The FINA Sports Medicine Web Pages are designed to provide team physicians and allied medical support staff with up to date medical and scientific information to guide their daily care of the aquatic athlete.
Coaches, athletes and parents can also use these pages to answer their questions regarding aquatic health issues.
For nine years I have had the pleasure of being the medical director and team physician for USA Water Polo. My medical training is in Internal Medicine. I have worked as a sports medicine physician with University athletes at the University of California Los Angeles (UCLA) for 20 years in addition to my private internal medicine practice. I set aside six weeks of the year to travel abroad for the USA national water polo teams. Needless to say, my two decades worth of experience in this sport have provided me with some lessons worth sharing.
Qualities of a Team Physician
Be open to assisting others. A team physician needs to be approachable and available to treat all team members and staff. But he or she should also be willing to care for other teams. Not all international teams have the resources to bring trainers and physicians on all overseas competitions, so team physicians need to be open to the fact that their responsibilities should extend beyond their own team. Some of my finest memories have been caring for members of other nationalities, FINA delegates, referees and families associated with the other traveling teams.
Establish and maintain trust. Teams that travel are close by nature and the way information is shared makes confidentiality challenging at times. Having a private room during road trips and developing trust with an athlete helps preserve their important right of confidentiality.
Project calm. In any competition, nerves and emotions can flare so team physicians need to remain calm and conduct themselves with a predictable demeanor that athletes and staff members can anchor to in times of chaos. This stability is important to restore order within a game and help redirect energies in a more positive direction. Above all, team physicians need to defuse problems and issues not contribute to them. We are here to serve the team and not the other way around.
Know your clientele. Once a national team has been chosen, I will then have the chance to do a history and physical examination before any major competition. I focus on all major components that I would perform on any patient. I update their vaccines to include protection against hepatitis A and B, meningitis, and shingles (chicken pox). Awareness to allergies and the seasonal differences that exist around the world can help sensitive athletes prior to any long road trip. A careful evaluation in conjunction with the trainer will help identify subtle problems that may include previous surgeries and chronic injuries that are failing current treatments.
Working on the road. Athletes that travel require special attention. As such, it’s imperative that I become extremely familiar with their sleep patterns, dietary habits, air travel issues and how to maintain their fluid, salt and water balance. Oftentimes, an athlete will inquire how they can get better sleep during a trip when they have been experiencing sleep deprivation.
Not all athletes enjoy the native food of foreign travel and they often resort to consuming candy and snack foods that contribute to a negative nitrogen balance. Not all athletes like to speak up about the anxiety they experience when flying. Even the anticipation of flying can be a problem for some athletes.
In warm climates, training in warm pools can contribute to fatigue in an athlete that is behind with their salt and water requirements. All of these common issues are preventable with constant monitoring of your athletes.
Take the time at meals or when the coach holds a meeting to bring up special issues and keep yourself available soon after to offer assistance. On the bus, take the time to sit with various athletes and hold conversations that allow them to open up to you.
Treating female athletes. Female athletes have additional concerns. Amenorrhea – a condition marked by loss of menstruation - can accompany weight loss and can lead to thinning of the bones long term. Weight loss can compromise an athlete’s ability to compete. It can be even more difficult to regain, not only because of the calories required to maintain weight but because of the extra calories needed to regain her previous fitness level.
Altered menstrual cycles can be a challenge for female athletes. Birth control medications can help but with changing travel schedules, sleep deprivation, and altered dietary habits it can still prove challenging to maintain a regular cycle.
Post 9/11 adjustments. Before 9/11 it was easier to travel with medications and personal medical equipment to care for athletes in route. While traveling, athletes at times will seek out medical attention and decide to discuss medical problems. This will, inevitably occur when I am without my medical bag, medications and other equipment, which now has to be in my checked luggage. The only thing you can do, then, is to teach your team how to reach for help at the right time and at the right place.
I find it quite difficult to assist athletes who present with medical issues at the airport. Though it is convenient for them to try and remedy their problems when they are not training, this is not appropriate. It is the responsibility of team physician to instruct members of the teams that there is a time and a place to care for their medical needs. This is not at an airport, bus or poolside, but in the privacy of our hotel or training room when we’re in a better position to help them.
Common Water Polo Injuries
Most sports medicine physicians like to separate injuries into acute injuries and chronic injuries. Most of the acute injuries are lacerations of the skin, eye injuries, and tympanic (eardrum) injuries and, in descending order, sprains of the fingers, elbows, shoulders and knees.
King of water polo injuries. A concussion, however, is the most important acute injury to care for. A fast moving ball, usually off the cage and into the back of the goalie’s head, or a hand that inadvertently hits the head of another player is usually the cause. Identifying and treating a concussion can be difficult since symptoms tend to be subjective and are hard to objectively measure. Even an astute physician watching a competition carefully can miss a blow to a team member’s head. Any reports of dizziness, headache, confusion, sleepiness and lack of concentration should be treated seriously. Guidelines from the Second International Symposium on Concussion in Sport (Prague 2004) can help assist the physician in the decision making process for return to play after concussion.
“Protective” equipment? Protective equipment can at times be not so protective. A good example would be the ear guards that protect the ears above water but damage the ears under water. Air can easily escape from the air vents that are manufactured into the plastic molding. Therefore, any body part or ball that hits the ear guard protects the skin of the ear as well as the eardrum. Under water trauma, however, is a different story. An overly used and flexible ear guard can compress under pressure. These forces, coupled with small air vents, won’t allow for the fast exodus of water. This can easily damage or rupture an ear drum. This usually occurs when a player is under water and an opposing player’s foot hits the ear guard on a counter play and forces water into the eardrum.
Women water polo athletes have the added disadvantage for skin injuries because of their suits. Most teams prefer a durable suit that is difficult to tear but as a result of this durability, when these types of suits are pulled from the front, the suit can cut into the back of the athlete’s neck causing either a laceration or abrasion. In the same manner, an opposing player’s fingers and fingernails can cause lacerations to the chest area as they attempt to use the player’s suit to gain a tactical advantage. These injuries are quite common in athletes that play or defend the two-meter set position in front of the goal.
Common chronic ailments. Chronic injuries in water polo mainly involve the shoulders and knees. Overtraining, poorly treated injuries or delay in care can contribute to these types of injuries.
Swim strokes in water polo include freestyle with head down, freestyle with head up and the backstroke. These strokes in the horizontal position can contribute to a variety of painful shoulder problems. Rotator cuff tendonitis, impingement syndrome, biceps tendonitis and acromioclavicular joint arthritis are the injuries most often encountered.
Once play has set up and the athletes have finished transitioning to offense or defense they assume a vertical position which begins to work the hips and knees. Known as the eggbeater kick, the lower extremities begin to spin in such a way that it puts forces on the inside portion of the athlete’s knees. Medial and lateral collateral ligament strain and medial compartment (cartilage) injury are the most commonly encountered injuries. In general, chronic injuries to the lower extremities are better tolerated than those suffered to the upper extremities. This is especially true when the injury involves the shooting arm.
The most important chronic injury is the same as that of an acute injury – chronic, repetitive head trauma that leads to concussions. Once the head receives its first impact that leads to a concussion it becomes more vulnerable to repeated injury. Second impact syndrome describes the brain’s vulnerability to repeated blows that can lead to permanent damage of the central nervous system and, in rare cases, death. The most difficult decision that a team physician can make in the 21st century is when an athlete can return to play after repeated head traumas.
Treating Water Polo Injuries
The most important position of any medical team is the role of the trainer. It is very important that the team trains and travels with a trainer that has extensive experience with water polo athletes. Typical taping and treatment regimens are altered because of the water environment. Ear and eye injuries are difficult to treat especially if the eardrum is ruptured or the player wears contact lenses since goggles are prohibited. Conditioning of the water polo athlete means swimming long distances during training and can contribute to reflux symptoms that may require treatment and alter their diet. Pool temperature can heat up in warmer climates and should alert the medical staff of premature dehydration.
When traveling, familiarization with other teams and their medical staff is important. I have had the pleasure over the past several years to become friends with the medical staffs of other international teams who have been a great source of information. While on the pool deck, get to know the medical personnel and the location of the backboard and other emergency supplies. Know if and where the facility’s portable defibrillator is and know how to use it. Know if there are stand-by paramedics and emergency transportation. While visiting a foreign country, look around the hotel and training facilities to see where local pharmacies, food markets and hospitals may be located.
Much of what it takes to be a team physician can be learned in books – how to diagnose and treat certain maladies, proper first-aid techniques, the best supplies to keep on hand – but as you may surmise from the information that I have discussed, there is also a great deal that can only be learned through experience. That’s why it’s important for me and my colleagues to network and to share with you the many ways that good doctors can be made great, whether at your local practice, or poolside with some of the world’s best athletes.
Ask the Doc
One of the players on my water polo team has a concussion. Should I let him train with the team?
Due to the nature of the sport, concussions can occur in water polo. In the injury research study conducted in Athens during the Olympic Games comparing injury incidence in all team sports, it was found that water polo was one of the safest of the team sports with a relative low injury rate. Head injury was the most common injury suffered in water polo. As mentioned in the article by Dr. Drum, there are Guidelines available for the diagnosis and management of concussion (Prague Consensus on Concussion 2004). In answer to your question, any athlete who has symptoms of concussion should not be training or competing. All athletes with concussion symptoms should seek medical attention.
Is doping control different in water polo than in other aquatic sports?
The same general rules for doping control apply to all athletes regardless of the sport (World Anti-Doping Code). There are some subtle differences for water polo. According to the FINA rules, the random draw for the water polo athletes occurs between the 3rd and 4th quarter. In all other aquatic sports, the random draw occurs prior to the event. There may be one or more players drawn per team. The testing process, sample analysis and results management are the same for water polo players as for other aquatic athletes. There are differences in repercussions or sanctions for teams for positive tests.(adverse analytical findings).