2008-09 NCAA® Sports Medicine Handbook

NCAA 65859-7/08 380,000 more than participating in The NCAAsalutesthemore than 1,000 23 sports member institutions student-athletes at MD 09

SPORTS MEDICINE Handbook Sports Medicine 2008-09 NCAA ® THE NATIONAL COLLEGIATE ATHLETIC ASSOCIATION P.O. Box 6222 Indianapolis, Indiana 46206-6222 317/917-6222 NCAA.org

Nineteenth Edition July 2008

Compiled By: David Klossner, Director of Education Services.

Distributed to directors of athletics, senior woman administrators, faculty athletics representatives, head athletic trainers, team physicians, CHAMPS/Life Skills coordinators, individual student-athlete advisory committees and conference commissioners.

Note: Revisions to the guidelines contained in the NCAA Sports Medicine Handbook may be made on a yearly basis. Between printings of the handbook, revisions will be published on NCAA.org. It is important that persons using this handbook be aware of any such revisions. The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports suggests that such revisions be recorded in the handbook, thereby keeping this publication current. New guidelines and major revisions have been highlighted with orange shading.

NCAA, NCAA logo and NATIONAL COLLEGIATE ATHLETIC ASSOCIATION are regis- tered marks of the Association and use in any manner is prohibited unless prior approval is obtained from the Association.

Member institutions and conferences may reproduce information in this publication for their own use, provided the NCAA copyright is included on the material.

Also found on the NCAA Web site at the following address: NCAA.org/health-safety.

1 PREFACE

The health and safety principle of required to follow to avoid legal the fall. Please view the NCAA the National Collegiate Athletic liability or disciplinary sanctions by Sports Medicine Handbook as a Association’s constitution provides the NCAA. However, an institution tool to help your institution develop that it is the responsibility of each has a legal duty to use reasonable its sports medicine administrative member institution to protect the care in conducting its intercolle- policies. Such policies should health of, and provide a safe envi- giate athletics program, and guide- reflect a commitment to protecting ronment for, each of its partici- lines may constitute some your student-athletes’ health and pating student-athletes. To provide evidence of the legal standard of well-being as well as an awareness guidance in accomplishing this care. of the guidelines set forth in this objective and to assist member handbook. schools in developing a safe inter- These general guidelines are not collegiate athletics program, the intended to supersede the exercise NCAA Committee on Competitive of medical judgment in specific Safeguards and Medical Aspects of situations by a member institu- Sports creates a Sports Medicine tion’s sports medicine staff. In all Handbook. The committee has instances, determination of the agreed to formulate guidelines for appropriate care and treatment of sports medicine care and protec- student-athletes must be based on tion of student-athletes’ health and the clinical judgment of the institu- safety for topics relevant to inter- tion’s team physician or athletic collegiate athletics, applicable to health care team that is consistent a large population of student- with sound principles of sports athletes, and not accessible in medicine care. These recommen- another easily obtainable source. dations provide guidance for an institution’s athletics administra- This handbook consists of tors and sports medicine staff in guidelines for each institution to protecting student-athletes’ health consider in developing sports med- and safety, but do not establish any icine policies appropriate for its rigid requirements that must be fol- intercollegiate athletics program. lowed in all cases. In some instances, accompanying references to sports medicine or This handbook is produced annual- legal resource materials are provid- ly and sent to directors of athletics, ed for further guidance. These senior woman administrators, recommendations are not intended faculty athletics representatives, to establish a legal standard of care athletic trainers, team physicians, that must be strictly adhered to by CHAMPS/Life Skills coordinators, member institutions. In other student-athlete advisory commit- words, these guidelines are not tees and conference commission- 2 mandates that an institution is ers at each member institution in 2008-09 Sports Medicine Guidelines Foreword ...... 4 1. Administrative Issues a. Sports Medicine Administration ...... 6 b. Medical Evaluations, Immunizations and Records ...... 8 c. Emergency Care and Coverage...... 11 d. Lightning Safety...... 13 e. Catastrophic Incident in Athletics...... 16 f. Dispensing Prescription Medication...... 18 g. Nontherapeutic Drugs...... 21 h. Institutional Alcohol, Tobacco and Other Drug Education Programs ...... 22 2. Medical Issues a. Medical Disqualification of the Student-Athlete ...... 26 b. Cold Stress...... 27 c. Prevention of Heat Illness...... 30 d. Weight Loss—Dehydration ...... 33 e. Assessment of Body Composition ...... 34 f. Nutrition and Athletic Performance ...... 39 g. Dietary Supplements and Banned Substances ...... 42 h. “Burners” (Brachial Plexus Injuries)...... 45 i. Concussion or Mild Traumatic Brain Injury...... 48 j. Skin Infections in Athletics ...... 52 k. Menstrual-Cycle Dysfunction...... 60 l. Blood-Borne Pathogens and Intercollegiate Athletics ...... 62 m. The Use of Local Anesthetics in College Athletics ...... 69 n. The Use of Injectable Corticosteroids in Sports Injuries...... 70 o. Depression: Interventions for Intercollegiate Athletics ...... 72 3. Special Populations a. Participation by the Student-Athlete with Impairment ...... 78 b. Participation by the Pregnant Student-Athlete ...... 80 c. The Student-Athlete with Sickle Cell Trait...... 82 4. Equipment a. Protective Equipment...... 86 b. Eye Safety in Sports...... 92 c. Mouth Guards...... 94 d. Use of the Head as a Weapon in Football and Other Contact Sports ...... 96 e. Guidelines for Helmet Fitting and Removal in Athletics...... 97 f. Use of Trampoline and Minitramp...... 100 Appendixes a. NCAA Legislation Involving Health and Safety...... 104 b. NCAA Injury Surveillance System Summary ...... 109 c. Acknowledgements...... 119 d. Banned-Drug Classes ...... 121

New or significantly revised guidelines are highlighted on this page. Smaller revisions are highlighted 3 within the specific guideline. FOREWORD Shared Responsibility for Intercollegiate Sports Safety

Participation in intercollegiate ath- Coaches should appropriately warn letics involves unavoidable expo- student-athletes about the sport’s sure to an inherent risk of injury. inherent risks of injury and instruct However, student-athletes rightfully them how to minimize such risks assume that those who sponsor while participating in games, prac- intercollegiate athletics have taken tices and training. reasonable precautions to minimize the risks of injury from athletics The team physician and athletic participation. In an effort to do so, health care team should assume the NCAA collects injury data in responsibility for developing an intercollegiate sports. When appro- appropriate injury prevention priate, the NCAA Committee on program and providing quality Competitive Safeguards and sports medicine care to injured Medical Aspects of Sports makes student-athletes. recommendations to modify safety guidelines, equipment standards, Student-athletes should fully or a sport’s rules of play. understand and comply with the rules and standard of play that gov- It is important to recognize that rule ern their sports and follow estab- books, safety guidelines and equip- lished procedures to minimize their ment standards, while helpful risk of injury. means of promoting safe athletics participation, are themselves insuf- In summary, all persons participat- ficient to accomplish this goal. To ing in, or associated with, an effectively minimize the risks of institution’s intercollegiate athletics injury from athletics participation, program share responsibility for everyone involved in intercollegiate taking steps to reduce effectively athletics must understand and the risk of injury during intercolle- respect the intent and objectives of giate athletic competition. applicable rules, guidelines and standards.

The institution, through its athletics director, is responsible for establishing a safe environment for its student-athletes to participate in its intercollegiate athletics program.

4 1

ADMINISTRATIVE ISSUES Also Found on the NCAA Web site at: NCAA.org/health-safety GUIDELINE 1a Sports Medicine Administration October 1977 • Revised August 2000

The following components of a 4. Acceptance of Risk. Any informed medical resources should be safe athletics program are an consent or waiver by student- based on established medical cri- important part of injury preven- athletes (or, if minors, by their teria (e.g., injury rates, rehabilitation. They should serve both as a parents) should be based on an tion) rather than the sport itself. checklist and as a guideline for awareness of the risks of partici- use by athletics administrators in pating in intercollegiate sports. Member institutions should not the development of safe pro- place their sports medicine staffs grams. 5. Planning/Supervision. Safety in in compromising situations by intercollegiate athletics can be having them provide inequitable 1. Preparticipation Medical Exam. attained only by appropriate plan- treatment in violation of their Before student-athletes accept ning for and supervision of prac- medical codes of ethics. the rigors of any organized sport, tice, competition and travel. their health should be evaluated Institutions should be encour- by qualified medical personnel. 6. Minimizing Potential Legal Liability. aged to incorporate questions Such an examination should Liability must be a concern of regarding adequacy of medical determine whether the student- responsible athletics administra- care, with special emphasis on athlete is medically cleared to tors and coaches. Those who equitable treatment, in exit inter- engage in a particular sport (see sponsor and govern athletics views with student-athletes. NCAA Bylaw 17.1.5). programs should accept the responsibility of minimizing the 8. Equipment. Purchasers of equip- 2. Health Insurance. Each student- risk of injury. ment should be aware of and use athlete should be covered by indi- safety standards. In addition, vidual, parental or institutional 7. Equitable Medical Care. Member attention should be directed to medical insurance to defray the institutions should neither prac- maintaining proper repair and fit- costs of significant injury or illness. tice nor condone illegal discrimi- ting of equipment at all times in all nation on the basis of race, sports. Student-athletes should: 3. Preseason Preparation. The stu- creed, national origin, sex, age, dent-athlete should be protected disability, social status, financial a. Be informed what equipment from premature exposure to the status, sexual orientation or reli- is mandatory and what consti- full rigors of sports. Preseason gious affiliation within their tutes illegal equipment; conditioning should provide the sports medicine programs. student-athlete with optimal b. Be provided the mandated readiness by the first practice. Availability and accessibility to equipment;

6 Sports Medicine Administration c. Be instructed to wear and how to wear mandatory equipment during participation; and d. Be instructed to notify the coaching staff when equipment becomes unsafe or illegal. 9. Facilities. The adequacy and conditions of the facilities used for particular intercollegiate athletics events should not be overlooked, and periodic examination of the facilities should be conducted. Inspection of the facilities should include not only the competitive area, but also warm- up and adjacent areas. 10. Blood-Borne Pathogens. In 1992, The Occupational Safety and Health Administration (OSHA) developed a standard directed to minimizing or eliminating occupational exposure to blood-borne pathogens. Each member institution should determine the applicability of the OSHA standard to its personnel and facilities. 11. Emergency Care. See Guideline 1c.

7 GUIDELINE 1b Medical Evaluations, Immunizations and Records July 1977 • Revised June 2008

Preparticipation medical evalua- Important changes in medical Evaluation (see reference No. 6). tion. A preparticipation medical status or abnormalities may evaluation should be required upon require more formal cardiovascu- 5.Immunizations. It is recom- a student-athlete’s entrance into lar evaluation. mended that student-athletes be the institution’s intercollegiate ath- immunized for the following: letics program (see NCAA Bylaw Medical records. Student-athletes have a responsibility to a. Measles, mumps, rubella 17.1.5). This initial evaluation (MMR); should include a comprehensive truthfully and fully disclose their health history, immunization histo- medical history and to report any b. Hepatitis B; ry as defined by current Centers for changes in their health to the Disease Control and Prevention team’s health-care provider. c. Diptheria, tetanus (and boost- (CDC) guidelines and a relevant Medical records should be main- ers when appropriate); and physical exam, with strong empha- tained during the student-ath- sis on the cardiovascular, neuro- lete’s collegiate career and d. Meningitis. should include: logic and musculoskeletal evalua- 6.Written permission, signed by tion. After the initial medical evalu- 1. A record of injuries, illnesses, the student-athlete, that autho- ation, an updated history should be new medications or allergies, preg- rizes the release of medical infor- performed annually. Further nancies and operations, whether mation to others should be preparticipation physical examina- sustained during the competitive signed annually. Such permis- tions are not believed to be neces- season or the off-season; sion should specify all persons to sary unless warranted by the whom the student-athlete autho- updated history or the student-ath- 2.Referrals for and feedback rizes the information to be lete’s medical condition. from consultation, treatment or released. The consent form also rehabilitation; The American Heart Association should specify which information may be released and to whom. has modified its 1996 recom- 3.Subsequent care and clear- mendation for a cardiovascular ances; Note: Records maintained in the screening every two years for athletic training facility are medical 2 3 collegiate athletes. The revision 4. A comprehensive entry-year records, and therefore subject to recommends cardiovascular health-status questionnaire and an state and federal laws with regard to screening as a part of the physi- updated health-status questionnaire confidentiality and content. Each cal exam required upon a stu- each year thereafter. Components of institution should obtain from dent-athlete’s entrance into the the questionnaire should consider appropriate legal counsel an opinion intercollegiate athletics program. recommendations from the regarding the confidentiality and In subsequent years, an interim American Heart Association (see content of such records in its state. history and blood pressure mea- reference Nos. 2 and 3) and the 3rd surement should be made. Edition Preparticipation Physical Medical records and the informa-

8 Medical Evaluations, Immunizations and Records tion they contain should be creat- Medical Hardship Waivers. dent-athlete’s and the institu- ed, maintained and released in Documentation standards should tion’s control. accordance with clear written assist conferences and institutions In order to demonstrate that an guidelines based on this opinion. in designing a medical treatment injury or illness prevented competi- All personnel who have access to a protocol that satisfies all questions student-athlete’s medical records tion and resulted in incapacitation of incapacitation and reflects such for the remainder of the playing should be familiar with such in the records. To clarify: guidelines and informed of their season, an institution needs to pro- role in maintaining the student- • hardship waiver: A hardship vide objective documentation to athlete’s right to privacy. waiver deals with a student-ath- substantiate the incapacitation. lete’s seasons of competition and Three key components need to be Institutions should consider state may only be granted if a student- included in this documentation: statutes for medical records reten- athlete has competed and used 1. Contemporaneous diagnosis of tion (e.g., 7 years; 10 years); insti- one of the four seasons of com- tutional policy (e.g., insurance injury/illness; petition. long term retention policy); and 2. Acknowledgement that the professional liability statute of lim- • extension waiver: An extension injury/illness is incapacitating; itations. waiver deals with time on a stu- and dent-athlete’s eligibility clock and Follow-up examinations. Those may be granted if, within a stu- 3. Length of incapacitation. who have sustained a significant dent-athlete’s period of eligibility For more information about medi- injury or illness during the sport (five years or 10 semesters), he cal hardship waivers, read the com- season should be given a follow-up or she has been denied more plete article at NCAA.org/ examination to re-establish medical than one participation opportuni- health-safety or contact the NCAA’s clearance before resuming partici- ty for reasons beyond the stu- student-athlete reinstatement staff. pation in a particular sport. This policy also should apply to pregnant student-athletes after delivery or pregnancy termination. These examinations are especially relevant if the event occurred before the student-athlete left the institution for summer break. Clearance for individuals to return to activity is solely the responsibility of the team physician or that physician’s designated representative.

9 Medical Evaluations, Immunizations and Records

Medical Documentation Standards Guidelines (from the NCAA) Contemporaneous Diagnosis of Injury ____ Contemporaneous medical documentation that validates timing of injury or illness (Required) ____ Contemporaneous medical documentation that verifies initial severity of injury or illness (demonstrates incapacitation likely results for remainder of season) (Recommended) ____ Operation report(s) or surgery report(s) or emergency room document(s) (Recommended) Acknowledgement that the Injury is Incapacitating ____ Contemporaneous letter or diagnosis from treating physician identifying injury or illness as “incapacitating” OR ____ Non-contemporaneous letter or diagnosis from treating physician identifying injury or illness as “incapacitating” AND ____ Treatment logs or athletic trainer’s notes (indicating continuing rehabilitation efforts) Length of Incapacitaion (verifying opportunity for injured student-athlete to resume playing within championship season in question is medically precluded) ____ Estimated length of incapacitation or recovery time range contained within original contemporaneous medical documentation AND ____ Contemporaneous documentation of follow-up doctors visits (within the estimated time range) in which student-athlete is not cleared to resume playing OR ____ Treatment logs or athletic trainer’s notes (indicating continuing rehabilitation efforts)

References 1. Cook LG, Collins M, Williams WW, 4. Hepatitis B Virus: a comprehensive Minneapolis, MN: McGraw-Hill Com- et. al.: Prematriculation Immunization strategy for eliminating transmission in panies, 2004. Requirements of American Colleges and the United States through universal child- 6. Eligibility Recommendations for hood vaccination: recommendations of the Universities. Journal of American College Competitive Athletes with Cardiovascular Immunization Practices Advisory Health 42:91-98, 1993. Abnormalities. 36th Bethesda Conference. Committee. Morbidity and Mortality 2. Recommendations and Considerations Journal of American College of Cardiology, Weekly Report 40 (RR-13), 1991. Related to Pre-Participation Screening for 45(8), 2005. 5. Preparticipation Physical Evaluation. Cardiovascular Abnormalities in Competitive 3rd Ed. American Academy of Family Athletics: 2007 Update: Circulation. Mar Physicians, American Academy of 2007; 115:1643-1655. Pediatrics, American Medical Society of 3. Gardner P, Schaffner W: Immunizations Sports Medicine, American Orthopaedic of Adults. The New England Journal of Society of Sports Medicine, and American 10 Medicine 328(17):1252-1258, 1993. Osteopathic Academy of Sports Medicine. GUIDELINE 1c Emergency Care and Coverage October 1977 • Revised July 2004

Reasonable attention to all possi- cal services, when warranted. visiting teams, of the personnel ble preventive measures will not Access to a working telephone or and procedures associated with eliminate sports injuries. Each other telecommunications device, the emergency-care plan; and whether fixed or mobile, should scheduled practice or contest of 8. Certification in cardiopul- be assured; an institution-sponsored intercol- monary resuscitation techniques legiate athletics event, and all out- 5. All necessary emergency (CPR), first aid, and prevention of of-season practices and skills ses- equipment should be at the site or disease transmission (as outlined sions, should include an emer- quickly accessible. Equipment by OSHA guidelines) should be gency plan. Like student-athlete should be in good operating con- required for all athletics personnel well-being in general, a plan is a dition, and personnel must be associated with practices, compe- shared responsibility of the athlet- trained in advance to use it prop- titions, skills instruction, and ics department; administrators, erly. Additionally, emergency strength and conditioning. New coaches and medical personnel information about the student- staff engaged in these activities should all play a role in the estab- athlete should be available both at should comply with these rules lishment of the plan, procurement campus and while traveling for within six months of employment. of resources and understanding of use by medical personnel; appropriate emergency response 9. A member of the institution's procedures by all parties. Com- 6. An inclement weather policy sports medicine staff should be ponents of such a plan should that includes provisions for deci- empowered to have the unchal- include: sion-making and evacuation plans lengeable authority to cancel or (See Guideline 1d); modify a workout for health and 1. The presence of a person qual- safety reasons (i.e., environmen- ified and delegated to render 7. A thorough understanding by all tal changes), as he or she deems emergency care to a stricken par- parties, including the leadership of appropriate. ticipant; 2. The presence or planned access to a physician for prompt medical evaluation of the situation, when warranted; 3. Planned access to early defrib- rillation; 4. Planned access to a medical facility, including a plan for communication and transportation between the athletics site and the medical facility for prompt medi-

11 Emergency Care and Coverage

Guidelines To Use During a Serious On-Field Player Injury: These guidelines have been recommended for National Football League (NFL) officials and have been shared with NCAA championships staff. 1. Players and coaches should go to and remain in the bench area once medical assistance arrives. Adequate lines of vision between the medical staffs and all available emergency personnel should be established and maintained. 2. Players, parents and nonauthorized personnel should be kept a significant distance away from the seri- ously injured player or players. 3. Players or non-medical personnel should not touch, move or roll an injured player. 4. Players should not try to assist a teammate who is lying on the field (i.e., removing the helmet or chin strap, or attempting to assist breathing by elevating the waist). 5. Players should not pull an injured teammate or opponent from a pile-up. 6. Once the medical staff begins to work on an injured player, they should be allowed to perform services without interruption or interference. 7. Players and coaches should avoid dictating medical services to the athletic trainers or team physicians or taking up their time to perform such services.

References 1. Halpern BC: Injuries and emergencies Freeway, Dallas, Texas) 2003. Exercise. 33(5):846-849, 2001. on the field. In Mellion MB, Shelton GL, 4. Van Camp SP, et al: Nontraumatic 7. Laws on Cardiac Arrest and Walsh WM (eds): The Team Physician's sports death in high school and college Defibrillators, 2007 update. Available at: Handbook St. Louis, MO: Mosby- athletics. Medicine and Science in Sports www.ncsi.org/programs/health/aed.htm. Yearbook, 1990, pp. 128-142. and Exercise 27(5):641-647, 1995. 8. Inter-Association Task Force 2. Harris AJ: Disaster plan—A part of the 5. Mass Participation Event Management game plan. Athletic Training 23(1):59, for the Team Physician: A Consensus Recommendations on Emergency 1988. Statement. Medicine and Science in Sports Preparedness and Management of Sudden 3. Recommendations and Guidelines for and Exercise 36(11):2004-2008, 2004. Cardiac Arrest in High School and College Appropriate Medical Coverage of 6. Sideline Preparedness for the Team Athletic Programs: A Consensus Intercollegiate Athletics. National Athletic Physician: A Consensus Statement. Statement. Journal of Athletic Training. 12 Trainers’ Association, (2952 Stemmons Medicine and Science in Sports and 42:143-158. 2007. GUIDELINE 1d Lightning Safety July 1997 • Revised June 2007

The NCAA Committee on Com- NOAA to mitigate the lightning everyone to take the proper pre- petitive Safeguards and Medical hazard: cautions. A NOAA weather radio Aspects of Sports acknowledges is particularly helpful in providing the significant input of Brian L. 1. Designate a person to moni- this information. Bennett, formerly an athletic train- tor threatening weather and to er with the College of William and make the decision to remove a 4. Know where the closest Mary Division of Sports Medicine, team or individuals from an athlet- “safer structure or location” is to Ronald L. Holle, a meteorologist, ics site or event. A lightning safe- the field or playing area, and know formerly of the National Severe ty plan should include planned how long it takes to get to that Storms Laboratory (NSSL), and instructions for participants and location. A safer structure or Mary Ann Cooper, M.D., Professor spectators, designation of warn- location is defined as: of Emergency Medicine of the ing and all clear signals, proper University of Illinois at Chicago, in signage, and designation of safer a.Any building normally occu- the development of this guideline. places for shelter from the light- pied or frequently used by peo- ning. ple, i.e., a building with plumb- Lightning is the most consistent ing and/or electrical wiring that and significant weather hazard 2. Monitor local weather re- acts to electrically ground the that may affect intercollegiate ath- ports each day before any practice structure. Avoid using the letics. Within the United States, or event. Be diligently aware of shower or plumbing facilities potential thunderstorms that may the National Oceanographic and and contact with electrical form during scheduled intercolle- Atmospheric Administration appliances during a thunder- giate athletics events or practices. (NOAA) estimates that 60 to 70 storm. fatalities and about 10 times as Weather information can be found many injuries occur from light- through various means via local b.In the absence of a sturdy, ning strikes every year. While the television news coverage, the frequently inhabited building, probability of being struck by Internet, cable and satellite weath- any vehicle with a hard metal lightning is low, the odds are sig- er programming, or the National roof (neither a convertible, nor nificantly greater when a storm is Weather Service (NWS) Web site a golf cart) with the windows in the area and proper safety pre- at www.weather.gov. shut provides a measure of cautions are not followed. 3. Be informed of National safety. The hard metal frame Education and prevention are the Weather Service (NWS) issued and roof, not the rubber tires, keys to lightning safety. The ref- thunderstorm “watches” or are what protects occupants by erences associated with this “warnings,” and the warning dissipating lightning current guideline are an excellent educa- signs of developing thunder- around the vehicle and not tional resource. Prevention storms in the area, such as high through the occupants. It is should begin long before any winds or darkening skies. A important not to touch the intercollegiate athletics event or “watch” means conditions are metal framework of the vehicle. practice by being proactive and favorable for severe weather to Some athletics events rent having a lightning safety plan in develop in an area; a “warning” school buses as safer shelters place. The following steps are means that severe weather has to place around open courses recommended by the NCAA and been reported in an area and for or fields. 13 Lightning Safety

Dangerous Locations consider suspending activities more) miles away from the rain Outside locations increase the and heading for your designated shaft. safer locations. risk of being struck by light- d.Avoid using landline tele- ning when thunderstorms are The following specific lightning phones, except in emergency in the area. Small covered safety guidelines have been devel- situations. People have been shelters are not safe from oped with the assistance of light- killed while using a landline lightning. Dugouts, rain shel- ning safety experts. Design your telephone during a thunder- ters, golf shelters and picnic lightning safety plan to consider storm. Cellular or cordless shelters, even if they are prop- local safety needs, weather pat- phones are safe alternatives to erly grounded for structural terns and thunderstorm types. a landline phone, particularly if safety, are usually not proper- a.As a minimum, lightning the person and the antenna are ly grounded from the effects located within a safer struc- of lightning and side flashes to safety experts strongly recommend that by the time the mon- tureor location, and if all other people. They are usually very precautions are followed. unsafe and may actually itor observes 30 seconds be- increase the risk of lightning tween seeing the lightning flash e.To resume athletics activi- injury. Other dangerous loca- and hearing its associated ties, lightning safety experts tions include areas connected thunder, all individuals should recommend waiting 30 min- have left the athletics site and to, or near, light poles, towers utes after both the last sound reached a safer structure or and fences that can carry a of thunder and last flash of location. nearby strike to people. Also lightning. If lightning is seen dangerous is any location that b.Please note that thunder may without hearing thunder, light- makes the person the highest be hard to hear if there is an ning may be out of range and point in the area. athletics event going on, partic- therefore less likely to be a sig- ularly in stadia with large nificant threat. At night, be 5. Lightning awareness should aware that lightning can be be heightened at the first flash of crowds. Implement your lightning safety plan accordingly. visible at a much greater dis- lightning, clap of thunder, and/or tance than during the day as other criteria such as increasing c.The existence of blue sky clouds are being lit from the winds or darkening skies, no and the absence of rain are not inside by lightning. This matter how far away. These guarantees that lightning will greater distance may mean types of activities should be not strike. At least 10 percent of that the lightning is no longer a treated as a warning or “wake-up lightning occurs when there is significant threat. At night, call” to intercollegiate athletics no rainfall and when blue sky is use both the sound of thunder personnel. Lightning safety often visible somewhere in the and seeing the lightning chan- experts suggest that if you hear sky, especially with summer nel itself to decide on re-set- thunder, begin preparation for thunderstorms. Lightning can, ting the 30-minute “return-to- evacuation; if you see lightning, and does, strike as far as 10 (or play” clock before resuming 14 Lightning Safety outdoor athletics activities. 911 community, call for help. delayed while searching for an Prompt, aggressive CPR has AED. f. People who have been struck been highly effective for the by lightning do not carry an Note: Weather watchers, real- survival of victims of lightning time weather forecasts and electrical charge. Therefore, strikes. cardiopulmonary resuscitation commercial weather-warning (CPR) is safe for the responder. Automatic external defibrilla- devices are all tools that can If possible, an injured person tors (AEDs) have become a be used to aid in decision- making regarding stoppage of should be moved to a safer common, safe and effective play, evacuation and return to location before starting CPR. means of reviving persons in play. Lightning-strike victims who cardiac arrest. Planned access show signs of cardiac or respi- to early defibrillation should be ratory arrest need prompt part of your emergency plan. emergency help. If you are in a However, CPR should never be

References 1. Cooper MA, Andrews CJ, Holle RL, 4. National Lightning Safety Institute Web Cooper MA, Kithil R. National Athletic Lopez RE. Lightning Injuries. In: site: www.lightningsafety.com. Trainer's Association Position Statement. Auerbach, ed. Management of Wilderness 5. Uman MA. All About Lightning. New Lightning Safety for Athletics and and Environmental Emergencies. 5th ed. York: Dover Publications. 1986. Recreation. Journal of Athletic Training. C.V. Mosby, 2007:67-108. 35(4);471-477. 2000. 6. NOAA lightning safety Web site: 2. Bennett BL. A Model Lightning Safety 9. Holle RL. 2005: Lightning-caused www.lightningsafety.noaa.gov. Policy for Athletics. Journal of Athletic recreation deaths and injuries. Preprints, Training. 32(3):251-253. 1997. 7. Walsh KM, Hanley MJ, Graner SJ, 14th Symposium on Education, January Beam D, Bazluki J. A Survey of Lightning 3. Price TG, Cooper MA: Electrical and 9-13, San Diego, California, American Safety Policy in Selected Division I Lightning Injuries. In: Marx et al. Rosen’s Meteorological Society, 6 pp. Emergency Medicine, Concepts and Colleges. Journal of Athletic Training. 10.The Weather Channel on satellite or Clinical Practice, Mosby, 6th ed. 2006; 22: 32(3);206-210. 1997. cable, and on the Internet at www.weath- 67-78. 8. Walsh KM, Bennett BL, Holle RL, er.com. 15 GUIDELINE 1e Catastrophic Incident in Athletics July 2004 • Revised July 2008

The NCAA Committee on Comp- 1. Definition of a catastrophic 5. Criminal circumstances: etitive Safeguards and Medical incident: The sudden death of a Outline the collaboration of the Aspects of Sports acknowledges student-athlete, coach or staff athletics department with univer- the significant input of Timothy member from any cause, or dis- sity, local and state law enforce- Neal, ATC, Syracuse University, abling and/or quality of life alter- ment officials in the event of acci- who originally authored this ing injuries. dental death, homicide or suicide. guideline. 2. A management team: A 6. Away contest responsibili- Catastrophes such as death or select group of administrators ties: Catastrophies may occur at permanent disability occurring in who receive all facts pertaining to away contests. Indicate who intercollegiate athletics are rare. the catastrophe. This team works should stay behind with the indi- However, the aftermath of a collaboratively to officially com- vidual to coordinate communica- catastrophic incident to a stu- municate information to family tion and act as a university repre- dent-athlete, coach or staff mem- members, teammates, coaches, sentative until relieved by the ber can be a time of uncertainty staff, the institution and media. institution. and confusion for an institution. It This team may consist of one or is recommended that NCAA more of the following: director of 7. Phone list and flow chart: member institutions develop their athletics, head athletic trainer, Phone numbers of all key individ- own catastrophic incident guide- university spokesperson, director uals (office, home, cell) involved line to provide information and of athletic communications and in the management of the catas- the support necessary to family university risk manager. This trophe should be listed and kept members, teammates, coaches team may select others to help current. Include university legal and staff after a catastrophe. facilitate fact finding specific to counsel numbers and the NCAA Centralizing and disseminating the incident. catastrophic injury service line the information is best served by number (800/245-2744). A flow developing a catastrophic inci- 3. Immediate action plan: At the chart of whom is to be called in dent guideline. This guideline moment of the catastrophe, a the event of a catastrophe is also should be distributed to adminis- checklist of whom to call and useful in coordinating communi- trative, sports medicine and immediate steps to secure facts cation. coaching staffs within the athlet- and offer support are items to be ics department. The guideline included. 8. Incident Record: A written should be updated and reviewed chronology by the management annually with the entire staff to 4. Chain of command/role team of the catastrophic incident ensure information is accurate delineation: This area outlines is recommended to critique the and that new staff members are each individual’s responsibility process and provide a basis for aware of the guideline. during the aftermath of the catas- review and enhancement of pro- trophe. Athletics administrators, cedures. Components of a catastrophic university administrators and incident guideline should include: support services personnel 9. Notification Process: After the should be involved in this area. catastrophic incident, the director 16 Catastrophic Incident in Athletics of athletics, assistant director of catastrophic incident manage- deductible and provides benefits athletics for sports medicine (head ment team in order to make as in excess of any other valid and athletic trainer), head coach many resources available as pos- collectible insurance. The policy (recruiting coach if available), and sible to the visiting team. The will pay $25,000 if an insured university risk manager/legal host institution may assist in person dies as a result of a cov- counsel, as available, will contact contacting the victim’s institution ered accident or sustains injury the parents/legal guardians/ and athletics administration, as due to a covered accident which, spouse of the victim. The director well as activating, as appropriate, independent of all other causes, of athletics, head coach and others the host institution’s catastrophic results directly in the death of the deemed necessary, will inform the incident guideline to offer sup- insured person within twelve (12) team, preferably in person, as port to the visiting team’s stu- months after the date of such soon as possible and offer coun- dent-athletes, coaches and staff. injury. Both catastrophic injuries seling services and support. and sudden deaths should be Catastrophic Injury Insurance reported to the NCAA national 10. Assistance to Visiting Program office insurance staff. For more Team’s Catastrophic Incident as The NCAA sponsors a cata- information, visit NCAA.org. Host Institution: In the event strophic injury insurance pro- that a visiting team experiences a gram that covers a student-ath- Sample guidelines may be found catastrophic incident, the host lete who is catastrophically at NCAA.org/health-safety. institution may offer assistance injured while participating in a by alerting the director of athlet- covered intercollegiate athletic ics or another member of the activity. The policy has a $75,000

References 1. Neal, TL: Catastrophic Incident Guideline Plan. NATA News: 12, May 2003. 2. Neal, TL: Syracuse University Athletic Department Catastrophic Incident Guideline, 2003.

17 GUIDELINE 1f Dispensing Prescription Medication May 1986 • Revised June 2008

Research sponsored by the NCAA dispensing prescription medica- keeping, and accountability for all has shown that prescription med- tions under current medication- drugs dispensed. ications have been provided to dispensing laws, since athletic student-athletes by individuals trainers are not authorized by law 2. Certified athletic trainers should other than persons legally autho- to dispense these drugs under any not be assigned duties that may be rized to dispense such medica- circumstances. The improper dele- performed only by physicians or tions. This is an important con- gation of authority by the physician pharmacists. A team physician can- cern because the improper dis- or the dispensing of prescription not delegate diagnosis, prescription- pensing of both prescription and medications by the athletic trainer drug control or prescription- nonprescription drugs can lead to (even with permission of the physi- dispensing duties to athletic trainers. serious medical and legal conse- cian), places both parties at risk for quences. legal liability. 3.Drug-distribution records should be created and maintained where Research also has shown that state If athletics departments choose to dispensing occurs in accordance and federal regulations regarding provide prescription and/or non- with appropriate legal guidelines. packaging, labeling, records keep- prescription medications, they The record should be current and ing and storage of medications must comply with the applicable easily accessible by appropriate have been overlooked or disre- state and federal laws for doing so. medical personnel. garded in the dispensing of medi- It is strongly encouraged that ath- cations from the athletic training letics departments and their team 4.All prescription and over-the- facility. Moreover, many states physicians work with their on-site counter (OTC) medications should have strict regulations regarding or area pharmacists to develop be stored in designated areas that packaging, labeling, records keep- specific policies. assure proper environmental (dry ing and storage of prescription and with temperatures between 59 and nonprescription medications. The following items form a mini- 86 degrees Fahrenheit) and securi- Athletics departments must be mal framework for an appropriate ty conditions. concerned about the risk of harm drug-distribution program in a col- to the student-athletes when these lege-athletics environment. Since 5.All drug stocks should be exam- regulations are not followed. there is extreme variability in state ined at regular intervals for re- laws, it is imperative for each insti- moval of any outdated, deteriorat- Administering drugs and dispens- tution to consult with legal counsel ed or recalled medications. ing drugs are two separate func- in order to be in full compliance. tions. Administration generally 6.All emergency and travel kits refers to the direct application of a 1.Drug-dispensing practices are containing prescription and OTC single dose of drug. Dispensing is subject to and should be in compli- drugs should be routinely inspect- defined as preparing, packaging ance with all state, federal and ed for drug quality and security. and labeling a prescription drug or Drug Enforcement Agency (DEA) device for subsequent use by a regulations. Relevant items include 7.Individuals receiving medication patient. Physicians cannot delegate appropriate packaging, labeling, should be properly informed about 18 to athletic trainers the authority for counseling and education, records what they are taking and how they Dispensing Prescription Medication should take it. Drug allergies, chron- 8.Follow-up should be performed ic medical conditions and concur- to be sure student-athletes are rent medication use should be docu- complying with the drug regimen mented in the student-athlete’s med- and to ensure that drug therapy is ical record and readily retrievable. effective.

Federal Regulations specific to the management of prescription medications in the athletic training medical facility

Prescription Drug Marketing Act 21 CFR 5.115 – Sample medication control 21 CFR 1301.23(1) – DEA certificate required for separate locations 21 CFR 1301.75 – Storage of controlled substances 21 CFR 1301.44 – DEA certificate readily retrievable 21 CFR 1301.90 – Security of personnel for handling of controlled substances 21 CFR 1301.92 – Responsibility to report drug diversion 21 CFR 1304.4 – Record-keeping requirements for controlled substances 21 CFR 1304.02(d) – Defines a physician which prescribes, administers, and dispenses controlled substances. 21 CFR 1304.11-12(b) – Inventory requirements for controlled substances 21 CFR 1304.13 – Reconciliation requirements for controlled substances 21 CFR 1305.12 – Reporting a theft of a controlled substance Food, Drug, and Cosmetic Act 21 USC 360(g) – Requirement to utilize a FDA-licensed pharmacy repackager 21 USC 353(b)(2) – Labeling of prescription medications 15 USC 1471 – Packaging of controlled substances and prescription medications 15 USC 1473(b) – Exception to PPPA for prescriber dispensing of non-child safety container Federal Controlled Substance Act 21 USC 824(a)(f) – DEA certificate required 21 USC 802(10) – Prescriber dispensing 21 USC 802(10) – Defines a dispensing physician vs. an individual practitioner 21 USC 823(f) – DEA certificate required for separate locations 21 USC 827(1)(A)(B) – Acquisition and disposition record-keeping requirements for individual practitioners dispensing controlled substances. 19 Dispensing Prescription Medication

References 1. Adherence to Drug-Dispensation and (ed): The Legal Aspects of Sports Medi- 6. Laster-Bradley M, Berger BA: Eval- Drug-Administration Laws and Guidelines cine Canton, OH: Professional Sports uation of Drug Distribution Systems in in Collegiate Athletic Training Rooms. Publications, 1991, pp. 215-224. University Athletics Programs: Develop- ment of a Model or Optimal Drug Journal of Athletic Training. 38(3): 252- 4. Huff PS: Drug Distribution in the Distribution System for Athletics 258, 2003. Training Room. In Clinics in Sports Programs. Unpublished report, 1991. 2. Anderson WA, Albrecht RR, McKeag Medicine. Philadelphia, WB Saunders Co: (128 Miller Hall, Department of Pharmacy DB, et al.: A national survey of alcohol and 211-228, 1998. Care Systems, Auburn University, Auburn, drug use by college athletes. The 5. Huff PS, Prentice WE: Using Phar- AL 36849-5506) Physician and Sportsmedicine 19:91-104, macological Agents in a Rehabilitation 7. Price KD, Huff PS, Isetts BJ, et.al: 1991. Program. In Rehabilitation Techniques in University-based sports pharmacy pro- 3. Herbert DL: Dispensing prescription Sports Medicine (3rd Ed.) Dubuque, IA, gram. American Journal Health-Systems 20 medications to athletes. In Herbert, DL WCB/McGraw-Hill 244-265, 1998. Pharmacy 52:302-309, 1995. GUIDELINE 1g Nontherapeutic Drugs July 1981 • Revised June 2002

The NCAA and professional soci- constant (28 percent). The full Drug testing should not be viewed eties such as the American results of the 2004 and past sur- as a replacement for a solid drug- Medical Association (AMA) and veys are available to all member education program. Indeed, the the American College of Sports institutions and can be used to most common drugs of abuse, Medicine (ACSM) denounce the educate staff and plan educational alcohol and tobacco, are not employment of nontherapeutic and treatment programs for its included in NCAA drug testing. The drugs by student-athletes. These student-athletes. use of spit or smokeless tobacco include drugs that are taken in an can drop by 30 percent due to a effort to enhance athletic perfor- The NCAA maintains a banned drug vigorous educational program. mance, and those drugs that are classes list and conducts drug test- used recreationally by student-ath- ing at championship events and All medical staff should be familiar letes. Examples include but are not year-round random testing in with the regulations regarding dis- limited to alcohol, amphetamines, sports. Some NCAA member insti- pensing medications as listed in ephedrine, (ma huang), anabolic- tutions have developed drug-test- Guideline 1f. ing programs to combat the use of androgenic steroids, barbiturates, All member institutions, their ath- caffeine, cocaine, heroin, LSD, nontherapeutic substances. Such programs should follow guidelines letics staff and their student-ath- PCP, marijuana and all forms of letes should be aware of current tobacco. The use of such drugs is established by the NCAA Com- mittee on Competitive Safeguards trends in drug use and abuse, and contrary to the rules and ethical the current NCAA list of banned principles of athletics competition. and Medical Aspects of Sports. While not all member institutions drug classes. It is incumbent upon The patterns of drug use and the have enacted their own drug-test- NCAA member institutions to act specific drugs change frequently, ing programs, it is essential to have as a positive influence in order to and it is incumbent upon NCAA some type of drug-education pro- combat the use of drugs in sport member institutions to keep gram as outlined in Guideline 1h. and society. abreast of current trends. The NCAA conducts drug-use surveys of student-athletes in all sports References and across all divisions every four years. According to the 2001 1. American College of Sports Medicine, 3. American Medical Association NCAA Study of Substance Use Position Stand: The Use of Anabolic- Compendium, Policy Statement: Non- Habits of College Student- Androgenic Steroids in Sports, 1984. (P.O. Therapeutic Use of Pharmacological Athletes, the percentage of stu- Box 1440, Indianapolis, IN 46206-1440) Agents by Athletes (105.016), 1990. (P.O. dent-athletes who use alcohol Box 10946, Chicago, IL 60610) decreased by 10 percent (88.5- 2. American Medical Association 79.5) over the last 12 years, while Compendium, Policy Statement: Medical 4. NCAA Study of Substance Use Habits the percentage of student-athletes and Non-Medical Use of Anabolic- of College Student-Athletes. NCAA, P.O. who use marijuana during those Androgenic Steroids (105.001), 1990. (P.O. Box 6222, Indianapolis, Indiana 46206- same 12 years remained fairly Box 10946, Chicago, IL 60610) 6222, June 2004. 21 GUIDELINE 1h Institutional Alcohol, Tobacco and Other Drug Education Programs August 2000 • Revised June 2003

The NCAA is committed to educa- ment’s drug and alcohol policy.* The NCAA subscribes to the tion in the area of drugs and Resource Exchange Center (REC), alcohol abuse. The following are 3. Review institutional drug and which provides a confidential hot- the minimum guidelines an institu- alcohol policy. line and Web site to answer question should have in place to assure tions from student-athletes and 4. Review conference drug and it is conducting an adequate drug- athletics personnel on whether alcohol policy. education program for its student- nutritional supplements and medi- athletes. 5. Review institutional or confer- cations contain banned sub- ence drug-testing programs (if stances. This service is free of In addition to the signing of the any). charge to all member institutions. NCAA drug-testing consent form, To access the REC, go to each athletics department should 6. Review NCAA alcohol, tobacco www.drugfreesport.com/rec. The conduct a drug and alcohol educa- and drug policy, including the password is ncaa1, ncaa2, or tion program for all athletic teams. tobacco ban, list of banned drug ncaa3, depending on your divi- The program should raise the classes and testing protocol. sional classification. awareness of current student-athletes and educate those students 7. View the NCAA drug-education *Each athletics department should who may transfer mid-year. The and drug-testing video.1 have a written policy on alcohol, athletics director, coach, compli- tobacco and other drugs. This ance officer and sports medicine 8. Discuss nutritional supple- policy should include a statement on recruitment activities, drug personnel should also participate ments and their inherent risks. testing, discipline, and counseling in the program. 9. Allow time for questions from or treatment options. This program should: student-athletes. 1 Compliance officers are sent a 1. Review and develop individual Schools are encouraged to contact copy of the NCAA Drug-Testing team drug and alcohol policies. the NCAA for specific banned drug Video. The video also can be and testing protocol questions. viewed online at NCAA.org/ 2. Review the athletics depart- health-safety.

22 Institutional Alcohol, Tobacco and Other Drug Education Programs

23 24 2

MEDICAL ISSUES

Also Found on the NCAA Web site at: NCAA.org/health-safety GUIDELINE 2a Medical Disqualification of the Student-Athlete January 1979 • Revised June 2004

Withholding a student-athlete from sor, the NCAA seeks to ensure that ify the student-athlete from con- activity. The team physician has all student-athletes are physically tinued participation. the final responsibility to deter- fit to participate in its champi- 2. For all other incidents, the stu- mine when a student-athlete is onships and have valid medical dent-athlete’s on-site team physi- removed or withheld from partici- clearance to participate in the cian can determine whether a stu- pation due to an injury, an illness competition. dent-athlete with an injury or ill- or pregnancy. In addition, clear- 1. The NCAA tournament physi- ness should continue to partici- ance for that individual to return to cian, as designated by the host pate or is disqualified. In the activity is solely the responsibility school, has the unchallengeable absence of a team physician, the of the team physician or that authority to determine whether a NCAA tournament physician will physician’s designated represen- student-athlete with an injury, ill- examine the student-athlete and tative. ness or other medical condition has valid medical authority to dis- Procedure to medically disqualify (e.g., skin infection) may expose qualify him or her if the student- a student-athlete during an NCAA others to a significantly enhanced athlete’s injury, illness or medical championship. As the event spon- risk of harm and, if so, to disqual- condition poses a potentially life threatening risk to himself or herself. 3. The chair of the governing sports committee (or a designated representative) shall be responsible for administrative enforcement of the medical judgment, if it involves disqualification.

Reference 1. Team Physician Consensus Statement. Project-based alliance for the advance- ment of clinical sports medicine com- posed of the American Academy of Family Physicians, the American Academy of Orthopedic Surgeons, the American College of Sports Medicine (ACSM), the American Medical Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine, 2000. 26 Contact ACSM at 317/ 637-9200. GUIDELINE 2b Cold Stress June 1994 • Revised June 2002

Cold exposure can be uncomfortable, impair performance and even become life-threatening. Conditions created by cold exposure include wind chill, frostbite and hypothermia. Wind chill can make activity uncomfortable and can impair performance when muscle temperature declines. Frostbite is the freezing of superfi- cial tissues, usually of the face, ears, fingers and toes. Hypothermia, a significant drop in body temperature, occurs with rapid cooling, exhaustion and energy depletion. The resulting failure of the temperature-regulating mechanisms constitutes a medical emergency. Hypothermia frequently occurs at temperatures above freezing. A wet and windy 30- to 50-degree exposure may be as serious as a subze- ro exposure. As the wind chill chart cause coughing, chest tightness as an early warning sign. Excessive indicates, wind speed interacts and discomfort, such as a burning shivering contributes to fatigue and with ambient temperature to signif- sensation in the throat and nasal makes performance of motor skills icantly increase body cooling. passages. more difficult. Other signs include When the body and clothing are Physiological factors, such as numbness and pain in fingers and wet (whether from sweat, rain, or strength, power, endurance and toes or a burning sensation of the snow or immersion), the cooling is aerobic capacity, are reduced by ears, nose or exposed flesh. As even more pronounced due to a drop in muscle temperature cold exposure continues, the core evaporation of the water held close or body core temperature. temperature drops. When the cold to the skin by wet clothing. Musculoskeletal injuries may reaches the brain, a victim may increase when exercising vigor- exhibit sluggishness, poor judg- Cold exposure affects many body ment and may appear disoriented. systems. The combination of cold ously in the cold, especially in the absence of adequate warm-up. Speech becomes slow and slurred, air and the deep breathing of exer- and movements become clumsy. cise can trigger an asthma attack Early recognition of cold stress is The victim wants to lie down and (bronchospasm). Cold air is not important. Shivering, a means for rest. This is a medical emergency. dangerous to lung tissue, but it can the body to generate heat, serves Transport as soon as possible. First 27 Cold Stress

aid involves getting the victim Polypropylene or wool wick mois- competition to prevent a drop in warm and dry and, if possible, ture away from the skin and retain muscle or body temperature. Time hydrated with a warm beverage. insulating properties when wet. the warm-up to lead almost imme- Prevention of cold stress is primar- Cotton is a poor choice for winter diately to competition. After com- ily a matter of dressing properly to wear since it holds moisture and petition, add clothing to avoid rapid control the climate next to the skin. loses insulating properties when cooling. Warm extremely cold air Inadequate energy and fluid intake wet. with a mask or scarf to prevent can significantly decrease cold tol- Energy/Hydration bronchospasm. erance. To prevent cold problems, Maintain energy levels via use of Partner student-athletes should be meals, energy snacks and carbo- Never train alone. An injury such as instructed as follows: hydrate/electrolyte sports drinks. a sprained ankle can become life Clothing Negative energy balance increases threatening when it occurs during Dress in layers and try to stay dry. the susceptibility to hypothermia. a cold-weather workout on an iso- Layers can be added or removed Stay hydrated, since dehydration lated trail. depending on temperature, activity affects the body’s ability to regulate Avoidance of cold injury is a matter and wind chill. Begin with a wick- temperature and increases the risk of recognizing the potential for cold ing fabric next to the skin. Add of frostbite. Fluids are as important stress and dressing appropriately. lightweight pile or wool layers for in the cold as in the heat. Avoid While there is considerable varia- warmth and use a windblock gar- alcohol, caffeine, nicotine and tion in cold tolerance, repeated ment to avoid wind chill. Because other drugs that cause water loss, exposure increases tolerance. heat loss from the head and neck vasodilatation or vasoconstriction Adequate energy, hydration and may be as much as 50 percent of of skin vessels. warm-up will minimize problems, total heat loss, the head should be Fatigue/Exhaustion as will avoidance of fatigue. covered during cold stress condi- Fatigue and exhaustion deplete Training with a partner helps to tions. Hand covering should be energy reserves. Exertional fatigue ensure early recognition of danger- worn as needed. Mittens are and exhaustion increase the sus- ous conditions and problems. warmer than gloves. ceptibility to hypothermia, as does Considerations for canceling a Moisture, whether from perspira- sleep loss. practice or event should include specific environmental conditions, tion or precipitation, significantly Warm-Up increases body heat loss. Keep dry the experience and cold tolerance Warm-up thoroughly and keep by wearing a wicking fabric next to of the student-athletes, and the fac- warm throughout the practice or the body, hands and feet. tors associated with cold stress.

28 Cold Stress

References

1. Prevention of Cold Injuries during 17(12):77-89, 1989. 1998. Exercise. ACSM Position Stand. Medicine 4. Frey C: Frostbitten feet: Steps to treat- 6. Robinson WA: Competing with the cold. & Science in Sports & Exercise. 2006: ment and prevention. The Physician and The Physician and Sportsmedicine 2012-2029. Sportsmedicine 21(1):67-76, 1992. 20(1):61-65, 1992. 2. Armstrong, LE: Performing in Extreme 5. Young, A.J., Castellani, J.W., O’Brian, 7. Thornton JS: Hypothermia shouldn’t Environments. Champaign, IL: Human C. et al., Exertional fatigue, sleep loss, freeze out cold-weather athletes. The Kinetics Publishers. and negative-energy balance increases Physician and Sportsmedicine 18(1): 109- 3. Askew EW: Nutrition for a cold environ- susceptibility to hypothermia. Journal of 114, 1990. 29 ment. The Physician and Sportsmedicine Applied Physiology. 85:1210-1217, GUIDELINE 2c Prevention of Heat Illness June 1975 • Revised June 2002

Practice or competition in hot 3. Clothing and protective equip- ommended. Use the ambient tem- and/or humid environmental con- ment, such as helmets, shoulder perature and humidity to assess ditions poses special problems for pads and shin guards, increase heat stress (see Figure 1). Utilize student-athletes. Heat stress and heat stress by interfering with the the wet-bulb temperature, dry- resulting heat illness is a primary evaporation of sweat and inhibiting bulb temperature and globe tem- concern in these conditions. other pathways for heat loss. Dark- perature to assess the potential Although deaths from heat illness colored clothing increases the impact of humidity, air tempera- are rare, constant surveillance and body’s absorption of solar radia- ture and solar radiation. A wet- education are necessary to prevent tion. Frequent rest periods should bulb temperature higher than 75 heat-related problems. The follow- be scheduled so that the gear and degrees Fahrenheit (24 degrees ing practices should be observed: clothing can be loosened to allow Celsius) or humidity above 90 per- heat loss. During the acclimatiza- cent may represent dangerous 1. An initial complete medical his- tion process, it may be advisable conditions, especially if the sun is tory and physical evaluation, fol- to use a minimum of protective shining or the student-athletes are lowed by the completion of a year- gear and clothing and to practice in not acclimatized. A wet-bulb globe ly health-status questionnaire T-shirts, shorts, socks and shoes. temperature (WBGT) higher than before practice begins, should be Excessive tape and outer clothing 82 degrees Fahrenheit (28 required. A history of previous that restrict sweat evaporation degrees Celsius) suggests that heat illness, and the type and dura- should be avoided. Rubberized careful control of all activity be tion of training activities for the suits should never be used. undertaken. The value for caution previous month, also are essential. may need to be adjusted down 4. To identify heat stress condi- 2. Prevention of heat illness when wearing protective equip- tions, regular measurements of begins with aerobic conditioning, ment (see reference No. 6). environmental conditions are rec- which provides partial acclimatization to the heat. Student-athletes

should gradually increase expo- Only fit and heat-acclimatized student- sure to hot and/or humid environ- athletes can participate safely. mental conditions over a period of Heat sensitive and unacclimatized seven to 10 days to achieve heat student-athletes may suffer. Little danger of heat stress for acclimatization. Each exposure acclimatized student-athletes. should involve a gradual increase in the intensity and duration of High exercise until the exercise is com- parable to that likely to occur in competition. When conditions are Moderate extreme, training or competition should be held during a cooler Low time of day. Hydration should be maintained during training and acclimatization. 30 Figure 1: Temperature-Humidity Activity Index Prevention of Heat Illness

5. Dehydration must be avoided lost during the activity. A two- that act as stimulants may not only because it hinders perfor- pound weight loss represents increase risk of heat illness. These mance, but also because it can approximately one quart of fluid substances may be found in some result in profound heat illness. loss. Urine volume and color can prescription and over-the-counter Fluid replacement must be readily be used to assess general hydra- drugs, nutritional supplements available. Student-athletes should tion. If output is plentiful and the and foods. be encouraged to drink as much color is “pale yellow or straw-col- Student-athletes should be and as frequently as comfort ored,” the student-athlete is not informed of and monitored for allows. They should drink one to dehydrated. signs of heat illness such as: ces- two cups of water in the hour Water and carbohydrate/elec- sation of sweating, weakness, before practice or competition, trolyte drinks are appropriate for cramping, rapid and weak pulse, and continue drinking during activ- exercise in heat. Carbohydrate/ pale or flushed skin, excessive ity (every 15 to 20 minutes). For electrolyte drinks enhance fluid fatigue, nausea, unsteadiness, dis- activity up to two hours in dura- intake, and the electrolytes aid in turbance of vision and incoheren- tion, most weight loss represents the retention of fluid. In addition, cy. If heat illness is suspected, water loss, and that fluid loss the carbohydrates provide energy prompt emergency treatment should be replaced as soon as and help maintain immune and is recommended. When training possible. After activity, the stu- cognitive function. in hot and/or humid conditions, dent-athlete should rehydrate with student-athletes should train with a volume that exceeds the amount 6. By recording the body weight of each student-athlete before and a partner or be under observation after workout or practice, progres- by a coach or athletic trainer. sive dehydration or loss of body First aid for heat illness fluids can be detected, and the potential harmful effects of dehy- Heat exhaustion—Symptoms us- dration can be avoided. Those who ually include profound weakness lose five percent of their body and exhaustion, and often dizzi- weight or more over a period of ness, syncope, muscle cramps several days should be evaluated and nausea. Heat exhaustion is a medically and their activity restrict- form of shock due to depletion of ed until rehydration has occurred. body fluids. First aid should include rest in a cool, shaded envi- 7. Some student-athletes may be ronment. Fluids should be given more susceptible to heat illness. orally. A physician should deter- Susceptible individuals include mine the need for electrolytes and those with: inadequate acclimati- additional medical care. Although zation or aerobic fitness, excess rapid recovery is not unusual, stu- body fat, a history of heat illness, a dent-athletes suffering from heat febrile condition, inadequate rehy- exhaustion should not be allowed dration, and those who regularly to practice or compete for the push themselves to capacity. Also, remainder of that day. 31 substances with a diuretic effect or Prevention of Heat Illness

Heatstroke—Heatstroke is a medical emergency. Medical care must RISK FACTORS be obtained at once; a delay in Air temperature, humidity and dehydration are common risk factors treatment can be fatal. This condi- associated with heat illness. In addition, the following factors also put tion is characterized by a very high student-athletes at increased risk: body temperature and usually (but not always) hot, dry skin, which 1. Nutritional supplements. Nutritional supplements may contain indicates failure of the primary stimulants, such as ephedrine, ma huang or caffeine.* These sub- temperature-regulating mecha- stances can dehydrate the body and/or increase metabolism and heat nism (sweating), and possibly production. They are of particular concern in people with underlying seizure or coma. First aid includes medical conditions such as hypertension, asthma and thyroid dys- immediate cooling of the body function. without causing the student-ath- 2. Medication/drugs. Certain medications and drugs have similar lete to shiver. Recommended effects. These substances may be ingested through over-the-counter methods for cooling include using or prescription medications or with food. Examples include antihista- ice, immersion in cold water, or mines, decongestants, certain asthma medications, Ritalin, diuretics wetting the body and fanning vig- and alcohol. orously. Victims of heatstroke 3. Medical conditions. Examples include illness with fever, gastro- should be hospitalized and moni- intestinal illness, previous heat illness, obesity or sickle cell trait. tored carefully. 4. Acclimatization/fitness level. Lack of acclimatization to the heat or poor conditioning. 5. Clothing. Dark clothing absorbs heat. Protective equipment limits heat dissipation.

*NOTE: Stimulant drugs such as amphetamines, ecstasy, ephedrine and caffeine are on the NCAA banned substance list and may be known by other names. A complete list of banned drug classes can be found on the NCAA Web site at NCAA.org/health-safety.

References 1. American College of Sports Medicine 4. Haynes EM, Wells CL: Heat stress and 6. Kulka TJ and Kenney WL: Heat balance Position Stand: The Prevention of Thermal performance. In: Environment and Human limits in football uniforms. The Physician Injuries During Distance Running, 1985. Performance. Champaign, IL: Human and Sportsmedicine. 30(7): 29-39, 2002. (P.O. Box 1440, Indianapolis, IN 46206- Kinetics Publishers, pp. 13-41, 1986. 1440) 5. Hubbard RW and Armstrong LE: The 2. Armstrong LE, Maresh CM: The induc- heat illness: Biochemical, ultrastructural tion and decay of heat acclimatization in and fluid-electrolyte considerations. In trained athletes. Sports Medicine Pandolf KB, Sawka MN and Gonzalez RR 12(5):302-312, 1991. (eds): Human Performance Physiology and 3. Armstrong, LE Performing in Extreme Environmental Medicine at Terrestial Environments. Champaign, IL: Human Extremes. Indianapolis, IN: Benchmark 32 Kinetics Publishers, pp 64, 2000. Press, Inc., 1988. GUIDELINE 2d Weight Loss–Dehydration July 1985 • Revised June 2002

There are two general types of are insufficient for body fluid and Dehydration is a potential health weight loss common to student- electrolyte homeostasis to be hazard that acts with poor nutrition athletes who participate in intercol- restored before competition. For and intense exercise to compro- legiate sports: loss of body water example, in wrestling this is espe- mise health and athletic perfor- or loss of body weight (fat and lean cially true between the official mance. The sensible alternative to tissue). Dehydration, the loss of weigh-in and actual competition. dehydration weight loss involves: body water, leads to a state of neg- All respected sports medicine preseason determination of an ative water balance called dehydra- authorities and organizations have acceptable (minimum) competitive tion. It is brought about by with- condemned the practice of fluid weight, gradual weight loss to holding fluids and carbohydrates, deprivation. To promote sound achieve the desired weight, and the promotion of extensive sweat- practices, student-athletes and maintenance of the weight over the ing and the use of emetics, diuret- coaches should be educated about course of the competitive season. ics or laxatives. The problem is the physiological and pathological Standard body composition proce- most evident in those who must be consequences of dehydration. The dures should be utilized to deter- certified to participate in a given use of laxatives, emetics and mine the appropriate competitive weight class, but it also is present diuretics should be prohibited. weight. Spot checks (body compo- in other athletics groups. Similarly, the use of excessive food sition or dehydration) should be There is no valid reason for sub- and fluid restriction, self-induced used to assure compliance with the jecting the student-athlete’s body vomiting, vapor-impermeable suits weight standard during the season. to intentional dehydration, which (e.g., rubber or rubberized nylon), Student-athletes and coaches can lead to a variety of adverse hot rooms, hot boxes and steam should be informed of the health physiological effects, including sig- rooms should be prohibited. consequences of dehydration, edu- nificant pathology and even death. Excessive food restriction or self- cated in proper weight-loss proce- Dehydration in excess of 3 to 5 induced vomiting may be symp- dures, and subject to disciplinary percent leads to reduced strength toms of serious eating disorders action when approved rules are and muscular endurance, reduced (see Guideline 2f). violated. plasma and blood volume, com- References promised cardiac output (elevated heart rate, smaller stroke volume), 1. American College of Sports Medicine, Box 9005, Chicago, IL 60604-9005). impaired thermoregulation, de- Position Stand: Weight Loss in Wrestlers, 4. Hyphothermia and Dehydration-Related creased kidney blood flow and fil- 1995. (P.O. Box 1440, Indianapolis, IN Deaths Associated with Intentional Rapid tration, reduced liver glycogen 46206-1440). Weight Loss in Three Collegiate Wrestlers. stores, and loss of electrolytes. 2. Armstrong, LE. Performing in Extreme Morbidity and Mortality Weekly 47(6):105- Pathological responses include 108, 1998. life-threatening heat illness, rhab- Environments. Champaign, IL: Human domyolysis (severe muscle break- Kinetics Publishers, pp 15-70, 2000. 5. Sawka, MN (chair): Symposium— down), kidney failure and cardiac 3. Horswill CA: Does Rapid Weight Loss Current concepts concerning thirst, dehy- arrest. by Dehydration Adversely Affect High- dration, and fluid replacement. Medicine With extensive dehydration, at- Power Performance? 3(30), 1991. and Science in Sports and Exercise 33 tempts at acute rehydration usually (Gatorade Sports Science Institute, P.O. 24(6):643-687, 1992. GUIDELINE 2e Assessment of Body Composition June 1991 • Revised June 2002

The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Dr. Dan Benardot, Georgia State University, who authored a revision of this guideline.

Athletic performance is, to a great degree, dependent on the ability of the student-athlete to overcome resistance and to sustain aerobic and/or anaerobic power. Both of these elements of performance have important training and nutritional components and are, to a large degree, influenced by the student- receivers, and this difference is man- fat percentage and lower muscle athlete’s body composition. Coupled ifested in physiques that are also dif- mass inevitably results in a perfor- with the common perception of ferent. mance reduction that motivates the many student-athletes who compete student-athlete to follow regimens in sports where appearance is a con- Besides the aesthetic and perfor- that produce even greater energy cern (swimming, diving, gymnas- mance reasons for wanting to deficits. This downward energy tics, skating, etc.), attainment of an achieve an optimal body composi- intake spiral may be the precursor to ‘ideal’ body composition often tion, there may also be safety rea- eating disorders that place the stu- becomes a central theme of training. sons. A student-athlete who is car- dent-athlete at serious health risk. rying excess weight may be more Therefore, while achieving an opti- Successful student-athletes achieve prone to injury when performing dif- mal body composition is useful for a body composition that is within a ficult skills than the student-athlete high-level athletic performance, the range associated with performance with a more optimal body composi- processes student-athletes often achievement in their specific sport. tion. However, the means student- use to attain an optimal body com- Each sport has different norms for athletes often use in an attempt to position may reduce athletic perfor- the muscle and fat levels associated achieve an optimal body composi- mance, may place them at a higher with a given height, and the student- tion may be counterproductive. injury risk and may increase health athlete’s natural genetic predisposi- Diets and excessive training often risks. tion for a certain body composition result in such a severe energy deficit Purpose of Body Composition may encourage them to participate that, while total weight may be Assessment in a particular sport or take a specif- reduced, the constituents of weight ic position within a sport. For also change, commonly with a lower The purpose of body composition instance, linemen on football teams muscle mass and a relatively higher assessment is to determine the stu- 34 have different responsibilities than fat mass. The resulting higher body dent-athlete’s distribution of lean Assessment of Body Composition

(muscle) mass and fat mass. A high dent-athlete on a team (using the and infrared interactance. The most lean mass to fat mass ratio is often same method of assessment), and common of the methods now used synonymous with a high strength to obtaining an average and standard to assess body composition in stu- weight ratio, which is typically asso- deviation for body fat percent for the dent-athletes are skinfold measure- ciated with athletic success. team. Student-athletes who are ments, DEXA, hydrostatic weighing However, there is no single ideal within 1 standard deviation (i.e., a Z- and BIA. While hydrostatic weigh- body composition for all student- score of ± 1) of the team mean ing and DEXA are considered by athletes in all sports. Each sport has should be considered within the many to be the “gold standards” of a range of lean mass and fat mass range for the sport. Those greater the indirect measurement tech- associated with it, and each student- than or less than ± 1 standard devi- niques, there are still questions athlete in a sport has an individual ation should be evaluated to deter- regarding the validity of these tech- range that is ideal for them. mine the appropriateness of their niques when applied to humans. Student-athletes who try to achieve training schedule and nutrient Since skinfold-based prediction an arbitrary body composition that is intake. In addition, it is important equations typically use hydrostatic not right for them are likely to place for coaches and student-athletes to weighing or DEXA as the criterion themselves at health risk and will not use functional performance mea- methods, results from skinfolds achieve the performance benefits sures in determining the appropri- typically carry the prediction errors they seek. Therefore, a key to body ateness of a student-athlete’s body of the criterion methods plus the composition assessment is the composition. Student-athletes out- added measurement errors associ- establishment of an acceptable side the normal range of body fat ated with obtaining skinfold values. range of lean and fat mass for the percent for the sport may have BIA has become popular because of individual student-athlete, and the achieved an optimal body composi- its non-invasiveness and speed of monitoring of lean and fat mass over tion for their genetic makeup, and measurement, but results from this regular time intervals to assure a may have objective performance technique are influenced by hydra- stability or growth of the lean mass measures (i.e., such as jump tion state. Since student-athletes and a proportional maintenance or height) that are well within the range have hydration states that are in reduction of the fat mass. of others on the team. constant flux, BIA results may be Importantly, there should be just as misleading unless strict hydration much attention given to changes in Body composition can be measured protocols are followed. In general, lean mass (both in weight of lean indirectly by several methods, all of the commonly used tech- mass and proportion of lean mass) including hydrostatic weighing, niques should be viewed as provid- as the attention traditionally given to skinfold and girth measurements ing only estimates of body compo- body fat percent. (applied to a nomogram or predic- sition, and since these techniques tion equation), bioelectrical imped- use different theoretical assump- In the absence of published stan- ance analysis (BIA), dual-energy x- tions in their prediction of body dards for a sport, one strategy for ray absorptiometry (DEXA), ultra- composition, values obtained from determining if a student-athlete is sound, computerized tomography, one technique should not be com- within the body composition stan- magnetic-resonance imagery, iso- pared with values obtained from dards for the sport is to obtain a tope dilution, neutron-activation another technique. body fat percent value for each stu- analysis, potassium-40 counting, 35 Assessment of Body Composition

Concerns with Body Composition and explain to each student-athlete lengthen the time the student-ath- Assessment that differences in height, age and lete can return to training after an gender are likely to result in differ- injury, reduce performance and 1. Using Weight as a Marker of Body ences in body composition, without increase the risk of an eating disor- Composition—While the collection of necessarily any differences in per- der. Body composition values weight data is a necessary adjunct formance. Strategies for achieving should be thought of as numbers to body composition assessment, this include: on a continuum that are usual for a by itself weight may be a misleading • Obtaining body composition sport. If a student-athlete falls any- value. For instance, young student- values with only one where on that continuum, it is likely athletes have the expectation of student-athlete at a time, to that factors other than body compo- growth and increasing weight, so limit the chance that the data sition (training, skills acquisition, gradual increases in weight should will be shared. etc.) will be the major predictors of not be interpreted as a body com- • Giving student-athletes infor- performance success. position problem. A student-athlete mation on body composition who has increased resistance train- using phrases such as “within 4. Frequency of Body Composition ing to improve strength may also the desirable range” rather Assessment—Student-athletes who have a higher weight, but since this than a raw value, such as say- have frequent weight and/or skin- increased weight is likely to result ing “your body fat level is 18 folds taken are fearful of the out- from more muscle, this should be percent.” come, since the results are often viewed as a positive change. The • Providing athletes with infor- (inappropriately) used punitively. important consideration for weight mation on how they have Real changes in body composition is that it can be (and often is) mis- changed between assess- occur slowly, so there is little need to used as a measure of body compo- ments, rather than offering assess student-athletes weekly, sition, and this misuse can detract the current value. biweekly or even monthly. If body from the purpose of body composi- • Increasing the focus on mus- composition measurements are suf- tion assessment. cle mass, and decreasing the ficient and agreed upon by all par- focus on body fat. ties, measurement frequency of 2. Comparing Body Composition Values • Using body composition val- twice a year should be sufficient. In with Others Athletes—Student- ues as a means of helping to some isolated circumstances in athletes often compare body com- explain changes in objectively which a student-athlete has been position values with other student- measured performance out- injured or is suffering from a disease athletes, but this comparison is not comes. state, it is reasonable for a physician meaningful and it may drive a stu- 3. Seeking an Arbitrarily Low Level of Body to recommend a more frequent dent-athlete to change body com- Fat—Most student-athletes would assessment rate to control for position in a way that negatively like their body fat level to be as low changes in lean mass. Student-ath- impacts both performance and as possible. However, student-athletes and/or coaches who desire health. Health professionals letes often try to seek a body fat more frequent body composition or involved in obtaining body compo- level that is arbitrarily low and this weight measurement should shift sition data should be sensitive to the can increase the frequency of ill- their focus to assessments of objec- 36 confidentiality of this information, ness, increase the risk of injury, tive performance-related measurers. Assessment of Body Composition

Summary with the same prediction equations inappropriate measurement and to derive valid comparative data use of body composition data might The assessment of body composi- over time. Institutions should have contribute to the student-athlete tion can be a useful tool in helping a protocol in place outlining the experiencing unhealthy emotional the student-athlete and coach rationale for body composition stress. This stress can lead to the understand the changes that are measurements, who is allowed to development or enhancement of occurring as a result of training and measure the student-athlete, who is eating disorders in the student-ath- nutritional factors. However, the permitted to discuss the results with lete (see Guideline 2f). All coaches body composition measurement the student-athlete and what fre- (sport or strength/conditioning) process and the values obtained can quency of body composition mea- should be aware of the sizable influ- be a sensitive issue for the student- ence they may have on the behav- surement is appropriate. The stu- athlete. A legitimate purpose for iors and actions of their student- dent-athlete should not feel forced body composition assessment athletes. Many student-athletes are should dictate the use of these mea- or obligated to undergo body com- sensitive about body fat, so care surement techniques. Health pro- position or weight measurement. should be taken to apply body com- fessionals involved in obtaining Everyone involved directly or indi- position measurement, when body composition data should rectly with body composition mea- appropriate, in a way that enhances focus on using the same technique surement should understand that the student-athlete’s well-being.

37 Assessment of Body Composition

References 1. Benardot D: Working with young ath- 6. Heymsfield SB and Want Z. 11. Lukaski HC. Methods for the assess- letes: Views of a nutritionist on the sports Measurement of total-body fat by under- ment of human body composition—tra- medicine team. Int. J. Sport Nutr. water weighing: new insights and uses ditional and new. Am. J. Clin. Nutr. 6(2):110-120, 1996. for old method. Nutrition 9:472-473, 46:537-56, 1987. 1993. 2. Boileau RA and Lohman TG. The mea- 12. Malina RM and Bouchard C. surement of human physique and its 7. Houtkooper LB and Going SB. Body Characteristics of young athletes. In: effect on physical performance. composition: How should it be mea- Growth, Maturation and Physical Activity. Orthopedic Clin. N. Am. 8:563-581,1977. sured? Does it affect sport performance? Champaign, IL: Human Kinetics Books, Sports Science Exchange SSE#52(7):1- pp. 443-463, 1991. 3. Clarkson PM. Nutritional supplements 15, 1994. for weight gain. Sports Science 13. Manore M, Benardot D, and Love P. Exchange SSE#68(11): 1-18, 1998. 8. Houtkooper LB, Going SB, Lohman TG, Body measurements. In: Benardot D (Ed). Roche AF, and Van Loan M. Bioelectrical Sports Nutrition: A Guide for 4. Clasey JL, Kanaley JA, Wideman L, impedance estimation of fat-free body Professionals Working with Active People Heymsfield SB, Teates CD, Gutgesell ME, mass in children and youth: a cross-vali- Chicago, IL: American Dietetic Thorner MO, Hartman ML, and Weltman dation study. J. Appl. Physiol. 72:366- Association, pp 70-93, 1993. A. Validity of methods of body composi- 373, 1992. tion assessment in young and older men 14. Melby CL and Hill JO. Exercise, and women. J. Appl. Physiol. 9. Jackson AS and Pollock ML. macronutrient balance, and body weight 86(5):1728-38, 1999. Generalized equations for predicting regulation. Sports Science Exchange body density in men. Br. J. Nutr. 40:497- SSE#72(12): 1-16, 1999. 5. Fleck SJ. Body composition of elite 504, 1978. American athletes. Am. J. Sports Med. 15. Thomas BJ, Cornish BH, Ward LC, 11:398-403, 1983. 10. Jackson AS, Pollock ML, and Ward A. and Jacobs A. Bioimpedance: is it a pre- Generalized equations for predicting dictor of true water volume? Ann. N.Y. body density of women. Med. Sci. Sports Acad. Sci. 873:89-93, 1999. Exerc. 12:175-182, 1980.

38 GUIDELINE 2f Nutrition and Athletic Performance January 1986 • Revised June 2002

Athletic performance and recovery ments are slightly higher in both their iron status should be evaluat- from training are enhanced by endurance (0.5 to 0.7 g per lb. ed. However, megadoses of spe- optimal nutrition. Proper nutrition body weight per day) and cific vitamins or minerals (10 to includes adequate quality and strength-trained student-athletes 100 times the dose of daily quantity of food and fluid to pro- (0.8 to 0.9 g per lb. body weight requirements) are not recom- vide energy and essential nutrients per day) above the typical recommended. during training and competition. mended daily intake (0.4 g per lb. During periods of heavy training, During the competitive season, of body weight). Fortunately, this adequate calories and fluid must energy and macronutrient needs recommendation for protein is be consumed. Strength-training (especially carbohydrate and pro- easily achieved in a well-balanced student-athletes need at least 20 to tein intake) must be met in order diet without additional supple- 23 calories per pound of body to maintain body weight, replenish ments. Fat intake should be less weight each day and endurance carbohydrate stores in muscle than 30 percent of total daily calo- student-athletes have even higher (glycogen), and provide adequate ries in student-athletes and is an energy requirements. Low energy protein for building and repair of important source of essential fatty intake can result in loss of muscle tissue. The following key points acids, fat-soluble vitamins and mass, risk of fatigue, injury and ill- summarize current energy, nutri- energy. ness. A low caloric intake (fewer ent and fluid recommendations for In general, vitamin and mineral than 1,800 to 2,000 calories) in competitive student-athletes as supplements are not required if a female student-athletes can lead recommended by the American student-athlete is consuming ade- to disruption of reproductive function. College of Sports Medicine. These quate energy from a variety of general guidelines should be foods to maintain body weight. The maintenance or attainment of specifically adjusted for each indi- However, the risk of micronutrient an ideal body weight is sport-spe- vidual student-athlete by a sports deficiencies are greatest in cific and represents an important nutrition expert. student-athletes restricting calo- part of a nutritional program. Carbohydrates are important fuels ries, engaging in rapid weight-loss However, student-athletes in cer- for all student-athletes in order to practices or eliminating specific replace muscle glycogen, prevent foods or food groups from their the loss of muscle mass and pre- diet. A multivitamin providing 100 vent low blood sugar or hypo- percent of the daily recommended glycemia. The recommendations intake is appropriate for these stu- for adequate carbohydrate are dent-athletes. Female student- between 4 to 5 grams (g) per athletes are especially prone to pound of body weight per day. It deficiencies in calcium and iron is assumed that the predominant due to the menstrual cycle, avoid- source of carbohydrates come ance of animal products and/or from nonrefined carbohydrates energy restriction. The diets of (whole grains, breads, pasta, fruits long-distance runners and vege- and vegetables). Protein require- tarians (especially females) and NCAA.org/nutritionandperformance 39 Nutrition and Athletic Performance

defined eating disorders. warning signs does not necessari- NCAA studies have shown that at ly indicate the presence of an eat- least 40 percent of member insti- ing disorder, but may indicate a subclinical form of disordered eat- tutions reported at least one case ing. Absolute diagnosis should be of anorexia nervosa or bulimia done by appropriate professionals. nervosa in their athletics programs. Anorexia Nervosa is Menstrual irregularities can be defined as self-imposed starvation associated with eating disorders in an obsessive effort to lose and other conditions. However, all weight and to become thin. student-athletes with menstrual Bulimia Nervosa involves recur- irregularities should be seen by a ring binge-eating, usually followed physician (see Guideline 2k). by some method of purging, such Eating disorders are often an as vomiting, diuretic or laxative expression of underlying emotion- abuse or intensive exercise. The al distress that may develop long number of student-athletes who before the individual was involved Available online at exhibit behaviors associated with in athletics. It has been suggested NCAA.org/health-safety. disordered eating (but do not fit that stress, whether it be from par- the diagnostic criteria of anorexia ticipating in athletics, striving for nervosa and bulimia nervosa) is academic success or pursuing tain sports face a difficult paradox even higher. Although eating dis- social relationships, may trigger in their training/nutrition regimen, orders are much more prevalent in psychological problems, such as particularly those competing in women (approximately 90 percent eating disorders, in susceptible “weight class” sports (e.g., of the reports in the NCAA studies individuals. Eating disorders can wrestling, rowing), sports that were in women’s sports), eating be triggered in such individuals by favor those with lower body disorders also occur in men. a single event or comments from a weight (e.g., distance running, person important to the individual. gymnastics), sports requiring The warning signs of the two most In athletic performance, such trig- student-athletes to wear body serious eating disorders include: gering mechanisms may include contour-revealing clothing (track, Anorexia Nervosa — Drastic loss offhand remarks about appearance diving, swimming, volleyball) and in weight, a preoccupation with sports with subjective judging or constant badgering about a stu- food, calories and weight, wearing dent-athlete’s body weight, body related to “aesthetics” (gymnas- baggy or layered clothing, relent- tics, diving). These student-ath- composition or body type. less, excessive exercise, mood Coaches, athletic trainers and letes are encouraged to eat to pro- swings, and avoiding food-related vide the necessary energy sources supervising physicians must be social activities. for performance, yet they often watchful for student-athletes who face self- or team-imposed weight Bulimia Nervosa — Recurring may be prone to eating disorders, restrictions. Emphasis on low binge eating, usually followed by particularly in sports in which body weight or low body fat may some method of purging, such as appearance or body weight is a fac- benefit performance only if the vomiting, diuretic or laxative abuse tor in performance. guidelines are realistic, the calorie or intensive exercise. Warning Disordered eating can lead to semi- intake is reasonable and the diet is signs — excessive concern about starvation and dehydration, result- nutritionally well-balanced accord- weight, bathroom visits after ing in loss of muscular strength and ing to the Food Pyramid. The use meals, depressive moods, strict endurance, decreased aerobic and of extreme weight-control mea- dieting followed by eating binges, anaerobic power, loss of coordina- sures can jeopardize the health of and increasing criticism of one’s tion, impaired judgment, and other the student-athlete and possibly body. It is important to note that complications that decrease perfor- 40 trigger behaviors associated with the presence of one or two of these mance and impair health. These Nutrition and Athletic Performance symptoms may be readily apparent loss should be based on the fol- appropriate medical and nutritional or may not be evident for an extend- lowing recommendations to personnel, with consultation from ed period of time. Many student- reduce the potential of an eating the coach. disorder: athletes have performed success- 4. A responsible and realistic fully while experiencing an eating 1. Frequent weigh-ins (either as weight loss plan should be devel- disorder. Therefore, diagnosis of a team or individually) are discour- oped on an individual basis. this problem should not be based aged. entirely on a decrease in athletic Along with the NCAA Nutrition and 2. If weight loss (fat loss) is Performance Web page, the performance. desired, it should start early — American College of Sports Body composition and body before the competitive season — Medicine has published position weight can affect exercise perfor- and involve a trained medical or stands on the female athlete triad, mance but should not be used as nutrition professional. nutrition and athletic performance. the main criteria for participation in 3. Weight loss should be agreed These materials are valuable sports. Decisions regarding weight upon by the student-athlete and resources for NCAA institutions.

For each student-athlete, there Health may be a unique optimal body composition for performance, for health and for self-esteem. Optimal However, in most cases, these three values are NOT identical. ≠ Body ≠ Mental and physical health should not be sacrificed for performance. An erratic or lost Composition menstrual cycle, sluggishness or an obsession with achieving a number on a scale may be signs Performance ≠ Self-Esteem that health is being challenged.

References

1. Brownell KD, Rodin J, Wilmore JH: 4. The Female Athlete Triad. American female athlete triad. Clinics in Sports Eating, Body Weight, and Performance in College of Sports Medicine (ACSM) Medicine:19:199-213, 2000. Athletes: Disorders of Modern Society Position Stand, 1997. (www.acsm.org) 7. Sundgot-Borgen J: Risk and trigger Malvern, PA: Lea and Febiger, 1992. 5. Nutrition and Athletic Performance- factors for the development of eating dis- 2. Dale, KS, Landers DM. Weight control American College of Sports Medicine, orders in female elite athletes. Medicine and Science in Sports and Exercise in wrestling: eating disorders or disor- American Dietetic Association, and 26:414-419, 1994. dered eating? Medicine and Science in Dietitians of Canada, Joint Position Stand, 8. Thompson RA, Sherman RT: Helping Sports and Exercise 31:1382-1389, 1999. Medicine and Science in Sports and Exercise. 32: 2130-2145, 2000. Athletes with Eating Disorders 3. Dick RW: Eating disorders in NCAA ath- Champaign, IL: Human Kinetics 6. Sandborn CF, Horea M, Siemers BJ, letics programs. Athletic Training 26:136- Publishers, 1993. Dieringer KI. Disordered eating and the 140, 1991. 41 GUIDELINE 2g Dietary Supplements and Banned Substances January 1990 • Revised June 2004

Nutritional and dietary supple- enhanced ability to train. The car- Protein and amino acid supplements are marketed to student- bohydrate content of the diet ments are popular with body- athletes to improve performance, should be 55 to 65 percent of builders and strength-training recovery time and muscle-build- total energy intake (about 5 to 10 student-athletes. Although pro- ing capability. Many student-ath- gm/kg body weight). The lower tein is needed to repair and build letes use nutritional supplements end of the range should be ingest- muscles after strenuous training, despite the lack of proof of effec- ed during regular training; the most studies have shown that tiveness. In addition, such sub- high end during intense training. student-athletes ingest a suffi- stances are expensive and may High-carbohydrate foods and cient amount without supple- potentially be harmful to health or beverages can provide the neces- ments. The recommended performance. Of greater concern sary amount of carbohydrate for amount of protein in the diet is the lack of regulation and safe- the high caloric demand of most should be 12 to 15 percent of ty in the manufacture of dietary sports to optimize performance. total energy intake (about 1.4 to supplements. Many compounds Low-carbohydrate diets are not 1.6 gm/kg of body weight) for all obtained from specialty “nutri- advantageous for athletes during types of student-athletes. Al- tion” stores and mail-order busi- intense training and may not though selected amino acid sup- nesses may not be subject to the enhance performance. A high- plements are purported to in- strict regulations set by the carbohydrate diet consisting of crease the production of anabolic United States Food and Drug complex carbohydrates, fruits, hormones, studies using manu- Administration. Therefore, the vegetables, low-fat dairy products facturer-recommended amounts contents of many of these com- and whole grains (along with ade- have not found increases in pounds are not represented accu- quate protein) is the optimal diet growth hormone or muscle mass. rately on the list of ingredients for peak performance. Ingesting high amounts of single and may contain impurities or banned substances, which may cause a student-athlete to test positive. Positive drug-test appeals based on the claim that the student-athletes did not know the substances they were taking contained banned drugs have not been successful. Therefore, student-athletes should be instructed to consult with the university’s sports medicine staff before taking ANY nutritional supplement. It is well known that a high-carbohydrate diet is associated with 42 improved performance and Dietary Supplements and Banned Substances amino acids is contraindicated cramps. To obtain necessary vita- plements are ineffective, costly because they can affect the mins and minerals, student-ath- and unnecessary. absorption of other essential letes should eat a wide variety of Student-athletes should be aware amino acids, produce nausea, foods because not all vitamins that nutritional supplements are and/or impair kidney function and and minerals are found in every not limited to pills and powders; hydration status. A supplement food. “energy” drinks that contain stim- that contains greater than 30 per- Other substances naturally occur- ulants are popular. Many of these cent of calories from protein is ring in foods, such as carnitine, contain large amounts of either not a permissible substance for herbal extracts and special caffeine or other stimulants, both distribution according to current enzyme formulations, do not proof which can result in a positive NCAA rules. vide any benefit to performance. drug test. Student-athletes Other commonly advertised sup- The high-protein diet has received should be wary of drinks that plements are vitamins and miner- recent attention, but data show- promise an “energy boost,” als. Most scientific evidence ing that this diet will enhance per- because they may contain banned shows that selected vitamins and formance are weak, plus there is stimulants. In addition, the use of minerals will not enhance perfor- concern that such a diet will neg- stimulants while exercising can mance provided no deficiency atively affect health. Creatine has increase the risk of heat illness. exists. Some vitamins and miner- been found in some laboratory Student-athletes should be pro- als are marketed to student-ath- studies to enhance short-term, vided accurate and sound infor- letes for other benefits. For exam- high-intensity exercise capability, mation on nutritional supple- ple, the antioxidants, vitamin E, C delay fatigue on repeated bouts of ments. It is not worth risking eli- such exercise and increase and beta-carotene are used by gibility for products that have not strength. Several studies have many student-athletes because been scientifically proven to contradicted these claims, and, they believe that these antioxi- improve performance and may moreover, the safety of creatine dants will protect them from the contain banned substances. supplements has not been veri- damaging effects of aerobic exer- Given the above information and fied. Weight gains of one to three cise. Although such exercise can consistent with NCAA Bylaw kilograms per week have been cause muscle damage, studies 16.5.2 (Nutritional Supplements), found in creatine users, but the have found that training will which states, “An institution may cause is unclear. increase the body’s natural provide only nonmuscle-building antioxidant defense system so Many other “high-tech” nutri- nutritional supplements to a stu- that megadoses of antioxidants tional or dietary supplements dent-athlete at any time for the may not be needed. The mineral may seem to be effective at first, purpose of providing additional chromium has been suggested to but this is likely a placebo effect calories and electrolytes, provid- increase muscle mass and — if student-athletes believe ed the supplements do not con- decrease fat, but studies have not these substances will enhance tain any NCAA banned sub- substantiated this claim. performance, they may train stances,” athletics staff should Similarly, magnesium is purport- harder or work more efficiently. not distribute or endorse nutri- ed, but not proven, to prevent Ultimately, most nutritional sup- tional or dietary supplements. 43 Dietary Supplements and Banned Substances

The NCAA subscribes to the Resource Exchange Center (REC), which provides a confidential hotline and Web site to answer questions from student- athletes and athletics personnel on whether nutritional supplements and medications contain banned substances. This service is free of charge to all member institutions. To access the REC, go to www.drugfreesport.com/rec. The password is ncaa1, ncaa2, or ncaa3, depending on your divisional classification.

References 1. Burke L: Practical issues in nutrition oral creatine supplementation. Medicine 7. Williams C: Macronutrients and perfor- for athletes. Journal of Sports Sciences and Science in Sports and Exercise. 32 mance. Journal of Sports Sciences 13:S1- 13:S83-90, 1995. (3): 706-717, 2000. 10, 1995. 2. Clarkson PM, Haymes EM: Trace 5. Lemon PWR: Do athletes need more 8. The National Center for Drug Free Mineral Requirements for Athletes. dietary protein and amino acids? Sport, Inc., 810 Baltimore, Suite 200, International Journal of Sport Nutrition International Journal of Sport Nutrition Kansas City, Missouri. 64105; 816/474- 4:104-19, 1994. 5:S39-61, 1995. 8655. 3. Clarkson PM: Micronutrients and exer- 6. Volek JS, Kraemer WJ: Creatine sup- 9. ACSM JOINT POSITION STATEMENT, cise: Antioxidants and minerals. Journal plementation: Its effect on human muscu- Nutrition and Athletic Performance, 2000. of Sports Sciences 12:S11-24, 1995. lar performance and body composition. Available at www.acsm-msse.org. 4. American College of Sports Medicine. Journal of National Strength and 44 The physiological and health effects of Conditioning Research 10:200-10, 1996. GUIDELINE 2h “Burners” (Brachial Plexus Injuries) June 1994 • Revised June 2003

“Burners” or “stingers” are so side. Contact to the side of the epineurium, perineurium, and named because the injuries can neck may cause a direct contu- endoneurium, which can serve as cause a sudden pain and numb- sion to the brachial plexus. In the conduit for the regenerating ness along the forearm and hand. football, improper blocking and axon as it re-grows at 1 to 7 mil- The more formal medical termi- tackling techniques may result in limeters per day. Weakness can nology is transient brachial plex- a brachial plexus injury. Coaches, last for weeks but full recovery opathy or an injury to the brachial parents and student-athletes typically occurs. Grade 3 in- plexus. A brachial plexus injury should be cautioned regarding juries, neurotmesis or complete may also involve injury to a cervi- the consequences of improper nerve transections are rare in ath- cal root. An injury to the spinal techniques which may result in letes. Surgical repair of the nerve cord itself is more serious and cervical spine injuries or trauma is required in these cases and frequently does not fall under this to the brachial plexus. complete recovery may not category of injury, although it occur. shares certain symptoms; there- Symptoms and Severity These classifications have more fore, spinal cord injuries should Student-athletes who suffer meaning with regard to anticipat- be ruled out when diagnosing burners may be unable to move ed recovery of function than a stingers. the affected arm from their side grading on the severity of symp- and will complain of burning The majority of stingers occur in toms at the time of initial injury. pain, and potentially, numbness football. Such injuries have been traveling from the injured side of reported in 52 percent of college Treatment and Return to the neck through the shoulder football players during a single Play down the arm and forehand, and season. As many as 70 percent sometimes into the hand. Burners and stingers typically of college football players have Weakness may be present in the result in symptoms that are sen- experienced stingers. Stingers muscles of the shoulder, elbow sory in nature, frequently involv- also can occur in a variety of and hand. ing the C5 and C6 dermatomes. other sports, including basket- All athletes sustaining burners ball, ice hockey, wrestling and Brachial plexus injuries can be should be removed from compe- some field events in track. classified into three categories. tition and examined thoroughly The mildest form (Grade 1) are for injury to the cervical spine Mechanism neuropraxic injuries that involve and shoulder. All cervical roots The most common mechanism demyelination of the axon sheath should be assessed for motor for stingers is head movement in without intrinsic axonal disrup- and sensory function. If symp- an opposite direction from the tion. Compete recovery typically toms clear within seconds to sev- shoulder either from a hit to the occurs in a few seconds to days. eral minutes and are not associ- head or downward traction of the Grade 1 injuries are the most ated with any neck pain, limita- shoulder. This can stretch the common in athletics. Grade 2 tion of neck movement or signs nerve roots on the side receiving injuries involve axonotmesis or of shoulder subluxation or dislo- the blow (traction), or compress disruption of the axon and myelin cation, the athlete can safely or pinch those on the opposite sheath with preservation of the return to competition. It is 45 “Burners” (Brachial Plexus Injuries)

important to re-examine the ath- Bilateral symptoms indicate that should report every occurrence lete after the game and for a few the cord itself has been trauma- to their certified athletic trainers successive days to detect any tized and may suggested tran- or team physician. Any player reoccurrence of weakness or sient quadriplegia. These athletes with persistent pain, burning, alteration in sensory exam. should also be immobilized and numbness and/or weakness transported to a medical facility (lasting longer than two minutes) If sensory complaints or weak- for a more thorough evaluation. should be held out of competition ness persists for more than a few and referred to a physician for minutes, a full medical evaluation All athletes sustaining burners or further evaluation. with radiographs and considera- stingers should undergo a physi- tion for a MRI should be done to cal rehabilitation program that rule out cervical disk or other includes neck and trunk strength- compressive pathology. If symp- ening exercises. The fit of shoul- toms persist for more than 2 to 3 der pads should be re-checked weeks, an EMG may be helpful in and consideration of other athlet- assessing the extent of injury. ic protective equipment, such as However, an EMG should not be neck rolls and/or collars, should used for return-to-play criteria, be given. The athlete’s tackling as EMG changes may persist for techniques should be reviewed. several years after the symptoms Stinger assessment should be have resolved. Shoulder injuries part of the student-athletes’ pre- (acromioclavicular separation, season physical and mental his- shoulder subluxation or disloca- tory (see handbook Guideline No. tion, and clavicular fractures) 1b) so that these “at-risk” ath- should be considered in the dif- letes can be instructed in a pre- ferential diagnosis of the athlete vention preventative exercise with transient or prolonged neu- program and be provided with rologic symptoms of the upper proper protective equipment. extremity. Any injured athlete who presents with specific cervi- Recurrent Burners cal-point tenderness, neck stiff- Recurrent burners may be com- ness, bony deformity, fear of mon; 87 percent of athletes in moving his/her head and/or com- one study had experienced more plains of a heavy head should be than one. Medical personnel immobilized on a spine board (as should pay special attention to one would for a cervical spine this condition. Although rare, fracture) and transported to a risk of permanent nerve injury medical facility for a more thor- exists for those with recurrent ough evaluation. burners. Therefore, participants 46 “Burners” (Brachial Plexus Injuries)

A Word of Caution the literature shows this risk to medical personnel so that a Management of the student-ath- be small for those with recurrent thorough physical examination, lete with recurrent burners can be episodes. The most important with particular attention to difficult. There are no clear guide- concern for student-athletes with strength and sensory changes, lines concerning return to play. recurrent burners is to stress can be obtained. Any worsening Although some risk of permanent the importance of reporting all of symptoms should provoke a nerve injury exists, a review of symptoms to the attending more thorough evaluation.

References 1. Meyer S, Schulte K, et al: Cervical 5. Cantu R: Stingers, Transient Non-catastrophic Athletic Cervical Spine Spinal Stenosis and Stingers in Collegiate Quadriplegia, and Cervical Spinal Injury. Clinic and Sports Medicine Football Players. American Journal of Stenosis: Return-to-Play Criteria. 17(1), 1998. Sports Medicine 22(2):158-166, 1994. Medicine and Science of Sports and 9. Shannon B, Klimkiewicz J, Cervical 2. Torg J, et al: Cervical Cord Exercise 7(Suppl):S233-235, 1997. Burners in the Athlete. Clinic and Sports Neuropraxia: Classification Pathomech- 6. Levitz C, et al: The Pathomechanics of Medicine 21(1):29-35 January 2002. anics, Morbidity and Management Chronic Recurrent Cervical Nerve Root Guidelines. Journal of Neurosurgery Neuropraxia, the Chronic Burner 10. Koffler K, Kelly J, Neuro- 87:843-850, 1997. Syndrome. American Journal of Sports vascular Trauma in Athletes. Orthop Clin 3. Feinberg J, et al: Peripheral Nerve Medicine 25(1), 1997. N Am 33: 523-534(2002). Injuries in the Athlete. Sports Medicine 7. Castro F, et al: Stingers, the Torg Ratio, 11. Feinberg J, Burners and Stingers, 12(6):385-408, 1997. and the Cervical Spine. American Journal Phys Med Rehab N Am 11(4): 771-783 4. Meyer S, et al: Cervical Spinal Stenosis of Sports Medicine 25(5), 1997. Nov 2000. and Stingers in Collegiate Football 8. Weinstein S: Assessment and Players. American Journal of Sports Rehabilitation of the Athlete With a Medicine 22(2), 1994. Stinger. A Model For the Management of 47 GUIDELINE 2i Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete June 1994 • Revised July 2004

More than 300,000 concussions sports traditionally considered of the injuries for these sports as occur every year, and participa- “noncontact.” reported by the NCAA Injury tion in sport is a common cause Surveillance System (ISS). of these injuries. These injuries The incidence in helmeted versus are often difficult to detect, with nonhelmeted sports is also simi- Assessment and management of athletes often underreporting lar. In the years 2000 to 2002, concussive injuries, and return- their injury, minimizing their the rate of concussion during to-play decisions remain some importance or not recognizing games per 1,000 athlete expo- of the most difficult responsibili- that an injury has occurred. At sures for football was 3.1, for ties facing the sports medicine the college level, these injuries men’s ice hockey 2.4, for men’s team. There are potentially seri- are more common in certain wrestling 1.6, for men’s lacrosse ous complications of multiple or sports, such as football, ice 1.4, for women’s ice hockey 2.4, severe concussions, including hockey, men’s and women’s soc- for women’s soccer 2.1, for second impact syndrome, post- cer, and men’s lacrosse. men’s soccer 1.7, for field hockey concussive syndrome, or post- However, they also account for a 0.8, for women’s lacrosse 0.8, for traumatic encephalopathy. significant percentage of injuries women’s basketball 0.7, and for Though there is some controver- in men’s and women’s basketball, men’s basketball 0.5, accounting sy as to the existence of second women’s lacrosse, and other for between 6.4 and 18.3 percent impact syndrome, in which a second impact with potentially catastrophic consequences occurs before the full recovery after a first insult, the risks include severe cognitive com- promise and death. Other associated injuries which can occur in the setting of concussion include seizures, cervical spine injuries, skull fractures and/or intracranial bleed. Due to the serious nature of mild traumatic brain injury, and these serious potential complications, it is imperative that the health care professionals taking care of athletes are able to recognize, evaluate and treat these injuries in a complete and progressive fashion. Concussion or mild traumatic 48 brain injury (mTBI) has been Concussion or Mild Traumatic Brain Injury defined as “a complex patho- associated injuries of skull frac- form of questions regarding the physiological process affecting ture, intracranial bleeding and particular practice or competi- the brain, induced by traumatic seizures, when there is concern tion, previous game results, and biomechanical forces.” Although for structural abnormalities or remote and recent memory, and concussion most commonly when the symptoms of an athlete questions to test the athlete’s occurs after a direct blow to the persist or deteriorate. recall of words, months of the head, it can occur after a blow Concussion is associated with year backwards and calculations. elsewhere that is transmitted to Special note should be made the head. Concussions can be clinical scenarios that often clear spontaneously, and may or may regarding the presence and dura- defined by the clinical features, tion of retrograde or anterograde pathophysiological changes and / not be associated with loss of consciousness (LOC). amnesia, and the presence and or biomechanical forces that duration of confusion. A timeline occur, and these have been The sideline evaluation of the of injury and the presence of described in the literature. The brain-injured athlete should symptoms should be noted. neurochemical and neurometa- include an assessment of airway, These sideline tests should be bolic changes that occur in con- breathing, and circulation performed and repeated as nec- cussive injury have been eluci- (ABC’s), followed by an assess- essary, but do not take the place dated, and exciting research is ment of the cervical spine and of other comprehensive neu- underway describing the genetic skull for associated injury. The ropsychological tests. factors that may play a role in sideline evaluation should also determining which individuals include a neurological and mental Once an injury occurs and an ini- are at an increased risk for sus- status examination and some tial assessment has been made, it taining brain injury. form of brief neurocognitive test- is important to determine an initial plan of action, which includes Most commonly, concussion is ing to assess memory function characterized by the rapid onset and attention. This can be in the deciding on whether additional of cognitive impairment that is self limited and spontaneously Table 1 resolves. The acute symptoms of SIGNS AND SYMPTOMS OF mTBI concussion, listed below, are felt Loss of consciousness (LOC) Visual Disturbances to reflect a functional disturbance Confusion (Photophobia, blurry Phono/ in cognitive function instead of Post-traumatic amnesia (PTA) photophobia vision, structural abnormalities, which is Retrograde amnesia (RGA) double vision) why diagnostic tests such as Disorientation Disequilibrium magnetic resonance imaging Delayed verbal and motor Feeling “in a fog,” “zoned out” (MRI) and computerized tomog- responses Vacant stare raphy (CT) scans are most often Inability to focus Emotional lability normal. These studies may have Headache Dizziness their role in assessing and evalu- Nausea/Vomiting Slurred/incoherent speech ating the head-injured athlete Excessive drowsiness 49 whenever there is concern for the Concussion or Mild Traumatic Brain Injury referral to a physician and/or Cantu). However, there may be by examining brain-behavior emergency department should limitations because they presume relationships. These tests are take place, and determining the that LOC is associated with more designed to measure a broad follow-up care. The medical staff severe injuries. It has been range of cognitive function, should also determine whether demonstrated that LOC does not including speed of information additional observation or hospital correlate with severity of injury in processing, memory recall, admission should be considered. patients presenting to an emer- attention and concentration, gency department with closed reaction time, scanning and visu- Follow-up care and instructions head injury, and has also been al tracking ability, and problem should be given to the athlete, and demonstrated in athletes with solving ability. Several comput- ensuring that they are not left concussion (Lovell ‘99). It has erized versions of these tests alone for an initial period of time been further demonstrated that have also been designed to should be considered. Athletes retrograde amnesia (RGA), post- improve the availability of these should avoid alcohol or other sub- traumatic amnesia (PTA), and the tests, and make them easier to stances that will impair their cog- duration of confusion and mental distribute and utilize. Ideally, nitive function, and also avoid status changes longer than five these tests are performed before aspirin and other medications that minutes may be more sensitive the season as a “baseline” with can increase their risk of bleeding. indicators of injury severity which post-injury tests can be (Collins ‘03). More recent grad- compared. Despite the utility of As mentioned previously, con- ing systems have been published neuropsychological test batteries ventional imaging studies such which attempt to take into in the assessment and treatment as MRI and CT scans are usually account the expanding research of concussion in athletes, several normal in mTBI. However, these in the field of mTBI in athletes. questions remain unanswered. studies are considered an adjunct Though it is useful to become Further research is needed to when any structural lesion, such familiar with these guidelines, it understand the complete role of as an intracranial bleed or frac- is important to remember that neuropsychological testing. ture, is suspected. If an athlete many of these injuries are best Given these limitations, it is experiences prolonged loss of treated in an individual fashion consciousness, confusion, essential that the medical care (Cantu ‘01, Vienna Conference, team treating athletes continue to seizure activity, focal neurologic NATA ‘04). deficits or persistent clinical or rely on its clinical skills in evalu- cognitive symptoms, then addi- Several recent publications have ating the head-injured athlete to tional testing may be indicated. endorsed the use of neurocogni- the best of its ability. It is essen- tive or neuropsychological test- tial that no athlete be allowed to There are several grading sys- ing as the cornerstone of concus- return to participation when any tems and return-to-play guide- sion evaluation. These tests pro- symptoms, including mild lines in the literature regarding vide a reliable assessment and headache, persist. It has also concussion in sport (AAN, Torg, quantification of brain function been recommended that for any injury that involves significant symptoms, long duration of Table 2 symptoms or difficulties with SYMPTOMS OF POST-CONCUSSION SYNDROME memory function (either retro- Loss of intellectual capacity Fatigue grade or antegrade), not be Poor recent memory Irritability allowed to return to play during Personality changes Phono/photophobia the same day of competition. Headaches Sleep disturbances The duration of time that an ath- Dizziness Sleep disturbances lete should be kept out of physi- Lack of concentration Depressed mood cal activity is unclear, and in most 50 Poor attention Anxiety instances, individualized return- Concussion or Mild Traumatic Brain Injury to-play decisions should be made. These decisions will often 1. Heads Up: Concussion Tool Kit depend on the clinical symptoms, CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm. previous history of concussion and severity of previous concussions. Additional factors include 2. Heads Up Video the sport, position, age, support system for the athlete and the NATA. Streaming online at www.nata.org/consumer/headsup.htm. overall “readiness” of the athlete to return to sport. an activity such as biking or run- passing, or other agilities. This Once an athlete is completely ning in which he/she increases allows the athlete to return to the asymptomatic, the return-to-play his/her heartrate and breaks a practice setting, albeit in a limited progression should occur in a sweat. If he/she does not experi- role. Finally, the athlete can be step-wise fashion with gradual ence any symptoms, this can be progressed to practice activities increments in physical exertion followed by a steady increase in with limited contact and finally and risk of contact. After a peri- exertion, followed by return-to- full contact. How quickly one od of remaining asymptomatic, sport-specific activities that do moves through this progression the first step is an “exertional not put the athlete at risk for con- remains controversial. challenge” in which the athlete tact. Examples include dribbling exercises for 15 to 20 minutes in a ball or shooting, stickwork or

References 1. Cantu RC: Concussion severity should concussion. Clin J Sport Med 2003; 11. Johnston K, Aubry M, Cantu R et al: not be determined until all postconcussion 13:222-229. Summary and Agreement Statement of the symptoms have abated. Lancet 3:437-8, 7. Collins MW, Grindel SH, Lovell MR et First International Conference on 2004. al: Relationship Between Concussion and Concussion in Sport, Vienna 2001, Phys & 2. Cantu RC: Recurrent athletic head Neuropsychological Performance in Sportsmed 30(2):57-63, 2002. injury: risks and when to retire. Clin Sports College Football Players. JAMA 282:964- 12. Lovell MR, Iverson GL, Collins MW et Med. 22:593-603, 2003. 970, 1999. al: Does loss of consciousness predict 3. Cantu RC: Post traumatic (retrograde/ neuropsychological decrements after con- 8. Guskiewicz KM, Bruce SL, Cantu R, cussion? Clin J Sport Med 9:193-198, anterograde)) amnesia: pathophysiology Ferrara MS, Kelly JP, McCrea M, Putukian and implications in grading and safe return 1999. to play. Journal of Athletic Training. 36(3): M, McLeod-Valovich TC; National Athletic 13. Makdissi M, Collie A, Maruff P et al: 244-8, 2001. Trainers’ Association Position Statement: Computerized cognitive assessment of Management of Sport-related Concussion: 4. Centers for Disease Control and concussed Australian Rules footballers. Journal of Athletic Training. 39(3): 280- Br. J Sports Med 35(5):354-360, 2001. Prevention. Sports-related recurrent brain 297, 2004. injuries: United States. MMWR Morb 14. McCrea M: Standardized mental status Mortal Wkly Rep 1997; 46:224-227. 9. Guskiewicz KM: Postural stability assessment of sports concussion. Clin J 5. Collie A, Darby D, Maruff P: assessment following concussion: One Sport med 11(3):176-181, 2001. Computerized cognitive assessment of piece of the puzzle. Clin J Sport Med 15. McCrea M, Hammeke T, Olsen G, Leo , athletes with sports related head injury. Br. 2001; 11:182-189. Guskiewicz K: Unreported concussion in J Sports Med 35(5):297-302, 2001. 10. Hovda DA, Lee SM, Smith ML et al: high school football players. Clin J Sport 6. Collins MW, Iverson GL, Lovell MR, The Neurochemical and metabolic cascade med 2004;14:13-17. McKeag DB, Norwig J, Maroon J: On- field following brain injury: Moving from ani- 16. Torg JS: Athletic Injuries to the Head, predictors of neuropsychological and mal models to man. J Neurotrauma Neck, and Face. St. Louis, Mosby-Year symptom deficit following sports-related 12(5):143-146, 1995. Book, 1991. 51 GUIDELINE 2j Skin Infections in Athletics July 1981 • Revised June 2008

Skin infections may be transmitted 2. Parasitic skin infections Open wounds and infectious skin by both direct (person to person) a. pediculosis; conditions that cannot be adequate- and indirect (person to inanimate ly protected should be considered surface to person) contact. b. scabies; cause for medical disqualification Infection control measures, or mea- 3. Viral skin infections from practice or competition (see sures that seek to prevent the Guideline 2a). The term “adequately spread of disease, should be used a. herpes simplex; protected” means that the wound or to reduce the risks of disease trans- b. herpes zoster (chicken pox); skin condition has been deemed as mission. Efforts should be made to non-infectious and adequately treat- c. molluscum contagiosum; and improve student-athlete hygiene ed as deemed appropriate by a practices, to use recommended 4. Fungal skin infections health care provider and is able to procedures for cleaning and disin- a. tinea corporis (ringworm). be properly covered. The term fection of surfaces, and to handle “properly covered” means that the blood and other bodily fluids appro- Note: Current knowledge indicates skin infection is covered by a priately. Suggested measures that many fungal infections are eas- securely attached bandage or include: promotion of hand and per- ily transmitted by skin-to-skin con- dressing that will contain all sonal hygiene practices; educating tact. In most cases, these skin con- drainage and will remain intact athletes and athletics staff; ensuring ditions can be covered with a recommended procedures for throughout the sport activity. A securely attached bandage or non- cleaning and disinfection of hard health care provider might exclude permeable dressing to allow partici- surfaces are followed; and verifying a student-athlete if the activity clean up of blood and other poten- pation. poses a risk to the health of the tially infectious materials is done, according to the Occupational Health and Safety Administration (OSHA) Blood-borne Pathogens Standard #29 CFR 1910.1030. Categories of skin conditions and examples include: 1. Bacterial skin infections a. impetigo; b. erysipelas; c. carbuncle; d. staphylococcal disease; MRSA; e. folliculitis (generalized); 52 f. hidradentitis suppurativa; Skin Infections in Athletics infected athlete (such as injury to the infected area), even though the Some common recommendations include: infection can be properly covered. If A. Keep hands clean by washing thoroughly with soap and warm water wounds can be properly covered, or using an alcohol-based sanitizer routinely good hygiene measures such as performing hand hygiene before and B. Encourage good hygiene after changing bandages and throw- • immediate showering after activity ing used bandages in the trash • ensure availability of adequate soap and water should be stressed to the athlete. • pump soap dispensers are preferred over bar soap C. Avoid whirlpools or common tubs Antibiotic Resistant Staph • individuals with active infections, open wounds, scrapes or scratches Infections could infect others or become infected in this environment There is much concern about the D. Avoid sharing towels, razors, and daily athletic gear presence and spread of antibiotic- • avoid contact with other people’s wounds or material contaminated resistant Staphylococcus aureus in from wounds intercollegiate athletics across F. Maintain clean facilities and equipment sports. Athletes are at-risk due to • wash athletic gear and towels after each use presence of open wounds, poor • establish routine cleaning schedules for shared equipment hygiene practices, close physical G. Inform or refer to appropriate health care personnel for all active skin contact, and the sharing of towels and equipment. Institutions and lesions and lesions that do not respond to initial therapy conferences should continue efforts • train student-athletes and coaches to recognize potentially infected and support for the education of wounds and seek first aid staff and student-athletes on the • encourage coaches and sports medicine staff to assess regularly for importance of proper hygiene and skin lesions wound care to prevent skin infec- • encourage health care personnel to seek bacterial cultures to establish tions from developing and infectious a diagnosis diseases from being transmitted. I. Care and cover skin lesions appropriately before participation Staphylococcus aureus, often • keep properly covered with a proper dressing until healed referred to as “staph”, are bacteria • “properly covered" means that the skin infection is covered by a commonly carried on the skin or in securely attached bandage or dressing that will contain all drainage the nose of healthy people. and will remain intact throughout the sport activity Occasionally, staph can cause an • if wounds can be properly covered, good hygiene measures should be infection. Staph bacteria are one of stressed to the student-athlete such as performing hand hygiene most common causes of skin infec- before and after changing bandages and throwing used bandages in tions in the U.S. Most infections are the trash minor, typically presenting as skin • if wound cannot be properly covered, consider excluding players with and soft tissue infections (SSTI) potentially infectious skin lesions from practice and/or competition such as pimples, pustules and boils. until lesions are healed or can be covered adequately They may be red, swollen, warm, 53 Skin Infections in Athletics

painful or purulent. Sometimes ath- spread among people having close MRSA infections in the community letes confuse these lesions with contact with infected people. MRSA are typically SSTI, but can also insect bites in the early stages of is almost always spread by direct cause severe illness such as pneu- infection. A purulent lesion could physical contact, and not through monia. Most transmissions appear present as draining pus; yellow or the air. Spread may also occur to be from people with active MRSA white center; central point or “head”; through indirect contact by touch- skin infections. Staph and MRSA or a palpable fluid-filled cavity. ing objects contaminated by the infections are not routinely reported In the past, most serious staph infected skin of a person with MRSA to public health authorities, so a bacterial infections were treated or staph bacteria (e.g. towels, precise number is not known. It is with antibiotics related to peni- sheets, wound dressings, clothes, estimated as many as 300,000 hos- cillin. In recent years, antibiotic workout areas, sports equipment). pitalizations are related MRSA infec- treatment of these infections has If a lesion cannot be properly cov- tions each year. Only a small pro- changed because staph bacteria ered for the rigors of the sport, con- portion of these have disease onset have become resistant to various sider excluding players with poten- occurring in the community. It has antibiotics, including the com- tially infectious skin lesions from also been estimated that there are monly used penicillin-related practice and competition until over 12 million outpatient (i.e., antibiotics. These resistant bacte- lesions are healed. physician offices, emergency and outpatient departments) visits for ria are called methicillin-resistant Staph bacteria including MRSA can Staphylococcus aureus, or MRSA. suspected staph and MRSA SSTIs be found on the skin and in the nose in the U.S. each year. Approximately Fortunately, the first-line treat- of some people without causing ill- ment for most purulent staph, 25 to 30 percent (80 million per- ness. The role of decolonization is sons) of the population is colonized including MRSA, skin and soft tis- still under investigation. Regimens sue infections is incision and in the nose with staph bacteria at a intended to eliminate MRSA colo- given time and approximately 1.5 drainage with or without antibi- nization should not be used in otics. However, if antibiotics are percent (4.1 million persons) is col- patients with active infections. onized with MRSA. prescribed, patients should com- Decolonization regimens may have plete the full course and consult a role in preventing recurrent infec- In an effort to educate the public physicians if the infection does tions, but more data are needed to about the potential risks of MRSA, not get better. The Centers for establish their efficacy and to identi- organizations such as the CDC, Disease Control and Prevention fy optimal regimens for use in com- NCAA and the National Athletic (CDC), American Medical munity settings. After treating active Trainers’ Association (NATA) have Association (AMA), and Infectious infections and reinforcing hygiene issued official statements recom- Diseases Society of America and appropriate wound care, con- mending all health care personnel (IDSA) have developed a treat- sider consultation with an infectious and physically active adults and ment algorithm that should be disease specialist regarding use of children take appropriate precau- reviewed; accessible at: decolonization when there are tions if suspicious skin infections http://www.cdc.gov/ncidod/dhqp/ recurrent infections in an individual appear, and immediately contact ar_mrsa_ca_skin.html. patient or members of a defined their health care provider. 54 Staph bacteria including MRSA can group. Individual cases of MRSA usually Skin Infections in Athletics are not required to be reported to strategies and infection control poli- quately protected should be con- most local/state health depart- cies and procedures. sidered cause for medical disquali- ments; however, most states have Skin Infections in Wrestling fication from practice or competi- laws that require reporting of certain tion (see Guideline 2a). The term communicable diseases, including Data from the NCAA Injury “adequately protected” means that outbreaks regardless of pathogens. Surveillance System (ISS) indicate the wound or skin condition has So in most states if an outbreak of that skin infections are associated been deemed as non-infectious and skin infections is detected, the local with at least 17 percent of the prac- adequately treated as deemed and/or state health department tice time-loss injuries in wrestling. appropriate by a health care should be contacted. It is recommended that qualified provider and is able to be properly Recognition of MRSA is critical to personnel, including a knowledge- covered. The term “properly cov- clinical management. Education is able, experienced physician exam- ered” means that the skin infection the key, involving all individuals ine the skin of all wrestlers before is covered by a securely attached associated with athletics, from stu- any participation (practice and bandage or dressing that will con- dent-athletes to coaches to medical competition). Male student-ath- tain all drainage and will remain personnel to custodial staff. letes shall wear shorts and female intact throughout the sport activity. Education should encompass prop- student-athletes should wear A health care provider might er hygiene, prevention techniques shorts and a sports bra during exclude a student-athlete if the medical examinations. and appropriate precautions if sus- activity poses a risk to the health of picious wounds appear. Each insti- Open wounds and infectious skin the infected athlete (such as injury tution should develop prevention conditions that cannot be ade- to the infected area), even though

55 Skin Infections in Athletics

the infection can be properly cov- ment, the wrestler presenting with a examined for completeness of ered. If wounds can be properly skin lesion shall provide a complet- response before wrestling. covered, good hygiene measures ed Skin Evaluation and Participation SCABIES such as performing hand hygiene Status Form from the team physi- before and after changing ban- cian documenting clinical diagno- Wrestler must have negative sca- dages and throwing used bandages sis, lab and/or culture results, if rel- bies prep at meet or tournament in the trash should be stressed to evant, and an outline of treatment to time. the athlete. (See WA-15.) date (i.e., surgical intervention, HERPES SIMPLEX Medical Examinations duration, frequency, dosages of medication). Primary Infection Medical examinations must be con- BACTERIAL INFECTIONS 1. Wrestler must be free of sys- ducted by knowledgeable physi- temic symptoms of viral infec- cians and/or certified athletic train- (Furuncles, Carbuncles, Folliculitis, tion (fever, malaise, etc.). ers. The presence of an experienced Impetigo, Cellulitis or Erysipelas, dermatologist is recommended. Staphylococcal disease, MRSA) 2. Wrestler must have developed no new blisters for 72 hours The examination should be con- 1. Wrestler must have been without before the examination. ducted in a systematic fashion so any new skin lesion for 48 hours that more than one examiner can before the meet or tournament. 3. Wrestler must have no moist evaluate problem cases. Provisions lesions; all lesions must be should be made for appropriate 2. Wrestler must have no moist, exudative or purulent lesions at dried and surmounted by a lighting and the necessary facilities FIRM ADHERENT CRUST. to confirm and diagnose skin infec- meet or tournament time. tions. 3. Gram stain of exudate from ques- 4. Wrestler must have been on tionable lesions (if available). appropriate dosage of sys- Wrestlers who are undergoing temic antiviral therapy for at treatment for a communicable skin 4. Active purulent lesions shall not least 120 hours before and at disease at the time of the meet or be covered to allow participation. the time of the meet or tourna- tournament shall provide written See above criteria when making ment. documentation to that effect from a decisions for participation status. 5. Active herpetic infections shall physician. The status of these indi- HIDRADENITIS SUPPURATIVA viduals should be decided before not be covered to allow partic- the screening of the entire group. 1. Wrestler will be disqualified if ipation. The decision made by a physician extensive or purulent draining See above criteria when making and/or certified athletic trainer “on lesions are present. decisions for participation status. site” should be considered FINAL. 2. Extensive or purulent draining Recurrent infection Guidelines for Disposition of lesions shall not be covered to allow participation. 1. Blisters must be completely Skin Infections dry and covered by a FIRM PEDICULOSIS Unless a new diagnosis occurs at ADHERENT CRUST at time of 56 the time of the medical examination Wrestler must be treated with competition, or wrestler shall conducted at the meet or tourna- appropriate pediculicide and re- not participate. Skin Infections in Athletics

2. Wrestler must have been on appropriate dosage of sys- temic antiviral therapy for at least 120 hours before and at the time of the meet or tournament. 3. Active herpetic infections shall not be covered to allow participation. See above criteria when making decisions for participation status. Questionable Cases 1. Tzanck prep and/or HSV antigen assay (if available). 2. Wrestler’s status deferred until Tzanck prep and/or HSV assay results complete. Wrestlers with a history of recurrent herpes labialis or herpes gladiatorum could be considered for season-long prophylaxis. This decision should be made after consultation with the team physician. HERPES ZOSTER (chicken pox) • Skin lesions must be surmounted by a FIRM ADHERENT CRUST at meet or tournament time and have no evidence of secondary bacterial infection. MOLLUSCUM CONTAGIOSUM 1. Lesions must be curetted or removed before the meet or tournament. 2. Solitary or localized, clustered lesions can be covered with a Six posters available for printing at NCAA.org/health-safety. 57 58 Skin Infections in Athletics

gaspermeable membrane, fol- have the lesions “adequately cov- judged either by use of KOH lowed by tape. ered.” preparation or a review of thera- VERRUCAE peutic regimen. Wrestlers with TINEA INFECTIONS (ringworm) solitary, or closely clustered, 1. Wrestlers with multiple digitate 1. A minimum of 72 hours of topical localized lesions will be disquali- verrucae of their face will be dis- therapy is required for skin lesions. fied if lesions are in a body loca- qualified if the infected areas can- tion that cannot be “properly cov- not be covered with a mask. 2. A minimum of two weeks of sys- ered.” Solitary or scattered lesions can temic antifungal therapy is 4. The disposition of tinea cases will be curetted away before the meet required for scalp lesions. be decided on an individual basis or tournament. 3. Wrestlers with extensive and as determined by the examining 2. Wrestlers with multiple verrucae active lesions will be disqualified. physician and/or certified athletic plana or verrucae vulgaris must Activity of treated lesions can be trainer.

References 1. Descriptive Epidemiology of Collegiate et. al.: An outbreak of herpes gladiatorium of Infectious Disease Transmission in Men’s Wrestling Injuries: National at a high school wrestling camp. The New Sports. SportsMedicine 24(1):1-7,1997. Collegiate Athletic Association Injury England Journal of Medicine. 11. Kohl TD, Martin DC, Nemeth R, Hill T, Surveillance System, 1988–1989 Through 325(13):906-910, 1991. Evans D.: Fluconazole for the prevention 2003–2004. Journal of Athletic Training Cordoro, KM and Ganz, JE. Training room and treatment of tinea gladiatorum. 2007;42(2):303–310. management of medical condition: Sports Pediatric Infectious Disease Journal 2. Adams, BB.: Transmission of cutaneous Dermatology. Clinics in Sports Medicine. 19(8):717-22, 2000 Aug. infection in athletics. British Journal of 24: 565-598, 2005. 12. Lindenmayer JM, Schoenfeld S, Sports Medicine 34(6):413-4, 2000 Dec. 7. Cozad, A. and Jones, R. D. Disinfection O’Grady R, Carney JK.: Methicillin-resis- 3. Anderson BJ.: The Effectiveness of and the prevention of disease. American tant Staphylococcus aureus in a high Valacyclovir in Preventing Reactivation of Journal of Infection Control, 31(4): 243- school wrestling team and the surround- Herpes Gladiatorum in Wrestlers. Clin J 254, 2003. ing community. Archives of Internal Medicine 158(8):895-9, 1998 Apr. Sports Med 9(2):86-90, 1999 Apr. 8. Centers for Disease Control and 4. Association for Professionals in Prevention (CDC) Division of Healthcare 13. Vasily DB, Foley JJ.: More on Tinea Infection Control and Epidemiology Quality Promotion. (2002). Campaign to Corporis Gladiatorum. J Am Acad (APIC). 1996. APIC infection control and prevent antimicrobial resistant in health Dermatol 2002, Mar. applied epidemiology principles and prac- care settings. Available at 14. Vasily DB, Foley JJ, First Episode tice. St. Louis: Mosby. www.cdc.gov/drugresistance/healthcare/. Herpes Gladiatorum: Treatment with 5. Beck, CK.: Infectious diseases in 9. Dorman, JM.: Contagious diseases in Valacyclovir (manuscript submitted for sports: Medicine and Science in Sports competitive sport: what are the risks? publication). Weiner, R. Methicillin- and Exercise 32(7 Suppl):S431-8, 2000 Journal of American College Health Resistant Staphylcoccus aureus on Campus: A new challenge to college Jul. 49(3):105-9, 2000 Nov. health. Journal of American College 59 6. Belongia EA, Goodman JL, Holland EJ, 10. Mast, E. and Goodman, R.: Prevention Health. 56(4):347-350. GUIDELINE 2k Menstrual-Cycle Dysfunction January 1986 • Revised June 2002

The NCAA Committee on menstrual-cycle irregularities. One maintenance of bone health. This Competitive Safeguards and reason is infertility; fortunately, the can be achieved by the re-estab- Medical Aspects of Sports long–term effects of menstrual lishment of a regular menstrual acknowledges the significant input cycle dysfunction appear to be cycle or by hormone replacement of Dr. Anne Loucks, Ohio reversible. Another medical conse- therapy, although neither change University, in the revision of this quence is skeletal demineraliza- has been shown to result in com- guideline. tion, which occurs in hypoestro- plete recovery of the lost bone genic women. Skeletal demineral- mass. Additional research is nec- In 80 percent of college-age ization was first observed in amen- essary to develop a specific prog- women, the length of the menstru- orrheic athletes in 1984. Initially, nosis for exercise-induced men- al cycle ranges from 23 to 35 days. the lumbar spine appeared to be strual dysfunction. Oligomenorrhea refers to a men- the primary site where skeletal strual cycle that occurs inconsis- All student-athletes with menstru- demineralization occurs, but new tently, irregularly and at longer al irregularities should be seen by techniques for measuring bone intervals. Amenorrhea is the ces- a physician. General guidelines mineral density show that dem- sation of the menstrual cycle with include: ineralization occurs throughout ovulation occurring infrequently or the skeleton. Some women with 1. Full medical evaluation, includ- not at all. A serious medical prob- menstrual disturbances involved ing an endocrine work-up and lem of amenorrhea is the lower in high-impact activities, such as bone mineral density test; level of circulating estrogen gymnastics and figure skating, (hypoestrogenism), and its poten- 2. Nutritional counseling with spe- display less demineralization than tial health consequences. cific emphasis on: women runners. Despite resump- The prevalence of menstrual-cycle tion of normal menses, the loss of a. Total caloric intake versus irregularities found in surveys bone mass during prolonged energy expenditure. depends on the definition of men- hypoestrogenemia is not com- b. Calcium intake of 1,200 to strual function used, but has been pletely reversible. Therefore, 1,500 milligrams a day; and reported to be as high as 44 per- young women with low levels of cent in athletic women. Research circulating estrogen, due to men- 3. Routine monitoring of the diet, suggests that failure to increase strual irregularities, are at risk for menstrual function, weight-train- dietary energy intake in compen- low peak bone mass which may ing schedule and exercise habits. sation for the expenditure of ener- increase the potential for osteo- If this treatment scheme does not gy during exercise can disrupt the porotic fractures later in life. An result in regular menstrual cycles, hypothalamic-pituitary-ovarian increased incidence of stress frac- estrogen-progesterone supple- (HPO) axis. Exercise training tures also has been observed in mentation should be considered. appears to have no suppressive the long bones and feet of women This should be coupled with effect on the HPO axis beyond the with menstrual irregularities. appropriate counseling on hor- impact of its strain on energy The treatment goal for women mone replacement and review of availability. with menstrual irregularities is the family history. Hormone-replace- 60 There are several important rea- re-establishment of an appropriate ment therapy is thought to be sons to discuss the treatment of hormonal environment for the important for amenorrheic women Menstrual-Cycle Dysfunction and oligomenorrheic women two components and referred for share a responsibility to prevent, whose hormonal profile reveals an medical evaluation. recognize and treat this disorder. estrogen deficiency. Other recommendations include: • Sports medicine professionals, The relationship between amenor- athletics administrators and offi- • All sports medicine profession- rhea, osteoporosis and disordered cials of sport governing bodies als, including coaches and athlet- eating is termed the “female ath- should work toward offering ic trainers, learn to recognize the lete triad.” In 1997, the American opportunities for educating and symptoms and risks associated College of Sports Medicine issued monitoring coaches to ensure with the female athlete triad. a position stand calling for all indi- safe training practices. viduals working with physically • Coaches and others should avoid • Young, physically active females active girls and women to be edu- pressuring female athletes to diet should be educated about proper cated about the female athlete triad and lose weight and should be nutrition, safe training practices, and develop plans for prevention, educated about the warning and the risks and warning signs recognition, treatment and risk signs of eating disorders. of the female athlete triad. reduction. Recommendations are • Sports medicine professionals, that any student-athlete who pre- athletics administrators and offi- sents with any one component of cials of sport governing bodies the triad be screened for the other

References 1. American Academy of Pediatrics 3. Loucks AB, Verdun M, Heath EM: Low Female Athlete Triad. Medicine and Committee on Sports Medicine: energy availability, not stress of exercise, Science in Sports and Exercise 29(5):i-ix, Amenorrhea in adolescent athletes. alters LH pulsatility in exercising women. 1997. Pediatrics 84(2):394-395, 1989. Journal of Applied Physiology 84(1):37- 5. Shangold M, Rebar RW, Wentz AC, 2. Keen AD, Drinkwater BL: Irreversible 46, 1998. Schiff I: Evaluation and management of menstrual dysfunction in athletes. Journal bone loss in former amenorrheic athletes. 4. Otis CT, Drinkwater B, Johnson M, of American Medical Association Loucks A, Wilmore J: American College of Osteoporosis International 7(4):311-315, 262(12):1665-1669, 1990. 1997. Sports Medicine Position Stand on the 61 GUIDELINE 2l Blood-Borne Pathogens and Intercollegiate Athletics April 1988 • Revised August 2004

Blood-borne pathogens are dis- mission on the athletics field is The incidence of HBV in student- ease-causing microorganisms that minimal. athletes is presumably low, but can be potentially transmitted those participating in risky behav- through blood contact. The blood- Hepatitis B Virus (HBV) ior off the athletics field have an borne pathogens of concern in- HBV is a blood-borne pathogen increased likelihood of infection clude (but are not limited to) the that can cause infection of the liver. (just as in the case of HIV). An hepatitis B virus (HBV) and the Many of those infected will have no effective vaccine to prevent HBV is human immunodeficiency virus symptoms or a mild flu-like illness. available and recommended for all (HIV). Infections with these (HBV, One-third will have severe hepati- college students by the American HIV) viruses have increased tis, which will cause the death of College Health Association. throughout the last decade among one percent of that group. Numerous other groups have recall portions of the general popula- Approximately 300,000 cases of ognized the potential benefits of tion. These diseases have potential acute HBV infection occur in the universal vaccination of the entire for catastrophic health con- United States every year, mostly in adolescent and young-adult popu- sequences. Knowledge and aware- adults. lation. ness of appropriate preventive HIV (AIDS Virus) strategies are essential for all Five to 10 percent of acutely infected adults become chronically members of society, including The Acquired Immunodeficiency infected with the virus (HBV carri- student-athletes. Syndrome (AIDS) is caused by the ers). Currently in the United States human immunodeficiency virus The particular blood-borne patho- there are approximately one million (HIV), which infects cells of the gens HBV and HIV are transmitted chronic carriers. Chronic complica- through sexual contact (hetero- tions of HBV infection include cir- immune system and other tissues, sexual and homosexual), direct rhosis of the liver and liver cancer. such as the brain. Some of those contact with infected blood or infected with HIV will remain blood components, and perinatally Individuals at the greatest risk for asymptomatic for many years. from mother to baby. In addition, becoming infected include those Others will more rapidly develop behaviors such as body piercing practicing risky behaviors of hav- manifestations of HIV disease (i.e., and tattoos may place student-ath- ing unprotected sexual intercourse AIDS). Some experts believe virtu- letes at some increased risk for or sharing intravenous (IV) nee- ally all persons infected with HIV contracting HBV, HIV or Hepatitis dles in any form. There is also evi- eventually will develop AIDS and C. dence that household contacts that AIDS is uniformly fatal. In the United States, adolescents are at The emphasis for the student-ath- with chronic HBV carriers can lead lete and the athletics health-care to infection without having had special risk for HIV infection. This team should be placed predomi- sexual intercourse or sharing of IV age group is one of the fastest nately on education and concern needles. These rare instances growing groups of new HIV infec- about these traditional routes of probably occur when the virus is tions. Approximately 14 percent of transmission from behaviors off transmitted through unrecog- all new HIV infections occur in per- the athletics field. Experts have nized-wound or mucous-mem- sons aged between 12 to 24 years. 62 concurred that the risk of trans- brane exposure. The risk of infection is increased Blood-Borne Pathogens and Intercollegiate Athletics by having unprotected sexual transmission than HIV. ing is a problem for the asympto- intercourse, and the sharing of IV matic HBV carrier (acute or chron- needles in any form. Like HBV, Testing of Student-Athletes ic) without evidence of organ there is evidence that suggests impairment. Therefore, the simple Routine mandatory testing of that HIV has been transmitted in presence of HBV infection does student-athletes for either HBV or household-contact settings with- not mandate removal from play. HIV for participation purposes is not out sexual contact or IV needle recommended. Individuals who de- Disease Transmission—The student- sharing among those household sire voluntary testing based on per- 5,6 athlete with either acute or chronic contacts . Similar to HBV, these sonal reasons and risk factors, how- rare instances probably occurred ever, should be assisted in obtaining HBV infection presents very limit- through unrecognized wound or such services by appropriate cam- ed risk of disease transmission in mucous membrane exposure. pus or public-health officials. most sports. However, the HBV Comparison of HBV/HIV carrier presents a more distinct Student-athletes who engage in transmission risk than the HIV car- high-risk behavior are encouraged Hepatitis B is a much more “stur- rier (see previous discussion of to seek counseling and testing. dy/durable” virus than HIV and is comparison of HBV to HIV) in Knowledge of one’s HBV and HIV much more concentrated in blood. sports with higher potential for infection is helpful for a variety of HBV has a much more likely trans- reasons, including the availability blood exposure and sustained mission with exposure to infected of potentially effective therapy for close body contact. Within the blood; particularly parenteral (nee- asymptomatic patients, and modi- NCAA, wrestling is the sport that dle-stick) exposure, but also expo- fication of behavior, which can best fits this description. sure to open wounds and mucous prevent transmission of the virus membranes. There has been one to others. Appropriate counseling The specific epidemiologic and well-documented case of trans- regarding exercise and sports par- biologic characteristics of hepatitis mission of HBV in the athletics ticipation also can be accom- B virus form the basis for the fol- setting, among sumo wrestlers in plished. lowing recommendation: If a stu- Japan. There are no validated dent-athlete develops acute HBV cases of HIV transmission in the Participation by the Student- illness, it is prudent to consider athletics setting. The risk of trans- Athlete with Hepatitis B (HBV) removal of the individual from mission for either HBV or HIV on Infection combative, sustained close-con- the field is considered minimal; tact sports (e.g., wrestling) until however, most experts agree that Individual’s Health––In general, loss of infectivity is known. (The the specific epidemiologic and bio- acute HBV should be viewed just best marker for infectivity is the logic characteristics of the HBV as other viral infections. Decisions HBV antigen, which may persist virus make it a realistic concern for regarding ability to play are made up to 20 weeks in the acute stage). transmission in sports with sus- according to clinical signs and Student-athletes in such sports tained close physical contact, such symptoms, such as fatigue or who develop chronic HBV infec- as wrestling. HBV is considered to fever. There is no evidence that tions (especially those who are e- have a potentially higher risk of intense, highly competitive train- antigen positive) should probably 63 Blood-Borne Pathogens and Intercollegiate Athletics

be removed from competition cian and the team physician. dent-athletes merely because they indefinitely, due to the small but Variables to be considered in are infected with HIV, although one realistic risk of transmitting HBV to reaching the decision include the court has upheld the exclusion of other student-athletes. student-athlete’s current state of an HIV-positive athlete from the health and the status of his/her contact sport of karate19. Participation of the HIV infection, the nature and inten- Student-Athlete with HIV sity of his/her training, and poten- Administrative Issues tial contribution of stress from ath- Individual’s Health—In general, the The identity of individuals infected decision to allow an HIV positive letics competition to deterioration of his/her health status. with a blood-borne pathogen must student-athlete to participate in remain confidential. Only those intercollegiate athletics should be There is no evidence that exercise persons in whom the infected stu- made on the basis of the individ- and training of moderate intensity dent-athlete chooses to confide ual’s health status. If the student- is harmful to the health of HIV- have a right to know about this athlete is asymptomatic and with- infected individuals. What little aspect of the student-athlete’s out evidence of deficiencies in data that exists on the effects of medical history. This confidentiali- immunologic function, then the intense training on the HIV-infect- ty must be respected in every case presence of HIV infection in and of ed individual demonstrates no evi- and at all times by all college offi- itself does not mandate removal dence of health risk. However, cials, including coaches, unless from play. there is no data looking at the the student-athlete chooses to The team physician must be effects of long-term intense train- make the fact public. knowledgeable in the issues sur- ing and competition at an elite, rounding the management of HIV- highly competitive level on the Athletics Health-Care infected student-athletes. HIV health of the HIV-infected student- Responsibilities must be recognized as a potential- athlete. The following recommendations ly chronic disease, frequently affording the affected individual Disease Transmission—Concerns of are designed to further minimize many years of excellent health and transmission in athletics revolve risk of blood-borne pathogens and productive life during its natural around exposure to contaminated other potentially infectious organ- history. During this period of pre- blood through open wounds or isms transmission in the context of served health, the team physician mucous membranes. Precise risk athletics events and to provide may be involved in a series of of such transmission is impossible treatment guidelines for care- complex issues surrounding the to calculate but epidemiologic and givers. In the past, these guidelines advisability of continued exercise biologic evidence suggests that it were referred to as “Universal and athletics competition. is extremely low (see section on (blood and body fluid) Precau- comparison of HBV/HIV). There tions.” Over time, the recognition The decision to advise continued have been no validated reports of of “Body Substance Isolation,” or athletics competition should transmission of HIV in the athletics that infectious diseases may also involve the student-athlete, the setting3,13. Therefore, there is no be transmitted from moist body 64 student-athlete’s personal physi- recommended restriction of stu- substances, has led to a blending of Blood-Borne Pathogens and Intercollegiate Athletics terms now referred to as “Standard 2. Assemble and maintain equip- of bleeding or as a port of entry for Precautions.” Standard precau- ment and/or supplies for treating blood-borne pathogens or other tions apply to blood, body fluids, injured/bleeding athletes. Items potentially infectious organisms. secretions and excretions, except may include: Personal Protective These wounds should be covered sweat, regardless of whether or not Equipment (PPE) [minimal protec- with an occlusive dressing that will they contain visible blood. These tion includes gloves, goggles, withstand the demands of competi- guidelines, originally developed for mask, fluid-resistant gown if tion. Likewise, care providers with health-care, have additions or mod- chance of splash or splatter]; anti- healing wounds or dermatitis ifications relevant to athletics. They septics; antimicrobial wipes; ban- should have these areas adequately are divided into two sections — the dages or dressings; medical equip- covered to prevent transmission to care of the student-athlete, and ment needed for treatment; appro- or from a participant. Student-ath- cleaning and disinfection of envi- priately labeled “sharps” container letes may be advised to wear more ronmental surfaces. for disposal of needles, syringes protective equipment on high-risk and scalpels; and waste recepta- areas, such as elbows and hands. Care of the Athlete: cles appropriate for soiled equip- 4. The necessary equipment and/or ment, uniforms, towels and other supplies important for compliance 1. All personnel involved in sports waste. who care for injured or bleeding with standard precautions should student-athletes should be proper- 3. Pre-event preparation includes be available to caregivers. These ly trained in first aid and standard proper care for wounds, abrasions supplies include appropriate precautions. or cuts that may serve as a source gloves, disinfectant bleach, anti- septics, designated receptacles for soiled equipment and uniforms, bandages and/or dressings, and a container for appropriate disposal of needles, syringes or scalpels. 5. When a student-athlete is bleeding, the bleeding must be stopped and the open wound covered with a dressing sturdy enough to withstand the demands of activity before the student-athlete may continue participation in practice or competition. Current NCAA policy mandates the immediate, aggressive treatment of open wounds or skin lesions that are deemed potential risks for transmission of disease. Partici- 65 Blood-Borne Pathogens and Intercollegiate Athletics

pants with active bleeding should Chemical germicides intended for able cloths; red plastic bag with the be removed from the event as use on environmental surfaces biohazard symbol on it or other soon as is practical. Return to play should never be used on student- waste receptacle according to facil- is determined by appropriate athletes. ity protocol; and properly diluted medical staff personnel and/or tuberculocidal disinfectant or fresh- sport officials. Any participant 9. Any needles, syringes or ly prepared bleach solution diluted whose uniform is saturated with scalpels should be carefully dis- (1:100 bleach/water ratio). blood must change their uniform posed of in an appropriately labeled 3. Put on disposable gloves. before return to participation. “sharps” container. Medical equipment, bandages, dressings and 4. Remove visible organic material 6. During an event, early recogni- other waste should be disposed of by covering with paper towels or tion of uncontrolled bleeding is the according to facility protocol. disposable cloths. Place soiled responsibility of officials, student- During events, uniforms or other towels or cloths in red bag or other athletes, coaches and medical per- contaminated linens should be dis- waste receptacle according to facil- sonnel. In particular, student-ath- posed of in a designated container ity protocol. (Use additional towels letes should be aware of their to prevent contamination of other or cloths to remove as much responsibility to report a bleeding items or personnel. At the end of organic material as possible from wound to the proper medical per- competition, the linen should be the surface and place in the waste sonnel. laundered and dried according to receptacle.) facility protocol; hot water at tem- 7. Personnel managing an acute peratures of 71°C (160°F) for 25- 5. Spray the surface with a proper- blood exposure must follow the minute cycles may be used. ly diluted chemical germicide used guidelines for standard precaution. according to manufacturer’s label Gloves and other PPE, if necessary, Care of Environmental Surfaces: recommendations for disinfection, should be worn for direct contact 1. All individuals responsible for and wipe clean. Place soiled towels with blood or other body fluids. cleaning and disinfection of blood in waste receptacle. Gloves should be changed after spills or other potentially infectious 6. Spray the surface with either a treating each individual participant. materials (OPIM) should be prop- After removing gloves, hands properly diluted tuberculocidal erly trained on procedures and the chemical germicide or a freshly should be washed. use of standard precautions. prepared bleach solution diluted 1:100, and follow manufacturer’s 8. If blood or body fluids are trans- 2. Assemble and maintain supplies label directions for disinfection; ferred from an injured or bleeding for cleaning and disinfection of wipe clean. Place towels in waste student-athlete to the intact skin of hard surfaces contaminated by receptacle. another athlete, the event must be blood or OPIM. Items include: stopped, the skin cleaned with Personal Protective Equipment 7. Remove gloves and wash antimicrobial wipes to remove (PPE) [gloves, goggles, mask, hands. gross contaminate, and the athlete fluid-resistant gown if chance of instructed to wash with soap and splash or splatter]; supply of 8. Dispose of waste according to 66 water as soon as possible. NOTE: absorbent paper towels or dispos- facility protocol. Blood-Borne Pathogens and Intercollegiate Athletics

Final Notes: for Bloodborne Pathogens standard directed to eliminating or (Standard #29 CFR 1910.1030) minimizing occupational exposure 1. All personnel responsible for and Hazard Communication to blood-borne pathogens. Many of caring for bleeding individuals (Standard #29 CFR 1910.1200) the recommendations included in should be encouraged to obtain a should be reviewed for further this guideline are part of the stan- Hepatitis B (HBV) vaccination. information. dard. Each member institution should determine the applicability 2. Latex allergies should be consid- Member institutions should ensure of the OSHA standard to its per- ered. Non-latex gloves may be that policies exist for orientation sonnel and facilities. used for treating student-athletes and education of all health-care and the cleaning and disinfection of workers on the prevention and environmental surfaces. transmission of blood-borne pathogens. Additionally, in 1992, the 3. Occupational Safety and Health Occupational Safety and Health Administration (OSHA) standards Administration (OSHA) developed a

67 Blood-Borne Pathogens and Intercollegiate Athletics

References 1. AIDS education on the college cam- 8. Klein RS, Freidland GH: Transmission of 14. World Health Organization consensus pus: A theme issue. Journal of American human immunodeficiency virus type 1 (HIV- statement: Consultation on AIDS and College Health 40(2):51-100, 1991. 1) by exposure to blood: defining the risk. sports. Journal of American Medical 2. American Academy of Pediatrics: Annals of Internal Medicine 113(10):729-730, Association 267(10):1312, 1992. 1990. Human immunodeficiency virus (AIDS 15. Human immunodeficiency virus (HIV) virus) in the athletic setting. Pediatrics 9. Public health services guidelines for and other blood-borne pathogens in 88(3):640-641, 1991. counseling and antibody testing to prevent HIV infection and AIDS. Morbidity and sports. Joint position statement by the 3. Calabrese L, et al.: HIV infections: Mortality Weekly Report 36(31):509-515, American Medical Society for Sports exercise and athletes. Sports Medicine 1987. Medicine (AMSSM) and the American 15(1):1-7, 1993. 10. Recommendations for prevention of Academy of Sports Medicine (AASM). The 4. Canadian Academy of Sports Medi- HIV transmission in health care settings. American Journal of Sports Medicine cine position statement: HIV as it relates to Morbidity and Mortality Weekly Report 23(4):510-514, 1995. sport. Clinical Journal of Sports Medicine 36(25):3S-18S, 1987. 3:63-68, 1993. 16. Most E, et al.: Transmissions of blood- 11. United States Olympic Committee 5. Fitzgibbon J, et al.: Transmissions borne pathogens during sport: risk and Sports Medicine and Science Committee: prevention. Annals of Internal Medicine from one child to another of human Transmission of infectious agents during 122(4):283-285, 1995. immunodeficiency virus type I with athletic competition, 1991. (1750 East azidovudine-resistance mutation. Boulder Street, Colorado Springs, CO 17. Brown LS, et al.: Bleeding injuries in New England Journal of Medicine 329 80909) professional football: estimating the risk (25):1835-1841, 1993. 12. Update: Universal precautions for pre- for HIV transmission. Annals of Internal 6. HIV transmission between two adoles- vention of transmission by human immun- Medicine 122(4):271-274, 1995. cent brothers with hemophilia. Morbidity odeficiency virus, hepatitis B virus, and 18. Arnold BL: A review of selected blood- and Mortality Weekly Report 42(49):948- other blood borne pathogens in health borne pathogen statements and federal 951, 1993. care settings. Morbidity and Mortality regulations. Journal of Athletic Training 7. Kashiwagi S, et al.: Outbreak of hepa- Weekly Report 37:377-388, 1988. 30(2):171-176, 1995. titis B in members of a high-school sumo 13. When sports and HIV share the bill, wrestling club. Journal of American smart money goes on common sense. 19. Montalov v. Radcliffe, 167 F. 3d 873 Medical Association 248 (2):213-214, Journal of American Medical Association (4th Cir. 1999), cert. denied, 120 S Ct. 48 1982. 267(10):1311-1314, 1992. 1999.

68 GUIDELINE 2m The Use of Local Anesthetics in College Athletics June 1992 • Revised June 2004

The use of local injectable anes- patient, when the use is not harm- 2. The administration of these thetics to treat sports-related in- ful to continued athletics activity drugs by anyone other than a qual- juries in college athletics is primar- and when there is no enhance- ified clinician licensed to perform ily left to the discretion of the indi- ment of a risk of injury. this procedure. vidual treating physician, since there is little scientific research on The following procedures are not 3. The use of these drugs in com- the subject. This guideline pro- recommended: bination with epinephrine or other vides basic recommendations for vasoconstrictor agents in fingers, the use of these substances, which 1. The use of local anesthetic injec- toes, earlobes and other areas commonly include lidocaine (Xylo- tions if they jeopardize the ability where a decrease in circulation, caine), one or two percent; bupiva- of the student-athlete to protect even if only temporary, could caine (Marcaine), 0.25 to 0.50 per- himself or herself from injury. result in significant harm. cent; and mepivacaine (Carbo- caine), three percent. The following recommendations do not include the use of corticosteroids. It is recommended that: 1. These agents should be administered only by a qualified clinician who is licensed to perform this procedure and who is familiar with these agents’ actions, reactions, interactions and complications. The treating clinician should be well aware of the quantity of these agents that can be safely injected.

2. These agents should only be administered in facilities equipped to handle any allergic reaction, including a cardiopulmonary emergency, that may follow their use.

3. These agents should only be administered when medically justified, when the risk of administration is fully explained to the 69 GUIDELINE 2n The Use of Injectable Corticosteroids in Sports Injuries June 1992 • Revised June 2004

Corticosteroids, alone or in combi- appropriate to treat acute syn- cause significant and long-lasting nation with local anesthetics, have dromes such as acromio-clavicu- deterioration in the mechanical been used for many years to treat lar (AC) joint separations or hip properties of ligaments and col- certain sports-related injuries. This pointers with a corticosteroid. lagenous tissues in animal mod- guideline is an attempt to identify els. Finally, studies have shown specific circumstances in which There is still much to be learned significant degenerative changes corticosteroids may be appropriate about the effects of intra-articular, in active animal tendons treated and also to remind both physicians intraligamentous or intratendinous with a corticosteroid as early as 48 and student-athletes of the inherent injection of corticosteroids. Re- hours after injection. dangers associated with their use. searchers have noted reduced synthesis of articular cartilage This research provides the basis The most common reason for the after corticosteroid administration for the following recommendations use of corticosteroids in athletics in both animals and human mod- regarding the administration of is the treatment of chronic overuse els. However, a causal relationship corticosteroids in college athletics. syndromes such as bursitis, between the intra-articular corti- tenosynovitis and muscle origin costeroid and degeneration of It is recommended that: pain (for example, lateral epi- articular cartilage has not been condylitis). They have also been established. Research also has 1. Injectable corticosteroids should used to try to prevent redevelop- shown that a single intraligamen- be administered only after more ment of a ganglion, and to reduce tous or multiple intra-articular conservative treatments, including keloid scar formation. Rarely is it injections have the potential to nonsteroidal anti-inflammatory

70 The Use of Injectable Corticosteroids in Sports Injuries agents, rest, ice, ultrasound and 5. Corticosteroid injections only joints. Intra-articular injections various treatment modalities, have should be done if a therapeutic have a potential softening effect on been exhausted. effect is medically warranted and articular cartilage. the student-athlete is not subject 2. Only those physicians who are to either short- or long-term sig- 2. Intratendinous injections, since knowledgeable about the chemical nificant risk. such injections have been associ- makeup, dosage, onset of action, ated with an increased risk of rup- duration and potential toxicity of 6. These agents should only be ture. these agents should administer administered when medically justi- corticosteroids. fied, when the risk of administra- 3. Administration of injected tion is fully explained to the corticosteroids immediately before 3. These agents should be admin- patient, when the use is not harm- a competition. istered only in facilities that are ful to continued athletics activity equipped to deal with allergic reac- and when there is no enhance- 4. Administration of corticosteroids tions, including cardiopulmonary ment of a risk of injury. in acute trauma. emergencies. 5. Administration of corticosteroids 4. Repeated corticosteroid injec- The following procedures are not in infection. tions at a specific site should be recommended: done only after the consequences and benefits of the injections have 1. Intra-articular injections, partic- been thoroughly evaluated. ularly in major weight-bearing

References

1. Corticosteroid injections: balancing the Induced Inflammation Park Ridge, IL: 7. Noyes FR, Nussbaum NS, Torvik PT, et benefits. The Physician and Sports American Academy of Orthopedic al.: Biomechanical and ultrastructural Medicine 22(4):76, 1994. Surgeons, pp. 527-545, 1990. changes in ligaments and tendons after local corticosteroid injections. Abstract, 2. Corticosteroid Injections: Their Use 5. Mankin HJ, Conger KA: The acute Journal of Bone and Joint Surgery and Abuse. Journal of the American effects of intra-articular hydrocortisone on 57A:876, 1975. Academy of Orthopaedic Surgeons 2:133- articular cartilage in rabbits. Journal of 140, 1994. 8. Pfenninger JL: Injections of joints and Bone and Joint Surgery 48A:1383-1388, soft tissues: Part I. General guidelines. 3. Kennedy JC, Willis RD: The effects of 1966. local steroid injections on tendons: A bio- American Family Physician 44(4):1196- mechanical and microscopic correlative 6. Noyes FR, Keller CS, Grood ES, et al.: 1202, 1991. study. American Journal of Sports Advances in the understanding of knee lig- 9. Pfenninger JL: Injections of joints and Medicine 4:11-21, 1970. ament injuries, repair and rehabilitation. soft tissues: Part II. Guidelines for specific 4. Leadbetter WB: Corticosteroid injection Medicine and Science in Sports and joints. American Family Physician 71 therapy in sports injuries. In: Sports Exercise 16:427-443, 1984. 44(5):1690-1701, 1991. GUIDELINE 2o Depression: Interventions for Intercollegiate Athletics June 2006

The NCAA Committee on Com- among student-athletes because it have difficulty interacting with the petitive Safeguards and Medical impacts overall personal well-being, coach or teammates, or if they lose Aspects of Sports acknowledges athletic performance, academic per- their passion for their sport, it can the significant input of Sam Maniar, formance and injury healing. No be very difficult to handle. Many Licensed Psychologist, Ohio State two people become depressed in athletes also define themselves by University; Margot Putukian, Team exactly the same way, but with the their role as an athlete, and an injury Physician, Princeton University, right treatment 80 percent of those can be devastating. and the National Institute of Mental who seek help get better, and many Health, Bethesda, Maryland; for people begin to feel better in just a Some attributes of athletics and their original content. few weeks. competition can make it extremely difficult for student-athletes to Depression is more than the blues, Depression and Intercollegiate obtain help. They are taught to “play let-downs from a game loss, or the Athletics through the pain,” struggle through normal daily ups and downs. It’s adversity, handle problems on their feeling “down” and “low” and Student-athletes may experience own and “never let your enemies “hopeless” for weeks at a time. depression because of genetic pre- see you cry.” Seeking help is seen Depression is a serious medical disposition, developmental chal- as a sign of weakness, when it condition. lenges of college transitions, acade- should be recognized as a sign of mic stress, financial pressures, strength. Little research has been conducted interpersonal difficulties and grief on depression among student-ath- over loss/failure. Team dynamics also may be a fac- letes; however, preliminary data tor. Problems often are kept “in the indicate that student-athletes expe- Participation in athletics does not family,” and it is common for teams rience depressive symptoms and ill- provide student-athletes any immu- to try to solve problems by them- ness at similar or increased rates nity to these stresses, and it has the selves, often ignoring signs or than non-athlete students. Approx- potential to pose additional de- symptoms of more serious issues. imately 9.5 percent of the popula- mands. Student-athletes must bal- Depression affects approximately tion — or one out of 10 people — ance all of the demands of being a 19 million Americans, and for many, suffer from a depressive illness dur- college student along with athletics the symptoms first appear before or ing any given one-year period. demands. This includes the physical during college. Women are twice as likely to experi- demands of their sport, and the ence depression as men; however, time commitment of participation, Early identification and intervention men are less likely to admit to strength and conditioning, and skill (referral/treatment) for depression depression. Moreover, even though instruction. or other mental illness is extremely the majority of peoples’ depressive important, yet may be inhibited disorders can be improved, most Most athletes participate almost within the athletics culture for the people with depression do not seek year-round, often missing holidays, following reasons: help. school and summer breaks, classes and even graduation. In addition, if • Physical illness or injury is more 72 Depression is important to assess they struggle in their performance, readily measured and treated within Depression: Intervention for Intercollegiate Athletics

ness, worthlessness and excessive little as two weeks, while manic guilt, which are commonly associat- episodes may last as little as four ed with depression in women. Men days. Manic signs and symptoms often mask depression with the use are presented in Table 2. of alcohol or drugs, or by the social- ly acceptable habit of working In addition to the three types of excessively long hours. depressive disorders, student-athletes may suffer from an Adjust- Types of Depressive Illness ment Disorder. Adjustment disorders occur when an individual expe- Depressive illnesses come in differ- riences depressive (or anxious) ent forms. The following are gener- symptoms in response to a specific al descriptions of the three most event or stressor (e.g., poor perfor- prevalent, though for an individual mance, poor relationship with a the number, severity and duration of coach). An adjustment disorder can symptoms will vary. also progress into major depressive Available online at disorder. NCAA.org/health-safety. Major Depression, or “clinical depression,” is manifested by a Establishing a relationship with combination of symptoms that mental health services sports medicine, and often there is interfere with a person’s once plea- less comfort in addressing mental surable activities (school, sport, Athletics departments should identi- illness. sleep, eating, work). Student-ath- fy and foster relationships with • Mental wellness is not always letes experiencing five or more mental health resources on campus perceived as necessary for athletic symptoms as noted in Table 1 for or within the local community that performance. two weeks or longer, or noticeable will enable the development of a • The high profile of student-ath- changes in usual functioning, are diverse and effective referral plan letes may magnify the attention paid factors that should prompt referral addressing the mental well-being of on campus and in the surrounding to the team physician or mental their student-athletes and staff. community when an athlete seeks health professional. Fifteen percent Because student-athletes are less help. of people with major depression die likely to use counseling than • History and tradition drive athlet- by suicide. The rate of suicide in nonathlete students, increasing in- ics and can stand as barriers to men is four times that of women, teraction among mental health staff change. though more women attempt it dur- members, coaches and student- • The athletics department may ing their lives. athletes will improve compliance have difficulty associating mental illness with athletic participation. Dysthymia is a less severe form of with referrals. Athletics departments depression that tends to involve can seek psychological services and Enhancing knowledge and aware- long-term, chronic depressive mental health professionals from ness of depressive disorders symptoms. Although these symp- the following resources. toms are not disabling, they do Sports medicine staff, coaches and affect the individual’s overall func- • Athletics department sports student-athletes should be knowl- tioning. medicine services. edgeable about the types of depres- • Athletics department academic sion and related symptoms. Men Bipolar Disorder, or “manic- services. may be more willing to report depressive illness,” involves • University student health and fatigue, irritability, loss of interest in cycling mood swings from major counseling services. work or hobbies and sleep distur- depressive episodes to mania. • University medical school. bances, rather than feelings of sad- Depressive episodes may last as • University graduate programs 73 Depression: Intervention for Intercollegiate Athletics

(health sciences, education, med- sive disorder, anorexia nervosa, physicians should consult with psy- ical, allied health). bulimia nervosa and borderline per- chiatrists regarding complex men- • Local community. sonality disorder. tal health issues.

Screening for depression and For depression screening, it is A referral should be made to a related risk for suicide recommended that sports medi- licensed mental health professional cine teams utilize the Center for when coaches or sports medicine One way to ensure an athletics Epidemiological Studies Depres- staff members witness any of the department is in tune with student- sion (CES-D) Scale published by following with their student-ath- athletes’ mental well-being is to sys- the National Institute for Mental letes: tematically include mental health Health (NIMH). The CES-D is free check-ups, especially around high- to use and available at • Suicidal thoughts. risk times such as the loss of a www.nimh.nih.gov. Other resourc- • Multiple depressive symptoms. coach, significant injury, being cut es include such programs as QPR • A few depressive symptoms that from the team and catastrophic (Question, Persuade, Refer) Gate- persist for several weeks. events. Members of the sports keeper training; the Jed Foundation • Depressive symptoms that lead medicine team and/or licensed U Lifeline; and the Screening for to more severe symptoms or de- mental health professionals should Mental Health Depression and structive behaviors. also screen athletes for depression Anxiety Screenings. Information • Alcohol and drug abuse as an at pre-established points in time about these programs, and ways to attempt at self treatment. (e.g., pre-participation, exit inter- incorporate them into student-ath- • Overtraining or burnout, since views). Research indicates that lete check-ups, can be found at depression has many of the same sports medicine professionals are NCAA.org/health-safety. symptoms. better equipped to assess depression with the use of appropriate Seeking help Coaches and sports medicine staff mental health instruments; simply members should follow the follow- asking about depression is not rec- Most individuals who suffer from ing guidelines in order to help ommended. depression will fully recover to lead enhancing student-athlete compli- productive lives. A combination of ance with mental health referrals: A thorough assessment on the part counseling and medication appears of a mental health professional is to be the most effective treatment • Express confidence in the mental also imperative to differentiate for moderately and severely de- health professional (e.g., “I know major depression from dysthymia pressed individuals. Although some that other student-athletes have felt and bipolar disorder, and other con- improvement in mood may occur in better after talking to Dr. Kelly.”). ditions, such as medication use, the first few weeks, it typically takes • Be concrete about what counsel- viral illness, anxiety disorders, over- three to four weeks of treatment to ing is and how it could help (e.g., training and illicit substance use. obtain the full therapeutic effect. “Amy can help you focus more on Depressive disorders may co-exist Medication should only be taken your strengths.”). with substance-abuse disorders, and/or stopped under the direct • Focus on similarities between 74 panic disorder, obsessive-compul- care of a physician, and the team the student-athlete and the men- Depression: Intervention for Intercollegiate Athletics tal health professional (e.g., “Bob • Emphasize the confidentiality • Eat regular and nutritious has a sense of humor that you of medical care and the referral meals. would appreciate.” “Dr. Jones is process. • Participate in activities that a former college student-athlete typically make you feel better. and understands the pressures The following self-help strategies • Let family, friends and coaches student-athletes face.”). may improve mild depression help you. • Offer to accompany the stu- symptoms: • Increase positive or optimistic dent-athletes to their initial • Reduce or eliminate the use of thinking. appointment. alcohol and drugs. • Engage in regular and ade- • Offer to make the appointment • Break large tasks into smaller quate sleep habits. (or have the student-athlete make ones; set realistic goals. the appointment) while in your • Engage in regular, mild exer- office. cise.

Table 1 Table 2 DEPRESSIVE SIGNS AND SYMPTOMS MANIC SIGNS AND SYMPTOMS Individuals might present: • Decreased performance in school or sport. Individuals might present: • Noticeable restlessness. • Abnormal or excessive • Significant weight loss or weight gain. elation. • Decrease or increase in appetite nearly every day • Unusual irritability. (fluctuating?). • Markedly increased energy. • Poor judgment. Individuals might express: • Inappropriate social • Indecisiveness. behavior. • Feeling sad or unusually crying. • Increased talking. • Difficulty concentrating. • Lack of or loss of interest or pleasure in activities that were once Individuals might express: enjoyable (hanging out with friends, practice, school, sex). • Racing thoughts. • Depressed, sad or “empty” mood for most of the day and nearly • Increased sexual desire. every day. • Decreased need for sleep. • Recurrent thoughts of death or thoughts about suicide. • Grandiose notions. • Frequent feelings of worthlessness, low self-esteem, hopeless- ness, helplessness or inappropriate guilt. 75 Depression: Intervention for Intercollegiate Athletics

Using a simple tool such as this can help students and staff look for signs of depression. Put a check mark by each sign that describes you: I am really sad most of the time. I don’t enjoy doing the things I’ve always enjoyed doing. I don’t sleep well at night and am very restless. I am always tired. I find it hard to get out of bed. I don’t feel like eating much. I feel like eating all the time. I have lots of aches and pains that don’t go away. I have little to no sexual energy. I find it hard to focus and am very forgetful. I am mad at everybody and everything. I feel upset and fearful, but can’t figure out why. I don’t feel like talking to people. I feel like there isn’t much point to living, nothing good is going to happen to me. I don’t like myself very much. I feel bad most of the time. I think about death a lot. I even think about how I might kill myself. If you checked several boxes, call your doctor. Take the list to show the doctor. You may need to get a check-up and find out if you have depression.

References

1. Backmand J, et. al. Influence of physical 02-3561). 25 pages. Available from 6. Pinkerton RS, Hinz LD, Barrow JC. The activity on depression and anxiety of former www.nimh.nih.gov/publicat/nimhdepres- college student-athlete: Psychological con- elite athletes. International Journal of Sports sion.pdf. siderations and interventions. Journal of Medicine. 2003. 24(8):609-919. 4. Maniar SD, Chamberlain R, Moore N. American College Health. 1989;37(5):218- 2. Hosick, M. Psychology of sport more Suicide risk is real for student-athletes. The 26. than performance enhancement. The NCAA NCAA News. November 7, 2005. Available 7. Putukian, M, Wilfert, M. Student-athletes News. March 14, 2005. Available online. online. also face dangers from depression. The 3. National Institute of Mental Health. 5. Maniar SD, Curry LA, Sommers- NCAA News. April 12, 2004. Available Depression. Bethesda (MD): National Flanagan J, Walsh JA. Student-athlete pref- online. Institute of Mental Health, National Institutes erences in seeking help when confronted 8. Schwenk, TL. The stigmatization and of Health, US Department of Health and with sport performance problems. The denial of mental illness in athletes. British 76 Human Services; 2000. (NIH Publication No Sport Psychologist. 2001;15(2):205-23. Journal of Sports Medicine. 2000. 34:4-5. 3

SPECIAL POPULATIONS Also Found on the NCAA Web site at: NCAA.org/health-safety GUIDELINE 3a Participation by the Student-Athlete with Impairment January 1976 • Revised August 2004

In accordance with the recom- that cannot be eliminated or 1. Available published informa- mendations of major medical reduced by reasonable accom- tion regarding the medical risks organizations and pursuant to the modations. Recent judicial deci- of participation in the sport with requirements of federal law (in sions have upheld a university’s the athlete’s mental or physical particular, the Rehabilitation Act legal right to exclude a student- impairment; of 1976 and The Americans With athlete from competition if the Disabilities Act), the NCAA team physician has a reasonable 2. The current health status of the encourages participation by stu- medical basis for determining student-athlete; dent-athletes with physical or that athletic competition creates 3. The physical demands of the mental impairments in intercolle- a significant risk of harm to the sport and position(s) that the giate athletics and physical activ- student-athlete or others. When student-athlete will play; ities to the full extent of their student-athletes with impair- interests and abilities. It is imper- ments not otherwise qualified to 4. Availability of acceptable pro- ative that the university’s sports participate in existing athletics tective equipment or measures to medicine personnel assess a stu- programs are identified, every reduce effectively the risk of dent-athlete’s medical needs and means should be explored by harm to the student-athlete or specific limitations on an individ- member institutions to provide others; and ualized basis so that needless suitable sport and recreational restrictions will be avoided and programs in the most appropri- 5. The ability of the student-ath- medical precautions will be taken ate, integrated settings possible lete (and, in the case of a minor, to minimize any enhanced risk of to meet their interests and abili- the parents or guardian) to fully harm to the student-athlete or ties.. understand the material risks of others from participation in the athletic participation. subject sport. Participation Considerations Organ Absence or Non-function A student-athlete with impair- Before allowing any student-ath- ment should be given an oppor- lete with an impairment to partic- When the absence or non-func- tunity to participate in an intercol- ipate in an athletics program, it is tion of a paired organ constitutes legiate sport if he or she has the recommended that an institution the impairment, the following requisite abilities and skills in require joint approval from the specific issues need to be spite of his or her impairment, physician most familiar with the addressed with the student-ath- with or without a reasonable student-athlete’s condition, the lete and his/her parents or accommodation. Medical exclu- team physician, and an appropri- guardian (in the case of a minor). sion of a student-athlete from an ate official of the institution as The following factors should be athletics program should occur well as his or her parent(s) or considered: only when a mental or physical guardian. The following factors 1. The quality and function of the impairment presents a significant should be considered on an indi- remaining organ; risk of substantial harm to the vidualized basis in determining health or safety of the student- whether he or she should partici- 2. The probability of injury to the 78 athlete and/or other participants pate in a particular sport: remaining organ; and Participation by the Student-Athlete with Impairment

3. The availability of current pro- that a properly executed docu- team physician and any consult- tective equipment and the likely ment of understanding and a ing physician, a representative of effectiveness of such equipment waiver release the institution for the institution’s athletics depart- to prevent injury to the remaining any legal liability for injury or ment, and the institutution’s legal organ. death arising out of the student- counsel. This document evidences Medical Release athlete’s participation with his or the student-athlete’s understand- her mental or physical impair- ing of his or her medical condition When a student-athlete with ment medical condition. The fol- and the potential risks of athletic impairment is allowed to com- lowing parties should sign this participation, but it may not immu- pete in the intercollegiate athlet- document: the student-athlete, nize the institution from legal liabil- ics program, it is recommended his or her parents/guardians, the ity for injury to the student-athlete.

References 1. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation. Pediatrics. 94(5): 757-60, 1994.

2. Mitten, MJ. Enhanced risk of harm to one’s self as a justifica- tion for exclusion from athletics. Marquette Sports Law Journal. 79 8:189-223, 1998. GUIDELINE 3b Pregnancy in the Student-Athlete January 1986 • Revised June 2008

The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Dr. James Clapp, FACSM, in the revision of this guideline.

Pregnancy Policies ability may not be reduced or can- risks to the fetus associated with celed during the period of its increased core body temperatures Pregnancy places unique chal- award because of an injury, illness that may occur with exercise, lenges on the student-athlete. or physical or mental medical especially in the heat. Each member institution should condition. have a policy clearly outlined to The fetus may benefit from exer- address the rights and responsibil- The team’s certified athletic trainer cise during pregnancy in several ities of the pregnant student ath- or team physician is often ways, including an increased tol- lete. The policy should address: approached in confidence by the erance for the physiologic stress- student-athlete. The sports medi- es of late pregnancy, labor and • Where the student-athlete can cine staff should be well-versed in delivery. receive confidential counseling; the athletics department’s policies The safety of participation in indi- • Where the student-athlete can and be able to access the identi- vidual sports by a pregnant access timely medical and obstet- fied resources. The sports medi- woman should be dictated by the rical care; cine staff should respect the stu- movements and physical dent-athlete’s requests for confi- • How the pregnancy may affect demands required to compete in dentiality until such time when that sport and the previous activi- the student-athlete’s team stand- there is medical reason to with- ing and institutional grants-in-aid; ty level of the individual. The hold the student-athlete from American College of Sports • That pregnancy should be competition. Medicine discourages heavy treated as any other temporary Exercise In Pregnancy weight lifting or similar activities health condition regarding receipt that require straining or valsalva. of institutional grants-in-aid; and Assessing the risk of intense, strenuous physical activity in Exercise in the supine position • That NCAA rules permit a one- pregnancy is difficult. There is after the first trimester may cause year extension of the five-year some evidence that women who venous obstruction and condition- period of eligibility for a female exercise during pregnancy have ing or training exercises in this student-athlete for reasons of improved cardiovascular function, position should be avoided. pregnancy. limited weight gain and fat reten- Sports with increased incidences Student-athletes should not be tion, improved attitude and mental of bodily contact (basketball, ice forced to terminate a pregnancy state, easier and less complicated hockey, field hockey, lacrosse, because of financial or psycholog- labor, and enhanced postpartum soccer, rugby) or falling (gym- ical pressure or fear of losing their recovery. There is no evidence nastics, equestrian, downhill ski- institutional grants-in-aid. See that increased activity increases ing) are generally considered Bylaw 15.3.4.3, which specifies the risk of spontaneous abortion higher risk after the first that institutional financial aid in uncomplicated pregnancies. trimester because of the potential 80 based in any degree on athletics There are, however, theoretical risk of abdominal trauma. The Participation by the Pregnant Student-Athlete student-athlete’s ability to com- medically indicated and require • Take care to remain well-hydrat- pete may also be compromised close supervision. ed and to avoid over-heating. due to changes in physiologic If a student-athlete chooses to After delivery or pregnancy ter- capacity, and musculoskeletal compete while pregnant she mination, medical clearance is issues unique to pregnancy. recommended to ensure the stu- should: There is also concern that in the dent-athlete’s safe return to ath- setting of intense competition a • Be made aware of the potential letics. (See Follow-up Exam- pregnant athlete will be less like- risks of their particular sport and inations section of Guideline 1b.) ly to respond to internal cues to exercise in general while pregnant; The physiologic changes of preg- moderate exercise and may feel nancy persist four to six weeks pressure not to let down the • Be encouraged to discontinue postpartum, however, there have team. exercise when feeling over-exert- been no known maternal compli- ed or when any warning signs cations from resumption of train- The American College of Ob- (Table I) are present; ing. Care should be taken to stetrics and Gynecology states individualize return to practice that competitive athletes can • Follow the recommendations of and competition. remain active during pregnancy their obstetrical provider in coordi- but need to modify their activity as nation with the team physician; and References

1. American College of Obstetrics and Gynecology Committee on Obstetric Practice: Exercise Table No. 1 During Pregnancy and the Warning Signs to Terminate Exercise While Pregnant Postpartum Period. Obstetrics and Gynecology 99(1) 171-173, Vaginal Bleeding 2002. Shortness of Breath Before Exercise 2. American College of Sports Dizziness Medicine: Exercise During Headache Pregnancy. In: Current Comment Chest Pain from the American College of Calf Pain or Swelling Sports Medicine, Indianapolis, Pre-term Labor IN, August 2000. Decreased Fetal Movement 3. Clapp JF: Exercise During Amniotic Fluid Leakage Pregnancy, A Clinical Update. Clinics in Sports Medicine 19(2) Muscle Weakness 273-286, 2000. 81 GUIDELINE 3c The Student-Athlete with Sickle Cell Trait October 1975 • Revised June 2008

Sickle cell trait is not a disease. It Sickle cell trait is generally Exertional rhabdomyolysis can is the inheritance of one gene for benign and consistent with a be life-threatening. During in- normal hemoglobin (A) and one long, healthy life. As they get tense exertion and hypoxemia, gene for sickle hemoglobin (S), older, some persons with the trait sickled red cells can accumulate giving the genotype AS. Sickle become unable to concentrate in the blood. Dehydration wors- cell trait (AS) is not sickle cell urine normally, but this is not a ens exertional sickling. Sickled anemia (SS), in which two abnor- key problem for college athletes. red cells can “logjam” blood ves- mal genes are inherited. Sickle Most athletes complete their sels in working muscles and pro- cell anemia causes major anemia careers without any complica- voke ischemic rhabdomyolysis. and many clinical problems, tions. However, there are three Exertional rhabdomyolysis is not whereas sickle cell trait causes constant concerns that exist for exclusive to athletes with sickle no anemia and few clinical prob- athletes with sickle cell trait: cell trait. Planned emergency lems. Sickle cell trait will not turn gross hematuria, splenic infarc- response and prompt access to into the disease. However, it is tion, and exertional rhabdomyol- medical care are critical compo- possible to have symptoms of ysis, which can be fatal. nents to ensure adequate the disease under extreme condi- response to a collapse or athlete tions of physical stress or low Gross hematuria, visible blood in in distress. oxygen levels. In some cases, the urine, usually from the left athletes with the trait have kidney, is an occasional compli- The U.S. Armed Forces linked expressed significant distress, cation of sickle cell trait. Athletes sickle trait to sudden unexplained collapsed and even died during should consult a physician for death during basic training. rigorous exercise. return-to-play clearance. Recruits with sickle trait were about 30 times more likely to die People at high risk for having Splenic infarction can occur in than other recruits. The deaths sickle cell trait are those whose people with sickle cell trait, typical- were initially classified as either ancestors come from Africa, ly at altitude. The risk may begin acute cardiac arrest of undefined South or Central America, at 5,000 feet and increases with mechanism or deaths related to Caribbean, Mediterranean coun- increasing altitude. Vigorous exer- heat stroke, heat stress, or rhab- tries, India, and Saudi Arabia. cise (e.g., skiing, basketball, foot- domyolysis. Further analysis Sickle cell trait occurs in about 8 ball, hiking, anaerobic condition- showed that the major risk was percent of the U.S. African- ing) may increase the risk. Splenic severe exertional rhabdomyolysis, American population and rarely infarction causes left upper quad- a risk that was about 200 times (between one in 2,000 to one in rant or lower chest pain, often with greater for recruits with sickle cell 10,000) in the Caucasian popula- nausea and vomiting. It can mimic trait. Deaths among college ath- tion. It is present in athletes at all pleurisy, pneumothorax, side letes with sickle trait, almost levels, including high school, col- stitch, or renal colic. Splenic exclusively in football dating back legiate, Olympic and profession- infarction at altitude has occurred to 1974, have been from exer- al. Sickle cell trait is no barrier to in athletes with sickle trait. tional rhabdomyolysis, including outstanding athletic perfor- Athletes should consult a physi- early cardiac death from hyper- 82 mance. cian for return-to-play clearance. kalemia and lactic acidosis and The Student-Athlete with Sickle Cell Trait later metabolic death from acute lead to life-threatening complica- be used as a gateway to targeted myoglobinuric renal failure. tions or even sudden death. The precautions. emergent management of a sick- In other cases, athletes have ling collapse is covered in the Precautions can enable student- survived collapses while running references. athletes with sickle cell trait to a distance race, sprinting on a thrive in their sport. These pre- basketball court or football field, Screening for sickle cell trait as cautions are outlined in the refer- and running timed laps on a part of the medical examination ences and in a 2007 NATA track. The harder and faster ath- process is an institutional deci- Consensus Statement on Sickle letes go, the earlier and greater sion. The references allude to Cell Trait and the Athlete. the sickling. Sickling can begin growing support for the practical Knowledge of a student-athlete’s in only two to three minutes of benefits of screening and cam- sickle cell status should facilitate sprinting, or in any other all-out puses that screen are increasing prompt and appropriate medical exertion of sustained effort, thus in frequency. Screening can be care during a medical emergency. quickly increasing the risk of accomplished with a simple collapse. Athletes with sickle blood test that is relatively inex- Student-athletes with sickle cell cell trait cannot be “conditioned” pensive. All 50 states now trait should be knowledgeable of out of the trait and coaches screen for hemoglobinopathies these precautions and institu- pushing these athletes beyond at birth, but too often families are tions should provide an environ- their normal physiological not told of a positive result for ment in which these precautions response to stop and recover sickle cell trait, so most colle- may be activated. In general, place these athletes at an giate athletes with the trait do not these precautions suggest stu- increased risk for collapse. know they have it. In a 2006 sur- dent-athletes with sickle cell trait vey of NCAA Division I Football should: A sickling collapse is a medical Bowl Subdivision schools, 64 emergency. Even the most fit percent of respondents screened • Set their own pace. athletes can experience a sickling for sickle cell trait; however, pre- • Engage in a slow and gradual collapse. Themes from the liter- cautions were inconsistent. If preseason conditioning regimen ature describe sickling athletes screening is done, it may be to be prepared for sports-specif- with ischemic pain and muscle done on a voluntary basis with ic performance testing and the weakness rather than muscular the informed consent of the stu- rigors of competitive intercolle- cramping or “locking up.” Unlike dent-athlete and should be giate athletics. cardiac collapse (with ventricular offered to all student-athletes, fibrillation), the athlete who because sickle cell trait occurs in • Build up slowly while training slumps to the ground from sick- all populations. If a test is posi- (e.g., paced progressions). ling can still talk. This athlete is tive, the student-athlete should typically experiencing major lac- be offered counseling on the • Use adequate rest and recov- tic acidosis, impending shock, implications of sickle cell trait, ery between repetitions, espe- and imminent hyperkalemia from including health, athletics and cially during “gassers” and sudden rhabdomyolysis that can family planning. Screening can intense station or “mat” drills. 83 The Student-Athlete with Sickle Cell Trait

• Not be urged to perform all- • Stop activity immediately agement. out exertion of any kind beyond upon struggling or experiencing two to three minutes without a symptoms such as muscle pain, • Refrain from extreme exercise during acute illness, if feeling ill, breather. abnormal weakness, undue fatigue or breathlessness. or while experiencing a fever. • Be excused from performance • Access supplemental oxygen tests such as serial sprints or • Stay well hydrated at all times, especially in hot and humid con- at altitude as needed. timed mile runs, especially if ditions. these are not normal sport activ- • Seek prompt medical care when ities. • Maintain proper asthma man- experiencing unusual distress.

References 1. NATA Consensus Statement: Sickle 6. Gardner JW, Kark JA: Fatal rhab- 10. Dincer HE, Raza T: Compartment syn- cell trait and the athlete, June 2007. domyolysis presenting as mild heat illness drome and fatal rhabdomyolysis in sickle 2. Clarke CE, Paul S, Stilson M, Senf J: in military training. Milit Med cell trait. Wisc Med J 2005;104:67-71. Sickle cell trait preparticipation screening 1994;159:160-163. 11. Makaryus JN, Catanzaro JN, Katona practices of collegiate physicians. Clin J 7. Bergeron MF, Gannon JG, Hall EL, KC: Exertional rhabdomyolysis and renal Sport Med 2007;16:440a Kutlar A: Erythrocyte sickling during exer- failure in patients with sickle cell trait: Is it 3. Eichner ER: Sickle cell trait. J Sport cise and thermal stress. Clin J Sport Med time to change our approach? Rehab 2007;16:197-203. 2004;14:354-356. Hematology 2007;12:349-352. 4. Eichner ER: Sickle cell trait and ath- 8. Eichner ER: Sickle cell trait and the 12. Mitchell BL: Sickle cell trait and sud- letes: three clinical concerns. Curr Sports athlete. Gatorade Sports Science Institute den death – bringing it home. J Nat Med Med Rep 2007;6:134-135. Sports Science Exchange 2006;19(4):1-4. Assn 2007;99:300-305. 5. Kark JA, Posey DM, Schumacher HR, 9. Browne RJ, Gillespie CA: Sickle cell Ruehle CJ: Sickle-cell trait as a risk factor trait: A risk factor for life-threatening for sudden death in physical training. N rhabdomyolysis? Phys Sportsmed 1993;21(6):80-88. 84 Engl J Med 1987;317:781-787. 4

EQUIPMENT

Also Found on the NCAA Web site at: NCAA.org/health-safety GUIDELINE 4a Protective Equipment June 1983 • Revised June 2007

Rules governing mandatory equipment standards should adhere to coach or equipment manager any ment and equipment use vary by those standards. need for its maintenance, the sport. Athletics personnel should student-athlete also is complying be familiar with what equipment is The NOCSAE mark on a helmet or with the purpose of the standard. mandatory by rule and what con- HECC seal on an ice hockey face stitutes illegal equipment; how to mask indicates that the equipment The following list of mandatory wear mandatory equipment during equipment and rules regarding pro- the contest, and when to notify the has been tested by the manufac- tective equipment use is based on coaching staff that the equipment turer in accordance with NOCSAE NCAA sports rules. The most has become illegal during compe- or HECC test standards. By keep- updated information should be tition. Athletics personnel involved ing a proper fit, by not modifying obtained from relevant NCAA rules in sports with established equip- its design, and by reporting to the committees.

Mandatory Protective Rules Governing Special Sport Equipment* Protective Equipment

1. Baseball 1. A double ear-flap protective None helmet while batting, on deck and running bases. Helmets must carry the NOCSAE mark. 2. All catchers must have a built- in or attachable throat guard on their masks. 3. All catchers are required to wear a protective helmet when fielding their position.

2. Basketball None Elbow, hand, finger, wrist or forearm guards, casts or braces made of fiberglass, plaster, metal or any other nonpliable substance shall be prohibited. Pliable (flexible or easily bent) material covered on all exterior sides and edges with no less than 0.5-inch thickness of a slow-rebounding foam shall be used to immobilize and/or protect an injury. The prohibition of the 86 use of hard-substance material Protective Equipment

Mandatory Protective Rules Governing Special Sport Equipment* Protective Equipment

Basketball (continued) does not apply to the upper arm, shoulder, thigh or lower leg if the material is padded so as not to create a hazard for other players. Equipment that could cut or cause an injury to another player is prohibited, without respect to whether the equipment is hard.

Equipment that, in the referee’s judgment, is dangerous to other players, may not be worn.

3. Fencing 1.Masks with meshes (space between the wires) of maximum 2.1 mm and from wires with a minimum gauge of 1 mm diameter. 2.Gloves, of which the gauntlet must fully cover approximately half the forearm of the competitor’s sword arm. 3.Jacket or vest and metallic lames. 4.Ladies’ chest protectors made of metal or some other rigid material. 5.Underarm protector.

4.Field Hockey 1.The following equipment is per- Players shall not wear anything mitted for use only by goal- that may be dangerous to other keepers: body and wrap-around players. Players have the option throat protectors, pads, kickers, of wearing soft headgear subject gauntlet gloves, helmet to game official approval. incorporating fixed full-face protection and cover for the head, and elbow pads. 2.Mouthguards for all players including goalkeepers. 3.Wrap-around throat protector and helmet for player designated as a “kicking back.” In the event of a defensive penalty corner, the “kicking back” must also wear a chest protector and distinguishing 87 jersey. Protective Equipment

Mandatory Protective Rules Governing Special Sport Equipment* Protective Equipment

1 5.Football 1. Soft knee pads at least ⁄2-inch Illegal equipment includes the fol- thick must cover the knees and be lowing: covered by pants. No pads or pro- 1. Equipment worn by a player, tective equipment may be worn out- including artificial limbs, that side the pants. would endanger other players. 2. Face masks and helmets with a 2. Hard, abrasive or unyielding sub- secured four- or six-point chin stances on the hand, wrist, fore- strap. All players shall wear hel- arm or elbow of any player, unless mets that carry a warning label covered on all exterior sides and regarding the risk of injury and a edges with closed-cell, slow- manufacturer’s or reconditioner’s recovery foam padding no less than 1 certification indicating satisfaction ⁄2-inch thick, or an alternate mate- of NOCSAE test standards. rial of the same minimum thickness 3. Shoulder pads, hip pads with and similar physical properties. tailbone protectors and thigh guards. Hard or unyielding substances are permitted, if covered, only to pro- 4. An intra-oral mouthpiece of any tect an injury. Hand and arm pro- readily visible color (not white or tectors (covered casts or splints) transparent) with FDA-approved are permitted only to protect a base materials (FDCS) that covers fracture or dislocation. all upper teeth. It is recommended that the mouthpiece be proper- 3. Thigh guards of any hard sub- ly fitted. stances, unless all surfaces are covered with material such as closed- 1 cell vinyl foam that is at least ⁄4-inch thick on the outside surface and at 3 least ⁄8-inch thick on the inside surface and the overlaps of the edges; shin guards not covered on both sides and all edges with closed-cell, slow-recovery foam padding at 1 least ⁄2-inch thick, or an alternate material of the same minimum thickness having similar physical properties; and therapeutic or preventive knee braces, unless worn under the pants and entirely covered from direct external exposure.

88 Protective Equipment

Mandatory Protective Rules Governing Special Sport Equipment* Protective Equipment

Football (continued) 4. Projection of metal or other hard substance from a player’s person or clothing. 6. Gymnastics None None 7. Ice Hockey 1.Helmet with chin straps secure- 1.The use of pads or protectors ly fastened. It is recommended made of metal or any other materi- that the helmet meet HECC stan- al likely to cause injury to a player dards. is prohibited. 2.An intra-oral mouthpiece that 2.The use of any protective equip- covers all the upper teeth. ment that is not injurious to the 3.Face masks that have met the player wearing it or other players standards established by the is recommended. HECC-ASTM F 513-89 Eye and 3.Jewelry is not allowed, except Face Protective Equipment for for religious or medical medals, Hockey Players Standard. which must be taped to the body. 8. Women’s Lacrosse 1. The goalkeeper must wear a hel- Protective devices necessitated on met with face mask, seperate genuine medical grounds must be throat protector, a mouth piece, a approved by the umpires. Close- chest protector. fitting gloves, nose guards, eye 2. All field players shall wear guards and soft headgear may be properly an intra-oral mouthpiece worn by all players. These devices that covers all upper teeth. must create no danger to other players. 3. All field players shall wear protective eyewear that meet current ASTM lacrosse standards (effective January 1, 2005).

9. Men’s Lacrosse 1. Protective helmet that carries 1. A player shall not wear any the NOCSAE mark, equipped with equipment that, in the opinion of face mask and chin pad, with a the official, endangers the individ- cupped four-point chin strap ual or others. (high-point hookup). 2. The special equipment worn by 2. Intra-oral mouthpiece that cov- the goalkeeper shall not exceed ers all the upper teeth and is yellow standard equipment for a field- or any other highly visible color. player, plus standard goalkeeper 3. Protective gloves, shoulder equipment, which includes shin- pads, shoes and jerseys. Shoulder guards, chest protectors and pads shall not be altered. throat protectors. 4. Throat protector and chest protector are required for the goalie.

89 Protective Equipment

Mandatory Protective Rules Governing Special Sport Equipment* Protective Equipment

10. Rifle Shooters and range personnel in None the immediate vicinity of the range required to wear hearing protection during smallbore. Shooters urged to wear shatterproof eye protection.

11. Soccer Players shall wear shin guards 1. A player shall not wear anything under the stockings in the manner that is dangerous to another player. intended, without exception. The 2. Knee braces are permissible pro- shin guards shall be professional- vided no metal is exposed. ly manufactured, age and size 3. Casts are permitted if covered appropriate and not altered to and not considered dangerous. decrease protection. The shin guards must meet NOCSAE stan- 4. A player shall not wear any jewel- dards. ry of any type whatsoever. Excep- tion: Medical alert bracelets or neck laces may be worn but must be taped to the body.

12. Skiing Helmets manufactured for ski racing None are required in all Alpine events and event training.

13. Softball 1. Catchers must wear foot-to-knee Casts, braces, splints and shinguards; NOCSAE approved protheses must be well-padded to protective helmet with face mask protect both the player and oppo- and built-in or attachable throat nent and must be neutral in color. If guard; and chest protector. worn by pitcher, cannot be dis- 2. A NOCSAE approved double-ear tracting on nonpitching arm. If flap protective helmet must be worn on pitching arm, may not worn by players while batting, cause safety risk or unfair compet- running the bases or warming-up itive advantage. in the on-deck circle. 14. Swimming and Diving None None

90 Protective Equipment

Mandatory Protective Rules Governing Special Sport Equipment* Protective Equipment

15. Track and Field None 1. No taping of any part of the hand, thumb or fingers will be permitted in the discus and javelin throws, and the shot put, except to cover or protect an open wound. In the hammer throw, taping of individual fingers is permissible. Any taping must be shown to the head event judge before the event starts. 2. In the pole vault, the use of a forearm cover to prevent injuries is permissible. 16. Volleyball None 1. It is forbidden to wear any object that may cause an injury or give an artificial advantage to the player, including but not limited to headgear, jewelry and unsafe casts or braces. Religious medal- lions or medical identifications must be removed from chains and taped or sewn under the uniform. 2. All jewelry must be removed. Earrings must be removed. Taping of earrings or other jewelry is not permitted. 3. Hard splints or other potentially dangerous protective devices worn on the arms or hands are prohibited, unless padded on all 1 sides with at least /2-inch thick of slow rebounding foam. 17. Water Polo Cap with protective ear guards. None

18. Wrestling Protective ear guard. 1. Anything that does not allow normal movement of the joints and prevents one’s opponent from applying normal holds shall be barred. 2. Any legal device that is hard and abrasive must be covered and padded. Loose pads are prohibited. It is recommended that all wrestlers wear a protective mouth guard. 3. Jewelry is not allowed. 91 GUIDELINE 4b Eye Safety in Sports January 1975 • Revised August 2001

Eye injuries in sports are relatively has been tested for sports and is Protective eyewear should be con- frequent, sometimes catastrophic, recommended for all sports with sidered for all sports that have a and almost completely pre- the potential for impact. Other projectile object (ball/stick) whose ventable with the use of appropri- impact resistant lens materials size and/or speed could potential- ate protective devices. A sports may be available in the near ly cause ocular damage. Eye pro- eye protector may be a spectacle, future. Contact lenses are not tection is especially important for a goggle, a face-supported pro- capable of protecting the eye from functionally one-eyed sports par- tector, or a protector attached to a direct blows. Student-athletes ticipants (whose best corrected helmet. It comes with or without who wear contact lenses for cor- vision in their weaker eye is 20/40 lenses, is capable of being held rective vision should wear appro- or worse). Eye protection devices securely in place, and may protect priate sports safety eyewear for are designed to significantly the face as well as the eyes. Some ocular protection. reduce the risk of injury, but can forms can be worn over regular never provide a guarantee against glasses. Sports eye protectors are The American Academy of such injuries. specially designed, fracture-resis- Opthalmology recommends that tant units that comply with the head, face and eye protection Summary American Society for Testing and should be certified by either Materials (ASTM), or the National the Protective Eyewear Certifi- 1. Appropriate for eye protection Operating Committee on cation Council (PECC — www. in sports: Standards for Athletic Equipment protecteyes.org/), the Hockey a. Safety sports eyewear that (NOCSAE) standards for specific Equipment Certification Council conforms to the requirements of sports. (HECC — www.hecc-hockey.org/), the American Society for Testing the National Operating Committee and Materials (ASTM) Standard Approximately one-third of all per- on Standards for Athletic F803 for selected sports (racket sons participating in sports Equipment (NOCSAE — www. sports, basketball, women’s require corrective lenses to nocsae.org/), or the Canadian lacrosse, and field hockey). achieve the visual acuity neces- Standards Association (CSA — b. Sports eyewear that is sary for proper and safe execution www.csa-international.org/). The attached to a helmet or is of their particular sports activity. cited Web sites will have more designed for sports for which Athletes who need corrective eye- specific information on these ASTM F803 eyewear alone pro- wear for participation should use standards. Certification ensures vides insufficient protection. lenses and frames that meet the that the protective device has been Those for which there are stan- appropriate safety standards. At properly tested to current standard specifications include: ski- this time polycarbonate plastic is dards. ing (ASTM 659), and ice hockey the only clear lens material that (ASTM F513). Other protectors with NOCSAE standards are available for football and men’s lacrosse. 92 Eye Safety in Sports

2. Not appropriate for eye protection in sports: a. Streetwear (fashion) specta- cles that conform to the requirements of American National Standards Institute (ANSI) Standard Z80.3. b. Safety eyewear that conforms to the requirements of ANSI Z87.1, mandated by OSHA for industrial and educational safety eyewear.

References

1. Prevent Blindness America : 3. Vinger PF: The Eye and 5. Vinger PF. A practical guide 1998 Sports and Recreational Sports Medicine.In Duane TD, for sports eye protection. Eye Injuries. Schaumburg, IL: Jaeger EA (eds): Clinical Physician and Sportsmedicine, Prevent Blindness America; Ophthalmology, vol. 5, chapter 2000;28;49-69. 45, J.B. Lippincott, Philadelphia, 1999. 6. Play hard—play safe. San PA 1994. 2. Napier SM, Baker RS, Francisco, CA: American Sanford DG, et al.: Eye Injuries 3. Vinger PF, Parver L, Alfaro Academy of Ophthalmology, in Athletics and Recreation. DV, Woods T, Abrams BS. 2001. Survey of Opthalmology. Shatter resistance of spectacle 41:229-244, 1996. lenses. JAMA 1997; 277:142- 144. 93 GUIDELINE 4c Mouth Guards January 1986 • Revised August 2007

The NCAA Committee on ping of tooth enamel surfaces coach, student-athlete and med- Competitive Safeguards and and reduce fractures of teeth, ical staff need to be educated Medical Aspects of Sports roots or bones. about the protective functions of acknowledges the significant a mouth guard and the game input of Dr. Jack Winters, past 2. “Properly fitted mouthguards” rules regarding mouth guard use could protect the lip and cheek president of the Academy of must be enforced. tissues from being impacted and Sports Dentistry, in the revision lacerated against tooth edges. of this guideline. 3. “Properly fitted mouthguards” The NCAA has mandatory equip- could reduce the incidence of a ment rules, including the use of fractured jaw caused by a blow mouthguards for selective delivered to the chin or head. sports. Various studies of “properly fitted mouthguards” indicate 4. “Properly fitted mouthguards” that they may reduce dental could provide protection to tooth- injuries when blows to the jaws less spaces, so support is given or head are received. to the missing dentition of the student-athlete. The American Dental Association has urged the mandatory use of Stock, mouth formed and cus- mouth guards for those engaged tom-fitted are three types of in athletics activities that involve mouthguards recognized by the body contact and endorsed their American Dental Association. All use “in sporting activities in need to be properly fitted for which a significant risk of oral maximum protection. Student- injury may occur.” It is important athletes should be advised as to when considering the optimum which “properly fitted mouth- protection for an athlete that a guard” is best for them and how thorough medical history be it is best maintained to assure the taken and the demands of his or maximum fit and protection for her position and sporting activity daily practices and game-day be considered. wear. Medical staff personnel should regularly oversee and Specific objectives for the use of observe the student-athletes and “properly fitted mouthguards” as the “properly fitted mouth- protective devices in sports are guards.” as follows: In order to realize fully the bene- 94 1. “Properly fitted mouthguards” fits of wearing a mouth guard, the could reduce the potential chip- Mouth Guards

Sport Position Intra-oral Mouthguard Color Covers All Upper Teeth When Field Hockey Field Mandatory (NCAA Mod. 8.1.b); Not specified Not specified Regular Season strongly recommended Competition for goalkeepers and NCAA Championships Football All Mandatory (NCAA 1.4.4.d) Readily Visible Color Yes Regular Season (not white or transparent) Competition, Postseason Competition and NCAA Championships Ice Hockey All Mandatory (NCAA 3.2) Recommended Covers all the Regular Season remaining teeth Competition and of one jaw. NCAA Championships Women’s All Mandatory (NCAA 2.8) Not specified Yes Regular Season Lacrosse Competition and NCAA Championships Men’s Lacrosse All Mandatory (NCAA 1.20) Yellow or any Yes Regular Season other visible color Competition and NCAA Championships

References 1. Using mouthguards to reduce cal parameters. MSSE. (38)8: 6. “Sports Dentistry.” (1991, the incidence and severity of 1500-1504. October. Revised 2000, April). sports-related oral injuries. 4. Academy for Sports Dentistry. Dental Clinics of North America. American Dental Association. 2006. “Position Statement: ‘A Properly 7. American Dental Association. 2. Kumamoto, D and Maeda, Y. A Fitted Mouthguard’ Athletic (1999). “Your Smile with a literature review of sports-related Mouthguard Mandates.” Mouthguard.” (211 East Chicago orofacial trauma. General Dentistry. www.acadsportsdent.org. 2004:270-281. 5. Stenger, J.M. (1964). Avenue, Chicago, IL, 60611) 3. Bourdin M, Brunet-Patru I, Hager “Mouthguards: Protection Against 8. Winters, J.E. (1996, June). “The P, Allard Y, Hager J, Lacour J, Shock to Head, Neck and Teeth.” Profession’s Role in Athletics.” Moyen B. 2006. Influence of max- Journal of the American Dental Journal of the American Dental illary mouthguards on physiologi- Association. Vol. 69 (3). 273-281. Association. Vol. 127. 810-811. 95 GUIDELINE 4d Use of the Head as a Weapon in Football and Other Contact Sports January 1976 • Revised June 2002

Head and neck injuries causing wearer and should not be used as a imizing the possibility of catastroph- death, brain damage or paralysis weapon, addresses this point as fol- ic injury. Using the helmet as an occur each year in football and other lows: injury-inflicting instrument is illegal, sports. While the number of these and should be strongly discouraged injuries each year is relatively small, 1. The helmet shall not be used as by coaches and game officials. This they are devastating occurrences the brunt of contact in the teaching concern is not only in football, but that have a great impact. Most of of blocking or tackling; also in other contact sports where these catastrophic injuries result 2. Self-propelled mechanical ap- helmets are used, e.g. ice hockey from initiating contact with the paratuses shall not be used in the and men’s lacrosse. head. The injuries may not be pre- teaching of blocking and tackling; Football and all contact sports vented due to the forces encoun- and tered during collisions, but they can should be concerned with the pre- be minimized by helmet manufac- 3. Greater emphasis by players, vention of catastrophic head turers, coaches, players and offi- coaches and officials should be injuries. The rules against butting, cials complying with accepted safe- placed on eliminating spearing. ramming and spearing with the hel- ty standards and playing rules. met are for the protection of the hel- Proper training in tackling and meted player as well as the oppo- The American Football Coaches blocking techniques, including a nent. A player who does not comply Association, emphasizing that the “see what you hit approach”, con- with these rules in any sport is a helmet is for the protection of the stitutes an important means of min- candidate for a catastrophic injury.

1. Heads Up: Concussion Tool Kit CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm. 2. Heads Up Video NATA. Streaming online at www.nata.org/consumer/headsup.htm.

References 1. Kleiner, D.M., Almquist, J.L., Bailes, J., 2. LaParade RF, Schnetzler KA, 4. Thomas BE, McCullen GM, Yuan HA: Burruss, P., Feurer, H., Griffin, L.Y., Herring, Broxterman RJ, Wentorf F, Wendland E, Cervical Spine Injuries in Football Players: S., McAdam, C., Miller, D., Thorson, D., Gilbert TJ: Cervical Spine Alignment in the J Am Acad Orthop Surg Sept-Oct; 7 (5), Watkins, R.G., Weinstein, S. Prehospital Immobilized Ice Hockey Player: A 338-47, 1999. Care of the Spine-Injured Athlete: A Computer Tomographic Analysis of the 5. Wojtys EM, Hovda D, Landry G, Boland Document from the Inter-Association Task Effects of Helmet Removal: Am J Sports A, Lovell M, McCrea M, Minkoff J: Force for Appropriate Care of the Spine- Med 27: 177-180, 1999. Concussion in Sports: Am J Sports Med Injured Athlete. Dallas, National Athletic 3. The Spine Injury Management Video 27: 676-687, 1999. 96 Trainers’ Association, March, 2001. Human Kinetics, Champaign, Illinois. GUIDELINE 4e Guidelines for Helmet Fitting and Removal in Athletics June 1990 • Revised June 2006

Several sports, including football, It is important that those involved the helmet shell by a uniform, men’s lacrosse and ice hockey, in the medical management of functional, shock-absorbing sup- require wearing tight-fitting, simi- teams engaged in collision and port lining. Daily evaluation of this larly constructed helmets. The fol- contact sports, and the student- support mechanism, including lowing guidelines, while focused athlete be knowledgeable about cheek and brow pads, for place- on football, are applicable to peri- the helmet. The student-athlete ment and resiliency should be odic evaluation, fitting and should be instructed in the fitting, taught to the student-athlete. Hel- removal of protective helmets care and use of the helmet. mets that require air inflation worn in any sport. These guide- Helmet manufacturer guidelines should be inflated and inspected lines represent minimal standards should be reviewed and followed daily by those assigned to equip- of care that are designed to assist for proper fitting and care ment care. Helmet shells should physicians, coaches, athletic techniques. be examined weekly for cracking trainers, paramedics, EMTs and and be inspected closely again if hospital personnel who care for The resilient plastic shell is shaped the face mask has been bent out student-athletes. spherically to deflect impacts. In- of shape. All helmets need to be terior suspension pads are designed reconditioned and the attach- Medical coverage of interscholas- to match the skull contour to ensure ments of the mask replaced on a tic and intercollegiate teams a snug crown fit. Various rigid and yearly basis. entails many routine preventive removable jaw and brow pads, and acute health-care duties for along with the chin strap, help to Although the helmet is designed for dedicated practicing profession- hold the sides of the helmet firmly a stable fit for protection during als; however, an occasional, seri- against the mandible and the fore- play, removal of the helmet by oth- ous, on-the-field, life-threatening head. When in place, the front edge ers is relatively difficult. In the case head and/or neck injury poses a of the helmet should be positioned of a head or neck injury, jostling and difficult challenge. It is incumbent pulling during removal presents upon those individuals assigned about a finger’s breadth above the high potential for further trauma. to provide medical coverage to be eyebrows. Pressure on the helmet prepared to handle each situation crown should be dissipated through efficiently and expertly. the interior suspension padding Unless there are special circum- over the top of the head. stances such as respiratory dis- Proper on-the-field management tress coupled with an inability to of head and neck injuries is essen- The helmet should fit snugly with- access the airway, the helmet tial to minimize sequelae, expedite out dependence on the chin strap. should never be removed during emergency measures and to pre- The helmet should not twist or the pre-hospital care of the pare for transportation. The action slide when an examiner grasps student-athlete with a potential of those in attendance must not the face mask and attempts to head/neck injury unless: compound the problem. For this rock or turn the helmet with the reason, clear communication wearer resisting the movement. 1. The helmet does not hold the between the medical staff and head securely, such that immobi- emergency-transportation per- With a properly fitted helmet, the lization of the helmet does not sonnel should be maintained. top of the head is separated from immobilize the head; 97 Guidelines for Helmet Fitting and Removal in Athletics

2. The design of the sport helmet the helmet. These loops may be can be cut. is such that even after removal of difficult to cut, necessitating the • While maintaining stability, the the facemask, the airway cannot use of PVC pipe cutters, garden cheek pads can be removed by be controlled or ventilation shears or a screwdriver. Those slipping the flat blade of a screw- provided; involved in the pre-hospital care of driver or bandage scissor under the injured student-athlete should the pad snaps and above the inner 3. After a reasonable period of have readily available proper tools surface of the shell. time, the facemask cannot be for easy facemask removal and • If an air cell-padding system is removed; or should frequently practice removal present, it can be deflated by techniques for facemasks and hel- releasing the air at the external 4. The helmet prevents immobi- mets. It should be noted that cold port with an inflation needle or lization for transportation in an weather and old loops may make large gauge hypodermic needle. appropriate position. cutting difficult. The chin strap can • By rotating the helmet slightly be left in place unless resuscitative forward, it should now slide off the When such helmet removal is nec- efforts are necessary. For resusci- occiput. If the helmet does not essary in any setting, it should be tation, the mouthpiece needs to be move with this action, slight trac- performed only by personnel trained manually removed. tion can be applied to the helmet in this procedure. as it is carefully rocked anteriorly Once the ABCs are stabilized, and posteriorly, with great care Ordinarily, it is not necessary to transportation to an emergency being taken not to move the remove the helmet on the field to facility should be conducted with head/neck unit. evaluate the scalp. Also, the hel- the head secure in the helmet and • The helmet should not be met can be left in place when eval- the neck immobilized by strap- spread apart by the earholes, as uating an unconscious student- ping, taping and/or using light- this maneuver only serves to tight- athlete, an individual who demon- weight bolsters on a spine board. en the helmet on the forehead and strates transient or persistent neu- When moving an athlete to the on the occipital regions. rological findings in his/her spine board, the head and trunk • All individuals participating in extremities, or the student-athlete should be moved as a unit, using this important maneuver must who complains of continuous or the lift/slide maneuver or a log roll proceed with caution and coordi- transient neck pain. technique. nate every move.

Before the injured student-athlete At the emergency facility, satisfac- If the injured student-athlete, after is moved, airway, breathing and tory initial skull and cervical X-rays being rehabilitated fully, is allowed circulation (ABCs) should be eval- usually can be obtained with the to participate in the sport again, uated by looking, listening and pal- helmet in place. Should removal of refitting his/her helmet is manda- pation. To monitor breathing, care the helmet be needed to initiate tory. Re-education about helmet for facial injury, or before transport treatment or to obtain special X- use as protection should be con- regardless of current respiratory rays, the following protocol should ducted. Using the helmet as an status, the facemask should be be considered: offensive, injury-inflicting instru- 98 removed by cutting or unscrewing • With the head, neck and helmet ment should be discouraged. the loops that attach the mask to manually stabilized, the chin strap Guidelines for Helmet Fitting and Removal in Athletics

References 1. Anderson C: Neck Injuries—Backboard, Association, 2000. (2952 Stemmons Free- 6. US Lacrosse. www.uslacrosse.org. bench or return to play? The Physician way, Dallas, Texas 75247, www.nata.org) Lacrosse Helmet Facemask/Chinguard and Sports Medicine 21(8): 23-34, 1993. 4. AOSSM Helmet Removal Guidelines. Removal Hints for Certified Athletic 2. Guidelines for Helmet Fitting and The American Orthopedic Society for Trainers. US Lacrosse, 2008. Available at Removal in Athletics. Illinois State Medical Sports Medicine. (6300 N. River Road, www.uslacrosse.org/safety. Society, 1990. (20 North Michigan Avenue, Suite 200, Rosemont, IL 60018) Chicago, Illinois 60602) www.sportsmed.org. 7. National Operating Committee on 3. Inter-Association Task Force for the 5. The Hockey Equipment Certification Standards for Athletic Equipment (NOC- Cervical Spine. National Athletic Trainers’ Council Inc. www.hecc.net. SAE). www.nocsae.org. 99 GUIDELINE 4f Use of Trampoline and Minitramp June 1978 • Revised June 2002

The NCAA recognizes that the c. Skills being encouraged poorly executed and/or spotted coaches and student-athletes in should be commensurate with tricks. Like the trampoline, the selected sports use the trampoline the readiness of the student- minitramp requires competent and minitramp for developing athlete, and direct observation instruction and supervision, spot- skills. The apparent safety record should confirm that the stu- ters trained for that purpose accompanying such use has been dent-athlete is not exceeding (spotting somersaults on the good, but the use of the trampo- his or her readiness; and minitramp differs from the tram- line can be dangerous. Therefore, poline because of the running these guidelines should be fol- d. Spotters are aware of the action preceding the somersault), lowed in those training activities in particular skill or routine being emphasis on the danger of som- which student-athletes use the practiced and are in an appro- ersaults and dive rolls, security trampoline: priate position to spot potential against unsupervised use, proper errors. Accurate communica- erection and maintenance of the 1. Trampolines should be super- tion is important to the suc- apparatus, a planned procedure vised by persons with compe- cessful use of these tech- for emergency care should an tence in the use of the trampoline niques. accident occur, and documenta- for developing athletics skills. This tion of participation and any acci- implies that: 2. Potential users of the trampo- dents that occur. In addition, no line should be taught proper pro- single or multiple somersault a. Fellow coaches, student- cedures for folding, unfolding, should be attempted unless: athletes, managers, etc., are transporting, storing and locking trained in the principles and the trampoline. 1. The student-athlete has demon- techniques of spotting with the strated adequate progression of overhead harness, “bungee 3. The trampoline should be skill before attempting any somer- system” and/or hand spotting erected in accordance with manu- sault (i.e., on the trampoline with on the trampoline; facturer’s instructions. It should a safety harness, off a diving be inspected regularly and main- board into a swimming pool or b. New skills involving som- tained according to established tumbling with appropriate spot- ersaults should be learned standards. All inspection reports, ting); while wearing an overhead including the date of inspection safety harness. (Exception: Use and name of inspector, should be 2. One or more competent spot- of the overhead system is not kept on file. ters who know the skill being recommended for low-level attempted are in position and are salto activities such as saltos Minitramp physically capable of spotting an from the knees or back.) Those improper execution; persons controlling the safety The minitramp, while different in nature and purpose from the harness should have the neces- 3. The minitramp is secured rea- trampoline, shares its association sary strength, weight and train- sonably or braced to prevent slip- with risk of spinal cord injury from ing for that responsibility; ping at the time of execution in 100 Use of Trampoline and Minitramp accordance with recommendations in the USA Gymnastics Safety Handbook; and

4. A mat is used that is sufficient- ly wide and long to prevent the performer from landing on the mat’s edge and to provide proper footing for the spotter(s).

References

1. American Alliance for Health, Physical Manual. Indianapolis, IN: U.S. Diving Pediatrics Vol. 103 (5) 1999 pp. 1053- Education, Recreation and Dance: The use Publications, 1990. 1056. (www.aop.org/policy/ re9844.html). of the trampoline for the development of 3. Larson BJ, Davis JW. Trampoline-relat- 5. USA Gymnastics: USA Gymnastics competitive skills in sports. Journal of ed injuries. J Bone Joint Surg Am. 1995; Safety Handbook, 1994. (201 S. Capitol Physical Education, Recreation and Dance 77:1174-1178. St., Ste. 300, Indianapolis, IN 46225) 49(8):14, 1978. 4. Trampolines at Home, School and 2. Hennessy JT: Trampoline safety and Recreational Centers Policy Statement of diving programs. U.S. Diving Safety the American Academy of Pediatrics. 101 102 APPENDIXES

Also Found on the NCAA Web site at: NCAA.org/health-safety APPENDIX A NCAA Legislation Involving Health and Safety Issues

This chart should be used as a quick reference for NCAA legislation involving health and safety issues that appears in the 2008-09 NCAA Divisions I, II and III Manuals. The comment section does not capture the full scope of the legislation; users are encouraged to review the full bylaw in the appropriate divisional manual. Because of the dynamic nature of the NCAA legislative process, the most current information on these and any new legislation should be obtained through the institution's athletics department compliance staff.

Regulations Involving Health and Safety Issues

Topic Issue NCAA Comments Bylaw Cite List of Banned Drug Classes 31.2.3.4 Lists all drug classes currently prohibited by the NCAA.

Drugs and Procedures Subject to 31.2.3.4.1 List of drugs and procedures that are Restrictions restricted.

Effect on Eligibility 14.1.1.1 A positive test for use of a banned (performance enhancing or "street") substance results in loss of eligibility.

Effect on Championship Eligibility 18.4.1.5 A positive test for a banned (performance enhancing or "street") substance results in Banned Drugs loss of eligibility, including eligibility for participation in postseason competition.

Transfer While Ineligible Due to 13.1.1.3.5 Institution at which student-athlete tested Positive Drug Test (Div. I), positive for use of a banned substance must 13.1.1.2.4 report the test result to the institution to (Div. II), which the student-athlete is transferring. 13.1.1.2.5 (Div. III)

Knowledge of Use of Banned Drugs 10.2 Athletics department staff members or others employed by intercollegiate athletics department must report a student-athlete's use of banned substance.

Banned Drugs and Drug-Testing 18.4.1.5.2 NCAA Executive Committee is charged with Drug Testing Methods developing a list of banned substances and approving all drug-testing procedures.

Consent Form: Content and Purpose 14.1.4.1 Consent must be signed before competition 104 or practice. Failure to sign consent results in loss of eligibility. NCAA Legislation Involving Health and Safety Issues

Consent Form: Administration 30.5.2, Institution must administer consent form to 14.1.4.2, all student-athletes each academic year at 3.2.4.7 the time the intercollegiate squads report for (Div. I); practice. At this time, institutions must also 30.5.2, distribute to student-athletes the official list 3.2.4.6 of banned substances. (Div. II); 30.5, 14.1.4.2, 3.2.4.6 (Div. III)

Consent Form: Exception, 14.1.4.3 Student-athletes who are trying out must 14-Day Grace Period (Div. I only) sign the form within 14 days of the first athletics-related activity or before they compete, whichever occurs first. Drug Testing Effect of Non-NCAA Athletics 18.4.1.5.3 Executive Committee to develop method of Organization's Positive Drug Test testing student-athletes who previously tested positive to a test administered by a non- NCAA athletics organization.

Failure To Properly Administer Drug- 30.5.1.1 Failure to properly administer drug-testing Testing Consent Form consent form is considered an institutional (Div. I and Div. II only) violation.

Drug Rehabilitation Program 16.4.1 Permissible for institution to cover the costs Expenses (Div. I and of a student-athlete's drug rehabilitation pro- Div. II), gram. 16.4 Drug (Div. III) Rehabilitation Travel To and From Drug 16.12.1 Permissible to file a waiver under Bylaw Rehabilitation Program 16.12.1 to cover costs associated with a drug rehabilitation program.

Permissible Supplements 16.5.2(h) Institution may provide only non-muscle (Div. I), building nutritional supplements. See Bylaw 16.5.1(h) for details. Nutritional (Div. II) Supplements Impermissible Supplements 31.2.3.4 See list of banned substances for those supplements not considered in compliance with Bylaw 16.5.2(h) (Div. I) or Bylaw 16.5.1(h) (Div. II). 105 NCAA Legislation Involving Health and Safety Issues

Restricted Advertising and 31.1.14 No tobacco advertisements in, or sponsor- Sponsorship Activities (Div. I), ship of NCAA Championships or regular sea- 31.1.12 son events. (Div. II and Div. III) Tobacco Use Tobacco Use at Member Institution 11.1.5, Use of tobacco products is prohibited by all 17.1.8 game personnel and all student-athletes in (Div. I and all sports during practice and competition. Div. II), 17.1.10 (Div. III)

Permissible Medical Expenses 16.4.1 Permissible medical expenses are outlined. (Div. I and If expense is not on the list, refer to Bylaw Div. II), 16.4 16.12.1 for waiver procedure. (Div. III)

Eating Disorders 16.4.1 Institution may cover expenses of counsel- (Div. I and Div. II only) ing related to the treatment of eating disor- Medical ders. Expenses Transportation for Medical Treatment 16.4.1 Institution may cover or provide transporta- (Div. I and Div. II only) tion to and from medical appointments.

Summer Conditioning - Football 13.2.8 Institution may finance medical expenses for and Basketball (Div. I only) a prospect who sustains an injury while participating in nonmandatory summer conditioning activities that are conducted by an institution's strength and conditioning coach with department-wide duties.

Hardship Waiver 14.2.4 Under certain circumstances, a student-ath- (Div. I), lete may be awarded an additional season of 14.2.5 competition to compensate for a season that (Div. II and was not completed due to incapacitating Medical Div. III) injury or illness. Waivers Five-Year/10-Semester Rule Waiver 30.6.1 Under certain circumstances, a student-athlete may be awarded an additional year of eligibility if he or she was unable to participate in intercollegiate athletics due to incapacitating physical or mental circumstances.

HIPAA/Buckley Amendment Consent 3.2.4.9, The authorization/consent form shall be Forms 14.1.6, administered individually to each student-ath- Medical Records 30.12 lete by the athletics director or the athletics 106 and Consent Forms (Div. I); director's designee before the student-ath- 3.2.4.7, lete's participation in intercollegiate athletics NCAA Legislation Involving Health and Safety Issues

14.1.5, each academic year. Signing the authoriza- 30.12 tion/consent shall be voluntary and is not (Div. II); required by the student-athlete's institution 3.2.4.7, for medical treatment, payment for treatment, 14.1.6, enrollment in a health plan or for any benefits 30.12 (if applicable) and is not required for the stu- (Div. III) dent-athlete to be eligible to participate. Any signed authorization/consent forms shall be kept on file by the director of athletics.

Time Restrictions on Athletics- 17.1.6 All NCAA sports are subject to the time limi- Related Activities tations in Bylaw 17.

Daily/Weekly Hour Limitation – Inside 17.1.6.1 During the playing season, a student-athlete Playing Season cannot engage in more than 20 hours of ath- (Div. I and Div. II only) letics-related activity (see Bylaw 17.02.1) per week, with not more than four hours of such activity in any one day.

Weekly Hour Limitations – Outside 17.1.6.2 Outside of the playing season, student-ath- Playing Season letes cannot engage in more than eight (Div. I and Div. II only) hours of conditioning activities per week.

Skill Instruction Exception 17.1.6.2.2 Outside of the playing season, two of the (Div. I and Div. II only) (Div. I), student-athlete's eight hours of conditioning 17.1.6.2.1 activity may be skill-related instruction with Student-Athlete (Div. II) coaching staff. Welfare and Safety Required Day Off – Playing Season 17.1.6.4 During the playing season, each student-ath- (Div. I and lete must be provided with one day per week Div. II), on which no athletics-related activities are 17.1.6 scheduled. (Div. III)

Required Days Off – Outside Playing 17.1.5.5 Outside the playing season, each student- Season (Div. I and Div. II only) athlete must be provided with two days per week on which no athletics-related activities are scheduled.

Voluntary Summer Conditioning 13.12.3.9 Prospects, who signed an NLI or received a (Div. I only) (basketball), written offer of admission to the institution, 13.12.3.8 may engage in voluntary summer workouts (football) conducted by an institution's strength and conditioning coach with department-wide duties.

Discretionary Time 17.02.14 Student-athletes may only participate in ath- (Div. I only) letics activities at their initiative during dis- 107 cretionary time. NCAA Legislation Involving Health and Safety Issues

Mandatory Medical Examinations 17.1.5 All student-athletes beginning their initial season of eligibility must undergo a medical exam before they are permitted to engage in any physical activity. The exam must take place within six months before the physical activity. Each subsequent year, an updated medical history must be administered by an institutional medical staff member.

Five-Day Acclimatization Period – 17.11.2.3 Five-day acclimatization for conducting Football administrative and initial practices is Student-Athlete required for first-time participants (freshmen Welfare and and transfers) and continuing student-ath- Safety letes.

Preseason Practice Activities – 17.11.2.4 Preseason practice time limitations and Football general regulations.

Out-of-Season Athletics-Related 17.11.6 Permissible summer conditioning activities. Football Activities (Div. I and Div. III), 17.11.8 (Div. II)

Sport-specific Safety Exceptions 13.11.3.10 A coach may be present during voluntary (Archery; Equestrian; Fencing; (Div. I); individual workouts in the institution’s regular Gymnastics; Rifle; Women’s Rowing; 17.2.7; practice facility (without the workouts being Skiing; Swimming; Synchronized 17.8.7; considered as countable athletics-related Swimming; Track and Field; Water 17.9.7; activities) when the student-athlete uses Polo; and Wrestling.) 17.13.7; sport-specific equipment. The coach may (Div. I and Div. II only) 17.16.7; provide safety or skill instruction but cannot 17.17.7 conduct the individual’s workouts. (Div. I), 17.17.9 (Div. II); 17.19.7; 17.23.7; 17.24.7; 17.27.7; 17.29.8; 17.30.7

Playing Rules Oversight Panel 21.1.6.1 The panel, subject to the discretion of the Executive Committee, shall be responsible for resolving issues involving player safety, financial impact or image of the game that do not have unanimous Division I, II or III support. 108 APPENDIX B NCAA Injury Surveillance System Summary

The NCAA Injury Surveillance Sys- It is important to recognize that Injury Rate tem (ISS) was developed in 1982 this system does not identify every to provide current and reliable data injury that occurs at NCAA institu- An injury rate is simply a ratio of the on injury trends in intercollegiate tions in a particular sport. Rather, number of injuries in a particular athletics. Injury data are collected the emphasis is collecting all category to the number of athlete yearly from a sample of NCAA injuries and exposures from exposures in that category. In the member institutions, and the schools that voluntarily participate ISS, this value is expressed as resulting data summaries are in the ISS. The ISS attempts to injuries per 1,000 athlete exposures. reviewed by the NCAA Committee balance the dual needs of main- on Competitive Safeguards and taining a reasonably representative All Sports Figures Medical Aspects of Sports. The cross-section of NCAA institutions The following figures outline se- committee’s goal continues to be while accommodating the needs lected information from the 16 to reduce injury rates through sug- of the voluntary participants. sports currently monitored by gested changes in rules, protective the ISS. equipment or coaching techniques, Injuries based on data provided by the ISS. Figure Nos. 1 and 2 compare the A reportable injury in the ISS is practice and competition injury Sampling defined as one that: rates across 16 sports without regard to severity. Comparisons of Participation in the ISS is volun- 1. Occurs as a result of participa- injury rates between sports are dif- tary and limited to NCAA member tion in an organized intercollegiate ficult because each sport has its institutions. ISS participation is practice or competition; own unique schedule and activi- available to the population of insti- ties. If such comparisons are nec- tutions sponsoring a given sport. 2. Requires medical attention by a essary, it may be best to use the Schools qualifying for inclusion in team athletic trainer or physician; game data for which the intensity the final ISS sample are selected and variable is most consistent. from the total participating schools for each ISS sport, with Figure Nos. 3 through 6 examine the goal of a minimum 10 percent 3. Results in restriction of the student-athlete’s participation or two measures of severity found in representation of all three NCAA the ISS — time loss and injuries divisions. A school is selected as performance for one or more days beyond the day of injury. that required surgery. These com- qualifying for the sample if they bined practice and game data are meet the minimum standards for presented to assist in decisions data collection set forth by the ISS Exposures regarding appropriate medical staff. For a more detailed explana- coverage for a sport; however, tion of ISS sampling methodology, An athlete exposure (A-E), the unit each severity category has some see: National Collegiate Athletic of risk in the ISS, is defined as one limitations that should be consid- Association Injury Surveillance athlete participating in one prac- ered. Summary for 15 Sports, 1988- tice or competition in which he or 1989 Through 2003-2004. J Athl she is exposed to the possibility of 1. Time loss—Figure Nos. 3 Train. 2007;42(2). athletics injury. through 5 evaluate the rate of report- 109 NCAA Injury Surveillance System Summary

ed injuries that caused restricted or loss of participation of seven days or more. Limitations to this type of severity evaluation include: a.An injury that restricts participation in one sport may not restrict participation in another sport; and b.Injuries that occur at the end of a season can only be estimated with regard to time loss. 2. Injuries that require surgery— Figure Nos. 3, 4 and 6 evaluate the rate of reported injuries that required either immediate or postseason surgery. Limitations to this severity evaluation include: a.The changing nature of surgical techniques and how they are applied; b.The assumption that all sports had access to the same quality of medical evaluation; and c. Injuries can occur that may be categorized as severe, such as concussions, that may not require surgery. Any questions regarding the ISS or its data reports should be directed to: David Klossner, Director of Education Services, NCAA, P.O. Box 6222, Indianapolis, Indiana 46206- 6222 (317/917-6222). 110 Figure 1 Competition and Practice Injury Rates Summary (All Sports)

Spring Football 10.5 Football 5.9 38.4 Wrestling 8.1 26.4 Men’s Soccer 6.1 20.7 Women’s Soccer 5.7 18.0 Women’s Gymnastics* 8.6 17.0 Men’s Ice Hockey 2.4 16.0 Figure 1 represents the average competition Men’s Lacrosse (black) and practice (orange) injury rates (expressed as injuries per 1,000 athlete-expo- 4.2 14.8 sures) for all sports analyzed in the ISS for the Men’s Basketball 2004-05, 2005-06 and 2006-07 seasons. *Two-season average. 5.2 10.6 Competition Injury Rate Field Hockey Practice Injury Rate 5.6 9.8 Women’s Basketball 5.0 9.3 Women’s Lacrosse 3.5 8.2 Women’s Ice Hockey 2.8 8.0 Baseball 2.6 6.1 Women’s Volleyball 4.9 4.8 Softball 3.6 4.7

0 5 10 15 20 25 30 35 40 Injury Rate (per 1,000 A-E) 111 Figure 2 Percentage of All Injuries Occurring in Practices and Competition

Women’s Gymnastics* 81.9 18.1 Figure 2 represents the average percentage of all injuries that occurred in practices and in competition in the 2004-05, 2005-06 and Wrestling 70.8 29.2 2006-07 seasons. The relatively few injuries that occurred in the weight room were not Women’s Volleyball 69.9 30.1 included in the practice and competition per- centages. It should be noted that these calculations are based only on the absolute number Men’s Basketball 66.3 33.7 of injuries and do not take exposures into consideration. Women’s Basketball 65.6 34.4 *Two-season average.

Women’s Lacrosse 62.9 37.1 Practice Men’s Lacrosse 62.8 37.2 Competition Field Hockey 61.7 38.3

Football 61.5 38.5

Softball 52.6 47.4

Women’s Ice Hockey 50.7 49.3

Men’s Soccer 50.2 49.8

Women’s Soccer 48.1 51.9

Baseball 47.3 52.7

Men’s Ice Hockey 32.7 67.3

0 102030405060708090100 Percentage of All Injuries

112 Figure 3 Competition Injury Rates Summary (All Sports)

Football 38.4 2.6 19.1 Wrestling 26.4 2.8 18.3 Men’s Soccer 20.7 0.8 8.2 Women’s Soccer 18.0 1.4 7.8

Women’s Gymnastics* Figure 3 represents the average overall competition 17.0 0.6 12.5 injury rate (black), the game rate of injuries that caused reduced or missed participation for seven or Men’s Ice Hockey more days (orange) and the game rate of reported injuries that required surgery (light orange). The rates 6.4 16.0 0.5 are expressed as injuries per 1,000 athlete-exposures Men’s Lacrosse for all sports analyzed in the ISS for the 2004-05, 2005- 06 and 2006-07 seasons. 14.8 0.6 6.6 *Two-season average. Men’s Basketball Competition Injury Rate 3.2 10.6 0.6 Injuries with 7+ days Timeloss Competition (IR)

Field Hockey Injuries Requiring Surgery Competition (IR) 9.8 0.42.2 Women’s Basketball 9.3 0.8 3.7 Women’s Lacrosse 8.2 1.3 3.7 Women’s Ice Hockey 8.0 0.6 3.4 Baseball 6.1 0.4 3.1 Women’s Volleyball 4.8 0.21.8 Softball 4.7 0.3 2.1 0 4 8 12 16 20 24 28 32 36 40 44 Injury Rate (per 1,000 A-E) 113 Figure 4 Practice Injury Rates Summary (All Sports) Spring Football 10.5 1.0 5.7 Women’s Gymnastics* 8.6 0.1 5.2 Wrestling 8.1 0.5 3.9 Men’s Soccer 6.1 0.2 2.2 Football 5.9 0.3 2.4 Figure 4 represents the average overall practice injury rate (black), the practice rate of injuries that caused Women’s Soccer reduced or missed participation for seven or more days 5.7 0.3 2.5 (orange) and the practice rate of reported injuries that required surgery (light orange). The rates are Field Hockey expressed as injuries per 1,000 athlete-exposures for 5.6 all sports analyzed in the ISS for the 2004-05, 2005-06 0.3 1.7 and 2006-07 seasons. Men’s Basketball *Two-season average. 5.2 0.3 1.7 Practice Injury Rate

Women’s Basketball Injuries with 7+ days Timeloss Practice (IR) 5.0 0.3 1.9 Injuries Requiring Surgery Practice (IR) Women’s Volleyball 4.9 0.2 1.9 Men’s Lacrosse 4.2 0.3 2.0 Women’s Lacrosse 3.5 0.2 1.9 Softball 3.6 0.2 1.6 Women’s Ice Hockey 2.8 0.1 0.7 Baseball 2.6 0.2 1.4 Men’s Ice Hockey 2.4 0.1 1.0 0 1 2 3 4 5 6 7 8 9 10 11 114 Injury Rate (per 1,000 A-E) Figure 5 Competition and Practice 7+ Days Time Loss Injury Rates Summary (All Sports)

Football 2.4 19.1 Wrestling 3.9 18.3 Women’s Gymanstics* 5.2 12.5 Men’s Soccer 2.2 8.2 Women’s Soccer Figure 5 represents the average rate of injuries that 2.5 7.8 caused reduced or missed participation for seven or more days, suffered either in competition (black) or in practice Men’s Lacrosse (orange). The rates are expressed as injuries per 1,000 athlete-exposures for all sports analyzed in the ISS for 6.6 2.0 the 2004-05, 2005-06 and 2006-07 seasons. *Two-season average. Men’s Ice Hockey 1.0 6.4 Injuries with 7+ Days Timeloss Competition (IR)

Women’s Basketball Injuries with 7+ Days Timeloss Practice (IR) 1.9 3.7

Women’s Lacrosse 1.5 3.7 Men’s Basketball 1.7 3.2 Baseball 1.4 3.1 Women’s Ice Hockey 0.7 2.9 Field Hockey 1.7 2.2 Softball 1.6 2.1 Women’s Volleyball 1.9 1.8

0 5 10 15 20 Injury Rate (per 1,000 A-E) 115 Figure 6 Competition and Practice Injuries Requiring Surgery Rate Summary (All Sports)

Women’s Gymnastics* 0.6 3.8

Wrestling 0.5 2.8 Football 0.3 2.6 Women’s Soccer 0.3 1.4 Figure 6 represents the average rate of reported injuries Women’s Lacrosse that required surgery, suffered either in competition 0.2 1.3 (black) or in practice (orange). The rates are expressed as injuries per 1,000 athlete-exposures for all sports ana- Women’s Basketball lyzed in the ISS for the 2004-05, 2005-06 and 2006-07 0.8 seasons. 0.3 *Two-season average. Men’s Soccer Injuries Requiring Surgery Competition (IR) 0.2 0.8 Injuries Requiring Surgery Practice (IR) Men’s Basketball 0.3 0.6 Men’s Lacrosse 0.3 0.6 Women’s Ice Hockey 0.1 0.6 Baseball 0.2 0.4 Men’s Ice Hockey 0.1 0.4 Field Hockey 0.3 0.4 Softball 0.2 0.3 Women’s Volleyball 0.2 0.2

0 1 2 3 4 5 116 Injury Rate (per 1,000 A-E) 16 years of injury data across 15 sports published in the Journal of Athletic Training, 2007. Available online under the sport specific injury data section listed below.

For more information about the NCAA Injury Surveillance System, visit our Web site at NCAA.org/iss.

The Web site contains:

General Information • ISS Methods, Definitions and Information • ISS Updates • HIPAA Updates • NCAA Sponsorship and Participation Report

Data Collection • Institution Participation Form • Injury and Exposure Forms • Directions/Other Information • Web-Based Enhancement • Participation and Student-Athlete Consent Form

NCAA ISS Data • Game comparison Across 16 Sports • Practice comparison Across 16 Sports • Sport-Specific Injury Data • ISS Articles from The NCAA News

Catastrophic Injury

• National Center for Catastropic Sport Injury Research Web site

NCAA Injury Surveillance System P.O. Box 6222 Indianapolis, Indiana 46206-6222 Phone: 317/917-6314 Fax: 317/917-6363

117 118 APPENDIX C Acknowledgements

From 1974 to 2008, the following individuals have served on the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports and contributed to the information in the NCAA Sports Medicine Handbook:

John R. Adams Millersville University of Paul W. Gikas, M.D. Western Athletic Conference Pennsylvania University of Michigan Ken Akizuki Marino H. Casem Pamela Gill-Fisher University of San Francisco Southern University, Baton Rouge University of California, Davis James R. Andrews, M.D. Nicholas J. Cassissi, M.D. Gordon L. Graham Troy University University of Florida Minnesota State University Mankato Elizabeth Arendt, M.D. Rita Castagna Gary A. Green, M.D. University of Minnesota, Assumption College University of California, Twin Cities Charles Cavagnaro Los Angeles William F. Arnet University of Memphis Letha Griffin, M.D. University of Missouri, Columbia Kathy D. Clark Georgia State University James A. Arnold University of Idaho Eric Hamilton The College of New Jersey University of Arkansas, Kenneth S. Clarke Kim Harmon Fayetteville Pennsylvania State University University of Washington Janet Kay Bailey Priscilla M. Clarkson Richard J. Hazelton Glenville State College University of Massachusetts, Trinity College (Connecticut) Dewayne Barnes Amherst Larry Holstad Whittier College Bob Colgate National Federation of State High Winona State University Amy Barr School Associations Maria J. Hutsick Eastern Illinois University Donald Cooper, M.D. Boston University Fred L. Behling Oklahoma State University Nell C. Jackson Stanford University Kip Corrington State University of New York Daphne Benas Texas A&M University, College at Binghamton Yale University Station John K. Johnston John S. Biddiscombe Lauren Costello, M.D. Princeton University Wesleyan University (Connecticut) Princeton University Don Kaverman Carl S. Blyth Ron Courson Southeast Missouri State University University of North Carolina, University of Georgia Janet R. Kittell Chapel Hill Carmen Cozza California State University, Chico Cindy D. Brauck Yale University Fran Koenig Missouri Western State College Bernie DePalma Central Michigan University Donald Bunce, M.D. Cornell University Olav B. Kollevoll Stanford University Jerry L. Diehl Lafayette College Elsworth R. Buskirk National Federation of State High Jerry Koloskie Pennsylvania State University School Associations University of Nevada, Las Vegas Peter D. Carlon Larry Fitzgerald Roy F. Kramer University of Texas, Arlington Southern Connecticut State Vanderbilt University Gene A. Carpenter University Michael Krauss, M.D. 119 Acknowledgements Purdue University Joseph V. Paterno Jen Palancia Shipp Carl F. Krein Pennsylvania State University University of North Carolina, Central Connecticut State Marc Paul Greensboro University University of Nevada, Reno Gary Skrinar Russell M. Lane, M.D. Daniel Pepicelli Boston University Amherst College St. John Fisher College Bryan W. Smith, M.D. John Lombardo, M.D. Frank Pettrone, M.D. University of North Carolina, The Ohio State University George Mason University Chapel Hill Scott Lynch Marcus L. Plant Michael Storey Pennsylvania State University University of Michigan Bridgewater State College William B. Manlove Jr. Nicole Porter Grant Teaff Delaware Valley College Shippensburg University Baylor University Arnold Mazur, M.D. of Pennsylvania Carol C. Teitz, M.D. Boston College James C. Puffer, M.D. University of Washington Chris McGrew, M.D. University of California, Patricia Thomas University of New Mexico Los Angeles Georgetown University Susan S. True William D. McHenry Margot Putukian National Federation of State High Washington and Lee University Princeton University School Associations Malcolm C. McInnis Jr. Ann Quinn-Zobeck Laurie Turner University of Tennessee, Knoxville University of Northern University of California, San Diego Douglas B. McKeag, M.D. Colorado Jerry Weber Michigan State University Tracy Ray University of Nebraska, Lincoln Kathleen M. McNally Samford University Christine Wells La Salle University Joy L. Reighn Arizona State University Robin Meiggs Rowan University Kevin M. White Humboldt State University Frank J. Remington Tulane University Dale P. Mildenberger University of Wisconsin, Madison Robert C. White Utah State University Rochel Rittgers Wayne State University Melinda L. Millard-Stafford Augustana College (Illinois) (Michigan) Georgia Institute of Technology Darryl D. Rogers Sue Williams Fred L. Miller Southern Connecticut State University of California, Davis Arizona State University University Charlie Wilson Matthew Mitten Yvette Rooks Olivet College Marquette University University of Maryland, College Park G. Dennis Wilson Frederick O. Mueller Debra Runkle Auburn University University of North Carolina, University of Dubuque Mary Wisniewski Chapel Hill Richard D. Schindler University of Chicago David M. Nelson National Federation of State High Glenn Wong University of Delaware School Associations University of Massachusetts, William E. Newell Kathy Schniedwind Amherst Purdue University Illinois State University Joseph P. Zabilski Jeffrey O’Connell Brian J. Sharkey Northeastern University University of Virginia University of Montana Connee Zotos Roderick Paige Willie G. Shaw Drew University 120 Texas Southern University North Carolina Central University APPENDIX D Banned-Drug Classes

2008-09 The NCAA list of banned-drug classes is subject to change by the NCAA Executive Committee. Contact the NCAA education services staff or go to ncaa.org/health-safety for the current list. The term “related compounds” com- prises substances that are included in the class by their pharmacological action and/or chemical structure. No substance belonging to the prohibited class may be used, regardless of whether it is specifically listed as an example. Many nutritional/dietary supplements contain NCAA banned substances. In addition, the U.S. Food and Drug Administration (FDA) does not strictly regulate the supplement industry; therefore, purity and safety of nutritional dietary supplements cannot be guaranteed. Impure supplements may lead to a positive NCAA drug test. The use of supplements is at the student-athlete’s own risk. Student-athletes should contact their institution’s team physician or athletic trainer for further information. Bylaw 31.2.3. Banned Drugs The following is a list of banned-drug classes, with some examples of substances under each class. No substance belonging to the banned-drug class may be used, regardless of whether it is specifically listed as an example.

Stimulants: ephedrine (ephedra, ma huang) phentermine amiphenazole ethamivan phenylpropanolamine (ppa) amphetamine ethylamphetamine picrotoxine bemigride fencamfamine pipradol benzphetamine meclofenoxate prolintane bromantan methamphetamine strychnine caffeine1 (guarana) methylenedioxymethamphetamine synephrine (citrus aurantium, chlorphentermine (MDMA, ecstasy) zhi shi, bitter orange) cocaine methylphenidate and related compounds cropropamide nikethamide The following stimulants are not crothetamide pemoline banned: diethylpropion pentetrazol phenylephrine dimethylamphetamine phendimetrazine pseudoephedrine doxapram phenmetrazine Anabolic Agents: Anabolic steroids epitrenbolone oxymesterone androstenediol fluoxymesterone oxymetholone androstenedione gestrinone stanozolol boldenone mesterolone testosterone2 clostebol methandienone tetrahydrogestrinone (THG) dehydrochlormethyl- methyltestosterone trenbolone testosterone nandrolone and related compounds dehydroepiandro- norandrostenediol Other Anabolic Agents sterone (DHEA) norandrostenedione clenbuterol dihydrotestosterone (DHT) norethandrolone dromostanolone oxandrolone 121 Banned-Drug Classes

Substances Banned for Specific Sports:

Rifle: alcohol nadolol timolol atenolol pindolol and related compounds metoprolol propranolol

Diuretics and Other Urine Manipulators:

acetazolamide flumethiazide quinethazone bendroflumethiazide furosemide spironolactone benzhiazide hydrochlorothiazide triamterene bumetanide hydroflumethiazide trichlormethiazide chlorothiazide methyclothiazide and related compounds chlorthalidone metolazone ethacrynic acid polythiazide

Street Drugs: heroin marijuana3 tetrahydrocannabinol (THC)3

Peptide Hormones and Analogues corticotrophin (ACTH) growth hormone (hGH, somatotrophin) human chorionic gonadotrophin (hCG) insulin-like growth hormone (IGF-1) leutenizing hormone (LH) (All the respective releasing factors of the above-mentioned substances also are banned.) erythropoietin (EPO) darbepoetin sermorelin Anti-Estrogens: anastrozole tamoxifen and related compounds clomiphene

122 Banned-Drug Classes

Definitions of positive depends on the following:

1 for caffeine—if the concentration in urine exceeds 15 micrograms/ml. 2 for testosterone—if the administration of testosterone or use of any other manipulation has the result of increasing the ratio of the total concentration of testosterone to that of epitestosterone in the urine to greater than 6:1, unless there is evidence that this ratio is due to a physiological or pathological condition. 3 for marijuana and THC—if the concentration in the urine of THC metabolite exceeds 15 nanograms/ml.

NCAA Bylaw 31.2.3.4.1 Drugs and Procedures Subject to Restrictions. The use of the following drugs and/or procedures is subject to certain restrictions and may or may not be permissible, depending on limitations expressed in these guidelines and/or quantities of these substances used: (Revised: 8/15/89) (a) Blood Doping. The practice of blood doping (the intravenous injection of whole blood, packed red blood cells or blood substitutes) is prohibited, and any evidence confirming use will be cause for action consistent with that taken for a positive drug test. (Revised: 8/15/89, 5/4/92) (b) Local Anesthetics. The Executive Committee will permit the limited use of local anesthetics under the following conditions: (1) That procaine, xylocaine, carbocaine or any other local anesthetic may be used, but not cocaine; (Revised: 12/9/91, 5/6/93) (2) That only local or topical injections can be used (i.e., intravenous injections are not permitted); and (3) That use is medically justified only when permitting the athlete to continue the competition without potential risk to his or her health. (c) Manipulation of Urine Samples. The Executive Committee bans the use of substances and methods that alter the integrity and/or validity of urine samples provided during NCAA drug testing. Examples of banned methods are catheterization, urine substitution and/or tampering or modification of renal excretion by the use of diuretics, probenecid, bromantan or related compounds, and epitestosterone administration. (Revised: 8/15/89, 6/17/92, 7/22/97) (d) Beta 2 Agonists. The use of beta 2 agonists is permitted by inhalation only. (Adopted: 8/13/93) (e) Additional Analysis. Drug screening for select nonbanned substances may be conducted for nonpunitive purposes. (Revised: 8/15/89) 123 124 NCAA 65859-7/08 380,000 more than participating in The NCAAsalutesthemore than 1,000 23 sports member institutions student-athletes at MD 09

SPORTS MEDICINE Handbook Sports Medicine 2008-09 NCAA ®