgery.¹³ Although the authors claimed that many thousands of unnecessary arthroscopies are performed each year, there has been no reaction from orthopaedic surgery bodies, or insurance companies, to limit the indications for this potentially lucrative procedure.¹⁴ There is something of a role for arthroscopic management of certain chondral lesions, but the indications should probably be limited to cases in which there are loose bodies, mechanical symptoms of locking, or recurrent large effusions rather than knee pain with evidence of degenerative change on X-ray or MRI.

Where there are degenerative changes in the knee causing pain (but not to a degree that indicates that joint replacement is needed), the best management is to recommend moderate activity, quadriceps strengthening, glucosamine and chondroitin tablets and hyaluronic acid injections. Hyaluronic acid injections are normally given as a series of 3–5 × 2–3 mL injections weekly. While evidence indicates that outcomes are improved in knee osteoarthritis,¹⁵ the patient and their insurer must decide whether the possible benefits are worth the expense of the treatment.

PATELLOFEMORAL PAIN SYNDROME

The history in this condition usually includes pain on activities that involve prolonged knee bending (such as sitting) and during knee squatting, sometimes with obvious wasting of the vastus medialis (inner quadriceps) muscle. Although patellofemoral pain syndrome is primarily a clinical diagnosis best managed conservatively, investigations using MRI suggest that subtle patellofemoral joint articular cartilage lesions are common. Treatment includes strengthening of the muscle plus taping or bracing the patella (usually into a more medial position) to assist the muscle in holding the patella in its correct alignment.

Non-impact forms of training may be required, to maintain fitness while the symptoms are settling. Ensure quality sports footwear. Orthotics and arch supports may also be advised.

ANTERIOR CRUCIATE LIGAMENT INJURIES

The knee anterior cruciate ligament (ACL) injury is rightly considered the most important acute diagnosis of the sporting knee because of its frequency and devastating impact on athletes. However, it is worth bearing in mind that an unstable ACL is a condition that affects the ability to participate in multidirectional sports and has relatively minimal effect on straight-line sports and everyday activities. Although the absolute number of ACL injuries occurring is greater in males (due to the greater likelihood of them playing at-risk sports),¹⁶ numerous studies have shown that the relative risk for ACL injury in females in much greater when they play the same sports.^17,¹⁸

The most common mechanisms of ACL injury are:

• a non-contact change of direction when the foot becomes ‘stuck’ to the surface

• a hyperextension on landing from a jump

• a direct valgus force from a blow to the leg from the outside.

The clinical diagnosis of ACL instability can be made in most cases using the Lachman and pivot shift tests. With the Lachman test (Fig 44.1), the amount of anterior drawer at 30° of flexion is relevant, but the ‘end point’ feel to movement is even more important for determining an intact ACL. When the pivot shift test is performed on a deficient ACL the tibia can be subluxed forward in internal rotation (relative to the femur) with an extended knee, and relocates with passive flexion. Successful use of these tests requires substantial exposure to examining stable and unstable knees, which is normally not part of medical school curriculum. Most sports physicians and orthopaedic surgeons who treat knee injuries can make the diagnosis clinically, particularly in either chronic cases or in the immediate acute scenario (on the sideline). The most difficult time to diagnose an ACL injury is in the days immediately after the injury, when there may be a large, tense haemarthrosis. At this time the accuracy of MRI examination may be greater than that of an experienced examiner. The natural history of an ACL injury is that the ligament generally heals in a suboptimal position, meaning that the knee is prone to instability (and therefore secondary cartilage injuries) during twisting movements.

After a diagnosis of ACL injury has been made, the patient is faced with difficult decisions about surgical reconstruction and whether to return to twisting sport. Younger patients are more likely to fail conservative treatment for ACL injuries. However, even surgical reconstruction cannot promise a completely normal knee. On return to sports such as football after reconstruction, the player has a four- to ten-fold increase in the risk of re-injuring the ACL (on either the graft or the contralateral side),¹⁹ and further surgery for cartilage injuries is not uncommon. The choice of graft for ACL reconstruction is made by the surgeon, but there have been many randomised controlled trials comparing the two most popular choices (patellar tendon graft and four-strand hamstring tendon grafts). A consistent finding has been equivalent levels of function and patient satisfaction for each type of graft, but with trends towards greater stability in the patellar tendon graft groups and less secondary morbidity from the graft site in the hamstring tendon groups.²⁰ This means certain patients can be recommended to have certain grafts based on their relative needs for stability versus avoiding morbidity, but either graft choice is satisfactory in the hands of an experienced knee surgeon.

Management of the major knee injuries is summarised in Table 44.2.

TABLE 44.2 Recommended management (conservative versus surgical) for the major knee injuries

Diagnosis	Conservative management	Surgical management
Anterior cruciate ligament (ACL) tear	In patients who do not have symptomatic instability, older athletes and/or those prepared to avoid multidirectional sports	ACL reconstruction is the management of choice for the young athlete who wishes to continue with multidirectional sports
Posterior cruciate ligament tear	Usually rest for 6–8 weeks is sufficient	Rarely indicated (?only when combined with posterolateral instability)
Medial collateral ligament tear	Rest (± knee brace) for 1–12 weeks, depending on severity Low-level laser therapy may improve healing ²¹	Rarely indicated (?high-level athletes with complete ruptures at the tibial insertion)
Tibio-fibular sprains/posterolateral complex injuries	Minor lateral ligament sprains can recover with 2–6 weeks’ rest	Biceps tendon ruptures and/or combined lateral and posterior cruciate ligament injuries (rare) are managed surgically
Meniscal tears	Degenerative tears in the older athlete that do not give rise to mechanical symptoms can be managed conservatively	Arthroscopic partial meniscectomy is generally the treatment of choice for mensical tears. Meniscal repair can occasionally be successful in acute peripheral tears in younger athletes
Articular cartilage injuries	Almost all mild–moderate articular cartilage injuries (extremely common) should be managed conservatively, even though complete cure is unlikely	Arthroscopic surgery for articular cartilage lesions is probably over-performed (as it also fails to cure), although it is still indicated when there are mechanical symptoms such as locking. Total knee replacement in severe cases
Patellar tendinopathy	Physiotherapy, eccentric strengthening, activity within pain limits and some other therapeutic treatments (although COX-2 inhibitors and cortisone are not recommended)	Rarely indicated
Patellar tendon rupture	Treat surgically	Acute surgical repair is the most appropriate treatment
Osgood-Schlatter syndrome (in adolescents)	Activity within pain limits, calf and gluteal strengthening, reassurance	Rarely indicated (?when impingement caused by excessive ossification)
Hamstring insertional tendinopathy	Anti-inflammatory gel, cortisone injection, eccentric strengthening	Occasionally indicated for chronic cases with bursa formation
Iliotibial band syndrome	Cortisone injection, avoidance of aggravating activities (e.g. downhill jogging)	Indicated for cases resistant to conservative treatment
Patellofemoral pain	Physiotherapy, taping, strengthening	Rarely indicated (?when there is persistent knee joint effusion)
Prepatellar bursitis	Aspiration and cortisone injection (± antibiotics)	Indicated for cases resistant to conservative treatment
Patellofemoral instability	Physiotherapy, bracing, strengthening	Indicated for recurrent dislocations
Knee infections or inflammatory conditions	Cortisone injections for proven inflammatory conditions (e.g. gout)	Hospital admission (antibiotics, lavage) for knee joint infections

TENDON INJURIES

Tendon injuries make up a large proportion of musculoskeletal pain in both athletes and the general community. The most common form is ‘tendinopathy’, which was previously but inaccurately known as ‘tendinitis’ when it was thought that these were inflammatory conditions.^22,²³ It is now best to think of tendinopathies as degenerative conditions although, fortunately, the degenerative change is semi-reversible. Some of the most common forms of tendinopathy are tennis elbow (lateral epicondylitis), rotator cuff tendinopathy, De Quervain’s wrist tendinopathy, adductor (groin) tendinopathy, Achilles tendinopathy and patellar tendinopathy (‘jumper’s knee’). The other common condition related to tendinopathies is plantar fasciitis, which strictly speaking is an enthesopathy, not a tendinopathy, as there is no muscle directly attached to the plantar fascia (and hence it is not a tendon).

The most common variety of tendinopathy is insertional (affecting the bone–tendon interface), although Achilles tendinopathy is an exception as it most commonly affects the mid-tendon substance. Some types of insertional tendinopathy are prone to intra-tendinous calcification. Insertional tendinopathies appear to be a combined ‘underuse–overuse’ injury, with the weakened under-surface of the tendon not bearing enough load and the normal outer portion of the tendon often overloaded.²³ The key underlying management is to recommend moderate loads that the injured tendon can withstand, rather than continuing with overloads or recommending complete rest. Sudden increases in load are risky for all tendons and hence complete inactivity is risky for tendon injury (as return to ‘normal’ activity will represent a sudden increase in load). This paradigm explains why tendinopathy is common in middle-aged people who suddenly take up exercise after a period of inactivity.

The middle-ground approach to tendinopathy is moderate loading within pain limits, followed by gradual increases in load as the weakened section of the tendon repairs itself. Some experts recommend exercising through the pain barrier, with complete immobilisation now out of favour and considered overly conservative.¹⁸ Eccentric strengthening (loading as the tendon is lengthening) appears to be the best type of specific rehabilitation exercise.²⁴

Because inflammation and impingement are not generally considered significant pathologies in this condition, NSAIDs and cortisone injections are not generally recommended.²⁵ Other newer treatment options successfully used for patellar or similar tendinopathies include nitrate patches,²⁵^–²⁸ extracorporeal shock-wave therapy²⁹ and polidocanol injections.²⁵ Nitrate patches are those used to treat angina, with the lowest dose (5 mg/24 h) cut into quarters (NITRO-DUR® or Minitran™) and applied daily to the affected body part (Fig 44.2).

FIGURE 44.2 Nitrate patches used in quarters for ‘tennis elbow’

ROTATOR CUFF TENDINOPATHY AND ‘TENNIS ELBOW’

The two most common tendinopathies in the upper limb affect the supraspinatus tendon in the shoulder and the common extensor origin at the elbow. Supraspinatus tendinopathy is a special case as the phenomenon of impingement is generally associated with this condition. It is clinically important to assess how much of the patient’s pain is due to the intrinsic pathology of tendon, compared with secondary impingement. Weakness on rotator cuff strength testing can suggest tendon damage, but shoulder ultrasound is probably the best way to accurately differentiate this from impingement. If impingement is the predominant cause of pain, NSAIDs and cortisone injections are indicated. For intrinsic tendinopathy, scapular stabilising exercises and nitrate patches are more-specific treatments.

While tennis elbow is common in amateur tennis players, it is such a ubiquitous form of tendinopathy in middle-aged patients that the vast majority of cases are in non-tennis players. The pain on the lateral side of the elbow can radiate down the forearm, but it is wrist and finger extension movements that aggravate the pain.

Therapeutics

• Modalities that may assist recovery include physiotherapy, massage, acupuncture ³⁰ and transcutaneous electrical nerve stimulation (TENS).

• Try a brace centered over the proximal forearm.

• Check sports equipment (e.g. racquet size) for correct fit.

Supplements

• Healing may be assisted by vitamin C (1 g/day)

• Calcium (1500 mg/day) and magnesium (750 mg/day) to aid healing of connective tissues and muscles

• Vitamin E (400–800 mg/day)

• Essential fatty acids from fish oil (1000–1500 IU one to three times a day) to reduce inflammation

• Bromelain (250–750 mg three times a day between meals)

• Curcumin (Curcuma longa) / turmeric (200–400 mg three times a day between meals) to reduce inflammation.

Pharmaceutical

• Nitrate patches and eccentric exercises have been shown to help recovery.

• Cortisone injections give short-term pain relief but may damage the tendon in the longer term.³⁰

• Botulinum toxin injections into the muscle can relieve the pain of tennis elbow but at a cost of temporary loss of extension of the third finger.

LOWER-LIMB TENDINOPATHIES

Management of lower-limb tendinopathies follows similar principles, although because the tendons bear heavy loads, cortisone injections are riskier and should generally be avoided. The key management principle is graduated loading, including eccentric (lengthening only) strengthening exercises.²⁴ An example of an eccentric exercise is shown in Fig 44.3 for the hamstring muscle group. For patellar tendinopathy (‘jumper’s knee’) the exercises are best done on a decline board (30° downslope), which encourages loading of the patellar tendon while lengthening only.³¹ Other exercises should strengthen or mobilise other deficiencies in the lower limb (e.g. calf and gluteal strengthening and hamstring stretching). Very few patients require total rest from weightbearing or immobilisation. Surgery for many lower-limb tendinopathies has limited success, although it is indicated for tendon rupture.

FIGURE 44.3 Hamstring eccentric exercises

In adolescents, similar conditions are common but with more tendency to self-limitation as they are epiphyseal overloads. They are, unfortunately, known by their cumbersome eponymous names such as Osgood-Schlatter disease (at the tibial tubercle just below the knee) and Sever’s disease (below the Achilles attachment on the calcaneus).

In most cases (both adults and adolescents) there is little need to investigate; when this is necessary, plain X-ray in adolescents and ultrasound in adults are the modalities of choice. As is the case with many other pathologies, there is a high incidence of tendon imaging abnormalities in asymptomatic athletes.

GROIN INJURIES

Groin injuries are often due to chronic tendinopathy (particularly of the adductor muscle group), although the differential diagnosis of groin pain is extremely complicated.³² Chronic groin pain is often due to osteitis pubis,³³ which is probably a bony stress overload lesion at the end stage of insertional tendinopathy. The standard treatment of chronic groin overuse injuries is reduction of load (rather than total rest) to a level where the pain is not worsening. Fortunately, many football players can continue to play once a week and limit their training without aggravating a chronic groin injury. In the off-season, jogging is generally encouraged, followed in order by faster running, maximal sprinting, kicking from a standing start, change of direction movements and then kicking on the run. Surgery is sometimes indicated, including hernia repair and adductor tenotomy.³⁴ In addition to unresolved chronic pain, the indication for adductor tenotomy includes painful reduction of range of passive hip abduction, as surgery can correct this. A hernia repair is indicated if there is pain and clinical or imaging (usually ultrasound) evidence of a hernia or posterior inguinal wall deficit.³⁵

TENDON RUPTURES

The other tendon injuries of note are complete ruptures of tendons, which are not uncommon in older individuals and particularly affect the supraspinatus tendon and the Achilles tendon. Other common tendons to rupture in ball-sport players are the finger flexor tendons. The optimal management is acute surgical repair, as this leads to the best functional outcome. This management is problematic in high-level football players, for example, who are likely to wish to return shortly after surgery, which jeopardises the surgical repair. Many professional players elect to continue to play important games and put up with the inevitable fixed flexion deformity. Tendons that rupture and have nearby agonists, such as long head of biceps brachii and distal semitendinosus, are often managed conservatively as the functional deficit is generally acceptable. Full-thickness rotator cuff tendon tears, proximal hamstring, Achilles tendon and patellar tendon ruptures are not common but need to be managed surgically in active individuals.

DRUGS IN SPORT

The topic of drugs in sport is of major interest to those who work in the sports medicine field and the lay public who follow professional sport. However, even GPs who have no interest in sport must now have a basic understanding of the restrictions on drugs in elite sport. The reason for this is that any doctor can potentially treat an elite athlete as a patient and therefore has a responsibility to try to avoid prescribing medications that would be illegal in that sport. Drugs in sport laws follow a principle of strict liability, where, unfortunately, it is not a defence to have been prescribed a banned drug for a medical condition not related to sport. This can put a GP in a difficult position in which he or she can be seen as an accessory to breaking ‘drugs in sport’ laws for following routine medical practice.

Prohibitions on the use of dangerous performance-enhancing drugs have been introduced to almost all elite-level sports over the past four decades. Anti-doping laws attempt to minimise the number of athletes engaging in doping, although the enforcement of anti-doping laws is, predictably, not 100% successful. However, sport without anti-doping laws would further disadvantage those athletes who want to compete at an elite level without risking their health.

The World Anti-Doping Agency (WADA) is responsible for developing and implementing uniform anti-doping standards worldwide (with respect to lists of banned drugs and penalties for abusing them). The World Anti-Doping Code (WADA Code) was adopted after consultation with governments, sporting bodies, national anti-doping agencies and other relevant parties in 2003 by all Olympic federations, many nations and many elite sports.

Anti-doping laws do not relate just to positive tests for prohibited substances. Refusing to submit to testing procedures, tampering with samples (before or after they are submitted), possession and/or trafficking of illegal substances, and refusal to supply accurate regular whereabouts information to authorities (to allow for regular unannounced out-of-competition testing) can lead to doping infringements. Therefore, medical practitioners may also be subject to doping sanctions and suspended from involvement in elite sport.

WADA enforces the principle of strict liability because there is generally no reasonable doubt that a drug discovered within an athlete’s urine or blood sample (taken under a strict protocol) was present within the athlete’s system, yet it would be far too difficult, in the majority of cases, to prove intent to cheat beyond reasonable doubt. Strict liability for doping offences is controversial, although the WADA Code does offer the athlete some opportunity to consider the unique circumstances of each case.

THERAPEUTIC USE EXEMPTIONS

The WADA Code has a process for granting exemptions for the legitimate medical use of banned substances. All applications must be prospective and registered (except in emergency situations). Some medications are banned with the proviso that they may be used for certain medical indications, which require notification prior to their use. Prospective approval to take a banned drug via a Therapeutic Use Exemption (TUE) process for a documented medical condition is currently provided (under the WADA Code) if:

• the condition poses significant impairment to health, and

• there is no additional enhancement of performance (other than return to normal state of health following treatment of the legitimate medical condition), and

• no reasonable therapeutic alternative exists to treat the condition.

Drugs with a potential for abuse and performance enhancement must be assessed by an expert panel. Each country has its sports drug agency to assess these claims. TUEs are commonly granted for the use of oral glucocorticosteroids to treat severe asthma or inflammatory bowel disease.

Major controversy also surrounds testing for non-performance-enhancing but illegal drugs, which athletes may take for social (or recreational) purposes. The banning of stimulants, such as cocaine, when competing is universally accepted. The dilemma lies in whether stimulant drugs should be tested out-of-competition (where presumably they convey no performance advantage) and whether drugs such as marijuana, which are illegal but unlikely to confer any performance advantage, should be tested for and potentially lead to disqualification. The argument offered by WADA is that these drugs affect the health of the athlete, and that taking drugs inappropriately is against the spirit of sport.

It may be considered an invasion of privacy to test for non-performance-enhancing drugs out of athletic competition. However, it is hard to argue in defence of athletes who choose to break not only anti-doping but also criminal laws by using illicit social drugs. It may be more appropriate that these athletes receive counselling, and perhaps shorter suspensions, than other athletes found using drugs that would give them an unfair performance advantage.

SPORTS PSYCHOLOGY

Any person who has participated in sport, let alone competed at the elite level, will recognise that sport involves the mind as much as it does the body. Sports psychology is therefore important for two main reasons: in relation to improving performance, and in relation to mental health.

PERFORMANCE

Most serious athletes now dedicate a significant amount of time in their training regimen to training their minds. Understanding, for example, how to train attention, particularly when under pressure, can mean the difference between a higher or lower level of performance when the pressure is greatest. Athletes speak about states like the ‘zone’ or ‘flow states’ and we now know that these are trainable states of attention through practices such as mindfulness or visualisation exercises. A crucial aspect of this is being able to train one’s attention onto the process and to unhook attention from anxiety about the outcome, which often distracts attention from performing in the moment. Training teams requires particular skills in setting common goals, fostering team spirit and cohesion, and in dealing with conflict between team members.

Another aspect of mental training is learning how to cope with physical discomfort, particularly in endurance sports such as distance running, cycling or swimming, and in playing with injuries, which is increasingly common particularly in professional sports. Deciding how fast to go, when to stop or when not to participate in the first place is an important aspect of being able to perform safely and well, as well as assisting in being able to recover more quickly and to have a sustainable career in the longer term. Athletes are prone not only to injuring their bodies through driving them too hard, but also to over-anxiousness regarding injury, particularly where the stakes associated with being injured are high.

MENTAL HEALTH

Athletes are not only subject to the normal mental health issues prevalent in the community, but they also have a range of particular mental health issues to deal with. For example, competing at a high level is associated with significant self-restraint from activities that others would enjoy as a normal part of life. Rigorous diets and training schedules can be very hard to maintain and this issue can be particularly important for young athletes, especially when being trained and driven overly hard by ambitious parents.

Anxiety and depression are common among high-performing athletes. The unbridled joy often publicly displayed when winning is the other side of the coin of the intense disappointment often borne privately when having lost or performed poorly. Furthermore, ambition or anxiety about performance can lead elite athletes to set extraordinarily high expectations or participate when they possibly should not. Such concerns are also a significant contributor to the risk of taking performance-enhancing drugs and all the health and legal problems that this entails.

Having long-term injuries can lead to intense disappointment and even depression, especially when a long-term and valued goal has been worked towards but is no longer possible. When an athlete’s career comes to an end, especially when that end is unexpected and premature, it is not uncommon for there to be a significant and challenging period of adjustment. Often the disappointment and isolation associated with retirement from the sport is compounded by adjusting to a new life and career for which the athlete has not adequately prepared.

CONCLUSION

Knee injuries, tendinopathy and drugs in sport have been chosen as example topics with high current relevance to both specialist sports physicians and GPs. However, sports medicine has a far wider scope that cannot be fully covered in a single book chapter. For further resources, please consult the Resources list below.

Sports medicine is an emerging field that particularly has scope for community (non-hospital) practice, and hence it is very relevant to general practice. GPs are now aware that lack of exercise is a major risk factor for many diseases. There is a move towards treating non-exercisers as the medical profession treats smokers—that doctors must try to convince these patient that their lifestyle choices are unhealthy and require changing. However, doctors who are correctly advising their patients that they must exercise need to be in a position where they can provide basic management of the injuries that may be associated with exercise. For this reason, the past ostracism of sports medicine by much of the mainstream medical community has been misplaced.³⁶

Australia has been a world leader in the development of quality sports medicine practice, possibly because of the elevated status of professional sport in this country.³⁶ However, in prevention of sports injuries and recognition of sports medicine as a specialty area, it has fallen behind other countries, most notably New Zealand.^37,³⁸ In Australia, only 50% of the population is physically active at recommended levels, meaning that physical inactivity may soon surpass cigarette smoking as the number one cause of preventable diseases.³

For the sake of preventing illness and disease, the exercise prescription is probably the most important prescription that a GP can write in the twenty-first century. A basic knowledge of sports medicine is essential to assist patients in adhering to this important prescription.

RESOURCES

ASDMAC (Australian Sports Drug Medical Advisory Committee). http://www.asdmac.org.au.

Australasian College of Sports Physicians. http://www.acsp.org.au/.

Brukner P, Khan K. Clinical sports medicine, 3rd edn. Sydney: McGraw Hill, 2006. One of the world’s leading general sports medicine texts. Pitched at a perfect level for medical students, physiotherapists, general practitioners and doctors undertaking postgraduate study in sports medicine. For information: http://www.clinicalsportsmedicine.com/

injuryupdate, an Australian website on sports injuries. http://www.injuryupdate.com.au/.

Medical Journal of Australia, sports medicine papers. http://www.mja.com.au/Topics/Sports%20medicine.html.

National Sports Information Centre, Australian Institute of Sport. http://www.ausport.gov.au/nsic/index.asp.

Sports Medicine Australia. http://www.sma.org.au/.

World Anti-Doping Agency. http://www.wada-ama.org/en/.

REFERENCES

1 Finer N. Rationing joint replacements: Trust’s decision seems to be based on prejudice or attributing blame [letter]. BMJ. 2005;331:1472.