ENERGY

The Body's Healing Process

From the moment a bone breaks or a ligament tears, your body goes to work to repair the damage. Here's what happens at each stage of the healing process:

At the moment of injury: Chemicals are released from damaged cells, triggering a process called inflammation. Blood vessels at the injury site become dilated; blood flow increases to carry nutrients to the site of tissue damage.

Within hours of injury: White blood cells (leukocytes) travel down the bloodstream to the injury site where they begin to tear down and remove damaged tissue, allowing other specialized cells to start developing scar tissue.

Within days of injury: Scar tissue is formed on the skin or inside the body. The amount of scarring may be proportional to the amount of swelling, inflammation, or bleeding within. In the next few weeks, the damaged area will regain a great deal of strength as scar tissue continues to form.

Within a month of injury: Scar tissue may start to shrink, bringing damaged, torn, or separated tissues back together. However, it may be several months or more before the injury is completely healed.

Who Should I See for My Injury?

While severe injuries will need to be seen immediately in an emergency room, particularly if they occur on the weekend or after office hours, most sports injuries can be evaluated and, in many cases, treated by your primary health care provider.

Depending on your preference and the severity of your injury or the likelihood that your injury may cause ongoing, long-term problems, you may want to see, or have your primary health care professional refer you to, one of the following:

	Orthopaedic surgeon: A doctor specializing in the diagnosis and treatment of the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.
	Physical therapist/physiotherapist: A health care professional who can develop a rehabilitation program. Your primary care physician may refer you to a physical therapist after you begin to recover from your injury to help strengthen muscles and joints and prevent further injury.

How Are Sports Injuries Treated?

Although using the RICE technique described previously can be helpful for any sports injury, RICE is often just a starting point. Here are some other treatments your doctor or other health care provider may administer, recommend, or prescribe to help your injury heal.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

The moment you are injured, chemicals are released from damaged tissue cells. This triggers the first stage of healing: inflammation (see "The Body's Healing Process" box). Inflammation causes tissues to become swollen, tender, and painful. Although inflammation is needed for healing, it can actually slow the healing process if left unchecked.

To reduce inflammation and pain, doctors and other health care providers often recommend taking an over-the-counter (OTC) nonsteroidal anti-inflammatory drug (NSAID) such as aspirin, ibuprofen (Advil1, Motrin IB, Nuprin), ketoprofen (Actron, Orudis KT), or naproxen sodium (Aleve). For more severe pain and inflammation, doctors may prescribe one of several dozen NSAIDs available in prescription strength.2

1 Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

2 Like all medications, NSAIDs can have side effects. The list of possible adverse effects is long, but major problems are few. The intestinal tract heads the list with nausea, abdominal pain, vomiting, and diarrhea. Changes in liver function frequently occur in children (but not in adults) who use aspirin. Changes in liver function are rare in children using the other NSAIDs. Questions about the appropriate use of NSAIDs should be directed toward your health care provider or pharmacist.

Though not an NSAID, another commonly used OTC medication, acetaminophen (Tylenol), may relieve pain. It has no effect on inflammation, however.

Immobilization

Immobilization is a common treatment for sports injuries that may be done immediately by a trainer or paramedic. Immobilization involves reducing movement in the area to prevent further damage. By enabling the blood supply to flow more directly to the injury (or the site of surgery to repair damage from an injury), immobilization reduces pain, swelling, and muscle spasm and helps the healing process begin. Following are some devices used for immobilization:

Slings, to immobilize the upper body, including the arms and shoulders.

Splints and casts, to support and protect injured bones and soft tissue. Casts can be made from plaster or fiberglass. Splints can be custom made or ready made. Standard splints come in a variety of shapes and sizes and have Velcro straps that make them easy to put on and take off or adjust. Splints generally offer less support and protection than a cast, and therefore may not always be a treatment option.

Leg immobilizers, to keep the knee from bending after injury or surgery. Made from foam rubber covered with fabric, leg immobilizers enclose the entire leg, fastening with Velcro straps.

Surgery

In some cases, surgery is needed to repair torn connective tissues or to realign bones with compound fractures. The vast majority of sports injuries, however, do not require surgery.

Rehabilitation (Exercise)

A key part of rehabilitation from sports injuries is a graduated exercise program designed to return the injured body part to a normal level of function.

With most injuries, early mobilization - getting the part moving as soon as possible - will speed healing. Generally, early mobilization starts with gentle range-of-motion exercises and then moves on to stretching and strengthening exercise when you can without increasing pain. For example, if you have a sprained ankle, you may be able to work on range of motion for the first day or two after the sprain by gently tracing letters with your big toe. Once your range of motion is fairly good, you can start doing gentle stretching and strengthening exercises. When you are ready, weights may be added to your exercise routine to further strengthen the injured area. The key is to avoid movement that causes pain.

As damaged tissue heals, scar tissue forms, which shrinks and brings torn or separated tissues back together. As a result, the injury site becomes tight or stiff, and damaged tissues are at risk of reinjury. That's why stretching and strengthening exercises are so important. You should continue to stretch the muscles daily and as the first part of your warm-up before exercising.

When planning your rehabilitation program with a health care professional, remember that progression is the key principle. Start with just a few exercises, do them often, and then gradually increase how much you do. A complete rehabilitation program should include exercises for flexibility, endurance, and strength; instruction in balance and proper body mechanics related to the sport; and a planned return to full participation.

Throughout the rehabilitation process, avoid painful activities and concentrate on those exercises that will improve function in the injured part. Don't resume your sport until you are sure you can stretch the injured tissues without any pain, swelling, or restricted movement, and monitor any other symptoms. When you do return to your sport, start slowly and gradually build up to full participation. For more advice on how to prevent injuries as you return to active exercise, see the "Tips for Preventing Injury" box.

Rest

Although it is important to get moving as soon as possible, you must also take time to rest following an injury. All injuries need time to heal; proper rest will help the process. Your health care professional can guide you regarding the proper balance between rest and rehabilitation.

Other Therapies

Other therapies commonly used in rehabilitating sports injuries include:

Electrostimulation: Mild electrical current provides pain relief by preventing nerve cells from sending pain impulses to the brain. Electrostimulation may also be used to decrease swelling, and to make muscles in immobilized limbs contract, thus preventing muscle atrophy and maintaining or increasing muscle strength.

Cold/cryotherapy: Ice packs reduce inflammation by constricting blood vessels and limiting blood flow to the injured tissues. Cryotherapy eases pain by numbing the injured area. It is generally used for only the first 48 hours after injury.

Heat/thermotherapy: Heat, in the form of hot compresses, heat lamps, or heating pads, causes the blood vessels to dilate and increase blood flow to the injury site. Increased blood flow aids the healing process by removing cell debris from damaged tissues and carrying healing nutrients to the injury site. Heat also helps to reduce pain. It should not be applied within the first 48 hours after an injury.

Ultrasound: High-frequency sound waves produce deep heat that is applied directly to an injured area. Ultrasound stimulates blood flow to promote healing.

Massage: Manual pressing, rubbing, and manipulation soothe tense muscles and increase blood flow to the injury site.

Most of these therapies are administered or supervised by a licensed health care professional.

Who Is at Greatest Risk for Sports Injuries?

If a professional athlete dislocates a joint or tears a ligament, it makes the news. But anyone who plays sports can be injured. Three groups—children and adolescents, middle-aged athletes, and women—are particularly vulnerable.

Children and Adolescents

While playing sports can improve children's fitness, self-esteem, coordination, and self-discipline, it can also put them at risk for sports injuries: some minor, some serious, and still others that may result in lifelong medical problems.

Young athletes are not small adults. Their bones, muscles, tendons, and ligaments are still growing and that makes them more prone to injury. Growth plates—the areas of developing cartilage where bone growth occurs in growing children—are weaker than the nearby ligaments and tendons. As a result, what is often a bruise or sprain in an adult can be a potentially serious growth-plate injury in a child. Also, a trauma that would tear a muscle or ligament in an adult would be far more likely to break a child's bone.

Because young athletes of the same age can differ greatly in size and physical maturity, some may try to perform at levels beyond their ability in order to keep up with their peers.

Injuries in Kids, by Sport

Children aged 5 through 14 sustained an estimated 2.38 million sports and recreational injuries annually from 1997 through 1999. By sport, this number includes the following:

Pedal cycling                       332,000 injuries
Basketball                             261,000 injuries
Football                                 243,000 injuries
Playground equipment        219,000 injuries
Baseball/softball                  185,000 injuries

Source: National Health Interview Survey

Contact sports have inherent dangers that put young athletes at special risk for severe injuries. Even with rigorous training and proper safety equipment, youngsters are still at risk for severe injuries to the neck, spinal cord, and growth plates. Evaluating potential sports injuries on the field in very young children can involve its own special issues for concerned parents and coaches. Some helpful hints are presented in the Appendix.

Adult Athletes

More adults than ever are participating in sports. Many factors contribute to sports injuries as the body grows older. The main one is that adults may not be as agile and resilient as they were when they were younger. It is also possible that some injuries occur when a person tries to move from inactive to a more active lifestyle too quickly.

Women

More women of all ages are participating in sports than ever before. In women's sports, the action is now faster and more aggressive and powerful than in the past. As a result, women are sustaining many more injuries, and the injuries tend to be sport specific.

Injuries in Adults, by Sport

Adults age 25 and over sustained an estimated 2.29 million sports and recreational injuries annually from 1997 through 1999. By sport, this number includes the following:

Recreational sports*             370,000 injuries
Exercising                              331,000 injuries
Basketball                              276,000 injuries
Pedal cycling                         231,000 injuries
Baseball/softball                   205,000 injuries

Source: National Health Interview Survey
*Includes racquet sports, golf, bowling, hiking, and other leisure sports.

Female athletes have higher injury rates than men in many sports, particularly basketball, soccer, alpine skiing, volleyball, and gymnastics. Female college basketball players are about six times more likely to suffer a tear of the knee's anterior cruciate ligament (ACL) than men are, according to a study of 11,780 high school and college players. Information on injuries collected since 1982 by the National Collegiate Athletic Association shows that female basketball and soccer players have a much higher incidence of ACL injuries than their male counterparts.

Previous assumptions that methods of training, risks of participation, and effects of exercise are the same for men and women are being challenged. Scientists are working to understand the gender differences in sports injuries.

While poor conditioning has not been related to an increased incidence of ACL injuries specifically, it has been associated with an increase in injuries in general. For most American women, the basic level of conditioning is much lower than that of men. Studies at the U.S. Naval Academy revealed that overuse injuries were more frequent in women; however, as women became used to the rigors of training, the injury rates for men and women became similar.

Aside from conditioning level, other possible factors in women's sports injuries include structural difference of the knee and thigh muscles, fluctuating estrogen levels caused by menstruation, the fit of athletic shoes, and the way players jump, land, and twist. Also, "the female triad," a combination of disordered eating, curtailed menstruation (amenorrhea), and loss of bone mass (osteoporosis), is increasingly more common in female athletes in some sports. Its true prevalence is unknown, but it appears to be greater in athletes, adolescents, and young adults, especially in people who are perfectionists and overachievers.

Scientists trying to better understand sports injuries in women met in June 1999 for a workshop sponsored jointly by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Academy of Orthopaedic Surgeons. The workshop proceedings were published in a book titled Women's Health in Sports & Exercise, edited by William Garrett, M.D., Ph.D., and Gayle Lester, Ph.D. The book may be purchased from the American Academy of Orthopaedic Surgeons (www.aaos.org).

What Can Groups at High Risk Do to Prevent Sports Injuries?

Anyone who exercises is potentially at risk for a sports injury and should follow the injury prevention tips. But additional measures can be taken by groups at higher risk of injury.

Children

Preventing injuries in children is a team effort, requiring the support of parents, coaches, and the kids themselves. Here's what each should do to reduce injury risk.

What parents and coaches can do:

Try to group youngsters according to skill level and size, not by chronological age, particularly during contact sports. If this is not practical, modify the sport to accommodate the needs of children with varying skill levels.

Match the child to the sport, and don't push the child too hard into an activity that she or he may not like or be physically capable of doing.

Try to find sports programs where certified athletic trainers are present. These people, in addition to health care professionals, are trained to prevent, recognize, and give immediate care to sports injuries.

See that all children get a preseason physical exam.

Don't let (or insist that) a child play when injured. No child (or adult) should ever be allowed to work through the pain.

Get the child medical attention if needed. A child who develops any symptom that persists or that affects athletic performance should be examined by a health care professional. Other clues that a child needs to see a health professional include inability to play following a sudden injury, visible abnormality of the arms and legs, and severe pain that prevents the use of an arm or leg.

Provide a safe environment for sports. A poor playing field, unsafe gym sets, unsecured soccer goals, etc., can cause serious injury to children.

What children can do:

Be in proper condition to play the sport. Get a preseason physical exam.

Follow the rules of the game.

Wear appropriate protective gear.

Know how to use athletic equipment.

Avoid playing when very tired or in pain.

Make warm-ups and cool downs part of your routine. Warm-up exercises, such as stretching or light jogging, can help minimize the chances of muscle strain or other soft tissue injury. They also make the body's tissues warmer and more flexible. Cool down exercises loosen the muscles that have tightened during exercise.

Tips for Preventing Injury

Whether you've never had a sports injury and you're trying to keep it that way or you've had an injury and don't want another, the following tips can help.

	Avoid bending knees past 90 degrees when doing half knee bends.
	Avoid twisting knees by keeping feet as flat as possible during stretches.
	When jumping, land with your knees bent.
	Do warm-up exercises not just before vigorous activities like running, but also before less vigorous ones such as golf.
	Don't overdo.
	Do warm-up stretches before activity. Stretch the Achilles tendon, hamstring, and quadriceps areas and hold the positions. Don't bounce.
	Cool down following vigorous sports. For example, after a race, walk or walk/jog for five minutes so your pulse comes down gradually.
	Wear properly fitting shoes that provide shock absorption and stability.
	Use the softest exercise surface available, and avoid running on hard surfaces like asphalt and concrete. Run on flat surfaces. Running uphill may increase the stress on the Achilles tendon and the leg itself.

Adult Athletes

To prevent injuries, adult athletes should take the following precautions:

	Don't be a "weekend warrior," packing a week's worth of activity into a day or two. Try to maintain a moderate level of activity throughout the week.
	Learn to do your sport right. Using proper form can reduce your risk of "overuse" injuries such as tendinitis and stress fractures.
	Remember safety gear. Depending on the sport, this may mean knee or wrist pads or a helmet.
	Accept your body's limits. You may not be able to perform at the same level you did 10 or 20 years ago. Modify activities as necessary.
	Increase your exercise level gradually.
	Strive for a total body workout of cardiovascular, strength training, and flexibility exercises. Cross-training reduces injury while promoting total fitness.

Women

Increased emphasis on muscle strength and conditioning should be a priority for all women. Women should also be encouraged to maintain a normal body weight and avoid excessive exercise that affects the menstrual cycle. In addition, women should follow precautions listed above for other groups.

What Are Some Recent Advances in Treating Sports Injuries?

Today, the outlook for an injured athlete is far more optimistic than in the past. Sports medicine has developed some near-miraculous ways to help athletes heal and, in most cases, return to sports. Following are some procedures that have greatly advanced the treatment of sports injuries:

Arthroscopy

Most doctors agree that the single most important advance in sports medicine has been the development of arthroscopic surgery, or arthroscopy. Arthroscopy uses a small fiberoptic scope inserted through a small incision in the skin to see inside a joint. It is primarily a diagnostic tool, allowing surgeons to view joint problems without major surgery. Depending on the problem found, surgeons may use small tools inserted through additional incisions to repair the damage, such as a torn meniscus or a torn ligament that fails to heal naturally. Using arthroscopy, for example, a surgeon may reattach the torn ends of a ligament or reconstruct the ligament by using a piece (graft) of healthy ligament from the patient or from a cadaver.

Because arthroscopy uses tiny incisions, it results in less trauma, swelling, and scar tissue than conventional surgery, which in turn decreases hospitalization and rehabilitation times. Problems can be diagnosed earlier and treated without serious health risks or more invasive procedures. Furthermore, because injuries are often addressed at an earlier stage, operations are more likely to be successful.

Tissue Engineering

When joint cartilage is damaged by an injury, it doesn't heal on its own the way other tissues do. In recent years, however, the field of sports medicine and orthopaedic surgery has begun to develop techniques such as transplantation of one's own healthy cartilage or cells to improve healing. At present, this technique is used for small cartilage defects. Questions remain about its usefulness and cost.

Targeted Pain Relief

For people with painful sports injuries, new pain-killing medicated patches can be applied directly to the injury site. The patch is an effective method of delivering pain relief, especially for many people who prefer to put their pain medication exactly where it's needed rather than throughout their entire system.

What Advances Might We Expect in the Future?

Recent advances in treating sports injuries are likely to be just the beginning. Watch for developments in these areas in the not-too-distant future:

	The need for surgery may decline as improved rehabilitation techniques lead to a more "natural" progression to recovery for more musculoskeletal injuries.
	Technical advances and new imaging methods will lead to better ways to diagnose and treat injuries.
	Scientists will gain a better understanding of the role of nutrition in inflammation and healing. Such knowledge could lead to improvements in treatment.
	Tissue engineering will become more commonplace. Early studies of cartilage tissue engineering are now underway.
	Using gene therapy, doctors may be able to modify particular cells to induce repair of injured tissues.

Where Can People Find More Information About Sports Injuries?

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
(301) 495-4484 or (877) 22-NIAMS (free of charge)
TTY: (301) 565-2966
Fax: (301) 718-6366
niamsinfo@mail.nih.gov
http://www.niams.nih.gov

NIAMS provides information about various forms of arthritis and rheumatic disease and bone, muscle, joint, and skin diseases. It distributes patient and professional education materials and refers people to other sources of information. Additional information and updates can also be found on the NIAMS Web site.

American Academy of Orthopaedic Surgeons (AAOS)
PO Box 2058
Des Plaines, IL 60017
(800) 824-BONE (2663) (free of charge)
http://www.aaos.org

The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.

American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1098
(847) 434-4000
Fax: (847) 434-8000
http://www.aap.org

The American Academy of Pediatrics (AAP) and its member pediatricians dedicate their efforts and resources to the health, safety, and well-being of infants, children, adolescents, and young adults. Activities of the AAP include advocacy for children and youth, public education, research, professional education, and membership service and advocacy for pediatricians.

American College of Sports Medicine
PO Box 1440
Indianapolis, IN 46206-1440
(317) 637-9200
Fax: (317) 634-7817
http://www.acsm.org

The American College of Sports Medicine is the largest sports medicine and exercise science organization in the world. Nearly 18,500 members throughout the U.S. and the world are dedicated to promoting and integrating scientific research, education, and practical applications of sports medicine and exercise science to maintain and enhance physical performance, fitness, health, and quality of life.

American Medical Society for Sports Medicine (AMSSM)
11639 Earnshaw
Overland Park, KS 66210
(913) 327-1415
Fax: (913) 327-1491
http://www.amssm.org

The society fosters a collegial relationship among dedicated, competent sports medicine specialists and provides a quality educational resource for members, other sports medicine professionals, and the public.

American Orthopaedic Society for Sports Medicine
6300 N. River Road, Suite 500
Rosemont, IL 60018
(847) 292-4900
Fax: (847) 292-4905
http://www.sportsmed.org

The society is an organization of orthopaedic surgeons and allied health professionals dedicated to educating health care professionals and the general public about sports medicine. It promotes and supports educational and research programs in sports medicine, including those concerned with fitness, as well as programs designed to advance our knowledge of the recognition, treatment, rehabilitation, and prevention of athletic injuries.

American Physical Therapy Association
1111 North Fairfax Street
Alexandria, VA 22314-1488
(703) 684-2782 or (800) 999-2782 (free of charge)
Fax: (703) 684-7343
http://www.apta.org

The association is a national professional organization of physical therapists, physical therapist assistants, and physical therapy students. Its objectives are to improve physical therapy practice, research, and education to promote, restore, and maintain optimal physical function, wellness, fitness, and quality of life, especially as it relates to movement and health.

National Athletic Trainers Association
2952 Stemmons Freeway
Dallas, TX 75247-6916
(800) TRY-NATA (800-879-6282) (free of charge)
Fax: (214) 637-2206
http://www.nata.org

The association enhances the quality of health care for athletes and those engaged in physical activity. It also advances the profession of athletic training through education and research in the prevention, evaluation, management, and rehabilitation of injuries.

Appendix

Traumatic Brain and Spinal Cord Injuries

Traumatic brain injury (TBI) occurs when a sudden physical assault on the head causes damage to the brain. A closed injury occurs when the head suddenly and violently hits an object, but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters the brain tissue.

Several types of traumatic injuries can affect the head and brain. A skull fracture occurs when the bone of the skull cracks or breaks. A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain. This can cause bruising of the brain tissue, called a contusion. A contusion can also occur in response to shaking of the brain within the confines of the skull. Damage to a major blood vessel within the head can cause a hematoma, or heavy bleeding into or around the brain. The severity of a TBI can range from a mild concussion to the extremes of coma or even death.

What to do: For anything more than the most super-ficial injury, call for emergency medical assistance immediately. Observe symptoms so that you can report when help arrives. Do not allow the person to continue the activity. In more serious cases, do not move the person unless there is danger.

Spinal cord injury (SCI) occurs when a traumatic event results in damage to cells in the spinal cord or severs the nerve tracts that relay signals up and down the spinal cord. The most common types of SCI include contusion (bruising of the spinal cord) and compression (caused by pressure on the spinal cord). Other types include lacerations (severing or tearing of nerve fibers) and central cord syndrome (specific damage to the cervical region of the spinal cord).

What to do: In some cases, drugs called corticosteroids can minimize cell damage from a spinal cord injury. To be effective, they must be given within 8 hours of the injury. For this reason, it is important to call for emergency medical assistance immediately. Any person suspected of sustaining such a spinal cord injury should not be moved unless it is absolutely essential to keep the airway open so the person can breathe or to maintain circulation.

For more information, visit the Web site of the National Institute of Neurological Disorders and Stroke at http://www.ninds.nih.gov/ or call (800) 352-9424.

Bruises

A bruise, or muscle contusion, can result from a fall or from contact with a hard surface, a piece of equipment, or another player while participating in sports. A bruise results when muscle fiber and connective tissue are crushed; torn blood vessels may cause a bluish appearance. Most bruises are minor, but some can cause more extensive damage and complications.

What to do: Put the muscle in a gentle stretch position and begin using the RICE method to start the healing process. For more severe bruises, consult a doctor.

Sports Injuries in Young Children: Tips for Caregivers

Here are some "on-the-field" tips for helping a young child who has been injured:

Minor injuries are fairly common in young children; severe injuries are not.

A young child's self-esteem and enjoyment of a sport can be influenced by an adult's reaction when the child is injured.

Judging the intensity and finding the site of the pain in a preschool child may not be easy. The child's perception of severity, influenced by his/her temperament and developmental level, may not match reality. The child's response to an injury may also reflect his/her prior experiences or the experiences of a friend or family member who has had an injury.

Don't judge a child's reaction to an injury based on the child's age, sex, or size. Young children may vary greatly in their physical and mental development, temperaments, and reactions to and tolerance of pain and stress.

Acknowledge the child's feelings (pain, fright, and/or anxiety), provide emotional support, and convey a sense of protection and caring.

Treat children with respect. Never ridicule or belittle them in front of their peers, as this may be harmful to their developing self-esteem. Reassure the child that he/she will be cared for and the injury will be evaluated.

Inappropriate over concern can have negative effects and may lead to a more frightened child or eventually to a more vulnerable child. Parents may have difficulty remaining objective regarding their child's injury. On the other hand, parental knowledge of their child's temperament and typical reaction to pain can be immensely helpful to others trying to evaluate the severity of the injury.

Question the child simply and directly. An authoritative approach, gentle but firm, will be reassuring for some youngsters.

Listen to the injured youngster and get his/her reaction to reentering a sport or activity. Sometimes hidden fears will be expressed that can be addressed by a caregiver who listens. A child's mental health and development are as important as his/her physical health.

Time, ice, and a caring attitude will help to minimize many simple traumatic injuries.

Source: National Institutes of Health
National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIH Publication No. 04-5278

	Sudden, severe pain
	Swelling
	Inability to place weight on a lower limb
	Extreme tenderness in an upper limb
	Inability to move a joint through its full range of motion
	Extreme limb weakness
	Visible dislocation or break of a bone

	Rest. Reduce regular exercise or activities of daily living as needed. If you cannot put weight on an ankle or knee, crutches may help. If you use a cane or one crutch for an ankle injury, use it on the uninjured side to help you lean away and relieve weight on the injured ankle.
	Ice. Apply an ice pack to the injured area for 20 minutes at a time, four to eight times a day. A cold pack, ice bag, or plastic bag filled with crushed ice and wrapped in a towel can be used. To avoid cold injury and frostbite, do not apply the ice for more than 20 minutes. (Note: Do not use heat immediately after an injury. This tends to increase internal bleeding or swelling. Heat can be used later on to relieve muscle tension and promote relaxation.)
	Compression. Compression of the injured area may help reduce swelling. Compression can be achieved with elastic wraps, special boots, air casts, and splints. Ask your health care provider for advice on which one to use.
	Elevation. If possible, keep the injured ankle, knee, elbow, or wrist elevated on a pillow, above the level of the heart, to help decrease swelling.

	Pain when performing an activity
	A dull ache when at rest
	Swelling

	The injury causes severe pain, swelling, or numbness
	You can't tolerate any weight on the area
	The pain or dull ache of an old injury is accompanied by increased swelling or joint abnormality or instability

	Slings, to immobilize the upper body, including the arms and shoulders.
	Splints and casts, to support and protect injured bones and soft tissue. Casts can be made from plaster or fiberglass. Splints can be custom made or ready made. Standard splints come in a variety of shapes and sizes and have Velcro straps that make them easy to put on and take off or adjust. Splints generally offer less support and protection than a cast, and therefore may not always be a treatment option.
	Leg immobilizers, to keep the knee from bending after injury or surgery. Made from foam rubber covered with fabric, leg immobilizers enclose the entire leg, fastening with Velcro straps.

	Electrostimulation: Mild electrical current provides pain relief by preventing nerve cells from sending pain impulses to the brain. Electrostimulation may also be used to decrease swelling, and to make muscles in immobilized limbs contract, thus preventing muscle atrophy and maintaining or increasing muscle strength.
	Cold/cryotherapy: Ice packs reduce inflammation by constricting blood vessels and limiting blood flow to the injured tissues. Cryotherapy eases pain by numbing the injured area. It is generally used for only the first 48 hours after injury.
	Heat/thermotherapy: Heat, in the form of hot compresses, heat lamps, or heating pads, causes the blood vessels to dilate and increase blood flow to the injury site. Increased blood flow aids the healing process by removing cell debris from damaged tissues and carrying healing nutrients to the injury site. Heat also helps to reduce pain. It should not be applied within the first 48 hours after an injury.
	Ultrasound: High-frequency sound waves produce deep heat that is applied directly to an injured area. Ultrasound stimulates blood flow to promote healing.
	Massage: Manual pressing, rubbing, and manipulation soothe tense muscles and increase blood flow to the injury site.

	Try to group youngsters according to skill level and size, not by chronological age, particularly during contact sports. If this is not practical, modify the sport to accommodate the needs of children with varying skill levels.
	Match the child to the sport, and don't push the child too hard into an activity that she or he may not like or be physically capable of doing.
	Try to find sports programs where certified athletic trainers are present. These people, in addition to health care professionals, are trained to prevent, recognize, and give immediate care to sports injuries.
	See that all children get a preseason physical exam.
	Don't let (or insist that) a child play when injured. No child (or adult) should ever be allowed to work through the pain.
	Get the child medical attention if needed. A child who develops any symptom that persists or that affects athletic performance should be examined by a health care professional. Other clues that a child needs to see a health professional include inability to play following a sudden injury, visible abnormality of the arms and legs, and severe pain that prevents the use of an arm or leg.
	Provide a safe environment for sports. A poor playing field, unsafe gym sets, unsecured soccer goals, etc., can cause serious injury to children.

	Be in proper condition to play the sport. Get a preseason physical exam.
	Follow the rules of the game.
	Wear appropriate protective gear.
	Know how to use athletic equipment.
	Avoid playing when very tired or in pain.
	Make warm-ups and cool downs part of your routine. Warm-up exercises, such as stretching or light jogging, can help minimize the chances of muscle strain or other soft tissue injury. They also make the body's tissues warmer and more flexible. Cool down exercises loosen the muscles that have tightened during exercise.

	Minor injuries are fairly common in young children; severe injuries are not.
	A young child's self-esteem and enjoyment of a sport can be influenced by an adult's reaction when the child is injured.
	Judging the intensity and finding the site of the pain in a preschool child may not be easy. The child's perception of severity, influenced by his/her temperament and developmental level, may not match reality. The child's response to an injury may also reflect his/her prior experiences or the experiences of a friend or family member who has had an injury.
	Don't judge a child's reaction to an injury based on the child's age, sex, or size. Young children may vary greatly in their physical and mental development, temperaments, and reactions to and tolerance of pain and stress.
	Acknowledge the child's feelings (pain, fright, and/or anxiety), provide emotional support, and convey a sense of protection and caring.
	Treat children with respect. Never ridicule or belittle them in front of their peers, as this may be harmful to their developing self-esteem. Reassure the child that he/she will be cared for and the injury will be evaluated.
	Inappropriate over concern can have negative effects and may lead to a more frightened child or eventually to a more vulnerable child. Parents may have difficulty remaining objective regarding their child's injury. On the other hand, parental knowledge of their child's temperament and typical reaction to pain can be immensely helpful to others trying to evaluate the severity of the injury.
	Question the child simply and directly. An authoritative approach, gentle but firm, will be reassuring for some youngsters.
	Listen to the injured youngster and get his/her reaction to reentering a sport or activity. Sometimes hidden fears will be expressed that can be addressed by a caregiver who listens. A child's mental health and development are as important as his/her physical health.
	Time, ice, and a caring attitude will help to minimize many simple traumatic injuries.