Ten Truths About Sports Trauma

By October 17, 2015 October 18th, 2015 Athletic Performance, Exercise

Sports injuries share more with emergency-room trauma than meets the eye.

With injuries soaring in virtually all sports — including CrossFit’s 74 percent injury rate — it’s important to understand these problems are not random or normal, and usually are preventable. The events that lead up to a sports-trauma injury are often the true root of the cause.

The fact is we know a lot about the nature of sports trauma. While the origins are different, there is a surprising similarity between what occurs in athletes and trauma patients in a hospital emergency department. Catherine Dudick, M.D., is a trauma surgeon at AtlantiCare Regional Medical Center in Atlantic City, New Jersey, and recent past chair of the hospital nutrition therapy committee. She is also a triathlete and endurance athlete, and says she understands first-hand that trauma patients and athletes can share similar complications.

“At the cellular level, trauma and exercise resemble each other, with inflammation being the common response,” says Dr. Dudick. “While inflammation drives healing, it can also drive further injury.”

With this in mind, let us explore 10 truths about sports trauma.

1. Trauma happens.
Trauma comes in many forms, and the spectrum ranges from the severe and obvious, such as an auto collision or other accident, to the everyday seemingly minor micro-trauma of any repetitive motion. This may include even seemingly harmless activities like walking, but most certainly running, biking and swimming. While acute micro-trauma is considered the impetus for the body to make performance progress, going beyond this point into excessive training volume and/or intensity can bring more serious trauma and lead to injuries.

“From your body’s perspective, a proper workout enhances health and performance; but done poorly, it’s nothing more than scheduled trauma,” Dr. Dudick says.

Sports trauma grabs headlines, not unlike serious injuries sustained in a traffic or work accident. Professional athletes get injured in the line of duty. Recreational and professional cyclists crash their bikes. Even those in non-contact sports suffer a high incidence of injury, including non-competitive enthusiasts who enjoy aerobic dance, gym workouts and working out on stationary equipment.

Dr. Dudick says that while “trauma happens” in sport and life, this should not imply it is unavoidable or acceptable.

“While unintentional, it is no ‘accident’ that cars collide or tendons rupture,” Dr. Dudick says. “From an engineering and data perspective, multiple fail-safe mechanisms, such as wearing helmets, avoiding distracted driving and following a training program with a proper mix of exercise and rest, can be instituted so as to make trauma less likely to happen at all, and better tolerated when it does occur.”

2. Injury and ill health result from excess exercise trauma.
Trauma comes in both physical and chemical forms. Both are common and so intertwined as to not easily be separated except in discussion. Physical problems include neuromuscular imbalance and other soft-tissue damage (in tendons, ligaments, skin, etc.), and fractures and other bone injury. Chemical trauma can also play a large role in these injuries, and can include bodywide problems for the lungs, immune system, gut, brain and other areas that impact health and fitness.

3. Injury is not normal.
Almost all injuries I’ve seen in endurance athletes were unexpected consequences of some training and racing trauma. I’ve also seen the expected, such as injuries caused by two big athletes sprinting at each other and colliding in mid-field, resulting in major problems such as dislocation, whiplash, or concussion. While this might be considered a so-called normal consequence in football or other contact sports — these athletes actually are more likely to get injured during non-contact training. For endurance athletes it’s clearly not part of the game, except in the case of a crash or stumble (although many of these are associated with human-error).

4. Trauma patients and athletes share much.
It’s not just athletes that relate to trauma when it leads to an injury. Everyone reads, talks and hears about damaged bodies. Many rubberneck while passing an accident site, or pay more attention to the screen when the commentator says, “We must warn you that these pictures are graphic …” These unfortunate images are like looking into an injured body to see the extent of the damage in living color. I’m not saying a runner’s knee is as bad as a serious ER trauma patient, just that they are much more similar than not. If one could view the details of damage within chronic knee pain and the training trauma that instigated it, it would be horrifying.

Dr. Dudick agrees. “Acute and chronic athletic injuries are often silent and invisible to the outside world, but in truth are no less dramatic than a ghastly open wound,” she says.

5. Brain-Body Stress.
One common feature of all trauma is inflammation. More inflammation requires added recovery, and great nutrition to improve healing. The balanced consumption of healthy fats helps the body regulate healing in a powerful way. Avoiding refined carbohydrates, which promote inflammation, is vital too. Without the right recovery and diet, the stress of physical training and racing trauma can lead to HPA (hypothalamic-pituitary-adrenal) axis dysfunction, disturbing hormones, water and electrolyte regulation, muscle balance, and altering sleep and other aspects of health. Even a single workout beyond what the body can tolerate can be traumatic enough to create excess inflammation. Examples include training with too high a heart rate, too much duration, and too much competition.

6. Training trauma is the anthem of the no-pain, no-gain philosophy.
Our society thrives on “more is better.” More miles, more intensity, more racing — it can lead to more trauma, injuries, poor health and reduced performance.

“In the modern era, exercise has become a to-do list item, like anything else, adding stress and the physiologic consequences that other stress brings,” Dr. Dudick says. “This adds to the negative side of the trauma equation instead of the positive.”

She notes that modern exercise routines have replaced the natural exercise our ancestors achieved through natural movement, and physical work they did in the process of living and surviving.

“As we look to enhance fitness, we need to be holistic in our approach,” she says. “Running on a treadmill for an hour cannot equate to working in a garden, digging for an hour.”

She says the physical stress from a natural lifestyle, as opposed to repetitious training, provided a more temperate and consistent, but varied, work load. Training, on the other hand, leads to an attitude of more is better, while promoting less rest and recovery. This eventually leads to injury.

“We must not be overly simplistic and think that all exercise is good for us; we must consider exercise from the perspective of how it enhances our well being,” Dr. Dudick says.

7. The training equation helps balance trauma.
We train, we rest, we progress. Too much or too little, coupled with the lack of rest, allows trauma to accumulate. The equation I’ve used to emphasize this is simple:

Training = Workout + Recovery

An imbalanced training equation leads to overtraining — physical, chemical and mental-emotional trauma.

8. Total recovery.
Recovery from training and racing means no training, and sleeping uninterrupted 7-9 hours each night. It’s during recovery that the benefits of training are realized. Otherwise, even micro-trauma turns to trauma.

9. The root of most injuries.
Many athletes are caught in a vicious trauma-injury cycle. Some form of trauma, including micro-trauma, is usually the primary cause of athletic injuries, particularly among those who are less healthy. Trauma is commonly caused by poor footwear, which can traumatize the feet and the rest of the body upward. Other causes, such as one’s bike setup or wear and tear from riding rough trails, can traumatize muscles and joints. Overworking muscles, or twisting an ankle or knee, which often is predisposed due to previous training trauma, can also contribute to problems.

10. No cure in a pill.
Aspirin and other NSAIDs are not a primary treatment or prevention for trauma. These drugs can reduce inflammation and help you feel less of the stress you’ve created, but they also impair physical and chemical healing.

Instead, balancing both health and fitness, and the training equation, are the treatment and prevention of choice for those seeking optimal health and fitness, and increased performance.


  • Rachel says:

    Your point that modern exercise is attempting to replace the movements of our ancestors is an interesting one. Like you said, running on a treadmill for an hour is not the same as gardening for an hour. It makes me wonder if more natural, holistic approaches to exercise would be a better fit for some. As someone who would get very bored running on a treadmill for an hour, I can say that the holistic approach sounds much better to me.

    • Rachel:

      As a general rule with a few case-by-case exceptions, I’d say that you’re absolutely right. This is not to say that a treadmill has absolutely no place in a training routine of course. But there is really no human body that responds better (develops greater mobility, coordination, resiliency, and athletic longevity) to a treadmill than to a variety of exercises.

  • Vanessa says:

    While I am not an endurance athlete, I listen to Endurance Planet to help educate myself because I am a sports chiropractor who treats many endurance athletes. I greatly respect all the different forms of fitness, but I am a little upset about the 74% injury rate referenced for CF athletes. I would simply like to know the source of this. I have many CF athletes as well as patients and that sounds grossly overstated.
    Thanks for providing information for reference.

  • Thanks for the article Phil. I agree with all your points, but feel you are missing probably the number one cause of injury in sports. It is not excessive training volume or intensity, not caused by inflammation, not due to overuse, it is not lack of sleep or improper nutrition, and it is not caused by footwear. The number one cause of injury is physical imbalance or postural mis-alignment. Most foot, knee, hip, back, shoulder, elbow, etc injuries are on one side of the body. Runners who get Achilles tendonitis, patellofemoral pain syndrome, plantar fasciitis, knee or hip osteoarthritis, and many other injuries/pain get the problem on one side and not the other. This means it can’t be blamed on shoes, mileage, training intensity, lack of rest or recovery, nutrition, genetics, age, and everything else that is talked about as being the cause. The reason why a runner develops knee pain only in their right knee has to do with postural imbalances. It might be their right knee is internally or externally rotated or their right hip is elevated or rotated, or their shoulders are not even. These imbalances are not genetic in cause but rather the body’s natural response to the way we use it. The key to becoming pain free is looking at the entire body and figuring out what posture imbalances the individual has, doing functional testing to help confirm why, and then prescribing specific posture exercises to restore balance and normal function. Without this holist approach to injuries, athletes will keep having the same injury or related injuries appear because the root cause of the problem was never addressed.

    • Matt:

      Thanks for commenting! I (almost) absolutely agree with you, and I think that Phil would second me on this. I don’t think the goal of this article was to discuss the biggest causes—for instance I would characterize “muscle imbalance” as #2 and “previous injury” as #1, at least if we’re talking statistics—but rather the ones that the average reader (who we assume to be a fitness enthusiast with little knowledge of the body’s biomechanics) has the most personal control over.

      In other words, I’d look at this as a “things to keep in mind” list, more than “this is how to render yourself immune to injury.”

      That said, I really do think that it isn’t imbalance itself that causes injury, but rather a series of stressors that the weakened joint wasn’t able to cope with: a certain degree of power transmission or absorption, often in compounded by other problems such as inflammation. I’ve often seen muscle imbalances or compensation strategies entrenched by such stressors. Often, while a muscle imbalance is the direct mechanism for a particular injury, a metabolic condition entrenches it, meaning that the first step back to health may not be (and I think that according to Phil, often isn’t) to address the mechanical problem itself. But addressing that imbalance may be a necessary second or third step to take.

      This gets me to the core of what I’m trying to say. The average fitness enthusiast tries to increase their athletic output often in the face of a staggering amount of stressors: bad nutrition, chronic inflammation, insulin resistance, chronic stress, and yes, muscle imbalance. I think that the key factor here is directionality: resolving the mechanical stressor (muscle imbalance) will not resolve the metabolic stressors (chronic stress, insulin resistance, bad nutrition, or chronic inflammation), although it may resolve local acute inflammation, and chronic stress in the cases that muscle imbalance was the major stressor, but removing the metabolic stressors may help it resolve a majority of the muscle imbalances at least in some measure (but rarely, of course, completely).

      Why? Because once those stressors are mitigated, the body is much more capable of re-adapting to more advantageous movement patterns as arthritis fades and chronic inflammation wanes.

      I think, then, what Phil was thinking in discussing these mechanisms at the exclusion for muscle imbalance, was that the more you watch out for the stuff laid out in this article, the less you have to know about kinesiology and movement patterns, since it becomes more and more likely that the body will do that job for you.

      • Tree says:

        Ivan- Awesome! Matt- Yes! Matt’s reply is great because I think some of us needed to hear a little more in the fantastic article, about the musculoskeletal imbalance aspect of injury- that piling athletic moves or endurance miles on top of a compromised structure (even if only speaking anatomically) is a recipe for reinforcing the imbalance and courting injury. I know because I am in the throes of recovery of a mystery hip/sciatic/knee epic that took me from competitive as a stand up paddler to crushed and nearly immobile in one month’s time. In my rehab, I have really seen myself and the little signals that were trying to speak to me. Now there is no way to ignore any of it, and I am facing it.

        Anyway, upon reading Ivan’s response to Matt, I am very happily grounded in grandma’s chicken soup. In other words, I simply need to be healthy, and the body knows pretty well what to do. Back in the day, Grandma made me slow down and eat warm, hydrating foods. I had to miss out on a game or two. Just because I am older doesn’t mean the same isn’t true, and in fact is moreso. Grounding into Grandma’s soup takes some of the nerve-racking need to find out exactly what the muscular imbalance is and pay money to all sorts of physical therapists and practitioners all over town. I can intuit a lot about what is going on, get a couple of good assessments, do the postural exercises, and own my life and my health again.

        I do feel that I will come out much better from this, because the nagging things will have finally been given their due. Off to do my Egoscue exercises.

  • pdiddy says:

    good article. I recently had an accident while doing aikido. I thought that night, while on my way to class, that I was a little tired, not feeling great, but not awful either.

    And then I had an accident where my left foot got caught while taking a fall.

    Fortunately, my conditioning was such that it wasn’t a major deal. I finished the class practicing at a much lower level and did so for the next week while dealing with minor soreness.

    So three take aways: accidents happen, but they happen more when you’re not at your peak and they are less serious if you are generally well conditioned.

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