athletes versus mere mortals

Monday, July 1, 2013

Elite athletes try very hard to minimize or hide their injuries for fear that their opponents would exploit a potential weakness. Most pros will play hurt because of their love of the game and their commitment to team, but hockey players carry their mystique to potential self-harm. This year’s poster child is Patrice Bergeron of the Boston Bruins, who was taken off the bench and then spirited away to a local hospital for care. Rumors ran rampant, but players and coach would not confirm or deny any injury. Bergeron came back to play the next game and it was only after the final whistle blew that it was revealed he had a broken rib, torn rib cartilage and a separated shoulder.

This is where hockey players separate themselves from mere mortals. We breathe like a bellows. The ribs swing out, the diaphragm muscle that divides the chest from the abdomen, pushes down and air is sucked into the lungs. If the chest wall is damaged, whether a rib is broken or just bruised, pain makes taking a deep breath incredibly painful. Plus the muscles surrounding the injury go into spasm, further impairing the breathing mechanism.

Healing takes a long time. If an arm is hurt, it is put in a sling to rest. If a leg is injured, crutches can be used. But you can’t stop breathing, so 12-14 times a minute, with every breath, the broken rib edges rub against each other, causing pain and making it hard for them to set and heal. While it takes ordinary people four to six weeks to recover, Patrice Bergeron was on the ice within 48 hours. Of course, he had a little help and this is where the story gets complicated. To decrease the pain and allow him to function, doctors performed a nerve block, injecting Bergeron’s rib area to anesthetize the nerves, allow him to take a deep breath and lace up his skates.

Unfortunately for Bruin fans, the Chicago Blackhawks won the Stanley Cup and while they celebrated on the ice, Bergeron developed a complication of either the broken rib or the nerve block. Either way, he developed a pneumothorax or collapsed lung and ended back in hospital.

Both the lung and the chest wall are covered with a shiny, slippery surface called pleura. The lung is held against the chest wall by negative pressure in the space between the pleural linings. With each breath in and out, the lung slides along the chest wall. If the pleura is damaged and the negative pressure seal is damaged, the lung can shrivel away from the chest wall and collapse. It can collapse completely, minimally or somewhere in between. While a pneumothorax can occur spontaneously, it is a known complication of chest wall trauma.

Bergeron had two potential causes of his collapsed lung. The first is that the needle, used for the nerve block which is inserted in between the ribs, was placed too deep. The second is that the broken rib damaged the pleura. The broken rib could have immediately caused the collapse by puncturing the lung and letting air into the pleural space. Or a bit of lung got caught in the fracture line (remember that broken, fractures and cracked all mean the same thing) and over days, that bit of lung pinches off. The reason doesn’t really matter because the end result is the same, a damaged lung. Fortunately, Bergeron responded well to treatment and was released from hospital relatively quickly. Interestingly, in non-trauma patients, depending upon the circumstances and if the pneumothorax is small, the body can heal the damage on its own and the patient may be observed at home. Other patients need a tube placed into the pleural space, hooked up to suction and re-inflating the lung.

There are lessons to be learned from the Bergeron saga.

  • Chest wall injuries hurt, whether a rib is broken or not. They take time to heal and the worry is not the rib injury but the status of the underlying lung.
  • Minor procedures can have major complications.
  • Pro athletes are treated differently that regular patients so that they can return to play sooner. The risk reward decision is skewed to higher risk than is usually tolerated by the general public. It might be extrapolated that athletes would apply the risk paradigm to steroid use, other performance enhancing drugs, and playing with concussion.

While athletes may be role models with their pursuit and commitment to performing at their personal best, their decision making regarding return to play after injury should not be celebrated. Playing hurt might be a badge of honor but regular people should listen to their bodies and know that pain is not normal and might be a warning sign that something isn’t right.

 

 

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