US Pharm. 2010;35(7):8-15.
The pharmacist has always been a frequent source for patients to receive counseling in regard to minor health care problems. Some of these ailments are seasonal in nature, such as seasonal allergic rhinitis. Other seasonal health problems include those that are more commonly encountered during the summer months. Examples are insect stings and bites and injuries incurred as a result of participating in summer sports.
Which Summer Sports Are the Most Dangerous?
The American Academy of Orthopaedic Surgeons (AAOS) once carried out a campaign entitled, Prevent Injuries America.1 A linchpin of the effort was the AAOS ranking of specific summer sports or recreational activities and the estimated number of yearly injuries caused by each. AAOS created the ranking using data from the U.S. Consumer Product Safety Commission. The top two offenders were basketball and bicycling, each causing 1.5 million or more injuries yearly. The next three were baseball, soccer, and softball, each responsible for almost half a million injuries yearly. They were followed, in descending order, by trampolines (246,875 injuries), inline skating (233,806), horseback riding (196,260), weight lifting (189,942), volleyball (187,391), swimming (149,482), wrestling (136,055), roller skating (115,763), and gymnastics (86,479). While not included on the list, golf is also dangerous, causing perhaps as many as 132,000 injuries yearly.1
A similar list from the AAOS ranked children’s summer sports and their associated injury rates. The specific sports and their yearly injury rates were basketball (1,066,004), bicycling (832,775), baseball/softball (211,646), swimming (117,889), volleyball (92,409), inline skating (82,903), and tennis (20,514).2
Skateboarding is also a potential risk. A retrospective study over a 5-year period in the United Kingdom uncovered a host of skateboarding injuries.3 Victims were mostly males under the age of 15 years, with the most common injury being a fracture of the upper limb. A California study of skatepark injuries estimated that the average time lost from school and work per injury was 1.1 and 5.5 days, respectively, with estimated medical costs and lost wages totaling $3,167.4
Pharmacist Assessment of Injuries
What can community pharmacists do for patients who approach them with possible summer sports injuries? Pharmacists may initially inquire about symptoms of a fracture or dislocation, which include an out-of-place or swollen limb or joint; intense pain, numbness, and tingling; limited mobility of, or inability to move, a limb; or the presence of swelling, bruising, or bleeding.5-7 These patients require an immediate referral.
Engaging in assessment beyond the simple questions above is controversial at best for community pharmacists. Some colleges of pharmacy include coursework or laboratory exercises training students in the rudiments of assessment. They may be trained to use otoscopes, ophthalmoscopes, and reflex hammers. The express purpose of assessment using this equipment is to gather the information necessary to reach a diagnosis. Faculty members should question these exercises for several reasons.8 First, the general medical community at large does not consider pharmacists to be diagnosticians, an opinion shared by boards of pharmacy. In fact, state pharmacy practice acts usually specifically prohibit attempts at diagnosis. Thus, there is no meaningful reason for the community pharmacist to engage in patient assessment, and to do otherwise may violate the state practice acts. Second, the typical community pharmacy does not have the equipment required for assessment, such as otoscopes. Third, community pharmacists are not allowed to ask patients to disrobe to the extent that a full assessment would require, nor do they have private examining rooms. Finally, pharmacy malpractice insurance only protects the pharmacist against malpractice while engaging in legal acts. The community pharmacist who desires to begin patient assessment must thus consider numerous issues before proceeding.
For these reasons, the typical community pharmacist must refer patients with anything other than the most innocuous summer sports injuries to a physician for a true assessment, which may involve x-rays, CAT scans, and/or other sophisticated inquiries carried out by trained diagnosticians whose education includes in-depth training in diagnosis and evaluation of injuries, continually reinforced by articles in their professional journals.9,10
Emergency Cryotherapy
When the pharmacist is satisfied that the patient’s injuries are minor and do not require a formal assessment, there are several options that may be suitable, such as cryotherapy. As part of the PRICE regimen (Protection, Rest, Ice, Compression, Elevation), cryotherapy is widely respected for its ability to limit the extent of inflammation within acutely injured tissues by inhibiting release of histamine and reducing activity of neutrophils, collagenase, and synovial leukocytes.8,11,12 Cryotherapy also causes local vasoconstriction, reducing the extent of hematoma. Reducing the extent of postinjury inflammation speeds the return to normal function.
Pharmacists may suggest several cryotherapy modalities.8 Ice bags are rubber containers that are partially filled with ice cubes or crushed ice and a small amount of water, if desired. Reusable cryogel packs are plastic bags containing a gel (often blue in color) that must be cooled prior to application. Single-use packs contain two chemicals in a flexible plastic container. The bag is squeezed at the time of use, which ruptures an inner membrane, allowing the two chemicals to mix and triggering a cryogenic reaction. These devices are particularly useful when the injury occurs at a venue such as a soccer field or during a hike when there is no access to precooled devices. All of the devices are flexible and conform easily to different areas of the body after application.
Patients with acute injuries may be advised to apply cryotherapy for the first 48 to 72 hours post-injury.8 The usefulness of cryotherapy declines after this time. A common regimen for an injury such as an ankle sprain is cryotherapy applied for 20 minutes once or twice daily.
Patients should be advised of several precautions with cryotherapy that prevent damage.8,13 Reusable gel packs should be placed in the lower, non-freezer section of the refrigerator to prevent frostbite. Cryotherapy should not be applied longer than 20 minutes or after the area feels numb, whichever is shorter.
Internal Analgesics
Internal analgesics may be useful in treatment of acute sports injuries. In recommending these medications, it is vital for the pharmacist to be intimately acquainted with their voluminous labeling in regard to dosing and precautions. Adults should not use these products for more than 10 days, and all warn against use if the patient ingests three or more alcohol-based drinks daily.8
External Analgesics
External analgesics are widely used choices for care of summer sports injuries. Applied topically, they provide a sensation of heat (e.g., methyl salicylate) or coolness (e.g., menthol, camphor).8 For this reason, they have traditionally been referred to as counterirritants (producing a surface irritation that counters pain in deeper tissues). Typical products include BenGay, Icy Hot, and Flexall. They are not the best therapeutic choices for two reasons. First, there is a widespread misconception that these products are beneficial to the underlying sports injury. However, there is little evidence that they are able to improve injured tissues by materially increasing temperature in the area to any extent. Using them gives a sense that an effective therapy has been chosen, and the patient may not seek a more effective therapeutic option.
Second, applying a product that does little but provide a surface sensation of heat and/or cold may mask pain arising from a sports injury. Thus, patients may feel that the injury has improved and continue the activity when they should have rested or sought medical help. Playing sports while injured can further the extent of the injury and greatly prolong the period of rehabilitation.
If the pharmacist chooses to recommend these products, several precautions should be communicated to the patient.8 For instance, these analgesics should not be used in patients under the age of 2 years, nor should they be used if symptoms persist for more than 7 days, or clear up but recur within a few days. They should only be used 3 to 4 times daily and discontinued if the condition worsens. The area should not be bandaged, and the products should not be applied to wounds or broken skin. They should never be used with any source of external heat, such as a heating pad.
Thermotherapy Devices
Thermotherapy devices are useful in relieving pain arising from acute injury once the 48- to 72-hour cryotherapy treatment period has elapsed.8 Several devices deliver low-level heat. Hot water bottles are rubber bags that must be filled and refilled with warm water. The weight of the bag is problematic since an injury is usually sensitive to pressure. Further, patients cannot secure hot water bottles to the body to carry out the normal activities of daily living (ADLs).
Other heating devices contain clay or beads and are prewarmed in a microwave and placed on the injured area. Initial heating and reheating is dependent on microwave access. Use during ADLs is questionable at best since most cannot be secured to a moving body.
Heating pads are ubiquitous but must be used carefully to ensure safety.8,14 They are dependent on electricity, making them the least portable thermotherapy device. The heating pad does not eventually cool down as the hot water bottle does, but delivers heat as long as it is plugged in. A patient falling asleep while lying on a heating pad risks serious burns because of this shortcoming.
Patients may consider trying a therapeutic heat wrap (e.g., ThermaCare).15 When the package is opened, cells containing iron powder begin to oxidize, producing heat at a constant temperature of 104˚F. Patients may sleep with the wrap in place. It is sufficiently thin to allow it to be worn while carrying out all ADLs. The 8-hour wearing time provides 16 hours of pain relief. One product is marketed for the lower back and hip and another for the neck, wrist, and shoulder.
General Advice to Prevent Injury
Before playing any sport, you must learn the rules of the activity and obey them carefully. You should also research the types of protective gear available for that sport and invest in the best and most protective types of appliances. This includes such accessories as soccer shin guards, a hard-shell baseball helmet when the player must face a pitcher, and a top-notch helmet when riding a bicycle. You should investigate whether the sports complex in which you or your child will play has installed the safest and most current equipment. For example, leg injuries in children are reduced if baseball diamonds have breakaway bases.
You should also engage in appropriate warm-up exercises before beginning the recreational activity. If you become tired or develop pain, you should cease activity and consider a physician visit if the pain does not abate shortly. You should take frequent breaks and drink enough fluids during and after the activity to maintain adequate hydration.
Conditioning Advice
The Federal Occupational Health (FOH) arm of the Department of Labor gives advice on injury prevention. One section concerns conditioning. The agency reminds you that you may have become deconditioned (i.e., out of shape) over the inactive winter months, so you should not expect to be able to return to your sport at the same level you were at the end of the previous summer. You should spend 6 to 8 weeks stepping up to your last level. Start with 30 minutes of cardiovascular exercise 3 days a week, working up slowly to 40 to 45 minutes—4 to 5 days a week. Starting slowly allows the body to adjust to its new demands.
Safety Equipment
The FOH stresses that every athletic endeavor requires protective gear. There are no exceptions. This includes wrist guards, elbow protectors, knee pads, life jackets, and mouthpieces. If the head might be struck or you might fall from a height at a high rate of speed, head protection is crucial. Such sports as bicycling, inline skating, baseball, horseback riding, and skateboarding require head protection.
You should also learn how to fall properly. You should practice falling without tensing up and try putting out your arms to break the fall. You must learn to relax and to roll with the direction of the fall.
Treatment Options for When You Are Injured
When you have experienced a sports-related injury, it is a wise idea to make a physician appointment before medicating yourself. Doing so allows a trained professional to rule out such serious problems as a fracture or dislocation. It also assures you that, in many cases, the problem is a simple sprain, strain, or other self-treatable condition. In that event, you may use internal analgesics, cold therapy (for the first 48-72 hours), heat therapy (after 72 hours have passed), and other nonprescription products.
Consult your pharmacist for advice on choosing these products, and be sure to read and follow all labeling.
Remember, if you have questions, Consult Your Pharmacist.
REFERENCES
1. List of top 10 summer sports with most injuries provides warning for Olympics enthusiasts. Medscape Medical News. September 1, 2000. www.medscape.com/viewarticle/
2. Top children’s summer sports injuries. Medical News Today. April 21, 2005. www.medicalnewstoday.com/
3. Rethnam U, Yesupalan RS, Sinha A. Skateboards: are they really perilous? A retrospective study from a district hospital. BMC Res Notes. 2008;1:59.
4. Vaca F, Mai D, Anderson CL, et al. Associated economic impact of skatepark-related injuries in Southern California. Clin Med Res. 2007;5:149-154.
5. Fractures. MedlinePlus. www.nlm.nih.gov/medlineplus/
6. Dislocations. MedlinePlus. www.nlm.nih.gov/medlineplus/
7. Deakin DE, Crosby JM, Moran CG, et al. Childhood fractures requiring inpatient management. Injury. 2007;38:1241-1246.
8. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
9. El-Sheikh Y, Wong I, Farrokhyar F, et al. Diagnosis of finger flexor pulley injury in rock climbers: a systematic review. Can J Plast Surg. 2006;14:227-231.
10. Riyami M, Rolf C. Evaluation of microfracture of traumatic chondral injuries to the knee in professional football and rugby players. J Orthop Surg Res. 2009;4:13.
11. Owoeye OB. Pattern and management of sports injuries presented by Lagos state athletes at the 16th National Sports Festival (KADA Games 2009) in Nigeria. Sports Med Arthrosc Rehabil Ther Technol. 2010;2:3.
12. Peer KS, Barkley JE, Knapp DM. The acute effects of local vibration therapy on ankle sprain and hamstring strain injuries. Phys Sportsmed. 2009;37:31-38.
13. Brown WC, Hahn DB. Frostbite of the feet after cryotherapy: a report of two cases. J Foot Ankle Surg. 2009;48:577-580.
14. Dini GM, Ferreira LM. Burns due to heating pads. Plast Reconstr Surg. 2007;120:2126-2127.
15. ThermaCare HeatWraps. Wyeth Consumer Healthcare. www.thermacare.com/
To comment on this article, contact rdavidson@uspharmacist.com.
