Arthritis

With the increasing problem of the obesity epidemic, it has been shown that youths with low levels of physical activity and high body fat are at increased risk for cardiovascular disease. In contrast, it is a challenge for our patients who suffer from chronic illnesses to be encouraged to stay active and fit while keeping their condition under control. One such condition is juvenile idiopathic arthritis (JIA), which is the most common chronic rheumatoid disease in childhood. Exercise is an integral part of managing this condition to preserve joint mobility and maintain muscle mass and strength. However, data show that these patients are less active than their peers. It is vital to have a multidisciplinary team approach to achieve success and adherence to a sound and practical exercise program.

Despite having no significant effects on endurance and functional ability of patients with JIA, an aquatic-based program studied by Takken and colleagues has been shown to positively influence the health-related quality of life of these patients. Takken and colleagues found this to be a safe program, with no signs of worsening in the health status of patients. A land-based aerobic program that included warm-up and stretching used by Singh-Grewal and colleagues in a randomized controlled trial resulted in improved physical function as measured in the Child Health Assessment Questionnaire. There was better compliance with the control group that involved the qigong regimen, which is similar to tai chi. An intensive Cochrane review did not show statistically significant evidence that exercise therapy can improve functional ability, quality of life, aerobic capacity, or pain, but it did affirm that exercise does not exacerbate arthritis.

Participation in sports needs to be individualized for each patient with JIA, as is the case for any chronic condition. Aerobic, flexibility, static, dynamic, and neuromuscular demands of the sport should be considered, as well as the potential for contact or collision. The availability of safety equipment has to be explored, alongside the need for splints or orthosis. The family and coaches have to assess the athlete’s ability to self-limit participation.

JIA often persists into adulthood, although fewer than 10% become severely disabled. Promoting sports during childhood and adolescence hopefully will help individuals to acquire healthy practices and maintain an active lifestyle as they transition into adulthood.

Eye injuries

Eye injuries are rare among high-school and college athletes but have the potential for high morbidity. Baseball and basketball in the United States and soccer in European countries are most commonly implicated to cause eye injuries. Injuries range from the more benign eyelid laceration, corneal abrasion, foreign bodies, and hyphema to the more serious blow-out fracture, retinal detachment, or globe rupture. Children and adolescents are still developing their muscle coordination and reaction time, making them more vulnerable to these injuries.

Injured players may return to play immediately, depending on the extent of the trauma, but, if they received a topical anesthetic in the eye, then they should not be allowed to resume play. The affected eye should be pain free and have adequate recovery of vision. Symptoms like foreign-body sensation, vision loss, proptosis interfering with vision, pain, loss of visual field, or a flash sensation are warnings for an ophthalmology evaluation and clearance for return to play.

The American Academy of Pediatrics (AAP) and American Academy of Ophthalmology issued a joint policy statement in 2004 recommending that all youths in organized sports should wear appropriate eye protection. There are sport-specific eye protectors such as a face guard attached to the helmet in baseball or a full-face shield in hockey. Protective eye wear for sports should meet the requirements of certifying bodies like the Protective Eyewear Certification Council, American Society for Testing and Materials (ASTM), Hockey Equipment Certification Council (HECC) and the National Operating Committee on Standards in Athletic Equipment (NOCSAE). Regular spectacles and contact lenses do not offer protection, so the appropriate eyewear is still strongly recommended. Functionally one-eyed athletes should wear protective eyewear as well as those whose ophthalmologists recommend eye protection after surgery or trauma. Sport-appropriate and properly fitting eye protectors reduce the risk of significant eye injury by at least 90%, so young athletes should develop the habit of using this protective gear early to avoid potentially blinding injuries.

Eye injuries

Eye injuries are rare among high-school and college athletes but have the potential for high morbidity. Baseball and basketball in the United States and soccer in European countries are most commonly implicated to cause eye injuries. Injuries range from the more benign eyelid laceration, corneal abrasion, foreign bodies, and hyphema to the more serious blow-out fracture, retinal detachment, or globe rupture. Children and adolescents are still developing their muscle coordination and reaction time, making them more vulnerable to these injuries.

Injured players may return to play immediately, depending on the extent of the trauma, but, if they received a topical anesthetic in the eye, then they should not be allowed to resume play. The affected eye should be pain free and have adequate recovery of vision. Symptoms like foreign-body sensation, vision loss, proptosis interfering with vision, pain, loss of visual field, or a flash sensation are warnings for an ophthalmology evaluation and clearance for return to play.

The American Academy of Pediatrics (AAP) and American Academy of Ophthalmology issued a joint policy statement in 2004 recommending that all youths in organized sports should wear appropriate eye protection. There are sport-specific eye protectors such as a face guard attached to the helmet in baseball or a full-face shield in hockey. Protective eye wear for sports should meet the requirements of certifying bodies like the Protective Eyewear Certification Council, American Society for Testing and Materials (ASTM), Hockey Equipment Certification Council (HECC) and the National Operating Committee on Standards in Athletic Equipment (NOCSAE). Regular spectacles and contact lenses do not offer protection, so the appropriate eyewear is still strongly recommended. Functionally one-eyed athletes should wear protective eyewear as well as those whose ophthalmologists recommend eye protection after surgery or trauma. Sport-appropriate and properly fitting eye protectors reduce the risk of significant eye injury by at least 90%, so young athletes should develop the habit of using this protective gear early to avoid potentially blinding injuries.

Solitary kidney

Should an athlete with a solitary kidney be allowed to participate in contact sports? The answer to this question remains inconsistent, controversial, and difficult. In 1994, a survey of 438 members of the American Medical Society of Sports Medicine (AMSSM) showed that 54% would allow participation, but that this decreased to 42% when the athlete was their own child. More recently, Grinsell and colleagues showed only 34% of respondents from the American Society of Pediatric Nephrology (ASPN) would allow participation, and Sharp and colleagues likewise found that 32% of pediatric urologists surveyed would agree to contact sports for these patients. However, studies suggest that the risk of renal injury in contact or collision sports is extremely low. Recreational activities such as cycling, skiing, sledding, snowboarding, and horseback riding have shown higher risks of renal injury. A review of data from the National Pediatric Trauma Registry (NPTR) by Wan and colleagues during a 10-year span from 1990 to 1999 concluded that abdominal and testicular injuries are rare in team and individual contact and collision sports. Another extensive NPTR study reported that much more common causes of catastrophic kidney loss were those from motor vehicle crashes, pedestrians being struck by a vehicle or other object, and falls.

Several factors are considered when arriving at the decision of precluding an athlete with a solitary kidney from participating in contact or collision sports. These include the perception of injury risk (whether accurate or not), weighing the benefits of participation versus the tragic consequence of the potential loss of the remaining kidney, absence of a clear consensus, and ethical and medicolegal concerns. Restriction not based on clinical evidence can result in depriving an athlete of the physical, social, and educational rewards of their involvement in sports. Some would even argue that we let athletes with solitary brain, heart, and spinal cord play, and these have higher injury rates.

The AAP recommends a “qualified yes” for athletes who have a solitary kidney, with an individual assessment. As with athletes with a solitary testicle, providing protective equipment is essential. It is imperative that an open discussion on potential risks and benefits of sports participation take place among the athlete, the parents, and the clinician before making the informed decision not only about whether to play contact sports but also about participating in certain recreational activities.

Skin conditions

Unlike most other organ systems that show benefits from increased physical activity, skin actually develops pathologic conditions directly attributed to sports participation. Skin is subjected to direct repetitive trauma producing abrasions, blisters, chafing, corns, calluses, and black heel. Most of these lesions will not lead to significant interruption of athletic participation if recognized early and treated appropriately.

Making return-to-play decisions for infectious dermatologic conditions is another issue altogether. Skin infections are commonly encountered in the athletic setting. Player hygiene; close physical contact in locker rooms, buses, and benches; moist environments; and sharing of towels, equipment, and even housing accommodation all contribute to the host factors of the incubation and transmission process. An epidemiologic study on wrestling done by the National Collegiate Athletic Association (NCAA) Injury Surveillance System from 1988/1989 to 2003/2004 recorded that infectious dermatoses accounted for the most missed practice time, amounting to more than 17% of the reported events.

For bacterial (most commonly staphylococcal or streptococcal) infections including impetigo, folliculitis, furuncles (boils), carbuncles, abscesses, and cellulitis, the NCAA will preclude an athlete from participating if they are at risk of transmitting the infection. According to the NCAA protocol, the athlete must meet the following criteria: (1) no new lesions within the past 48 hours, (2) completion of 72 hours of antibiotic therapy, and (3) no moist, exudative, or purulent lesions at time of play. The National Federation of State High School Associations (NFHS) endorses these guidelines for wrestling and football, which they consider high risk for significant contact with opponent or equipment. Methicillin-resistant Staphylococcus aureus (MRSA), frequently called the superbug, has been the latest sports epidemic because of the emergence of antibiotic resistance. Increasing prevalence and reports of significant morbidity and mortality have brought MRSA to the attention of the sports community. The Centers for Disease Control and Prevention (CDC) reinforces the NCAA guidelines of excluding the athlete if the wound cannot be properly covered during participation, and even if it can be covered but still poses a risk to the health of the infected athlete, such as a further injury to the affected area.

Herpetic infections include simplex, fever blisters, zoster, and gladiatorum. To be allowed to participate, a wrestler must: (1) be free of systemic symptoms of viral infection; (2) have no new blisters for 72 hours before the examination; (3) have no moist lesions, and any remaining lesions must be dried and have a firm adherent crust; (4) have been on antiviral therapy for at least 120 hours before meet time; and (5) not cover active lesions.

Tinea lesions need oral or topical treatment for a minimum of 72 hours for skin lesions and 14 days on scalp lesions before the athlete is allowed to return to play. Wrestlers with solitary or clustered lesions will be disqualified if the lesions are in a location that cannot be adequately covered. If wrestlers have contracted scabies, they should have a negative prep at tournament time. Because there are no clear rules for most other sports, it is recommended that the guidelines for wrestling be used for any contact or collision sports or other sports that involve shared equipment or facilities like a gymnasium or pool. As the NCAA/CDC poster says, “If in doubt, check it out.”