1970 World Clinic
MEDICAL PROBLEMS OF SWIMMERS AND DIVERS
By Dr. Sammy Lee Santa Ana, California
When Jim Gaughran wrote to me in August asking me to participate in the American Swimming Coaches Association Clinic, I accepted on the basis that I am no authority on shoulder or knee injuries but I could speak with some knowledge on problems related to ear, nose, and throat and very little on diseases of the eye secondary to swimming. It is most difficult for a doctor who has spent more and more time learning about less and less to try and swim around in strange waters of injuries pertaining to a swimmer’s shoulders or lees. As Jim said, “Since the advent of weight training and the use of the whip kick by breaststrokers, we are seeing more and more cases of bursitis of the shoulder and knee injuries.”
To date I have been unable to find any textbook written on injuries resulting from swimming but all are oriented to football primarily. I have obtained most of my material regarding injuries from “Treatment of Injuries to Athletes, written by a Dr. O’Donoghue. He is a professor of orthopedic surgery at the University of Oklahoma Medical School.
The basic principle of treatment of any athlete is that he has prompt recovery and return to his fullest capacity as an athlete. As in any accident or disease, an ounce of prevention is worth a pound of cure. But when one does occur, it is important that when the injury occurs, the practice of “waiting and seeing” is incompatible with the first principle of treatment. Delay in examination and appraisal allows the injury to develop swelling and inflammation which tend to cloud the picture. If treatment is instituted too late, then the recovery is delayed and the possibility of permanent disability is increased. The team doctor must recognize that athletics is a part of the patient and he must do everything in his power to restore the athlete to his fullest potential. You as the swimmer’s coach must realize that when in doubt about injury, seek immediate consultation. Don’t try and sway the doctor’s medical judgment by” yours and your swimmer’s desire and enthusiasm.
You as the coach have a definite responsibility that at the time of injury you can make the following observations which will help the doctor. Observe the location of the swelling, any possible deformity, and any damage to the skin or evidence of a direct blow, by feeling the area, one can determine whether there is blood underneath the skin and whether the skin is hot or if there is tenderness or crepitation.
.By gently manipulating and checking the range of free motion, the location of pain on motion and significant instability or abnormal motion can be noted at this time.
Contusions are from direct blows against the skin causing a bruising and swelling of the underlying tissue which results from capillary ruptures a d amount of blood that seeps under the skin and subcutaneous tissues. This is best treated by application of cold and pressure bandages in the early stages together with immobilization protection to prevent further injuries. The principle of cold is to prevent further sub capillary bleeding. This is usually followed by local heat, rest and protection to the injured part. Naturally I would assume that if it is questionable as to the degree of injury, it will be in the hands of your team doctor who may resort to injecting hyaluronidase into the area to hasten rapid absorption.
Rehabilitation should begin slowly, and the amount and degree of rehabilitation is proportional to the amount of pain that occurs when the swimmer attempts to participate in his training. He must be honest to himself, to you and to the physician because if he continues to train when he is in pain he is further injuring himself. If the hematoma involves a muscle or joint the mobility can be resumed within the limits of pain almost at once, since voluntary pain free contraction helps in the absorption
of blood. The improper treatment of the contusion or hematoma may result in myositis ossificans. The inflammation of the muscle is followed by ossification and one will notice a simple overgrowth of this calcified replacement, When this occurs; the treatment is not surgical but preventive.
When such a condition is impending it is best to put the muscle at rest and rehabilitation again carried out within the limits of pain at least for the first several months. During the early stages of myositis ossificans around the long bone there have been some tragedies. An early biopsy can show early cellular changes which cannot be distinguished from cancer.
This is usually ruled out by repeat X rays at two week intervals. Myositis will show a diminution of the calcium around the margins and is quite different from an osteogenic type tumor. An operation for the purpose of a biopsy could even be disastrous and a few weeks delay probably would be of little importance in the development of an osteogenic tumor. Strain is the result of overuse or overstress of a muscle causing damage to the muscle itself or its tendon, It is most important to distinguish between a strain and a sprain. A strain of a tendon could consist of anything from minor irritation to near complete tearing of a tendon from its attachment. Strain of a muscle includes those of overuse and overstretching short of an actual muscle rupture either from a forcible avulsion or from a direct blow. A sprain refers to ligaments.
In simple strains there is no appreciable hemorrhage, and a diagnosis is based on testing the muscle function and pain location. Treatment is usually physiotherapy consisting of heat, and possible injecting with local anesthetic and cortisone. Unfortunately strains have a tendency to recur. A violent strain can result in complete separation and pulling apart of the muscle, One should consult with the orthopedic specialist because if there is a complete avulsion then immediate surgical repair can be extremely gratifying. Later surgical repair may be impossible.
A sprain is an injury to a ligament resulting from over-stress which causes tearing of ligament fibers or their attachment. A ligament is a structure designed to prevent abnormal motion of a joint while permitting functional motion.
A mild strain is when a few fibers are torn with no loss of function but weakened, A moderate sprain is when some portion of the ligament is ripped and some degree of function is lost. If damage is severe, there is a complete loss of function due to the ligament being completely torn or separated. In this case efficient repair is dependent on suturing together the torn edges.
A dislocation is an actual displacement of the opposing contiguous surfaces making up a joint. This means a loss of function in some of the ligament structures of the joint since the ligaments are designed to prevent displacement or abnormal motion. Subluxation is partial dislocation. Since dislocation is a simple end result of a severe sprain it can be treated as such. Dr. O’Donoghue states that dislocations are under-treated and as a result, notoriously end in poor results. A minimum of six weeks is needed for a ligament to repair under ideal conditions.
Bursitis is defined as an inflammatory reaction within a bursa and naturally there are various degrees of bursitis from irritation to actual abscess formation. All bursa are designed to facilitate motion between contiguous layers of the human body, and the athlete with his extremes of motion is particularly prone to bursitis either from repeated trauma from direct blows or from tissue friction. Treatment of shoulder and knee bursitis is toward its prevention, however, the orthopod might have to aspirate the fluid, give a local injection of cortisone, and apply a pressure bandage to protect the walls of the sac. If condition becomes chronic then removal of bursa may be needed.
The glenohumeral joint is commonly known as the shoulder joint. It has so many structures making up the foundation of this joint and each ligament arid muscle functions differently under different stresses; It is structurally a modified ball and socket joint without bony stability in contrast to the hip joint which is stable but not mobile. The major bursae about the shoulder are the sub acromial and the subscapular. However, generally speaking, whenever a swimmer complains of pain whenever he moves his arm away from the chest wall, and has tenderness of the tuberosity (shoulder point), and pain on rotation of his shoulder, he has a bursitis.
What is the treatment besides committing hari-kari when it is your star breaststroker? It is best treated by rest and local heat using wet packs, radiant lamp or diathermy. It may not subside rapidly enough for you or the swimmer, but if he continues to work out and ignores the pain, he will have a chronic condition necessitating surgery. Again I stress the importance of the swimmer, the coach, and the doctor working together as a team. The swimmer must not put out beyond the non-painful effort, and the coach must rely on his statements, “it doesn’t hurt” when pulling, and the doctor must be sympathetic and yield to some degree but not far enough to jeopardize the athlete’s future.
The most vulnerable joint in the body from the standpoint of athletic injury, is the knee joint, It is a hinge joint and a gliding joint. The femoral condyle rolls over the saucers of the tibial plateau which are slightly deepened by the semilunar cartilages. It is protected posteriorly by ligaments that prevent overextension of the joint and also lateral ligaments that prevents lateral motion. Anteriorly it is supported by the quadriceps.
It is beyond my ability and knowledge to go into the anatomy of the knee and shoulder but when ever there is an injury to the knee there is usually swelling, and tenderness. It is always safer to treat every knee injury as a serious one. Place on cold packs to reduce bleeding and swelling. Consult with the orthopedic surgeon who may have to aspirate the blood clots, or inject hyaluronidase (an enzyme to increase absorption). Strains involving the extensor mechanism cause pain when one tries to straighten out the leg against pressure or against resistance. The swimmer will notice some pain on squatting or doing a kick. Even though this isn’t disabling it does lessen his efficiency. What is the treatment of a knee strain? First eliminate the function of the muscles involved, and in some cases this will require the use of a splint
a splint; in others, merely the avoidance of strenuous activity. Use of a diathermy, whirl pool baths, hot packs, etc. can all be useful. In the final analysis, a relatively severe strain of the tendons about the knee means non-participation in any form of activity which will produce further trauma to the joint,
Common terms we hear in back injuries are usually congenital deformities. They are common in the lower back, specifically from L4, L5 and Sl. These congenital deformities usually are not caused by injuries but are a problem to the athletes nee after its discovery; one must be able to advise him whether he can continue his particular athletic interest, Spina bifida occult means a failure of fusion of the arch of one or more vertebrae posteriorly. It is not reason enough to quit swimming, or even football.
Spondylolysis or spondylolisthesis is a failure of the vertebral arch and usually occurs between the articular processes, Spondylolistheses is spondylolysis where there is displacement of ruptured vertebrae forward on the one below it. Laminal defect causes weakness of the spine but of an extremely variable nature. Many of us have it and we don’t know about it. The condition does not limit your activities unless it produces symptoms,
Head injuries unfortunately occur whenever a diver strikes the board, or by careless running on a pool deck. The immediate problem is to see whether the injured is breathing, and if not, to institute emergency measures such as mouth to mouth resuscitation, I need not add that one should be sure there is no blood or mucous blocking the nasopharynx or oral pass ages, One should notice whether he has lost consciousness, and if he is to ask him questions pertaining to current events to see if he is oriented, If there is bleeding about the scalp, usually pressure will stop the bleeding, how ever, if one sees blood escaping from ears, nose or throat, it would be wise to send him to the hospital. I assume that you will take the necessary precaution of immobilizing his head and neck if you suspect possible neck injury.
Shock must always be foremost in one’s mind and it is characterized by rapid respirations and a reduction of pulse pressure. When adequate air way has been established, the patient’s head should be lower than the rest of his body with his legs elevated moderately, Turn his head to the side so that the mouth will be in a dependent position, After you have taken care of the emergency, then the injured is in the hands of the doctor and hospital, Before I take the “Bridge over Troubled Waters” into a pool more my depth, I would like to say something about muscle cramps or spasms. The cause is confusing to the medical field as well as to you since there are many. A few causes include a direct blow to the muscle, or over stretching of the muscle, or loss of salt from excess perspiration which causes the muscle to cramp. It can be due to sudden changes in temperature, and even dietary considerations. One of the causes can be due to too tight a uniform which can cause decreased circulation and over fatigue, Its treatment is usually by the athlete himself who applies local pressure to the spastic muscle and tries to force it through a normal range of motion. You apply a steady, traumatic local pressure to the muscle by simply trying to stretch it. If the swimmer needs help in relaxing a muscle the principle of passive manipulation applied steadily without a jerk or pulling because excessive manipulation can result in tearing the muscle. Diathermy, whirl pool baths, and infrared heat to the muscle can help relax the cramp, Dr. O’Donoghue does not advocate a marked kneading or pounding of the muscle.
As I am crossing over the bridge of troubled waters I suddenly realized that this dissertation would not be complete without my mentioning one of the oldest diseases of man venereal diseases disabling your star performer, If he or she suddenly develops a very painful and sore knee, warm to touch, and may have run a febrile course similar to the flu with generalized joint and muscle aches a week or so prior to having arthritic like pains in his knee you had better have a fatherly man to man talk with him and have him see a physician immediately, In this modern era of the pill and the rebellion of youth, they forget that modern antibiotics has not eliminated venereal. diseases. Unfortunately gonorrhea and syphilis are making a fantastic comeback and it is getting almost epidemic in proportion. When you have the responsibility of being· either a coach or manager, or chaperone for an American team travelling abroad, one must be cognizant of the fact that antibiotics such as penicillin can be bought over the counter without prescription by anyone. Most of those who contract syphilis or gonorrhea treat themselves and take the medication self-administered and feel that since they no longer have the symptoms are free of disease,
Unfortunately they have killed only part of the infection and those that survive are now resist ant to penicillin or whatever medicine they have taken. So when one of our boys or girls get it from one of these people and gets one of those strains, it is most difficult to treat and also insidious in onset if he too takes an inadequate amount of the specific antibiotics. If someone gets the typical symptoms of burning on urination, yellow discharge from his urethra then he had better be checked thoroughly before coming home, and even after he does come home he should have a blood check some four weeks, then eight weeks after the exposure to make sure he did not get more than gonorrhea or syphilis, I have been amazed at the number of cases who have positive blood since the hospital is now doing routine serological tests on all admissions now. They cannot recall ever having the primary chancre or the clap or any symptoms suspicious of V.D.
What about the effects of swimming on the eyes? There are three categories according to the ophthalmologist, The most common is IRRITATION. It is a chemical irritation from the chlorine or salt water. Characteristically it is a diffuse vascular injection of the conjunctiva. This distinguishes it from a foreign body which is usually a deeper purplish red and surrounds the cornea. Treatment is relatively simple by using Vision Regular eye drops and also other nonprescription over the counter eye drops as Zinc, Prefrin, and Visine.
The next most common condition of the eye is INCLUSION CONJUNCTIVITIS commonly referred to as swimming pool conjunctivitis” and it is viral in origin. The eye has a thick pus-like tearing, whereas a gonococcal conjunctivitis is a more pebbly and bumpy appearance of the lower lid,
TRAUMA occurs primarily in that species referred to as fancy divers and water polo players. Following an injury there is a diffuse subconjunctival hemorrhage involving part or the entire eye but not interfering with one’s vision. This usually looks worse than it feels. It can come on even after a violent sneeze.
RETINAL DETACHMENT is unusual but when it does occur, the injured may see thru a veil or see partially, Naturally I will assume that all of us here are intelligent enough to know that when in doubt, send your swimmer or diver to the proper specialist,
What would I do when one of my patients says, 11I have a head cold, can I work out?” My immediate answer· would be “no,” not during the first 48 to 72 hours. Why? Because it may be a prodromal of a severe infection such as the flu, measles, mumps and workig out could lead to sinusitis, bronchitis, or middle ear infection (otitis media). So instead of losing only three days, you might lose a month or the entire season. If your swimmer says his nose is constantly congested after working out, I would have him evaluated by a specialist. He might find a deformed nasal septum, allergy, or a chronic infection. If allergic to the water, a nose clip might help. Eliminate possible allergies to food such as milk, whole wheat, chocolates by the provocative food tests. Take one away fora month then let him start back on it. His nose and sinuses will tell you whether he has a food allergy.
What about the one who has a constant sore throat and has to be on antibiotics for repeated tonsillitis? I would advise he consult a doctor as he may need his tonsils out. If he does, don’t plan on his being up to par for workouts for at least three weeks. It is one of the most painful periods of any surgical procedure known to man. I know from personal experience.
The so called SWIMMER’S EAR is usually told to discontinue swimming until the pain subsides and he is given ear drops, He hits the water and within a week your swimmer again complains of an earache. This is called TENDERNESS EXTERNAL. I have found that most of these cases are due to the doctor’s not cleaning out the excess debris that collects inside the ear canal. It just sits there and continuously keeps the ear canal moist and becomes a breeding ground for infection. It is like never wiping the toe jam between your toes, then trying to apply athlete’s foot powder on it over a dirty sock. It takes time to carefully de-epithelize the ear canal of all the dead skin by not just irrigating the ear canals but vacuuming and pulling the debris out. For the one-half faint I advise the swimmer to use at least 90 percent alcohol, Isopropyl is all right too. You can’t drink it but you can pour it into the ear canal.
What about the water polo player or diver who breaks an ear drum especially just before the championship game? Generally speaking it is not a catastrophe. If one uses an ear plug fitted properly he can continue his workouts and training providing there is no secondary infection resulting from a middle ear and possible mastoiditis. Again in the average case, the eardrum is healed within a month, and it is good as new. It is best that he see an ear specialist as soon as it happens because under the microscope we can pick up the torn edges and allow it to heal more rapidly. Even if over 50 percent of the eardrum is gone, it can heal spontaneously.
There is also the swimmer who constantly complains of an earache despite getting clearance from his team physician, coach and ear specialist. If he notes that it is worse in cold water, or when the wind is blowing, then you may be dealing with an athlete who has a TEMPER MANDIBULAR JOINT SYNDROME. His bite is incorrect and usually you can elicit the pain by placing your fingers in his ear canal and have him open and close his mouth and one can hear and feel a painful audible click. Send him to a knowledgeable dentist who mows about this.
We are now encountering NERVE TYPE HEARING LOSSES secondary to SCUBA DIVING. It is similar to the type loss we find in those who are around loud noises or weapon’s firing. A too rapid descent causes an increased amount of pressure thereby retracting the eardrum driving the stapes down too deeply into the oval window and too much pressure in the inner ear fluid injures the fine hair cells in the cochlea. It can also happen on improper ascent from depths. It is like the bends, but limited to the inner ear thereby producing irreparable nerve damage. The lesser of the two evils is to get a perforated eardrum. In most cases this can be taken care of by mother nature or by surgical means.
Neck injuries can occur in diving or by some idiot diving into the shallow end of the pool. As in all head injuries from foolishness around the pool deck, it is you who will have to see that the injured has a proper airway, and to see that there is no further injury by not immobilizing his head when he is moved. I have heard of only one known case of a diver being paralyzed while diving and that was when he dove into the pool from the 10 meter without warming up and snapped .his neck. It is best to teach divers to grasp their hands over their head to poke a hole in the water whether diving from the tower or springboard and catch the bottom of the pool. Dr. Schneider, the neurosurgeon from Michigan, surveyed all the divers from Acapulco and found that those divers, who grasped their hands and punctured the surface of the water as they made their entry, had no chipped lateral processes of their vertebrae or any arthritic Changes in their neck.
(Talk given at 1970 ASCA Clinic)