Medical Coverage for Track and Field Events

Abstract

Providing medical coverage at a track and field event is similar to other spectator events, but there are some important differences. With simultaneous events occurring over a large area, reliable communication with quick access to all event sites is mandatory. Preparation needs to include a prearranged emergency response plan for each event. Because field events involve throwing heavy and sometimes sharp objects (discus, hammer, shot put, and javelin) or landing in a cushioned pit (high jump, pole vault), sites need well-demarcated, constantly monitored boundaries with properly installed, well-maintained safety equipment. All personnel involved in monitoring these events should be educated on proper procedure in managing potential head or neck injuries. Event officials must also remained focused on their tasks, avoiding the distractions that simultaneous events can cause. Because most events are outdoors, appropriate protection and recovery sites for heat, cold, and sun exposure should be arranged.

Introduction

Track and field encompasses a variety of events, including running, throwing, and jumping, and is a popular and growing sport, with more than 950,000 high school athletes participating each year [¹]. Although two thirds of the injuries track and field athletes obtain occur during practice, many acute injuries will present to athletic trainers or the medical tent on race day. About 85% of those injuries will involve the lower extremity [²]. Most injuries that occur at a track and field event can be handled on site, but preparation is required for potential catastrophic injuries that can occur to athletes and spectators.

Special Considerations When Providing Medical Coverage to Track and Field Events

Arrangement of quick and easy access to acutely injured athletes is key to providing appropriate onsite medical care. A well-marked medical tent should be located to one side of the track away from the field events. The main medical tent needs reliable communication with satellite personnel situated at the events likely to have serious injuries. Data from the National Center for Catastrophic Sport Injury [^3•] reports the most deaths occurring at track and field events resulted from head injuries of pole-vaulters sustained by landing or bouncing outside of the landing pit. Therefore, medical personnel at the high jump and pole vault should be very knowledgeable in the proper approach to evaluating head- and neck-injured athletes. Available at these sites should be airway management tools and a c-spine board. These are two sites where a clear access plan for emergency medical services is essential. For athletes requiring nonemergent transport, a golf cart or similar vehicle works well.

Although jumpers can injury themselves, throwers can cause significant injuries to other athletes, officials and even spectators by the objects they throw [⁴]. The key to safety is to remain observant to the action and boundaries of the event. It is the responsibility of the throwing athlete, monitoring officials, surrounding athletes and spectators to be aware of events occurring on the field that could be potentially unsafe [⁵]. Hammer and discus throws should be conducted in an enclosure or cage to provide observer safety [⁶].

Because many of the injuries presenting to the medical tent are strains and sprains, a section separate from the medical tent can be set up for trainers and physical therapists to provide ice, stretching, and massage. Each area should provide appropriate protection from the ambient environment and weather. It is a good idea to have sunscreen available and recommend to all athletes to apply sunscreen. Sunscreen of SPF 15 or higher should be used on all sun-exposed skin and reapplied every 2 to 4 hours as sweat may lessen the sunscreen's effect. Medical coordinators also need to be concerned about heat and sometimes even cold illness at outdoor events. Because track athletes often participate in several events throughout the day, attention to symptoms of heat illness and hydration status can prevent serious complications. Athletes should be advised to seek shade and to hydrate regularly. Events involving children may need required water breaks, as children tend to have a delay in their thirst mechanism.

Injuries to Sprinters and Hurdlers

Sprinting and hurdling involve explosive lower extremity activity, so the most common musculoskeletal injuries involve hamstrings or rectus femoris strains. These athletes often present with sudden pain in the posterior or anterior thigh. If the athlete is skeletally immature, consideration should be given for radiographs of the pelvis to evaluate for avulsion fractures. Ice should be available for acute treatment and pain relief. Having medication available is at the discretion of the medical provider.

Thigh strains are the most common acute injury, but a potentially career ending acute injury is a rupture of the Achilles tendon. Athletes often report a “hit” sensation in the calf at the start of a sprint and fall to the ground. Physical examination findings may reveal a palpable defect in the Achilles tendon and inability to resist plantar flexion. On-site care should consist of a posterior leg splint in equinus, ice, and transfer to an acute care facility for evaluation.

Stress fractures and posterior tibial tendonitis are the most common foot injuries present in sprinters, and although they are usually chronic injuries, symptomatic flare-ups often present acutely to the medical tent. Athletes with significant pain and limitation should be withdrawn from competition. For posterior tibial tendonitis, sprinters often tolerate a medial wrap up on their arch for reduction of their pain, and possible continuation of participation.

Hurdlers and steeplechasers can be injured from the obstacles they jump over. Occasionally, a hurdler may land astride a hurdle and need emergent evaluation for urethral disruption if hematuria develops. A more common occurrence is taking off too close to the hurdle and having the trail leg contused or abraded from the obstacle. Protection of the site with a pad can keep the athlete in the competition.

Injuries to Distance Runners

Although distance runners can have acute injuries, they often present to the medical tent with aggravation of their chronic injuries such as medial tibial stress syndrome (MTSS) and patellofemoral pain syndrome (PFPS). MTSS generally presents as pain over the lower or middle third of the posteromedial portion of the tibia. Ice massage, arch supports, and the use of tape for compression at the site can help alleviate pain during competition, but the athlete should be warned about the risks of increasing the severity of injury (such as stress fractures) should they choose to continue. PFPS, also known as “runner's knee,” presents as pain on the medial and/or lateral tissues around the patella. It is often ascribed to patellar tracking problems, vastus medialis obliquus weakness or a tight vastus lateralis. As with MTSS, ice massage and taping are also acute treatment options for PFPS, but again the athlete should be warned of advancing the severity of injury when using these modalities in order to continue.

Injuries to Jumping Athletes

Track and field jumping events include the high jump, long jump, triple jump, and pole vault. Jumping events require a running approach, and therefore, these athletes experience many of the injuries seen in running athletes [^7•]. Patellar tendinosis, also known as “jumpers knee,” is seen commonly in explosive jumping athletes. Diagnosis of this condition can be easily made by palpation of the patellar tendon. Patella tendinosis is generally a chronic injury, and athletes with sudden acute pain in the patellar tendon should be evaluated for a possible rupture or sleeve injury (if prepubescent), and careful consideration given before allowing return to competition. Tape or a fulcrum strap can be tried to return the athlete back to competition with tendinosis, but the athlete should be warned about the risk of rupture before returning to competition [⁸].

Ankle sprains are the most common injuries in jumping events. A jumper must load the ankle in dorsiflexion in order to provide stability. Injury results when the foot lands unexpectedly on the ground in a plantar flexed and inverted position. As a result, the lateral ankle is sprained. Immediate icing and support tape for mild sprains may return the athlete back to competition, as long as proper evaluation to rule out fracture is conducted. To give more time for an injury evaluation, a high jumper or pole-vaulter can decide to skip a height, if the height that the injury occurred during was successfully completed. All athletes with ankle sprains should be counseled to follow up with their trainer for proper rehabilitation [⁹].

Athletes participating in the long jump and triple jump are prone to Achilles tendinosis and Achilles tendon rupture, particularly in the older athlete. An Achilles rupture may occur when there is an eccentric load placed on the tendon, such as when a jumper takes off. The athlete usually feels as if struck from behind in the calf but sometimes only feels a pop. The athlete will not be able to continue and should be splinted in equines, iced, and sent for evaluation at an acute care facility [¹⁰].

Heel bruise, plantar fasciitis, and plantar fascia rupture may also occur at track and field events. The heel pad consists of a fatty layer of multiple arcades and septae to cushion heel strike. The heel can be injured acutely on one particular landing or through repetitive trauma. Chronic injury such as fat pad atrophy with plantar heel pain can be caused and aggravated by walking, jumping and running on hard surfaces. Physical examination reveals a heel that appears atrophic, feels soft, and has a persistent imprint from the knuckle when pressure is applied. Acute care involves applying a cushion to the heel [¹¹].

Chronic injuries in jumpers that present to the medical tent can include repetitive overload to the posterior tibialis tendon leading to tendonitis and possible rupture. These conditions usually present in the athlete's take-off foot, and are often associated with hyperpronation of the foot. A rupture can be diagnosed in an athlete with a newly collapsed arch. These athletes may be able to return to competition if arch taping decreases their pain level [¹²].

The athlete who competes in the triple jump has to master the hop, step, and jump. The athlete may suffer injury if he or she lands in the pit during the step phase. Injuries sustained when stepping in the pit can be knee strains, meniscal tears and anterior cruciate ligament tears. Back strains are common in the triple jump secondary to repetitive landings on the runway.

Upper extremity injuries can occur in jumpers, especially in pole vaulters and high jumpers, if they land on an outstretched arm. Resulting fractures will need splinting and further evaluation at an acute care facility. Pole vaulters can also strain their rotator cuff by not correctly placing the pole in the vault box.

An area of controversy that the medical director may be asked about is the use of helmets in pole vaulters to reduced head injuries. Although helmets are required for pole vaulters in some states, it is uncertain what level of protection that helmets provide, and there is even concern that helmets may increase flexion injuries. If the athlete does choose to use a helmet, a lacrosse type helmet without face gear or visor is recommended. Education is the key to prevention of injury, and an experienced coach can identify and correct faults to reduce the risk of missing or bouncing out of the landing pit area [^13•].

Medical Coverage in Throwing Sports (Discus, Hammer Throw, Javelin, Shot Put)

Because these events involve throwing of a heavy or sharp object, there is an inherent and obvious risk to all observers of these events. Serious injury and death have resulted because of errant throws and distracted or out-of-position observers and officials. Fields for these events must be clearly marked and monitored, with safe areas for observers provided. Officials who mark and measure throws must pay constant attention.

The discus weighs about 2 kg and is 22 cm in diameter. It is gripped by the palm and fingers and thrown by the athlete following several spins toward the front of a circle 2.5 m in diameter [^14,15]. The hammer is a wire with a handle and metal ball that weighs 7.3 kg, and it is thrown in a spinning motion similar to the discus event [^14,15]. The shot is a round metal ball weighing 7.3 kg and can be thrown with a couple of backward steps, or in a series of spins followed by an extending forward thrust of the elbow and shoulder. Cages should be securely placed to deflect the errant throw, which are more common in the discus and hammer given the less controlled nature of the spin and release. The javelin weighs 800 g and is 260 to 270 cm long. It is held near its center and is thrown overhand following a sprint down a runway [^14,15]. The javelin is very sharp and requires a very expansive area for participation.

Injuries in Throwers

Blisters and finger injuries are the most common acute injuries occurring in throwing athletes. Discus and hammer throwers are at increased risk for finger dislocations and sprains [¹⁶]. There are strict rules in how tape can be applied to the hand, and only someone familiar with these rules should apply tape. It is important to know that taping of two or more fingers together is not allowed because it may assist in the throw. Taping of individual fingers is permissible and must be shown to the main judge before the event starts. Taping of the hand is not allowed except to cover an open wound. Gloves can be used in the hammer throw to protect blisters [¹⁷]. Shot putting can put significant stress on the wrists [¹⁸]. Tape can be applied on the wrist to allow for continued competition.

Almost all other injuries in throwers that present to the medical tent are aggravation of chronic injuries. All track and field throwing athletes are prone to shoulder injuries, particularly impingement. The rotator cuff resides in the space between the coracoacromial arch and the humerus. With abduction of the arm, the supraspinatus tendon, the long head of the biceps tendon, and the subacromial bursa can be impinged [¹⁹]. Primary impingement is typically seen in athletes older than 35 and occurs because of degenerative spurs of the acromion or clavicle. Younger athletes tend to have secondary impingement from subtle glenohumeral instability. The speed and forces resulting from throwing, particularly follow-through, can place a great amount of stress directly on the rotator cuff. The rotator cuff is mainly responsible for the deceleration of the humerus through eccentric contraction.

Physical examination findings include tenderness over the involved structures and positive impingement signs such as the Neer and Hawkins test. Weakness and pain with resistance of the supraspinatus (empty can test) as well as the external rotators (teres minor and infraspinatus) is frequently seen. The subscapularis, tested by the lift-off test, is less commonly involved. Athletes with secondary impingement may have subtle signs of instability, such as a positive load and shift, sulcus, apprehension, and relocation tests [²⁰]. Acute care at the track meet can consist of ice and nonsteroidal anti-inflammatory medications, but injection to continue in an event is not recommended.

In the javelin, competitors with good technique throw over the shoulder with elbow extension. When the incorrect round-arm method is used, the elbow comes around at the level of the shoulder, and an ulnar collateral ligament (UCL) strain or rupture may occur [²¹]. Athletes often report a popping sensation with sudden pain and loss of function. The athlete will have tenderness over the UCL complex about 2 cm distal to the medial epicondyle and pain with valgus stress [²²]. If a UCL rupture is suspected, the athlete should be sent for urgent radiograph of the elbow to evaluate for bony avulsion. If ice is applied to the medial elbow, care must be taken not to put ice over the ulnar nerve.

Another overuse injury commonly seen in the javelin is medial epicondylitis. It occurs from repetitive forearm pronation and wrist flexion as seen in the late acceleration phase of throwing and involves the pronator teres and flexor carpi radialis. The close proximity of the ulnar nerve to the medial epicondyle can cause concomitant ulnar symptoms [²³]. In this condition, patients report a dull aching pain in the medial elbow that worsens with activity. Tenderness is present at the medial epicondyle. Pain is reproduced with resisted wrist flexion and forearm pronation [²⁴]. Important in the evaluation is checking the integrity of the ulnar collateral ligament. Athletes may continue in competition if forearm taping or a fulcrum strap reduces their pain and allows correct throwing technique.

Conclusions

Providing medical coverage to track and field athletes is challenging because of the diversity of events occurring at the same time and the many distractions that are present. Medical personnel should be assigned to the pole-vault and high jump areas for quick access and assessment of athletes that may have the most severe injuries. Proper marking and monitoring of throwing events should prevent most severe injuries from these sports.