SPORTS and ATHLETIC INJURIES: A PHYSIOTHERAPIST S APPROACH

Injury is acknowledged to be the occupational hazard o f sport, and is a constant threat to all sportsmen and athletes. A high proportion o f these injuries are minor, but all prevent the sportsman from taking part in his particular sport or greatly reduce his ability, and if neglected or illtreated may easily become major disabilities. It is well known that a great number o f sportsmen lack confidence in the medical profession and turn to quack treatment in search o f a rapid cure. This, I feel, is due mainly to the fact that few doctors or physiotherapists realize that even a minor injury to a keen sportsman as­ sumes the proportions o f a major disaster, threatening his hard-won fitness, sporting prowess, and possibly his posi­ tion in a team. Too frequently, his reaction to injury is considered to be somewhat neurotic, and he is sent off to rest at home, with little or no instruction as to the length o f rest required, what steps he should take to hasten his recovery, and when or how to resume exercise. -Conse­ quently, either he is afraid to use the limb at all-, or he walks too soon on an already-damaged muscle or joint, thereby putting further strain on it. In either case he tends to return to sport before he is fit, once his pain is alleviated, and the lesion recurs or he suffers a secondary injury, with resultant lowering o f morale and further loss o f confidence in medical advice. In order to get the best results from the treatment o f this type o f patient, it is necessary to recognize the fact that he needs a sympathetic and positive approach to the handling o f his injury; demands 100 per cent recovery in the shortest possible time; and has no use at all for the widespread pre­ scription o f ‘rest’. There is no doubt that lay-off periods, with the concomitant drawbacks o f loss o f form and fit­ ness, are greatly reduced by the early initiation of active intensive treatment, with the ideal balance o f rest and gentle exercises, graded according to the severity o f the iryury. Because so many injuries occur on a Saturday, when hospital and other medical and physiotherapy departments are closed, the average sportsman has to rely on inadequate home remedies before he is able to obtain professional assistance. Valuable time is thereby lost, and the injury is already subacute or chronic before being seen. To overcome this time-lag it would be o f great value if regular Sundaymorning injury clinics were available which sportsmen could attend.

Injury is acknowledged to be the occupational hazard o f sport, and is a constant threat to all sportsmen and athletes. A high proportion o f these injuries are minor, but all prevent the sportsman from taking part in his particular sport or greatly reduce his ability, and if neglected or illtreated may easily becom e major disabilities.
It is well known that a great number o f sportsmen lack confidence in the medical profession and turn to quack treatment in search o f a rapid cure. This, I feel, is due mainly to the fact that few doctors or physiotherapists realize that even a minor injury to a keen sportsman as sumes the proportions o f a major disaster, threatening his hard-won fitness, sporting prowess, and possibly his posi tion in a team. T oo frequently, his reaction to injury is considered to be somewhat neurotic, and he is sent off to rest at home, with little or no instruction as to the length o f rest required, what steps he should take to hasten his recovery, and when or how to resume exercise. -Conse quently, either he is afraid to use the limb at all-, or he walks too soon on an already-damaged muscle or joint, thereby putting further strain on it. In either case he tends to return to sport before he is fit, once his pain is alleviated, and the lesion recurs or he suffers a secondary injury, with resultant lowering o f m orale and further loss o f confidence in medical advice.
In order to get the best results from the treatment o f this type o f patient, it is necessary to recognize the fact that he needs a sympathetic and positive approach to the handling o f his injury; demands 100 per cent recovery in the shortest possible time; and has no use at all for the widespread pre scription o f 'rest'. There is no doubt that lay-off periods, with the concom itant drawbacks o f loss o f form and fit ness, are greatly reduced by the early initiation o f active intensive treatment, with the ideal balance o f rest and gentle exercises, graded according to the severity o f the iryury.
Because so many injuries occur on a Saturday, when hospital and other medical and physiotherapy departments are closed, the average sportsman has to rely on inadequate hom e remedies before he is able to obtain professional assistance. Valuable time is thereby lost, and the injury is already subacute or chronic before being seen. To overcome this time-lag it would be o f great value if regular Sundaymorning injury clinics were available which sportsmen could attend. In a sport-loving country like South Africa there is a great need for this type o f centre, especially if interested orthopaedic consultants would be prepared to run them and be available to diagnose and prescribe for the injuries at the earliest possible moment.

SP O R T S IN JU R Y CLINICS
Such centres would, I feel sure, attract the interest of coaches and sportsmen alike, and would gain recognition and support from the various sporting and athletics bodies. The essential team-work on behalf o f the sportsman from doctor, physiotherapist and coach or trainer could be obtained, the importance o f early treatment explained, and the necessity o f full recovery and the regaining o f fitness before the resumption o f full training or return to com petitive sport stressed.
The co-operation o f the coach, which is at present only obtainable am ong professional athletic and sports clubs (apart from the occasional doctor who coaches in his spare time, and some school coaches), is in any case essential in order to get the best results with this type o f case. Too often the amateur sportsman disregards medical advice, or attempts to hide an injury, because his coach insists on his taking part in training sessions, with the threat that he will not be considered for the team unless he does so.
Should recognized Sports Injury Clinics be established, the vital co-operation o f the coaches would be far more easily obtained; harmful practices such as making the sportsman try to 'run out' a muscle pull, in spite o f pain and spasm, could be stopped, and the chronic injuries (resulting from neglect o f minor tears and strains) could be reduced, both in severity and number.

PH Y SIC A L FITN ESS A N D TRAINING
The average sportsman needs about 6-8 weeks' pre-season and 4 or more weeks' 'during season' training in order to reach a sufficiently high standard o f fitness to enable him to avoid the less serious type o f injury. Even if pre-season training has been carried out for many weeks, soft-tissue and other injuries are m ost com m on in the first month or 6 weeks o f the season, although naturally, the better the player has prepared himself, the less liable he is to sustain | an injury. A s the players get fitter and more hardened, especially in body-contact sports like rugby, the injury rate drops; then, towards the end o f the season, when fatigue and staleness set in, and chronic injuries begin to need not only treatment but also rest, a second peak o f injuries occurs.
There are several types o f training, and the sportsman or athlete will choose the kind m ost suited to his needs. In every case it is important to include graduated progressive resistance exercises, to increase the tone and strength of muscles sufficiently to protect the joints over which they work, thus reducing the likelihood o f injury. A s it has been found that fully extensible muscles are less prone to tears on sudden exertion and fast movements, daily exercises to put the muscles, especially those o f the legs, through their full range (plus a little overstretch) are also important. Bertie M ee, physiotherapist with the Arsenal F ootball Club, states that the incidence o f pulled muscles has been re d u c e d considerably since this practice was introduced as a routine in training, and before participation in any game.
Other points which are invaluable in pre-season training are: practice in falling, ending in a roll or somersault; attempting to land on the more heavily-padded parts o f the

JUNE, 1971
tody in a fall, thus reducing the point o f im pact; learning to 'giye' when receiving the impact of, say, a cricket ball; and, o f the greatest importance, learning to relax unneed ed muscles, in order to conserve energy for the task in hand and so reduce the onset o f fatigue.

(A great deal o f information on this subject can be found in W ells's book on Kinesiology.)
A dequate w arm ing-up exercises before p a rticip atio n in strenuous games o r athletic events are im p o rta n t as a safe guard against soft-tissue injuries, as -especially w hen ® 0ld -sudden exertion is a frequent cause o f pulls and tears. A ccidents also occur w hen a sportsm an is to o tired to be alert, a n d the m uscles a re fatigued, w hich underlines the necessity o f com plete fitness before com peting in an event o r playing in a m atch. The main injuries occurring in sport and athletics are muscular strains or tears; contusions and haematomas; joint injuries, with cartilage, capsule and ligament involve ment; and bony injuries, including fractures arid bony haematomata.
In rugby, it is the backs who suffer the most leg injuries of all kinds. Hamstring injuries are m ost com m on among the wings, possibly because they are frequently called upon to make a sudden sprint, or swerve at speed after a period o f reduced activity, when the muscles have lost som e o f their warmth and are unable to take the load without som e fibres being stretched or torn. These tears also tend to occur towards the end o f the game, when the player is fatigued or loses concentration.
The backs also suffer shoulder injuries from tackles and falls. Scrum-halves get acromioclavicular strains and con tusions from dive-passing, as well as being subjected to face and hand injuries.
Among the forwards, back-strain is com m on, and face, head, ear and neck injuries prevail, with the constant danger o f a cervical fracture-dislocation if the scrum collapses. Consequently it is particularly important for them to strengthen neck and back muscles.
All players are liable to get contusions and haematomas, and it is amazing that a far greater number o f more serious injuries do not occur follow ing hard tackles, or rucks and loose mauls; in fact, one frequently wonders how the chaps at the bottom o f a struggling, hacking mass o f bodies ever get up at all, let alone in one piece! In cricket, bowlers are the m ost injury-prone as, in addition to leg injuries, they tend to stretch and strain back muscles and frequently develop supraspinatus tendinitis. Fast-bowlers often pull their external oblique muscles (found on the left in right-handed bowlers), and spinbowlers develop soreness o f the spinning finger.
Among batsmen one sees contusions o f fingers, thighs, ankles, feet and knees; pulled medial ligaments or menisci; sprained ankles; pulled leg muscles; and sometimes strained backs.
Fielders, too, pull leg muscles and tendons, but suffer more finger and hand injuries, as well as straining acromio clavicular joints, or shoulder tendons from dive-catches and throw-ins.
Among athletes, hurdlers pull adductors and hamstrings; get contusions and haematomas from hitting high hurdles, t so™etjn?e s.strain their mid-tarsal joints. High-jumpers get ankle injuries, shoulder or elbow injuries from falling, ana contusions to the thigh from hitting the bar; longjumpers develop bruised heels, and often get backache or Page 3 sacro-iliac strain due to the jerk o f landing. Sprinters mainly pull leg muscles.

Discus-throwers tend to develop a triceps extensor strain, and javelin-throwers a type o f tennis-elbow, known as 'javelin elbow ', and sometimes strain o f the deep muscles o f the back.
I, personally, have little experience o f soccer injuries, mainly because my practice is in a rugby-playing centre, but D onald Featherstone's book on Sports Injuries deals specifically with these.
A s a matter o f general interest, Tucker gives the following ages as those at which a sportsman reaches his prime in his particular sp ort: in athletics, at about 25; in tennis and similar games, a couple o f years later; in football, at an average o f 28; and in cricket and golf, at 30 or over.

PATH O LO G Y
Before discussing treatment it will be useful to outline briefly the body's reaction to injury, in which, incidentally, reparative measures far in excess o f those required to restore and repair damage are produced. The normal tissue reaction includes inflammation and haemorrhage from ruptured blood-vessels; serum plus fibrin and white cells exude from the surrounding blood-vessels, and adjacent structures are torn or stretched. The part becom es swollen and painful on pressure, and movements becom e limited.
In the next, or repair stage, the phagocytes try to absorb the break-down products and later fibroblasts grow in to repair the damage.
The repair o f muscle fibres, and even o f tendinous lesions, is good, especially jn youth, when the tissues are so versatile that they can repair, replace and even grow after injury.
If absorption o f effusion and space-occupying haemato mata is delayed, or does not take place, the lymph becomes organized and forms adhesions. Therefore, the more rapidly one can disperse the swelling, and the sooner gentle stretching o f the reparative tissue to prevent it from contracting can be started, the better, and the less likely the sportsman will be to develop a chronic condition.
It may be worth stressing at this stage that the treatment for inflammatory conditions due to trauma is opposite to that for those due to bacterial infection.

TREATM ENT
According to most authorities on the subject, complete rest is only required in a few sports injuries, such as complete rupture o f muscle or tendon; in fractures; after dislocations, especially o f the elbow; in the presence o f myositis ossificans, and in som e cases o f tenosynovitis. The value o f accurate diagnosis, the prescription o f Tanderil, Varidase, or similar drugs, early first-aid treatment, and immediate steps to combat the injury and start rehabilitation in all other sports injuries cannot be overstressed.
The management o f the less serious type o f injury can be varied according to whether the sportsman is hurt at the end o f the season or near the beginning o f it. If the former, he may be patched up sufficiently to continue play ing if he wishes, and can then rest in the closed season. If, however, the injury occurs at the start o f the season, he should be m ade to wait until recovery is complete before being allowed to return to sport.
For the initial first-aid treatment o f all these injuries (and by this I mean medical and physiotherapeutic firstaid) the key-word is ICE. That is (i) ice-cold water com presses or ice packs over the site o f injury, which lessens the bleeding into the tissues by axon reflex and so prevents, or reduces, the size o f the haem atoma; (ii) compression bandage' over the area, or the application o f a Sorbo-rubber or felt pad, held in place by a crepe bandage; and (iii) elevation o f the limb, to prevent the spread o f swelling. This should be done as a routine for the first 24-72 hours, depending on the severity o f the injury, and the muscle or joint should be rested in its m ost comfortable position. A t the same time the sportsman should be instructed to apply ice or cold packs at home, and to persist with gentle nori-weight-bearing exercises hourly, in order to keep up muscle tone, assist absorption, and prevent the formation o f adhesions.
Physiotherapy is started immediately, if possible, and done 2 or even 3 times a day in the acute phase, so that the swelling does not have time to becom e consolidated, and the repair and recovery stage is speeded up. Massage over the area should be avoided at first, but I find that very gentle effleurage around and above the injury helps to disperse effusion and relieves pain. H eat is contraindicated for an average o f 48 hours, because o f the bleeding into the tissues, but is needed after that in order to promote absorption.
Diathermy o f any kind may further engorge an alreadydistended part if it is used too early, so that it is best to start with infrared, or a m oist heat such as Hydropak, or hot wet towels to reduce muscle spasm.
A s the condition improves, short-wave or microwave can be substituted, the sportman's hom e treatment can be changed to hot packs or contrast bathing, and all active exercises can gradually be increased -graded progressive resistance exercises being added as soon as possible, and, later, gentle graduated training.
Opinions vary as to the use o f ultrasound, but I personally find it invaluable, particularly for reducing effusions and haematomas. Combined with massage and other physio therapy modalities, I use it from the outset, starting with a very low dosage for a few minutes around and above the lesion, gradually including the whole area o f injury.
Tucker prefers the use o f short-wave, galvanism, faradism or interferential currents. H e believed that the claims m ade for ultrasound were exaggerated and that it was of very limited use. Since the publication o f his book Injury in Sport, however, I find that he has been 'converted' and it is now used a great deal in his clinic.
Williams approves o f ultrasound, and states that 'faradism and galvanism are o f no value in the treatment o f muscle injuries in athletes'; C em ey advocates moist heat, such as whirlpool baths or infrared through wet towels and stimu lating currents and massage; and also describes the use o f ethyl chloride or similar spray for sprains and even muscle lesions. I have found this quite a useful variation in many cases, especially for those patients whose time available for treatment is limited (such as in visiting teams). For those unfamiliar with the technique, I shall describe it briefly: Surface anaesthesia produces relaxation and relieves muscle spasm. If complete relief is obtained, for instance in a sprained ankle, a simple sprain is indicated; if, however, continued deep pain persists, the damage is o f a more serious nature.
The skin must be unbroken for this treatment, and a thin layer o f Vaseline should be spread over the area to protect the skin. A fine spray o f anaesthetic is directed at the part for about 45 seconds, or until the skin blanches, and then the physiotherapist's hand is placed over the area. This is repeated and then tests are done to localize the points o f pain. Repeat again on trigger points and re-test, doing active m ovem ents and gentle passive stretchings or manipulations.
The limb or joint should then be bandaged so as to give rest and support to the injured part, and the patient is instructed to apply cold packs and do gentle non-weightbearing exercises at hom e, in addition to reporting for daily physiotherapy. After that, the routine progresses as it does

JUNE, 1971
for the other__types o f treatment, with contrast bathing at hom e replacing cold packs, and so on.
Physical fitness, which takes many 'weeks o f training to obtain, is only maintained through physical activity; this level o f fitness falls off rapidly when training is discon tinued, even for a few weeks. The enthusiastic sportsman needs no encouragement to take an active part in his own rehabilitation, and the moralebuilding effect o f intensive active treatment, together with the use o f modified, graded progressive resistance and training during his recovery period, is o f enormous physical and psychological benefit.
Featherstone The main problem one encounters with the average sportsman is, in m y experience, that o f dissuading him from returning to sport too soon. M y com posite mental picture o f som eone suffering from a sports injury is that o f a patient, with an expression o f mixed agony and apprehension, plus a touching dash o f faith, who hobbles in hardly able to put his foot to the ground, and turns out to have a severely sprained ankle; a partial tear o f hamstring or quadriceps; or a pulled medial ligament with effusion of the knee; saying hopefully, 'I will be able to play on Satur day, w on't I?' Generally speaking, it is useless to warn a young sports man that if he does not wait until his injury is healed before returning to sport, he may, for example, injure a strained joint sufficiently badly to cause a traumatic arthritis and damage himself for life. To teenagers and those in their twenties, middle age is so far off that they cannot even envisage it, and they are quite prepared to risk a hypothetical permanent disability in their anxiety to resume playing. Consequently I usually find that the only way to restrain them is to stress the fact that they will let dow n their teams if they are not com pletely match-fit, or if they have to leave the field, or com plete the game as a passenger if the injury breaks down.

M uscle Lesions
A m ong atheletes and sportsmen, muscle lesions occur in the follow ing order o f frequency: hamstrings, quadriceps, calf, adductors, external obliques, dorsal and intercostal muscles. Tendon pulls, which usually occur at the teno-( periosteal junction, are most com m on in the tendo-calcaneus, and then the supraspinatus.
Causes. There are many theories put forward to explain the incidence o f muscle tears, but the exact cause is not yet known. Treatment. Tucker stresses that rest and strapping only, even for 2 weeks, will not cure muscle tears, which are likely to recur as soon as any strain is put on them, but with proper treatment they should be at least 80 per cent recovered in that time. Full function will have been regained and there should be no pain on ordinary normal movement, but the muscles need at least 1-2 more weeks, in which time strengthening and stretching exercises should progress and training be gradually increased, before they will be fully fit to return to sport.

Tucker believes they are due to a postural fault ; Williams thinks that a breakdown occurs in the co-ordination of the 'two-span' muscles (i.e. in the hamstrings, quadriceps and calf muscles, each o f which performs two actions), so that both prime mover and antagonist contract together, instead o f one giving way to the other. Travers c o n sid e rs that faulty technique (of which 'overstriding' is a symptom, and which he blames for hamstring tears) is the cause; and both Lloyd and Archer believe that frictional resistance is to blame, the former considering it occurs in a fully
R outine physiotherapy and hom e treatm ent are carried out, with the emphasis on obtaining a full pain-free stretch of the affected muscle. Labile faradism can be given, as long as the fibres are not over-tired, and som e authorities advocate deep frictions as the condition improves, to over come the formation o f adhesions. This I have not usually found necessary, except in the chronic 'knotty' type of muscle, as long as active exercises and gentle passive stretchings have been done from the commencement of treatment.

In the case o f a hamstring or gastrocnemius pull, I find that a Sorbo-rubber heel-lift, worn in the shoe or boot, is a great help in reducing the strain on the injured muscle fibres and in relieving pain.
In strains resistant to treatment it is always wise to have the patient, however young, checked for a toxic focusa fact stressed by Sir Adolphe Abrahams.

Contusions and H aem atom ata
The symptoms o f a haematoma are very similar to those of a muscle lesion, but there is usually a history o f a definite blow or fall. The swelling may be more diffuse, the tissues being very tender, and often function is lost. If these are not treated early, shortening o f muscles and tendons may develop and the swelling become consolidated, recovery being retarded by the clot.
Treatment. It is the opinion o f a great m any authorities that the best way to deal with large haematomas in the thigh or buttock, which will take weeks to disperse, or with those which form a fluctuant swelling on the surface o f muscles, is to aspirate or express them through a small incision.
For those not requiring aspiration, the routine first-aid and physiotherapy are given. Ice should not be used for more than 2 days, as once the clotting has been controlled the further use o f ice will make the congealed blood into a hard indissoluble m ass. I find it a good idea to keep the muscle stretched, within the limit o f pain, while applying ice and ultrasound in order to help prevent contractures.

It is important to note here that in the case o f a haema toma o f the thigh, if there is any reduction in the range o f movement, or little or no relief o f pain after a couple of treatments, the commencement o f myositis ossificans should be suspected, and the patient immediately referred back to the doctor, as physiotherapy or even active movement can encourage this condition.
The period o f disability follow ing a haematoma may be anything from a few days to 3 weeks or more, depending on the severity o f the condition and the speed with which treatment has been commenced.
•A P°int to rem em ber w hen treating a c ontusion over the Patella is th a t this m ay be follow ed by chondrom alacia Patella, because o f th e undersurface suffering a contrecoup injury.

Joint Injuries
The most com m on o f these am ong sportsmen and athletes rc knee and ankle injuries, follow ed by those to the acromio

clavicular joint. Pain and tenderness are usually less localized in a joint injury than in a muscle lesion, unless a ligament only is affected. M ovement is painful or there is a painful arc o f movement, and there may be protective spasm o f a group o f muscles. (a)
The knee jo in t. Particularly in rugby, the knee is the m ost often injured, by either direct or indirect means. Every variation is seen, including acute flexion injuries, which sprain the joint; abduction injuries, which involve medial and lateral ligaments; and rotation injuries, with displacement or tearing o f menisci and ligaments.
Traumatic synovitis is concurrent with nearly every acute knee injury, and the effusion occurs within 6 hours or there abouts. A more rapid or immediate swelling may indicate an acute traumatic haemarthrosis, which needs medical attention and aspiration at the earliest possible moment.

It is not usually necessary to aspirate traumatic effusion if the first-aid routine o f ice packs, compression bandage and rest in elevation has been carried out.
Added to routine treatment, faradism under pressure is helpful in reducing effusion, as well as for stimulating the vital quadriceps which should, if at all possible, be made stronger than they were before the injury, so as to protect the knee joint.
Fortunately the sportsman usually has a very welldeveloped quadriceps, so that he regains tone and strength rapidly, but when treating a knee it is important to pay attention to the hamstrings as well. T oo often they are neglected and become shortened during the time the sports man walks with a bent knee; consequently, after the knee injury has apparently fully recovered, the sportsman fre quently suffers a hamstring tear.
Complications to watch out for are Pellegrini's disease, which is ossification at the femoral attachment o f the medial ligament, and chondromalacia patella, in which localized tenderness develops on both sides o f the patellar tendon, and marked grating is present. If either condition is suspected, treatment should be stopped and the patient referred back to the doctor.
Specific exercises fo r knee injuries. Beware o f allowing too-early weight-bearing, weight-lifting or strenuous m obi lization on an injured knee, or there will be a recurrence o f effusion. The progression o f exercises should be gradual, and the patient should be able to do a full knee-bend without pain before being allowed to return to sport.   If pain and stiffness persist after about 8 w eeks,-adhesions have probably formed, and a m anipulation under anaesthesia will be indicated. A s adhesions take at least 2 months or longer to become avascular, however, a too-vigorous m anipulation before this time will tear fleshy vascular tissues, resulting in haemorrhage, fibrin and serum exudate and so on, and the patient will be back to square one! Specific exercises fo r ankle injuries. Added to routjne exercises are tip-toe walking; heel raising and lowering while standing on a brick to increase dorsiflexion; progressed to the same exercise carrying a weight across the shoulders; bicycling; walking up and dow n an incline board (the greater the incline, the greater the stress on the ligaments); heel raise and lower, follow ed by deep knee-bends; pushing balls o f varying weights and sizes with the foot in soft sand or water; and the normal progression from walking to jogging, skipping, stop-start running, and finally sprinting and swerving at speed.

Useful strengthening exercises for the sportsman include the use o f a weighted boot, starting at 5 lb and building up in patterns o f 10 lifts before a rest period, and progressing both in weight and number o f lifts; resisted flexion and extension against a spring, or self-resisted; stepping-up activities onto a bench, carrying a progression o f weights in the hands, or across the shoulders on a bar-bell (M ee); knee-bend and stretch, carrying a gradual increase o f weights on a bar-bell across the shoulders (Featherstone
In the treatment o f the sprained ankle, there is a marked improvement for the first few days, which is follow ed by a static period o f 3-4 days -about which the sportsman should be warned -after which there is a second rapidrecovery stage (Featherstone).
The best way o f strapping an ankle for sport is to use a stirrup o f 3-in. extension plaster, fixed, with the pull towards the side o f the injured ligament, by a figure-of-eight in 3-in. Elastoplast. This will limit inversion and eversion as well as extreme plantar flexion, but if it is too firmly applied a mid-tarsal strain may be produced when a football is kicked.

(c)
O ther injuries. I shall not discuss any other injuries, except to m ention that -again because o f the danger of adhesion form ation -all shoulder injuries should be given modified active exercises from the outset, starting with pendulum movements, but no forcible movements or manipu lations should be attempted until all pain, especially pain at night, has ceased.
It is also worth noting that in a sprained shoulder, with local swelling and pain on movement, if movements decrease in spite o f treatment or the muscles fibrillate on initiation o f movement, the patient should be referred' back to be checked for a toxic focus.

PER SO N A L FIN D IN G S
On going through my case cards for the last 6 years, I find that I have treated 585 sports and athletic injuries, o f which

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males m ake up at least 80 per cent. Seventy-six o f these cases comprised fractures, subluxations, bursitis, tenosyno vitis, and postoperative patients, and the remaining 509 cases are analysed in Table I, The treatments I use as routine are those I have already outlined, and once the acute phase has passed I am a great believer in the 'trea t and tra in ' method as advocated by Featherstone. Early intensive treatment reduces disability time greatly, the risk o f minor injuries becoming chronic due to neglect is lessened, and general fitness and morale are kept high. In Table II I have compared the average disability times o f patients who were referred immediately or within 48 hours o f injury for treatment, and those who reported after varying periods o f rest. When compiling this table I did not differentiate between mild and moderate or severe cases, so that these are over-all averages for the specific injuries mentioned. As will be seen, the time spent off training was reduced to one-third in the cases o f muscle lesions, knee-ligament injuries and sprained ankles, and to less than one-quarter in the case o f haematomas. I have been pleasantly surprised by these figures, but have, o f course, no way o f comparing them with results achieved by other methods.
Rehabilitation after injury is extremely important, and a full physical fitness test should always precede the sports man's return to full participation in his particular sport. Thus the recurrences o f muscle lesions and sprained ankles, so often seen, would be reduced, and aggravation o f existing injuries lessened. This is, o f course, the ideal condition, seldom attained with amateurs, except perhaps among schoolchildren, who are more strictly controlled by coaches on the staff, or top-flight athletes, whose trainers guard and nurse them. For the rest, it is usually left to the individual to make a decision as to when he is fit to return to sport, and the best advice one can give them is 'When in doubt, don't'.' To carry out the intensive active treatment outlined, and to return the sportsman to his particular sport as soon and m as fit a condition as possible, one needs early diagnosis and prescription o f the required drugs and treatment by a sports-minded doctor; intensive but carefully graded treat ment by the physiotherapist; the carp'ing-out o f home treatment and the perseverance with active exercises by the patient, and, ideally, co-operation o f coach or trainer. This type o f work is most rewarding, and the co-operation, enthusiasm and gratitude o f the sportsman or athlete for any assistance in his battle for recovery from injury makes him a pleasure to treat.

SU M M AR Y
Jh e isoft-tissue injuries m ost frequently occurring in sports and ahtletics are briefly discussed, and the routine active Page 7 treatments found m ost successful are outlined. The incidence o f these injuries sustained in different sporting and athletic activities am ong 509 cases treated in a 6-year period is recorded, and som e statistics o f relative disability periods are given.
There remains little doubt that the essence o f handling sports and athletic injuries is prompt diagnosis and the initiation o f early intensive active treatment, followed by a planned campaign o f rehabilitation. This could be the most easily obtained if recognized sports injury clinics were established, with the stress on full co-operation between patient, doctor, physiotherapist and coach or trainer.