When is playing a bad idea?

Sara Mackenzie, MD, MPH and

Gary Strokosch, MD

Regional Health Specialists

November 8, 2012

After this presentation, you will be able to:

• Describe common components of a sports physical

• Describe red flags that need further evaluation prior to sports clearance

• List common sports-related injuries• Identify common treatments for

sports-related injuries

Can I get a sense of who is on call?

• Center physician?• Health and wellness manager?• Center nurse or LPN?• TEAP/CMHC? • Recreation specialists?• Other?

Pre-participation physical purpose:

• Detect potentially life threatening or disabling medical or musculoskeletal conditions

• Identify pre-existing conditions that may predispose to injury

• Satisfy administrative requirements• Promote health and safety• General health assessment

Why discuss?• Regulatory reasons – Job Corps and

broader• 50 of 51 states require pre-participation

sports physicals for high school students prior to competitive sports participation

• American Heart Association recommends for competitive athletes to detect underlying cardiac abnormalities in an attempt to reduce risk of sudden death

Job Corps PRH 6.11 R2• All students participating in organized contact

or rigorous sports shall be medically cleared • Physical exam at entry within 1 year of

organized sport activity can fulfill requirement• Repeat annually• Staff member trained in CPR/first aid must be

present at all organized contact and rigorous sports activities, including practice and sports events

Identification of life threatening conditions:

• Sudden cardiac death – leading cause of death in young athletes

• Stimulates discussion about appropriate screening and preparation at events

• Range from 1/50,000 to 1/200,000 high school athletes/year

• 1/70,000 college athletes/year• Due to lack reporting—likely

underestimated rates

Causes of sudden cardiac death:

• Under age 35:– Cardiomyopathy or structural–genetic

link– Primary electrical disease–genetic link– Acquired heart disease/myocarditis– Congenital heart disease

• Over age 35:– Coronary artery disease

Hypertrophic Cardiomyopathy

• Leading cause SCD in U.S. • Autosomal dominant with variable expression

(over 10 genes isolated and >200 mutations identified)

• Symptoms can include: exertion chest pain, shortness of breath, palpitations, fatigue, dizziness, near syncope or syncope

• Most athletes are asymptomatic• Some will be identified by family history or

murmur on exam

Cardiac Exam

• If present, harsh systolic murmur due to left ventricular outflow obstruction

• Murmur increases with decreased systolic return (so louder murmur when standing, valsalva; softer murmur when squatting)

What is standard of care?

• No universally accepted standards for what constitutes appropriate sports screening

• Usually some level of history and physical

History:• Most critical component – required part of entry

exam for all students• Detection of previous and current medical

issues or injuries is key • Key areas in relations to sports:

– History of concussion– History of dizziness or collapse with exertion– Family history of exercise related death or

unexplained death <age 50– History of asthma– History of loss or dysfunction of paired organs

Physical:• Most components already included in

routine required entry physical• Height, weight, blood pressure, vision• Skin exam – infection• Heart exam – sitting and supine• Lung exam• Abdominal exam• Genital exam – males, controversial• Musculoskeletal

Draft Job Corps specific history and physical forms:

• Proposed to replace SF 88 and SF 93

• Incorporate recommended sports screening questions

• Should help identify those at increased risk

DRAFT History form

DRAFT History form

DRAFT History form

Syncope or dizziness during exercise:

• Prior history of exertional syncope or near syncope found in 17% to 23% of SCD (1)

• Of 6.4% athletes reporting syncope only 1.3% related to exertion and 33% of those had structural disease known to cause SCD on exam (2)

• Work up—EKG, ECHO; possible stress test

1) Maron, JAMA, 19962) Colivicchi, Epidemiology and prognostic implications of syncope in young, competitive athletes. European Heart Journal, 2004

DRAFT History form

Rice, S.G. Pediatrics (2008) Medical Conditions affecting Sports Participation. 121; 841 available at: http://pediatrics.aappublications.org/content/121/4/841.long

Resource for assisting clearance decision

making:

Common musculoskeletal conditions:

• Knee – Osgood Schlatter– Knee Injuries

• ACL, PCL, MCL• Meniscus tear

– Anterior knee pain• Ankle

Osgood-Schlatter Condition

• Painful condition of the knee(s)• Located at the tibial tuberosity, the

bump where the ligament from the patella is inserted into the tibia

• Characterized by tiny, microfractures of the tibial tuberosity that occur primarily during a growth spurt

Osgood-Schlatter Condition

Osgood-Schlatter Condition

• More likely to affect junior high and high school age athletes

• Found in athletes of either sex who are active in games requiring substantial running and/or jumping

• It is an overuse condition• Requires rest and restraint from further

strenuous activity for periods of time• It usually clears by late adolescence

Osgood-Schlatter Condition

• It does not require an x-ray to diagnose• Tenderness and swelling at one or both tibial

tuberosities• The swelling persists into adulthood, long after

the tenderness is resolved• Most athletes will want to play through the pain,

try anti-inflammatory medication, or ice and rest for periods of time

Knee• It is the largest joint in the body• The upper and lower bones are separated by 2

discs (menisci)• The distal femur and proximal tibia and fibula

are connected by ligaments and tendons• The surface of the bones inside the knee joint

is covered by articular cartilage• Injuries of one of these structures are the most

common knee problems

Knee Injuries• Caused by direct blow to the knee,

abnormal twisting or bending the knee, or falling on the knee – these lead to pain, bruising and swelling

• Injuries most commonly include ligament sprain, tendon strain, meniscus tear, ligament tears (anterior cruciate or medial collateral), fracture (distal femur, proximal tibia or fibula, or patella) and dislocation of the patella

Anterior Cruciate Ligament Tear

• A tear usually occurs when a force is applied to the knee while the foot is firmly planted on the ground or upon landing

• Pain and swelling start quickly and student may report hearing a popping or cracking sound at the time of injury

• Pain occurs in the knee or calf region and student feels instability of joint (giving way)

Posterior Cruciate Ligament Tear

• Injured less than ACL and is thicker/stronger

• From direct impact to the front of tibia, usually when the knee is bent

• Pain, swelling in the back of knee and instability of the joint (giving way)

Medical Collateral Ligament TearLateral Collateral Ligament Tear

• They connect the femur and tibia on the medical and lateral side of the knee

• They protect a force from the opposite side• MCL is torn more frequently from lateral trauma

forces on the knee• Pain, stiffness, swelling and tenderness along

the side of the knee• The knee may feel unsteady or it may lock or

catch

Meniscus Tear

• The injury usually occurs with forcefully rotating knee while bearing weight

• Pain occurs, especially when the leg is straightened

• Swelling usually occurs• May report an audible click or pop

and the knee may lock or feel weak

Treatment of Knee Injury

• RICE treatment as first aid as outlined above

• NB: The injury is more severe if– there is/was a popping sound– the knee gives out– the pain is severe– cannot move the knee– cannot bear weight of any kind

Anterior Knee Pain

• Anterior knee pain that occurs at the front and center of the knee

• Also known as:– Patellofemoral Syndrome– Chondromalacia Patella– Runner’s Knee– Patellar Tendonitis– Jumper’s Knee

Etiology (?)

• Patellofemoral malalignment• Quadriceps tightness• Overuse of jumping or twisting,

running, skiing, playing soccer or bicycling

• Obesity• Flat feet• Adolescent or young adult

Findings

• The knee may be tender and mildly swollen

• Examiner may feel a grinding sensation below patella with flexion

• Pressing the patella when straightened may be painful

• X-rays or scans are not helpful

Treatments

• Rest and anti-inflammatory meds• Strengthen and stretch the

hamstrings and quadriceps• Lose weight if needed• Orthotics for flat feet• Good quality sports or running

shoes

Ankle Injuries

• The ankle is where 3 bones meet: the tibia and fibula of the lower leg with the talus of the foot

• These 3 bones are held together by ligaments

• Tendons attach muscles to the bones to do the work of moving the ankle and foot and help keep the joints stable

Ankle Injuries• A fracture describes a break in one or more

of the bones• A sprain is the term that describes damage

to ligaments when they are stretched beyond their normal range of motion and can range from many microscopic tears in the fibers to a complete tear or rupture

• Muscle or tendon strains from over stretching commonly affect the peroneal tendons

ANKLE

Ankle Injuries

• Most injuries occur when the ankle joint is twisted too far out of its normal position, mostly during sports activities

• Symptoms include pain, swelling, bruising, inability to walk or bear weight, stiffness, tenderness, and deformed or out of place. NB: The latter two may suggest a fracture

R.I.C.E.

• Rest: this helps prevent further damage and keep weight of ankle

• Ice: this helps slow or reduce swelling and may numb the pain

• Compression: wrapping the injured ankle with elastic bandage helps keep it immobile and supported

• Elevate: this may reduce swelling and pain

Examination and Re-examination

• This is usually to determine if x-rays are needed for the uncommon finding of a fracture – tenderness, deformity or lack of improvement over time

• With conservative management, re-examination is suggested to be certain that improvement is occurring with sprains or strains

• However, students often continue sports activities with an injury and prevent healing and/or injure the ankle further

Ankle Sprains

• Mild (grade 1): several days of RICE

• Moderate (grade 2): RICE for longer period of time and immobilization of ankle

• Severe (grade 3): Immobilization of joint for a much longer period of time to allow healing

Ankle Treatment Time

• The initial treatment of a sprain includes resting and protecting the ankle until the swelling goes down for about one week

• That is followed by one to two weeks of exercise to restore range of motion, strength and flexibility

• Complete healing may take several more weeks to several months to return to normal activities

Concussion

• A disturbance in brain function following trauma to the head

• An athlete in a contact sport has a 19% chance of experiencing a concussion each season

Observed

• Dazed or stunned• Confused• Forgetful• Unsure of game/score/opponent• Moves clumsily• Answers questions slowly• Loss of consciousness• Behavior/personality change• Retrograde & anterograde amnesia

Experienced

• Headache• Nausea• Balance problem or dizziness• Double or fuzzy vision• Sensitivity to light or noise• Feeling sluggish• Feeling foggy• Change in sleep pattern• Concentration or memory problems

Assessment

• Note any signs and symptoms from two previous slides

• Especially, determine if there was any loss of consciousness

• X-rays and neuroimaging tests not helpful

• Monitor over time – next 24 hours

Management

• Any signs or symptoms noted above warrants removal from game

• Immediate evaluation: LOC >30 seconds, increasing headache, repeat vomiting; slurred speech, increasing confusion, irritability, unusual symptoms, seizure, weakness or numbness, significant neck pain

Management:

• Should have medical evaluation prior to return to activity

• No activity until asymptomatic– Repeat head injury prior to full

recovery raises risk of long term damage or even death

Additional resources

• www.cdc.gov/concussions• www.preventingconcussions.org

Questions