Injury prevention is better than cure: the vademecum for 'safe' sport

There are so many preparation exercises, the two experts explain: from muscle strengthening in the gym to muscle strengthening, but also observing oneself while practising a certain sport or being followed by competent people. If we think trivially of running, the activity that everyone tends to do most frequently, getting help from a 'personal' in understanding how to set the stride phase in walking can be of great support.

Prevention also passes through the use of appropriate equipment: for running we need the right shoe, for trekking in the mountains the right boot for the ankle, the effort and the season so that in the event of a sprain it can prevent the traumatic event to the lower limbs, while for a bicycle outing we need to have the right position on the saddle so that we can face the sporting activity coordinated. And coordination can be trained: through very simple exercises that are proprioceptive, i.e. useful for improving central nervous system feedback and neuromuscular control. There is a vast scientific literature that shows how important it is to undergo these exercises, which are very static and sometimes 'boring' but effective in giving us greater control and coordination.

The years have a decisive influence: one should play sports according to one's age. Whereas often people with an initial degenerative picture of the major joints approach sports that subject the joints to significant stress. This is absolutely wrong, the two doctors again emphasise, because it further wears down the joint framework of a person who already has worn cartilage.

In general, sport should be done on the basis of our physical function, and preceded by preparation, with lots of stretching that lengthens the two main extensor and flexor chains so as to create a balance that makes them work in synergy without one prevailing over the other. These may seem like basic concepts, but very often they are forgotten precisely because of the eagerness to achieve the goal as quickly as possible.

Second level prevention

After the rupture of a cruciate ligament or following another injury, is there a second-level prevention to return to sporting activity? 'In the case of an anterior cruciate ligament reconstruction,' Roberto Pozzoni goes on to explain, 'it is obvious that the return to sporting activity follows the biological healing times that are the responsibility of the new ligament. The tendon graft must integrate perfectly into the bone and be a whole, allowing the knee to return to any sporting activity and withstand any stress. This is of course after a period of careful physiotherapy, And once an anterior cruciate ligament has been reconstructed,' he warns, 'in any case, we should go back to primary prevention: that is, to having the care and attention that characterises a healthy knee.

But how many professional sportsmen and women manage to restore full efficiency? 'The chances of rupturing an anterior cruciate ligament are unfortunately quite high, and the return to pre-injury sporting activity in professional footballers, to give an example, is unfortunately four out of ten. Forty per cent return to sport at the same pre-injury level, while others go down in category because they are no longer at their best, and this is in most cases due to a psychomotor issue: one loses confidence and ability. One no longer 'feels' the knee as much as before despite having an excellent surgical result,' Pozzoni points out.

Skiers on Sunday or on the last day of the skiing week, with suitcases already packed and ready to return to town, are a school case: most ACL injuries occur on the last downhill run, when the snow is 'plump' and wet and therefore unable to steer the skis. The double watchword here is 'don't overdo it' and 'listen to your body', which can never be asked to go too far. The advice to skiers (and not only) is 'when you are tired, stop'. "The number of injuries we see in January is resounding," says Accetta, "because fractures go according to the sporting activity, while when the warm weather arrives there are many cyclists who land in the emergency room.
"In general," continues Pozzoni, "according to the literature, the most dangerous sport is skiing, where we have the most injuries also because it is practised by many inexperienced people. This is followed by all contact sports. If, on the other hand, we think of cycling, among the most frequent pathologies is the fracture of the collarbone due to a fall, while tennis and paddle sports put the knee or ankle at greater risk. Every sport is characterised by certain more frequent pathologies. Certainly, sports that are not very linear and indeed require continuous changes of direction, imposing a rotational component of the joint, are those most at risk, so prevention should be more careful'.

How do great champions, who live by the performance of their bodies and their own performance, deal with the test of an operation? In these cases, the approach can be more complex, even in the choice of the surgeon and the facility to be entrusted, which one perhaps arrives at after a series of 'second opinions' and following the advice of teammates. The pressure for the surgeon and his staff in this case can be considerable, especially on the part of the sports club and the entire entourage, but the sport of origin also has a big impact. 'Depending on the type of sport, the approach also changes,' stresses Dr Pozzoni, who recalls in particular the 'great humility of the players of the national rugby team'. However, even in football, par excellence the crossroads of great tension in the event of injury, there are cases of champions who, after a difficult approach, once they had overcome their initial diffidence, turned to the specialist. 'Once their trust was won, the therapeutic relationship got off to a good start and this is also very important for the outcome of the treatment,' Pozzoni emphasises.

Riccardo Accetta then goes on to explain what the prevention rules are for older people, pointing out that the World Health Organisation has already announced that it wants to move the definition of an elderly patient from the current 65 to 75 years. 'Prevention and quality of life have led to an improvement in an individual's general condition,' warns the expert, 'which improves posture and walking as well as better bone trophism. That is why the average age of femur fractures - and therefore of operations to be performed within 48 hours - today has shifted to between 80 and 90-100 years, because by now people in their 70s are in full health'. With advancing years, however, the issue is the loss of proprioception, i.e. the sensitivity in space given by position receptors, present in all joints, which tell our brain how the joints are placed. 'This aspect,' the specialist continues, 'affects walking, which becomes even more complex because the brain delegates to the legs where to place the feet. Generally, the receptors in the ankles, knees and hips, sensing the movement of the ground, automatically make the muscles contract in walking. These are called 'reflexes', but when the receptors in the elderly begin to fail with loss of elasticity, they have the effect of slowing down the message and alter walking, so that small bumps such as a carpet in the hallway at home can be among the causes of a fall. This is why it is necessary to continue to have an active life, do yoga and lots of balance exercises'.

Adolescence is characterised by a capacity for coordination that certainly exceeds that of adulthood, and boys and girls are able to achieve their goals in much less time than in adulthood. The problem in this group can be caused by even very frequent dysformisms such as a 'flat foot', a valgus knee or an asymmetry of the lower limbs. These factors can create an imbalance that in turn can cause trauma or injury. If, on the other hand, we consider a normally developed adolescent, the advice is to leave him free to choose the sport he prefers because there are no particular contraindications.

In the case of professional sport in adolescence, the risk is even excessive workloads that can cause injury due to muscle or joint fatigue or psychophysical stress. Elements that many times lead to achieving goals beyond the capabilities of the individual youngster. The responsibility lies with coaches, trainers, and sports clubs that 'push' and may tend to take agonism to extremes. Pozzoni explains: 'Observing the injuries that occur in professional football clubs, we notice that in recent years there has been a significant increase in injuries to the anterior cruciate ligament, now among the most frequent pathologies in younger professional footballers. This is because of the type of stress the youngsters are subjected to, but also because of the demand to achieve performance in a short time. And, last but not least, because of the playing fields that today are predominantly synthetic, which is one of the main causes of lower limb injuries'.