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.

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.

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.

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.

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 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.

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 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 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 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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.