INTRODUCTION
SPORTS
MEDICINE IN THE STUDENT ATHLETE
Keith S. Feder, MD
In order to participate in interscholastic sports in
California, an athlete must have a pre-participation physical examination. This can only be performed and signed by a
M.D. or D.O.
Interscholastic football games must be covered in the
State of California and coverage must be provided by a M.D., ATC, EMT or school
nurse (dependent on school district regulations).
Although, having received considerable training and
some even with post-graduate training in sports medicine, other health care
professionals should not perform and/or sign a pre-participation physical or
provide coverage for an interscholastic football game.
Pre-participation physical examination is not a
substitute for routine periodic comprehensive health screenings or ongoing
relationship between a family physician or pediatrician and the young
athlete. The objective of the
pre-participation physical examination is to 1) evaluate general health of the
athlete 2) determine cardiovascular fitness
3) evaluate preexisting
injuries 4) evaluate size and maturity 5)
restrict activity based on physical limitations or disease which would
preclude safe participation 6) recommend alternative but safe activities
based on above 7) establish a database.
The medical history is a key to the overall
examination. Optimally the history
should be provided by the parent and athlete together. Focus should be on the athletes past medical
history/problems and past injuries as well as the history of treatment of those
injuries.
I.
SPECIAL CONSIDERATIONS FOR THE ADOLESCENT ATHLETE
William Hohl, MD
Adolescent athletes are generally quite healthy and are
able to withstand the rigors of competitive sports with surprisingly few
injuries. This is especially remarkable
considering that they are often participating with a degree of enthusiasm and
competitive drive that often exceeds their physical preparedness. This situation arises because many of these
athletes are participating in a sport that is new to them or because they find
themselves in full-fledged competition after a very short preseason. Coaches are often forced to forgo some
aspects of physical preparation in order to teach fundamentals of a particular
sport and to prepare a group of individuals to function as a team. In addition, many adolescent athletes participate
in more than one sport with no period of rest and recovery between
seasons. Still others participate in
one sport throughout the year; combining school and club play with little or no
rest between. Although athletes are
more at risk for certain types of injuries because they are still involved with
adolescent athletes with some of the unique aspects of their anatomy and
physiology with the hope that this knowledge will help prevent injuries to
these athletes.
Adolescents are either still growing or have only
recently reached skeletal maturity. On
average, females achieve their full height at age fourteen, and males, at age
sixteen. However, there is a wide range
of skeletal maturation rates, and variations of a year or two on either side of
these averages are not unusual. The
so-called adolescent growth spurt typically begins about two years prior to
skeletal maturity, peaks during the succeeding twelve months, and then
gradually slows to a stop during the twelve month prior to maturity.
Younger children, prior to adolescence, are growing but
more slowly and steadily than during adolescence. At this age participation is also generally less intense than
during the adolescent year (although higher intensity at ever younger ages
seems to be a trend). For both of these
reasons children are less susceptible to many injuries than adolescent.
GROWTH PLATE INJURIES
Many of the injuries which adolescents sustain in sports
are a result of the fact that they are still growing or have only recently
achieved skeletal maturity. Growth in
the length of the bones occurs through the multiplication of specialized
cartilage cells located in the growth plate or physis of the long bones. Many bones have physes at both ends. The cartilage cells, which make up the
physes form a layer with, bone on either side toward the end of a long
bone. During growth, these cartilage
cells multiply and move away from their point of origin, toward the center of
the bone. They are then gradually
transformed from cartilage into bone, increasing length. In the last year of growth, the growth
plates narrow as the rate of multiplication of the cartilage cells
dwindles. As growth ends, the physis
has narrowed to the point where the bone on either side fuses together, and no
more growth can occur.
The physis itself is a source of injuries in many
adolescents. The cartilage of the
physis is mechanically weaker than the surrounding bone and can be fractured if
a violent force is applied to it.
Fractures involving the physis are thought to occur more frequently
during periods of rapid growth, including the adolescent growth spurt. A fracture involving the physis is a serious
injury, which can result in abnormal growth of the involved limb that can lead
to progressive deformity or complete cessation of growth at the involved
physis. While injuries of this type are
seldom preventable, the consequences can be minimized if the injury is
recognized and treated appropriately.
The most common physeal fractures in the adolescent age
group involve the ankle and wrist.
Physeal injuries about the ankle come about as a result of a twisting
force and usually produce significant swelling and severe pain with weight
bearing or a complete inability to bear weight on the injured side. These signs
should be used to differentiate these injuries from mild sprains and should
prompt those involved with the athlete to arrange medical evaluation. Physeal injuries at the wrist usually result
from an attempt to break a fall by putting the hand out, and usually produce
significant swelling about the wrist and frequently visible deformity as
well. Many so-called
"sprains" of the wrist and ankle in adolescents are actually growth
plate injuries.
Some growth plate injuries are of a more chronic nature
with symptoms developing insidiously with a specific moment of injury. A gradual slipping of the growth plate of
the femur bone adjacent to the hip (known as a slipped capital femoral
epiphysis) produces pain in the hip or knee of the affected side, and a
limp. This occurs most often in
overweight adolescents between eleven and fifteen years of age. If untreated, this condition can lead to
severe, lifelong hip problems. A
persistent complaint of pain, particularly in the presence of a limp, should
always receive prompt medical evaluation.
STRESS FRACTURES
Another type of fracture seen in adolescents is the
stress fracture of fatigue fracture.
These come about from repetitive activity rather than a single violent
event. The repetitive trauma produces
microscopic cracking of the involved bone that produces pain. Continuing the offending activity causes
more microscopic cracking at a rate that exceeds the ability of the body to
repair the cracks. This leads to
worsening symptoms. This type of
fracture is seen in the leg or foot in athletes involved in running sports such
as cross-country. A special type of
stress fracture, which occurs almost exclusively in adolescents, involves the
lumbar spine. This condition, known as spondylosis produces chronic lower back pain
and is seen most commonly in athletes who repeatedly hyperextend their lower
spines, such as gymnasts and divers.
MUSCLE AND TENDON INJURIES
Muscle strains (pulled or torn muscles) occur in
adolescents as in other age groups.
Growing adolescents may be more susceptible to these injuries for a
variety of reasons. First, as bones
grow longer, muscle tendon units must also grow longer. During periods of rapid growth, the muscles
and tendons may lag behind in the lengthening process, leading to periods of
relative muscle tightness. Weight
training produces swelling and tightness of muscles and can exacerbate the
problem when not balanced by a proper stretching regimen. Even when coaches who recognize the
importance of stretching prior to vigorous activity allow adequate time for it
in their practice schedule, adolescent athletes may not be sufficiently aware
of its importance and may loaf through stretching exercises and render
themselves more susceptible to injury.
Education of these athletes as to the importance of stretching, as well
as close supervision during stretching can help prevent muscle injuries. Although practice time for student athletes
is limited, the importance of stretching and warm-up time cannot be
overemphasized.
Tendon injuries can occur in adolescents as well. Fortunately complete tendon ruptures are
less common in this age group than in the adult population. Most adolescent tendon problems fall into
the category of tendonitis, which is inflammation of a tendon usually due to a
repetitive activity and overuse. A
common example in the adolescent group would be knee pain from tendonitis of
the patellar tendon in a jumping athlete such as a basketball player. While not completely preventable, tendonitis
can be made less frequent by a balanced training and stretching regimen. Appropriate treatment for tendonitis
includes ice after activity, heat and stretching before activity and
modification or cessation of activity.
A physician should evaluate persistent symptoms.
APOPHYSEAL INJURIES
A special type of growth plate, known as an apophysis,
is present at the site of many large muscle attachments to bones. These growth plates have a role in shaping
bones appropriately to accommodate the large stresses that major muscles place
on them. Examples of apophyses include
the heel at he insertion of the Achilles tendon, the front of the knee at the
tibia at the site of attachment of the patellar tendon, and the medial
epicondyle, on the inner side of the elbow, where the wrist flexor and forearm
pronator muscles originate. Although
acute fractures from a single violent trauma can occur at these apophyses, they
are more commonly injured by chronic repetitive tensile stress. Many of these chronic injuries can be
prevented by proper warm-up and stretching.
Others, such as the medial epicondyle at the elbow, are more
problematic. "Little League
elbow", which is caused by inflammation of the apophysis at the inner side
of the elbow, can be a problem well into the adolescent years and may require
instruction in proper throwing mechanics, decreased use of the curveball in
pitchers, changing positions (from pitcher to first base, for example), or
cessation of throwing activity altogether.
In general this type of apophyseal injury responds to rest and will only
get worse if the offending activity is continued. "Playing through pain" will in general only lead to
more severe pain and impaired performance.
Persistent pain should always merit medical evaluation.
There are a number of apophyses around the pelvis that
can produce sudden severe pain after a sharp movement (not necessarily a
collision or a fall). In these
instances a vigorous muscle contraction pulls the muscle off of its
cartilaginous attachment to a bone. An
example of this type of injury would be a high hurdler who experiences sudden
sharp pain in the front of the hip as she goes over a hurdle. An avulsion or
pulling off of the rectus femoris muscle attachment to the pelvis is what
occurred. Proper stretching before
exercise can decrease the likelihood of these injuries as well.
OVERUSE SYNDROMES
Overuse syndromes occur in all age groups but are very
common in adolescent athletes.
Anatomically, overuse syndromes can involve inflammation and pain
originating from muscle, tendon, joint, or other structures. Some of the syndromes previously discussed
in this chapter, such as tendonitis and stress fracture, could fall into the
category of overuse injuries.
In coming off of a period of relative inactivity, such
as summer vacation, or after a change from one sport to another with very
different physical demands, or even in persisting in a single sport without a
period of rest and healing from day to day wear and tear (as in a year round
club and school soccer player), an adolescent athlete may begin to experience
pain in a muscle, tendon or joint as a result of overuse. These problems can be exacerbated by the
limited time periods for training prior to the start of a season. It is actually far more likely that this
type of syndrome comes about as a result of increasing the demands on the
affected body part too rapidly rather than placing demands that would be
excessive under any circumstances.
While not entirely preventable, overuse syndromes can be minimized by
cross training, by education of the athletes to begin preparing themselves
prior to the start of the season, and by carefully thought out training
regimens designed to increase demands on body parts in a manner as slow and
steady as possible within the given time constraints.
Injuries to adolescent athletes can be made less
frequent and less severe by awareness of the types of injuries most common in
this age range as well as their prevention, early recognition and appropriate
treatment. Education of the athletes
themselves, on matters such as conditioning prior to the start of formal
practice, and the importance of stretching, warm-up, cool down and proper rest
and diet can all play a major role in minimizing injuries. Well designed training programs emphasizing
an appropriate balance of aerobic conditioning, strength training and
stretching can also decrease the incidence of many injuries commonly seen in
these athletes. The creation of an
environment where an athlete would not be embarrassed to report an injury to
his coach, for example, can lead to earlier recognition and treatment which may
serve the team in the end by minimizing "down time" for the
athlete. More importantly these
principles can, by educating these athletes to take proper care of their
bodies, ensure a lifetime of enjoyment and benefit from sports participation.
II. ACUTE TREATMENT OF TRAUMATIC
INJURIES OF THE EXTREMITIES
Keith S. Feder, MD
Severe traumatic injuries are at many levels, there may not be a deformity
even when there is a fracture. Obvious
deformities in the extremities certainly reflect a severe high energy injury.
Initial treatment consists of splinting the deformity in a position which
it is found and applying ice. No
attempts should be made at correcting the deformity other than by a M.D. an M.D. evaluation should be carried out
immediately.
PRICEMM is a good guideline to remember in treating acute injuries.
If the pain lasts more than 24 to 48 hours following the injury, pain
during play, persistent pain following play and pain with daily activities
require immediate orthopaedic evaluation.
PRICE MM
P Protect the area
of injury with sling, immobilization, brace or cast as indicated.
R Rest - Limit the
use of the injured area. Severe injury
may necessitate a complete rest but less severe injuries may allow cross
training and rehabilitation.
I Ice - Always
applied in acute injuries to limit swelling for 20 minutes at each session for
a minimum of the first 72 hours following acute injury.
C Compression - to limit
or decrease the swelling of the injured area.
E Elevation - Aids
venous return to the heart. Limits and
decreases swelling.
M Modalities - Ice,
heat, ultrasound, phonophoresis and iontophoresis. Other than ice and heat is applied by athletic trainer or
physical therapist as directed to reduce swelling, inflammation and speed
recovery.
M Medicine -
Non-steroidal anti-inflammatory (NSAID) medicine can be used in over the
counter dosage or higher dosage as prescribed by a physician. Limits and helps reduce
swelling/inflammation.
III. HEAD INJURIES AND
CONCUSSIONS
Iam
Armstrong, MD
Head injuries constitute the most frequent cause of death in sports
related events and accidents.
10% of college football players and 20% of high-school football players
suffer from significant head injuries and/or concussions. Approximately 85% of deaths in football are
a result of significant head or neck injuries. Modification of tackling techniques have decreased the incidence
of head injury. Despite proper
equipment and technique, significant head injuries do occur. Head injuries must be fully evaluated on
the sideline by trained personnel.
Inappropriate return to play with a reinjury can result in sudden death.
Anatomy
The brain is certainly one of the most delicate structures in the body
and one of the most critical. Hence, it
has been carefully protected by the surrounding bony structure of the skull. The brain is surrounded by a thick covering
called the dura. The brain floats in a
lake of cerebrospinal fluid. This
anatomic configuration offers maximal protection for the brain.
Mechanism/Types of Brain Injury
Head injuries can occur as a result of a direct blow to the skull causing
local trauma to the skull (contusion/fracture) and injury to the brain. A
sudden acceleration/deceleration, without a direct blow to the head, can cause
the brain to strike against the surrounding hard skull causing a brain
injury. A player can receive a direct
blow to one side of the head but actually sustain a brain injury on the
opposite side of the head. The brain
will strike the opposite side of the skull resulting in a brain injury on the
opposite side of the direct blow. This
is called a contra-coup injury. Another
type of brain injury is called diffuse axonal injury. Rotatory forces or tangential forces cause a shearing effect in
the deep substance of the brain causing contusion or bleeding within the brain.
Concussion
A concussion is an alteration of mental status or mental function as a
result of trauma to the brain. A
concussion may be as a result of a direct blow, acceleration/deceleration or a contra-coup injury. A concussion is jarring of the brain that
is significant enough to cause altered
function of the brain. The hallmarks of
a concussion are confusion and amnesia.
An athlete does not have to have loss of consciousness to have a
concussion.
Classic characteristics of a
concussion
Blank stare, delayed verbal response to questions, delayed ability to
follow instructions, inability to focus attention, patient is distracted and
unable to follow a conversation, disorientation and walking in the wrong
direction, unaware of place, time or date, slurred speech, poor coordination
with stumbling, or inability to walk a straight line (drunk test or heel to toe
test).
More subtle signs are emotionality, crying for no apparent reason, memory
deficits, poor intellectual function.
Loss of Consciousness Equals
Concussion
Early complaints by the athlete may include
headaches, dizziness, lack of awareness of surrounding, nausea, vomiting.
Later Complaints
Later complaints include persistent low grade headaches, light
headedness, inability to concentrate, memory dysfunction, excessive fatigue,
irritability, intolerance to bright lights, intolerance to loud noises or
ringing in the ears.
Classification of Concussion
Concussions are defined by mild (grade I), moderate (grade II) or severe
(grade III).
Grade 1 Concussion
Grade I is certainly the most common type of concussion and certainly the
most difficult to recognize and diagnose.
The athlete does not have any loss of consciousness, amnesia and usually
has only a brief period of confusion.
Most players refer to this as having their "bell rung". There may be minimal evidence for this and
is only after careful observation and questioning by sideline personnel will
this diagnosis be evident.
Grade II Concussion
Grade II concussion will exhibit short term confusion, no loss of
consciousness, but will have amnesia (loss of memory). The patient may have
amnesia for the events following the injury (post-traumatic amnesia) or amnesia
for events preceding the injury (retrograde amnesia). A thorough neurological evaluation must be performed and the
player may not return to the game.
Grade III Concussion
Any loss of consciousness is considered a grade III concussion. Loss of consciousness for only seconds is
still considered a loss of consciousness.
This requires immediate removal from game and transportation to hospital
for evaluation. A CT or MRI scan of the
brain must be performed on any athlete rendered unconscious for any period of
time.
Guidelines for Return to Competition
Grade I concussion
Remove from contest and examine immediately and every 5 minutes for post
concussion symptoms. He may return to
the game if amnesia does not appear and no symptoms develop for at least 20
minutes. If the athlete is symptomatic. He may not return to the game. Symptoms
include headache, dizziness, impaired orientation, impaired concentration or
memory problems. In order to return to
play, symptoms must resolve while at rest and with exertion. Exertion/provocation testing should be done
on the sidelines. Return to play is
allowed only if the athlete is asymptomatic during rest and exertion for at
least 20 minutes. If the player has a
second Grade I concussion in the same contest, this eliminates the player for
competition for the day. CT scan or MRI
is recommended in all incidences in which a headache persists. These players should be given head injury
precaution sheet to be followed at home.
The patient should be evaluated over the next 24 hours for signs of
evolving intra-cranial problems with explicit written instructions for the
family. The patient is removed from contact
sports until he is asymptomatic for one week at rest and with exertion. A CT scan or MRI is recommended for those
who have persistent headaches or symptoms for longer than a week. After a second Grade I concussion, the
player should be pulled from contact sports for at least one month, and
termination of the season should be considered. Termination of the season is mandated by a 3rd Grade I
concussion. The patient must have a
formal neurological evaluation before consideration of return to play.
Grade II Concussion
Symptoms of Grade I concussion with amnesia, retrograde or
post-traumatic. The player may not
return to the games and a CT scan should be carried out.
Grade III concussion
Any loss of consciousness necessitates removal from the game, transfer to
the hospital, final neurological evaluation and CT scan of head. The athlete is held from contact sports for
one month after a Grade III concussion.
If the athlete returns and is asymptomatic at rest and at exertion for
at least 2 weeks, there may be consideration for early return to play. CT scan or MRI imaging is mandatory. The season is terminated by two Grade III
concussions.
Sideline evaluation of concussions
History
1) Check orientation of person,
place and time situation, or circumstances surrounding the injury. 2) Concentration may be tested by a counting
test, counting backwards in reverse order, or memory test such as the
president, news worthy events or remembering 3 words or 3 objects at 0 and 5
minutes, 3) Memory test of details of the game and the events which were going
on at the time of the injury.
Neurological Testing
1) Check the pupils for asymmetry and reaction to light. 2) Test coordination by heel to toe
walking. 3) Finger to nose with eyes
closed. 4) Hopping up and down on one
foot. If the patient is asymptomatic
for headaches, dizziness and has clear mental function, this is a Grade 1
concussion, and the examiner can move on to exertional provocation tests on the
sidelines to determine return to play.
Sideline Exertion Testing
1) Only if athlete has no
headache, no dizziness, no loss of consciousness and clear mental
function. 2) A 40 yard sprint, 3) 5
push-ups, 4) 5 sit-ups, 5) 5 knee bends.
If headache, nausea, dizziness or other mental changes appear following
exertional testing, the athlete can not return to play.
It is important to be able to define, evaluate and grade a concussion
as grade I, grade II, and grade III on
the sidelines. Concussions are
associated with significant brain damage or injury requiring further medical
intervention. Intra-cranial (inside the
skull or brain) bleeding can occur even if there is only mild head trauma.
Intra-cranial Injury
An intra-cranial injury is most often a collection blood that causes pressure
on the brain tissue which can cause loss of consciousness, coma, permanent
motor deficits or death. A subdural hematoma is a collection of blood
under the dura (covering of the brain) that may press on to the brain causing
brain damage, coma or death. Epidural
hematoma is a collection of blood outside of the dura (covering of the brain),
but inside the skull, and is usually associated with a fracture of the temporal
bone of the skull or laceration of the middle meningeal artery inside the
brain.
Epidural hematoma usually results from a head injury that only causes
mild confusion (grade 1). This is
followed by a lucent interval where the patient is awake, alert and may be only
mildly symptomatic. As the blood
accumulates between the skull and the brain, the patient then rapidly
deteriorates into coma. Death can occur
if not treated aggressively with surgical intervention to remove the blood
clot. Subdural hematoma usually
results from a more serious (grade II or III) head injury. The blood will usually accumulate more
rapidly. With an subdural hematoma, the
patient will deteriorate rapidly following the actual injury. Emergency surgical removal of the hematoma
is mandatory. Intra-cerebral hematomas
is a bruise within the substance of the brain or a blood clot within in the
substance of the brain. Surgery is not usually necessary but close observation
is essential. Cerebral contusion is a
bruise in the brain. Diffuse axonal
injury is usually associated with the translational or rotational forces on the
brain that actually result in shearing of the neuronal tissues of the
brain. This may result in significant
long-lasting neurological consequences (deficit).
Second Impact Syndrome
This is the rapid development of swelling of the brain after a second
concussion.
This can result if a concussion is missed or if a player incorrectly
returned to play. The second concussion
results in brain edema (swelling), rapid increase in epidural intra-cranial
pressure and can not be treated surgically as the subdural, and sometimes the
intra-cerebral hematomas can be treated.
The second impact syndrome has a very high rate of death. This problem must be avoided. If there is any doubt as to the severity of
a concussion or if the athlete has any ongoing symptoms or complaints, the
athlete should not return to play.
Post Concussion Syndrome
Patients who have had a concussion sometimes have difficulty sleeping,
prolonged headaches, either with exertion or at rest, dizziness, and
disorientation changes. This is post
concussion syndrome. It is also
important to realize that the diagnosis of a post concussion syndrome is only
given once a thorough neurological evaluation and neural imaging (CT or MRI)
has proven there is no significant intra-cranial pathology.
In summary, it is important to recognize and evaluate head injuries to
prevent further significant consequences.
A team physician, trainer or sideline personnel should watch and observe
the players, play to play. Catastrophic
consequences (death) of mis-diagnosis emphasize the importance of being clear
on the above outlined definitions and criteria for return to play.
IV.
CERVICAL SPINE (NECK) INJURIES
Ian
Armstrong, MD
Cervical spine injuries are as important as identifying head injuries. The permanent neurological damage from a
missed spine fracture can be devastating and includes permanent weakness,
numbness, paralysis and death.
Cervical spine injuries include cervical ligament sprain and muscle
strain, intervertebral disc injury or herniated disc, cervical fractures, and
brachial plexus neuropraxia, also known as a stinger or a burner.
Acute cervical sprain and strain is the most common cervical spine injury
in contact sports. This involves injury
to the soft tissues surrounding and supporting the neck as a result of forces
applied to the neck during contact. The
patient will usually complain of neck pain, limitation of cervical spine motion
without radiation of pain in the arms and without neurological complaints such
as weakness and numbness. These cervical sprain and strains fully resolve on
their own but initially, more serious injury should be ruled out through a
neurological examination and determination of cervical range of motion. When a neck injury is suspected and the player
complains of neck pain, any athlete with less than a full pain free
range of motion or persistent weakness or numbness should be treated as a
cervical spine fracture, excluded from activity and properly immobilized in a
collar. The evaluation and treatment
should be left up to medical personnel and include the appropriate x-rays
including flexion and extension views, as well as MRI or CT scan if
indicated.
The player with neck pain is given a diagnosis of cervical sprain/strain
only after the appropriate evaluation is completed to rule out more serious
injury. PRICEMM is started
immediately. The athlete can return to
play after only the symptoms subside, the player is completely pain free,
strength is normal and range of motion of the neck is full.
Cervical spine fracture is a severe injury and can cause permanent
paralysis or death. In a cervical spine fracture the vertebrae can split and
put pressure directly on the spinal cord. Any player who is found unconscious
or unresponsive is treated as if they have a cervical spine fracture, or until
proven otherwise. Any athlete with
neurologic deficit, weakness or numbness in the upper extremities, is also
treated as a cervical spine fracture until proven otherwise.
Any player with significant neck pain, weakness or numbness after going
down on the playing field should be moved only by trained medical personnel (an
appropriately trained lifting team) with proper immobilization with a neck
collar, back board. A fracture of the
cervical spine can occur with or without a neurological deficit. The patient does not necessarily have to
have weakness or numbness in his extremities to have a cervical spine
fracture. The athlete may only complain
of pain. If the athlete is moved
improperly or the neck is moved neurological deficit can occur causing
permanent weakness and/or numbness or death.
Cervical Disc Herniation
Cervical disc herniation (slipped disc) is unusual in contact sports,
however, this must be considered in the athlete with neck pain after a
collision with associated weakness or numbness in the upper extremities. The cervical fracture is always considered
first. Player should be pulled from the
game, have a full neurological evaluation
and the appropriate x-ray and MRI evaluation.
The treatment plan is conservative management with repeat neurological
evaluation, anti-inflammatories, limited activities and PRICEMM. The player is not allowed to return to play
until they are completely asymptomatic have full range of motion of the cervical
spine and full strength. A cervical
spine disc herniation gelatin like shock absorber between the vertebrae pouches
out and puts pressure on the nerves as they exit the spinal cord.
Transient Quadriplegia
This problem can occur in a contact athlete with a congenitally small
spinal canal. The bony canal in which
the spinal cord lies and protects the spinal cord is small than normal. There is less room in the canal for the
spinal cord. The problem arises when
there is a hyperflexion or hyperextension injury of the neck. The athlete will complain of complete
paralysis of both arms and legs.
The episodes are transient. There is complete sensory and motor recover
in usually 10 to 15 minutes. In some
patients recovery will be gradual over 24 to 36 hours. There may be a residual paresthesia (burning
sensation shooting down arm or leg).
This player clearly should be pulled from the playing field and kept
from playing until a complete evaluation and x-rays are done to rule out any fracture or disc
herniation. The size, magnitude and
significance of the spinal, canal tightness (stenosis) must be evaluated with
x-ray and MRI. Return to play
guidelines for athletes with cervical stenosis are mixed, but contact sports
such as football are not allowed.
The most important aspect of preventing cervical spine injuries is
learning proper tackling techniques and strict adherence to the rules. A historical note that reinforces the
importance of tackling technique and adherence to rules is illustrated by the
demographics of neck injuries related to some rule changes in the guidelines of
football. The quality of helmets was
increased adding greater protection for the head. However, with the advent
of the improved helmet, there was a decrease in the number of head injuries but
there was a increase in the number of neck injuries. This, with careful analysis, was determined to be due to the fact
that players were using their helmets as a weapon (i.e., spearing increased). Spearing was eliminated from the game. The number of neck injuries decreased
significantly with the implementation of this ruling. Spearing with the head down puts maximal force of the cervical
spine and maximizes the potential trauma and injury to the spine.
Burners or stingers
The stinger syndrome generally occurs after contact with head, neck or
shoulder characterized by a sharp burning pain radiating down the arm into the
hand lasting from several seconds to several minutes. The key to the diagnosis of this lesion is its short duration and
the presence of full pain free range of motion of the neck. An athlete's whose paresthesia (burning
pain), weakness and numbness completely resolves, demonstrates full muscle
strength and full pain free range of motion of the neck may return to play. Persistence of symptoms indicates the
patient should be removed from play. A
full cervical spine and neurological evaluation should be completed.
The evaluation includes neurological exam as well as cervical spine
examination by qualified personnel.
When a burner or stinger is suspected, the first obligation is to rule
out serious cervical spine injury, fracture, herniated disc or ligamentous
injury that may indicate a more serious problem. A history of bilateral symptoms or symptoms including the lower
extremities are more frequently associated with spinal injuries. If the player complains of neck pain, a
complete cervical evaluation is mandatory including x-rays.
Prevention of stingers is based on aggressive neck and shoulder
strengthening programs. Neck rolls or
devices such as a cowboy collar is worn under the shoulder pads and effectively
limits the extremes of extension, and lateral bending of the cervical spine.
These particular terms refer to stretching of brachial plexus and nerve roots
and is characterized by a burning pain which involves usually one upper
extremity. The mechanism of injury generally occurs as a result of stretching
of the cervical nerve roots or brachial plexis after lateral flexion of the
neck away from the shoulder. There may
be a weakness or numbness. The player
will usually grab the upper extremity and is holding that upper extremity after
play. This may also be a warning of
cervical stenosis.
V. LUMBOSACRAL SPINE (LOW BACK)
INJURIES
Ian Armstrong, MD
All athletes should have radiographic studies that include a full spine
series with flexion and extension.
Oblique views are important to look at the pars intra-articularis. If a stress fracture is suspected, a
special bone scan (spec scan) is done.
A bone scan shows increase in biological activity in the area of the
fracture and is the most sensitive study.
One may have a negative x-ray or normal plain x-rays but have a positive
spec scan. A CT scan is also useful in
further evaluation of the bony abnormalities and anatomy of the pars defect.
Treatment of low back pain as a result of
spondylolysis: 1) The patient should
not participate in contact sports or provocative activities. There are two basic treatment options. The first is complete activity modification
with no sports activities for at least 3 months. The second is bracing with activity modification and no sports
for at least 3 months. The patient may
return to play if he is asymptomatic at that time. If the brace option is chosen, the patient is to wear the brace
24 hours a day. Once he is pain free
from his daily activities with a brace he may have an increase in
activity. The athlete can then
gradually return to competition. Most
adolescent athletes can begin to return to exercise after 3 to 4 weeks of
bracing. If the pain recurs then the
patient is removed from play and activity.
Adolescents may participate in contact sports using bracing as long as
they are asymptomatic and pain free.
Spondylolysis is a stress fracture without slippage. Grade I spondylolisthesis (stress fracture),
less than 25% slippage; Grade II spondylolisthesis, less than 50% slippage;
Grade III, less than 75%; and Grade IV complete slip of one vertebral body on
another. Grade I spondylolisthesis that
is asymptomatic does not restrict an athlete from sports including
football. Grade II spondylolisthesis;,
these athletes should not compete in sports that include gymnastics, football
and other contact sports.
Lumbar Spine
Injury to the lumbar spine (low back) is more common but usually less
severe than in the cervical spine.
Injuries to the lumbar spine include herniated disc, stress fracture or
spondylosis. The most common injury
in the lumbar spine is a ligament sprain or muscle strain. There is usually a history of a specific
twisting injury, forceful movement, or direct blow. These are treated with PRICEMM for usually 3 to 6 weeks. During this time the athlete is advised to
avoid provocative (pain causing) activity.
There may be an underlying problem.
The patient should not return to play unless he is asymptomatic and has
returned to pre-injury level of strength and conditioning.
A herniated disc may also be found in the high-school
athlete, but is rare. A herniated disc
is most commonly caused by a twisting injury.
An athlete with a herniated disc may complain of pack pain, radiating
leg pain, weakness or numbness. Severe
disc herniation can cause bowel or bladder problems. Any athlete with low back pain and radiating leg pain should not
be allowed to participate in contact sports.
A thorough neurological evaluation is necessary and evidence of
weakness, numbness, radiating pain or chronic low back pain suggests that the
athlete should have an MRI. If MRI shows
a herniated disc, initial treatment is PRICE MM unless numbness and weakness is
severe or worsening. The athlete can
not return to play unless there is a complete resolution of pain, numbness and
weakness.
Isolated low back pain in a contact or jumping sport athlete which lasts
more than 3 - 6 weeks with the proper treatment, may be a stress fracture
(spondylolysis). Athletes most commonly
develop these problems between the ages of 10 and 18 years of age.
This pain may be unilateral, bilateral and most often is not associated
with leg pain. Pain most often occurs
with the low back in the extended rather than a forward flexed position.
Spondylolysis is a stress defect in the pars intra-articularis. The pars intra-articularis is the bone that
connects the vertebrae together. Spondylolysis is stress fracture without
slippage of the vertebrae.
Spondylolisthesis is a forward slippage of one vertebra in relationship
to the vertebrae below it. This forward
slippage results from a lack of support from the posterior arch (pars
intra-articularis) secondary to the spondylolysis (stress fracture).
Grade III (IV) spondylolisthesis (greater than 50%) should not
participate in sports.
VI.
SHOULDER INJURY
Keith
S. Feder, MD
The shoulder is a minimally constrained ball and socket joint. The shoulder consists of 3 tissue
levels. The inner most level is the
ligament or capsular level, a thick tissue layer that holds the bones (ball and
socket) together. The middle level
consists of the four rotator cuff muscles and tendons. This muscular tendon level creates the
motion in the shoulder joint and is integral in the throwing motion. The most superficial level is the 3 heads
(parts) of the deltoid muscle. The
shoulder is suspended from the sternum (chest) by the clavicle (collar bone)
and is connected by the AC (acromioclavicular joint).
Contusion
Contusions around the shoulder are a common problem. Contusion (bruise) is caused by a direct
blow to the muscle or any tissue overlying a bony prominence. Contusions are usually accompanied by
bleeding within the muscle tissue leading to swelling and ecchymosis (white and
blue). Acute treatment consists of RICE
(rest/ice/compression/elevation).
Return to play is allowed with full return of range of motion, strength
and per pain tolerance.
Fracture
The most common fracture (bone break) around the shoulder is a fracture
of the clavicle. This is usually a
direct trauma injury. Fall on the side of the shoulder. This is treated in a figure of 8 bandage or
sling depending on the severity of the fracture. Surgery is usually not indicated in this injury. Healing time is approximately 6 weeks, but
it may be longer before contact sports are allowed. After healing, shoulder strength and function usually return to
normal. Many patients have a bump at
the site of the fracture.
Dislocation
The glenohumeral (shoulder joint) derives the vast majority of its
stability from the ligaments or capsule.
Traumatic dislocation or subluxation of the shoulder is a common
problem. A dislocation is when the ball
comes completely out of the socket, 99% of the time separating the ligament
attachments to the bone. This injury
requires a physician to put the ball back in the socket, occasionally with
anesthesia. In subluxation, the ball
only partially comes out of the socket, usually stretching rather than
detaching the ligaments.
Initial treatment for both, after reduction, (ball back in the socket) is
immobilization in a sling, ice and anti-inflammatory medication. The length of immobilization has been
debated. The consensus is that a sling
should be used until the pain is reduced enough to begin range of motion
exercises. Once range of motion is
established, strengthening is begun. The player may return to contact sports once full range of
motion/strength is re-established and using a shoulder stabilizing brace. Redislocation or subluxation is unfortunately
rather common in spite of optional treatment and bracing.
Surgery is not generally indicated following initial
dislocation/subluxation. It is
accepted, however, that with each subsequent dislocation/subluxation, the
ligaments become more stretched out and therefore easier to re-dislocate. Surgery to repair or reattach the ligaments
may be necessary following recurrent episodes of dislocation/subluxation.
AC JOINT INJURY
The AC (acromioclavicular) joint injuries are most common in football and
hockey. The injury usually results from
direct blow or impact to the top of the shoulder. The severity of the injury is based on the amount of damage to
the 3 ligaments that support or stabilize the joint.
A Grade 1 injury involves only the AC joint capsule or ligament. The athlete will complain of pain and there
will be swelling but no separation of the joint.
A Grade II injury is a tear of the AC joint capsule, stretching of the
two stabilizing (conoid/trapezoid/ coracoacromial) ligaments and slight (less
than 1 cm) separation of the joint.
A Grade III injury is a tear of the AC capsule and tear of the 2
stabilizing ligaments creating a significant separation (1 to 2 cm) and a obvious deformity.
A Grade V injury is a Grade III injury and an injury to the trapezius
muscle/fascia and massive displacement/deformity (greater than 2 cm).
All of the above injuries are initially treated with ice, compression and
a sling. X-rays must be obtained to
check for a clavicle or growth plate fracture.
Treatment for a Grade I, II, III injury most often consists of a sling,
PRICE MM, range of motion as pain permits and shoulder strengthening when pain
free. The athlete may return to sport
when pain free, has full range of motion and equal shoulder girdle strength. For return to contact sports
(hockey/football), closed protective padding may be necessary (skeleton pads).
Severe Grade III or V injuries may require surgery to re-establish and
restabilize the AC joint and supporting ligaments. Surgery is not indicated for any Grade I or II injury.
Overuse
Injuries
A vast majority of overuse or repetitive microtrauma injuries of the
shoulder occur in overhead or throwing athletes. This includes baseball, football, volleyball, softball, track and
field. The shoulder capsules
(ligaments) that support the ball and socket joint and the rotator cuff are the
two structures mainly effected. The end
point of untreated "throwers shoulder" is a shoulder that has become
so ligamentously loose (stretched out) that the rotator cuff muscles cannot
effectively support the ball and socket joint.
Because the rotator cuff now must work overtime to attempt to support
the joint, there is resulting inflammation and weakness. If this is not treated properly, this will
lead to partial tearing of the rotator cuff tendon and ultimately complete
tearing and surgery.
It is certainly better to prevent throwers shoulder rather than to treat
it. The coach must not overwork and
overhead athlete. It is of utmost importance that proper shoulder
strengthening, conditioning and throwing technique be instituted at a young age
and be carried through the entire career of a thrower. It is as important that the coach does not overwork the athletes shoulder. This may create an injury no matter how good
the training regimen.
Nonoperative treatment of the shoulder can be effective if tearing of the
rotator cuff tendon has not yet occurred.
This involves PRICE MM. The
athlete must stop throwing completely, then must become pain free and then
begin a strengthening program. Only
when equal strength has been restored only can a throwing regimen begin. Endurance must be built slowly over
time. Strengthening exercises must be
continued for the remainder of the athlete's throwing career.
If rest, anti-inflammatory medication, and physical therapy over a 3 to 6
month period do not resolve the shoulder pain, a MRI may be indicated to rule
out a rotator cuff tendon or ligament injury.
Significant shoulder instability and/or rotator cuff injury may be an
indication for surgical intervention and correction.
HUMERAL PHYSEAL INJURY
A physis is the growth plate, the area of the bone at which growth
occurs. The same repetitive
micro-trauma that can stretch out the shoulder ligaments can effect the growth
plate near the shoulder. In the younger
athlete, there is a higher incidence of injury to the growth plate as the
athlete ages, the growth plate injury becomes less likely and the ligament
(capsule) injury more likely.
The actual injury is a stress fracture of the growth plate. The injury is much more common in athletes
less than 13 years old. Treatment for
this injury is rest, ice, and NSAIDs.
The athlete is usually finished for the season. Once the athlete is pain free a rotator cuff
strengthening is instituted. The
athlete then goes to a pre-season conditioning program. Throwing motion must be examined for
problems, the problems corrected and only then return to sport is allowed.
VII. ELBOW INJURIES
Keith S. Feder, MD
Trauma
The two most common traumatic injuries around the elbow are fracture
and/or dislocation. The mechanism of
injury is direct trauma or falling on an outstretched extended arm. Acute treatment of the suspected fracture or
dislocation is splinting of the limb in the position in which it is found
following the trauma. No attempts
should be made at correcting the deformity except by a MD.
Most fractures and dislocations can be treated with manipulation (setting
the fracture) and immobilization.
Occasionally a surgical procedure with or without fixation (screws,
pins, plates) is necessary to treat those injuries. Overuse injury around the elbow like the shoulder is most common
in the throwing athlete. As in the
shoulder, the forces around the elbow with overhead sports is significant.
Biomechanically speaking the throwing motion creates a significant valgus
force on the elbow. In other words,
there is compression (squeezing) in the lateral (inside portion of the elbow)
and tension (stretching) placed on the medial (outside portion of the
elbow).
The throwing athlete that complains of swelling and ongoing lateral elbow
pain that increases with activity, but has full motion of the elbow (Panner's
disease). Panner's disease is an injury
to the capitellum that occurs between 7 and 12 years of age. This problem usually can usually be
diagnosed by the history and with an x-ray.
Acute treatment is ice, splint and/or sling may be necessary if pain and
swelling are significant. No throwing
is allowed until the injury heals. This
problem will usually resolve without residual impairment if no throwing is
allowed until resolution.
A more serious injury to the lateral growth plate is called
osteochondritis dessicans (OCD). This
usually occurs in the 13 and 16 year old age group.
The athlete will complain of ongoing increasing lateral elbow pain, worse
with activity accompanied by swelling and loss of elbow motion. In untreated cases, there will be complaints
of locking and catching.
The diagnosis is made by history, physical examination and initial x-rays
which may sometimes be normal.
Acute treatment is ice with splinting and/or sling for up to 4
weeks. If caught early, the injury may
heal and the athlete may return to overhead sports participation.
If not caught early, this is a significant injury to the growth plate. Surgery may be indicated in these cases and
the athlete will probably be unable to return to overhead sports.
Injury to the medial (inside) portion of the elbow is due to the tension
(stretching) placed on the elbow. This
involves inflammation (apophysitis) and sometimes a stress fracture of the
growth plate. There is progressive
medial pain, decrease in throwing effectiveness and throwing distances. There is also recurrent swelling as well as
loss of motion.
Acute treatment is no activity for a minimum of 6 weeks, ice and
NSAID. When pain free, muscles around
the elbow are strengthened and gradual return to overhead activity is allowed.
If pain returns, the athlete is rested until the following season. Playing through pain will only lead to
worsening symptoms.
As previously stated, ligament injury occur more often as the athlete
ages and growth plate injuries occur less often. The ulnar collateral ligament (inside elbow ligament) are more injured commonly in the older
adolescent and young adult
athlete. A complete tear of the ulnar
collateral ligament usually occurs in the throwing athlete who complains of
recurrent pain and swelling over the years.
The athlete will usually be pain free until he returns to over head
sports. This is then usually followed
by one event of which there is a "pop" in the elbow with significant
pain as well as the inability to continue to throw.
History, physical exam, an x-ray, stress test and/or MRI are necessary to
make a definitive diagnosis. Surgery is
usually necessary in order for the athlete to return to throwing sports.
Less severe overuse injuries to the elbow involve the muscles and
tendons. Injury to the lateral
(outside) muscle and tendons of the elbow is called lateral epicondylitis or
tennis elbow. Injury to the medial
(inside) muscle and tendons of the elbow is called a medial epicondylitis. Treatment of choice is PRICE MM. Return to sport is allowed when the athlete
is pain free and strength has been restored as well as sports specific techniques
which have been reviewed and corrected.
VIII. WRIST AND HAND INJURIES
Keith S. Feder, MD
Fracture
A vast majority of wrist and hand injuries are traumatic. A vast majority of traumatic injuries are
fractures. Fractures involve the radius
and ulna (forearm) scaphoid, small wrist bone, the metacarpals (hand) and
phalanges (fingers). The injury is most
often the result of a direct trauma.
Deformity is not always obvious but swelling and tenderness is almost
universal. Initial treatment is
splinting and ice. X-rays are
mandatory. Reduction (setting)
immobilization is the most common treatment.
Surgery is much less likely in the adolescent athlete than the
adult. Return to sport is following
healing, and rehabilitation with the time depending on the location and
severity of the injury.
Dislocation
Finger and thumb dislocations are not uncommon. They may be accompanied by a fracture. Dislocations should be splinted and only reduced by a MD. X-rays are mandatory and splinting for 7 to
10 days is usually required, more if a fracture is present.
Ligament Injury
The most common ligament injury is to the ulnar collateral ligament (of
the thumb). This can be a ligament
injury as well as a growth plate fracture.
Physical examination and x-rays are mandatory and a stress x-ray may be
necessary for diagnosis.
Immobilization (cast) for a minimum of 4 to 6 weeks is necessary. Surgery is unusual.
Tendon Injury
Jersey finger is the most common
tendon injury of the hand and wrist.
This occurs when a player gets its fingers stuck in another player's
jersey. The player and coach usually
assume that there is just a sprain. The
player is in fact unable to make a fist normally. This injury can only be corrected with surgery, and if untreated
can be difficult or impossible to correct at a later time.
IX.
THE
KNEE
Keith
S. Feder, MD
The knee joint is made of bones, the femur, tibia and patella. The joint is made up of multiple ligaments
(bone to bone attachments) that together give the joint stability. The four major ligaments are the medial
collateral (inside, side ligament) that the, the lateral collateral (outside,
side ligament) the anterior cruciate ligament/ACL (central, front and the
posterior cruciate ligament/PCL (central, back). The articular cartilage is soft, shiny, white covering at the end
of each knee joint bone. The articular
cartilage is a slippery surface, lubricated by fluid within the joint, that
allows the knee to glide smoothly through its range of motion.
The meniscus, sometimes called the "cartilage", is actually a
firm but rubbery disc. There is both a
medial (inside) and lateral (outside) meniscus in each knee. The meniscus is a shock absorber of the
knee.
FRACTURE:
The treatment of a fracture is the splint in the position in which the
limb is found. If there is a
significant deformity present, only a M.D. should reduce (correct) the
deformity. Ice should be applied
immediately. Evaluation should always
include x-rays. Sometimes stress x-rays
and/or MRI/CT scan is necessary to make a definitive diagnosis and treatment
plan.
Fracture around the knee can be quite serious and that if there is
significant deformity, arteries, vein and nerves around the knee joint are at
risk.
Although, most fractures can be reduced (aligned) and then immobilized
(casted) sometimes surgery and internal fixation (screws, pins and plates) is
necessary.
Return to play is only allowed with complete healing of the fracture
followed by a full rehabilitation program and
return to sports specific activities (drills and skills associated with
the sport) and then followed by return to sport.
MENISCUS:
The meniscus is a shock absorber of the knee. The most common mechanism of injury are twisting with a fixed
foot and hyperflexion of the knee.
The athlete will complain of delayed as well as recurrent swelling, pain
along the joint line as well as catching and locking of the knee. Diagnosis is made based on history and
physical examination. X-rays do not
show the meniscus but should be taken to rule out other bony injuries. MRI could be used to reinforce diagnosis.
Many medical studies show that when a portion of the meniscus is removed,
the articular cartilage that the meniscus protects will wear faster than normal
resulting in early onset of arthritis or degenerative joint disease. Therefore, we do all we can to preserve the
meniscus. A meniscus tear generally
will require surgical correction but unless there is locking and recurrent
catching, conservative treatment is an option.
This includes PRICE MM and rehabilitation. If the athlete becomes pain free on this program a trial return
to sports is undertaken. If symptoms
return, surgery should be considered.
The surgery is performed arthroscopically only through three very small
incisions. Every effort should be made
to repair (sew back together the meniscus).
The majority of tears are usually repairable but occasionally partial
meniscectomy (trimming at the torn area) must be done.
Rehabilitation is a must following each type of surgery. On full range of motion, equal strength and
ability to perform sport specific activities is achieved and return to sport is
allowed.
ARTICULAR CARTILAGE:
The articular cartilage is the
slippery surface that allows a smooth motion of the joint. Mechanism of injury to the articular
cartilage is similar to that of the meniscus.
Isolated injury to the articular cartilage is must less likely then
injuries to the meniscus.
Articular cartilage injuries are difficult to diagnose. The athlete will complain of pain, swelling,
locking and catching as in the meniscal lesion. X-rays will not show isolated articular cartilage lesions. X-rays may show articular cartilage lesions
if bone is involved. MRI is usually
necessary for definitive diagnosis.
Occasionally, there can be an injury involving both articular cartilage
as well as the bone to which the cartilage is attached. This is called osteochondritis dessicans
(OCD).
Injury to the articular cartilage is a catching and/or locking, will
usually require arthroscopic surgery to trim out the injured area.
Suspected OCD must be evaluated by MRI and/or CT scan. If the lesion is not detached, it usually
can be treated without surgery but will require crutches and a nonweightbearing
period followed by rehabilitation. If
the lesion is partially attached and especially if fully detached, surgery is
usually necessary for reattachment and stabilization. Articular cartilage injuries must not be ignored, especially if
OCD is present. Articular cartilage
especially OCD are difficult problems to treat. Please be aware that surgery is not always successful and the
athlete may be unable to return to sports activities.
LIGAMENT INJURIES:
Ligaments attach bone to bone and provide stability to a joint. An injury to the ligament is called a
sprain. There are three grades of
injury to a ligament. The Grade I
sprain is an injury to the substance of a ligament causing pain but minimal or
no instability. A Grade II sprain is a
stretch injury to the ligament which is accompanied by moderate
instability. A Grade III sprain is a
complete tear of the ligament.
The medial collateral ligament (MCL) is the most often injured ligament
around the knee. The medial collateral
ligament and lateral collateral ligaments are most often injured by direct
trauma, usually an impact from the side.
The athlete will complain of swelling, pain and instability on the inside
part of the knee for the MCL and the outside part of the knee for the LCL. Acute treatment is Price MM, crutches and splinting. X-rays are mandatory to rule out a fracture. Ongoing treatment is PRICE MM and a
functional hinge brace. Return to play
is when the athlete is pain free, strength is equal and the athlete is able to
perform sports specific activities (drills and skills associated with the
sport) without pain. Grade I sprains
will usually take 4 to 6 weeks. Grade
II injury is 8 to 10 weeks and Grade III injuries are 12 to 14 weeks. Treatment of isolated medial or lateral
collateral injuries does not include surgery.
Conservative treatment is in most cases successful.
The anterior cruciate ligament is much more often injured than the
posterior cruciate ligament, approximately at a 10 to 1 ratio. The most common mechanisms of injury to the
ACL is a hit from the side with a twist, a planted foot with a twist in
hyperextension of the knee over the top of the fixed foot. The diagnosis of ligament injuries may be by
history and physical examination, MRI can be used to reinforce the diagnosis.
If there is minimal or partial tear of the ACL with only minimal
instability, the athlete can avoid surgery, undergo rehabilitation and use a
brace to return to sports. A complete
tear of the ACL accompanied by significant functional instability will usually
require surgical reconstruction in order for the athlete to return to sports
activities.
Occasionally, the ACL can be torn but a portion of the femur or tibia
attached, in this case, surgical reattachment is usually necessary and
performed and the patient can return to sports following rehabilitation.
Care must be taken after the timing of the surgical reconstruction in the
younger athletes with open growth plates.
Special testing (bone age) must be done to determine the amount of
potential growth remaining. If there is
less then 1 cm of growth remaining, the athlete is treated as an adult and
reconstruction can be performed if necessary.
If there is greater than 1 cm growth remaining, eventually ACL reconstruction
is usually not performed. A modified
technique of ACL reconstruction that is less likely to damage the growth plate,
but not as effective as the conventional reconstruction, is an option, but a
detailed discussion should be undertaken between parent and M.D. prior to
surgical intervention.
If there is a combined ligament injury, reconstruction is more likely
necessary. If there is a combined ACL
and meniscus injury, the course of
treatment will be at least repair of the meniscus and reconstruction of the ACL
as per outlined above. Please be aware
that return to play from ACL reconstruction is a minimum of six months. The initial period following ACL
reconstruction, a brace is required and rehabilitation is instituted early
on. The athlete will progress to full
weightbearing to functional exercise, weight training and then sports specific
activities (drills and skills associated with the sport) when strength and
stability is restored. Again, return to
play following ACL reconstruction is a minimum of six months and in contact
sports, the athlete should be braced as well.
POSTERIOR CRUCIATE LIGAMENT (PCL) INJURIES
PCL injuries are very rare in adults and more rare in adolescence. The mechanism of injury for the PCL are one
direct anterior (front) to posterior (back) force on a flexed (bent knee) to
hyperextension (over the top) of the knee.
High energy injury to the PCL can occasionally cause posterior
dislocation of the knee and a significant risk to the arteries, veins and
nerves behind the knee that course into the lower leg.
Diagnosis is made by history, physical examination and x-ray. X-rays should be undertaken to determine if
there is ligament injury with detachment of bone from the femur or tibia. MRI is usually necessary to determine the
extent and location of the ligament injury.
Ligament injuries with bone attached (avulsion fracture), from the femur
or tibia are usually repaired surgically.
Isolated, complete or partial tear of the PCL without significant
instability is treated conservatively.
This includes PRICE MM, rehabilitation and bracing on return to
sports. Isolated, complete or partial
tears of the PCL joint generally will not require surgery. Multiple ligament injuries usually will
require surgery but PCL reconstruction falls within the same parameters
pertaining to growth remaining as the anterior cruciate ligament.
PATELLA DISLOCATION AND SUBLUXATION
Patella dislocation/subluxation is also known as patella (kneecap)
instability. There are two mechanisms
of injury, direct trauma to the patella causing the displacement of the patella
(dislocation/subluxation) and indirect injuries associated with sudden slowing
or stopping with twist or change of direction.
Complete dislocation of the patella where the kneecap comes completely
out of the patellofemoral groove, will usually spontaneously reduce (go back
into place) when the athlete straightens the kneecap. If this remains dislocated, the knee should be splinted, ice applied
and only a M.D. should attempt reduction.
Athletes with subluxation may complain of recurrent giving way. The athlete may never have a complete
dislocation.
Factors that may predispose an athlete to these patella problems are 1)
ligamentous laxity (loose joints)
2) a combination of pes planus
(flat feet), hip anteversion (internal rotated hips and knock knee) 3)
quadriceps weakness (thigh muscles).
Acute treatment of patella dislocation following reduction is PRICE
MM. History, physical examination and
x-rays should be taken following the reduction. The only surgical indication in a x-ray that shows large loose
bodies or osteocartilaginous bodies floating within the knee joint that may
cause further damage. Immobilization in
extension for a period of time.
Conservative treatment is somewhat controversial. Some suggest removal of the joint fluid
(swelling) from the knee and application of a cylinder cast to allow the
patella stabilizing ligament to heal.
This is followed by rehabilitation and return to sports.
Some others suggest removal of the joint fluid followed by bracing, rehab
and return to sport.
Still others suggest that surgical repair of the patella stabilizing
ligament is the treatment of choice followed by rehabilitation and return to
sport. There are some new functional
patella braces that may enhance stability following return to sport.
Recurrent dislocation/subluxation can certainly become a problem. Corrective surgery is indicated if a full
rehab program has been completed, full quadriceps strength is present and
bracing has been attempted and all of the above have failed to prevent
redislocation/subluxation.
KNEE OVERUSE
Anterior knee pain is a big problem.
There are multiple positive causes of anterior knee pain, patellofemoral
syndrome, quadriceps tendinitis, patellar tendinitis, Osgood-Schlatter's
disease, iliotibial band syndrome.
The problem usually stems from overuse or "to much to soon
". In other words, the frequency
duration, intensity of workouts increase too rapidly causing muscle fatigue and
compensatory injury or repetitive micro-trauma in a poorly conditioned
athlete. This cycle causes structural
injuries. Footwear and surface must
also be considered as an etiologic factor.
Patellofemoral syndrome refers to a problem in the kneecap joint. Those athletes with the terrible triad (pes
planus), hip anteversion, knee valgus as well as those who are overweight may
be predisposed to this problem. The
problem usually begins with maltracking of the patella or direct trauma to the
patella causing injury to the patella articular cartilage surface.
The diagnosis is made with history, physical examination and x-rays. The athlete will usually complain of vague
anterior knee pain and probably cannot point to a specific area of pain. The athlete usually will concur, though, if
asked if the pain is behind the kneecap.
The acute treatment is Price MM.
This is followed by an aggressive lower extremity stretching program as
well as strengthening of the quadriceps, musculature, especially the VMO,
vastus medialis obliquus (the inside portion of the quadriceps muscle). Functional patella bracing is somewhat
helpful following rehabilitation and return to sport. Surgery is rarely required for this problem.
Quadriceps/patellar tendinitis are both a variant of "jumpers knee". Injuries actually inflammation of the
quadriceps and its insertion above the patella and the patellar tendon and its
insertion below the patella (kneecap).
This is a true overuse injury most commonly seen in basketball and volleyball
because of the hard surface on which these sports are played and intense jump
training.
The acute treatment is PRICE MM.
Quadriceps and patellar tendinitis will not resolve without complete
rest/avoidance of precipitating activity.
Stretching is important in the rehab regimen as well as strengthening
the quadriceps. Well cushioned athletic
shoes will also help prevent recurrence after return to sport.
If the problem is ignored and the athlete tries to play through pain, the
tendinitis may become a partial or complete tear and surgery will be required
for correction.
Osgood-Schlatter's disease is not really a "disease". It is also an overuse injury. Injury occurs at the attachment site at the
patellar tendon to the tibial tubercle (lower leg). The site is actually a growth plate. Repetitive jumping or running causes recurrent micro-fractures at
the growth plate site. The ongoing
healing/fracture cycle causes a characteristic painful bump.
PRICE MM is effective in acute treatment. The athlete must stop sports in order to become pain free. In some severe cases, a cylinder cast is
necessary. When pain is free a
stretching and straightening program is instituted. As long as the athlete is pain free, return to sports is
permitted.
Maturity brings closure of the growth plate at the attachment site of the
patella tendon below the patella and usually an end to this problem. Surgery is only indicated if a residual bone
spur develops that continues to be painful.
The bone spur is simply removed and the problem will usually be
resolved.
ILIOTIBIAL BAND SYNDROME
The iliotibial band is a thick fibrous band that runs from the hip down
to the knee and passes over the joint line on the lateral or outside portion of
the knee. Iliotibial band syndrome is
an overuse injury often seen in runners and is characterized by complaints of
pain over the outside portion of the knee.
This injury is not associated with any trauma. It is associated with hill running or too rapid an increase in
hill running. It is also associated
with running on banked surfaces.
Acute treatment is PRICE MM followed by an aggressive stretching
program. A change of shoes may be
necessary as well to prevent recurrence.
On return to running, slower training progression is necessary to
prevent recurrence.
X.
Foot and
Ankle Injuries
Carol Frey, MD
ANKLE SPRAINS
GENERAL
Approximately 1 out of 10,000 people experiences an
ankle sprain per day. This accounts for
27,000 ankle sprains per day in the United States alone. If one were to look at all ankle sprains,
which occurred secondary to athletic injuries, 45% occurred in basketball, 31%
in soccer and 25% in volleyball players.
An ankle sprain is a ligament injury. The most commonly injured ligaments are the
lateral collateral ligaments of the ankle.
These ligaments are composed of the anterior talofibular ligament,
calcaneofibular ligament and the posterior talofibular ligament. There are also 3 degrees of injury. Grade I is mild, Grade II is moderate and
the Grade III is severe. Other
structures can be injured at the time of the original injury. Bones of the ankle or the foot may fracture,
a tendon can be torn or strained, and nerves may be stretched. Remember that an ankle sprain is not always
"just a sprain".
Usually the athlete has a history of having their foot
in a plantar flexed and inverted position.
They may hear a pop and may or may not have an ability to bear weight on
the limb. It is important to find out
if there is a history of a previous sprain or if they have a "trick
ankle". If the athlete heard a pop
or was not able to bear weight on the ankle after the injury, chances are that
the injury was a grade II or III.
The goal of treatment is to prevent long term problems
of instability or pain. Rehabilitation
is the key to avoiding future problems.
All ankle sprains are treated in 3 phases.
PHASE I
1. Protection.
2. RICE.
PHASE II
1. Peroneal tendon strengthening and dorsiflexion strengthening.
2. Achilles tendon stretching.
PHASE
III
1. Functional
conditioning.
A. Brisk walking.
B. Running.
C. Figure 8 running.
D. Hopping.
E. Jumping.
F. Cutting.
2. Proprioception.
A. Coordination exercises.
3. Agility.
4. Endurance.
Grade I and II injuries usually progress very rapidly
through the phases of rehabilitation.
During phase 2 and 3 Grade II and II injuries are protected with tape,
brace or tape and brace. Grade III
injuries are protected for 6 months to one year after the injury. Grade II injuries are protected at least
until the end of the season. With the
severe injuries, grade III, it is important during phase I of treatment to
protect the ankle so that the ligament will heal with the proper tension. This can be accomplished with a dorsiflexion
brace or cast. It is important that if
a cast is used that it is weight bearing as soon as the athlete can tolerate
and that it is removed, the patient is advanced to phase 2 and 3 of
treatment. Surgery is not recommended
in the acute setting for any grade of injury.
If the coach/trainer decides to tape the athlete it
should be noted that although tape does restrict extremes of motion, shorten
reaction time of the peroneal tendons and improve proprioception, it may also
restrict subtalar motion, may cost more than braces, loosens, displaces and
tears. It also takes experience to
apply tape well and may restrict vertical jump.
It has been shown that braces do not impede performance,
is easier to apply than tape, and is cheaper as it can be reused, improves
balance, and doesn't loosen much.
Although, high top athletic shoes have been found in research studies to
decrease ankle sprains in basketball players and braces have been shown to
decrease ankle sprains in football players, it should be pointed out, that no
form of external support completely eliminates ankle sprains.
FRACTURES
The most common fractures of the foot/ankle are ankle,
heel, navicular, metatarsal, tarsometatarsal joint, toe, and sesamoid
bones. The diagnosis of a fracture is
usually straight forward, provided basic guidelines are followed when viewing
the x-ray. It is important to recognize
that a x-ray only represents a moment in time.
A large amount of damage also occurs to soft tissues like ligaments and
tendons at the time of a fracture.
The treatment of fractures is based on clinical judgment
that includes examination, x-rays, and amount of injury to surrounding tissues
like skin. A decision to perform
surgery takes into account all aspects of the athlete's condition. In general the best long-term results will
restore full function and avoid degenerative arthritis in the future. This will result from the treatment that
will restore the original anatomy and allow early range of motion and weight
bearing.
ANKLES
Although closed reduction may accomplish the above goals
of restoration to original anatomy and return to full function, open reduction
and internal fixation with screws and plates can achieve the desired goals and
lead to the best long-term results in general.
The use of plates and screws usually allows earlier range of motion and
weight bearing. However, if the
orthopaedic surgeon determines that a cast restores the original anatomy with
out surgery, this may be the best treatment for the athlete.
HEEL
BONE (CALCANEUS)
Fractures of the heel bone are some of the most common
fractures that occur in the foot. The
heel bone bears about half the body's weight during walking and standing. Fractures that seriously distort the anatomy
and function of the heel can disrupt normal foot function. About 25% of heel fractures do not involve a
joint but about 75% do involve the joint that is just below the ankle (subtalar
joint). This joint is important for
adapting the foot to uneven ground and for normal walking, standing and
running. The degree of distortion in
the joint, swelling and hemorrhage are directly related to the amount of
energy, which caused the fracture.
Falls or jumps cause most of these fractures.
A fracture of the heel bone can be treated without
surgery and with early range of motion, elevation and control of swelling. This approach is possible if there is not
much disruption of the subtalar joint.
More and more, orthopaedic surgeons are recommending surgery for this
fracture, especially if it involves the joint.
A CT scan is usually recommended to better evaluate the subtalar
joint. It is felt that with surgery,
the joint can be better reconstructed and lead to a better functional result.
NAVICULAR
BONE
Fractures of the navicular bone can occur in athletes,
particularly basketball players and runners.
These fractures are usually stress fractures but can also be from acute
trauma. The repetitive impact on the
navicular bone while running makes runners susceptible to stress
fractures. Navicular fractures can lead
to serious disability if not diagnosed early and treated appropriately.
Some fractures to the navicular bone are not complete
and are best treated in a short leg cast with no weight on the cast. If the fracture becomes complete, an
operation is needed. A screw is usually
placed in the bone to hold it together.
METATARSAL
Metatarsal fractures commonly occur as a result of
crushing injuries or from overuse (stress fractures). The treatment is directed toward obtaining a painless foot with
plantigrade weight bearing surfaces under the metatarsal heads. This restores normal anatomy and normal
motion. Fractures that are minimally
displaced can be treated in a cast or a firm shoe with taping. Walking is allowed as soon as possible for
these fractures. Displaced fractures
can lead to a foot that does not bear weight evenly on the bottom of the
foot. In these cases, surgery may be
necessary to restore the normal anatomy and function of the foot.
Fractures of the fifth metatarsal are treated
differently because they can be more difficult to treat and may lead to more
problems if not treated correctly. They
can occur after a fall, jump, on a twisted foot or as stress fractures from
overuse. Some of these fractures occur
in an area that has a poor blood supply (Jone's fracture) and require a cast
with no weight bearing for up to 8 weeks.
Often, this type of fracture does no heal and is called a
non-union. When a non-union occurs it is
necessary for the athlete to have surgery and often times a bone graft and a screw
are used to help heal the fracture. If
the athlete had a history of pain along the lateral border of the foot that was
an "achy" area, prior to the fracture, the athlete was probably
developing a stress fracture. This
effect of aching followed by a more recent increase in pain is typical of a
stress fracture. A x-ray should show
the orthopaedic surgeon if there is evidence of a stress fracture.
TARSOMETATARSAL
INJURY
Fracture dislocation of the tarsometatarsal joint (also
known as the Lisfranc's joint) can occur after a major injury or after a more
minor twisting injury. The diagnosis is
made on x-ray and shows a disruption of the normal anatomy of the
tarsometatarsal joint in the middle part of the foot. This is not uncommonly seen in football players. Sometimes the diagnosis is not certain on
regular x-ray and a special stress x-ray is taken where the athletes foot is
pushed into a position, which makes the bones move out of position, thus
establishing the diagnosis. The
treatment for this fracture is to restore anatomy. This is seldom accomplished with closed reduction in a cast and
usually requires surgery to restore normal anatomy and function.
TOES
The toe bones are commonly fractured and usually are
treated with taping of the toes together.
It is rare to require surgery or anything more than tape to treat these
fractures. The exception includes
fractures, which enter a joint, are greatly displaced, or involve the big
toe. These fractures may occasionally
require surgery to restore normal function and anatomy.
TENDON
INJURIES
Thirteen tendons cross the ankle joint and transmit
force from muscle to bone. They are
therefore subjected to large loads, which can lead to injury and overuse. Factors that contribute to tendon injury
include poor sports technique, excessive intensity or duration of activity,
improper conditioning, malalignment, and the athlete's age. Tendons are most vulnerable to injury when
load is applied rapidly, obliquely, or during maximal eccentric contraction of
the associated muscle. The most common
tendon derangements include inflammation, subluxation and rupture.
Achilles tendonitis is one of the most common injuries
in sports, particularly those that involve running or jumping. It has been reported to be responsible for
up to 11% of all running injuries.
Etiologic factors include training errors, such as increase in mileage,
intensive training sessions, repetitive hill running, running after inactivity,
or running on uneven ground. Wearing an
athletic shoe with inadequate heel wedges or a soft heel counter that doesn't
stabilize the heel may contribute to the injury.
With Achilles tendonitis there is usually pain,
swelling, heat and weakness secondary to pain, decreased motion and tenderness
to touch. The initial treatment
includes ice, nonsteroidal anti-inflammatories and rest. It is recommended that runners decrease
their mileage and avoid hills and uneven ground. It may be helpful to use orthotics to correct malalignment. A shoe with a molded Achilles pad to prevent
irritation and a 10-15 mm heel wedge to decrease the excursion the tendon is
helpful. Steroid injections are
CONDEMNED. They have been associated
with ruptures of the tendon.
Occasionally casting or even surgery is necessary in very chronic cases.
The peroneal tendons wrap around the outside of the
ankle and help stabilize the ankle.
They can be injure during an "ankle sprain" and may even move
out of their normal groove behind the anklebone (the fibula). When they move out of the groove they are
called subluxed peroneal tendons and can be treated with casting and
taping. However, surgery is usually
necessary to place the tendons back into the normal position behind the fibula
bone.
The peroneal tendons may also develop a tendonitis and
should then be treated like the Achilles tendon until the inflammation is under
control.
The posterior tibial tendon runs behind the inside of
the ankle behind the medial malleolus.
The tendon helps to maintain the normal height of the arch of the foot. When it is inflamed the tendon will be
swollen, tender and weak and the arch may appear flatter. Tendonitis of this tendon should be treated
with rest, ice, non-steroidal anti-inflammatories and a medial internal heel
wedge and arch support. Casting and/or
surgery may be required in cases that do not get better with the conservative
approach mentioned above.
HEEL
PAIN
Heel pain is one of the most common complaints in
running athletes. The cause of heel
pain is usually something called plantar fasciitis. Plantar fasciitis is an inflammation of the strong tissue that
runs along the base of the toes. Along
with the muscles and bones, this connective tissue - plantar fascia - forms the
arch of the foot.
Usually the athlete feels pain in the arch near the
heel. It can be quite intense,
particular when walking or pressing down on that area, and is usually bad first
thing in the morning, just after getting out of bed. Over the course of the day or with increased activity the pain
may increase. Some athletes have this
problem for years.
Low arches may contribute to plantar fasciitis. People with low arches may have tight calf
muscles and may put too much stress on the plantar fascia; tight muscles may
cause the fasciitis. When the muscles
that attach to the Achilles tendon in the back of the heel are tight, the ankle
is less flexible. And because the
Achilles tendon connects to the plantar fascia, the fascia also tightens. Therefore, stretching the Achilles tendon
regularly may help decrease the discomfort in the heel.
A good rehabilitation program addresses the pain and
flexibility of the ankle and the arch, strengthening the muscles in and around
the foot and encourages a gradual resumption of full activity.
PHASES
OF TREATMENT FOR HEEL PAIN
PHASE 1
Anti-inflammatory medications, shoe modification, shoe
insert, temporarily decrease activity and heel cord stretching will usually
relieve the condition when it begins.
PHASE 2
If the problem continues, the tender area may be
injected with cortisone. It also may
help to tape the arch or possibly use an arch support.
PHASE 3
In more chronic cases a night splint or cast may be
used.
PHASE 4
Surgery may be recommended if all the above fails. The aim is to release tight ligaments and
fascia and relieve pressure on the bottom of the foot.
COMMON
SHOE LACING PATTERNS
Chances are that you learned how to lace your shoes in
kindergarten and haven't thought about it since. Given all the differences and idiosyncrasies in feet, one lacing
pattern for shoes couldn't possibly fit the needs of everyone. In fact, certain lacing patterns prevent
injuries, alleviate pain and relieve foot problems. If your shoes aren't feeling comfortable, you might consider
changing the way you lace them. The
following are lacing patterns prevent injuries, alleviate pain and relieve foot
problems. If your shoes aren't feeling
comfortable, you might consider changing the way you lace them. The following are lacing tips from Carol
Frey, M.D., Associate Clinical Professor of Orthopaedic Surgery at the
University of Southern California.
Some
General Lacing Tips
1) Loosen the
laces as you slip into the shoes. This
prevents unnecessary stress on the eyelets and the backs of the shoes.
2) Always
begin at the bottom and pull the laces one set of eyelets at a time to
tighten. This prevents unnecessary
stress on the top eyelets and provides for a more comfortable shoe fit.
3) When buying
shoes, remember that those with large number of eyelets will make it easier to
adjust the laces for a custom fit.
4) The
conventional method of lacing, criss-cross to the top of the shoe, works best
for the majority of athletes.
Seven
Lacing Patterns
The following seven lacing patterns alleviate some
common foot discomforts.
Narrow
Feet
If you have narrow feet, consider using the eyelets set
wider apart on the shoe. This will
bring up the sides of the shoe more tightly across the top of the narrow foot.
Wider
Feet
If you have wide feet, consider using the eyelets closer
to the tongue of the shoe. Using the
eyelets that are closer together will give more width to the lacing area and
have the same effect as letting out a corset.
Narrow
Heel and Wider Forefoot
If you have a narrow heel and wide ball of the foot or
forefoot, consider using two laces to achieve a combination fit. Use both sets of eyelets to achieve a custom
fit that accommodates the width of the forefoot and tightens around the narrow
heel. Use the closer-set eyelets to
adjust the width of the shoe at the forefoot and the wide-set eyelets to snug
up the heel.
Specific
Pain
If you have a bump on the top of your foot, a high arch,
a bone that sticks out, or pain from a nerve or tendon injury, consider leaving
a space in the lacing to alleviate pressure.
Simply skip the eyelets at the point of pain and draw the laces to the
next set of eyelets. This lacing
pattern will greatly increase the comfort of the shoe.
High
Arches
If you have a high arch, consider lacing your shoes so
the laces travel in a straight line from eyelet to eyelet. By avoiding the criss-cross method, this
lacing pattern creates no pressure points at the laces.
Toe
Problems
If you have hammertoes, corns, bleeding toes or toe nail
problems, consider lacing you shoes so the toe-box area is lifted. You can adjust the height of the toe box by
pulling on the lace that travels directly from the toe to the top of the shoe.
Heel Fit
To prevent pistoning of the heel in the shoe and heel
blisters try threading the top laces through each other before tying the shoe.
XI. HEAT
ILLNESS
INTRODUCTION
Heat illness is a very important, but often-neglected
aspect of an athlete's health. The lack
of an understanding of proper body temperature control can lead to a very
dangerous situation and possible death for even the most fit individual.
Heat is produced by the body's normal metabolism. Increased amounts of heat are generated by
exercising muscle. In addition the
body's heat burden can be increased by both internal (e.g, illness) and
external (e.g. humid and/or hot days) factors.
Normally the individual dopes with excess heat by delivering warm core
blood to the skin where it can be cooled by the surrounding air and thus
maintain a normal body temperature. In
order to properly regulate the body temperature an adequate fluid intake is
necessary. With increased body heat the
athlete will perspire (sweat) in order to cool the body. In climates with increased humidity the
ability to sweat is hampered and increased body temperature often results. If an athlete is unable to maintain a normal
body temperature a variety of problems can occur.
HEAT
CRAMPS
The most common of the heat related problems are heat
cramps. These are the intense pains
that occur in the muscles when they have been used to excess or used without
adequate fluid replacement. A variety
of fluids and "sports drinks" have been introduced to prevent this
problem. In most cases proper
conditioning, attention to fluid intake, and limiting activity on hot humid
days is the best prevention.
HEAT EXHAUSTION
Beyond heat cramps is heat exhaustion. With this problem the athlete might feel
weak, fatigue, dizziness, nausea, and muscle cramps. This is a more extreme form of heat illness than heat
cramps. Again the key issue is
prevention by the same methods mentioned above. The athlete must be removed from the heat environment and
encouraged to take fluids by mouth. If
he/she is unable to do so, medical attention should be obtained.
HEAT
STROKE
Heat stoke is the most severe form of heat illness. Here too, the athlete is depleted of fluids
and suffers from an increase in the core body temperature. In this more extreme form of heat illness,
the athlete can suffer severe brain injury and even death if proper medical
care is not administered. These patients
are typically in a confused state. In
classic heat stoke the patient is volume depleted and has stopped
sweating. In the athlete, where the
problem is in large part due to excessive heat production by exercising muscle,
the patient continues to sweat. Their
core body temperature is elevated, blood pressure is low, and their heart rate
is increased. Diagnosis on the
sidelines of the event might be somewhat difficulty since rectal temperatures
are necessary to confirm that the core body temperature is elevated. The athlete should be removed to a cool
place immediately, where the diagnosis can be confirmed and cooling measures
started. Ice packs are usually
available at the event and can be placed on the neck, arm pits and groin.
PREVENTION
The most important factor in preventing heat illness is
having an informed athlete, coaching staff and parents. The days of restricting water, as a
punishment for poor performance on the athletic field is a thing of the
past. Activities such as sweating down
to make wrestling weight requirements cannot be encouraged nor tolerated. It is crucial that every athlete is
instructed to take adequate fluids before, during, and after athletic
competition. The best gauge to an
athlete's fluid status is their weight.
People do not lose 4 lbs. of body fat in one day. A drop in weight of this magnitude in 24
hours is due to the loss of about 2 quarts of fluids with inadequate
replacement. Additionally, the urine
color becomes darker and urine volume is decreased with reduced fluid status.
WHAT
SHOULD THE ATHLETE DRINK?
It is a very controversial issue as to what is the
perfect replacement fluid drink. Water
is inexpensive and absorbed quickly.
Sports drinks are more expensive but are sources of sodium, potassium and
carbohydrate (used as fuel for muscle function). A good rule of thumb is that cool water is sufficient, if not
preferred, for events lasting less than 90 minutes. In events that last longer than 90 minutes it can be anticipated
that energy reserves will be depleted and a replacement will be needed (i.e. a
sports drink) for optimal performance.
SHOULD
THIRST DETERMINE HOW MUCH SHOULD AN ATHLETE DRINK?
NO! An athlete is
partially volume depleted prior to the onset of the sensation of thirst. It is important that every athlete drink
replacement fluids to prevent significant fluid depletion. It would be prudent for every athlete to be
sure to drink sufficient fluids during the days leading up to their event. This method of "pre-hydration"
will help prevent problems with fluids during their competition.
SUMMARY
In summary, athletes, along with their coaches and
parents need to be aware of the risks of exertion in conditions of excessive
heat and humidity. Adequate fluid
replacement and cooling measures should be used to prevent potential
debilitating and even life threatening conditions.
A Comparison of
Heatstroke and Heat Exhaustion
|
|
Heat Stroke
|
Heat Exhaustion
|
|
Cause
|
Inadequate heat loss due
to a breakdown of the thermoregulatory system.
|
Excessive fluid and
electrolyte loss.
|
|
Symptoms
|
Headache, weakness,
blurred vision, sudden loss of consciousness, slurred speech and
confusion. Changes increase in
severity over time.
|
Gradual weakness, nausea,
headache, fatigue, dizziness, lightheadedness,
chills, faintness.
|
|
Signs
|
HOT, RED, DRY skin;
absence of sweating, rapid pulse, high temperature, widening pulse pressure
with low diastolic.
|
Pale, cool, clammy skin,
rapid pulse, narrowing pulse pressure, active sweating.
|
|
Management
|
Remove from the sun. Rapid colling by full body immersion in
cold water, ice packs, fanning: Immediate activation of EMS, Monitor Vitals.
|
Remove from the sun. Fluid replacement, rapid body cooling,
Monitor Vitals.
|
XII. AVOIDING DEHYDRATION
Joseph M. Horrigan, DC, CSCS
Dehydration is a common problem for athletes. This is particularly true for athletes who
train and /or compete in the warmest seasons of the year. This is magnified when an athlete is wearing
heavy clothing and pads like in football.
The heavy clothing prevents the body heat from being dispersed and
causes increased sweating. Hard
training itself will cause increased perspiration and all of these factors
cause the body to dehydrate, which means loss of body fluid or water.
Dehydration causes a number of problems to occur. A 3-4% of body weight loss due to
dehydration can cause physical performance to decrease by as much as 30%. The athlete would not be as fast, quick,
strong and would have less stamina. As
dehydration continues, the athlete would also begin to cramp and fatigue. If training continues, the athlete would, at
the very least, be susceptible to muscular strain but more importantly would be
moving towards heat related illness (covered in another chapter of this manual
by Robert Reiss, M.D.).
An athlete must drink plenty of fluids. Most athletes do not drink enough. Coaches must allow the athlete the
opportunity to drink as well -- both for the health and safety of the athlete
and to maintain performance in a game, meet or practice environment.
Several of the Training To Win doctors and athletic
trainers provide medical care for the Long Beach Ice Dogs IHL hockey team. We performed two dehydration research
projects with the team last season. The
first study allowed the athletes to drink fluids on their own accord. The body weight of the athletes was
monitored before and after each game and practice for a period of time. The athlete's performance was rated in each
game by the coaches. The top 5 ranked
players had the least body weight loss.
The bottom 5 ranked players lost the most weight. Of the 18 players in the study, 5 required
5-7 days to regain their starting body weight.
Three players did not regain their weight for 9 days. Only 1 of the top 5 layers required 5-7 days
to regain his weight. Four of the
bottom 5 players required 5-9 days to regain their weight.
The study was repeated after the team received a
hydration protocol from Douglas Andersen, DC, Certified Clinical Nutritionist
and Director of Sports Medicine for the Association of Volleyball Professionals
(AVP). The players were instructed to
drink 16 ounces of water per hour for three hours before the game; drink as
much as needed during the game drink as much as needed during the game; drink 1
pint per pound lost within 6 hours after the game. The study was repeated and all players regained their weight
within 2 days. Players were losing 5-9
pounds during a game. This hydration
protocol helped the team maintain the stamina during the four rounds of Turner
Cup Playoffs. This was most evident
late in the second period and definitely in the third period.
Recent studies presented at the American college of
Sports Medicine National conference revealed that the more the athletes drank
when replenishing the fluid levels, the more effectively they gained their
weight back in the same time frame as those who drank a little less.
The thirst mechanism is not directly proportional and
timed with dehydration. If an athlete
waits to drink until they are thirsty, then they are already dehydrated. The athlete will try to "play
catch-up" with regard to the fluid intake and will fail to do so. Fluid replacement does not occur
rapidly. The athletes must drink prior
to the event, during the event and follow a simple guideline described above:
drink 16 ounces per hour for three hours prior to the game or hard practice;
drink during the game and practice; drink 1 pint of water per pound of body
weight lost and this should occur during the six hours following the conclusion
of the game or meet (or practice).
A few clues of dehydration include a lack of need to
urinate or having little urine expelled.
If the urine is dark or has a slight tinge of brown, the athlete is
significantly dehydrated.
In conclusion, the athlete must drink more fluid than
the average person. Water will
certainly do the job very nicely as fluid replacement. The concentrations of sugar and electrolytes
in sports drinks can slow down absorption.
However, if the drink has a pleasant taste, the athlete will drink more
fluid and the sports drink may come in handy.
The athlete should also sip the fluid regularly during an event. Carbonated drinks will cause gas to form in
the intestinal tract and this will slightly delay absorption.
XIII. THE IMPORTANCE OF STRENGTH TRAINING
Joseph M. Horrigan, DC,CSCS
Strength and conditioning are being recognized as means
to prevent or reduce injuries. Studies
have been published, in soccer and football, which demonstrate lower injuries
in teams that have a strength and conditioning program. This has been noted in ice hockey as
well. The first goal of strength and
conditioning is to reduce or prevent injuries.
The second goal is increased sports performance. This can be achieved by improving the
vertical jump, explosive power, anaerobic power and by balancing the strength
of muscles around the knee, shoulder and spine. Training To Win consultant, Ian Armstrong, M.D., Chief of
Neurosurgery at Century City Hospital, notes that neck strengthening is one way
to help reduce concussions. The
stronger neck decreases the acceleration and deceleration forces of the head
and brain.
The strength training of an athlete involves selecting
exercises that allow the athlete to train their body as a unit or system. The athlete runs, throws, swings, shoots,
and tackles, blocks and kicks as a unit.
Bodybuilding uses exercises for body parts. Body part training does not allow the athlete to train the body
as a unit.
There are key considerations when dealing with an
adolescent athlete and strength training:
Adolescent athletes need to learn how to left, as they
would have to learn a position in a sport or any other motor skill. It is important for competitive, young
athletes to avoid pushing their maximum efforts too often. This applies both to a maximum weight and to
a maximum number of repetitions with a given weight. The more fatigued the athlete becomes in training, the longer the
recovery period must become. Hence, the
athlete cannot be trained as often. The
increased fatigue also increases the chance of injury. The adolescent athlete needs to learn that
the importance of the strength training session is the training effect
itself...performing the target weight, sets and reps for that day, even if it
may seem too easy. The volume (sets and
reps) and the intensity (weight) may have been reduced by the coach to allow
for more recovery from previous training sessions that were more difficult. The coach may want the athletes to
concentrate on technique and speed in a session.
If an athlete misses planned lifts, then the athlete is
either too fatigued or the planned lifts were incorrect (too high) to begin
with. Much can be gained in a strength
and conditioning program by simply improving the motor skills involving the
major movements.
The National Strength and Conditioning Association
(NSCA) and the American Pediatric Association (APA) have identified certain
common denominators as potential problems with adolescent weight training. Cases are noted in journals in which
adolescent athletes incurred fractures of the growth plates near the wrist when
performing overhead lifts. The cases
also cited a lack of supervision when lifting.
The lack of supervision, and perhaps minimal instruction, seems to be
the biggest problem. The young athletes
become competitive with each other and push the weight and/or horse around in
the weight room and an injury may follow.
However other data seeming contradicts this but actually supports
it. Mike Reed, DC, CSCS, of Grover
Beach, CA is the Co-Chair of Sports Medicine for the United States
Weightlifting Federation (USWF). Dr.
Reed is about to publish a paper in a journal regarding the age group National
Championships in Olympic Weightlifting over the last three years. These prepubescent and adolescent athletes
competed by performing maximum lifts in the snatch and clean and jerk. No injuries were reported in the three
championships. Neither Dr. Reed nor
myself endorse prepubescent athletes performing maximum lifts. However, these athletes are most likely
well coached and are supervised in their lifting which probably prevented
injuries. Horseplay in the weight room
should not be tolerated. Conversely,
the athletes should have a positive environment to train.
It is important to realize that a high school athlete
who does not have significant weight training or weight lifting experience
should be considered a beginner. A
beginner needs to have a lower volume of training and needs to develop
technique and speed. Absolute strength
will come later as the athlete matures.
The athlete needs to be encouraged and told that the long-term goals are
being kept in mind and the athlete should not push to see how strong they are
in one month. If the athlete performs
too many sets and reps too often, fatigue will occur and an injury is
predictable. If the athlete trains too
heavy, too often, a phenomenon known as central nervous system fatigue can
occur and the athlete will regress in the training and may also incur an
injury. It requires effort by the coach
to hold back an over-enthusiastic athlete.
An athlete that is less physically mature should be trained with caution
so those maximum attempts are not required very often or not at all until the
athlete catches up with his/her peers.
These athletes should still train and develop their skill and speed.
The prepubescent athlete should have fun in their
training and practices. The journals of
sports psychology are filled with cases of good athletes who dropped out of
sports due to the excessive pressures placed on them. This may be due to the fact that the athlete wasn't as gifted as
their parents though, or the athlete was so talented that the athlete was
expected to win all the time and to carry the team. Sometimes, even the gifted athlete doesn't want to lead the team;
they just want to play.
A free weight program is considered by most strength
coaches to be the most effective way of training for an athlete. The specificity of the movement and the
balance and weight bearing aspect of free weight training are most
productive. Machines do not always have
a carry-over effect to sports performance.
Machines do not always fit all athletes and they are very costly and may
serve one purpose only.
XIV.
DENTAL-FACIAL TRAUMA IN HIGH SCHOOL
ATHLETICS
PATRIC
COHEN D.D.S.
INTRODUCTION
With
the increased level of competition
today, we are seeing a higher incidence of facial trauma in sports such as
soccer, basketball, squash, gymnastics, baseball, and volleyball. Decisions involving emergency treatment of
facial injuries have many components.
Unlike injuries to the extremities that may affect function, facial
injuries involve cosmetic as well as functional considerations. The face is
responsible for protection of the skull, the airway, the esophagus, as well as
for communication.
Dental-facial
injuries can be life threatening by themselves or by associated injury to the
airway or nervous system. Dental-facial
injuries involve muscles, tendons, and bones. As with head and spine trauma,
facial-dental injuries must have systematic
evaluations prioritization of treatment and consideration of other
trauma.
This
chapter is designed to give the reader an overview of the types of
dental-facial injuries that occur in high school athletics and their treatment,
a discussion of on-site management of dental-facial trauma , a systematic
approach to dealing with these injuries, when and how to get emergency
treatment, as well as prevention of some of these injures using state of the
art protective equipment.
ANATOMY
(Patric,
please create this section.......................................)
TYPES OF INJURIES AND THEIR
TREATMENT
Lacerations and Contusions-
Cuts,
scrapes, bruises and bumps to the face and mouth are common occurrences in many
high school sports. Generally, these
are the result of facial contact with another player, piece of equipment or a
ball. The severity of the injury will
dictate treatment as well as whether the player should be allowed to resume
playing and when. Whenever there is a
blow to the head or face, laceration or contusion, the player should be
examined for a concussion. An example
of on- site protocol for this type of exam is discussed later in this
chapter. In the case of lacerations to
the face, the use of steri-strips and/or surgicell often is helpful. Depending upon the level of play, immediate
referral to a surgeon or plastic surgeon may be desirable. Suturing of a laceration, when necessary,
should be done as quickly as possible to avoid as much scarring as possible.
Dentoalveolar injuries- definition
There
are a variety of different types of injuries that can take place affecting the
teeth and surrounding structures. The
first of these is trauma to the tooth without any visible damage. This often results in what is termed tooth concussion and results in damage
to the blood vessels supplying the nerve of the tooth. The tooth may become discolored over time or
the nerve in the tooth may die. The
player may experience soreness or sensitivity with pressure or biting. Emergency treatment is not necessary. The player should avoid direct stress on the
tooth. If symptoms persist or get
worse, a visit to the dentist with appropriate X-rays is indicated.
The
next type of dentoalveolar injury is a fracture
of the crown or root of the tooth. These
come in a variety of shapes and sizes depending upon the severity of the
blow. Uncomplicated fractures or “chips” are generally
asymptomatic, but may be sensitive to temperature change or touch. This type of fracture is easily repaired by
smoothing or recontouring the tooth.
More moderate fractures may require the dentist to “bond" some resin material to the tooth. Severe fractures generally involve the front
teeth, often resulting in involvement of the nerve. This type of injury generally requires root canal therapy. If there is no nerve involvement, then
conventional bonding or porcelain veneers can be used to replace the damaged
tooth structure. Fracture of the root
of the tooth can be confirmed by dental x-ray.
Treatment of root fracture depends on the type of fracture. Generally, stabilization of the tooth by
splinting it to adjacent teeth is the treatment of choice. The bite is adjusted so there is no biting
force on the tooth. Follow-up visits
are necessary to monitor any possible abscess or other infection.
Periodontal luxations -
This blow is absorbed by the tooth and supporting
structures without any apparent fracture or loss of tooth structure. There are
4 types of luxations. First, there is a 1) concussion type injury. In this type of luxation there is no
displacement or movement of the tooth.
The surrounding structures may be sensitive or bruised. No treatment is necessary. 2) subluxation. Subluxations show minor movement of the
tooth but the tooth is not displaced from the alveolus. No specific treatment is indicated unless
the symptoms persists for more than a few weeks. 3) displacement
luxation. This is a true luxation
in that the tooth is physically displaced from the socket. Treatment for a
minor displacement (less than 5 mm) reposition the tooth with or without
splinting for 2-8 weeks. Major
displacement i.e. (greater than 5 mm).
Good chance of nerve, vascular and periodontal injury. Treatment consists of splinting the tooth
for 4-8 weeks. If the vitality of the
tooth does not return in 8-12 weeks,
then a root canal is required.
Avulsion -
This
is a complete displacement of the tooth - the tooth is knocked out. The prognosis in this type of injury is
better the less time the tooth is out of the mouth. Acting quickly can make the difference between retaining or
losing the tooth. There is a 90% success rate with reimplantation occurring
within 30 minutes of injury. After 2
hours, the chance for success drops to 5%. Proper handling of the tooth increases the success if
re-implanted as follows: The avulsed tooth should be rinsed off but not
scrubbed, to remove any dirt or foreign debris. It is preferable to use sterile water or milk to rinse with. Immediate
reimplantation is best, but if not possible, gently wrap the tooth in
gauze and place in Hank’s Save-A-Tooth
solution or a container of milk and transport to the dental office as
quickly as possible. Reimplantation and
recommended splinting with stabilization for 7-14 days is recommended
treatment. Oral antibiotic therapy
should be started the day of the injury.
The faster the tooth is re-implanted, the better rate of success.
FACIAL FRACTURES
The
facial bones most prone to injury in high school athletics are the upper jaw
(maxilla), cheek bones (zygomatic arches), malar and other bones that form the
eye sockets (orbits), and the nose. The
soft tissue that surrounds the fracture site, including the nerves, tendons,
ligaments, salivary glands, blood vessels and connective tissue, are also at
risk of injury.
60%-70
of all facial fractures involve the eye sockets (orbits) in some way. A local nasal bone fracture (broken nose), a
zygomatic arch (cheek bone) fracture, and the Lefort I fracture are the only
fractures not involving the orbits.
CLASSIFICATION
The
first would be a fracture of the nose.
This is the most frequently injured facial structure. It is also the most commonly missed fracture. The nose fracture does not show up well on
standard lateral skull x-rays. It is
important to remember that a nasal bone fracture may be associated with more
extensive injuries, such as the orbital rim or the frontal sinuses
The
second most common fracture is that of the zygomatic arch (cheek bone). These usually are the result of a blow to
the side of the face from an elbow or fist.
Patients with this injury often have a flatness of the cheek area and an
inability to open their mouth due to impingement of the zygomatic arch fragment
on the coronoid process (hinge) of the
lower jaw or the temporalis muscle (on the side of the head).
A
"blowout fracture is usually the result of a blow to the eye by a baseball
or other such object. The force of the
blow is transmitted to the thin floor
of the eye socket (orbit) resulting in
the fracture. This often results in
bleeding in or around the eye.
LeFort
fractures are complex bilateral (both
sides of the face) fractures associated with a large unstable fragment
resulting in a “floating face”. There
are 4 types of LeFort fractures (I-IV).
The fracture we are concerned with in high school athletics is primarily the LeFort I or
transmaxillary. This runs between the floor of the maxilla (upper jaw) and the
floor of the orbits. It involves the
maxillary sinuses. The “floating
fragment” will be the lower portion of the maxilla with the maxillary teeth. This complex fracture and requires immediate
attention by a maxiollo-facial surgeon and surgical correction.
SIGNS/SYMPTOMS OF FRACTURE
Generally,
the player will complain of severe pain at the injury site. There will often be swelling and bruising of
the soft tissue around the fracture, including white eyes. There may be a visible deformity if the
fracture is complex and bone fragments separate enough to cause distortion of
normal facial contours. The site will
be very tender to the touch but may exhibit numbness due to involvement of the
nerves. Bleeding from the nose or eyes
is usually indicative of some type of facial fracture. The player will be unable to bite normally.
TREATMENT
First,
1) evaluate the airway and cervical spine.
Check for excessive bleeding and swelling that could interfere with the
player’s breathing. If the player is
not breathing administer CPR. Second,
2) Apply ice packs to the face to decrease swelling and pain. The upper body should be elevated so the
face is above the level of the heart.
This will reduce swelling and help prevent accumulation of excess fluid. Pillows can be used to prop the head up if
there is no evidence of neck injury. 3)
Keep the player warm with blankets to decrease the possibility of shock and
arrange for immediate transportation to a maxllio-facial surgeon or emergency
room. Many facial fractures require
surgery to realign facial bones and restore normal appearance. To obtain the best results, surgery should
be performed as soon as possible after the injury is sustained. In the case of a fractured maxilla, it may
be necessary to secure the teeth with wire or plastic splints so the jaw will
heal properly.
MANDIBULAR FRACTURES
Fractures
of the mandible (lower jaw) reportedly comprise 40-60% of all facial fractures
in sports. In addition, the ligamentous
and cartilaginous structure of temperomandibular joint (hinge of the jaw) can
be disrupted by both direct blunt trauma (a ball or stick hitting the joint) or
by a deceleration type of injury known as mandibular whiplash". Condylar and sub condylar fractures account
for 26%-36%; angle fractures, 20%-26%;
symphyseal fractures,14%-23%; ramus fractures 25%-30%; and coronoid fractures,
l%-2%.
A
direct fracture is the result of and at the site of impact. An indirect fracture may result if the blow
is extremely forceful. For example, a
severe blow to the left side of the chin may result in a direct fracture at the
left angle as well as an indirect fracture of the right body of the
mandible. A complete examination is
mandatory.
TEMPEROMANDIBULAR JOINT (TMJ )
INJURIES
The
TMJ is the joint that allows the jaw to open and close. The TMJ can be fractured or the joint can be disrupted by direct trauma
or by a deceleration type of injury termed “mandibular whiplash". The force of the jaw resulting from a linebacker tackling a
running back, can cause damage to the surrounding tissues, tearing attachments
and causing inflammation. The muscles
of mastication (chewing) may be injured due to undue stretching. In addition, inside the TMJ is a disc that
can be injured resulting in swelling
and chronic inflammation.
Treatment
of the mandibular fracture and TMJ injury will be covered in the next section.
ON-SITE PROTOCOL FOR TREATING
FACIAL INJURIES
Diagnosis and On-Site Exam
Determine
if the player has an open airway to maintain that airway. Remembering the ABC’S of CPR is critical to
onsite treatment of any type of head injury.
2) Check the neurological status of the patient. A standard cranial nerve examination is
recommended. The following simple
procedures can be used: Check the extra-ocular muscles to see that they are
intact and functioning appropriately.
Can the player track your finger while it moves vertically and
horizontally through the visual field with the eyes working in tandem?; Are the
pupils equal and round and do they react to light and accommodate?; Is sensory
function normal? Light contact to
various areas of the face will indicate whether Cranial Nerve has been damaged. Finally, examination of symmetry of motor function, including
tongue movement, should be checked by having the patient go through a series of
facial movements including frowning, smiling, sticking out the tongue and other
similar voluntary muscle movements.
Once it has been established that the airway is open and that the player
has not suffered any sort of neurological injury or concussion, the rest of the
facial trauma on-site exam can proceed.
3) Check the skin of the
face. We want to look for the presence
of swelling, hematoma (accumulation of blood) and lacerations. One of the most common sites for
lacerations is under the chin. This
should alert the examiner to the possibility of fractures of the lower jaw. Another common site for lacerations is lateral to the eye. The thin bone surrounding the eye (orbit)
should be checked carefully for fractures.
The second step is to gently palpate both sides of the face starting
with the entire lower jaw, including the angle of the lower jaw, the cheek
area, eye sockets and nose. We are
checking for areas of swelling, deformity or tenderness. Patients with a fracture of the body or
angle of the lower jaw will often exhibit numbness of the mental nerve (chin
area) on the affected side. This is due
to damage to the mandibular (inferior alveolar) nerve. An assessment of skin sensitivity should be
performed. This can be done by testing
for perception of touch using a wisp of cotton and pain sensation with a sharp
instrument such as a pin. 4) Palpate
movement of the condyle of the lower jaw via the ear. The fifth finger is placed in each ear and the player is asked to
open and close. Any significant
deviation upon opening is indicative of a fracture of the condylar neck of the
lower jaw. Generally, a fracture of this
area will produce pain and limited opening.
(Limited jaw opening may also result from: reflex muscle spasm, effusion
(fluid) in the TMJ, or obstruction to the coronoid process as result of
depression of the zygomatic arch (cheek bone)). Carefully inspect the ear
for signs of hemorrhage. 5) Check the
mouth. We want to look for any tears or
lacerations. Look carefully at the
floor of the mouth for sublingual (below the tongue) ecchymosis (swelling).
This is usually indicative of a fracture of the lower jaw. The teeth should be examined for evidence of
broken teeth or other irregularities in the dental arch. 6) Check for an abnormal bite. Have the player bite teeth together. Any alteration of bite is abnormal.
Three causes of an altered bite in a trauma patient: a displaced
fracture of the jaw; a TMJ effusion or dislocation; or a displaced tooth. 7)
If a fracture of the lower jaw is suspected, hold the lower jaw firmly
on each side. Gently manipulate the jaw.
If there is mobility, there is a fracture. If there is no mobility, but a fracture is suspected, applying
firm pressure over both angles of the
mandible or jaw pain will occur at the site of the fracture.
On-site Treatment
Fracture
of the lower jaw - The lower jaw should be gently positioned so that the lower
teeth rest against the upper teeth. The
player should be transported on his side to allow drainage, assuming there are
no spinal injuries. The airway should
constantly be monitored to prevent obstruction and the player should be
transported to a maxillo-facial surgeon or emergency room.
If the
lower jaw is dislocated, treatment can only be carried out on site by a trained
oral surgeon. If none is available, the
patient should be immobilized and transported.
If no
injury is found at the field of play, but the player is suspected or proven to
have significant facial trauma it should be treated as follows: Use cold packs to reduce any possible
swelling; Transport the player to a maxillo-facial surgeon or emergency room; a
panorex x-ray and standard skull series should be taken; the player should
maintain a soft diet until the pain and soreness disappear.
PREVENTION
There
are 3 preventative measures to reduce the incidence of facial trauma in high
school athletics. The first and
foremost is the use of proper fitting headgear and facemasks. Today, headgear is required in football,
hockey, lacrosse, boxing, baseball, wrestling and martial arts. All facemasks and headgear should fit
properly, meaning that the facemask or shield should be securely fastened to
the headgear and the headgear should fit snugly on the players head and not
flop around. Athletes must be taught
the proper techniques at all levels of play.
Avoidance of illegal checking,
spearing, or other illegal maneuvers is mandatory to prevent serious
catastrophic injuries. The third and
most important preventative measure is the use of properly fitted mouthguards.
Mouthguards-the ultimate
preventative measure.
In the
60's and 70's mouthguards were used primarily in boxing and football. Today they are used in a variety of sports
including football, field hockey, ice hockey, wrestling, soccer,
basketball, gymnastics, lacrosse, the
martial arts, volleyball, boxing and weight lifting. Many of the mouthguards used today are almost 100% effective in
preventing oral injuries. The incidence
of mouth injuries amongst football players in the United States today is
approximately 48% of all injuries.
Basketball, where mouthguards are not required, has a mouth injury rate
of 34%.
There
are basically four types of mouth protectors: the ready-made or stock mouth
protector, the mouth-formed protector and the custom made protector type 1 and
type 2. The stock mouth protector is intended to fit any mouth. They are available in a limited number of
sizes and can be found in sporting goods stores and pharmacies. The stock mouth protector is the least
expensive of the four and doesn't involve any type of “fitting". Stock mouth guards are usually made of
rubber, polyvinyl chloride or polyvinyl acetate-polyethylene copolymer. Although the physical properties of these
materials are excellent, the physical design of these protectors is the least
desirable of all, due to their poor fit.
They interfere with speech and breathing, and require the mouth to
remain closed in order for them to stay in place. As the public becomes better educated, fewer athletes are using
them.
The
thermoplastic mouth-formed protector is commonly known as a “boil and bite”. It is made of polyvinyl acetate.
This mouth guard is pre-formed by the manufacturer in standard sizes' To
fit it the athlete immerses it in boiling water for about 1 minute, then puts
it in cold water for 1 second and then immediately places it in their
mouth. The advantages of this system
are that it can be refitted if not properly fitted the first time, the cost is
relatively low, and all fitting procedures can be accomplished at one
sitting. The disadvantages include
decreased retention over time and hardening of the material from continued
exposure to oral fluids. Studies have
shown that because the occlusion (bite) is unbalanced when these are made, the
stability of these guards is poor and cannot withstand the forces that can
cause facial trauma.
The
type 1 custom mouth guard is the type
of custom mouth guard that dentists have made in the past. It is one sheet of ethyl vinyl acetate
copolymer 3 mm thick that is vacuum formed over a cast of the athlete's
teeth. The problem with this type of
mouth guard is that because there is such variety in the types of vacuum
forming machines and the heat they produce that the thickness of the guard can vary in different parts. There is no way of knowing if you will end
up with the 2-2.5 mm range of thickness in the back teeth that is optimum to
protect against concussion and other trauma.
The advantages of these types of custom guards are that they are better
than the stock or boil and bites as far as retention, they are relatively
inexpensive, and they can be used for children who are in braces whose bites
are changing every few months.
The
type 2 custom fitted mouth guard can be bi or tri-laminated and it is a thermal
pressure molded material that can be 2-5 mm thick. For heavy contact sports e.g. football, we prefer to use 4-5 mm
of material. By multilaminating these
guards, we are assuring the necessary thickness to help prevent trauma. There is a uniform thickness throughout the
guard as a result of the pressure used in forming them. These can also be used for players who have
missing teeth to give them a true custom fit.
The major advantages of this type of protector are that they have the
best fit, most retention, are the least bulky and cause the least amount of
interference with breathing. most players think that mouth guards interfere
with breathing.
In
summary, comparing custom mouth guards with stock or boil type mouth guards
shows significant differences. The custom fitted guards fit more accurately,
are more comfortable, and protect the athlete better. It is the author's opinion that non-custom mouth guards should
not be worn by any athlete playing contact sports.
Mouth
guard protection has many benefits.
There is a much lower incidence of oral injuries when mouth guards are
used. Injuries involving the teeth and
lips can usually be completely evaluated.
Studies have shown that the incidence of fractured jaws and soft tissue
injuries decreases significantly when mouth protection is used. A study by Hickey in 1967 used cadavers to
show that when a blow to the chin was received, the mouth guard reduced the
amplitude of intracranial pressure wave and decreased the amount of bone
deformation by 50%. This study shows
that proper use of mouth guards can reduce the amount of trauma to the brain,
decreasing the chance for concussion.
Finally, the psychological benefit of a player knowing that there is a
lower chance of his being hurt while wearing a mouth guard allows him to do
what he his supposed to, which is focus on playing. Coaches exert great influence upon their players. The coach's attitude toward the importance
of wearing mouth protection during both practice and games is directly
reflected in the player's behavior.
This is specially true during practice. more injuries occur during
practice than at any other time. It is
imperative that coaches impress upon their athletes the need for mouth guard
use at all times.
In
conclusion, there are many types of oral-facial injuries that occur in high
school athletics, some obviously more severe than others. Many of these injuries can severely limit or
end an athlete’s career. This is a risk
that should not be assumed at any level of play. Proper on-site diagnosis and treatment is essential to minimizing
potential damage. The use of high
quality protective equipment is a must if the players are going to perform at
optimum levels in the safest manner possible.
All organized sports team should have available to them a team dentist
to help ensure that players maintain the best possible oral health.
XV. THE FEMALE ATHLETE
Jeff Halbrecht, MD
FEMALE ATHLETES ARE DIFFERENT
Certain physiological and sociological factors differentiate the
female athlete. The sociological
differences are based on generations of attitudes in society that create
conflicting images for the young female.
Although sports have become more accepted for girls, the media continues
to bombard young women with the perception that they also need to also maintain
a super model figure and certain feminine image. These conflicting signals create significant stress for some
females, causing eating disorders and along with certain physiological female
traits can combine to create a serious disorder called the female triad.
With greater participation of women in sports, has come an increased
understanding of injuries and problems associated specifically with the female
athlete. It is important for the
coach, trainer, parent and athlete to be aware of these risks.
Physiologically, the female athlete has to deal with menstruation
and hormonal balance. Stress, diet,
overeating and other factors can alter the normal menstrual cycle and hormonal
balance, which can then affect the musculoskeletal system. There are also gender specific anatomical
differences affecting the musculoskeletal system.
Body Shape:
Femoral
Joint (knee cap joint): Women have wider
hips than men, which creates a wider angle at the knee, where the knee cap
(patella) articulates with the femur (picture). This increased angle (often called the Q angle) affects the
tracking of the patella and predisposes the female athlete to tracking
problems. Abnormal tracking of the
patella may lead to instability or dislocation of the patella, or simply cause
pain due to unbalanced loading of the joint.
Think of this as a tire out of alignment, where unbalanced loads lead to
the treads wearing out of one side of the tire. A similar phenomenon occurs under the knee cap. The female athlete should emphasize
strengthening exercises that help to stabilize the patella, to help improve
tracking and prevent injury. These
exercises should focus on the inner quadriceps (thigh) muscles (vastus medialis
oblique or VMO), (picture).
The ACL: The female athlete seems to be
disproportionately at risk for injury to the major knee stabilizer, the
anterior cruciate ligament (ACL). There
are several theories for this. For one,
females tend to have a narrower space in the knee available for this ligament
so that less stress is required to tear the ligament than in the male athlete
(picture). A recent study has also
shown that the female athletes tend to rely on their quadriceps more than their
hamstrings as compared to their male counterparts. Since the hamstring muscles are one of the main protectors of the
ACL, relative weakness in this structure may lead to ACL injuries. Additional risk of injury is relative to
estrogen levels. Female athletes tend
to sustain injury to their ACL during the ovulatory period of their menstrual
cycle (day 10-14). This is the period
of when estrogen levels are highest.
Researchers have shown that the ACL contains estrogen receptors and that
the ACL responds to estrogen by decreasing cell activity and synthesis of the
basic ligament fibers (collagen).
Pre season and in-season strength and conditioning programs build
and maintain knee muscle strength, particularly the hamstrings, may help reduce
the risk of injury.
Foot and ankle:
Female athletes have been shown to have a higher incidence of ankle
sprains than males. This is more likely
due to several factors including increased ligamentous laxity and decreased
muscle strength and coordination. Women
also have a narrower heel in relation to their forefoot than men, possibly
increasing the likelihood of an inversion (turn-in) ankle sprain. Strengthening and coordination exercises for
the ankle are recommended to limit the risk of this injury. Use of a balance board and elastic bands for
inversion (turn-in) and eversion (turn-out) exercises are particularly
helpful. Women can be just as competitive
as men, and can enjoy sports as much as men, but there are physiological and
anatomical differences which affect these athletes. PHYSIOLOGIC FACTORS:
Strength: Female athletes as a group are not as strong
as their male counterparts. Upper extremity strength is 50-75% of men. Lower extremity strength is 60-80% of men. Studies have shown that with weight
training, females will increase their strength percentage wise in equal
increments to males, but that their overall strength will begin and end at
lower levels. Due to lower testosterone
in women, the size of muscles will not increase as much as in men.
Speed: Leg length in women is a smaller percentage
of overall body length and may be one reason that females tend to be slower
runners than men.
Endurance: Women seem to be approaching men in
endurance performance much more rapidly that in strength or speed events. It is speculated that women may in fact be
more suited physiologically to endurance activity than men due to an enhanced
ability to conserve muscle glycogen and ability to utilize fat for energy. (more efficient utilizers of oxygen). However, women have lower oxygen carrying
capacity, lower blood volume, fewer red blood cells (that carry oxygen), lower
blood count (hemoglobin), small heart and lower stroke volume (amount of blood
pushed with each heart beat) preventing them from obtaining performance equal
to that of men.
ANATOMICAL FACTORS:
OK, so we all know that girls are different than boys. Here are some differences you may not have
been aware of.
Laxity: Females tend to have more lax ligaments that
males, which is thought to put their joints at increased risk for injury. A recent study has shown that the risk of
injury in females may correlate to hormonal changes associated with the
menstrual cycle. In particular, female
athletes may be more prone to knee ligament injuries, shoulder instability and
ankle sprains.
Shin Splints:
Exertional
compartment syndrome is one of the causes of leg pain commonly known as shin
splints. This form of shin splints
occurs only during exercise, and quickly resolves after activity ceases. In female athletes, menstrual cycle and use
of birth control pills can affect fluid shifts in the muscle compartments. In the female athlete suspected of having
exertional compartment syndrome, modification of birth control medication may
be curative.
Scoliosis:
Scoliosis
is a curvature of the spine that occurs in growing adolescents and is much more
common in females than males. In the
early stages of scoliosis, there are usually no symptoms. Suspicion should arise in the tall female
athlete who appears to have an imbalance in shoulder or pelvic height. Small curves are not a contra-indication to
sports participation, but should be referred to a physician for evaluation and
should be monitored for progression.
Spondylolysis:
The
younger female gymnast, ballerina and jumping athlete (volleyball, basketball)
is particularly at risk for developing a spinal injury called
spondylolysis. This is a stress
fracture of the posterior elements of the spine that connect the
vertebrae. This is thought to result
from the repetitive hyperextension required of these activities. Many of these athletes are also amenorrheic
making them more prone to develop stress fractures. The at risk female athletes with localized back pain that does
not resolve quickly should be referred for medical evaluation as well as x-ray
evaluation.
Pre Season Sports Physical:
In addition to the usual pre-participation examination, female
athletes need to be evaluated for certain specific problems specific to women.
Scoliosis: Curvature of the spine is much more common
in females, and tends to occur in adolescence.
Pre season screening should evaluate for curvature of the spine and if
identified referral should be made for x-rays and medical evaluation. Altered posture, particularly a difference
in shoulder height or hip height should raise concern and prompt coaches or
parents to suggest evaluation as well.
Mitral Valve Prolapse: A common and usually benign abnormality of one of the heart valves and occurs primarily in females. This entity is identified usually by a very
specific type of murmur found on pre season cardiac evaluations with a simple
stethoscope. The great majority of
cases are asymptomatic and will not affect sports participation. Athletes with a history of syncope
(fainting) arrhythmias, chest pain, or family history of heart disease should
be referred for evaluation by a cardiologist.
Menstruation: The medical history should include a
menstrual history. Delayed onset of
amenorrhea (loss of menses) should be identified as a flag for possible eating
disorders and/or menstrual dysfunction.
Ligament laxity: Females with excessive laxity of their
ligaments should be advised that they may be at increased risk of knee,
shoulder and ankle injuries and should be particularly encouraged to
participate in pre season strengthening exercises to protect the joints. Additionally, certain findings might be
useful in advising young female regarding choice of sport. For example, at an early age, females with
hyperlax shoulders might be dissuaded from pursuing such sports as swimming or
volleyball, and those with unstable patellas might be discouraged from running
and twisting type sports.
Women tend to get bunions and hammertoes from narrow shoe wear. These can be painful and affect athletic
performance. Wider athletic shoes and
bunion pads may be helpful. Improved
shoe wear off the field may help prevent this problem
Shoulder:
Increased
ligament laxity may place the female athlete at higher risk for shoulder
instability. Particularly in overhead
sports such as volleyball, tennis, swimming and softball. Women tend to have decreased upper body
strength as well, adding to the risk.
Rotator cuff strengthening exercises may help to prevent this injury. Internal and external rotation exercises
using elastic tubing with the arm at the side is particularly helpful.
The
Female Triad:
Eating
Disorders/Amenorrhea/Osteoporosis
Eating disorders: Eating disorders are most common in
appearance sports, such as gymnastics, ice skating and diving. Severity ranges from occasional binge eating
to extreme self starvation (anorexia nervosa), and prolonged binge eating and
purging or vomiting (bulimia). The
prevalence of eating disorders is between 15-62% depending on the survey. Coaches, parents and trainers should be
alert to behaviors like eating alone, trips to the bathroom during or after
meals and the use of laxatives. Other signs
or symptoms of the female athlete triad may include fatigue, anemia, depression,
cold intolerance and eroded tooth enamel from frequent vomiting.
Anorexia Nervosa: One should suspect anorexia in the athlete
who demonstrates an unreasonable fear of being fat, has a distorted sense of
body image, fails to maintain body weight within 15% of the mean for her age
and height. Associated problems with
extreme and prolonged weight loss include disturbances of the cardiovascular,
endocrine, and gastrointestinal systems, disruption of temperature regulation,
psychological sequelae, and irreversible bone loss. The mortality rate in severe cases is particularly high at 10-15%
with death occurring primarily due to the cardiovascular failure, endocrine
disturbances or suicide.
Bulimia: The bulemic athlete engages in binge eating
and forces purging either with vomiting or with laxatives. These athletes may engage in excessive
exercise or fasting due to a morbid fear of gaining weight. Athletic performance tends to fluctuate
dramatically. Suicide attempts are
common with the disorder.
Menstruation: The onset of menstruation is between 12-15
for non-athletic females, and 13-15.5 in the athlete. Menstruation can be delayed or disrupted as a part of the female
triad. Amenorrhea is defined by a
decrease in periods to less than 6-9/year.
Poor nutrition from eating disorders, and excessive exercise contribute
to this problem. Amenorrhea tends to
occur when body fate falls below 17-18%.
Osteoporosis: Decreased estrogen associated with amenorrhea, along with
decreased calcium intake from eating disorders leads to decreased
mineralization of bone. This can
increase the risk of stress fractures in these athletes. Multiple stress fractures or fractures
associated with limited activity or trauma should raise a red flag for the
female triad.
SYMPTOMS OF EATING DISORDERS
Danger Signs
Anorexia Nervosa
Weight
loss
Obsession with exercise
Withdrawal "loner"
Excessive concern with weight, diet and appearance
Overlying sense of unhappiness
Stress fractures, shin splints, etc.
Avoids social eating situations (likes to eat alone)
Complaining of always being cold
Bulimia
Irregular weight loss
Variable athletic performance
Drug abuse
Binges
Disappears after binges
Multiple complaints such as weakness, aches and pains
Use of laxatives
Treatment of Eating Disorders:
If an athlete is suspected of having the female triad, a
multi-disciplinary approach is often necessary for treatment. Parents, coaches, friends and professional
assistance are required. Treatment
includes nutritional guidance, emotional support and psychiatric guidance. Hormonal replacement therapy may be
required.
If you are struggling with extremes of disordered eating-anorexia or
bulimia-or if you are a concerned parent, coach, or friend, you can turn to the
following organizations for help:
American Anorexia/Bulimia Association, Inc National Anorexia Aid Society
418 E. 76th Street 1925
East Dublin Granville Rd
New York, NY 10021 Columbus, OH
43299
(212) 734-1114 (614)
436-1212
American Dietetic Association OvereatersAnonymous
Headquarters
National Center for Nutrition and Dietetics World Service Office
216 W. Jackson Blvd., Suite 800 383
Van Ness Blvd., Suite 1601
Chicago, IL 60606-6995 Torrance, CA
90501
(800) 366-1655 (310)
618-8835
Anorexia Nervosa and National
Collegiate Athletic
Related Eating Disorders (ANRED) Association
Box 5102 c/o
Karol Media
Eugene, OR 97405 350
N. Pennsylvania Avenue
(503) 344-1144 Wilkes-Barne, PA
18773
(800)
526-4773
(provides
videotapes on
eating
disorders)
MENSTRUAL DYSFUNCTION
Problems with menstruation include both oligomenorrhea (irregular
cycle length of 35 to 90 days) and amenorrhea.
Amenorrhea can be primary (failure of menstruation to begin) and
secondary amenorrhea (cessation of cycle in a female who previously had a
normal cycle). Secondary amenorrhea is
a 3 to 6 months or greater absence of the menstrual cycle.
The female may also have regular menses, but with hormone level
abnormalities. A normal menstrual cycle
has 2 phases (the follicular phase and the gluteal phase) that depend on the
correct balance of estrogen and progesteron).
Hyperestrogenic amenorrhea is the most common menstrual dysfunction in
athletes.
The prevalence of the amenorrhea or oligomenorrhea can be up to 66%
in the athletic population, but only 2 to 5% in the general population. Appearance sports (gymnastics, figure
skating and dance) and endurance sports (distance running) seem to be at higher
risk for menstrual dysfunction.
An athlete with menstrual dysfunction is at risk for infertility, an
increased incidence for cardiovascular disease, uterine problems, as well as
bone demineralization (loss of calcium in the bone).
These problems are usually all reversible with the correction of the
menstrual dysfunction, however, bone mineral loss in an amenorrheic athlete can
be rapid and not entirely reversible.
An athlete with bone mineral loss is at higher risk for both stress
fracture and posttraumatic fracture.
Evaluation
If the menstrual cycle is absent for 3 more months, or irregular
menses is seen on a recurrent basis, evaluation is recommended. If menses has not begun by age 16, thorough
evaluation is recommended.
A thorough history, physical examination and lab testing should be
carried out. Exercise induced menstrual
dysfunction is the diagnosis only if all others are ruled out.
Treatment
Depending on the specific diagnosis, treatment can range from no
treatment (gluteal dysfunction), monthly doses or progesterone/ or birth
control pills (chronic an ovulation) along with proper diet (nutrition) and
appropriate calcium supplementation. In
only the hypoestrogenic amenorrheic women does training need to be addressed
and decreased.
NUTRITION IN THE FEMALE
ATHLETE
Male and female athletes have similar nutritional needs with the
exception of iron and calcium. In
female athletes with normal menstruation and estrogen levels, 1200 mgs/day of
calcium is recommended. Those with
amenorrhea, 1500 mg/day is necessary.
Dietary calcium is preferred to supplementation.
20 to 30% of female athletes have iron deficiency. There are 3 types of iron deficiency that
include iron deficiency anemia, iron deficiency without anemia, and pseudo
anemia. Iron can be lost through menstruation,
iron poor diet, GI blood loss (distance runners), sweat and urine. High risk athletes (endurance athletes) with
disordered eating, unusual onset of increased fatigue and/or decreased
performance should be evaluated for iron deficiency anemia.
Blood tests determine the type of anemia present. Iron deficiency anemia is treated with up to
6 months or oral iron supplementation and proper dietary recommendations to
prevent reoccurrence. Iron deficiency
without anemia is usually only be treated with a change in diet. Pseudo anemia occurs in endurance athletes
who have high fluid intake causing dilution of blood levels. Pseudo anemia does not require specific
treatment. Iron deficiency can be
prevented with proper diet.
XVI. The Role of the Certified Athletic Trainer in the High School
Jill Sleight, ATC
NATA (BOC) Certified
Athletic Trainers are highly educated and skilled professionals specializing in
athletic health care. Together with
team physicians and other allied healthcare professionals, certified athletic
trainers function as a key member of the athletic health care team in secondary
schools, colleges and universities, sports medicine clinics, hospitals,
professional sports teams and other athletic health care settings.
The National Athletic Trainer’s Association Board of Certification,
requires that individuals take extensive written and oral examinations testing
their skills in the five domains or practice areas of athletic training:
˙ Prevention of athletic
trainer
˙ Recognition,
evaluation and immediate care of athletic injuries
˙ Rehabilitation and
reconditioning of athletic injuries
˙ Health care
administration
˙
Professional
development and responsibility
The Certified AthleticTrainer
plays an important role between the Physicians, Coaches and the Athlete. Coaches and athletic trainers wear many
different professional hats, but most coaches are relieved to have certified
athletic trainers working in their high school. The team physician also relies
on the athletic trainer to properly screen athletic injuries and refer them
appropriately to the physician when necessary.
The athletic trainers role can be pivital for the athletes safety and
future.
Certified Athletic Trainers
work very closely with Coaches. A
mutual respect between coaches and athletic trainers is important for the well
being of the student athletes. The
athletic trainer is the person responsible for the athletes health care, from
injury prevention programs to injury rehabilitation programs, first aid, injury
management and evaluating athletic injuries.
Medical
Information to have at all practices and games
1. Medical History Cards- An
alphabetical card file box should be on file with each coach, trainer and
athletic director.
2. Informed
Parental Consent and Acknowledgment of Risk forms signed by athlete and parent/guardian.
3. Insurance information of
all athletes on file.
4. Physical Forms –
Copy needs to be kept on file.
5. Injury Report Forms
- Record Keeping.
6. Athlete’s with Special needs –
Physical forms need to be flagged and coaching staff and trainer must be aware
of athletes participating in sports with special medical needs (asthma,
epilepsy, diabetic ). There should be a
"quick reference log" for all special needs athletes easily
accessable.
7. Emergency Action Plan- Home
and Away Plan - This
plan must be in writing so there is no confusion during an emergency. Staff inservice and plan in writing to all
coaches and administrators.
8. CPR and First Aid Certificates
of all Coaches - all
coaches should be CPR and First Aid Certified.
In addition to the important
paperwork a coach needs to have regarding the athletes medical health, you also
need to be prepared with a traveling medical kit. Athletic Trainers can’t always travel with the team so having a
stocked medical kit is important. See
the attached medical supply list.
Sideline
Medical Team
Pre-event communication is the
key to efficient sideline management of injuries. All trainers and coaches must have a Game Day Plan. It is important to include all the key
players of injury management in this emergency plan by pre-game communication,
before the event begins. Communication
between the team physician, the athletic trainer, the athletic director, the
coaching staff, and the (EMS) emergency medical system is imperative for
quality medical care on the sideline.
Game Day Emergency Plan:
(make information
available for the visiting team)
CHECK LIST:
1. Who is
the Physician on Duty
2. Make
sure you know where your team Physician is at all times. Make sure your visiting team knows who and
where your MD is on the field.
3. Certified
Athletic Trainer on Duty- Into yourself
to the visiting team coaches or trainer
4. Ambulance:
yes/no location
5. Nearest
Phone: location/availability
6. Someone
must be assigned to make the emergency call when needed.
That
person must have all the important information when placing the call to
activate EMS.
¨ Type
of emergency situation
¨ Type
of suspected injury
¨ Present
condition of the athlete
¨ Current
assistance being given (CPR, fracture)
¨ Location
of the phone (if not a cell phone on the field)
¨ Exact
location of emergency (street address and cross streets)
¨ Assign
someone to meet the Ambulance at the gate
7. Emergency
Phone Number is________
8. Address
of where you are __________
9. If you
need an ambulance, is the gate locked for them to enter the school. Who has the key? Make sure they will have
easy access to you and the school field.
10. Directions
to closest hospital.
11. Medical
history and insurance info with you
12. First
Aid Kit (location)
13. Training
Room (location)
14. Ice
Availability (location)
PRE-SEASON READINESS: (CHECKLIST)
1. Trainer
Meeting
2. Meet
the Physician’s
3. Pre-Season
Physicals – preferably done by team doctors, and if not , reviewed by team
athletic trainer.
4. Medical
Kits
5. Medical
Notebook/Card File
6. Pre-season
conditioning program
7. Review
Training room coverage
8. Review
Medical coverage
9. Injury
Plan – when there is not a trainer present
10. Stretching
programs
11. Strengthening
programs
12. Hydration
programs
Assembling the Sports Medicine Team:
High School Athletes should
have the same access to specialists as do the college and professional
teams. Here are some suggestions of
medical professionals that would value the opportunity to work with team
sports. If you have difficulty
assembling a medical team contact your local college sports medicine
department.
1. Certified
Athletic Trainer- Medical Team Coordinator
2. Orthopedic
Surgeon
3. Doctor
of Osteopathic Medicine
4. Internist
5. Dentist
6. Strength
and Conditioning Coach
7. Sports
Psychologist
8. Nutritionist
9. Chiropractor
10. Physical
Therapist
11. Sports
Medicine Clinic
XVII. The Importance of Stretching
Jill Sleight, ATC
The
Warm-Up
The importance of the Warm-up
is to prepare the body for physical activity.
The The Warm-up has been found to be a crucial part of injury prevention
and decreasing muscle soreness. The
warm-up increases the body temperature, stretches ligaments and muscles, and
increases flexibility.
It is important to be sports
specific. The warm-up should include
both a general warm up and a sport specific warm up.
General Warm-up: To elevate the bodies core
temperature and perform static stretching exercises.
Stretching is intended to
increase flexibility and may help to reduce pain and spasm of muscles. Stretching is an important part of injury
prevention. Flexibility helps to
increase the range of motion a muscle has to work, meaning that with better
flexibility you have more muscle available to utilize through a given range of
motion. The more Flexible an athlete is
the more agile he/she will become. Good
flexibility is an essential component of successful physical performance.
Sport-Specific Warm Up: Involves sport specific
activities and should gradually increase in intensity.
Time allocated for warm-up: 10-15 minutes is ideal.
Example: 2-3 minutes of light jogging, biking,
skating to increase metabolic rate and core temp. Followed by stretching program, then onto the sport specific
warm-up activities.
¨
Warm-up
and Cool-down decrease the chance of
athletic injuries and muscle soreness.
The
Importance of Stretching
Types of stretching:
Ballistic: Bouncing and not
recommended
Static: Holding nice/easy
stretch for 20-60 seconds
Advantages
of proper stretching:
1.
Reduces muscle tension
2.
