Sports Medicine



Sports Medicine


Gregory L. Landry



Pediatricians involved in primary care practice sports medicine on a daily basis. In most practices, at least one patient each day is involved in athletic pursuits and brings to the physician an agenda related to sports participation. Athletically inclined children and their parents ask difficult questions that are different from those of other patients seeking primary medical care. Advances in the diagnosis and treatment of medical problems in athletes have provided answers to many of those questions.

Sports medicine in the United States traditionally has been a subspecialty of orthopedic surgery. It developed from the evaluation and treatment of injuries occurring in professional and Olympic athletes. Techniques were discovered in the diagnosis and treatment of these conditions in athletes that minimized time lost from their sport as a result of injury. These techniques were applied quickly to college athletes, trickled down to high school athletes, and currently have many applications in youth sports. More and more families are demanding the same kind of treatment and care for younger patients that is provided for college and professional athletes. It no longer is acceptable simply to explain the diagnosis of and treatment for a particular injury or illness. Young athletes want to know how soon they can return to participation in their sport and what they can do to speed their recovery. When an illness or injury strikes, “When can I … ?” becomes the patient’s chief concern in the disposition. To maximize safe return to activity, a physical therapist or an athletic trainer may assist with rehabilitation of the injury. In addition, if the child cannot perform a favorite athletic activity, an alternative activity should be suggested to enable the patient to maintain some degree of fitness during rehabilitation.

To care for young athletes, physicians need not be knowledgeable about sports (although it helps), but they must be sensitive to the importance of sports activities in the lives of athletic children. Similar in a sense to children with special educational needs, young athletes also have special needs. Athletes may be physically talented, and medical illness or injury may take on more significance than it would in children who are less physically talented. The principles of sports medicine have applications in pediatrics in a broader sense, however. For example, young musicians who are ill or injured and who are working toward a musical performance have needs similar to those of injured athletes who are working toward an athletic performance.

Once thought to be a passing fad, sports medicine has become an important area of health care. This chapter addresses some of the most common medical questions that may be encountered by a pediatrician who cares for children who participate in athletic activities.


PREPARTICIPATION HEALTH INVENTORY

Children should have a yearly health checkup with a primary care health provider that includes a preparticipation health inventory for those patients who participate in sports activities. Unfortunately, this is not always possible. Adolescents tend to seek health care infrequently and often only when they are required to do so by an employer or when it is a contingency for athletic participation. Most states require that athletes obtain a physician’s statement of approval before they participate in sports activities, and this preparticipation visit provides an opportunity to address many health issues that may not come up at visits made for injuries.

The goals of a preparticipation health inventory vary somewhat from those of a routine health inventory in a nonathlete. In addition to assessing general health and diagnosing treatable conditions, conditions should be identified that may interfere with athletic participation or worsen as a result of it, especially any condition that may cause sudden death. Education related to the prevention of athletic injuries also should be included in the inventory process.


Group Examinations

Some physicians are faced with providing evaluations for a large number of athletes at one time. The most inefficient method practiced traditionally is for one or two physicians to perform a cursory examination of each athlete in a locker room. Instead, when large numbers of athletes require examination, the use of revolving stations provides the opportunity for more thorough and highly efficient evaluation. If additional health providers are recruited, the physical examination can be divided by organ systems into stations, and the tasks can be divided among the examiners. A list of possible stations appears in Table 130.1. Parents and coaches may help in administration of the process.

A few drawbacks to the station method deserve consideration. In a large group, the athletes face multiple examiners; with little time available in which to develop rapport, it is difficult to address sensitive topics such as sexual issues or drug use or to perform examinations of breasts and external genitalia in girls. For this reason, one-on-one evaluation by the primary care provider always is preferable.


Areas of Highest Yield

The history and orthopedic examination portions of the preparticipation inventory yield the most useful information. Most important in the history are questions pertaining to past injuries and to risk factors for sudden death. Athletes should be questioned regarding any family history of premature, nonaccidental death and about fainting or dizziness with exercise. Some of the cardiac causes of sudden death in the young athlete can be identified (Table 130.2). The low prevalence of these problems in the general population makes it difficult to justify the cost of an electrocardiogram and echocardiogram for every athlete. Some common causes of sudden death in athletes are familial, such as hypertrophic cardiomyopathy, prolonged
QT syndrome, and aortic rupture associated with Marfan syndrome. Because athletes with Marfan syndrome are at risk for sudden death caused by aortic rupture, examiners should scrutinize tall, thin athletes for findings consistent with the syndrome, such as scoliosis, pectus excavatum, hyperextensible joints, and a click and murmur consistent with mitral valve prolapse. Sudden, unexplained death in the family, fainting with exercise, or findings consistent with Marfan syndrome warrant further evaluation.








TABLE 130.1. STATIONS FOR THE PREPARTICIPATION EVALUATION WITH SUGGESTIONS ABOUT PERSONNEL, EQUIPMENT, AND SPACE NEEDS






  1. History: parent or coach—must be completed before the athlete proceeds to any station
  2. Blood pressure: athletic trainer or nurse—must have thigh cuffs available for large athletes; should be right arm, sitting
  3. Visual acuity: athletic trainer or nurse—Snellen chart best; need well-lit area
  4. Head and neck: physician or nurse practitioner—disposable specula, extra batteries
  5. Heart and lungs: physician or nurse practitioner—need quietest area available
  6. Abdomen: physician or nurse practitioner—gloves for male genitalia and hernia examinations
  7. Orthopedic: physician or athletic trainer—large examination table
  8. Laboratory: medical or nursing assistant—gloves and specimen containers
  9. Review and disposition: physician—best if it is the team physician

A good screening orthopedic examination can be performed in 90 seconds by primary care physicians as part of a general physical examination. The screening orthopedic examination is outlined in Table 130.3. If a history of any injury or a positive finding on the screening orthopedic examination exists, a more thorough evaluation is necessary.


Disposition

Most athletes fear that something will be discovered during the evaluation that will result in their disqualification from sports participation. Examiners should work toward allowing participation and should not disqualify any youngster who is physically and emotionally fit. In the group setting, the disposition should be made very clear. Ideally, the disposition should be written. If further medical evaluation is necessary, it should be made clear to the athlete that this either precludes participation or simply is a recommendation for further care.








TABLE 130.2. CARDIAC CAUSES OF SUDDEN DEATH IN YOUNG ATHLETES




















Cardiomyopathy
Hypertrophic cardiomyopathy*
Congenital heart disease
Anomalous left coronary artery
Aortic rupture*
Hypoplastic coronary arteries
Prolonged QT syndrome*
Unknown
*Causes of death that are potentially preventable through detection of a family history of sudden, unexplained death or symptoms during exercise.








TABLE 130.3. ORTHOPEDIC SCREENING EXAMINATION














































Athletic Activity (Instructions) Observation
Stand facing examiner Acromioclavicular joints; general habitus
Look at ceiling, floor, over both shoulders; touch ears to shoulders Cervical spine motion
Shrug shoulders (examiner resists) Trapezius strength
Abduct shoulders 90 degrees (examiner resists at 90 degrees) Deltoid strength
Rotate arms fully externally Shoulder motion
Flex and extend elbows Elbow motion
Arms at sides, elbows flexed 90 degrees, move wrists into pronation and supination Elbow and wrist motion
Spread fingers; make fist Hand or finger motion and deformities
Tighten (contract) quadriceps; relax quadriceps Symmetry and knee effusion; ankle effusion
“Duck walk” four steps (away from examiner with buttocks on heels) Hip, knee, and ankle motion
Back up to examiner Shoulder symmetry; scoliosis
Knees straight, touch toes Scoliosis, hip mition, hamstring tightness
Rise up on toes (raise heels) Calf symmetry, leg strength
Reprinted with permission from Garrick JG. Sports medicine. Pediatr Clin North Am 1977;24:737.


ROLE OF THE TEAM PHYSICIAN

Immediate, and often ongoing, care of injuries in the estimated 20 million young athletes in the United States falls into the hands of coaches. Eighty percent of the sports injuries that occur in this country may be evaluated and treated first by coaches. This statistic points to a need to promote greater involvement by health professionals and to educate coaches regarding sports injuries. Pediatricians may feel unqualified to help with athletic teams because of the number of orthopedic injuries that occur. Actually, pediatricians make excellent team physicians because of their broad knowledge of primary care and their sensitivity to the young athlete psychologically. Most college and professional sports teams involve both a primary care physician and an orthopedic surgeon in team care. Few of the injuries that occur require extensive musculoskeletal evaluation on the field, but many do require a physician who is knowledgeable about sports injuries.

The basic requirements for a team physician are interest and a willingness to read about problems unique to the field of sports medicine. Team physician duties typically are voluntary, and most of us do the job because it is fun.

The specific duties of a team physician must be defined. Some medicolegal problems can be avoided if these responsibilities are delineated clearly in writing. Physicians’ responsibilities vary greatly from team to team, and defining the responsibilities protects a physician to some extent from incurring an excessive time commitment. Most coaches and athletic directors welcome physician involvement, because they recognize
their expertise in caring for medical problems and injuries. Occasionally, however, an overzealous coach cannot understand why an athlete with a particular injury cannot participate. To minimize this problem, the team physician’s authority regarding the ability of the athletes to play in the event of any medical illness or injury should be clarified in writing.

Ideally, the school or team should enlist the services of a certified athletic trainer. The expertise of an experienced certified athletic trainer in assessing an injury and evaluating a player’s ability to participate can be invaluable. In addition, a trainer can provide rehabilitation for the injury. If a school or team does not have one, hiring a trainer should be one of the first investments made toward improving the medical care of its athletes. The trainer will make the job of a team physician much easier.

The equipment available to a physician on the field is limited by cost considerations. The minimum requirements include a first aid kit, water jug, and ice chest containing plastic bags. These items are inexpensive, and the importance of having water available for hydration and ice available for injuries cannot be emphasized too strongly to both coaches and athletes.

The supplies included in the medical bag can be extensive, especially if those that usually are available in a trainer’s bag are provided. A checklist for the medical bag appears in Table 130.4. Not all these items are required, but the team physician may want to consider them for adequate on-the-field coverage.


MANAGEMENT OF ATHLETIC INJURIES


Emergencies

When physicians provide medical coverage for any event, they must be prepared for any eventuality. They should have a plan in the event of a catastrophic injury, such as a spinal cord injury or cessation of pulse and breathing in an athlete. Team physicians also should be prepared to care for spectators in the event of a crisis. The ability to communicate with sources of emergency help can be critical. Do you have a cellular phone? Will it work in the remote area of the sports field? The location of the nearest telephone always should be known. If it is a pay telephone, loose change must be available to those individuals who are responsible for the care of the spectators and athletes; medical help can be delayed if coins for a pay telephone are not available. Determining in advance those individuals who will call for help if an ambulance is needed and those who should be called, including the location of the closest ambulance service, saves valuable time. This information probably should be written on the medical bag and the coach’s first aid kit.


Management on the Field

Management of injuries on the field is applied first aid. When an athlete goes down on the playing surface, physicians should remain calm, because other people look to them for direction. Whenever possible, using the athlete’s name has a calming effect. Once the athlete’s attention is gained, the physician should ask the child to indicate where the pain is located. If the athlete is unresponsive, basic principles of life support (i.e., “A, B, C,” for airway, breathing, and circulation) should be followed.

An unconscious athlete who has been injured in a contact sport, such as football, should be treated as if a fracture of the cervical spine has been sustained. If any pain in the neck or back occurs, palpation of the cervical spine and back should be performed before the athlete is allowed to move. If any suggestion of a significant neck or back injury exists, the athlete should be transported by an emergency vehicle to the nearest emergency facility for radiography. Injuries to the extremities should be assessed by visual observation and palpation and by determination of range of motion and stability. Immediate swelling, bony tenderness, deformity, lack of range of motion, or instability indicates that the athlete may need assistance in leaving the field of play.








TABLE 130.4. SPORTS MEDICINE BAG: ITEMS THE TEAM PHYSICIAN MAY WANT TO INCLUDE IN THE ON-THE-FIELD MEDICAL BAG FOR SPORTS EVENT COVERAGE










Airway supplies
Oral airways
Nasal airways
Ambu bag with face mask and endotracheal tube adapter
Laryngoscope with light source and blades
Cricothyrotomy kit with tracheostomy tubes
Medications
Epinephrine 1:10,000 for resuscitation
Lidocaine hydrochloride, 100-mg vial, for arrhythmias
Lactated Ringer’s solution with intravenous tubing and catheters
Epinephrine 1:1,000 for endotracheal tube instillation or subcutaneous use for anaphylaxis
Diazepam, 10-mg vial, for seizures
Methylpednisolone for spinal cord injury
Ophthalmologic saline for irrigation
Antibiotic ointment
Beta-agonist inhaler
Equipment
Stethoscope
Otoscope/ophthalmoscope
Thermometer
Penlight
Swiss Army knife
Sphygmomanometer
Tongue blades
Surgical towel clip, for SC dislocation
Dressings
White bandage tape
Sterile gauze pads
Cotton swabs
Elastic bandages
Sterile suture kits (gloves, suture material, syringes, and lidocaine)
Steri-Strips
Tincture of benzoin
Povidone-iodine solution or hexachlorophene
Bandage scissors
Finger splints
Plaster bandages and cotton web roll

An examination should be repeated after the athlete has left the playing surface. In the absence of suspicion of fracture, ligamentous instability, or any neurovascular compromise, the question of the child’s ability to play arises.


Determining an Athlete’s Ability to Play

Determining an athlete’s ability to play can be a challenge, even to a physician who has vast experience in sports injuries. Simple guidelines are helpful in dealing with medical problems that arise in the heat of the action.


Once the injury has been evaluated and determined to be relatively minor, the athlete’s ability to play is assessed by functional evaluation. The athlete should be asked to perform a function that is similar to, or related to, actions that are required during the athletic event. If any pain, weakness, or instability is experienced during the functional examination, participation should be disallowed. For example, the athlete with a mildly sprained ankle can be asked to jump up and down on the toes of the injured foot while avoiding weight bearing on the uninjured foot. If this task can be performed without difficulty, return to play is reasonable. Other functional tests may be added, such as running in a figure-of-eight pattern or in zigzag sprints. Playing when an injury is present can increase the risk of further injury, and a functional examination shows the athlete that some degree of impairment exists. Functional testing takes some of the guesswork out of this sometimes difficult decision.

Stability should be assessed immediately after an injury occurs, because a ligament examination can be obtained best before swelling, hemorrhage, and inflammation have started to cause pain and protective muscle guarding. Any instability or increased joint laxity precludes athletic participation. Whereas the first examination is best for determining stability in regard to the athlete’s ability to return to play, the extent of the injury may become clearer 15 to 20 minutes after the injury has occurred, when tissue damage has caused more inflammation. Protective taping or bracing will not, and should not, be used to permit an athlete with a significant injury to participate, but it may be used to protect a mild injury from exacerbation when the athlete returns to play.


HEAT ILLNESS

Heat illness is relevant to physicians in both cool and warm climates, because sporting events occur indoors as well as outdoors. Our understanding of the pathophysiology of heat illness has improved markedly, which is important, because life-threatening heat illness (heat stroke) probably is entirely preventable.

The terminology in this area can be confusing and often is misunderstood. Heat cramps, heat syncope, heat exhaustion, and heat stroke are part of a continuum.


Heat Cramps

Heat cramps are painful and forceful muscle contractions that usually occur in the gastrocnemius or hamstring muscles. They probably are related to heat, dehydration, and lack of training. Treatment includes rest, stretching, and the ingestion of copious amounts of water or a sports drink, if available. Occasionally, the cramps are the result of salt depletion in addition to the other factors, and the athlete needs more dietary sodium chloride.


Heat Syncope

Heat syncope is a term often used to describe a phenomenon that is common in runners in which they stop running at the end of a race and experience hypotensive syncope as a result of venous pooling. This is not life-threatening but is indicative of hypovolemia and the redistribution of blood volume that is caused by sweating and mild hyperthermia. Treatment consists of rest and the ingestion of generous amounts of water or a sports drink.


Heat Exhaustion

Heat exhaustion is manifested by pale skin color, vasoconstriction, dizziness, visual disturbances, syncope, and a moderately elevated rectal temperature (38° to 40°C, or 101° to 105°F). As with muscle cramps, treatment involves rest and rehydration. Ice packs and a fan may speed recovery. In some cases, intravenous fluid therapy may be required because of nausea and vomiting. Most authorities recommend normal saline, which approximates the composition of the sweat that has been lost.


Heat Stroke

The presence of central nervous system symptoms such as delirium, convulsions, and coma is indicative of heat stroke. A rectal temperature greater than 41°C (106°F) characteristically is seen in acute exercise-induced heat stroke. In the absence of exercise, heat stroke is associated with the absence of sweating and the presence of warm, flushed skin. The young, exercising athlete with heat stroke, however, usually still is sweating profusely and may have peripheral vasodilation. The central nervous system symptoms are more specific for heat stroke and indicate a medical emergency. Heat stroke can be fatal if it is not treated. Immediate immersion of the athlete in ice water is the most efficient means of cooling, but if this not available, the athlete should be packed in ice bags applied to the head, neck, and groin areas. Intravenous fluids (normal saline) should be administered as soon as possible, and immediate transport to a hospital is imperative. Because heat stroke may cause multisystem failure, the athlete may require admission to the hospital for observation.


Prevention of Heat Illness

The environmental conditions that cause the greatest heat stress must be considered. These include high environmental temperatures, high levels of relative humidity (as measured by a wet-bulb thermometer), and high levels of solar radiation (as occurs during the hottest part of the day). Evaporation is less effective when there is little wind. The greatest risk probably occurs on relatively warm days that follow cooler weather, especially in the early spring when athletes have not had time to adjust to the temperature change.


Susceptible Individuals

Certain types of individuals are at greater risk for sustaining heat injury, including those who are obese, poorly trained, dehydrated, or not used to heat. Age also is a risk factor, primarily for young children and the elderly. Anyone with a history of heat stroke is at risk for recurrence.

Football players are more susceptible to heat illness than are other athletes because their ability to lose heat through evaporation is abolished almost completely. Football uniforms cover most of the body, and practices start during some of the hottest days of the summer. Because coaches often are the only ones in contact with these athletes, they bear the main responsibility for preventing heat illness. Football players often have two practices a day, and they may not rehydrate their bodies before each practice. To address this problem, coaches should require that weight measurements be taken before and after each practice. The weights are recorded on a chart in the locker room next to the scales. At the beginning of a practice session, athletes who have lost 3% or more of their body weight are observed
carefully and should not be allowed to participate, because they are at higher risk of the development of heat illness. Most coaches modify practices on hot days and allow the players to wear shirts and shorts for all or part of the practice session.

In addition to identifying risk factors, unlimited water or a sports drink should be provided to the athletes. Children drink more fluid if it tastes good, so a sports drink should be provided when possible.


COMMON MEDICAL ILLNESSES IN ATHLETES


Common Viral Infections

Exercise causes changes in the immune system, the significance of which is unknown. Exercise causes transient granulocytosis and lymphocytosis as well as an increase in circulating endogenous pyrogen. Despite these changes, athletes are just as susceptible as nonathletes to common viral illnesses. For individuals participating in team sports, the exposure rate probably is as high as it is for other children and adolescents attending school.

Few scientific data exist regarding common viral illnesses in relation to the ability of a child to participate in sports activities. The objective finding of fever is helpful. Excellent studies have shown increased cardiopulmonary effort and reduced exercise capacity in response to fever. Fever also is associated with poor tolerance of orthostatic stress, poor tolerance of submaximal exercise, and abnormal temperature regulation. For these reasons, fever should preclude participation in most instances.

Some physicians are extremely conservative because of the fear of precipitating myocarditis in an athlete who exercises in the presence of viral infections. The only suggestion of this occurred in an animal study, which showed that coxsackievirus B27 infection in mice produced a significant incidence of myocarditis when exercise was forced. No studies in humans have proven this connection. If exercise is a precipitating factor, it would seem that a much higher incidence of myocarditis would be seen in athletes. Most physicians use the presence of fever and the severity of symptoms to determine an athlete’s ability to play.

Many of the common cold viruses are well known to cause significant impairment of small airways for several weeks after the infection. Exercise-induced chest tightness or cough should alert the physician that reactive airways may be impairing the athlete’s performance, especially in any athlete who has known reactive airways. Exercise-induced asthma is as common in athletes as it is in nonathletes. Rather than automatically restricting the athlete from competition because of cough, wheezing, and shortness of breath, the bronchospasm should be treated aggressively with a beta2-sympathomimetic aerosol, such as albuterol. This controls asthmatic symptoms in at least 80% of children who have exercise-induced symptoms.

Treatment with albuterol can safely provide marked improvement in symptoms. Additional agents such as cromolyn, nedrocromil, or a corticosteroid may be necessary for adequate treatment of the athlete with symptoms caused by bronchospasm.


Infectious Mononucleosis

Most practicing pediatricians care for athletes who have infectious mononucleosis. In almost all sports, this illness usually has a significant effect on the individual’s ability to participate in sports activities. Infectious mononucleosis is of special concern in collision and contact sports because of the high incidence of splenomegaly and the risk of splenic rupture. A review of the literature regarding splenic rupture reveals that it is a rare event and that most ruptures occur during the first 3 weeks of the illness. Moreover, in more than 50% of the splenic ruptures reported, the spleen was not palpable during the initial examination.

The duration of illness and degree of splenomegaly vary greatly from person to person. Rather than setting an arbitrary interval during which an athlete must not participate in a sport, each individual should be observed on a weekly basis, with the ability to play determined by clinical symptoms and physical examinations. Most athletes with mononucleosis are too ill to consider resuming competition before 3 to 4 weeks after the onset of the illness. By the 3- to 4-week mark, they are past the period of high risk for splenic rupture and should be allowed to play sports if they feel able to do so.

Occasionally, athletes have a mild case of mononucleosis, and their symptoms abate as early as 2 weeks after the onset of the illness. Because palpation on physical examination is a poor method of assessing splenic size, radiologic evaluation should be considered, especially in an athlete who is participating in collision sports such as football or hockey. Plain radiographs of the abdomen are approximately 70% accurate in assessing splenic size. Ultrasound, if it is available, provides an accurate measurement of splenic volume. With documentation by radiography or sonography that the spleen is not enlarged, return to competition probably carries little risk. The athlete certainly should avoid physical stress early in the illness when fever and other symptoms are present. Light workouts probably can be resumed when the athlete feels able; however, the effects of exercise on the severity and duration of mononucleosis have not been studied. In a study of infectious hepatitis in army personnel, no difference was found in recovery time (4 weeks) or relapse rate between patients who performed regular exercise and light work and patients those who were kept at rest.


SPORTS NUTRITION

Nutrition is an increasingly important aspect of sports medicine. Unfortunately, many athletes do not ask for nutritional information from health professionals but seek advice from their coaches and teammates. Many experts in the field of sports medicine believe that the most significant advances made in sports medicine in the future will be in the area of nutrition. The pregame meal, fluid replacement, and weight gain and loss methods are common topics that pediatricians may be asked to address by athletes and coaches.


Pregame Meal

The meal that is eaten just before an athletic contest is important to athletes who want to be at their best at game time. Most athletes are not comfortable exercising on a full stomach. Ideally, the meal should be consumed 2 to 4 hours before exercise, and it should consist mostly of complex carbohydrates. High-fat meals tend to prolong the full feeling and take longer to digest.

A “quick-energy” candy bar or simple sugar snack consumed immediately before an event is more likely to be detrimental than helpful to an athlete. Rebound hypoglycemia may occur during athletic activity as a result of the relative hyperinsulinemia that occurs after the sugar load. This effect has been demonstrated in studies of patients who underwent aerobic exercise on a treadmill after sugar loading.



Fluid Replacement

During most athletic events that last less than 2 hours, the most practical fluid to use for rehydration is cold water. It certainly is the cheapest and most easily obtainable fluid. Most of the commercial sports drinks are pleasant tasting, replace sodium loss, and provide a source of carbohydrate. The carbohydrate and electrolyte composition of the replacement fluid probably is important only in endurance events that involve 30 minutes or more of continuous exercise. Hypertonic solutions once were thought to impede gastric emptying and intestinal absorption, but research has shown that oral solutions containing as much as 6% glucose are absorbed rapidly and provide an important source of carbohydrate for endurance athletes. Athletes should be reminded that thirst is not a sensitive indicator of hydration status and that they should replace fluid before they feel thirsty.


Weight Gain

An athlete who is interested in gaining weight to improve performance in a particular sport, such as football, should be trying to gain lean body mass. The athlete may be tempted to buy all kinds of nutritional products that are claimed to promote rapid weight gain. Numerous amino acid supplements are available, but studies have not shown them consistently to have any effect other than being an additional source of calories.

Free amino acid supplements cause both proven and theoretic harm to the athlete, and use is associated with a significant incidence of diarrhea and abdominal pain. Physiologically, polypeptides are absorbed more efficiently in the gut than are free amino acids. Animal studies on amino acid supplementation show a high incidence of nephropathy, but this never has been shown in humans. Creatine monophosphate is expensive and appears to produce few side effects. It has shown promise in studies on strength training and power sports and may have a detrimental effect on endurance athletes. The long-term effects of this popular supplement are unknown.

A careful dietary analysis often is helpful in assessing the daily caloric intake of an athlete, and it may reveal a level of caloric intake that is insufficient for adequate weight gain. If the athlete needs to increase the total daily caloric intake, ingesting more carbohydrates should be emphasized, because the diets of most U.S. residents already are rich in protein. While attempting to gain weight, the athlete should be involved in a strength training program so the gain is more likely to be in lean body mass.


Weight Loss

For some athletes, thinness is vital to their success. Ballet dancers, wrestlers, gymnasts, and distance runners often feel pressured to stay thin or to lose weight. These athletes are just as prone as are nonathletes to use unhealthy rapid weight loss methods, and they may be at risk for the development of eating disorders.

In general, athletes should use the same sensible weight loss methods as nonathletes, by decreasing their caloric intake while increasing their caloric expenditure. For most athletes, a reasonable maximum weight loss per week is 0.90 kg (2 lb). Faster weight loss probably will result in ketosis, loss of muscle mass, and dehydration. Use of saunas, rubber suits, or diuretics to lose weight should be discouraged strongly because of the associated risks of electrolyte disturbance and excessive dehydration. Fortunately, many of the unhealthy eating behaviors seen in athletes are transient, practiced only during participation in the particular sport, and do not become integrated permanently into their behavior patterns.


DERMATOLOGIC CONCERNS IN ATHLETES

Few skin problems disqualify athletes from playing sports, but contagious skin infections do rule out competition in sports that involve close contact, such as wrestling or rugby. Impetigo and herpesvirus infections are seen most commonly, although tinea corporis also is contagious enough to warrant disqualification. Impetigo and herpes infections can spread through a team quickly unless the athletes and coaches are cognizant of the importance of early diagnosis and treatment. With aggressive treatment, the amount of time lost from participation can be minimized.


Impetigo

The athlete with impetigo usually is infected by the same organism as is the nonathlete, predominantly Staphylococcus aureus or Streptococcus pyogenes. The diagnosis of impetigo may be more difficult in the wrestler because any bulla or crust may be rubbed off during a match or in the shower. Moreover, the lesions occur anywhere on the body, and they may not look much more impressive than do fresh abrasions. An athlete with recurrent impetigo may suspect infection early in the course of the infection and seek medical care. Skin cultures do not distinguish pathogens from normal flora and probably need not be performed unless recurrences are frequent or treatment response is poor.

Treatment involves good local care, including scrubbing with an antiseptic soap and applying an antibacterial ointment such as mupirocin. Systemic antibiotics should be used more liberally in most athletes, to speed recovery and decrease contagiousness to the other participants.

The ability of an athlete with impetigo to participate in a sport is subjective, but a waiting period of at least 24 to 48 hours after the initiation of a systemic antibiotic is necessary. Covering lesions with an occlusive dressing often is impractical because of perspiration and constant trauma to the dressing.

Impetigo can be prevented by frequent washing of the mats that serve as fomites. Athletes with impetigo should be disqualified promptly from competition. It may be reasonable for some athletes who are particularly susceptible to impetigo to take an antibiotic prophylactically during a designated period. This may be useful especially toward the end of the season, just before tournaments. The use of a prophylactic antibiotic increases the risk that resistant bacteria will develop, however, and this possibility should be weighed against the benefit of preventing an outbreak. Methicillin-resistant S. aureus (MRSA) has been reported in wrestlers.


Herpes Simplex

Herpetic infection in athletes who are involved in high-contact sports such as wrestling sometimes is called herpes gladiatorum. Lesions develop anywhere on the trunk or extremities and are more likely to occur in a break in the skin caused by an abrasion. The signs and symptoms are the same as for herpes simplex infections occurring elsewhere on the body, except the lesions often are more widespread.

Treatment includes disqualification until all vesicles are crusted over. As with impetigo, evaluation of a player’s ability to participate is subjective. Some athletes have outbreaks that
last for 5 to 7 days, which is a significant time away from competition. Systemic therapy with acyclovir or a similar agent should be instituted as soon as possible to speed recovery and reduce contagion.

As athletes become better educated about acyclovir, they are quicker to seek treatment because it speeds recovery. Some wrestling team physicians are using acyclovir prophylactically. Prophylactic acyclovir, 400 mg twice a day, or valacyclovir, 500 mg once a day, has been shown to be effective against recurrent herpetic lesions in other populations.


COMMON INJURIES INVOLVING THE HEAD AND NECK

Head and neck trauma can be anxiety provoking for the athlete, family, and physician covering an athletic event. Fortunately, in most sports, severe injuries are rare, but mild head and neck traumatic injuries are common occurrences in contact sports such as football and ice hockey.


Assessment on the Field

When physicians evaluate the extent of an athlete’s injury while he or she still is on the field, they should ask the athlete whether any neck pain is present. Even when neck pain is denied, if the athlete has sustained a concussion, the neck should be palpated carefully along the cervical spine for any area of tenderness. It also is important, before the athlete is allowed to sit up or to stand, to ask him or her whether any neurologic symptoms are felt in the extremities, such as numbness, tingling, or weakness. If any neck pain exists, especially any cervical spine tenderness, the athlete must be considered to have sustained a neck fracture and must not be moved. After being immobilized properly, the athlete should be transported by trained personnel to an emergency facility. If the individual is unconscious, he or she must be assumed to have a neck fracture and should be treated accordingly. If an airway must be established, this potential injury must be assumed. In sports that involve the use of protective helmets, the team physician should be prepared to remove the face mask in case of a head or neck injury requiring access to the airway. Using a screwdriver or knife to remove the fasteners connecting the face mask to the helmet allows quick removal of the face mask and access to the airway without moving the athlete’s neck.


Concussions

Concussions occur frequently in contact sports, and determining an athlete’s ability to return to play afterward can be difficult. Some physicians unnecessarily disqualify athletes with even the mildest head trauma. The diagnosis of a concussion should be made in any athlete who sustains a transient loss of cognitive ability as a result of trauma to the head. The mildest form of concussion is commonly referred to as the ding, and it consists of a few seconds of confusion, loss of balance, and “seeing stars.” This can be brief enough to go undetected by teammates and coaches.

Criteria for return to play after concussion are similar to those after other injuries; the athlete must pass a functional examination. Gait analysis and balance should be evaluated on the sideline. The most sensitive examination is a test for memory. In addition to asking simple information about the athlete’s address or events that took place earlier in the day, it is helpful to have a teammate discuss the higher cognitive aspects of the game. If the athlete stumbles when being asked questions about the game plan or the assignments, then return to competition is forbidden. These cognitive abilities may return during the event, and the athlete may return to competition at that time if no nausea, vomiting, or headache is noted and no other symptoms occur. If symptoms persist longer than 15 minutes, an athlete usually should not return to the same contest.

The longer the athlete experiences loss of higher cognition, the more severe is the concussion. The athlete should be questioned carefully about events that occurred earlier in the day. The presence of retrograde amnesia signals a more severe concussion, even without a history of loss of consciousness. The athlete with evidence of retrograde amnesia will be unlikely to regain full cognition during the game, will have a headache, and should not be allowed to compete.

Any athlete who loses consciousness for more than a brief time (a few seconds) during a competition should be disqualified from further participation in that competition. In sports that require headgear for participation, nonparticipation almost is guaranteed if the physician retains the athlete’s headgear. In the heat of the moment, especially if he or she is not thinking clearly, the athlete may try to resume competition against medical advice. In contrast to other sports injuries, it usually is not a good idea to send to the showers an athlete who has sustained a head injury, because medical personnel may not be available to accompany the individual. The athlete must be observed closely after sustaining a concussion, and the team physician can usually best keep an eye on the athlete on the sidelines.

The headache that an athlete experiences after sustaining a concussion can last for days or weeks. Because headache indicates some cerebral dysfunction, an athlete should not be allowed to participate in sports in the presence of headache after a concussion. When the headache resolves, the athlete may be allowed to do some light jogging and, eventually, sprinting. If running produces headache, the athlete should not be allowed to proceed to competition. Occasionally, an athlete has postconcussion syndrome, with frequent headaches, poor concentration, irritability, and loss of certain cognitive abilities for days to weeks after the injury. An athlete with a persistent headache or a progressively worsening headache warrants a computed tomographic scan or a magnetic resonance imaging study, and a neurologic or neurosurgical evaluation should be considered.

Once an athlete has received a concussion, his or her risk of sustaining another concussion is increased. Traditionally, physicians have disqualified athletes from participating in a sport when they have sustained three concussions. The “three concussions and you are out” rule may be appropriate in some cases, but every patient must be approached individually. Both the severity of the concussions and the time between their occurrence should be considered. The possibility of delayed cerebral dysfunction, documented in professional athletes who have sustained recurrent concussions, should be kept in mind when counseling the athlete and the family.


Brachial Plexus Injuries

Many spectators of football, ice hockey, or wrestling are familiar with the athlete who comes off the field dangling or shaking an arm. Frequently, this athlete has sustained an injury commonly known as a burner or stinger, which is often a stretch or direct blow to the brachial plexus. The burning pain with associated shoulder and arm weakness usually abates in a few minutes; in a few instances, weakness may persist for a few days to a few months. This injury is thought to be caused by a blow that hyperextends the neck or causes lateral flexion of the neck away from the side of the injury, with or without a
concomitant blow to the shoulder. Traction of the brachial plexus produces paresthesias in the shoulder, radiating down the arm and frequently into the hand. The athlete may complain of pain in the area of the trapezius muscle, but the injury seldom, if ever, should be associated with true cervical spine pain. Bilateral symptoms are strongly suggestive of spinal cord injury rather than plexus injury. The athlete should be removed from the game, and appropriate imaging studies should be taken to rule out the possibility of spinal stenosis in an individual with bilateral paresthesias or weakness.

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Sports Medicine

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