Ch 7 Protective Equipment

A compressive pullover bra is perhaps the most common and is recommended for women with medium-size breasts.

Compressive bras function like wide elastic bandages, binding the breasts to the chest wall

Groin and Genitalia Protection

Sports involving high-velocity projectiles (e.g., hockey, lacrosse, and baseball) require cup protection for male participants. The cup comes as an off-the-shelf item that fits into place in a jockstrap, or athletic supporter

Arch support

The arch support should be made of a durable yet soft supportive material and should smoothly join with the insole. The support should not have any rough seams or ridges inside the shoe, which may cause blisters.

Shank

The shank is the part of the sole between the heel and the metatarsal heads. It is usually reinforced with material of sufficient density to support the weight of the wearer.

Heat-forming plastics

are of the low-temperature variety and are the most popular in athletic training. When heated to 140°F to 180°F (60°C to 82.2°C), depending on the material, the plastic can be accurately molded to a body part. Orthoplast and X-Lite (synthetic rubber thermoplast) are popular types

Rehabilitative braces

are widely used following surgical repair or reconstruction of the knee joint to allow for controlled progressive immobilization (Figure 7-29C).6 These braces have hinges that can be easily adjusted to allow range of motion to be progressively increased.

Felt

is a material composed of matted wool fibers pressed into varying thicknesses that range from ¼ to 1 inch (0.6 to 2.5 cm) (Figure 7-33B). Its benefit lies in its comfortable, semiresilient surface, which gives a firmer pressure than most sponge rubbers. Because felt absorbs perspiration, it clings to the skin, and it has less tendency to move than sponge rubber does. Because of its absorbent qualities, felt should be replaced daily. Currently, it is most often used as support and protection for a variety of foot conditions.

Customized Hard-Shell Pads

A hard-shell pad is often required for an athlete who has an injury, such as a painful contusion (bruise), that must be completely protected from further injury.

Foot Orthotics

An orthotic is a device for correcting biomechanical problems that exist in the foot that can potentially cause an injury.31,66 The orthotic is a plastic, thermoplastic, rubber, sorbethane, or leather support that is placed in the shoe as a replacement for the existing insole (see Figure 7-35).56 Ready-made orthotics can be purchased in sporting goods or shoe stores. Some athletes need orthotics that are custom made by a physician, a podiatrist, an athletic trainer, a physical therapist, or an orthotist. These are more expensive but can be well worth the expense if the athlete's feet cause pain and discomfort, especially when exercising

Ankle Braces

Ankle stabilizers, either alone or in combination with ankle taping, are becoming increasingly popular (Figure 7-26).9,32,52,77 There has been significant debate regarding the efficacy of ankle supports in the prevention of ankle sprains.30,35 Most studies indicate that bracing is effective in reducing ankle injury,26,71 but other studies have shown no effects8,34 or even negative effects.8,30 Bracing probably has little or no effect on performance; any change in performance is due to the athlete's perception of support and comfort.61 When compared with ankle taping, these devices do not loosen significantly during exercise.22 A study that Page 205collectively analyzed the data from 19 studies of the effects of different types of ankle support on ankle motion before and after activity showed significantly greater frontal-plane ankle-motion restriction after exercise for a semirigid stirrup brace design than for taping or a lace-up-type brace.22 Several studies have documented a beneficial effect of semirigid ankle bracing on sprain incidence, whereas others comparing the effects of taping and a lace-up brace on sprain incidence support the superiority of bracing for injury prevention.20,30,41,74 Recent studies have focused on the proprioceptive effects and how ankle braces influence balance, postural sway, and joint position sense.

Knee Braces

Because of the high incidence of injury to the knee joint, manufacturers have designed a host of different knee braces for a variety of purposes.11 Protective knee braces are used prophylactically to prevent injuries to the medial collateral ligament in contact sports such as football (Figure 7-29).60 Although these protective braces have been widely used in the past, the American Page 206Orthopedic Society for Sports Medicine has expressed concern about their efficacy in reducing injuries to the collateral ligaments.53 Several studies have actually shown an increase in the incidence of injuries to the medial collateral ligament in athletes wearing these braces.60 Others have shown a positive influence on joint position sense4 but little or no effect on performance

Knee Pads

Elastic knee pads or guards are extremely valuable in sports in which the athlete falls or receives a direct blow to the anterior aspect of the knee. An elastic sleeve containing a resilient pad may help dissipate an anterior striking force and reduce contusions but fails to protect the knee against lateral, medial, or twisting forces that result in stress to the ligaments.

The lightweight Revolution Speed helmet from Riddell

Extends the protective shell to the jaw area to provide protection to the side of the head and the jaw as well as improved front-to-back fit and stability.55 The face guard system is designed to isolate the attachment points of the face guard from the shell, thus reducing jarring to the player from low-level impacts to the face guard. The latest in helmet technology attempts to minimize the impact forces transmitted to the athlete's head by having a shell that flexes at specific points to reduce and dissipate the forces. The Riddell SpeedFlex also incorporates a system of five accelerometers (sensors) that measure forces and the direction of an impact to the helmet and transmits that information to a computer that warns an athletic trainer whenever an athlete sustains a significant impact to the head.

Shoe Fitting

Fitting athletic shoes can be difficult.7 Frequently, the athlete's left foot varies in size and shape from the right foot. Therefore, measuring both feet is imperative. To fit the sports shoe properly, the athlete should approximate the conditions under which he or she will perform, such as wearing athletic socks, jumping up and down, or running. It is also desirable to fit the athlete's shoes at the end of the day to accommodate the gradual increase in foot volume that occurs during weight-bearing. The athlete must carefully consider this shoe choice because he or she will be spending countless hours in those shoes (see Focus Box 7-8: "Proper running shoe design and construction" for suggestions about shoe fitting)

Heel Cups

Heel cups should be used for a variety of conditions, including plantar fasciitis, a heel spur, Achilles tendinitis, and heel bursitis (Figure 7-25). The heel cup helps to compress the fat pad under the heel, providing more heel cushioning during weight-bearing activities. Heel cups may be either hard plastic or spongy rubber. They should generally be worn bilaterally.

Eye and Glasses Guards

It is essential that athletes take special precautions to protect their eyes, especially in sports that use fast-moving projectiles and implements, such as handball and racquetball (Figure 7-12).40 Besides the more obvious sports of ice hockey, lacrosse, and baseball, the racquet sports can also cause serious eye injury. Athletes not wearing glasses should wear closed eye guards to protect the orbital cavity. Athletes who normally wear glasses with plastic or case-hardened lenses are to some degree already protected against eye injury from an implement or a projectile; however, greater safety is afforded by the polycarbonate frame that surrounds and fits over the athlete's glasses. The protection that the guard affords is excellent, but it hinders vision in some planes. Polycarbonate eye shields can be attached to football face masks, hockey helmets, and baseball and softball helmets.

Sports Bras

Manufacturers have made significant efforts to develop athletic support bras for women who participate in all types of physical activity. In the past, the primary concern was for breast protection against external forces that could cause bruising. Most sports bras are now designed to minimize excessive vertical and horizontal movements of the breasts that occur with running and jumping.

Thorax and Rib Protection

Many of the thorax protectors and rib belts can be modified by replacing stock pads with customized thermomoldable plastic protective devices.49 Many lightweight pads have been developed to protect the athlete against external forces. A jacket for the protection of a rib injury incorporates a pad composed of air-inflated, interconnected cylinders that protect against severe external forces (Figure 7-19). The same principle has been used in the development of other protective pads.

baseball/softball batting helmet

Must withstand high-velocity impacts.24 Unlike football and ice hockey, baseball and softball have not produced a great deal of data on batting helmets. It has been suggested, however, that baseball and softball helmets do little to adequately dissipate the energy of the ball during impact (Figure 7-4). A possible solution is to add external padding or to improve the helmet's suspension. The use of a helmet with an ear flap can afford some additional protection to the batter. Each runner and on-deck batter is required to wear a baseball or softball helmet that carries the NOCSAE stamp, which is similar to the warning on football helmets.

Off-the-Shelf Foot Pads

Off-the-shelf foot pads are intended for use by the general public and are not usually designed to withstand the rigors of sports activities. Off-the-shelf pads that are suited for sports are generally not durable enough for hard, extended use. If money is no object, the ready-made off-the-shelf pad, Page 204which is replaced more often, has the advantage of saving time. Off-the-shelf pads are manufactured for almost every type of common structural foot condition, ranging from corns and bunions to fallen arches and pronated feet. Off-the-shelf foot pads are commonly used before more customized orthotic devices are made. These products offer a compromise to the custom-made foot orthotics by providing some biomechanical control.37 Indiscriminate use of these aids, however, may intensify the pathological condition or cause the athlete to delay seeing the team physician or team podiatrist for evaluation

Hip and Buttock Protection

Pads in the region of the hips and buttocks are often needed in collision and high-velocity sports, such as hockey and football. Other athletes needing protection in this region are amateur boxers, snow skiers, equestrians, jockeys, and water skiers. The most popular commercial pads are the girdle types, in which lightweight hip and coccyx pads are inserted into pockets in the girdle

Socks

Poorly fitted socks can cause abnormal stresses on the foot. For example, socks that are too short crowd the toes, especially the fourth and fifth ones. Socks that are too long can wrinkle and cause skin irritation. All athletic socks should be clean, dry, and without holes to avoid topical fungal infections and other irritations. Manufacturers are now providing different types of socks for various sports. The composition of the sock's material also should be noted. Cotton socks can be too bulky, whereas a combination of materials such as cotton and polyester is less bulky and dries faster.

Trunk and thorax protection is essential in many contact and collision sports.

Sports such as football, ice hockey, baseball, and lacrosse use extensive body protection. Areas that are most exposed to impact forces must be properly covered with some material that offers protection against soft-tissue compression. Of particular concern are the external genitalia and the exposed bony protuberances of the body that have insufficient soft tissue for protection, such as shoulders, ribs, and spine

Shoe Selection

The athletic and fitness shoe manufacturing industry has become extremely sophisticated and offers a number of options when it comes to purchasing shoes for different activities.1 Shoes are specifically manufactured and marketed for running, walking, basketball, tennis, and aerobics. (See Table 7-1 for shoe comparisons.) If an individual participates in multiple sports, it is strongly recommended that separate shoes be purchased and worn for each sport.38,44 It must also be stressed that shoes don't last forever. Over time, they break down, degrade, and lose shock absorption from use. For example, a running shoe is expected to last for 350 to 550 miles before it begins to develop wear patterns and break down to the point where it should no longer be used for running. Thus, for an active individual shoes must constantly be replaced.

headgear for soccer players

The headgear is essentially a headband with a piece of foam in the front that is about 1½ to 2 inches (3.8 to 5 cm) wide. To date there is one study that demonstrates that headgear is effective in reducing the risk of concussions or other head injuries.25 Interestingly, some have identified increases in head accelerations during heading while wearing soccer headgear.68,70 Furthermore, conflicting evidence exists regarding the effectiveness of soccer headgear to reduce impact responses associated with heading a soccer ball.12,75 While some evidence suggests that a soccer player may become concussed after heading a soccer ball, it is far more likely that the soccer player will get a concussion by hitting his or her head on another player.

Heel counter

The heel counter is the portion of the shoe that prevents the foot from rolling from side to side at heel strike. The heel counter should be firm but well fitted to minimize movement of the heel up and down or side to side. A good heel counter may prevent ankle sprains and painful blisters.

Shin and Lower Leg

The shin and lower leg are particularly vulnerable to being kicked, especially in soccer, or hit with a stick in field hockey. The anterior surface of the tibia is exposed, lacking any soft-tissue protection. Contusion to the anterior surface of the tibia can result in swelling and significant pain. Contusion of the exposed muscle either lateral or medial to the tibia can result in compartment syndromes (see Chapter 19). Shin guards should be used to protect the anterior shin from direct blows. For maximum protection, the shin guards should extend from just below the tibial tubercle proximally to just above the malleoli distally

Sole

The sole should possess two qualities. First, it must provide shock absorption; second, it must be durable. Most shoes have three layers on the sole: a thick, spongy layer, which absorbs the force of the foot strike under the heel; a midsole, which cushions the midfoot and toes; and a hard rubber layer, which comes in contact with the ground. The average runner's feet strike the ground between 1,500 and 1,700 times per mile. Thus, it is essential that the force of the heel strike be absorbed by the spongy layer to prevent overuse injuries from occurring in the ankles and knees. Heel wedges are sometimes inserted on either the inside or the outside surface of the sole underneath the heel counter to accommodate and correct for various structural deformities of the foot that may alter normal biomechanics of the running gait. A flared heel may be appropriate for running shoes but is not recommended in aerobic or court shoes. The sole must provide good traction and must be made of tough material that is resistant to wear. Most of the better-known brands of shoes have well-designed, long-lasting soles.

Shoe upper

The upper part of the shoe is made of some combination of nylon and leather. The uppers should be lightweight, quick drying, and well ventilated. They should have some type of extra support in the saddle area, and there should be some extra padding in the area of the Achilles tendon just above the heel counter.

Toe box

There should be plenty of room for the toes in the athletic shoe. A distance of ½ to ¾ inch Page 200(1.3 to 1.9 cm) between the longest toe and the front of the shoe is recommended. A few fitness shoes are made in varying widths. If an athlete has a very wide or narrow foot, most shoe salespersons can recommend a specific shoe for that foot. The best way to make sure the toe box offers adequate room is to have the foot measured and then try on the shoe.

Support bras are a bit more heavy duty and provide good upward support with elastic material and an underwire.

They tend to have wide bands under the breasts with elastic shoulder straps in the back. They are designed for women with larger breasts

Thigh and Upper Leg

Thigh and upper-leg protection is widely used in collision sports, such as hockey, football, and soccer. Generally, pads slip into ready-made pockets in the uniform (Figure 7-28A). In some instances, customized pads should be constructed and held in place with tape or an elastic wrap. Neoprene sleeves can be used for support following strain to the hamstring, groin, or quadriceps muscles

Last

This is the form on which the shoe is built. The last may be straight, semicurved, or curved. A straight-lasted shoe is filled in on the inside/medial side of the shoe to increase stability for people who have a flat arch or run on the inside of their foot (pronators). A semicurved last is designed for the average or normal foot. There is a small curve on the medial side of the foot to fit a normal arch. The curved last is built with a larger curve on the medial side of the shoe and has a wider outside portion of the shoe to provide more forefoot stability. A curved last is built for people with an abnormally high arch and for runners who run on the outside of their foot (supinators

Baseball catchers, lacrosse goalies, and ice hockey goalies are most at risk.

Throat protection should be mandatory for these sports. Throat protectors may be built into the helmet or they can be attached separately

Football Shoulder Pads

Two general types of shoulder pads are available: cantilevered and noncantilevered (Figure 7-14). A cantilever is a strap that extends from the front to the back of the shoulder pads that causes the shoulder pads to arch above the tip of the shoulder, thus dispersing pressure onto the pads rather than on the shoulder. The player who uses the shoulder a great deal in blocking and tackling requires the bulkier, cantilevered type, whereas a quarterback, receiver, or youth football player might prefer to use the noncantilevered pads, which don't restrict shoulder motion as much as the cantilevered pads. Over the years, the shoulder pad's front and rear panels have been extended along with the cantilever. Focus Box 7-7: "Rules for fitting football shoulder pads" summarizes fitting guidelines

Price

Unfortunately, in many instances price is the primary consideration in buying athletic shoes. When buying athletic shoes, remember that in many activities shoes are important for performance and prevention of injury. Thus, it is worth a little extra investment to buy a quality pair of shoes.

Ear Guards

With the exception of wrestling, water polo, and boxing, most contact sports do not make a special practice of protecting the ears. All these sports can cause irritation of the ears to the point that permanent deformity can ensue. To avoid this problem, ear guards should be worn routinely

Mouth guards

also minimize lacerations to the lips and cheeks and fractures to the mandible. The mouth protector should give the athlete proper and tight fit, comfort, unrestricted breathing, and unimpeded speech during competition. A loose mouth guard will soon be ejected onto the ground or left unused in the locker room.2 The athlete's air passages should not be obstructed in any way. It is best when the mouth guard is retained on the upper jaw and projects backward only as far as the last molar, thus permitting speech. Maximum protection is afforded when the mouth guard is composed of a flexible, resilient material and is formed to fit to the teeth and upper jaw.

cycling helmets

are designed to protect the head during one impact. Football, hockey, and baseball helmets are more durable and can survive repeated impacts.49 Helmet use in high-velocity sports such as cycling has been shown to protect against traumatic head and facial injury Many states require the use of cycling helmets, especially by adolescents. "Guidelines for fitting a cycling helmet" outlines fitting procedures.

Lacrosse helmets

are made of a hard plastic with a wire mesh cage, or face mask, to protect the front of the face (Figure 7-6). The face mask must have a center bar running from the top to the bottom. The helmet is designed to absorb repeated impact from a hard, high-velocity projectile. Helmets come in a variety of sizes and are usually measured in inches. Lacrosse helmets use a four-point buckling system both to ensure that they stay on and to allow for a better fit. Goalie helmets add a throat protector.

Heat-plastic foams

are plastics that have differences in density as a result of the addition of liquids, gas, or crystals. They are commonly used as shoe orthotic inserts and other body padding. Plastazote and Aliplast Page 209(polyethylene foams) are two commonly used products. Usually, the plastic is heated until soft and malleable. It is then molded into the desired shape and allowed to cool, thereby retaining its shape. Various pads and other materials can also be fastened in place. The rules and regulations of various sport activities may place limitations on the use of rigid thermomoldable plastics.

Face guards

are used in a variety of sports to protect against flying or carried objects during a collision with another player (Figure 7-7). Since the adoption of face guards and mouth guards for use in football, the incidence of facial injuries (e.g., lacerations, nose fractures, eye injuries) has dramatically decreased. However, the number of concussions and, to some extent, neck injuries has increased because the head is more often used to make initial contact.15 The catcher in baseball, the goalie in hockey, and the lacrosse player should all be adequately protected against facial injuries, particularly lacerations and fractures

Contact lenses

come mainly in two types: the corneal type, which covers just the iris of the eye, and the scleral type, which covers the entire front of the eye, including the white. Peripheral vision as well as astigmatism and corneal waviness are improved through the use of contact lenses. Unlike glasses, contact lenses do not normally cloud during temperature changes. They also can be tinted to reduce glare. For example, yellow lenses can be used against ice glare and blue ones against glare from snow. Some serious disadvantages of wearing contact lenses are the possibility of corneal irritation caused by dust getting under the lens and the possibility of a lens becoming dislodged during body contact. In addition, only certain individuals can wear contacts with comfort, and some individuals are unable to ever wear them because of certain eye idiosyncrasies. Athletes currently prefer the soft, hydrophilic lenses to the hard type. Adjustment time for the soft lenses is shorter than for the hard, they can be more easily replaced, and they are more adaptable to the sports environment. Disposable lenses and lenses that can be worn for an extended period are also available. In the last few years, the cost of contact lenses has dropped significantly.

Jaw pads

essential to keep the helmet from rocking laterally. They should fit snugly against the player's cheekbones. Certification of a helmet's ability to withstand the forces of the game is of no avail if the helmet is not properly fitted or maintained. Loop straps can be used to fix the face mask to the helmet. These can be easily cut to remove the face mask should there be an injury that requires CPR or spinal injury. Various quick release face mask attachment systems have also been developed for use in securing the face mask to the helmet. While these systems have been designed to facilitate face mask removal in an emergency, athletic trainers should gain familiarity with these new systems and the obstacles they may present

The majority of dental traumas can be prevented

if the athlete wears a correctly fitted, customized intraoral mouth guard (Figure 7-10).43,46,58 Consistent evidence to support the use of mouth guards for reducing or minimizing concussion is not available. However, substantial evidence demonstrates that a properly fitted mouth guard reduces dental injuries

Chin straps

important in maintaining the proper head and helmet relationship. Three basic types of chin straps are in use today: a two-snap, a four-snap, and a six-snap strap. Many coaches prefer the four-snap chin strap because it keeps the helmet from tilting forward and backward. The chin strap should always be locked so that it cannot be released by a hard external force to the helmet.

Cotton

is a cheap and widely used material that has the ability to absorb, to hold emollients, and to offer a mild padding effect.

Gauze padding

is less versatile than other pad materials. It is assembled in varying thicknesses and can be used as an absorbent or protective pad.

For women with smaller breasts

it is not as critical to provide compression or support, and thus a less elastic, lightweight bra is sufficient

Adhesive felt (moleskin) or sponge rubber

material contains an adhesive mass on one side, thus combining a cushioning effect with the ability to be held in place by the adhesive mass. It is a versatile material that is useful on all body parts

Neoprene braces with medial and lateral supports

may be used by individuals who have sustained injury to the collateral ligaments and feel that they need extra support medially and laterally

Functional knee braces

may be worn both during and following the rehabilitative period to provide support during functional activities (Figure 7-29B).14,16,62 Functional braces can be purchased ready made or can be custom made.72 Some physicians strongly recommend that their patients consistently51 wear these braces during physical activity, whereas others do not feel that they are necessary.

An ice hockey helmet

must withstand not only high-velocity impacts (e.g., being hit with a stick or a puck, which produces low mass and high velocity) but also the high-mass-low-velocity forces produced by running into the boards or falling on the ice.50 In each instance, the hockey helmet, like the football helmet, must be able to disperse the impact over a large surface area through a firm exterior shell and, at the same time, be able to decelerate forces that act on the head through a proper energy-absorbing liner. It is essential for all hockey players to wear protective helmets that carry the stamp of approval from either the Canadian Standards Association (CSA)

In football

no face guard should have less than two bars. Proper mounting of the face mask and bars is imperative for maximum safety. All mountings should be made in such a way that the bar attachments are flush with the helmet. A 3-inch (7.62 cm) space should exist between the top of the face guard and the lower edge of the helmet. No helmet should be drilled more than one time on each side, and this drilling must be done by a factory-authorized reconditioner. Attachment of a bar or face mask not specifically designed for the helmet can invalidate the manufacturer's warranty.

Athletes should wear

polycarbonate lenses, which are virtually unbreakable.73 These are the newest type of lenses available, and they are the safest. If the athlete has glass lenses, they must be case-hardened to prevent them from splintering on impact. When a case-hardened lens breaks, it crumbles, eliminating the sharp edges that may penetrate the eye. The cost of this process is relatively low. The only disadvantages are that the glasses are heavier than average and may be scratched more easily than regular glasses.40 Another possible sports advantage of glass-lensed glasses is that they can be created so the lenses become color-tinted when exposed to ultraviolet rays from the sun and then return to a clear state when removed from the sun's rays. These lenses are known as photochromic lenses.

During performance conditions,

the new shoe should feel snug but not too tight. The sports shoe should be long enough that all toes can be fully extended without being cramped. Its width should permit full movement of the toes, including flexion, extension, and some spreading. The wide part of the shoe should match the wide part of the foot to allow the shoe to crease evenly when the athlete is on the balls of the feet. The shoe should bend (or "break") at its widest part; when the break of the shoe and the ball joint coincide, the fit is correct. However, if the break of the shoe is in back of or in front of the normal bend of the foot (metatarsophalangeal joint), the shoe and the foot will oppose one another, causing abnormal skin and structural stresses to occur. Page 202Two measurements must be considered when fitting shoes: (1) the distance from the heel to the metatarsophalangeal joint and (2) the distance from the heel to the end of the longest toe. An individual's feet may be equal in length from the heels to the balls of the feet but different between the heels and the toes. No single type of shoe is appropriate for all athletes in a particular sport. Shoes therefore should be selected for the longer of the two measurements.7 Other factors to consider when buying a sports shoe are the stiffness of the sole and the width of the shank, or narrowest part of the sole. A shoe with a sole that is too rigid and nonyielding places a great deal of extra strain on the foot tendons. A shoe with a shank that is too narrow also causes extra strain because it fails to adequately support the athlete's inner, longitudinal arches.42 Lacing techniques can help adjust the width of the shoe to the foot. Focus Box 7-9: "Shoe lacing techniques" provides some suggestions for alternative lacing techniques. Two other shoe features to consider are insoles to reduce friction and arch supports.

There are two types of traction

translational traction, which allows for straight line movement, and rotational traction, which allows for side-to-side movement or directional changes. Shoes with the best translational traction have cleats on the forefoot that grip the playing surface providing good traction in a forward direction, but they also have the lowest incidence of injuries to the lower extremities. Shoes with high rotational traction, on the other hand, have multiple long cleats and or nodules on the outside of the sole that provide good traction when changing direction but tend to have a higher incidence of lower extremity injury. From an injury prevention perspective, shoes that grip the playing surface when sprinting forward but do not stick when cutting or changing direction seem to be the safest. The incidence of injury is similar on both synthetic turf and natural-grass playing surfaces.