® 2011-12 NCAA Handbook THE NATIONAL COLLEGIATE ATHLETIC ASSOCIATION P.O. Box 6222 Indianapolis, Indiana 46206-6222 317/917-6222 NCAA.org

Twenty-second Edition July 2011

Compiled By: David Klossner, Director of Student- Affairs.

Distributed to head athletic trainers. Available online at NCAA.org/health-safety.

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 revi- sions 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 registered 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 publica- tion for their own use, provided the NCAA copyright is included on the material.

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

Copyright, 2011, by the National Collegiate Athletic Association. Printed in the of America.

1 PREFACE

The health and safety principle of the ics program. In some instances, letic team that is consistent National Collegiate Athletic accompanying best practices, and ref- with sound principles of sports medi- Association’s constitution provides that erences to sports medicine or legal cine care. These recommendations pro- it is the responsibility of each member resource materials are provided for fur- vide guidance for an institution’s athlet- institution to protect the health of, ther guidance. These recommendations ics administrators and sports medicine and provide a safe environment for, are not intended to establish a legal staff in protecting student-’ each of its participating student-ath- standard of care that must be strictly health and safety, but do not establish letes. To provide guidance in accom- adhered to by member institutions. In any rigid requirements that must be plishing this objective and to assist other words, these guidelines are not followed in all cases. member schools in developing a safe mandates that an institution is required intercollegiate athletics program, the to follow to avoid legal liability or dis- This handbook is produced annually, NCAA Committee on Competitive ciplinary sanctions by the NCAA. sent to head athletic trainers, and made Safeguards and Medical Aspects of However, an institution has a legal duty available online to directors of athletics, Sports creates a Sports Medicine to use reasonable care in conducting its senior woman administrators, faculty Handbook. The committee has agreed intercollegiate athletics program, and athletics representatives, athletic train- to formulate guidelines for sports med- guidelines may constitute some evi- ers, team , Life Skills coordi- icine care and protection of student- dence of the legal standard of care. nators, and student-athlete advisory athletes’ health and safety for topics committees at each member institution, relevant to intercollegiate athletics, These general guidelines are not and conference commissioners. Please applicable to a large population of stu- intended to supersede the of view the NCAA Sports Medicine dent-athletes, and not accessible in medical judgment in specific Handbook as a tool to help your institu- another easily obtainable source. situations by a member institution’s tion develop its sports medicine admin- sports medicine staff. In all instances, istrative policies. Such policies should This handbook consists of guidelines determination of the appropriate care reflect a commitment to protecting your for each institution to consider in and treatment of student-athletes must student-athletes’ health and well-being developing sports medicine policies be based on the clinical judgment of as well as an awareness of the guide- appropriate for its intercollegiate athlet- the institution’s team or ath- lines set forth in this handbook.

2 2 011-12 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 ...... 20 h. NCAA Alcohol, Tobacco and Other Education Guidelines...... 21 i. Preseason Preparation...... 23 2. Medical Issues a. Medical Disqualification of the Student-Athlete...... 28 b. Cold Stress and Cold Exposure...... 29 c. Prevention of Heat Illness...... 33 d. Weight Loss—Dehydration...... 37 e. Assessment of Body Composition...... 38 f. and Athletic Performance...... 43 g. Dietary Supplements...... 47 h. “Burners” (Brachial Plexus )...... 50 i. Concussion or Mild Traumatic Brain in the Athlete...... 53 j. Skin in Athletics...... 59 k. Menstrual-Cycle Dysfunction...... 66 l. Blood-Borne Pathogens and Intercollegiate Athletics...... 68 m. The Use of Local Anesthetics in College Athletics...... 74 n. The Use of Injectable Corticosteroids in Sports Injuries...... 75 o. Depression: Interventions for Intercollegiate Athletics...... 77 p. Participation by the Student-Athlete with Impairment...... 82 q. Pregnancy in the Student-Athlete...... 84 r. The Student-Athlete with Sickle Cell Trait...... 86 3. Equipment a. Protective Equipment...... 90 b. Eye Safety in Sports...... 96 c. Mouthguards...... 98 d. Use of the Head as a Weapon in Football and Other Contact Sports...... 100 e. Guidelines for Helmet Fitting and Removal in Athletics...... 101 f. Use of Trampoline and Minitramp...... 104 Appendixes a. Banned-Drug Classes...... 108 b. NCAA Legislation Involving Health and Safety Issues...... 109 c. NCAA Injury Surveillance Program Summary...... 115 d. Acknowledgements...... 119 New or significantly revised guidelines are highlighted on this page. Limited revisions are highlighted within the specific guideline. 3 FOREWORD Shared Responsibility for Intercollegiate Sports Safety

Participation in intercollegiate athletics director, is responsible for establishing involves unavoidable exposure to an a safe environment for its student-ath- inherent risk of injury. However, stu- letes to participate in its intercollegiate dent-athletes rightfully assume that athletics program. those who sponsor intercollegiate ath- letics have taken reasonable precau- Coaches should appropriately warn stu- tions to minimize the risks of injury dent-athletes about the ’s inherent from athletics participation. In an risks of injury and instruct them how to effort to do so, the NCAA collects minimize such risks while participating injury data in intercollegiate sports. in games, practices and training. When appropriate, the NCAA Committee on Competitive Safeguards The and athletic health and Medical Aspects of Sports makes care team should assume responsibility recommendations to modify safety for developing an appropriate injury guidelines, equipment standards, or a prevention program and providing sport’s rules of play. quality sports medicine care to injured student-athletes. It is important to recognize that rule books, safety guidelines and equipment standards, while helpful means of pro- Student-athletes should fully under- moting safe athletics participation, are stand and comply with the rules and themselves insufficient to accomplish standard of play that govern their sports this goal. To effectively minimize the and follow established procedures to risks of injury from athletics participa- minimize their risk of injury. tion, everyone involved in intercolle- giate athletics must understand and In summary, all persons participating respect the intent and objectives of in, or associated with, an institution’s applicable rules, guidelines intercollegiate athletics program share and standards. responsibility for taking steps to reduce effectively the risk of injury during The institution, through its athletics intercollegiate athletic competition.

4 Adminstrative issues Also found on the NCAA website at: NCAA.org/health-safety 1 GUIDELINE 1a Sports Medicine Administration

October 1977 • Revised July 2011

The following components of a 3. Preseason Preparation. The practice, competition and travel. safe athletics program are an student-athlete should be protected important part of injury prevention. from premature exposure to the full 6. Minimizing Potential Legal They should serve both as a rigors of sports. Preseason condi- Liability. Liability must be a checklist and as a guideline for use tioning should provide the student- concern of responsible athletics administrators and coaches. Those by athletics administrators in the athlete with optimal readiness by who sponsor and govern athletics development of safe programs. the first practice (see Guideline 1i, Preseason Preparation). programs should accept the 1. Preparticipation Medical responsibility of minimizing the Exam. Before student-athletes 4. Acceptance of Risk. Any risk of injury. accept the rigors of any organized informed consent or waiver by 7. Equitable Medical Care. sport, their health should be student-athletes (or, if minors, by Member institutions should neither evaluated by qualified medical their parents) should be based on practice nor condone illegal personnel. Such an examination an awareness of the risks of partic- discrimination on the basis of race, should determine whether the ipating in intercollegiate sports. creed, national origin, sex, age, student-athlete is medically cleared 5. Planning/Supervision. Safety in disability, social status, financial to engage in a particular sport (see intercollegiate athletics can be status, sexual orientation or NCAA Bylaw 17.1.5). attained only by appropriate religious affiliation within their planning for and supervision of Division I requires student-athletes sports medicine programs. new to their campus to complete a sickle cell solubility test, show results of a prior test, or sign a written release declining the test.

2. Health Insurance. Each student-athlete should be covered by individual, parental or institutional medical insurance to defray the costs of significant injury or illness.

NCAA institutions must certify insurance coverage for medical expenses resulting from athletically related injuries in a covered event (see Bylaw 3.2.4).

6 Sports Medicine Administration

Availability and accessibility to 10. Blood-Borne Pathogens. In medical resources should be based 1992, the Occupational Safety and on established medical criteria Health Administration (OSHA) (e.g., injury rates, rehabilitation) developed a standard directed to rather than the sport itself. minimizing or eliminating occupational exposure to blood- Member institutions should not borne pathogens. Each member place their sports medicine staffs in institution should determine the compromising situations by having applicability of the OSHA standard them provide inequitable treatment to its personnel and facilities. in violation of their medical codes of ethics. 11. Emergency Care. See Guideline 1c. Institutions should be encouraged to incorporate questions regarding 12. Concussion Management adequacy of medical care, with Plan. NCAA member institutions special emphasis on equitable must have a concussion treatment, in exit interviews with management plan for their student- student-athletes. athletes on file with specific components as described in Bylaw 8. Equipment. Purchasers of 3.2.4.16 (see Guideline 2i). equipment should be aware of and use safety standards. In addition, 13. Drug Testing. NCAA member attention should be directed to institutions are responsible for maintaining proper repair and ensuring compliance with NCAA fitting of equipment at all times in drug testing program requirements all sports. Student-athletes should: (see NCAA Drug Testing Program book and Appendix A). a. Be informed what equipment is mandatory and what constitutes 14. Legislation. NCAA member illegal equipment; institutions are responsible for ensuring compliance with the b. Be provided the mandated NCAA bylaws relevant to health equipment; and safety as outlined in the division manuals (see Appendix B c. Be instructed to wear and how to for a quick reference guide). 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.

7 GUIDELINE 1b Medical Evaluations, Immunizations and Records July 1977 • Revised June 2011

Preparticipation medical In a five-year review of sudden off-season; evaluation. A preparticipation deaths involving NCAA student- medical evaluation should be athletes, the incidence of SCD was 2. Referrals for and feedback from required upon a student-athlete’s approximately one in every 40,000 consultation, treatment or entrance into the institution’s inter­ student-athletes per year. The rehabilitation; collegiate athletics program (see American Heart Association has 3. Subsequent care and clearances; NCAA Bylaw 17.1.5). Division I modified its 1996 recommendation requires student-athletes new to their for a cardiovascular screening 4. A comprehensive entry-year campus to complete a sickle cell every two years for collegiate health-status questionnaire and an 2 3 solubility test, show results of a prior athletes. The revision updated health-status questionnaire test, or sign a written release recommends cardiovascular screen­ each year thereafter. Components of declining the test. This initial ing as a part of the physical exam the questionnaire should consider evaluation should include­ a required upon a student-athlete’s recommendations from the American comprehensive health his­ tory,­ entrance into the intercollegiate Heart Association (see reference Nos. immunization history as defined­ by athletics program. In subsequent 2 and 3) and the 4th Edition current Centers for Disease­ Control years, an interim history and blood Preparticipation Physical Evaluation and Prevention (CDC) guidelines pressure measurement should be (see reference No. 5). and a relevant physical exam, with made. Important changes in strong emphasis on the ­medical status or abnormalities 5. Immunizations. It is recommended cardiovascular, neurologic and may require more formal that student-athletes be immunized musculoskeletal evaluation. After the cardiovascular evaluation. for the following: initial medical evaluation, an updated history­ should be performed Medical records. Student-athletes a. Measles, mumps, rubella annually.­ Further preparticipation­ have a responsibility to truthfully (MMR); physical examinations are not and fully disclose their medical b. Hepatitis B; believed to be necessary unless history and to report any changes warranted by the updated history or in their health to the team’s health- c. Diptheria, tetanus (and boosters the student-athlete’s medical care provider. Medical­ records when appropriate); and condition. should be maintained during the student-athlete’s collegiate career d. Meningitis. Cardiac. Sudden cardiac death and should include: (SCD) is the leading medical cause 6. Written permission, signed of death in NCAA athletes and 1. A record of injuries, illnesses, new annually by the student-athlete, represents 75 percent of all sudden medications or , pregnancies which authorizes the release of death cases that occur during and operations, whether­ sustained medical information to others. training, exercise or competition. during the competitive­ season or the Such permission should specify all 8 Medical Evaluations, Immunizations and Records persons to whom the student- solely the responsibility of the team incapacitation. Three key athlete authorizes the information physician or that physician’s components need to be included in to be released. The consent form designated representative. this documentation: also should specify which 1. Contemporaneous diagnosis of information may be released and to Medical Hardship Waivers. injury/illness; whom. Documentation standards should assist conferences and institutions in 2. Acknowledgement that the Note: Records maintained in the designing a medical treatment injury/illness is incapacitating; athletic training facility are medical protocol that satisfies all questions of and records, and therefore subject to state incapacitation and reflects such in the and federal laws with regard to records. To clarify: 3. Length of incapacitation. confidentiality and content. Each For more information about • hardship waiver: A hardship waiver institution should obtain from medical hardship waivers, read the deals with a student-athlete’s appropriate legal counsel an opinion complete article at NCAA.org/ seasons of competition and may regarding the confidentiality and health-safety or contact the only be granted if a student-athlete content of such records in its state. NCAA’s student-athlete has competed and used one of the reinstatement staff. Medical records and the information four seasons of competition. they contain should be created, • extension waiver: An extension maintained and released in waiver deals with time on a accordance with clear written student-athlete’s eligibility clock guidelines based on this opinion. All and may be granted if, within a personnel who have access to a student-athlete’s period of student-athlete’s medical records eligibility (five years or 10 should be familiar with such semesters), he or she has been guidelines and informed of their role denied more than one participation in maintaining the student-athlete’s opportunity for reasons beyond the right to privacy. student-athlete’s and the Institutions should consider state institution’s control. statutes for medical records retention In order to demonstrate that an injury (e.g., 7 years, 10 years); institutional or illness prevented competition and policy (e.g., insurance long term resulted in incapacitation for the retention policy); and professional remainder of the playing season, an liability statute of limitations. institution needs to provide objective documentation to substantiate the Follow-up examinations. Those who have sustained a significant injury or illness during the sport season should be given a follow-up examination to re-establish medical clearance before resuming participation 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

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 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 “incapacitat- ing” OR ____ Non-contemporaneous letter or diagnosis from treating physician identifying injury or illness as “inca- pacitating” AND ____ Treatment logs or ’s notes (indicating continuing rehabilitation efforts) Length of Incapacitaion (verifying opportunity for injured student-athlete to resume playing within cham- pionship 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 2010. Available at ppesportsevaluation. et. al.: Prematriculation Immu­ni­za­tion strategy for eliminating transmission in org. Requirements of American Colleges­ and the United States through universal 6. Eligibility Recommendations for Universities. Journal of Ameri­can childhood vaccination: recommendations Competitive Athletes with Cardiovascular College Health 42:91-98, 1993. of the Immunization Practices­ Advisory Abnormalities. 36th Bethesda Conference. 2. Recommendations and Considerations Committee. Morbidity­ and Mortality Journal of American College of Related to Pre-Participation Screening for Weekly Report 40 (RR-13), 1991. , 45(8), 2005. Cardiovascular Abnormalities in 5. Preparticipation Physical Evaluation.­ 7. Harmon KG, Asif IM, Klossner D, Competitive Athletics: 2007 Update: 4th Ed. American Academy of Family Drezner JA. Incidence of Sudden Cardiac Circulation. Mar 2007; 115:1643-1655. Physicians, American Academy of Death in NCAA Athletes. Circulation. Apr 3. Gardner P, Schaffner W: Immu­ni­ , American Medical Society of 2011. zations of Adults. The New England Jour­ Sports Medicine, American Orthopaedic­ nal of Medicine 328(17):1252-1258, Society of Sports Medicine. Published by 1993. the American Academy of Pediatrics,

10 GUIDELINE 1c Emergency Care and Coverage October 1977 • Revised July 2004

Reasonable attention to all possible whether fixed or mobile, should be 8. Certification in cardiopulmonary preventive measures will not assured; resuscitation techniques (CPR), eliminate sports injuries. Each 5. All necessary emergency first aid, and prevention of disease scheduled practice or contest of an equipment should be at the site or transmission (as outlined by OSHA institution-sponsored intercollegiate quickly accessible. Equipment guidelines) should be required for athletics event, and all out-of- should be in good operating all athletics personnel associated season practices and skills sessions, condition, and personnel must be with practices, competitions, skills should include an emergency plan. trained in advance to use it instruction, and strength and Like student-athlete well-being in properly. Additionally, emergency conditioning. New staff engaged in general, a plan is a shared information about the student- these activities should comply with responsibility of the athletics athlete should be available both at these rules within six months of department; administrators, campus and while traveling for use employment. Refer to Appendix B coaches and medical personnel by medical personnel; for NCAA Coach Sport Safety should all play a role in the legislative requirements. establishment of the plan, 6. An inclement weather policy procurement of resources and that includes provisions for 9. A member of the institution's understanding of appropriate decision-making and evacuation sports medicine staff should be emergency response procedures by plans (See Guideline 1d); empowered to have the all parties. Components of such a 7. A thorough understanding by all unchallengeable authority to cancel plan should include: parties, including the leadership of or modify a workout for health and 1. The presence of a person visiting teams, of the personnel and safety reasons (i.e., environmental qualified and delegated to render procedures associated with the changes), as he or she deems emergency care to a stricken emergency-care plan; and appropriate. participant; 2. The presence or planned access to a physician for prompt medical evaluation of the situation, when warranted; 3. Planned access to early defibrillation; 4. Planned access to a medical facility, including a plan for communication and transportation between the athletics site and the medical facility for prompt medical services, when warranted. Access to a working telephone or other telecommunications device, 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 seriously 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 4. Van Camp SP, et al: Nontraumatic 7. Laws on Cardiac Arrest and on the field. In Mellion MB, Shelton GL, sports death in high school and college Defibrillators, 2007 update. Available at: Walsh WM (eds): The Team Physician's athletics. Medicine and Science in Sports www.ncsi.org/programs/health/aed.htm. Handbook St. Louis, MO: Mosby- and Exercise 27(5):641-647, 1995. 8. Inter-Association Task Force Yearbook, 1990, pp. 128-142. 5. Mass Participation Event Recommendations on Emergency 2. Harris AJ: Disaster plan—A part of Management for the Team Physician: A Preparedness and Management of Sudden Cardiac Arrest in High School the game plan. Athletic Training Consensus Statement. Medicine and and College Athletic Programs: A 23(1):59, 1988. Science in Sports and Exercise Consensus Statement. Journal of Athletic 36(11):2004-2008, 2004. 3. Recommendations and Guidelines for Training. 42:143-158. 2007. 6. Sideline Preparedness for the Team Appropriate Medical Coverage of 9. National Athletic Trainers’ Association Intercollegiate Athletics. National Physician: A Consensus Statement. Position Statement: Acute Management of Athletic Trainers’ Association, (2952 Medicine and Science in Sports and the Cervical Spine-Injured Athlete. Journal Stemmons Freeway, Dallas, Texas) 2003. Exercise 33(5):846-849, 2001. of Athletic Training. 44:306-331. 2009.

12 GUIDELINE 1d Lightning Safety July 1997 • Revised June 2007

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

13 Lightning Safety

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

References

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

15 GUIDELINE 1e Catastrophic Incident in Athletics

July 2004 • Revised July 2008

The NCAA Committee on Comp­ members are aware of the checklist of whom to call and etitive Safeguards and Medical guideline. immediate steps to secure facts and Aspects of Sports acknowledges the offer support are items to be significant input of Timothy Neal, Components of a catastrophic included. ATC, Syracuse University, who incident guideline should include: originally authored this guideline. 4. Chain of command/role 1. Definition of a catastrophic delineation: This area outlines Catastrophes such as death or incident: The sudden death of a each individual’s responsibility permanent disability occurring in student-athlete, coach or staff during the aftermath of the intercollegiate athletics are rare. member from any cause, or catastrophe. Athletics However, the aftermath of a disabling and/or quality of life administrators, university catastrophic incident to a student- altering injuries. administrators and support services athlete, coach or staff member can personnel should be involved in be a time of uncertainty and 2. A management team: A select this area. confusion for an institution. It is group of administrators who recommended that NCAA member receive all facts pertaining to the 5. Criminal circumstances: Outline the collaboration of the institutions develop their own catastrophe. This team works athletics department with catastrophic incident guideline to collaboratively to officially university, local and state law provide information and the communicate information to family enforcement officials in the event support necessary to family members, teammates, coaches, of accidental death, homicide or members, teammates, coaches and staff, the institution and media. suicide. staff after a catastrophe. This team may consist of one or Centralizing and disseminating the more of the following: director of 6. Away contest responsibilities: information is best served by athletics, head athletic trainer, developing a catastrophic incident Catastrophes may occur at away university spokesperson, director­ of contests. Indicate who should stay guideline. This guideline should be athletic communications and distributed to administrative, sports behind with the individual to university risk manager. This team coordinate communication and act medicine and coaching staffs may select others to help facilitate within the athletics department. as a university representative until fact finding specific to the relieved by the institution. The guideline should be updated incident. and reviewed annually with the 7. Phone list and flow chart: entire staff to ensure information is 3. Immediate action plan: At the accurate and that new staff Phone numbers of all key moment of the catastrophe, a individuals (office, home, cell)

16 Catastrophic Incident in Athletics involved in the management of the spouse of the victim. The director Catastrophic Injury catastrophe should be listed and of athletics, head coach and others Insurance Program kept current. Include university deemed necessary, will inform the The NCAA sponsors a catastrophic­ legal counsel numbers and the team, preferably in person, as soon injury insurance pro­gram that NCAA catastrophic injury service as possible and offer counseling covers a student-athlete who is line number (800/245-2744). A services and support. catastrophically injured while flow chart of who is to be called in participating in a covered the event of a catastrophe is also 10. Assistance to Visiting Team’s intercollegiate athletic activity. The useful in coordinating Catastrophic Incident as Host policy has a $90,000 deductible communication. Institution: In the event that a and provides benefits in excess of visiting team experiences a any other valid and collectible 8. Incident Record: A written catastrophic incident, the host insurance. The policy will pay chronology by the management institution may offer assistance by $25,000 if an insured person dies team of the catastrophic incident is alerting the director of athletics or as a result of a covered accident or recommended to critique the another member of the catastrophic sustains injury due to a covered process and provide a basis for incident management­ team in order accident which, independent of all review and enhancement of to make as many resources other causes, results directly in the procedures. available as possible to the visiting death of the insured person within team. The host institution may twelve (12) months after the date 9. Notification Process: After the of such injury. Both catastrophic catastrophic incident, the director assist in contacting the victim’s injuries and sudden deaths should of athletics, assistant director of institution and athletics athletics for sports medicine (head administration, as well as be reported to the NCAA national athletic trainer), head coach activating, as appropriate, the host office insurance staff. For more (recruiting coach if available), and institution’s catastrophic incident information, visit NCAA.org. university risk manager/legal guideline to offer support to the counsel, as available, will contact visiting team’s student-athletes, Sample guidelines may be found the parents/legal guardians/ coaches and staff. at NCAA.org/health-safety.

References Dr. Fred Mueller at the National Center for Catastrophic Research continues to research catastrophic injuries in sports through 1. Neal, TL: Catastrophic funding by the NCAA and the American College Football Coaches Incident Guideline Plan. NATA Association. The football fatality research and data collection has been done since 1931. The football catastrophic research started in News: 12, May 2003. 1977 at the University of North Carolina, Chapel Hill, and the 2. Neal, TL: Syracuse University research on fatalities and catastrophic injuries in all other sports was Athletic Department added beginning in 1982. Reports can be found on the NCCSI Catastrophic Incident Guideline, website at www.unc.edu/depts/nccsi/. 2003.

Catastrophic injuries include the following: 1. Fatalities. 2. Permanent disability injuries. 3. Serious injuries (fractured neck or serious head injury) even though the athlete has a full recovery. 4. Temporary or transient paralysis (athlete has no movement for a short time but has a complete recovery).

Please contact Dr. Mueller at the National Center for Catastrophic Sports Injury Research to report an incident at 919/962-5171 or via email at [email protected]. 17 GUIDELINE 1f Dispensing Prescription Medication May 1986 • Revised June 2008

Research sponsored by the NCAA to athletic trainers the authority for must comply with the applicable has shown that prescription dispensing prescription medications state and federal laws for doing so. medications have been provided to under current medication-dis­ It is strongly encouraged that ­student-athletes by individuals other pensing laws, since athletic trainers athletics departments and their team than persons legally authorized to are not authorized by law to physicians work with their on-site or dispense such medications. This is dispense these drugs under any area pharmacists to develop an important concern because the circumstances. The improper specific policies. improper dispensing of both delegation of authority by the prescription and nonprescription physician or the dispensing of The following items form a minimal drugs can lead to serious medical prescription medications by the framework for an appropriate drug- and legal consequences. athletic trainer (even with distribution program in a college- permission of the physician), place athletics environment. Since there is Research also has shown that state both parties at risk for legal extreme variability in state laws, it and federal regulations regarding liability. is imperative for each institution to packaging, labeling, records keeping consult with legal counsel in order and storage of medications have If athletics departments choose to to be in full compliance. been overlooked or disregarded in provide prescription and/or the dispensing of medications from nonprescription medications, they 1. Drug-dispensing practices are the athletic training facility. Moreover, many states have strict regulations regarding packaging, labeling, records keeping and storage of prescription and nonprescription medications. Athletics departments must be concerned about the risk of harm to the student-athletes when these regulations are not followed.

Administering drugs and dispensing drugs are two separate functions. Administration generally refers to the direct application of a single dose of drug. Dispensing is defined as preparing, packaging and labeling a prescription drug or device for subsequent use by a 18 patient. Physicians cannot delegate Dispensing Prescription Medication subject to and should be in be created and maintained where 6. All emergency and travel kits compliance with all state, federal dispensing occurs in accordance containing prescription and OTC and Drug Enforcement Agency with appropriate legal guidelines. drugs should be routinely inspected (DEA) regulations. Relevant items The record should be current and for drug quality and security. include­ appropriate packaging, label­ easily accessible by appropriate ing, counseling and education, medical personnel. 7. Individuals receiving medication records keeping, and accountability­ should be properly informed about for all drugs dispensed. 4. All prescription and over-the- what they are taking and how they counter (OTC) medications should should take it. Drug allergies, chronic 2. Certified athletic trainers should be stored in designated areas that medical conditions and concurrent not be assigned duties that may be ensure proper environmental (dry medication use should be documented performed only by physicians or with temperatures between 59 and in the student-athlete’s pharmacists. A team phy­si­cian 86 degrees Fahrenheit) and security and readily retrievable. cannot delegate diagnosis, conditions. prescription-drug control or 8. Follow-up should be performed to ­prescription-dispensing duties to 5. All drug stocks should be be sure student-athletes are athletic trainers. examined at regular intervals for complying with the drug regimen removal­ of any outdated, deteriorated and to ensure that drug is 3. Drug-distribution records should or recalled medications. effective.

References

1. Adherence to Drug-Dispensation and Publications,­ 1991, pp. 215-224. Distribution System for Athletics Drug-Administration Laws and 4. Huff PS: Drug Distribution in the Programs. Unpublished report, 1991. Guidelines in Collegiate Athletic Training Training Room. In in Sports (128 Miller Hall, Department of Phar­ Rooms. Journal of Athletic Training. Medicine. Philadelphia, WB Saunders macy Care Systems, Auburn Univer­sity, 38(3): 252-258, 2003. Co: 211-228, 1998. Auburn, AL 36849-5506) 2. Anderson WA, Albrecht RR, McKeag 5. Huff PS, Prentice WE: Using Phar­ 7. Price KD, Huff PS, Isetts BJ, et.al: DB, et al.: A national survey of alcohol macological Agents in a Reha­bili­ta­tion University-based sports and drug use by college athletes. The Program. In Rehabilitation Tech­niques in program. American Journal Health- Physician and Sportsmedicine 19:91- Sports Medicine (3rd Ed.) Dubuque, IA, Systems Pharmacy 52:302-309, 1995. 104, 1991. WCB/McGraw-Hill 244-265, 1998. 8. National Athletic Trainers’ Association 3. Herbert DL: Dispensing prescription 6. Laster-Bradley M, Berger BA: Eval­ Consensus Statement: Managing medications to athletes. In Herbert, DL uation of Drug Distribution Systems in Prescriptions and Non-Prescription (ed): The Legal Aspects of Sports Medi­ Uni­versity Athletics Programs: Devel­op­ Medication in the Athletic Training cine Canton, OH: Professional Sports ment of a Model or Optimal Drug Facility. NATA News. January 2009.

19 GUIDELINE 1g Nontherapeutic Drugs July 1981 • Revised June 2002

The NCAA and professional 1997. Use of spit tobacco is down in Sports. While not all member societies such as the American all divisions, but more so in institutions have enacted their own Medical Association (AMA) and the Divisions II and III. use is drug-testing programs, it is essential American College of Sports up slightly in all divisions since to have some type of drug-education Medicine (ACSM) denounce the 2001. The full results of the 2005 program as outlined in Guideline 1h. employment of nontherapeutic drugs and past surveys are available to all Drug testing should not be viewed as by student-athletes. These include member institutions and can be used a replacement for a solid drug- drugs that are taken in an effort to to educate staff and plan educational education program. enhance athletic performance, and and treatment programs for its those drugs that are used student-athletes. All medical staff should be familiar recreationally by student-athletes. with the regulations regarding Examples include, but are not The NCAA maintains a banned drug dispensing medications as listed in limited to, alcohol, , classes list and conducts drug testing Guideline 1f. , ma huang, anabolic- at championship events and year- androgenic steroids, barbiturates, round random testing in sports. All member institutions, their , cocaine, , LSD, PCP, Some NCAA member institutions athletics staff and their student- marijuana and all forms of tobacco. have developed drug-testing athletes should be aware of current The use of such drugs is contrary to programs to combat the use of trends in drug use and abuse, and the the rules and ethical principles of nontherapeutic substances. Such current NCAA list of banned drug athletics competition. programs should follow best practice classes. It is incumbent upon NCAA guidelines established by the NCAA member institutions to act as a The patterns of drug use and the Committee­ on Competitive positive influence in order to combat specific drugs change frequently, Safeguards and Medical Aspects of the use of drugs in sport and society. and it is incumbent upon NCAA member institutions to keep abreast of current trends. The NCAA conducts drug-use surveys of student-athletes in all sports and across all divisions every four years. References According to the 2005 NCAA Study of Substance Use Habits of College 1. American College of Sports Medicine, Compendium, Policy Statement: Non- Student-Athletes, the percentage of Position Stand: The Use of Anabolic- Therapeutic Use of Pharmacological student-athletes who use alcohol Androgenic Steroids in Sports, 1984. (P.O. Agents by Athletes (105.016), 1990. (P.O. decreased by 12 percent (88.9-76.9) Box 1440, Indianapolis, IN 46206-1440) Box 10946, Chicago, IL 60610) during the last 16 years, while the 2. American Medical Association 4. NCAA Study of Substance Use Habits percentage of student-athletes who Compendium, Policy Statement: Medical of College Student-Athletes. NCAA, P.O. use marijuana during those same 16 and Non-Medical Use of Anabolic- years also decreased (27.5-20.3). Box 6222, Indianapolis, Indiana 46206- Among the entire group of student- Androgenic Steroids (105.001), 1990. 6222, June 2006. Available at www. athletes, the use of amphetamines (P.O. Box 10946, Chicago, IL 60610) NCAA.org. has continually increased since 3. American Medical Association

20 GUIDELINE 1h NCAA Alcohol, Tobacco and Other Drug Education Guidelines August 2000 • Revised June 2003, June 2009, June 2010

NCAA bylaws require that the program policies and update Tasks and Timelines director of athletics or his or her handbook materials accordingly. for educating designee disseminate the list of student-athletes banned drug classes to all student- • Include the NCAA list of banned athletes and educate them about drug classes and NCAA written By July 1: products that might contain banned policies in the student-athlete • Send out the NCAA list of drugs. The following provides a handbook. banned drug classes, the dietary framework for member schools to supplement warning and REC* assure they are conducting adequate • Identify NCAA, conference and information to all returning drug education for all student- institutional rules regarding the student-athletes and known athletes. Athletics administrators, use of street drugs, performance coaches and sports medicine enhancing substances, and incoming student-athletes. personnel should also participate in nutritional supplements, and consequences for breaking the Orientation at Start drug-education sessions. Campus of Academic Year: colleagues may provide additional rules. support for your efforts. • Display posters and other NCAA • Ensure that student-athletes sign NCAA compliance forms. In preparation for educational materials in high- institution drug- traffic areas. • Provide student-athletes with a education programs, • Include the following printed copy of the written drug policies annually: warning in the student-athlete as outlined prior. • Develop a written policy on handbook: • Show NCAA Drug-Education alcohol, tobacco and other drugs. and Testing video. This policy should include a Before consuming any nutritional/ statement on recruitment dietary supplement product, review • Verbally explain all relevant drug activities, drug testing, the product and its label with your policies with student-athletes disclosure of all medications and athletics department staff. Dietary and staff: supplements, discipline, and supplements are not well regulated counseling or treatment options. and may cause a positive drug test • NCAA banned drug classes result. Any product containing a (note that all related • Review the NCAA, conference dietary supplement ingredient is compounds under each class and institutional drug-testing taken at your own risk.* are banned, regardless if they 21 NCAA Alcohol, Tobacco and Other Drug Education Guidelines

are listed as an example.)

• NCAA drug-testing policies and consequences for testing positive, including failure to show or tampering with a urine sample.

• Risks of using nutritional/ dietary supplements – read the dietary-supplement warning.

• NCAA tobacco use ban during practice or competition.

• Conference and institutional drug-testing program policies, if appropriate.

• Street drug use policies and institutional sanctions for violations, if appropriate.

Team Meetings: Throughout the Year:

• Repeat the information from the • Provide additional drug- orientation at team meetings education opportunities using throughout the year. NCAA resources found at www. NCAA.org/drugtesting. Start of Each New Academic Term: *For authoritative information on NCAA banned substances, • Repeat the information from the medications and nutritional orientation at the start of new supplements, contact the Resource academic terms to reinforce Exchange Center (REC) at messages and to ensure transfer 877/202-0769 or www. student-athletes are exposed to drugfreesport.com/rec (password this information. ncaa1, ncaa2 or ncaa3).

22 GUIDELINE 1i Preseason Preparation July 2011

Athletic performance training is often Specifically, student-athletes should on-campus experience, athletes divided into separate segments: know that the designated preseason should be encouraged to improve preparation segment, competitive practice period might be considered fitness through a progressive segment and offseason segment. The part of the competitive season and training and conditioning program NCAA Sports Medicine Handbook therefore a time when they may at least four weeks before starting Guideline 1a notes that the student- practice at contest-level intensities. the preseason segment. athlete should be protected from A shortened preseason period based premature exposure to the full rigors only on time spent on campus or The preparatory and preseason of sports. Optimal readiness for the coach expectations for contest-level phases provide ample time to first practice and competition is often intensities during the preparation improve fitness and skill; however, individualized to the student-athlete period often increases the time performing novel exercise or rather than a team as a whole. spent practicing sport-specific skills actively doing too much too soon However, there is a lack of scientific without ample opportunity for can result in a disparity between evidence to set a specific number of preparatory conditioning workload and load tolerance, thus days of sport practice that is needed and can lead to injury and increasing risk for injury. In for the first sport competition. overtraining. If this is the addition, a student-athlete’s expectation for the preparatory psychological well-being can be It is commonly accepted that student-athletes should participate Practice Injury Rates for Fall Sports in at least six to eight weeks of preseason conditioning. Gradual (2004-05 to 2008-09 NCAA Injury Surveillance) progression of type, frequency, Preseason In-Season intensity, recovery and duration of training should be the focus of the 9.6 preparation segment. In addition to Football these areas warranted for 3.2 progression, 10 to14 days are 8.9 needed for heat acclimatization Women’s Field Hockey when applicable (see Guideline 2c). 3.3 The fall sport preseason period is often challenging as August 8.2 Men’s Soccer presents added heat risks for sports 3.6 and there is a lack of time limits for practice activities (with the 7.8 8.7 exception of football). Women’s Soccer 3.0 Changes to practice opportunities 6.5 or the preseason period should be Women’s Volleyball 4.7 accompanied by an educational 3.2 campaign for both coaches and student-athletes as to the 0 2 4 6 8 10 expectations for the sport season. Injury rate (per 1,000 athlete-exposures) 23 Preseason Preparation

directly dependent on the level of intensity, long duration exercise between multiple practice sessions fatigue driven by volume (quantity) training or competition. on the same calendar day. and intensity of training. Similarly, Fall Preseason Period. Institutions • Subsequent to the initial the incidence in stress-related acclimatization period, an injuries (e.g., stress fractures, are encouraged to regularly review their preseason policies for fall sports institution should consider a tendinitis) can be proportional to practice model that promotes the work-rest ratio of the athlete. and consider the following points of emphasis for protecting the health of recovery if practice sessions are to Preparatory Phase. The following and providing a safe environment for occur on consecutive days (e.g., are general concepts to consider all student-athletes participating in two-one-two-one format). during the preparatory phase of preseason workout sessions. • Student-athletes should be training: • Before participation in any provided at least one recovery preseason-practice activities, all day per week on which no • Training should be periodized so student-athletes should have athletics-related activities are that variation in the volume and completed the medical scheduled, similar to the regular intensity occurs in a scheduled examination process administered playing season. manner. by medical personnel (see Bylaw • Coaches are encouraged to • Plan recovery to allow for growth 17.1.5). consult with healthcare staff (e.g., and development while avoiding • Institutions should implement an athletic trainer) in the acute and overtraining injuries. appropriate rest and recovery plan development of the conditioning that includes a hydration strategy. sessions. All personnel should be • A proper heat acclimatization aware of the impact of exercise • Preseason practice should begin plan is essential to minimize the intensity and duration, heat with an acclimatization period for risk of exertional heat illness acclimatization, hydration, first-time participants, as well as during the fall preseason practice medications and drugs, existing continuing student-athletes. period. Minimizing exertional medical conditions, nutritional heat illness risk requires • During the acclimatization supplements, and equipment on gradually increasing athletes’ period, an institution should student-athletes’ health while exposure to the duration and conduct only one practice per participating in strenuous intensity of physical activity and calendar day. workouts. to the environment over a period • Practice sessions should have of 10 to 14 days. • Appropriate on-field personnel maximum time limits based on should review, practice and • Prolonged, near-maximal sport and individual needs, as follow their venue emergency exertion should be avoided well as environmental factors. plan, as well as be trained in before acquired • An institution should ensure administering first aid, and heat acclimatization are student-athletes have continuous cardiopulmonary resuscitation sufficient to support high- recovery time (e.g., three hours) (CPR) and AED use.

24 Preseason Preparation

References

1. Joy, EA, Prentice, W, and Nelson-Steen, 5. Herring et al. The team physician and [part 1-2]. Strength & Conditioning S. Coaching and Training. SSE conditioning of athletes for sports: A Journal, 26(1): 50-69 Roundtable #44: Conditioning and consensus statement. 10. Plisk, S and Stone, MH. (2003). nutrition for football. GSSI: Sports 6. United Educators. (2006). Putting Periodization strategies. Strength & Science Library. Available Online: www. safety before the game: College and high Conditioning Journal, 25(6): 19-37. gssiweb.com/Article_Detail.aspx?articleid school athletic practices. Risk Research 11. Armstrong et al. (2007). ACSM =277&level=2&topic=14 . Bulletin, Student Affairs, June/July. Position Stand: Exertional heat illness 2. Bompa, Tudor O. (2004). Primer on Available online: www.ue.org. during training and competition. Periodization. Olympic Coach, 16(2): 7. National Athletic Trainer’s Medicine & Science in Sports & Exercise. 4-7. Association. Pre-Season heat Available Online: www.acsm-msse.org 3. Kraemer, WJ and Ratamess, NA. 2004. acclimatization practice guidelines for Fundamentals of resistance training: secondary school athletics. J Athl Train. Progression and exercise prescription. 2009 May-June; 44(3): 332–333. Medicine & Science in Sports & Exercise. 8. Hartmann, U and Mester, J. (2000). Available Online: www.acsm-msse.org. Training and overtraining markers in 4. Pearson et al. (2000). The national selected sports events. Medicine & strength and conditioning association’s Science in Sports & Exercise, 32(1): 209 basic guidelines for the resistance – 215. training of athletes. Strength and 9. Haff, G et al. (2004). Roundtable Conditioning Journal, 22(4): 14-27. discussion: Periodization of training

25 Preseason Preparation

NCAA Football Preseason Model (see Bylaw 17).

The following concepts outline the legislation involving the NCAA football preseason period. Institutions should refer to division-specific legislation for exact requirements.

Five-Day Acclimatization Period.

In football, preseason practice begins with a five-day acclimatization period for both first-time participants (e.g., freshmen and transfers) and continuing student-athletes. All student-athletes, including walk-ons who arrive to preseason practice after the first day of practice, are required to undergo a five-day acclimatization period. The five-day acclimatization period should be conducted as follows:

(a) Before participation in any preseason practice activities, all prospects and student-athletes initially entering the intercollegiate athletics program shall be required to undergo a medical examination administered by a physician.

(b) During the five-day period, participants shall not engage in more than one on-field practice per day, not to exceed three hours in length.

(c) During the first two days of the acclimatization period, helmets shall be the only piece of protective equipment student-athletes may wear. During the third and fourth days of the acclimatization period, helmets and shoulder pads shall be the only pieces of protective equipment student-athletes may wear. During the final day of the five-day period and on any days thereafter, student-athletes may practice in full pads.

The remaining preseason practice period is conducted as follows:

(a) After the five-day period, institutions may practice in full pads. However, an institution may not conduct multiple on-field practice sessions (e.g., two-a-days or three-a-days) on consecutive days;

(b) Student-athletes shall not engage in more than three hours of on-field practice activities on those days during which one practice is permitted;

(c) Student-athletes shall not engage in more than five hours of on-field practice activities on those days during which more than one practice is permitted; and

(d) On days that institutions conduct multiple practice sessions, student-athletes must be provided with at least three continuous hours of recovery time between the end of the first practice and the start of the last practice that day. During this time, student-athletes may not attend any meetings or engage in other athletically related activities (e.g., weightlifting); however, time spent receiving medical treatment and eating meals may be included as part of the recovery time.

26 Medical issues Also found on the NCAA website at: NCAA.org/health-safety 2 GUIDELINE 2a Medical Disqualification of the Student-Athlete January 1979 • Revised June 2004

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

References

1. Team Physician Consensus Statement. Project-based alliance for the advancement of clinical sports medicine composed 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. Contact ACSM at 317/ 28 637-9200. GUIDELINE 2b Cold Stress and Cold Exposure June 1994 • Revised June 2002, June 2009

Any individual can lose body heat exposure are due to a combination factors are, but not limited to, when exposed to cold air, but when of low air or water temperatures previous cold weather injury the physically active cannot and the influence of wind on the (CWI), race, geological origin, maintain heat, cold exposure can body’s ability to maintain a ambient temperature, use of be uncomfortable, impair normothermic core temperature, medications, clothing attire, performance and may be life- due to localized exposure of fatigue, hydration, age, activity, threatening. A person may exhibit extremities to cold air or surface. body size/composition, aerobic cold stress due to environmental or The variance in the degree, signs fitness level, clothing, non-environmental factors. The and symptoms of cold stress may acclimatization and low caloric NATA position statement (2008) also be the result of non- intake. Nicotine, alcohol and states that injuries from cold environmental factors. These other drugs may also contribute Wind Chill Chart

References

See reprint access permission for .gov websites: http://www.weather.gov/om/reprint.shtml 29 Cold Stress and Cold Exposure

to how the person adapts to the symptoms include edema, redness hour in endurance and alpine stresses of cold. or mottled gray skin, and transient events, and team sports, in which tingling and burning. clothing remains wet. The feet and Early recognition of cold stress is hands are usually affected. important. Shivering, a means for Hypothermia the body to generate heat, serves as Hypothermia is a significant drop Prevention of an early warning sign. Excessive in body temperature [below 95 shivering contributes to fatigue and degrees Fahrenheit (35 degrees Cold Exposure makes performance of motor skills Celsius)] as the body’s heat loss and Cold Stress more difficult. Other signs include exceeds its production. The body is Educating all participants in proper numbness and pain in fingers and unable to maintain a normal core prevention is the key to decreasing toes or a burning sensation of the temperature. An individual may the possibility of cold exposure ears, nose or exposed flesh. As cold exhibit changes in motor function injury or illness. Individuals exposure continues, the core (e.g., clumsiness, loss of finger unaccustomed to cold conditions temperature drops. When the cold dexterity, slurred speech), cognition participating at venues that may reaches the brain, a victim may (e.g., confusion, memory loss) and place them at risk for cold stress exhibit sluggishness, poor loss of consciousness (e.g., drop in may need to take extra judgment and may appear heart rate, stress on the renal precautionary measures (e.g., disoriented. Speech becomes slow system, hyperventilation, sensation proper clothing, warm-up routines, and slurred, and movements of shivering). The signs and nutrition, hydration, sleep). symptoms of hypothermia will vary become clumsy. If the participant The sports medicine staff and with each individual, depending wants to lie down and rest, the coaches should identify upon previous cold weather injury situation is a medical emergency participants or conditions that may (CWI), race, geological origin, and the emergency action plan place members of their teams at a ambient temperature, use of should be activated. greater risk (e.g., predisposing medications, clothing attire, Cold injuries can be classified into medical conditions, physiological fatigue, hydration, age, activity, and three categories: freezing or factors, mechanical factors, others. nonfreezing of extremities and environmental conditions). Hypothermia can occur at hypothermia. Clothing temperatures above freezing. A wet Individuals should be advised to and windy 30- to 50-degree Definitions of Common dress in layers and try to stay dry. exposure may be as serious as a Cold Injuries in Sports Moisture, whether from subzero exposure. As the Wind- Frostbite perspiration or precipitation, Chill Equivalent Index (WCEI) Frostbite is usually a localized significantly increases body heat indicates, wind speed interacts with response to a cold, dry loss. Layers can be added or ambient temperature to environment, but in some incidents, removed depending on significantly increase body cooling. moisture may exacerbate the temperature, activity and wind When the body and clothing are condition. Frostbite can appear in chill. Begin with a wicking fabric wet, whether from sweat, rain, three distinct phases: frostnip, mild next to the skin; wicking will not snow or immersion, the cooling is frostbite and deep frostbite. only keep the body warm and dry, even more pronounced due to but also eliminates the moisture Frostnip, also known as prefreeze, evaporation of the water held close retention of cotton. Polypropylene is a precursor to frostbite and many to the skin by wet clothing. or wool wick moisture away from times occurs when skin is in Chilblain and Immersion the skin and retain insulating contact with cold surfaces (e.g., (Trench) Foot properties when wet. Add sporting implements or liquid). The Chilblain is a non-freezing cold lightweight pile or wool layers for most characteristic symptom is a injury associated with extended warmth and use a wind-blocking loss of sensation. cold and wet exposure and results garment to avoid wind chill. Frostbite is the actual freezing of in an exaggerated or inflammatory Because heat loss from the head skin or body tissues, usually of the response. Chilblain may be and neck may account for as much face, ears, fingers and toes, and can observed in exposure to cold, wet as 40 percent of total heat loss, the 30 occur within minutes. Signs and conditions extending beyond one head and ears should be covered Cold Stress and Cold Exposure during cold conditions. Hand Practice and When traveling to areas of adverse coverings should be worn as Competition Sessions weather conditions, the following needed and in extreme conditions, The following guidelines, as terms will be consistently referred a scarf or facemask should be outlined in the 2008 NATA position to in weather forecasting. worn. Mittens are warmer than statement, can be used in planning Wind Chill activity depending on the wind- gloves. Feet can be kept dry by Increased wind speeds accelerate chill temperature. Conditions wearing moisture-wicking or wool heat loss from exposed skin, and should be constantly re-evaluated socks that breathe and should be the wind chill is a measure of this for change in risk, including the dried between wears. effect. No specific rules exist for presence of precipitation: Energy/Hydration determining when wind chill Maintain energy levels via the • 30 degrees Fahrenheit and becomes dangerous. As a general use of meals, energy snacks and below: Be aware of the potential guideline, the threshold for carbohydrate/electrolyte sports for cold injury and notify potentially dangerous wind chill drinks. Negative energy balance appropriate personnel of the conditions is about minus-20 increases the susceptibility to potential. degrees Fahrenheit. hypothermia. Stay hydrated, since • 25 degrees Fahrenheit and Wind Chill Advisory dehydration affects the body’s below: Provide additional The National Weather Service ability to regulate temperature protective clothing; cover as issues this product when the wind and increases the risk of frostbite. much exposed skin as practical; chill could be life threatening if Fluids are as important in the provide opportunities and action is not taken. The criteria for cold as in the heat. Avoid alcohol, facilities for re-warming. this warning vary from state to caffeine, nicotine and other drugs state. that cause water loss, • 15 degrees Fahrenheit and vasodilatation or vasoconstriction below: Consider modifying Wind Chill Factor of skin vessels. activity to limit exposure or to Increased wind speeds accelerate allow more frequent chances to heat loss from exposed skin. No Fatigue/Exhaustion re-warm. specific rules exist for determining Fatigue and exhaustion deplete • 0 degrees Fahrenheit and below: when wind chill becomes energy reserves. Exertional fatigue dangerous. As a general rule, the and exhaustion increase the Consider terminating or rescheduling activity. threshold for potentially dangerous susceptibility to hypothermia, as wind chill conditions is about does sleep loss. Environmental minus-20 degrees Fahrenheit. Warm-Up Conditions Wind Chill Warning Warm-up thoroughly and keep The National Weather Service warm throughout the practice or To identify cold stress conditions, regular measurements of issues this product when the wind competition to prevent a drop in chill is life threatening. The criteria muscle or body temperature. Time environmental conditions are recommended during cold for this warning vary from state to the warm-up to lead almost state. immediately to competition. After conditions by referring to the competition, add clothing to avoid Wind-Chill Equivalent Index Blizzard Warning rapid cooling. Warm extremely (WCEI) (revised November 1, The National Weather Service cold air with a mask or scarf to 2001). The WCEI is a useful tool issues this product for winter prevent bronchospasm. to monitor the air temperature storms with sustained or frequent index that measures the heat loss winds of 35 miles per hour or Partner from exposed human skin surfaces. higher with considerable falling Participants should never train Wind chill is the temperature it and/or blowing snow that alone. An injury or delay in “feels like” outside, based on the frequently reduces visibility to one- recognizing early cold exposure rate of heat loss from exposed skin quarter of a mile or less. symptoms could become life- caused by the effects of the wind threatening if it occurs during a and cold. Wind removes heat from cold-weather workout on an the body in addition to the low isolated trail. ambient temperature. 31 Cold Stress and Cold Exposure

References

1. Cappaert, Thomas A etal: National 4. Askew EW: Nutrition for a cold cold. The Physician and Sportsmedicine Athletic Trainers’ Association Position environment. The Physician and 20(1):61-65, 1992. Statement: Environmental Cold Injuries. Sportsmedicine 17(12):77-89, 1989. 8. Thornton JS: Hypothermia shouldn’t Journal of Athletic Training 5. Frey C: Frostbitten feet: Steps to freeze out cold-weather athletes. The 2008:43(6):640-658 treatment and prevention. The Physician Physician and Sportsmedicine 18(1): 2. Prevention of Cold Injuries During and Sportsmedicine 21(1):67-76, 1992. 109-114, 1990. Exercise. ACSM Position Stand. 6. Young, A.J., Castellani, J.W., O’Brian, 9. NOAA National Weather Service, www. Medicine & Science in Sports & C. et al., Exertional fatigue, sleep loss, weather.gov/om/windchill/images/wind- Exercise. 2006: 2012-2029. and negative-energy balance increases chill-brochure.pdf. 3. Armstrong, LE: Performing in susceptibility to hypothermia. Journal of 10. Street, Scott, Runkle, Debra. Athletic Extreme Environments. Champaign, IL: Applied Physiology. 85:1210-1217, 1998. Protective Equipment: Care, Selection, Human Kinetics Publishers. 7. Robinson WA: Competing with the and Fitting. McGraw-Hill, 2001.

32 GUIDELINE 2c Prevention of Heat Illness June 1975 • Revised June 2002, June 2010

Practice or competition in hot and/or that likely to occur in competition. it may be advisable to use a mini- humid environmental conditions When environmental conditions are mum of protective gear and clothing poses special problems for student- extreme, training or competition and to practice in T-shirts, shorts, athletes. Heat stress and resulting should be held during a cooler time socks and shoes. Rubberized suits heat illness is a primary concern in of day. Hydration should be main- should not be worn. these conditions. Although deaths tained during training and acclimati- 4. To identify heat stress conditions, from heat illness are rare, exertional zation sessions. regular measurements of environ- heat stroke (EHS) is the third-lead- 3. Clothing and protective equip- mental conditions are recommended. ing cause of on-the-field sudden ment, such as helmets, shoulder pads The wet-bulb globe temperature death in athletes. There have been and shin guards, increase heat stress (WBGT), which includes the mea- more deaths from heat stroke in the by interfering with the evaporation surement of wet-bulb temperature last five-year block (2005-2009) of sweat and inhibiting other path- (humidity), dry-bulb temperature than any other five-year block dur- ways needed for heat loss. Dark- (ambient temperature) and globe ing the past 35 years. Constant sur- colored clothing increases the body’s temperature (radiant heat), assesses veillance and education are neces- absorption of solar radiation, while the potential impact of environmen- sary to prevent heat-related prob- moisture wicking-type clothing tal heat stress. A WBGT higher than lems. The following practices should helps with the body’s ability to dissi- 82 degrees Fahrenheit (28 degrees be observed: pate heat. Frequent rest periods Celsius) suggests that careful control 1. An initial complete medical histo- should be scheduled so that the gear of all activity should be undertaken. ry and physical evaluation, followed and clothing can be removed and/or Additional precautions should be by the completion of a yearly health- loosened to allow heat dissipation. taken when wearing protective status questionnaire before practice During the acclimatization process, equipment (see reference No. 6). begins, is required, per Bylaw 17.1.5. A history of previous heat ill- nesses, sickle cell trait and the type Intense exercise, hot and humid weather and dehydration can seriously and duration of training activities for compromise athlete performance and increase the risk of exertional heat the previous month, should also be injury. Report problems to medical staff immediately. considered. Protect Yourself and Your Teammates: 2. Prevention of heat illness begins with gradual acclimatization to envi- Know the Signs Report your Symptoms ronmental conditions. Student- • Muscle cramping. • High body temperature. athletes should gradually increase • Decreased performance. • Nausea. exposure to hot and/or humid envi- • Unsteadiness. • Headache. ronmental conditions during a mini- • Confusion. • Dizziness. mum period of 10 to 14 days. Each • Vomiting. • Unusual fatigue. exposure should involve a gradual • Irritability. • Sweating has stopped. increase in the intensity and duration • Pale or flushed skin. • Disturbances of vision. of exercise and equipment worn • Rapid weak pulse. • Fainting. until the exercise is comparable to 33 Prevention of Heat Illness

The American College of Sports duration, most weight loss represents out, practice and competition. This Medicine has recently (2007) revised water loss, and that fluid loss should procedure can detect progressive its guidelines for conducting athletic be replaced as soon as possible. dehydration and loss of body fluids. activities in the heat (see After activity, the student-athlete Those who lose five percent of their reference No. 1). should rehydrate with a volume that body weight or more should be evalu- exceeds the amount lost during the 5. EHS has the greatest potential of ated medically and their activity activity. In general, 16-24 ounces of restricted until rehydration has occurrence at the start of preseason fluid should be replaced for every practices and with the introduction occurred. For prevention, the routine pound lost. Urine volume and color measurement of pre- and post-exer- of protective equipment during prac- can be used to assess general hydra- tice sessions. The inclusion of mul- cise body weights is useful for deter- tion. If output is plentiful and the mining sweat rates and customizing tiple practice sessions during the color is “pale yellow or straw-col- fluid replacement programs. same day may also increase the risk ored,” the student-athlete is not dehy- of EHS. Ninety-six percent of all drated. As the urine color gets dark- 8. Some student-athletes may be heat illnesses in football occur er, this could represent dehydration more susceptible to heat illness. in August. of the student-athlete. Water and Susceptible individuals include those 6. Hydration status also may influ- sport drinks are appropriate for with: sickle cell trait, inadequate ence the occurrence of EHS, there- hydration and rehydration during acclimatization or aerobic fitness, fore fluid replacement should be exercise in the heat. Sport drinks excess body fat, a history of heat ill- readily available. Student-athletes should contain carbohydrates and ness, a febrile condition, inadequate should be encouraged to drink fre- electrolytes to enhance fluid con- rehydration, and those who regularly quently throughout a practice ses- sumption. In addition, the carbohy- push themselves to capacity. Also, sion. They should drink two cups or drates provide energy and help main- substances with a diuretic effect or tain immune and cognitive function. more of water and/or sports drink in that act as may increase the hour before practice or competi- 7. During the preseason period or risk of heat illness. These substances tion, and continue drinking during periods of high environmental stress, may be found in some prescription activity (every 15 to 20 minutes). the student-athletes’ weight should be and over-the-counter drugs, nutri- For activities up to two hours in recorded before and after every work- tional supplements and foods.

Tips for student-athletes and coaches Acclimatize Stay cool √ Avoid workouts during unusually hot temperatures by picking the right time of day. √ Conduct warm-ups in the shade. √ Progress your exercise time and intensity slowly √ Schedule frequent breaks. during a two-week period before preseason. √ Break in the shade. √ Reduce multiple workout sessions; if multiple √ Use fans for cooling. sessions are performed, take at least three hours √ Take extra time – at least three hours – between of recovery between them. two-a-day practices. √ Wear light-colored, moisture-wicking, Coaches be prepared loose-fitting clothing. √ Use appropriate medical coverage. √ Increase recovery interval times between √ Have a cell phone on hand. exercise bouts and intervals. √ Know your local emergency numbers and Stay hydrated program them in your phone. √ Drink before you are thirsty (20 oz. two to three √ Report problems to medical staff immediately. hours before exercise). √ Schedule breaks for hydration and cooling √ Drink early (8 oz. every 15 minutes during (e.g., drinks, sponges, towels, tubs, fans). exercise). √ Provide ample recovery time in practice and √ Replace fluids (20 oz. for every pound lost). between practices. √ Lighter urine color is better. √ Monitor weight loss. 34 √ Incorporate sports drinks when possible. √ Encourage adequate nutrition. Prevention of Heat Illness

9. Student-athletes should be edu- cated on the signs and symptoms of POTENTIAL RISK FACTORS EHS, such as: elevated core temper- As identified throughout Guideline 2c, the following are potential risk factors ature, weakness, cramping, rapid and associated with heat illness: weak pulse, pale or flushed skin, excessive fatigue, nausea, unsteadi- 1. Intensity of exercise. This is the leading factor that can increase core body temperature higher and faster than any other. ness, disturbance of vision, mental confusion and incoherency. If heat 2. Environmental conditions. Heat and humidity combine for a high wet-bulb stroke is suspected, prompt emer- globe temperature that can quickly raise the heat stress on the body. gency treatment is recommended. 3. Duration and frequency of exercise. Minimize multiple practice When training in hot and/or humid sessions during the same day and allow at least three hours of recovery conditions, student-athletes should between sessions. train with a partner or be under 4. Dehydration. Fluids should be readily available and consumed to aid in the observation by a coach or body’s ability to regulate itself and reduce the impact of heat stress. athletic trainer. 5. nutritional supplements. Nutritional supplements may contain stimulants, such as ephedrine, ma huang or high levels of caffeine.* These substances can First aid for have a negative impact on hydration levels and/or increase metabolism and heat heat illness production. They are of particular concern in people with underlying medical conditions such as sickle cell trait, hypertension, asthma and thyroid dysfunction. Heat exhaustion—Heat exhaustion 6. Medication/drugs. Certain medications and drugs have similar effects as is a moderate illness characterized nutritional supplements. These substances may be ingested through over-the- by the inability to sustain adequate counter or prescription medications, recreational drugs, or consumed in food. cardiac output, resulting from stren- Examples include antihistamines, decongestants, certain asthma medications, uous physical exercise and environ- Ritalin, diuretics and alcohol. mental heat stress. Symptoms usual- 7. medical conditions. Examples include illness with fever, gastro-intestinal ly include profound weakness and illness, previous heat illness, obesity or sickle cell trait. exhaustion, and often dizziness, syn- 8. acclimatization/fitness level. Lack of acclimatization to the heat or poor cope, muscle cramps, nausea and a conditioning. core temperature below 104 degrees 9. Clothing. Dark clothing absorbs heat. Moisture wicking-type material Fahrenheit with excessive sweating helps dissipate heat. and flushed appearance. First aid should include removal from activi- 10. Protective equipment. Helmets, shoulder pads, chest protectors, and thigh and leg pads interfere with sweat evaporation and increase heat retention. ty, taking off all equipment and plac- ing the student-athlete in a cool, 11. Limited knowledge of heat illness. Signs and symptoms can include shaded environment. Fluids should elevated core temperature, pale or flushed skin, profound weakness, muscle cramping, rapid weak pulse, nausea, dizziness, excessive fatigue, fainting, be given orally. Core temperature confusion, visual disturbances and others. and vital signs should be serially assessed. The student-athlete should *NOTE: drugs such as amphetamines, ecstasy, ephedrine and caffeine are on be cooled by ice immersion and ice the NCAA banned substance list and may be known by other names. A complete list of towels, and use of IV fluid replace- banned drug classes can be found on the NCAA website at NCAA.org/health-safety. ment should be determined by a physician. Although rapid recovery is typical, student-athletes should not student-athlete likely will still be immediate cooling of the body with be allowed to practice or compete sweating profusely at the time of cold water immersion. Another for the remainder of that day. collapse, but may have hot, dry skin, method for cooling includes using which indicates failure of the cold, wet ice towels on a rotating Exertional Heatstroke—Heatstroke primary temperature-regulating basis. Student-athletes who incur is a medical emergency. Medical mechanism (sweating), and CNS heatstroke should be hospitalized and care should be obtained at once; a dysfunction (e.g., altered monitored carefully. The NATA’s delay in treatment can be fatal. This consciousness, seizure, coma). First Inter-Association Task Force condition is characterized by a very aid includes activation of the recommends, “cool first, transport high body temperature (104 degrees emergency action plan, assessment second” in these situations (see Fahrenheit or greater) and the of core temperature/vital signs and reference No. 7). 35 Prevention of Heat Illness

References

1. American College of Sports Medicine 8. Casa DJ, Armstrong LE, Ganio MS, Position Stand: Exertional Heat Illness Yeargin SW. Exertional Heat Stroke in during Training and Competition. Med: Competitive Athletes. Current Sports Sci Sport Exerc. 2007;39(3):556-72. Medicine Reports 2005, 4:309–317. 2. Armstrong LE, Maresh CM: The 9. Casa DJ, McDermott BP, Lee EC, induction and decay of heat Yeargin SW, Armstrong LE, Maresh CM. acclimatization in trained athletes. Sports Cold Water Immersion: The Gold Medicine 12(5):302-312, 1991. Standard for Exertional Heatstroke 3. Armstrong, LE: Performing in Extreme Treatment. Exercise and Sport Sciences Environments. Champaign, IL: Human Reviews. 2007. 35:141-149. Kinetics Publishers, pp 64, 2000. 10. Casa DJ, Becker SM, Ganio MS, et al. 4. Haynes EM, Wells CL: Heat stress and Validity of Devices That Assess Body performance. In: Environment and Human Temperature During Outdoor Exercise in Performance. Champaign, IL: Human the Heat. Journal of Athletic Training Kinetics Publishers, pp. 13-41, 1986. 2007; 42(3):333–342. 5. Hubbard RW and Armstrong LE: The 11. National Athletic Trainers’ Association heat illness: Biochemical, ultrastructural Position Statement: Exertional Heat and fluid-electrolyte considerations. In Illnesses. Journal of Athletic Training Pandolf KB, Sawka MN and Gonzalez RR 2002; 37(3):329–343. (eds): Human Performance Physiology 12. American College of Sports Medicine and Environmental Medicine at Terrestial Position Stand: Exercise and Fluid Extremes. Indianapolis, IN: Benchmark Replacement. Med: Sci Sport Exerc. Press, Inc., 1988. 2007; 384-86. 6. Kulka TJ and Kenney WL: Heat balance limits in football uniforms. The Physician and Sportsmedicine. 30(7): 29-39, 2002. 7. Inter-Association Task Force on Exertional Heat Illnesses Consensus Statement. National Athletic Trainers’ Association, June 2003.

36 GUIDELINE 2d Weight Loss­– Dehydration July 1985 • Revised June 2002

There are two general types of muscular endurance, reduced plasma practices, student-athletes and weight loss common to student- and blood volume, compromised coaches should be educated about athletes who participate in cardiac output (elevated heart rate, the physiological and pathological intercollegiate sports: loss of body smaller stroke volume), impaired consequences of dehydration. The water or loss of body weight (fat and thermoregulation, decreased kidney use of laxatives, emetics and lean tissue). Dehydration, the loss of blood flow and filtration, reduced diuretics should be prohibited. body water, leads to a state of liver glycogen stores, and loss of Similarly, the use of excessive food negative water balance called electrolytes. Pathological responses and fluid restriction, self-induced dehydration. It is brought about by include life-threatening heat illness, vomiting, vapor-impermeable suits withholding fluids and rhabdomyolysis (severe muscle (e.g., rubber or rubberized nylon), carbohydrates, the promotion of breakdown), kidney failure and hot rooms, hot boxes and steam extensive sweating and the use of cardiac arrest. rooms should be prohibited. emetics, diuretics or laxatives. The Excessive food restriction or self- With extensive dehydration, at­tempts problem is most evident in those who induced vomiting may be symptoms at acute rehydration usually are must be certified to participate in a of serious eating disorders (see insufficient for body fluid and given weight class, but it also is Guideline 2f). electrolyte homeostasis to be restored present in other athletics groups. before competition. For example, in Dehydration is a potential health hazard There is no valid reason for wrestling this is especially true that acts with poor nutrition and intense subjecting the student-athlete’s body between the official weigh-in and exercise to compromise health and to intentional dehydration, which can actual competition. athletic performance. The sensible lead to a variety of adverse alternative to dehydration weight loss All respected sports medicine physiological effects, including involves: preseason determination of an authorities and organizations have significant and even death. acceptable (minimum) competitive condemned the practice of fluid Dehydration in excess of 3 to 5 weight, gradual weight loss to achieve deprivation. To promote sound percent leads to reduced strength and the desired weight, and maintenance of the weight during the course of the References competitive season. Standard body composition procedures should be used 1. American College of Sports Medicine, Box 9005, Chicago, IL 60604-9005). to determine the appropriate Position Stand: Weight Loss in Wrestlers, 4. Hyphothermia and Dehydration- competitive weight. Spot checks (body 1995. (P.O. Box 1440, Indianapolis, IN Related Deaths Associated with composition or dehydration) should be 46206-1440). Intentional Rapid Weight Loss in Three used to ensure compliance with the weight standard during the season. 2. Armstrong, LE. Performing in Extreme Collegiate Wrestlers. Morbidity and Environments. Champaign, IL: Human Mortality Weekly 47(6):105-108, 1998. Student-athletes and coaches should Kinetics Publishers, pp 15-70, 2000. be informed of the health 5. Sawka, MN (chair): Symposium— consequences of dehydration, 3. Horswill CA: Does Rapid Weight Loss Current concepts concerning , educated in proper weight-loss by Dehydration Adversely Affect High- dehydration, and fluid replacement. procedures, and subject to Power Performance? 3(30), 1991. Medicine and Science in Sports and disciplinary action when approved 37 (Gatorade Institute, P.O. Exercise 24(6):643-687, 1992. rules are violated. 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, 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 football teams have different body fat percentage and lower a large degree, influenced by the responsibilities than receivers, and muscle mass inevitably results in a student-athlete’s body composition. this dif­fer­ence is manifested in performance reduction that Coupled with the common physiques that are also different. motivates the student-athlete to perception of many student-athletes follow regimens that produce even who compete in sports in which Besides the aesthetic and greater energy deficits. This appearance is a concern performance reasons for wanting to downward energy intake spiral may (swimming, diving, gymnastics, achieve an optimal body be the precursor to eating disorders skating, etc.), attainment of an composition, there may also be that place the student-athlete at ‘ideal’ body composition often safety reasons. A student-athlete serious health risk. Therefore, becomes a central theme of who is carrying excess weight may while achieving an optimal body training. be more prone to injury when composition is useful for high-level performing difficult skills than the athletic performance, the processes Successful student-athletes achieve student-athlete with a more optimal student-athletes often use to attain a body composition that is within a body composition. However, the an optimal body composition may range associated with performance means student-athletes often use in reduce athletic performance, may achievement in their specific sport. an attempt to achieve an optimal place them at a higher injury risk Each sport has different norms for body composition may be and may increase health risks. counterproductive. Diets and the muscle and fat levels associated Purpose of Body with a given height, and the excessive training often result in such a severe energy deficit that, Composition student-athlete’s natural genetic Assessment predisposition for a certain body while total weight may be reduced, composition may encourage them the constituents of weight also The purpose of body composition to participate in a particular sport change, commonly with a lower assessment is to determine the or take a specific position within a muscle mass and a relatively higher student-athlete’s distribution of lean 38 sport. For instance, linemen on fat mass. The resulting higher (muscle) mass and fat mass. A Assessment of Body Composition high lean mass to fat mass ratio is determine the appropriateness of often synonymous with a high their training schedule and nutrient strength to weight ratio, which is intake. In addition, it is important typically associated with athletic for coaches and student-athletes to success. However, there is no use functional performance single ideal body composition for measures in determining the all student-athletes in all sports. appropriateness of a student- In the absence of Each sport has a range of lean athlete’s body composition. published standards for mass and fat mass associated with Student-athletes outside the normal it, and each student-athlete in a range of body fat percent for the a sport, one strategy for sport has an individual range that is sport may have achieved an determining if a ideal for him or her. Student- optimal body composition for their athletes who try to achieve an genetic makeup, and may have student-athlete is arbitrary body composition that is objective performance measures within the body not right for them are likely to (e.g., jump height) that are well composition standards place themselves at health risk and within the range of others will not achieve the performance on the team. for the sport is to benefits they seek. Therefore, a obtain a body fat key to body composition Body composition can be measured assessment is the establishment of indirectly by several methods, percent value for each an acceptable range of lean and fat including hydrostatic weighing, student-athlete on a mass for the individual student- skinfold and girth measurements athlete, and the monitoring of lean (applied to a nomogram or team (using the same and fat mass over regular time prediction equation), bioelectrical method of assessment), intervals to assure a stability or impedance analysis (BIA), dual- and obtaining an growth of the lean mass and a energy x-ray absorptiometry proportional maintenance or (DEXA), ultrasound, computerized average and standard reduction of the fat mass. tomography, magnetic-resonance deviation for body fat Importantly, there should be just as imagery, isotope dilution, neutron- much attention given to changes in activation analysis, potassium-40 percent for the team. lean mass (both in weight of lean counting, and infrared interactance. mass and proportion of lean mass) The most common of the methods as the attention traditionally given now used to assess body to body fat percent. composition in student-athletes are skinfold measurements, DEXA, In the absence of published hydrostatic weighing and BIA. standards for a sport, one strategy While hydrostatic weighing and for determining if a student-athlete DEXA are considered by many to is within the body composition be the “gold standards” of the standards for the sport is to obtain indirect measurement techniques, a body fat percent value for each there are still questions regarding student-athlete on a team (using the the validity of these techniques same method of assessment), and when applied to humans. Since obtaining an average and standard skinfold-based prediction equations deviation for body fat percent for typically use hydrostatic weighing the team. Student-athletes who are or DEXA as the criterion methods, within 1 standard deviation (i.e., a results from skinfolds typically Z-score of ± 1) of the team mean carry the prediction errors of the should be considered within the criterion methods plus the added range for the sport. Those greater measurement errors associated with than or less than ± 1 standard obtaining skinfold values. BIA has deviation should be evaluated to become popular because of its non- 39 Assessment of Body Composition

invasiveness and speed of body composition values with other the student-athlete can return to measurement, but results from this student-athletes, but this training after an injury, reduce technique are influenced by comparison is not meaningful and performance and increase the risk hydration state. Since student- it may drive a student-athlete to of an eating disorder. Body athletes have hydration states that change body composition in a way composition values should be are in constant flux, BIA results that negatively impacts both thought of as numbers on a may be misleading unless strict performance and health. Health continuum that are usual for a hydration protocols are followed. professionals involved in obtaining sport. If a student-athlete falls In general, all of the commonly body composition data should be anywhere on that continuum, it is used techniques should be viewed sensitive to the confidentiality of likely that factors other than body as providing only estimates of body this information, and explain to composition (training, skills composition, and since these each student-athlete that acquisition, etc.) will be the major techniques use different theoretical differences in height, age and predictors of performance success. assumptions in their prediction of gender are likely to result in body composition, values obtained differences in body composition, 4. Frequency of Body from one technique should not be without necessarily any differences Composition Assessment— compared with values obtained in performance. Strategies for Student-athletes who have frequent from another technique. achieving this include: weight and/or skinfolds taken are • Obtaining body composition fearful of the outcome, since the Concerns with values with only one results are often (inappropriately) Body Composition student-athlete at a time, to used punitively. Real changes in Assessment limit the chance that the data body composition occur slowly, so will be shared. there is little need to assess 1. Using Weight as a Marker of • Giving student-athletes student-athletes weekly, biweekly Body Composition—While the information on body or even monthly. If body collection of weight data is a composition using phrases composition measurements are necessary adjunct to body such as “within the desirable sufficient and agreed upon by all composition assessment, by itself range” rather than a raw parties, measurement frequency of weight may be a misleading value. value, such as saying “your twice a year should be sufficient. For instance, young student- body fat level is 18 percent.” In some isolated circumstances in athletes have the expectation of • Providing athletes with which a student-athlete has been growth and increasing weight, so information on how they injured or is suffering from a gradual increases in weight should have changed between disease state, it is reasonable for a not be interpreted as a body assessments, rather than physician to recommend a more composition problem. A student- offering the current value. frequent assessment rate to control athlete who has increased • Increasing the focus on for changes in lean mass. Student- resistance training to improve muscle mass, and decreasing athletes and/or coaches who desire strength may also have a higher the focus on body fat. more frequent body composition or weight, but since this increased • Using body composition weight measurement should shift weight is likely to result from more values as a means of helping their focus to assessments of muscle, this should be viewed as a to explain changes in objective performance-related positive change. The important objectively measured measurers. consideration for weight is that it performance outcomes. can be (and often is) misused as a 3. Seeking an Arbitrarily Low Summary measure of body composition, and Level of Body Fat—Most student- this misuse can detract from the athletes would like their body fat The assessment of body purpose of body composition level to be as low as possible. composition can be a useful tool in assessment. However, student-athletes often try helping the student-athlete and to seek a body fat level that is coach understand the changes that 2. Comparing Body Composition arbitrarily low and this can increase are occurring as a result of training Values with Other Athletes— the frequency of illness, increase and nutritional factors. However, 40 Student-athletes often compare the risk of injury, lengthen the time the body composition measurement Assessment of Body Composition

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

41 Assessment of Body Composition

process and the values obtained can permitted to discuss the results with stress. This stress can lead to the be a sensitive issue for the student- the student-athlete and what development or enhancement of athlete. A legitimate purpose for frequency of body composition eating disorders in the student- body composition­ assessment measurement is appropriate.­ The athlete (see Guideline 2f). All should dictate the use of these student-athlete should not feel coaches (sport or strength/ conditioning) should be aware of measurement techniques. Health forced or obligated to undergo body the sizable influence they may have professionals involved in obtaining composition or weight on the behaviors and actions of body composition data should focus measurement. on using the same technique with their student-athletes. Many the same prediction equations to Everyone involved directly or student-athletes are sensitive about derive valid comparative data over indirectly with body composition body fat, so care should be taken to time. Institutions­ should have a measurement should understand apply body composition protocol in place outlining the that inappropriate measurement and measurement, when appropriate, in rationale for body composition use of body composition data might a way that enhances the student- measurements, who is allowed to contribute to the student-athlete athlete’s well-being. measure the student-athlete, who is experiencing unhealthy emotional

References

1. Benardot D: Working with young 7. Houtkooper LB and Going SB. Body 13. Manore M, Benardot D, and Love P. athletes: Views of a nutritionist on the composition: How should it be Body measurements. In: Benardot D sports medicine team. Int. J. Sport Nutr. measured? Does it affect sport (Ed). : A Guide for 6(2):110-120, 1996. performance? Sports Science Exchange Professionals Working with Active SSE#52(7):1-15, 1994. People Chicago, IL: American Dietetic 2. Boileau RA and Lohman TG. The Association, pp 70-93, 1993. measurement of human physique and its 8. Houtkooper LB, Going SB, Lohman effect on physical performance. TG, Roche AF, and Van Loan M. 14. Melby CL and Hill JO. Exercise, Orthopedic Clin. N. Am. 8:563- Bioelectrical impedance estimation of macronutrient balance, and body weight 581,1977. fat-free body mass in children and regulation. Sports Science Exchange youth: a cross-validation study. J. Appl. SSE#72(12): 1-16, 1999. 3. Clarkson PM. Nutritional Physiol. 72:366-373, 1992. supplements for weight gain. Sports 15. Thomas BJ, Cornish BH, Ward LC, Science Exchange SSE#68(11): 1-18, 9. Jackson AS and Pollock ML. and Jacobs A. Bioimpedance: is it a 1998. Generalized equations for predicting predictor of true water volume? Ann. body density in men. Br. J. Nutr. N.Y. Acad. Sci. 873:89-93, 1999. 4. Clasey JL, Kanaley JA, Wideman L, 40:497-504, 1978. Heymsfield SB, Teates CD, Gutgesell ME, Thorner MO, Hartman ML, and 10. Jackson AS, Pollock ML, and Ward Weltman A. Validity of methods of body A. Generalized equations for predicting composition assessment in young and body density of women. Med. Sci. older men and women. J. Appl. Physiol. Sports Exerc. 12:175-182, 1980. 86(5):1728-38, 1999. 11. Lukaski HC. Methods for the 5. Fleck SJ. Body composition of elite assessment of American athletes. Am. J. Sports Med. composition—traditional and new. Am. 11:398-403, 1983. J. Clin. Nutr. 46:537-56, 1987. 6. Heymsfield SB and Want Z. 12. Malina RM and Bouchard C. Measurement of total-body fat by Characteristics of young athletes. In: underwater weighing: new insights and Growth, Maturation and Physical uses for old method. Nutrition 9:472- Activity. Champaign, IL: Human 42 473, 1993. Kinetics Books, pp. 443-463, 1991. GUIDELINE 2f Nutrition and Athletic Performance January 1986 • Revised June 2002, May 2009

Athletic performance and recovery continued throughout the year. training and performance. from training are enhanced by Carbohydrate intake has been well The competitive phase usually attention to nutrient intake. documented to have a positive reflects a decrease in training Optimal nutrition for health and volume, and perhaps higher- impact on adaptation to training, performance includes the intensity training sessions with performance and improved immune identification of both the quantity extended periods of tapering function. and quality of food and fluids leading up to competition and During base training, a daily intake needed to support regular training travel. During the competitive of between 5 to 7 grams of and peak performance. As training phase, athletes should adjust carbohydrate per kilogram of body demands shift during the year, calorie and macronutrient intake to weight per day is advised. As athletes need to adjust their caloric prevent unwanted weight gain, and training intensity and/or volume intake and macronutrient learn how to eat before competition increase, carbohydrate need may distribution while maintaining a and while traveling, and how to easily exceed 10 grams of high nutrient-dense diet that adjust fluid needs based on carbohydrate per kilogram of body supports their training and environmental impacts. Athletes weight. Athletes should begin to competition nutrient needs. The who consume a balanced, adequate think about fueling for their next following key points summarize diet will likely exhibit the best athletics activity immediately after the impacts of training on energy, performance, and experience less the one they just completed. nutrient and fluid recommendations illness during the competitive for competitive student-athletes as Recovery carbohydrate, to replace phase. recommended by the American glycogen stores, can be calculated College of Sports Medicine The transition phase, during which based on 1 to 1.2 grams of (ACSM) and the American Dietetic athletes’ training volume and carbohydrate per kilogram of body Association (ADA). intensity are likely at their lowest, weight and should be consumed requires some attention to the immediately after training sessions It is helpful to think of collegiate prevention of unwanted changes in athletes’ training year as including body weight (increased body fat or three phases: base, competition and decreased muscle mass). During transition. During base training this phase, athletes may need to when training volume is high decrease total calorie intake and (practices are longer and/or more resist overindulging while still frequent), athletes’ energy needs maintaining a nutrient-dense diet. are likely to be at their highest. A high-quality nutritional plan is key Carbohydrate, the primary fuel during this phase. Base training is for higher intensity activity, is also the best phase to experiment required to replenish liver and with and define event fueling and glycogen stores and to prevent low hydration strategies that can be blood sugar (hypoglycemia) during NCAA.org/nutritionandperformance 43 Nutrition and Athletic Performance

longer than 90 minutes or high- of foods to maintain body weight. intensity, shorter-duration training However, the risk of micronutrient sessions. Within two hours after deficiencies is greatest in student- training, additional carbohydrate athletes who are restricting will help continue glycogen calories, engaging in rapid weight- repletion. loss practices or eliminating The U.S. Dietary Guidelines and specific foods or food groups from experts in performance nutrition their diet. A multivitamin recommend that athletes focus providing not more than 100 their food choices on less-refined percent of the daily recommended types of carbohydrate, as these intake can be considered for these contain essential micronutrients student-athletes. Female student- vital to health and performance. athletes are especially prone to Whole grains, breads, pasta, whole deficiencies in calcium and iron fruits and vegetables are excellent due to the impacts of regular sources of high-quality menstrual cycles, avoidance of carbohydrate. animal products and/or energy restriction. The diets and iron Protein requirements are slightly status of endurance athletes and higher in both endurance (1.2 to vegetarians (especially females) 1.4 grams per kilogram body should be evaluated. However, weight) and strength-training megadoses of specific vitamins or student-athletes (1.6 to 1.7 grams minerals (10 to 100 times the dose per kilogram body weight), above Available online at NCAA.org/ of daily requirements) are not the typical recommended daily health-safety. recommended. intake (0.8 grams per kilogram body weight). Fortunately, the Hydration status impacts health higher intakes recommended for and performance. Athletes should athletes are easily achieved in a consume fluids throughout their well-balanced diet without the day (water, low fat milk, 100 use of additional supplements. percent fruit juices) and before, during and after training. Fat intake is an important source of essential fatty acids and carrier Fluids containing electrolytes and for fat-soluble vitamins necessary carbohydrates are a good source of for optimal physiological function. fuel and re-hydration. Fluids (e.g., During prolonged, lower-intensity energy drinks) containing training, fats are a major energy questionable supplement contributor and are stored in ingredients and high levels of muscle as triglyceride for use caffeine or other stimulants may be during activity. Dietary intake is detrimental to the health of the suggested to be between 20 to 35 competitive athlete and are not percent of total daily caloric effective forms of fuel or intake. Diets low in fat intake can hydration. negatively impact training, nutrient Adequate overall energy intake density of the diet and the ability spread out across the day is to consistently improve important for all student-athletes. performance. Insufficient energy intakes (due to In general, vitamin and mineral skipped meals or dieting) will have supplements are not required if a a rapid negative impact on training student-athlete is consuming and performance, and over time, on 44 adequate energy from a variety bone, immune function and injury Nutrition and Athletic Performance risk. Inadequate energy intakes psychological and nutritional increase fatigue, deplete muscle therapy. glycogen stores, increase the risk of A more prevalent issue is the large dehydration, decrease immune number of sub-clinical or function, increase the risk of injury chronically dieting athletes. and result in unwanted loss of Department-wide efforts to educate Eating disorders are muscle mass. A low caloric intake staff and student-athletes should often an expression of in female student-athletes can lead include addressing the negative to menstrual dysfunction and impacts of under-fueling and underlying emotional decreased bone mineral density. weight/food preoccupation on the distress that may have The maintenance or attainment of athletes’ performance and overall developed long before an ideal body weight is sport- well-being. Although dysfunctional the individual was specific and represents an eating is much more prevalent in important part of a nutritional women (approximately 90 percent involved in athletics. program. However, student-athletes of the reports in the NCAA studies Eating disorders can be were in women’s sports), in certain sports face a difficult triggered in paradox in their training/nutrition dysfunctional eating also occurs in regimen, particularly those men. Female athletes who miss psychologically competing in “weight class” sports three or more menstrual cycles in a vulnerable individuals year, are preoccupied with weight, (e.g., wrestling, rowing), sports that by a single event or favor those with lower body weight experience rapid changes in body (e.g., distance running, weight, avoid eating with others, or comments (such as gymnastics), sports requiring are over-focused on shape and food offhand remarks about are exhibiting warning signs worth student-athletes to wear body appearance, or contour-revealing clothing (track, addressing, if prevention of eating diving, swimming, volleyball) and disorders is desired. The medical constant badgering sports with subjective judging examination and updated history about a student- related to “aesthetics” (gymnastics, (Bylaw 17.1.5) is an opportunity to athlete’s body weight, diving). These student-athletes are assess athletes for these risk factors encouraged to eat to provide the and refer them to appropriate body composition or necessary fuel for performance, yet professionals for further evaluation body type) from a they often face self- or team- and diagnosis. person important to imposed weight restrictions. Eating disorders are often an the individual. Emphasis on low body weight or expression of underlying emotional low body fat may benefit distress that may have developed performance only if the guidelines long before the individual was are realistic, the calorie intake is involved in athletics. Eating reasonable and the diet is disorders can be triggered in nutritionally well-balanced. psychologically vulnerable The use of extreme weight-control individuals by a single event or measures can jeopardize the health comments (such as offhand remarks of the student-athlete and possibly about appearance, or constant trigger behaviors associated with badgering about a student-athlete’s eating disorders. NCAA studies body weight, body composition or have shown that at least 40 percent body type) from a person important of member institutions reported at to the individual. Coaches, athletic least one case of anorexia nervosa trainers, sport dietitians and or bulimia nervosa in their athletics supervising physicians must be programs. Once identified, these watchful for student-athletes at individuals should be referred for higher risk for eating disorders. medical evaluation and Disordered eating can lead to 45 Nutrition and Athletic Performance

dehydration, resulting in loss of should not be used as the main personnel, with consultation muscular strength and endurance, criteria for participation in sports. from the coach. decreased aerobic and anaerobic Decisions regarding weight loss 4. Weight-loss plans should be power, loss of coordination, impaired should be based on the following individualized and realistic. judgment, and other complications recommendations to reduce the risk For each student-athlete, there may that decrease performance and of disordered eating. impair health. These symptoms may be a unique optimal body 1. Frequent weigh-ins (either as a be readily apparent or may not be composition for performance, for team or individually) are evident for an extended period of health and for self-esteem. discouraged unless part of However, in most cases, these three time. Many student-athletes have strategies outlined in Guideline 2c. values are NOT identical. Mental performed successfully while and physical health should not be experiencing an eating disorder. 2. Weight loss (fat loss) should be sacrificed for performance. An Therefore, diagnosis of this problem addressed during base or erratic or lost menstrual cycle, should not be based entirely on a transition phases. sluggishness or an obsession with decrease in athletic performance. 3. Weight-loss goals should be achieving a number on a scale may Body composition and body weight determined by the student-athlete be signs that a student-athlete's can affect exercise performance but and medical and nutritional health is being challenged.

References

1. Nutrition and Athletic Performance. 5. Dale, KS, Landers DM. Weight American College of Sports Medicine, control in wrestling: eating disorders or American Dietetic Association, and disordered eating? Medicine and Dietitians of , Joint Position Science in Sports and Exercise 31:1382- Stand, Medicine and Science in Sports 1389, 1999. and Exercise. 109:3:509-527, March 6. Dick RW: Eating disorders in NCAA 2009 athletics programs. Athletic Training 2. The Female Athlete Triad. American 26:136-140, 1991. College of Sports Medicine (ACSM) 7. Sandborn CF, Horea M, Siemers BJ, Position Stand, Medicine and Science in Dieringer KI. Disordered eating and the Sports and Exercise, 39:10: 1-10 2007. female athlete triad. Clinics in Sports 3. Exercise and Fluid Requirements. Medicine:19:199-213, 2000. American College of Sports Medicine (ACSM) Position Stand. 2007 4. Brownell KD, Rodin J, Wilmore JH: Eating, Body Weight, and Performance in Athletes: Disorders of Modern Society Malvern, PA: Lea and Febiger, 1992.

46 GUIDELINE 2g Dietary Supplements

January 1990 • Revised June 2004, June 2009

Nutritional and dietary It is well known that a high- decreases, and fatigue rapidly supplements are marketed to carbohydrate diet is associated with increases. A high-carbohydrate diet student-athletes to improve improved performance and consisting of complex performance, recovery time and enhanced ability to train. carbohydrates, fruits, vegetables, muscle-building capability. Many Carbohydrates in the form of low-fat dairy products and whole student-athletes use nutritional glycogen are the body's main fuel grains (along with adequate supplements despite the lack of for high-intensity activity. A large protein) is the optimal diet for peak proof of effectiveness. In addition, number of student-athletes only performance. (See Guideline 2f, such substances are expensive and consume 40 to 50 percent of their Nutrition and Athletic may potentially be harmful to total calories from carbohydrates, Performance.) versus the recommended 55 to 65 health or performance. Of greater Protein and amino acid percent for most people (about 5 to concern is the lack of regulation supplements are popular with 10 gm/kg body weight). The lower and safety in the manufacture of bodybuilders and strength-training end of the range should be ingested dietary supplements. Many student-athletes. Although protein during regular training; the high compounds obtained from specialty is needed to repair and build end during intense training. “nutrition” stores and mail-order muscles after strenuous training, businesses may not be subject to High-carbohydrate foods and most studies have shown that the strict regulations set by the beverages can provide the student-athletes ingest a sufficient U.S. Food and Drug necessary amount of carbohydrate amount without supplements. The Administration. Therefore, the for the high caloric demand of recommended amount of protein in contents of many of these most sports to optimize the diet should be 12 to 15 percent compounds are not represented performance. Low-carbohydrate of total energy intake (about 1.4 to accurately on the list of ingredients diets are not advantageous for 1.6 gm/kg of body weight) for all and may contain impurities or athletes during intense training and types of student-athletes. Although banned substances, which may could result in a significantly selected amino acid supplements cause a student-athlete to test reduced ability to perform or train are purported to increase the positive. Positive drug-test appeals by the end of an intense week of production of anabolic hormones, based on the claim that the student- training. When the levels of studies using manufacturer- athletes did not know the carbohydrate are reduced, exercise recommended amounts have not substances they were taking intensity and length of activity found increases in contained banned drugs have not been successful. Student-athletes should be instructed to consult with The NCAA subscribes to the Resource Exchange Center (REC). the institution's sports medicine The REC (www.drugfreesport.com/rec) provides accurate staff before taking ANY nutritional information on performance-enhancing drugs, dietary supplements, supplement. Reference NCAA medications, new ingredients and validity of product claims, and Banned Drug Classes in whether a substance is banned by the NCAA. This service is Appendix A. provided 24 hours a day via a password-protected website for all NCAA member schools and their student-athletes and athletics Member institutions are restricted personnel. To access the REC, go to www.drugfreesport.com/rec. in the providing of nutritional The password is ncaa1, ncaa2, or ncaa3, depending on your supplements – see NCAA bylaws divisional classification. for divisional regulations. 47 Dietary Supplements

associated with use of certain or muscle mass. Ingesting high Other substances naturally amounts of single amino acids is occurring in foods, such as amino acid supplements. Creatine contraindicated because they can carnitine, herbal extracts and has been found in some laboratory affect the absorption of other special enzyme formulations, do studies to enhance short-term, essential amino acids, produce not provide any benefit to high-intensity exercise capability, nausea, and/or impair kidney performance. The high-protein diet delay fatigue on repeated bouts of function and hydration status. has received recent attention, but such exercise and increase strength. data showing that this diet will Several studies have contradicted Other commonly advertised enhance performance are weak. these claims, and, moreover, the supplements are vitamins and High-protein diets are discouraged safety of creatine supplements has minerals. Most scientific evidence by most nutrition experts due to not been verified. Weight gains of shows that selected vitamins and increased stress placed on the one to three kilograms per week minerals will not enhance kidneys. Mild to severe stomach have been found in creatine users, performance provided no but the cause is unclear. deficiency exists. Some vitamins cramping and diarrhea, and minerals are marketed to dehydration, and gout have been Many other “high-tech” nutritional student-athletes for other benefits. For example, the antioxidants, vitamins E and C, and beta- carotene, are used by many student-athletes because they believe that these antioxidants will protect them from the damaging effects of aerobic exercise. Although such exercise can cause muscle damage, studies have found that training will increase the body’s natural antioxidant defense system so that mega doses of antioxidants may not be needed. Supplementation in high dosages of antioxidants, such as vitamins E and C, and beta-carotene, could disrupt the normal balance of these compounds and the balance of free radicals in the body and cause more harm than good. (American Council on Science and Health) The mineral chromium has been suggested to increase muscle mass and decrease fat; these claims have little, if any, credible support. In fact, the Federal Trade Commission has declared such claims to be unsubstantiated and deceptive. Similarly, magnesium is purported, but not proven, to prevent cramps. To obtain necessary vitamins and minerals, student-athletes should eat a wide variety of foods because not all vitamins and minerals are 48 found in every food. Dietary Supplements or dietary supplements may seem performance and may contain banned substances. Member to be effective at first, but this is Caution: “Nutritional/ likely a placebo effect — if student- institutions should review NCAA dietary supplements may athletes believe these substances Bylaw 16.5.2, educational columns contain NCAA banned will enhance performance, they and interpretations for guidance on substances. The U.S. may train harder or work more restrictions on providing Food and Drug efficiently. Ultimately, most supplements to student-athletes. Administration does not nutritional supplements are Institutions should designate an strictly regulate the sup- ineffective, costly and unnecessary. individual (or individuals) as the plement industry; there- Student-athletes should be aware athletics department resource for fore, purity and safety of that nutritional supplements are not questions related to NCAA banned nutritional/dietary sup- plements cannot be limited to pills and powders; drugs and the use of nutritional guaranteed. Impure sup- “energy” drinks that contain supplements. In addition, plements may lead to a stimulants are popular. Many of institutions should educate athletics positive NCAA drug test. these contain large amounts of department staff members who The use of supplements either caffeine or other stimulants, have regular interaction with is at the student-athlete’s both of which can result in a student-athletes that the NCAA own risk. Student- positive drug test. Student-athletes maintains a list of banned drug athletes should contact should be wary of drinks that classes and provides examples of banned substances in each drug their institution’s team promise an “energy boost,” because physician or athletic they may contain banned class on the NCAA website; any nutritional supplement use may trainer for further infor- stimulants. In addition, the use of mation.” stimulants while exercising can present risks to a student-athlete’s increase the risk of heat illness. health and eligibility; and questions regarding NCAA banned drugs and Student-athletes should be provided the use of nutritional supplements accurate and sound information on should be referred to the nutritional supplements. It is not institution’s designated department worth risking eligibility for resource individual (or individuals). products that have not been See Appendix B for Division I scientifically proven to improve legislative requirements.

References

1. Burke L: Practical issues in nutrition and Science in Sports and Exercise. 32 8. The National Center for Drug Free for athletes. Journal of Sports Sciences (3): 706-717, 2000. Sport, Inc., 810 Baltimore, Suite 200, 13:S83-90, 1995. 5. Lemon PWR: Do athletes need more Kansas City, Missouri. 64105; 816/474- 8655. 2. Clarkson PM, Haymes EM: Trace dietary protein and amino acids? Mineral Requirements for Athletes. International Journal of Sport Nutrition 9. ACSM JOINT POSITION International Journal of Sport Nutrition 5:S39-61, 1995. STATEMENT, Nutrition and Athletic Performance, 2000. Available at www. 4:104-19, 1994. 6. Volek JS, Kraemer WJ: Creatine supplementation: Its effect on human acsm-msse.org. 3. Clarkson PM: Micronutrients and muscular performance and body 10. Nutritional Supplements, The NCAA exercise: Antioxidants and minerals. composition. Journal of National News, April 15, 2005. Journal of Sports Sciences 12:S11-24, Strength and Conditioning Research 11. IOC study, 2001. 1995. 10:200-10, 1996. 12. HFL study, 2007. 4. American College of Sports Medicine. 7. Williams C: Macronutrients and The physiological and health effects of performance. Journal of Sports Sciences oral creatine supplementation. Medicine 13:S1-10, 1995. 49 GUIDELINE 2h “Burners” (Brachial Plexus Injuries) June 1994 • Revised June 2003

“Burners” or “stingers” are so on the opposite side. Contact to named because the injuries can the side of the neck may cause a The majority of stingers cause a sudden pain and numbness direct contusion to the brachial occur in football. Such along the forearm and hand. The plexus. In football, improper blocking and tackling techniques injuries have been more formal medical terminology is transient brachial plexopathy or may result in a brachial plexus reported in 52 percent an injury to the brachial plexus. A injury. Coaches, parents and stu- of college football brachial plexus injury may also dent-athletes should be cautioned players during a single involve injury to a cervical root. regarding the consequences of improper techniques, which may season. As many as 70 An injury to the spinal cord itself is more serious and frequently does result in cervical spine injuries or percent of college not fall under this category of inju- trauma to the brachial plexus. football players have ry, although it shares certain symp- experienced stingers. toms; therefore, spinal cord injuries Symptoms and Severity Stingers also can occur should be ruled out when diagnos- Student-athletes who suffer burn- ing stingers. ers may be unable to move the in a variety of other affected arm from their side and The majority of stingers occur in sports, including will complain of burning pain, football. Such injuries have been basketball, ice hockey, and potentially, numbness travel- reported in 52 percent of college ing from the injured side of the wrestling and some field football players during a single neck through the shoulder down events in track. season. As many as 70 percent of the arm and forehand, and some- college football players have times into the hand. Weakness experienced stingers. Stingers may be present in the muscles of also can occur in a variety of the shoulder, elbow and hand. other sports, including basketball, ice hockey, wrestling and some Brachial plexus injuries can be field events in track. classified into three categories. The mildest form (Grade 1) are Mechanism neuropraxic injuries that involve The most common mechanism for demyelination of the axon sheath stingers is head movement in an without intrinsic axonal disruption. opposite direction from the shoul- Compete recovery typically occurs der either from a hit to the head or in a few seconds to days. Grade 1 downward traction of the shoulder. injuries are the most common in This can stretch the nerve roots on athletics. Grade 2 injuries involve the side receiving the blow (trac- axonotmesis or disruption of the 50 tion), or compress or pinch those axon and myelin sheath with pres- “Burners” (Brachial Plexus Injuries) ervation of the epineurium, peri- extent of injury. However, an EMG neurium, and endoneurium, should not be used for return-to- which can serve as the conduit play criteria, as EMG changes may for the regenerating axon as it persist for several years after the re-grows at 1 to 7 millimeters symptoms have resolved. Shoulder per day. Weakness can last for injuries (acromioclavicular separa- All athletes sustaining weeks but full recovery typical- tion, shoulder subluxation or dislo- burners or stingers ly occurs. Grade 3 in­juries, cation, and clavicular fractures) should undergo a or complete nerve should be considered in the differ- transections are rare in athletes. ential diagnosis of the athlete with physical rehabilitation Surgical repair of the nerve is transient or prolonged neurologic program that includes required in these cases and com- symptoms of the upper extremity. neck and trunk plete recovery may not occur. Any injured athlete who presents strengthening exercises. with specific cervical-point tender- These classifications have more The fit of shoulder pads meaning with regard to anticipated ness, neck stiffness, bony deformi- recovery of function than a grading ty, fear of moving his/her head and/ should be re-checked and on the severity of symptoms at the or complains of a heavy head consideration of other time of initial injury. should be immobilized on a spine athletic protective board (as one would for a cervical equipment, such as neck Treatment and spine fracture) and transported to a rolls and/or collars, Return to Play medical facility for a more thor- Burners and stingers typically ough evaluation. should be given. The result in symptoms that are sensory athlete’s tackling Bilateral symptoms indicate that in nature, frequently involving the techniques should be C5 and C6 dermatomes. All ath- reviewed. letes sustaining burners should be removed from competition and examined thoroughly for injury to the cervical spine and shoulder. All cervical roots should be assessed for motor and sensory function. If symptoms clear within seconds to several minutes and are not associated with any neck pain, limitation of neck movement or signs of shoulder subluxation or dislocation, the athlete can safely return to competition. It is impor- tant to re-examine the athlete after the game and for a few successive days to detect any reoccurrence of weakness or alteration in sensory exam. If sensory complaints or weakness persists for more than a few min- utes, a full medical evaluation with radiographs and consideration for a MRI should be done to rule out cervical disk or other compressive pathology. If symptoms persist for more than 2 to 3 weeks, an EMG 51 may be helpful in assessing the “Burners” (Brachial Plexus Injuries)

the cord itself has been traumatized Although rare, risk of permanent and may suggested transient quadri- nerve injury exists for those with plegia. These athletes should also recurrent burners. Therefore, partic- be immobilized and transported to a ipants should report every occur- medical facility for a more thor- rence to their certified athletic train- ough evaluation. ers or team physician. Any player All athletes sustaining burners or with persistent pain, burning, numb- stingers should undergo a physical ness and/or weakness (lasting longer rehabilitation program that includes than two minutes) should be held out neck and trunk strengthening exer- of competition and referred to a phy- cises. The fit of shoulder pads sician for further evaluation. should be re-checked and consider- ation of other athletic protective A Word of Caution equipment, such as neck rolls and/ Management of the student-athlete or collars, should be given. The with recurrent burners can be diffi- athlete’s tackling techniques should cult. There are no clear guidelines be reviewed. concerning return to play. Although some risk of permanent nerve inju- Stinger assessment should be part of ry exists, a review of the literature the student-athletes’ preseason phys- shows this risk to be small for those ical and mental history (see hand- with recurrent episodes. The most book Guideline No. 1b) so that these “at-risk” athletes can be instructed in important concern for student-ath- a prevention preventative exercise letes with recurrent burners is to program and be provided with prop- stress the importance of reporting er protective equipment. all symptoms to the attending medical personnel so that a Recurrent Burners thorough physical examination, Recurrent burners may be common; with particular attention to strength 87 percent of athletes in one study and sensory changes, can be had experienced more than one. obtained. Any worsening of symp- Medical personnel should pay spe- toms should provoke a more cial attention to this condition. thorough evaluation.

References

1. Meyer S, Schulte K, et al: Cervical Football Players. American Journal of 8. Weinstein S: Assessment and Spinal Stenosis and Stingers in Sports Medicine 22(2), 1994. Rehabilitation of the Athlete with a Collegiate Football Players. American 5. Cantu R: Stingers, Transient Stinger. A Model for the Management of Journal of Sports Medicine 22(2):158- Quadriplegia, and Cervical Spinal Non-catastrophic Athletic Cervical Spine 166, 1994. Stenosis: Return-to-Play Criteria. Injury. and Sports Medicine 2. Torg J, et al: Cervical Cord Medicine and Science of Sports and 17(1), 1998. Neuropraxia: Classification Pathomech- Exercise 7(Suppl):S233-235, 1997. 9. Shannon B, Klimkiewicz J, Cervical anics, Morbidity and Management 6. Levitz C, et al: The Pathomechanics Burners in the Athlete. Clinic and Sports Guidelines. Journal of of Chronic Recurrent Cervical Nerve Medicine 21(1):29-35 January 2002. 87:843-850, 1997. Root Neuropraxia, the Chronic Burner 10. Koffler K, Kelly J, Neuro- 3. Feinberg J, et al: Peripheral Nerve Syndrome. American Journal of Sports vascular Trauma in Athletes. Orthop Injuries in the Athlete. Sports Medicine Medicine 25(1), 1997. Clin N Am 33: 523-534(2002). 12(6):385-408, 1997. 7. Castro F, et al: Stingers, the Torg 11. Feinberg J, Burners and Stingers, 4. Meyer S, et al: Cervical Spinal Ratio, and the Cervical Spine. American Phys Med Rehab N Am 11(4): 771-783 52 Stenosis and Stingers in Collegiate Journal of Sports Medicine 25(5), 1997. Nov 2000. GUIDELINE 2i Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete June 1994 • Revised July 2004, 2009, July 2010, July 2011

Estimates suggest that 1.6 to 3.8 account for a significant percentage soccer 1.4, for women’s lacrosse million concussions occur from of injuries in men’s and women’s 1.2, for field hockey 1.2, for participation in sports- and basketball, women’s lacrosse, and women’s basketball 1.2, and for recreation-related activities every other sports traditionally men’s basketball 0.6, accounting year (see reference No. 18). These considered “noncontact.” for between 4 and 16.2 percent of injuries are often difficult to detect, the injuries for these sports as with athletes often underreporting The incidence in helmeted versus reported by the NCAA Injury their injury, minimizing their nonhelmeted sports is also similar. Surveillance Program by the importance or not recognizing that In the years 2004 to 2009, the rate Datalys Center. an injury has occurred. At the of concussion during games per Assessment and management of college level, these injuries are 1,000 athlete exposures for football concussive injuries, and return-to- more common in certain sports, was 3.1, for men’s lacrosse 2.6, for play decisions remain some of the such as football, ice hockey, men’s men’s ice hockey 2.4, for women's most difficult responsibilities and women’s soccer, and men’s ice hockey 2.2, for women's soccer facing the sports medicine team. lacrosse. However, they also 2.2, for wrestling 1.4, for men's There are potentially serious complications of multiple or severe concussions, including second impact syndrome, postconcussive syndrome, or post-traumatic encephalopathy. Though there is some controversy as to the existence of second 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 compromise and death. Other associated injuries that 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 53 Concussion or Mild Traumatic Brain Injury

imperative that the health care injuries of skull fracture, noted. These sideline tests should professionals taking care of intracranial bleeding and seizures, be performed and repeated as athletes are able to recognize, when there is concern for structural necessary, but do not take the place evaluate and treat these injuries in abnormalities or when the of other comprehensive a complete and progressive symptoms of an athlete persist or neuropsychological tests. fashion. In April 2010, the NCAA deteriorate. Executive Committee adopted a Once an injury occurs and an Concussion is associated with policy that requires NCAA initial assessment has been made, it clinical scenarios that often clear institutions to have a concussion is important to determine an initial spontaneously, and may or may not management plan on file. (See plan of action, which includes be associated with loss of information box on page 56.) deciding on whether additional consciousness (LOC). referral to a physician and/or Concussion or mild traumatic brain emergency department should take The sideline evaluation of the injury (mTBI) has been defined as place, and determining the follow- brain-injured athlete should include “a complex pathophysiological up care. The medical staff should an assessment of airway, breathing process affecting the brain, induced also determine whether additional and circulation (ABCs), followed by traumatic biomechanical observation or admission by an assessment of the cervical forces.” Although concussion most should be considered. spine and skull for associated commonly occurs after a direct injury. The sideline evaluation blow to the head, it can occur after Follow-up care and instructions should also include a neurological a blow elsewhere that is transmitted should be given to the athlete, and and mental status examination and to the head. Concussions can be ensuring that they are not left alone some form of brief neurocognitive defined by the clinical features, for an initial period of time should testing to assess memory function pathophysiological changes and/or be considered. Athletes should and attention. This can be in the biomechanical forces that occur, avoid alcohol or other substances form of questions regarding the and these have been described in that will impair their cognitive particular practice or competition, the literature. The neurochemical function, and also avoid aspirin and previous game results, and remote and neurometabolic changes that other medications that can increase and recent memory, and questions occur in concussive injury have their risk of bleeding. to test the athlete’s recall of words, been elucidated, and exciting months of the year backwards and As mentioned previously, research is underway describing the calculations. Special note should conventional imaging studies such genetic factors that may play a role be made regarding the presence as MRI and CT scans are usually in determining which individuals and duration of retrograde or normal in mTBI. However, these are at an increased risk for anterograde amnesia, and the studies are considered an adjunct sustaining brain injury. presence and duration of confusion. when any structural lesion, such as Most commonly, concussion is A timeline of injury and the an intracranial bleed or fracture, is characterized by the rapid onset of presence of symptoms should be suspected. If an athlete cognitive impairment that is self limited and spontaneously resolves. Table 1 The acute symptoms of concussion, SIGNS AND SYMPTOMS OF mTBI listed below, are felt to reflect a Loss of consciousness (LOC) Visual Disturbances functional disturbance in cognitive Confusion (Photophobia, blurry Phono/ function instead of structural Post-traumatic amnesia (PTA) photophobia vision, abnormalities, which is why Retrograde amnesia (RGA) double vision) diagnostic tests such as magnetic Disorientation Disequilibrium resonance imaging (MRI) and Delayed verbal and motor Feeling “in a fog,” “zoned out” computerized tomography (CT) responses Vacant stare scans are most often normal. Inability to focus Emotional lability These studies may have their role Headache Dizziness in assessing and evaluating the Nausea/Vomiting Slurred/incoherent speech head-injured athlete whenever there Excessive drowsiness 54 is concern for the associated Concussion or Mild Traumatic Brain Injury experiences prolonged loss of consciousness, confusion, seizure 1. NCAA Concussion Fact Sheets and Video for Coaches activity, focal neurologic deficits or and Student-Athletes persistent clinical or cognitive Available at www.NCAA.org/health-safety. 2. Heads Up: Concussion Tool Kit symptoms, then additional testing CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm. may be indicated. 3. Heads Up Video There are several grading systems NATA. Streaming online at www.nata.org/consumer/headsup.htm. and return-to-play guidelines in the literature regarding concussion in individual fashion (Cantu ‘01, needed to understand the complete sport (AAN, Torg, Cantu). However, Zurich Conference, NATA ‘04). role of neuropsychological testing. there may be limitations because they presume that LOC is associated Several recent publications have Given these limitations, it is with more severe injuries. It has endorsed the use of neurocognitive essential that the medical care team been demonstrated that LOC does or neuropsychological testing as the treating athletes continue to rely on not correlate with severity of injury cornerstone of concussion its clinical skills in evaluating the in patients presenting to an evaluation. These tests provide a head-injured athlete to the best of its emergency department with closed reliable assessment and ability. It is essential that no athlete head injury, and has also been quantification of brain function by be allowed to return to participation demonstrated in athletes with examining brain-behavior when any symptoms persist, either concussion (Lovell ‘99). It has been relationships. These tests are at rest or during exertion. Any further demonstrated that retrograde designed to measure a broad range athlete exhibiting an injury that amnesia (RGA), post-traumatic of cognitive function, including involves significant symptoms, long amnesia (PTA), and the duration of speed of information processing, duration of symptoms or difficulties confusion and mental status changes memory recall, attention and with memory function should not be are more sensitive indicators of concentration, reaction time, allowed to return to play during the injury severity (Collins ‘03), thus an scanning and visual tracking ability, same day of competition. The athlete with these symptoms should and problem solving ability. Several duration of time that an athlete not be allowed to return to play computerized versions of these tests should be kept out of physical during the same day. These athletes have also been designed to improve activity is unclear, and in most should not return to any the availability of these tests, and instances, individualized return-to- participation until cleared by a make them easier to distribute and play decisions should be made. physician. More recent grading use. Ideally, these tests are These decisions will often depend systems have been published that performed before the season as a on the clinical symptoms, previous attempt to take into account the “baseline” with which post-injury history of concussion and severity expanding research in the field of tests can be compared. Despite the of previous concussions. Additional mTBI in athletes. Though it is utility of neuropsychological test factors include the sport, position, useful to become familiar with these batteries in the assessment and age, support system for the athlete guidelines, it is important to treatment of concussion in athletes, and the overall “readiness” of the remember that many of these several questions remain athlete to return to sport. injuries are best treated in an unanswered. Further research is Once an athlete is completely asymptomatic, the return-to-play Table 2 progression should occur in a step- SYMPTOMS OF POST-CONCUSSION SYNDROME wise fashion with gradual Loss of intellectual capacity Fatigue increments in physical exertion and Poor recent memory Irritability risk of contact. After a period of Personality changes Phono/photophobia remaining asymptomatic, the first Headaches Sleep disturbances step is an “exertional challenge” in Dizziness Sleep disturbances which the athlete exercises for 15 Lack of concentration Depressed mood to 20 minutes in an activity such as Poor attention Anxiety biking or running in which he/she increases his/her heart rate and 55 Concussion or Mild Traumatic Brain Injury

breaks a sweat. If he/she does not experience any symptoms, this can The NCAA Executive Committee adopted be followed by a steady increase in (April 2010) the following policy for exertion, followed by return-to- institutions in all three divisions. sport-specific activities that do not put the athlete at risk for contact. “Institutions shall have a concussion management plan on file such Examples include dribbling a ball that a student-athlete who exhibits signs, symptoms or behaviors con- or shooting, stickwork or passing, sistent with a concussion shall be removed from practice or competi- or other agilities. This allows the tion and evaluated by an athletics healthcare provider with experience athlete to return to the practice in the evaluation and management of concussions. Student-athletes setting, albeit in a limited role. diagnosed with a concussion shall not return to activity for the Finally, the athlete can be remainder of that day. Medical clearance shall be determined by the progressed to practice activities team physician or his or her designee according to the concussion with limited contact and finally full management plan. contact. How quickly one moves “In addition, student-athletes must sign a statement in which they ac- through this progression remains cept the responsibility for reporting their injuries and illnesses to the controversial. institutional medical staff, including signs and symptoms of concus- sions. During the review and signing process, student-athletes should be presented with educational material on concussions.”

NCAA Adopted Concussion Management Plan Legislation. Concussion Management Plan. An active member institution shall have a concussion management plan for its student-athletes. The plan shall include, but is not limited to, the following: (a) An annual process that ensures student-athletes are educated about the signs and symptoms of concussions. Student-athletes must acknowledge that they have received information about the signs and symptoms of concussions and that they have a responsibility to report concussion-related injuries and illnesses to a medical staff member; (b) A process that ensures a student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from athletics activities (e.g., competition, practice, conditioning sessions) and evaluated by a medical staff member (e.g., sports medicine staff, team physician) with experience in the evaluation and management of concussions; (c) A policy that precludes a student-athlete diagnosed with a concussion from returning to athletic activity (e.g., competition, practice, conditioning sessions) for at least the remainder of that calendar day; and (d) A policy that requires medical clearance for a student-athlete diagnosed with a concussion to return to athletics activity (for example, competition, practice, conditioning sessions) as determined by a physician (e.g., team physician) or the physician’s designee. 3.2.4.16.1 Effect of Violation. A violation of Constitution 3.2.4.16 shall be considered an institutional violation per Constitution 2.8.1; however, the violation shall not affect the student-athlete’s eligibility.

56 Concussion or Mild Traumatic Brain Injury

References

1. Cantu RC: Concussion severity should and Neuropsychological Performance in 13. Makdissi M, Collie A, Maruff P et al: not be determined until all College Football Players. JAMA Computerized cognitive assessment of postconcussion symptoms have abated. 282:964-970, 1999. concussed Australian Rules footballers. Lancet 3:437-8, 2004. 8. Guskiewicz KM, Bruce SL, Cantu R, Br. J Sports Med 35(5):354-360, 2001. 2. Cantu RC: Recurrent athletic head Ferrara MS, Kelly JP, McCrea M, 14. McCrea M: Standardized mental injury: risks and when to retire. Clin Putukian M, McLeod-Valovich TC; status assessment of sports concussion. Sports Med. 22:593-603, 2003. National Athletic Trainers’ Association Clin J Sport Med 11(3):176-181, 2001. Position Statement: Management of 3. Cantu RC: Post traumatic (retrograde/ 15. McCrea M, Hammeke T, Olsen G, anterograde) amnesia: pathophysiology Sport-related Concussion: Journal of Leo , Guskiewicz K: Unreported and implications in grading and safe Athletic Training. 39(3): 280-297, 2004. return to play. Journal of Athletic concussion in high school football 9. Guskiewicz KM: Postural stability players. Clin J Sport Med 2004;14:13- Training. 36(3): 244-8, 2001. assessment following concussion: One 17. 4. Centers for Disease Control and piece of the puzzle. Clin J Sport Med Prevention. Sports-related recurrent 2001; 11:182-189. 16. McCrory P, Meeuwisse W, Johnston brain injuries: United States. MMWR 10. Hovda DA, Lee SM, Smith ML et al: K, Dvorak J, Aubry M, Molloy M, Cantu Morb Mortal Wkly Rep 1997; 46:224- The Neurochemical and metabolic R. Concensus Statement on Concussion 227. cascade following brain injury: Moving in Sport: the Third International 5. Collie A, Darby D, Maruff P: from animal models to man. J Conference on Concussion in Sport. Computerized cognitive assessment of Neurotrauma 12(5):143-146, 1995. Zurich, , 2008. Br J Sports athletes with sports related head injury. 11. Johnston K, Aubry M, Cantu R et al: Med 2009;43:i76-i84. Br. J Sports Med 35(5):297-302, 2001. Summary and Agreement Statement of 17. Torg JS: Athletic Injuries to the Head, 6. Collins MW, Iverson GL, Lovell MR, the First International Conference on Neck, and Face. St. Louis, Mosby-Year McKeag DB, Norwig J, Maroon J: On- Concussion in Sport, Vienna 2001, Phys Book, 1991. field predictors of neuropsychological & Sportsmed 30(2):57-63, 2002. 18. Langlois JA, Rutland-Brown LV, Wald and symptom deficit following sports- 12. Lovell MR, Iverson GL, Collins MW MM. The Epidemiology and Impact of related concussion. Clin J Sport Med et al: Does loss of consciousness predict Traumatic Brain Injury. J Head Trauma 2003; 13:222-229. neuropsychological decrements after Rehabil. 2006; 21:375-8. 7. Collins MW, Grindel SH, Lovell MR et concussion? Clin J Sport Med 9:193- al: Relationship Between Concussion 198, 1999.

57 Concussion or Mild Traumatic Brain Injury

In Addition to the Executive Committee Policy Requirements, Additional Best Practices for a Concussion Management Plan Include, but are not Limited to: 1. Although sports currently have rules in place, for each student-athlete before the first practice athletics staff, student-athletes and officials should in the sports of baseball, basketball, diving, continue to emphasize that purposeful or flagrant equestrian, field hockey, football, gymnastics, head or neck contact in any sport should not be per- ice hockey, lacrosse, pole vaulting, rugby, mitted and current rules of play should be strictly soccer, softball, water polo and wrestling, at enforced. a minimum. The same baseline assessment tools should be used post-injury at appropriate 2. Institutions should have on file and annually update an emergency action plan for each athletics venue time intervals. The baseline assessment should to respond to student-athlete catastrophic injuries consist of one or more of the following areas of and illnesses, including but not limited to, con- assessment. cussions, heat illness, spine injury, cardiac arrest, 1) At a minimum, the baseline assessment should respiratory distress (e.g., asthma), and sickle cell consist of the use of a symptoms checklist and trait collapses. All athletics healthcare providers standardized cognitive and balance assess- and coaches should review and practice the plan at ments [e.g., SAC; SCAT; SCAT II; Balance least annually. Error Scoring System (BESS)]. 3. Institutions should have on file an appropriate 2) Additionally, neuropsychological testing (e.g., healthcare plan that includes equitable access to computerized, standard paper and pencil) has athletics healthcare providers for each NCAA sport. been shown to be effective in the evaluation and management of concussions. The develop- 4. Athletics healthcare providers should be empowered to have the unchallengeable authority to determine ment and implementation of a neuropsycho- management and return-to-play of any ill or injured logical testing program should be performed student-athlete, as the provider deems appropriate. in consultation with a neuropsychologist who For example, a countable coach should not serve as is in the best position to interpret NP tests by the primary supervisor for an athletics healthcare virtue of background and training. However, provider, nor should the coach have sole hiring or there may be situations in which neuropsy- firing authority over a provider. chologists are not available and a physician ex- perienced in the use and interpretation of such 5. The concussion management plan should outline testing in an athletic population may perform the roles of athletics healthcare staff (e.g., physician, or interpret NP screening tests. certified athletic trainer, nurse practitioner, physician assistant, neurologist, neuropsychologist). In addi- d. The student-athlete should receive serial tion, the following components have been specifi- monitoring for deterioration. Athletes should be cally identified for the collegiate environment: provided with written instructions upon dis- charge, preferably with a roommate, guardian or a. Institutions should ensure that coaches have ac- someone who can follow the instructions. knowledged that they understand the concussion management plan, their role within the plan and e. The student-athlete should be evaluated by a that they received education about concussions. team physician as outlined within the concus- sion management plan. Once asymptomatic b. Athletics healthcare providers should practice and post-exertion assessments are within normal within the standards as established for their baseline limits, return-to-play should follow a professional practice (e.g., physician, certified medically supervised stepwise process. athletic trainer, nurse practitioner, physician as- 6. Institutions should document the incident, evalua- sistant, neurologist, neuropsychologist). tion, continued management and clearance of the c. Institutions should record a baseline assessment student-athlete with a concussion.

For references, visit www.NCAA.org/health-safety. 58 GUIDELINE 2j Skin Infections in Athletics July 1981 • Revised June 2008

Skin infections may be transmitted by b. scabies; as performing hand hygiene before both direct (person to person) and 3. Viral skin infections and after changing bandages and indirect (person to inanimate surface a. herpes simplex; throwing used bandages in the trash to person) contact. Infection control should be stressed to the athlete. b. herpes zoster (chicken pox); measures, or measures that seek to c. molluscum contagiosum; and prevent the spread of disease, should Antibiotic Resistant be used to reduce the risks of disease 4. Fungal skin infections Staph Infections transmission. Efforts should be made a. tinea corporis (ringworm). There is much concern about the to improve student-athlete hygiene Note: Current knowledge indicates presence and spread of antibiotic- practices, to use recommended that many fungal infections are easily resistant Staphylococcus aureus in procedures for cleaning and transmitted by skin-to-skin contact. In intercollegiate athletics across sports. disinfection of surfaces, and to handle most cases, these skin conditions can Athletes are at-risk due to presence of blood and other bodily fluids be covered with a securely attached open wounds, poor hygiene practices, appropriately. Suggested measures bandage or nonpermeable dressing to close physical contact, and the sharing include: promotion of hand and allow participation. of towels and equipment. Institutions and conferences should continue personal hygiene practices; educating Open wounds and infectious skin efforts and support for the education athletes and athletics staff; ensuring conditions that cannot be adequately of staff and student-athletes on the recommended procedures for cleaning protected should be considered cause importance of proper hygiene and and disinfection of hard surfaces are for medical disqualification from wound care to prevent skin infections followed; and verifying clean up of practice or competition (see Guideline from developing and infectious blood and other potentially infectious 2a). The term “adequately protected” diseases from being transmitted. materials is done, according to the means that the wound or skin Occupational Health and Safety condition has been deemed as non- Staphylococcus aureus, often referred Administration (OSHA) Blood-borne infectious and adequately treated as to as “staph,” are bacteria commonly Pathogens Standard #29 CFR deemed appropriate by a health care carried on the skin or in the nose of 1910.1030. provider and is able to be properly healthy people. Occasionally, staph can Categories of skin conditions and covered. The term “properly covered” cause an infection. Staph bacteria are examples include: means that the skin infection is one of most common causes of skin covered by a securely attached infections in the U.S. Most infections are 1. Bacterial skin infections bandage or dressing that will contain minor, typically presenting as skin and a. impetigo; all drainage and will remain intact soft tissue infections (SSTI) such as b. erysipelas; throughout the sport activity. A health pimples, pustules and boils. They may c. carbuncle; care provider might exclude a student- be red, swollen, warm, painful or d. staphylococcal disease, MRSA; athlete if the activity poses a risk to purulent. Sometimes, athletes confuse the health of the infected athlete (such these lesions with insect bites in the early e. folliculitis (generalized); as injury to the infected area), even stages of infection. A purulent lesion f. hidradentitis suppurativa; though the infection can be properly could present as draining pus; yellow or 2. Parasitic skin infections covered. If wounds can be properly white center; central point or “head”; or a a. pediculosis; covered, good hygiene measures such palpable fluid-filled cavity. 59 Skin Infections in Athletics

In the past, most serious staph the full course and consult indirect contact by touching objects bacterial infections were treated with physicians if the infection does not contaminated by the infected skin of a antibiotics related to penicillin. In get better. The Centers for Disease person with MRSA or staph bacteria recent years, antibiotic treatment of Control and Prevention (CDC), (e.g. towels, sheets, wound dressings, these infections has changed American Medical Association clothes, workout areas, sports because staph bacteria have become (AMA), and Infectious Diseases equipment). resistant to various antibiotics, Society of America (IDSA) have If a lesion cannot be properly including the commonly used developed a treatment algorithm that covered for the rigors of the sport, penicillin-related antibiotics. These should be reviewed; it is accessible consider excluding players with resistant bacteria are called at www.cdc.gov/ncidod/dhqp/ar_ potentially infectious skin lesions methicillin-resistant Staphylococcus mrsa_ca_skin.html. from practice and competition until aureus, or MRSA. Fortunately, the lesions are healed. first-line treatment for most purulent Staph bacteria including MRSA can staph, including MRSA, skin and spread among people having close Staph bacteria including MRSA can soft tissue infections is incision and contact with infected people. MRSA be found on the skin and in the nose drainage with or without antibiotics. is almost always spread by direct of some people without causing However, if antibiotics are physical contact, and not through the illness. The role of decolonization is prescribed, patients should complete air. Spread may also occur through still under investigation. Regimens

Some common recommendations include: A. Keep hands clean by washing thoroughly with soap and warm water or using an alcohol-based sanitizer routinely B. Encourage good hygiene • immediate showering after activity • ensure availability of adequate soap and water • pump soap dispensers are preferred over bar soap C. Avoid whirlpools or common tubs • individuals with active infections, open wounds, scrapes or scratches could infect others or become infected in this environment D. Avoid sharing towels, razors, and daily athletic gear • avoid contact with other people’s wounds or material contaminated from wounds E. Maintain clean facilities and equipment • wash athletic gear and towels after each use • establish routine cleaning schedules for shared equipment F. Inform or refer to appropriate health care personnel for all active skin lesions and lesions that do not respond to initial therapy • train student-athletes and coaches to recognize potentially infected wounds and seek first aid • encourage coaches and sports medicine staff to assess regularly for skin lesions • encourage health care personnel to seek bacterial cultures to establish a diagnosis G. Care and cover skin lesions appropriately before participation • keep properly covered with a proper dressing until healed • “properly covered" means that the skin infection is covered by a securely attached bandage or dressing that will contain all drainage and will remain intact throughout the sport activity • if wounds can be properly covered, good hygiene measures should be stressed to the student- athlete such as performing hand hygiene before and after changing bandages and throwing used bandages in the trash • if wound cannot be properly covered, consider excluding players with potentially infectious skin lesions from practice and/or competition until lesions are healed or can be covered adequately 60 Skin Infections in Athletics intended to eliminate MRSA precautions if suspicious skin Recognition of MRSA is critical to colonization should not be used in infections appear, and immediately clinical management. Education is patients with active infections. contact their health care provider. the key, involving all individuals Decolonization regimens may have a Individual cases of MRSA usually are associated with athletics, from role in preventing recurrent infections, not required to be reported to most student-athletes to coaches to medical but more data are needed to establish local/state health departments; howev- personnel to custodial staff. their efficacy and to identify optimal er, most states have laws that require Education should encompass proper regimens for use in community hygiene, prevention techniques and settings. After treating active reporting of certain communicable appropriate precautions if suspicious infections and reinforcing hygiene and diseases, including outbreaks regard- wounds appear. Each institution appropriate wound care, consider less of pathogens. So in most states if consultation with an infectious disease an outbreak of skin infections is should develop prevention strategies specialist regarding use of detected, the local and/or state health and infection control policies and decolonization when there are department should be contacted. procedures. recurrent infections in an individual patient or members of a defined group. MRSA infections in the community are typically SSTI, but can also cause severe illness such as pneumonia. Most transmissions appear to be from people with active MRSA skin infections. Staph and MRSA infections are not routinely reported to authorities, so a precise number is not known. It is estimated that as many as 300,000 hospitalizations are related to MRSA infections each year. Only a small proportion of these have disease onset occurring in the community. It has also been estimated that there are more than 12 million outpatient (i.e., physician offices, emergency and outpatient departments) visits for suspected staph and MRSA SSTIs in the U.S. each year. Approximately 25 to 30 percent (80 million persons) of the population is colonized in the nose with staph bacteria at a given time and approximately 1.5 percent (4.1 million persons) is colonized with MRSA. In an effort to educate the public about the potential risks of MRSA, organizations such as the CDC, NCAA and the National Athletic Trainers’ Association (NATA) have issued official statements recommending all health care personnel and physically active adults and children take appropriate 61 Skin Infections in Athletics

Skin Infections remain intact throughout the sport in Wrestling activity. A health care provider might exclude a student-athlete if the activ- Data from the NCAA Injury ity poses a risk to the health of the Surveillance Program indicate that infected athlete (such as injury to the skin infections are associated with at infected area), even though the least 17 percent of the practice time- infection can be properly covered. If loss injuries in wrestling. wounds can be properly covered, It is recommended that qualified per- good hygiene measures such as per- sonnel, including a knowledgeable, forming hand hygiene before and experienced physician, examine the after changing bandages and throw- skin of all wrestlers before any par- ing used bandages in the trash ticipation (practice and competition). should be stressed to the athlete. Male student-athletes shall wear (See Wrestling Rule WA-15.) shorts and female student-athletes should wear shorts and a sports bra Medical Examinations during medical examinations. Medical examinations must be con- ducted by knowledgeable physicians Open wounds and infectious skin and/or certified athletic trainers. The conditions that cannot be adequately status of these individuals should be presence of an experienced dermatol- protected should be considered decided before the screening of the ogist is recommended. The examina- cause for medical disqualification entire group. The decision made by a tion should be conducted in a system- from practice or competition (see physician and/or certified athletic atic fashion so that more than one Guideline 2a). The term “adequately trainer “on site” should be considered examiner can evaluate problem cases. protected” means that the wound or FINAL. Provisions should be made for appro- skin condition has been deemed as priate lighting and the necessary facil- non-infectious and adequately treat- Guidelines for ities to confirm and diagnose skin ed as deemed appropriate by a Disposition infections. health care provider and is able to be of Skin Infections properly covered. The term “proper- Wrestlers who are undergoing treat- Unless a new diagnosis occurs at the ly covered” means that the skin ment for a communicable skin disease time of the medical examination con- infection is covered by a securely at the time of the meet or tournament ducted at the meet or tournament, the attached bandage or dressing that shall provide written documentation wrestler presenting with a skin lesion will contain all drainage and will to that effect from a physician. The shall provide a completed Skin

62 Skin Infections in Athletics

Evaluation and Participation Status new blisters for 72 hours before or tournament time and have no evi- Form from the team physician docu- the examination. dence of secondary bacterial infection. menting clinical diagnosis, lab and/or 3. Wrestler must have no moist culture results, if relevant, and an out- lesions; all lesions must be dried MOLLUSCUM CONTAGIOSUM line of treatment to date (i.e., surgical and surmounted by a FIRM 1. Lesions must be curetted or intervention, duration, frequency, dos- ADHERENT CRUST. removed before the meet or ages of medication). 4. Wrestler must have been on tournament. BACTERIAL INFECTIONS appropriate dosage of systemic 2. Solitary or localized, clustered (Furuncles, Carbuncles, Folliculitis, antiviral therapy for at least 120 lesions can be covered with a Impetigo, Cellulitis or Erysipelas, hours before and at the time of gaspermeable membrane, followed Staphylococcal disease, MRSA) the meet or tournament. by tape. 1. Wrestler must have been without 5. Active herpetic infections shall any new skin lesion for 48 hours not be covered to allow VERRUCAE before the meet or tournament. participation. 1. Wrestlers with multiple digitate ver- 2. Wrestler must have no moist, exu- See above criteria when making deci- rucae of their face will be disquali- dative or purulent lesions at meet or sions for participation status. fied if the infected areas cannot be tournament time. Recurrent Infection covered with a mask. Solitary or scattered lesions can be curetted 3. Gram stain of exudate from ques- 1. Blisters must be completely dry away before the meet or tourna- tionable lesions (if available). and covered by a FIRM ment. 4. Active purulent lesions shall not be ADHERENT CRUST at time of covered to allow participation. See competition, or wrestler shall not 2. Wrestlers with multiple verrucae above criteria when making deci- participate. plana or verrucae vulgaris must have the lesions “adequately sions for participation status. 2. Wrestler must have been on covered.” appropriate dosage of systemic HIDRADENITIS SUPPURATIVA antiviral therapy for at least 120 TINEA INFECTIONS (ringworm) 1. Wrestler will be disqualified if hours before and at the time of extensive or purulent draining the meet or tournament. 1. A minimum of 72 hours of topical therapy is required for skin lesions. lesions are present. 3. Active herpetic infections shall 2. Extensive or purulent draining not be covered to allow participa- 2. A minimum of two weeks of sys- lesions shall not be covered to allow tion. temic antifungal therapy is required for scalp lesions. participation. See above criteria when making deci- sions for participation status. 3. Wrestlers with extensive and active lesions will be disqualified. Activity PEDICULOSIS Questionable Cases Wrestler must be treated with appro- of treated lesions can be judged 1. Tzanck prep and/or HSV antigen either by use of KOH preparation or priate pediculicide and re-examined assay (if available). for completeness of response before a review of therapeutic regimen. 2. Wrestler’s status deferred until wrestling. Wrestlers with solitary, or closely Tzanck prep and/or HSV assay clustered, localized lesions will be results complete. SCABIES disqualified if lesions are in a body Wrestlers with a history of recurrent location that cannot be “properly Wrestler must have negative scabies herpes labialis or herpes gladiatorum covered.” prep at meet or tournament time. could be considered for season-long 4. The disposition of tinea cases will prophylaxis. This decision should be HERPES SIMPLEX be decided on an individual basis as made after consultation with the team determined by the examining physi- Primary Infection physician. cian and/or certified athletic trainer. 1. Wrestler must be free of system- ic symptoms of viral infection HERPES ZOSTER (chicken pox) (fever, malaise, etc.). Skin lesions must be surmounted by a 2. Wrestler must have developed no FIRM ADHERENT CRUST at meet

63 Skin Infections in Athletics

References

1. Descriptive Epidemiology of Collegiate 7. Cozad, A. and Jones, R. D. Disinfection 13. Vasily DB, Foley JJ.: More on Tinea Men’s Wrestling Injuries: National and the prevention of disease. American Corporis Gladiatorum. J Am Acad Collegiate Athletic Association Injury Journal of Infection Control, 31(4): 243- Dermatol 2002, Mar. Surveillance System, 1988–1989 Through 254, 2003. 14. Vasily DB, Foley JJ, First Episode 2003–2004. Journal of Athletic Training 8. Centers for Disease Control and Herpes Gladiatorum: Treatment with 2007;42(2):303–310. Prevention (CDC) Division of Healthcare Valacyclovir (manuscript submitted for 2. Adams, BB.: Transmission of cutaneous Quality Promotion. (2002). Campaign to publication). Weiner, R. Methicillin- infection in athletics. British Journal of prevent antimicrobial resistant in health Resistant Staphylcoccus aureus on Sports Medicine 34(6):413-4, 2000 Dec. care settings. Available at www.cdc.gov/ Campus: A new challenge to college 3. Anderson BJ.: The Effectiveness of drugresistance/healthcare/. health. Journal of American College Valacyclovir in Preventing Reactivation of 9. Dorman, JM.: Contagious diseases in Health. 56(4):347-350. Herpes Gladiatorum in Wrestlers. Clin J competitive sport: what are the risks? Sports Med 9(2):86-90, 1999 Apr. Journal of American College Health 15. Zinder SM, Basler RS, Foley J, 4. Association for Professionals in 49(3):105-9, 2000 Nov. Scarlata C, Vasily DB. National Athletic Infection Control and Epidemiology 10. Mast, E. and Goodman, R.: Trainers’ Association Position Statement; (APIC). 1996. APIC infection control and Prevention of Infectious Disease Skin Diseases. Journal of Athletic applied epidemiology principles and Transmission in Sports. SportsMedicine Training. 2010; 95 (H);411-428. practice. St. Louis: Mosby. 24(1):1-7,1997. 5. Beck, CK.: Infectious diseases in 11. Kohl TD, Martin DC, Nemeth R, Hill sports: Medicine and Science in Sports T, Evans D.: Fluconazole for the and Exercise 32(7 Suppl):S431-8, prevention and treatment of tinea 2000 Jul. gladiatorum. Pediatric Infectious Disease 6. Belongia EA, Goodman JL, Holland Journal 19(8):717-22, 2000 Aug. EJ, et. al.: An outbreak of herpes gladiatorium at a high school wrestling 12. Lindenmayer JM, Schoenfeld S, camp. The New England Journal of O’Grady R, Carney JK.: Methicillin- Medicine. 325(13):906-910, 1991. resistant Staphylococcus aureus in a high school wrestling team and the Cordoro, KM and Ganz, JE. Training room management of medical condition: surrounding community. Archives of Sports . Clinics in Sports 158(8):895-9, Medicine. 24: 565-598, 2005. 1998 Apr.

64 Skin Infections in Athletics

National Collegiate Athletic Association SKIN EVALUATION AND PARTICIPATION STATUS (Physician Release for Student-Athlete to Participate with Skin Lesion)

Student-Athlete: ______Date of Exam: ____ / ____ / ____

Institution: ______Please Mark Location of Lesion(s):

Dual(s)/Tournament: ______

Number of Lesion(s): ______

Cultured: No Yes Yes ______

Diagnosis: ______

______

Medication(s) used to treat lesion(s): ______

______

Date Treatment Started: ____ / ____ / ____ Time: ______

Earliest Date student-athlete may return to participation: ____ / ____ / ____

Physician Name (Printed): ______

Physician Signature:______Specialty: ______(M.D. or D.O.) Office Address: ______Contact #: ______

Institution Certified Athletic Trainer Notified: No Yes Yes Signature: ______

NoteNote to to Physicians: Physician: Non-contagious lesions do not require treatment prior to return to participation (e.g. eczema, psoriasis, etc.). Please familiarize yourself with NCAA Wrestling Rules which state: (refer to the NCAA Wrestling Rules and Interpretations publication for complete information) “9.6.4 … The presence of a communicable skin disease … shall be full and sufficient reason for disqualification.” “9.6.5 … If a student-athlete has been diagnosed as having such a condition, and is currently being treated by a physician (ideally a dermatologist) who has determined that it is safe for that individual to compete without jeopardizing the health of the opponent, the student-athlete may compete. However, the student- athlete or his/her coach or athletic trainer shall provide current written documentation from the treating physician to the medical professional at the medical examination, … ” “9.6.6 … Final determination of the participant’s ability to compete shall be made by the host site’s physician or certified athletic trainer who conducts the medical examination after review of any such documentation and the completion of the exam.”

Below are some treatment guidelines that suggest MINIMUM TREATMENT before return to wrestling: (please refer to the NCAA Sports Medicine Handbook for complete information)

Bacterial Infections (Furuncles, Carbuncles, Folliculitis, Impetigo, Cellulitis or Erysipelas, Staphylococcal disease, CA-MRSA): Wrestler must have been without any new skin lesion for 48 hours before the meet or tournament; completed 72 hours of antibiotic therapy and have no moist, exudative or draining lesions at meet or tournament time. Gram stain of exudate from questionable lesions (if available). Active bacterial infections shall not be covered to allow participation.

Herpetic Lesions (Simplex, fever blisters/cold sores, Zoster, Gladiatorum): Skin lesions must be surmounted by a FIRM ADHERENT CRUST at competition time, and have no evidence of secondary bacterial infection. For primary (first episode of Herpes Gladiatorum) infection, the wrestler must have developed no new blisters for 72 hours before the examination; be free of signs and symptoms like fever, malaise, and swollen lymph nodes; and have been on appropriate dosage of systemic antiviral therapy for at least 120 hours before and at the time of the competition. Recurrent outbreaks require a minimum of 120 hours of oral anti-viral treatment, again so long as no new lesions have developed and all lesions are scabbed over. Active herpetic infections shall not be covered to allow participation.

Tinea Lesions (ringworm): Oral or topical treatment for 72 hours on skin and 14 days on scalp. Wrestlers with solitary, or closely clustered, localized lesions will be disqualified if lesions are in a body location that cannot be adequately covered.

Molluscum Contagiosum: Lesions must be curetted or removed before the meet or tournament and covered.

Verrucae: Wrestlers with multiple digitate verrucae of their face will be disqualified if the infected areas cannot be covered with a mask. Solitary or scattered lesions can be curetted away before the meet or tournament. Wrestlers with multiple verrucae plana or verrucae vulgaris must have the lesions adequately covered. Hidradenitis Suppurativa: Wrestler will be disqualified if extensive or purulent draining lesions are present; covering is not permissible.

Pediculosis: Wrestler must be treated with appropriate pediculicide and re-examined for completeness of response before wrestling.

Scabies: Wrestler must have negative scabies prep at meet or tournament time.

DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made herein, or exam performed in 65 connection therewith, by the above named physician/provider, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided herein. GUIDELINE 2k Menstrual-Cycle Dysfunction January 1986 • Revised June 2002

The NCAA Committee on tion appear to be reversible. Another neither change has been shown to Competitive Safeguards and Medical medical consequence is skeletal result in complete recovery of the Aspects of Sports acknowledges the demineralization, which occurs in lost bone mass. Additional research significant input of Dr. Anne Loucks, hypoestrogenic women. Skeletal is necessary to develop a specific Ohio University, in the revision of demineralization was first observed prognosis for exercise-induced men- this guideline. in amenorrheic athletes in 1984. strual dysfunction. Initially, the lumbar spine appeared In 80 percent of college-age women, All student-athletes with menstrual the length of the menstrual cycle to be the primary site where skeletal irregularities should be seen by a ranges from 23 to 35 days. demineralization occurs, but new physician. General guidelines Oligomenorrhea refers to a menstru- techniques for measuring bone min- include: al cycle that occurs inconsistently, eral density show that demineraliza- 1. Full medical evaluation, including irregularly and at longer intervals. tion occurs throughout the skeleton. an endocrine work-up and bone min- Amenorrhea is the cessation of the Some women with menstrual distur- eral density test; menstrual cycle with ovulation bances involved in high-impact occurring infrequently or not at all. activities, such as gymnastics and 2. Nutritional counseling with spe- A serious medical problem of amen- figure skating, display less deminer- cific emphasis on: orrhea is the lower level of circulat- alization than women runners. a. Total caloric intake versus ing estrogen (hypoestrogenism), and Despite resumption of normal men- energy expenditure. its potential health consequences. ses, the loss of bone mass during prolonged hypoestrogenemia is not b. Calcium intake of 1,200 to The prevalence of menstrual-cycle completely reversible. Therefore, 1,500 milligrams a day; and irregularities found in surveys young women with low levels of cir- depends on the definition of men- culating estrogen, due to menstrual 3. Routine monitoring of the diet, strual function used, but has been irregularities, are at risk for low peak menstrual function, weight-training reported to be as high as 44 percent bone mass which may increase the schedule and exercise habits. in athletic women. Research sug- potential for osteoporotic fractures gests that failure to increase dietary If this treatment scheme does not later in life. An increased incidence energy intake in compensation for result in regular menstrual cycles, of stress fractures also has been the expenditure of energy during estrogen-progesterone supplementa- observed in the long bones and feet exercise can disrupt the hypothalam- tion should be considered. This of women with menstrual irregulari- ic-pituitary-ovarian (HPO) axis. should be coupled with appropriate ties. Exercise training appears to have no counseling on hormone replacement suppressive effect on the HPO axis The treatment goal for women with and review of family history. Hormone-replacement therapy is beyond the impact of its strain on menstrual irregularities is the re- thought to be important for amenor- energy availability. establishment of an appropriate hor- rheic women and oligomenorrheic monal environment for the mainte- There are several important reasons women whose hormonal profile nance of bone health. This can be to discuss the treatment of menstru- reveals an estrogen deficiency. al-cycle irregularities. One reason is achieved by the re-establishment of infertility; fortunately, the long-term a regular menstrual cycle or by hor- The relationship between amenor- 66 effects of menstrual cycle dysfunc- mone replacement therapy, although rhea, osteoporosis and disordered Menstrual-Cycle Dysfunction eating is termed the “female athlete pressuring female athletes to diet triad.” In 1997, the American and lose weight and should be edu- College of Sports Medicine issued a cated about the warning signs of position stand calling for all individ- eating disorders. uals working with physically active girls and women to be educated • Sports medicine professionals, ath- about the female athlete triad and letics administrators and officials develop plans for prevention, recog- of sport governing bodies share a nition, treatment and risk reduction. responsibility to prevent, recognize Recommendations are that any stu- and treat this disorder. dent-athlete who presents with any • Sports medicine professionals, ath- one component of the triad be letics administrators and officials screened for the other two compo- of sport governing bodies should nents and referred for work toward offering opportunities medical evaluation. for educating and monitoring Other recommendations include: coaches to ensure safe training • All sports medicine professionals, practices. including coaches and athletic • Young, physically active females trainers, should learn to recognize should be educated about proper the symptoms and risks associated nutrition, safe training practices, with the female athlete triad. and the risks and warning signs of • Coaches and others should avoid the female athlete triad.

References

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

67 GUIDELINE 2l Blood-Borne Pathogens and Intercollegiate Athletics

April 1988 • Revised August 2004

Blood-borne pathogens are disease- traditional routes of transmission household contacts with chronic causing microorganisms that can be from behaviors off the athletics field. HBV carriers can lead to infection potentially transmitted through blood Experts have concurred that the risk without having had sexual contact. The blood-borne pathogens of transmission on the athletics field intercourse or sharing of IV needles. of concern include­ (but are not is minimal. These rare instances probably occur limited to) the hepatitis B virus when the virus is transmitted through (HBV) and the human Hepatitis B Virus (HBV) unrecognized-wound or mucous- immunodeficiency virus (HIV). HBV is a blood-borne pathogen that membrane exposure. Infections with these (HBV, HIV) can cause infection of the liver. Many viruses have increased throughout The incidence of HBV in student- of those infected will have no the last decade among all portions of athletes is presumably low, but those symptoms or a mild flu-like illness. the general population. These participating in risky behavior off the One-third will have se­vere hepatitis, diseases have potential for athletics field have an increased which will cause the death of one catastrophic health consequences.­ likelihood of infection (just as in the percent of that group. Approximately Knowledge and awareness of case of HIV). An effective vaccine to 300,000 cases of acute HBV appropriate preventive strategies are prevent HBV is available and essential for all members of society, infection occur in the United States recommended for all college students including ­student-athletes. every year, mostly in adults. by the American College Health Association. Numerous­ other groups The particular blood-borne patho­ Five to 10 percent of acutely infected adults become chronically have recognized the potential gens HBV and HIV are transmitted benefits of universal vaccination of through sexual contact (heterosexual infected with the virus (HBV carriers). Currently in the United the entire adolescent and young-adult and homosexual), direct contact with population. infected blood or blood components, States there are approximately one million chronic carriers. Chronic and perinatally from mother to baby. HIV (AIDS Virus) In addition, behaviors such as body complications of HBV infection piercing and tattoos may place include cirrhosis of the liver and The Acquired Immunodeficiency student-athletes at some increased liver cancer. Syndrome (AIDS) is caused by the risk for contracting HBV, HIV or human immunodeficiency virus Hepatitis C. Individuals at the greatest­ risk for (HIV), which infects cells of the becoming infected include those immune system and other tissues, The emphasis for the student-athlete practicing risky behaviors of having such as the brain. Some of those and the athletics health-care team unprotected sexual intercourse or infected with HIV will remain should be placed predominately on sharing intra­venous (IV) needles in asymptomatic for many years. 68 education and concern about these any form. There is also evidence that Others will more rapidly develop Blood-Borne Pathogens and Intercollegiate Athletics manifestations of HIV disease (i.e., Testing of Student- carrier presents a more distinct AIDS). Some experts believe Athletes transmission risk than the HIV virtually all persons infected with Routine mandatory testing of carrier (see previous discussion of HIV eventually will develop AIDS ­student-athletes for either HBV or comparison of HBV to HIV) in and that AIDS is uniformly fatal. In HIV for participation purposes is not sports with higher potential for blood the United States, adolescents are at recommended.­ Individuals who exposure and sustained, close body special risk for HIV infection. This desire­ voluntary testing based on contact. Within the NCAA, wrestling age group is one of the fastest personal reasons and risk factors, is the sport that best fits this growing groups of new HIV however, should be assisted in description. infections. Approximately 14 percent obtaining such services by of all new HIV infections occur in The specific epidemiologic and appropriate campus or public-health biologic characteristics of hepatitis B persons aged between 12 to 24 years. officials. The risk of infection is increased by virus form the basis for the following recommendation: If a student-athlete having unprotected sexual Student-athletes who engage in high- develops acute HBV illness, it is intercourse, and the sharing of IV risk behavior are encouraged to seek prudent to consider removal of the needles in any form. Like HBV, there counseling and testing. Knowledge individual from combative, sustained is evidence that suggests that HIV of one’s HBV and HIV infection is close-contact sports (e.g., wrestling) has been transmitted in household- helpful for a variety of reasons, until loss of infectivity is known. contact settings without sexual including the availability of (The best mark­er for infectivity is the contact or IV needle sharing among potentially effective therapy for HBV antigen, which may persist up those household contacts5,6. Similar asymptomatic patients, and to 20 weeks in the acute stage). to HBV, these rare instances probably modification of behavior, which can Student-athletes in such sports who occurred through unrecognized- prevent transmission of the virus to develop chronic HBV infections wound or mucous-membrane others. Appropriate counseling (especially those who are e-antigen exposure. regarding exercise and sports positive) should probably be participation also can be removed from competition Comparison of HBV/HIV accomplished. indefinitely, due to the small but Hepatitis B is a much more “sturdy/ realistic risk of transmitting HBV to durable” virus than HIV and is much Participation by the other student-athletes. more concentrated in blood. HBV has Student-Athlete with a much more likely transmission with Hepatitis B (HBV) Participation of the exposure to infected blood; Infection Student-Athlete with HIV particularly parenteral (needle-stick) Individual’s Health––In general, Individual’s Health—In general, the exposure, but also exposure to open acute HBV should be viewed just as decision to allow an HIV-positive wounds and mucous membranes. other viral infections. Decisions student-athlete to participate in There has been one well-documented regarding ability to play are made intercollegiate athletics should be case of transmission of HBV in the according to clinical signs and symp­ made on the basis of the individual’s athletics setting,­ among sumo toms, such as fatigue or fever. There health status. If the student-athlete is wrestlers in . There are no is no evidence that intense, highly asymptomatic and without evidence validated cases of HIV transmission in competitive training is a problem for of deficiencies in immunologic the athletics setting. The risk of the asymptomatic HBV carrier function, then the presence of HIV transmission for either HBV or HIV (acute or chronic) without­ evidence infection in and of itself does not on the field is considered minimal; of organ impairment. Therefore, the mandate removal from play. however, most experts agree that the simple presence of HBV infection specific epidemiologic and biologic does not mandate removal from play. The team physician must be characteristics of the HBV virus make knowledgeable in the issues it a realistic concern for transmission Disease Transmission—The surrounding the management of in sports with sustained, close physical­ student-athlete with either acute or HIV-infected student-athletes. HIV contact, such as wrestling.­ HBV is chronic HBV infection presents very must be recognized as a potentially considered to have a potentially higher limited risk of disease transmission chronic disease, frequently affording risk of transmission than HIV. in most sports. However, the HBV the affected individual many years of 69 Blood-Borne Pathogens and Intercollegiate Athletics

excellent health and productive life infected with HIV, although one during its natural history. During this court has upheld the exclusion of an period of preserved health, the team HIV-positive athlete from the contact physician may be involved in a sport of karate19. series of complex issues surrounding the advisability of continued Administrative Issues The identity of individuals exercise and athletics competition. The identity of individuals infected infected with a blood- The decision to advise continued with a blood-borne pathogen must borne pathogen must athletics competition should involve remain confidential. Only those remain confidential. Only the student-athlete, the student- persons in whom the infected those persons in whom athlete’s personal physician and the student-athlete chooses to confide have a about this the infected student- team physician. Variables to be considered in reaching the decision aspect of the student-athlete’s athlete chooses to include the student-athlete’s current medical history. This confidentiality confide have a right to state of health and the status of his/ must be respected in every case and know about this aspect of her HIV infection, the nature and at all times by all college officials, the student-athlete’s intensity of his/her training, and including coaches, unless the student-athlete chooses to make the medical history. This potential contribution of stress from athletics competition to deterioration fact public. confidentiality must be of his/her health status. respected in every case Athletics Health-Care and at all times by all There is no evidence that exercise Responsibilities and training of moderate intensity is college officials, including The following recommendations are harmful to the health of HIV- designed to further minimize risk of coaches, unless the infected individuals. What little data blood-borne pathogens and other student-athlete chooses that exists on the effects of intense potentially infectious organisms training on the HIV-infected to make the fact public. transmission in the context of individual demonstrates no evidence athletics events and to provide of health risk. However, there is no treatment guidelines for caregivers. data looking at the effects of long- In the past, these guidelines were term intense training and referred to as “Universal (blood and competition at an elite, highly body fluid) Precautions.” Over time, competitive level on the health of the the recognition of “Body Substance HIV-infected student-athlete. Isolation,” or that infectious diseases Disease Transmission—Concerns may also be transmitted from moist of transmission in athletics revolve body substances, has led to a around exposure to contaminated blending of terms now referred to as blood through open wounds or “Standard Precautions.” Standard mucous membranes. Precise risk of precautions apply to blood, body such transmission is impossible to fluids, secretions and excretions, calculate, but epidemiologic and except sweat, regardless of whether biologic evidence suggests that it is or not they contain visible blood. extremely low (see section on These guidelines, originally comparison of HBV/HIV). There developed for health-care, have have been no validated reports of additions or modifications relevant to transmission of HIV in the athletics athletics. They are divided into two setting3,13. Therefore, there is no sections — the care of the student- recommended restriction of student- athlete, and cleaning and disinfection athletes merely because they are of environmental surfaces. 70 Blood-Borne Pathogens and Intercollegiate Athletics

Care of the Athlete: with an occlusive dressing that will NCAA policy mandates the 1. All personnel involved in sports withstand the demands of immediate, aggressive treatment of who care for injured or bleeding competition. Likewise, care open wounds or skin lesions that student-athletes should be properly providers with healing wounds or are deemed potential risks for trained in first aid and standard dermatitis should have these areas transmission of disease. Partici- precautions. adequately covered to prevent pants with active bleeding should transmission to or from a be removed from the event as soon 2. Assemble and maintain participant. Student-athletes may as is practical. Return to play is equipment and/or supplies for be advised to wear more protective determined by appropriate medical treating injured/bleeding athletes. equipment on high-risk areas, such staff personnel and/or sport Items may include: Personal as elbows and hands. officials. Any participant whose Protective Equipment (PPE) uniform is saturated with blood [minimal protection includes 4. The necessary equipment and/or must change their uniform before gloves, goggles, mask, fluid- supplies important for compliance return to participation. resistant gown if chance of splash with standard precautions should or splatter]; antiseptics; be available to caregivers. These 6. During an event, early antimicrobial wipes; bandages or supplies include appropriate gloves, recognition of uncontrolled dressings; medical equipment disinfectant bleach, antiseptics, bleeding is the responsibility of needed for treatment; appropriately designated receptacles for soiled officials, student-athletes, coaches labeled “sharps” container for equipment and uniforms, bandages and medical personnel. In disposal of needles, syringes and and/or dressings, and a container particular, student-athletes should scalpels; and waste receptacles for appropriate disposal of needles, be aware of their responsibility to appropriate for soiled equipment, syringes or scalpels. report a bleeding wound to the uniforms, towels and other waste. proper medical personnel. 5. When a student-athlete is 3. Pre-event preparation includes bleeding, the bleeding must be 7. Personnel managing an acute proper care for wounds, abrasions­ stopped and the open wound blood exposure must follow the or cuts that may serve as a source covered with a dressing sturdy guidelines for standard precaution. of bleeding or as a port of entry for enough to withstand the demands Gloves and other PPE, if necessary, blood-borne pathogens or other of activity before the student- should be worn for direct contact potentially infectious organisms. athlete may continue participation with blood or other body fluids. These wounds should be covered in practice or competition. Current Gloves should be changed after treating each individual participant. After removing gloves, hands should be washed.

8. If blood or body fluids are transferred from an injured or bleeding student-athlete to the intact skin of another athlete, the event must be stopped, the skin cleaned with antimicrobial wipes to remove gross contaminate, and the athlete instructed to wash with soap and water as soon as possible. NOTE: Chemical germicides intended for use on environmental surfaces should never be used on student-athletes.

9. Any needles, syringes or scalpels should be carefully disposed of in an appropriately labeled “sharps” container. Medical equipment, 71 Blood-Borne Pathogens and Intercollegiate Athletics

bandages, dressings and other waste 3. Put on disposable gloves. used for treating student-athletes and should be disposed of according to the cleaning and disinfection of facility protocol. During events, 4. Remove visible organic material environmental surfaces. uniforms or other contaminated by covering with paper towels or linens should be disposed of in a disposable cloths. Place soiled towels 3. Occupational Safety and Health or cloths in red bag or other waste designated container to prevent Administration (OSHA) standards for receptacle according to facility contamination of other items or Bloodborne Pathogens (Standard #29 protocol. (Use additional towels or personnel. At the end of CFR 1910.1030) and Hazard cloths to remove as much organic competition, the linen should be Communication (Standard #29 CFR material as possible from the surface 1910.1200) should be reviewed for laundered and dried according to and place in the waste receptacle.) further information. facility protocol; hot water at temperatures of 71 degrees Celsius 5. Spray the surface with a properly Member institutions should en­sure (160 degrees Fahrenheit) for 25- diluted chemical germicide used that policies exist for orientation and minute cycles may be used. according to manufacturer’s label education of all health-care workers recommendations for disinfection, on the prevention and transmission of Care of Environmental and wipe clean. Place soiled towels blood-borne patho­gens. Additionally, Surfaces: in waste receptacle. in 1992, the Occupational Safety and 1. All individuals responsible for Health Administration (OSHA) 6. Spray the surface with either a cleaning and disinfection of blood developed a standard directed to properly diluted tuberculocidal spills or other potentially infectious eliminating or minimizing chemical germicide or a freshly materials (OPIM) should be properly occupational exposure to blood-borne prepared bleach solution diluted trained on procedures and the use of pathogens. Many of the 1:100, and follow manufacturer’s standard precautions. recommendations included in this label directions for disinfection; wipe guideline are part of the standard. 2. Assemble and maintain supplies clean. Place towels in waste Each member institution should for cleaning and disinfection of hard receptacle. determine the applicability of the surfaces contaminated by blood or OSHA standard to its personnel 7. Remove gloves and wash hands. OPIM. Items include: Personal and facilities. Protective Equipment (PPE) [gloves, 8. Dispose of waste according to goggles, mask, fluid-resistant gown if facility protocol. chance of splash or splatter]; supply of absorbent paper towels or Final Notes: disposable cloths; red plastic bag 1. All personnel responsible for with the biohazard symbol on it or caring for bleeding individuals should other waste receptacle according to be encouraged to obtain a Hepatitis B facility protocol; and properly diluted (HBV) vaccination. tuberculocidal disinfectant or freshly prepared bleach solution diluted 2. Latex allergies should be (1:100 bleach/water ratio). considered. Non-latex gloves may be

72 Blood-Borne Pathogens and Intercollegiate Athletics

References

1. AIDS education on the college 11. United States Olympic Committee campus: A theme issue. Journal of Ameri­ Sports Medicine and Science Committee:­ can College Health 40(2):51-100, 1991. Transmission of infectious agents during 2. American Academy of Pediatrics: athletic competition, 1991. (1750 East Human immunodeficiency virus (AIDS Boulder Street, Colorado Springs, CO virus) in the athletic setting. Pediatrics 80909) 88(3):640-641, 1991. 12. Update: Universal precautions for 3. Calabrese L, et al.: HIV infections: prevention of transmission by human immunodeficiency virus, hepatitis B exer­cise and athletes. Sports Medicine virus, and other blood borne patho­gens 15(1):1-7, 1993. in health care settings. Morbidity and 4. Canadian Academy of Sports Medi­ Mortality Weekly Report 37:377-388, cine position statement: HIV as it relates­ 1988. to sport. Clinical Journal of Sports 13. When sports and HIV share the bill, Medicine 3:63-68, 1993. smart money goes on common sense. 5. Fitzgibbon J, et al.: Transmissions Journal of American Medical Association from one child to another of human 267(10):1311-1314, 1992. immunodeficiency virus type I with 14. World Health Organization azidovudine-resistance mutation. consensus statement: Consultation on New England Journal of Medicine 329 AIDS and sports. Journal of American (25):1835-1841, 1993. Medical Association 267(10):1312, 1992. 6. HIV transmission between two 15. Human immunodeficiency virus adolescent brothers with hemophilia. (HIV) and other blood-borne patho­gens Morbidity and Mortality Weekly Report­ in sports. Joint position statement by the 42(49):948-951, 1993. American Medical Society for Sports 7. Kashiwagi S, et al.: Outbreak of Medicine (AMSSM) and the American hepatitis­ B in members of a high-school Academy of Sports Medicine (AASM). sumo wrestling club. Journal of American The American Journal of Sports Medical Association 248 (2):213-214, Medicine 23(4):510-514, 1995. 1982. 16. Most E, et al.: Transmissions of 8. Klein RS, Freidland GH: Trans­mission blood-borne pathogens during sport: risk of human immunodeficiency virus type 1 and prevention. Annals of Internal (HIV-1) by exposure to blood: defining the Medicine 122(4):283-285, 1995. risk. Annals of Internal Medicine 17. Brown LS, et al.: Bleeding injuries in 113(10):729-730, 1990. professional football: estimating the risk 9. Public health services guidelines for for HIV transmission. Annals of Internal counseling and antibody testing to Medicine 122(4):271-274, 1995. prevent HIV infection and AIDS. 18. Arnold BL: A review of selected Morbidity and Mortality Weekly Report­ blood-borne pathogen statements and 36(31):509-515, 1987. federal regulations. Journal of Athletic 10. Recommendations for prevention of Training 30(2):171-176, 1995. HIV transmission in health care settings. 19. Montalov v. Radcliffe, 167 F. 3d 873 Morbidity and Mortality Weekly Report (4th Cir. 1999), cert. denied, 120 S Ct. 48 36(25):3S-18S, 1987. 1999. 73 GUIDELINE 2m The Use of Local Anesthetics in College Athletics June 1992 • Revised June 2004

The use of local injectable 3. These agents should only be anesthetics to treat sports-related administered when medically injuries­ in college athletics is justified, when the risk of primarily left to the discretion of the administration is fully explained to physician treating the individual, the patient, when the use is not since there is little scientific research harmful to continued athletics on the subject. This guideline activity and when there is no provides basic recommendations for enhancement of a risk of injury. the use of these substances, which The following procedures are not commonly include lidocaine (Xylo­ recommended: caine), one or two percent; bupivacaine (Marcaine), 0.25 to 0.50 1. The use of local anesthetic percent; and mepivacaine (Carbo­ injections if they jeopardize the caine), three percent. The following ability of the student-athlete to protect recommendations do not include the himself or herself from injury. use of corticosteroids. 2. The administration of these drugs It is recommended that: by anyone other than a qualified clinician licensed to perform this These agents should be 1. procedure. administered only by a qualified clinician who is licensed to perform 3. The use of these drugs in this procedure and who is familiar combination with epinephrine or with these agents’ actions, reactions, other vasoconstrictor agents in interactions and complications. The fingers, toes, earlobes and other treating clinician should be well areas where a decrease in circulation, aware of the quantity of these agents even if only temporary, could result that can be safely injected. in significant harm. 2. These agents should only be administered in facilities equipped to handle any allergic reaction, including a cardiopulmonary emergency, which may follow their use.

74 GUIDELINE 2n The Use of Injectable Corticosteroids in Sports Injuries June 1992 • Revised June 2004

Corticosteroids, alone or in use of corticosteroids in athletics is corticosteroid. combination with local anesthetics, the treatment of chronic overuse There is still much to be learned have been used for many years to syndromes such as bursitis, about the effects of intra-articular, treat certain sports-related injuries. tenosynovitis and muscle origin pain intraligamentous or intratendinous This guideline is an attempt to (for example, lateral epicondylitis). injection of corticosteroids. identify specific circumstances in They have also been used to try to Researchers­ have noted reduced which corticosteroids may be prevent redevelopment of a synthesis of articular cartilage after appropriate and also to remind both ganglion, and to reduce keloid scar corticosteroid administration in both physicians and student-athletes of formation. Rarely is it appropriate to animals and human models. the inherent dangers associated treat acute syndromes such as However, a causal relationship with their use. acromio-clavicular (AC) joint between the intra-articular The most common reason for the separations or hip pointers with a corticosteroid and degeneration of

75 The Use of Injectable Corticosteroids in Sports Injuries

articular cartilage has not been administered when medically References established. Research also has justified, when the risk of shown that a single intraligamentous administration is fully explained to or multiple intra-articular injections the patient, when the use is not 1. Corticosteroid injections: balancing have the potential to cause harmful to continued athletics the benefits. The Physician and Sports significant and long-lasting activity and when there is no Medicine 22(4):76, 1994. deterioration in the mechanical enhancement of a risk of injury. 2. Corticosteroid Injections: Their Use properties of ligaments and The following procedures are not collagenous tissues in animal and Abuse. Journal of the American recommended: models. Finally, studies have shown Academy of Orthopaedic Surgeons significant degenerative changes in 1. Intra-articular injections, 2:133-140, 1994. particularly in major weight-bearing active animal tendons treated with a 3. Kennedy JC, Willis RD: The effects of corticosteroid as early as 48 hours joints. Intra-articular injections have local steroid injections on tendons: A after injection. a potential softening effect on articular cartilage. biomechanical and microscopic This research provides the basis for correlative study. American Journal of the following recommendations 2. Intratendinous injections, since regarding the administration of such injections have been associated Sports Medicine 4:11-21, 1970. corticosteroids in college athletics.­ with an increased risk of rupture. 4. Leadbetter WB: Corticosteroid It is recommended that: 3. Administration of injected injection therapy in sports injuries. In: corticosteroids­ immediately before a Sports Induced Inflammation Park Ridge, Injectable corticosteroids should 1. competition. be administered only after more IL: American Academy of Orthopedic­ conservative treatments, including 4. Administration of corticosteroids­ Surgeons, pp. 527-545, 1990. nonsteroidal anti-inflammatory in acute trauma. 5. Mankin HJ, Conger KA: The acute agents, rest, ice, ultrasound and 5. Administration of corticosteroids­ effects of intra-articular hydrocortisone various treatment modalities, have in infection. on articular cartilage in rabbits. Journal been exhausted. of Bone and Joint Surgery 48A:1383- 2. Only those physicians who are 1388, 1966. knowledgeable about the chemical makeup, dosage, onset of action, 6. Noyes FR, Keller CS, Grood ES, et duration and potential toxicity of al.: Advances in the understanding of these agents should administer knee ligament injuries, repair and reha­ corticosteroids. bilitation. Medicine and Science in 3. These agents should be Sports and Exercise 16:427-443, 1984. administered only in facilities that 7. Noyes FR, Nussbaum NS, Torvik PT, are equipped to deal with allergic reactions, including et al.: Biomechanical and ultrastructural cardiopulmonary emergencies. changes in ligaments and tendons after local corticosteroid injections. Abstract, 4. Repeated corticosteroid injections at a specific site should be done only Journal of Bone and Joint Surgery after the consequences and benefits 57A:876, 1975. of the injections have been 8. Pfenninger JL: Injections of joints and thoroughly evaluated. soft tissues: Part I. General guidelines. 5. Corticosteroid injections only American Family Physician 44(4):1196- should be done if a therapeutic effect 1202, 1991. is medically warranted and the ­student-athlete is not subject to 9. Pfenninger JL: Injections of joints and either short- or long-term significant soft tissues: Part II. Guidelines for risk. specific joints. American Family 76 6. These agents should only be Physician 44(5):1690-1701, 1991. GUIDELINE 2o Depression: Interventions for Intercollegiate Athletics June 2006

The NCAA Committee on Com­ though the majority of peoples’ physical demands of their sport, and petitive Safeguards and Medical depressive disorders can be the time commitment of Aspects of Sports acknowledges the improved,­ most people with participation, strength and significant input of Sam Maniar, depression do not seek help. conditioning, and skill instruction. Licensed Psychologist, The Ohio Depression is important to assess Most athletes participate almost State University; Margot Putukian, among student-athletes because it year-round, often missing holidays, Team Physician, Princeton impacts overall personal well-being, school and summer breaks, classes University; and the National athletic performance, academic and even graduation. In addition, if Institute of Mental Health, performance and injury healing. No they struggle in their performance, Bethesda, Maryland; for their two people become depressed­ in original content. have difficulty interacting with the exactly the same way, but with the coach or teammates, or they lose Depression is more than the blues, proper treatment 80 percent of those their passion for their sport, it can let-downs from a game loss, or the who seek help get better, and many be very difficult to handle. Many normal daily ups and downs. It’s people begin to feel better in just a athletes also define themselves by feeling “down” and “low” and few weeks. their role as an athlete, and an injury “hopeless” for weeks at a time. Depression and can be devastating. Depression is a serious medical Intercollegiate Athletics­ condition. Some attributes of athletics and Student-athletes may experience competition can make it extremely Little research has been conducted depression because of genetic difficult for student-athletes to on depression among student- predisposition, developmental obtain help. They are taught to “play athletes; however, preliminary data challenges of college transitions, through the pain,” struggle through indicate that student-athletes academic stress, financial pressures, adversity, handle problems on their experience depressive symptoms interpersonal difficulties and grief own and “never let your enemies and illness at similar or increased over loss/failure. see you cry.” Seeking help is seen as rates than non-athlete students. a sign of weakness, when it should Approx­ imately­ 9.5 percent of the Participation in athletics does not be recognized as a sign of strength. population — or one out of 10 provide student-athletes any people — suffer from a depressive immunity to these stresses, and it Team dynamics also may be a illness during any given one-year has the potential to pose additional factor. Problems often are kept “in period. Women are twice as likely to demands.­ Student-athletes must the family,” and it is common for experience depression as men; balance all of the demands of being teams to try to solve problems by however, men are less likely to a college student along with themselves, often ignoring signs or admit to depression. Moreover, even athletics demands. This includes the symptoms of more serious issues. 77 Depression: Intervention for Intercollegiate Athletics

Depression affects approximately 19 Types of Depressive million Americans, and for many, Illness the symptoms first appear before or Depressive illnesses come in during college. different forms. The following are Early identification and intervention general descriptions of the three (referral/treatment) for depression most prevalent, though for an or other mental illness is extremely individual the number, severity and important, yet may be inhibited duration of symptoms will vary. within the athletics culture for the Major Depression, or “clinical following reasons: depression,” is manifested by a • Physical illness or injury is more combination of symptoms that readily measured and treated interfere with a person’s once within sports medicine, and often pleasurable activities (school, sport, there is less comfort in addressing sleep, eating, work). Student- mental illness. athletes experiencing five or more symptoms as noted in Table 1 for • Mental wellness is not always two weeks or longer, or noticeable perceived as necessary for changes in usual functioning, are athletic performance. factors that should prompt referral • The high profile of student- to the team physician or mental Available online at NCAA.org/ athletes may magnify the health professional. Fifteen percent health-safety. attention paid on campus and in of people with major depression die the surrounding community when by suicide. The rate of suicide in an athlete seeks help. men is four times that of women, though more women attempt it • History and tradition drive during their lives. athletics and can stand as barriers to change. Dysthymia is a less severe form of depression that tends to involve • The athletics department may long-term, chronic depressive have difficulty associating mental symptoms. Although these illness with athletic participation. symptoms are not disabling, they do Enhancing knowledge affect the individual’s overall and awareness of functioning. depressive disorders Bipolar Disorder, or “manic- Sports medicine staff, coaches and depressive illness,” involves cycling student-athletes should be mood swings from major depressive knowledgeable about the types of epi­sodes­ to mania. Depressive epi­­ depression and related symptoms. sodes may last as little as two Men may be more willing to report weeks, while manic episodes may fatigue, irritability, loss of interest in last as little as four days. Manic work or hobbies and sleep signs and symptoms are presented disturbances, rather than feelings of in Table 2. sadness, worthlessness and In addition to the three types of excessive guilt, which are depressive disorders, student- commonly associated with athletes may suffer from an Ad­just­ depression in women. Men often ment Disorder. Adjustment mask depression with the use of disorders occur when an individual alcohol or drugs, or by the socially experiences depressive (or anxious) acceptable habit of working symptoms­ in response to a specific 78 excessively long hours. event or stressor (e.g., poor Depression: Intervention for Intercollegiate Athletics performance, poor relationship with from the team and catastrophic counseling and medication appears a coach). An adjustment disorder events. Members of the sports to be the most effective treatment can also progress into major medicine team and/or licensed for moderately and severely depressive disorder. mental health professionals should de­pressed individuals. Although also screen athletes for depression at Establishing a some improvement in mood may pre-established points in time (e.g., relationship with mental occur in the first few weeks, it pre-participation, exit interviews). health services typically takes three to four weeks Research indicates that sports of treatment to obtain the full Athletics departments should medicine professionals are better therapeutic effect. Medication identify and foster relationships equipped to assess depression with should only be taken and/or stopped with mental health resources on the use of appropriate mental health under the direct care of a physician, campus or within the local instruments; simply asking about and the team physicians should community that will enable the depression is not recommended. consult with psychiatrists regarding development of a diverse and A thorough assessment on the part complex mental health issues. effective referral plan addressing the of a mental health professional is A referral should be made to a mental well-being of their student- also imperative to differentiate licensed mental health professional athletes and staff. Because student- major depression from dysthymia when coaches or sports medicine athletes are less likely to use and bipolar disorder, and other staff members witness any of the counseling than nonathlete students, conditions, such as medication use, following with their student- increasing interaction­ among mental viral illness, anxiety disorders, athletes: health staff members, coaches and overtraining and illicit substance student-athletes will improve use. Depressive disorders may • Suicidal thoughts. compliance with referrals. Athletics co-exist with substance-abuse • Multiple depressive symptoms. departments can seek psychological disorders, panic disorder, obsessive- • A few depressive symptoms that services and mental health compulsive disorder, anorexia persist for several weeks. professionals from the following nervosa, bulimia nervosa and resources. borderline personality disorder. • Depressive symptoms that lead to more severe symptoms or • Athletics department sports For depression screening, it is de­structive behaviors. medicine services. recommended that sports medicine • Athletics department academic teams use the Center for Epi­ • Alcohol and drug abuse as an services. demiological Studies Depression­ attempt at self treatment. (CES-D) Scale published by the • University student health and • Overtraining or burnout, since National Institute for Mental Health counseling services. depression has many of the same (NIMH). The CES-D is free to use symptoms. • University . and available at www.nimh.nih.gov. Other resourc­ es­ include such Coaches and sports medicine staff • University graduate programs programs as QPR (Question, members should follow the (health sciences, education, Persuade, Refer) Gatekeeper­ following guidelines in order to help medical, allied health). training; the Jed Foundation­ U enhancing student-athlete • Local community. Lifeline; and the Screening for compliance with mental health Screening for Mental Health Depression and referrals: depression and related Anxiety Screenings. Information • Express confidence in the mental risk for suicide about these programs, and ways to health professional (e.g., “I know incorporate them into student- that other student-athletes have One way to ensure an athletics athlete check-ups, can be found at felt better after talking to Dr. department is in tune with student- NCAA.org/health-safety. Kelly.”). athletes’ mental well-being is to systematically include mental health Seeking help • Be concrete about what check-ups, especially around high- Most individuals who suffer from counseling is and how it could risk times such as the loss of a depression will fully recover to lead help (e.g., “Amy can help you coach, significant injury, being cut productive lives. A combination of focus more on your strengths.”). 79 Depression: Intervention for Intercollegiate Athletics

• Focus on similarities between the student-athlete and the mental Table 1 health professional (e.g., “Bob has a sense of humor that you DEPRESSIVE SIGNS AND SYMPTOMS would appreciate.” “Dr. Jones is Individuals might present: a former college student-athlete • Decreased performance in school or sport. and understands the pressures • Noticeable restlessness. student-athletes face.”). • Significant weight loss or weight gain. • Decrease or increase in appetite nearly every day • Offer to accompany the student- (fluctuating?). athletes to their initial appointment. Individuals might express: • Indecisiveness. • Offer to make the appointment • Feeling sad or unusually crying. (or have the student-athlete make • Difficulty concentrating. the appointment) while in your • Lack of or loss of interest or pleasure in activities that were office. once enjoyable (hanging out with friends, practice, school, sex). • Emphasize the confidentiality of • Depressed, sad or “empty” mood for most of the day and medical care and the referral nearly every day. process. • Recurrent thoughts of death or thoughts about suicide. • Frequent feelings of worthlessness, low self-esteem, hopeless- The following self-help strategies ness, helplessness or inappropriate guilt. may improve mild depression symptoms: • Reduce or eliminate the use of alcohol and drugs. Table 2 • Break large tasks into smaller MANIC SIGNS ones; set realistic goals. AND SYMPTOMS • Engage in regular, mild exercise. Individuals might present: • Abnormal or excessive • Eat regular and nutritious meals. elation. • Participate in activities that • Unusual irritability. typically make you feel better. • Markedly increased energy. • Let family, friends and coaches • Poor judgment. help you. • Inappropriate social behavior. • Increase positive or optimistic • Increased talking. thinking. Individuals might express: • Engage in regular and adequate • Racing thoughts. sleep habits. • Increased sexual desire. • Decreased need for sleep. • Grandiose notions.

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

81 GUIDELINE 2p Participation by the Student-Athlete with Impairment January 1976 • Revised August 2004

In accordance with the significant risk of substantial harm his or her parent(s) or guardian. recommendations of major medical to the health or safety of the The following factors should be organizations and pursuant to the student-athlete and/or other considered on an individualized requirements of federal law (in participants that cannot be basis in determining whether he or particular, the Rehabilitation Act of eliminated or reduced by she should participate in a 1976 and The Americans With reasonable accommodations. particular sport: Disabilities Act), the NCAA Recent judicial decisions have 1. Available published information encourages participation by upheld a university’s legal right to regarding the medical risks of student-athletes with physical or exclude a student-athlete from participation in the sport with the mental impairments in competition if the team physician athlete’s mental or physical intercollegiate athletics and has a reasonable medical basis for impairment; physical activities to the full extent determining that athletic competition creates a significant of their interests and abilities. It is 2. The current health status of the risk of harm to the student-athlete imperative that the university’s student-athlete; sports medicine personnel assess a or others. When student-athletes student-athlete’s medical needs and with impairments not otherwise 3. The physical demands of the specific limitations on an qualified to participate in existing sport and position(s) that the individualized basis so that athletics programs are identified, student-athlete will play; needless restrictions will be every means should be explored by avoided and medical precautions member institutions to provide 4. Availability of acceptable suitable sport and recreational will be taken to minimize any protective equipment or measures programs in the most appropriate, enhanced risk of harm to the to reduce effectively the risk of integrated settings possible to meet student-athlete or others from harm to the student-athlete or their interests and abilities. others; and participation in the subject sport. Participation 5. The ability of the student-athlete A student-athlete with impairment Considerations [and, in the case of a minor, the should be given an opportunity to parent(s) or guardian] to fully participate in an intercollegiate Before allowing any student-athlete understand the material risks of sport if he or she has the requisite with an impairment to participate athletic participation. abilities and skills in spite of his or in an athletics program, it is her impairment, with or without a recommended that an institution Organ Absence reasonable accommodation. require joint approval from the or Non-function Medical exclusion of a student- physician most familiar with the athlete from an athletics program student-athlete’s condition, the When the absence or non-function should occur only when a mental team physician, and an appropriate of a paired organ constitutes the impairment, the following specific 82 or physical impairment presents a official of the institution as well as Participation by the Student-Athlete with Impairment issues need to be addressed with References the student-athlete and his/her parents or guardian (in the case of 1. American Academy of a minor). The following factors Pediatrics, Committee on Sports should be considered: Medicine and Fitness. Medical 1. The quality and function of the Conditions Affecting Sports remaining organ; Participation. Pediatrics. 94(5): 757-60, 1994. 2. The probability of injury to the remaining organ; and 2. Mitten, MJ. Enhanced risk of 3. The availability of current harm to one’s self as a protective equipment and the likely justification for exclusion from effectiveness of such equipment to athletics. Marquette Sports Law prevent injury to the remaining Journal. 8:189-223, 1998. organ. Medical Release

When a student-athlete with impairment is allowed to compete in the intercollegiate athletics program, it is recommended that a properly executed document of understanding and a waiver release the institution for any legal liability for injury or death arising out of the student-athlete’s participation with his or her mental or physical impairment/medical condition. The following parties should sign this document: the student-athlete, his or her parents/guardians,­ the team physician and any consulting physician, a representative of the institution’s athletics department, and the institution’s legal counsel. This document evidences the student-athlete’s understanding of his or her medical condition and the potential risks of athletic participation, but it may not immunize the institution from legal liability for injury to the student-athlete.

83 GUIDELINE 2q Pregnancy in the Student-Athlete January 1986 • Revised June 2009

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

Pregnancy places unique challeng- es on the student-athlete. Each member institution should have a policy clearly outlined to address the rights and responsibilities of the pregnant student-athlete. The policy should address: • Where the student-athlete can receive confidential counseling; • Where the student-athlete can access timely medical and obstetrical care; • How the pregnancy may affect the student-athlete’s team standing and institutional grants-in-aid; aid based in any degree on athletics when there is medical reason to • That pregnancy should be ability may not be reduced or withhold the student-athlete from treated as any other temporary canceled during the period of its competition. health condition regarding receipt award because of an injury, illness of institutional grants-in-aid; and or physical or mental medical Exercise in Pregnancy • That NCAA rules permit a one- condition. Assessing the risk of intense, year extension of the five-year The team’s certified athletic trainer strenuous physical activity in period of eligibility for a female or team physician is often pregnancy is difficult. There is some student-athlete for reasons of approached in confidence by the evidence that women who exercise pregnancy. student-athlete. The sports during pregnancy have improved Student-athletes should not be medicine staff should be well- cardiovascular function, limited forced to terminate a pregnancy versed in the athletics department’s weight gain and fat retention, because of financial or policies and be able to access the improved attitude and mental state, psychological pressure or fear of identified resources. The sports easier and less complicated labor, losing their institutional grants-in- medicine staff should respect the and enhanced postpartum recovery. aid. See Bylaw 15.3.4.3, which student-athlete’s requests for There is no evidence that increased 84 specifies that institutional financial confidentiality until such time activity increases the risk of Participation by the Pregnant Student-Athlete

spontaneous abortion in uncomplicated pregnancies. There Table 1 are, however, theoretical risks to the Warning Signs to Terminate Exercise fetus associated with increased core body temperatures that may occur While Pregnant with exercise, especially in the heat. Vaginal Bleeding Shortness of Breath Before Exercise The fetus may benefit from exercise during pregnancy in Dizziness several ways, including an Headache increased tolerance for the Chest Pain physiologic stresses of late Calf Pain or Swelling pregnancy, labor and delivery. Pre-term Labor Decreased Fetal Movement The safety of participation in individual sports by a pregnant Amniotic Fluid Leakage woman should be dictated by the Muscle Weakness movements and physical demands required to compete in that sport and the previous activity level of need to modify their activity as References the individual. The American medically indicated and require College of Sports Medicine close supervision. discourages heavy weight lifting or 1. Pregnant & Parenting Student- similar activities that require If a student-athlete chooses to athletes: Resources and Model Policies. straining or valsalva. compete while pregnant, she should: 2009. NCAA.org/health-safety. Exercise in the supine position • Be made aware of the potential 2. American College of and after the first trimester may cause risks of her particular sport and Gynecology Committee on Obstetric venous obstruction and exercise in general while pregnant; Practice: Exercise During Pregnancy and the Postpartum Period. Obstetrics and conditioning or training exercises • Be encouraged to discontinue in this position should be avoided. exercise when feeling over-exerted Gynecology 99(1) 171-173, 2002. Sports with increased incidences of or when any warning signs (Table 3. American College of Sports Medicine: bodily contact (basketball, ice 1) are present; Exercise During Pregnancy. In: Current hockey, field hockey, lacrosse, • Follow the recommendations of Comment from the American College of soccer, rugby) or falling her obstetrical provider in Sports Medicine, Indianapolis, IN, (gymnastics, equestrian, downhill coordination with the team August 2000. skiing) are generally considered physician; and 3. Clapp JF: Exercise During Pregnancy, higher risk after the first trimester A Clinical Update. Clinics in Sports because of the potential risk of • Take care to remain well- abdominal trauma. The student- hydrated and to avoid over-heating. Medicine 19(2) 273-286, 2000. athlete’s ability to compete may also After delivery or pregnancy be compromised due to changes in termination, medical clearance is physiologic capacity, and recommended to ensure the musculoskeletal issues unique to student-athlete’s safe return to pregnancy. There is also concern that athletics. (See Follow-up Exam­ in the setting of intense competition inations section of Guideline 1b.) a pregnant athlete will be less likely The physiologic changes of to respond to internal cues to pregnancy persist four to six weeks moderate exercise and may feel postpartum, however, there have pressure not to let down the team. been no known maternal The American College of complications from resumption of Ob­stetrics and Gynecology states training. Care should be taken to individualize return to practice and that competitive athletes can 85 remain active during pregnancy but competition. GUIDELINE 2r The Student-Athlete with Sickle Cell Trait October 1975 • Revised June 2008

Sickle cell trait is not a disease. It and consistent with a long, healthy Exertional rhabdomyolysis can be is the inheritance of one gene for life. As they get older, some life-threatening. During intense­ normal hemoglobin (A) and one persons with the trait become exertion and hypoxemia, sickled gene for sickle hemoglobin (S), unable to concentrate urine red cells can accumulate in the giving the genotype AS. Sickle normally, but this is not a key blood. Dehydration worsens cell trait (AS) is not sickle cell problem for college athletes. Most exertional sickling. Sickled red (SS), in which two athletes complete their careers cells can “logjam” blood vessels in abnormal genes are inherited. without any complications. working muscles and provoke Sickle cell anemia causes major However, there are three constant ischemic rhabdomyolysis. anemia and many clinical concerns that exist for athletes with Exertional rhabdomyolysis is not problems, whereas sickle cell trait sickle cell trait: gross hematuria, exclusive to athletes with sickle causes no anemia and few clinical splenic infarction, and exertional cell trait. Planned emergency response and prompt access to problems. Sickle cell trait will not rhabdomyolysis, which can medical care are critical turn into the disease. However, it is be fatal. possible to have symptoms of the components to ensure adequate disease under extreme conditions Gross hematuria, visible blood in response to a collapse or athlete in of physical stress or low the urine, usually from the left distress. levels. In some cases, athletes with kidney, is an occasional the trait have expressed significant The U.S. Armed Forces linked complication of sickle cell trait. sickle trait to sudden unexplained distress, collapsed and even died Athletes should consult a physician during rigorous exercise. death during basic training. for return-to-play clearance. Recruits with sickle cell 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 were sickle cell trait are those whose people with sickle cell trait, initially classified as either acute ancestors come from Africa, South typically at altitude. The risk may cardiac arrest of undefined or Central America, the Caribbean, begin at 5,000 feet and increases mechanism or deaths related to Mediterranean countries, , and with rising altitude. Vigorous Saudi Arabia. Sickle cell trait heat stroke, heat stress, or exercise (e.g., skiing, basketball, occurs in about 8 percent of the rhabdomyolysis. Further analysis football, hiking, anaerobic U.S. African-American population showed that the major risk was conditioning) may increase the and rarely (between one in 2,000 to severe exertional rhabdomyolysis, a risk. Splenic infarction causes left one in 10,000) in the Caucasian risk that was about 200 times upper quadrant or lower chest pain, population. It is present in athletes greater for recruits with sickle cell often with nausea and vomiting. It at all levels, including high school, trait. Deaths among college athletes can mimic pleurisy, pneumothorax, collegiate, Olympic and with sickle cell trait, almost professional. Sickle cell trait is no side stitch, or renal colic. Splenic exclusively in football dating back barrier to outstanding athletic infarction at altitude has occurred to 1974, have been from exertional performance. in athletes with sickle trait. rhabdomyolysis, including­ early Athletes should consult a physician cardiac death from hyperkalemia 86 Sickle cell trait is generally benign for return-to-play clearance. and lactic acidosis and later The Student-Athlete with Sickle Cell Trait metabolic death from acute NCAA Fact Sheets and Video for Coaches and Student- myoglobinuric renal failure. Athletes are available at www.NCAA.org/health-safety.

In other cases, athletes have survived collapses while running a distance race, sprinting on a basketball court or football field, and running timed laps on a track. The harder and faster athletes go, the earlier and greater the sickling. Sickling can begin in only two to three minutes of sprinting, or in any other all-out exertion of sustained effort, thus quickly increasing the risk of collapse. Athletes with sickle cell trait cannot be “conditioned” out of the trait and coaches pushing these athletes beyond their normal physiological response to stop and student-athlete or student-athlete recover place these athletes at an declines the test and signs a written Beginning August 1, increased risk for collapse. release. The references allude to 2010, Division I requires growing support for the practical student-athletes new to A sickling collapse is a medical benefits of screening and campuses their campus to complete emergency. Even the most fit that screen are increasing in a sickle cell solubility athletes can experience a sickling frequency. Screening can be test, show results of collapse. Themes from the accomplished with a simple blood a prior test, or sign a literature describe sickling athletes test that is relatively inexpensive. with ischemic pain and muscle Although sickle cell trait screening written release declining weakness rather than muscular is normally performed on all U.S. the test. See Division I cramping or “locking up.” Unlike babies at birth, many student- Bylaw 17.1.5.1. cardiac collapse (with ventricular athletes may not know whether fibrillation), the athlete who they have the trait. Following the slumps to the ground from sickling recommendations of the National Screening can be used as a gateway can still talk. This athlete is Athletic Trainers Association to targeted precautions. typically experiencing major lactic (NATA) and the College of acidosis, impending shock, and American Pathologists (CAP), if Precautions can enable student- imminent hyperkalemia from the trait is not known, the NCAA athletes with sickle cell trait to sudden rhabdomyolysis that can requires athletics departments to thrive in their sport. These lead to life-threatening confirm sickle cell trait status in precautions are outlined in the complications or even sudden all student-athletes, or have references and in a 2007 NATA death. The emergent management student-athletes sign a written Consensus Statement on Sickle of a sickling collapse is covered in release declining the sickle cell Cell Trait and the Athlete. the references. solubility test, during the medical Knowledge of a student-athlete’s examination (Bylaw 17.1.5) period. sickle cell status should facilitate Screening for sickle cell trait as prompt and appropriate medical part of the medical examination If a test is positive, the student- care during a medical emergency. process is required in Division I athlete should be offered institutions unless documented counseling on the implications of Student-athletes with sickle cell results of a prior test are provided sickle cell trait, including health, trait should be knowledgeable of to the institution or the prospective athletics and family planning. these precautions and institutions 87 The Student-Athlete with Sickle Cell Trait

should provide an environment in between repetitions, especially or breathlessness. which these precautions may be during “gassers” and intense station • Stay well hydrated at all times, activated. In general, these or “mat” drills. precautions suggest student-athletes especially in hot and humid conditions. • Not be urged to perform all-out with sickle cell trait should: exertion of any kind beyond two to • Maintain proper asthma • Set their own pace. three minutes without a breather. management. • Engage in a slow and gradual • Be excused from performance • Refrain from extreme exercise preseason conditioning regimen to be tests such as serial sprints or timed during acute illness, if feeling ill, or prepared for sports-specific mile runs, especially if these are while experiencing a fever. performance testing and the rigors of not normal sport activities. competitive intercollegiate athletics. • Access supplemental oxygen at • Stop activity immediately upon altitude as needed. • Build up slowly while training struggling or experiencing (e.g., paced progressions). symptoms such as muscle pain, • Seek prompt medical care when • Use adequate rest and recovery abnormal weakness, undue fatigue experiencing unusual distress.

References

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

88 Equipment Also found on the NCAA website at: NCAA.org/health-safety 3 GUIDELINE 3a Protective Equipment June 1983 • Revised June 2007

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

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 use of hard- substance material

90 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 a hazard for other players. Equipment that could cut or cause an injury to another player is prohibited, without respect to whether the equip­ ment 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 jersey.

91 Protective Equipment

Mandatory Protective Rules Governing Special Sport Equipment* Protective Equipment

5. Football 1. Soft knee pads at least ½-inch Illegal equipment includes the thick that are covered by pants. It is following: strongly recommended that they 1. Equipment worn by a player, cover the knees. No pads or including artificial limbs, that protective equipment may be worn would endanger other players. outside the pants. 2. Hard, abrasive or unyielding 2. Face masks and helmets with a substances on the hand, wrist, secured four- or six-point chin strap. forearm or elbow of any player, All players shall wear helmets that unless covered on all exterior sides carry a warning label regarding the and edges with closed-cell, slow- risk of injury and a manufacturer’s or recovery foam padding no less than reconditioner’s certification ½-inch thick, or an alternate material indicating satisfaction of NOCSAE of the same minimum thickness and test standards. similar physical properties. Hard or 3. Shoulder pads, hip pads with unyielding substances are permitted, tailbone protectors and thigh guards. if covered, only to protect an injury. Hand and arm protectors (covered An intra-oral mouthpiece of any 4. casts or splints) are permitted only to readily visible color (not white or protect a fracture or dislocation. transparent) with FDA-approved base materials (FDCS) that covers all 3. Thigh guards of any hard substances, unless all surfaces are upper teeth. It is recommended that covered with material such as closed- the mouthpiece be properly fitted. cell vinyl foam that is at least ¼-inch thick on the outside surface and at least 3/8-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 least ½-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.

92 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 securely 1. The use of pads or protectors made fastened. It is recommended that the of metal or any other material likely helmet meet HECC standards. to cause injury to a player is 2. An intra-oral mouthpiece that prohibited. covers all the upper teeth. 2. The use of any protective 3. Face masks that have met the equipment that is not injurious to the standards established by the HECC- player wearing it or other players is ASTM F 513-89 Eye and Face recommended. Protective Equipment for Hockey 3. Jewelry is not allowed, except for Players Standard. religious or medical medals, which must be taped to the body.

8. Women’s Lacrosse 1. The goalkeeper must wear a helmet Protective devices necessitated on with face mask, separate throat genuine medical grounds must be protector, a mouth piece, a chest approved by the umpires. Close- 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 meets current ASTM lacrosse standards (effective January 1, 2005).

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

93 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 under 1. A player shall not wear anything the stockings in the manner intend- that is dangerous to another player. ed, without exception. The shin 2. Knee braces are permissible pro- guards shall be professionally manu- vided no metal is exposed. factured, age and size appropriate 3. Casts are permitted if covered and not altered to decrease protec- and not considered dangerous. tion. The shin guards must meet 4. A player shall not wear any jewel- NOCSAE standards. 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 shin guards; NOCSAE-approved protheses must be well-padded to protective helmet with face mask protect both the player and opponent and built-in or attachable throat and must be neutral in color. If worn guard; and chest protector. by pitcher, cannot be distracting on 2. A NOCSAE-approved double-ear nonpitching arm. If worn on flap protective helmet must be pitching arm, may not cause safety worn by players while batting, risk or unfair competitive advantage. running the bases or warming-up in the on-deck .

14. Swimming and Diving None None

94 Protective Equipment

Mandatory Protective Rules Governing Special Sport Equipment* Protective Equipment

15. None 1. No taping of any part of the hand, thumb or fingers will be per- mitted in the discus and javelin throws, and the , except to cover or protect an open wound. In the , taping of indi- vidual fingers is permissible. Any taping must be shown to the head event judge before the event starts. 2. In the , the use of a forearm cover to prevent injuries is permissible.

It is forbidden to wear any 16. Volleyball None 1. 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 medallions 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 prohibit- ed, unless padded on all sides with at least ½-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 wres- tlers wear a protective mouth guard. 3. Jewelry is not allowed. 95 GUIDELINE 3b Eye Safety in Sports

January 1975 • Revised August 2001

Eye injuries in sports are relatively athletes who wear contact lenses for Summary frequent, sometimes catastrophic, corrective vision should wear and almost completely preventable appropriate sports safety eyewear 1. Appropriate for eye protection with the use of appropriate for ocular protection. in sports: protective devices. A sports eye a. Safety sports eyewear that protector may be a spectacle, a The American Academy of conforms to the requirements of goggle, a face-supported protector, Opthalmology recommends that the American Society for Testing or a protector attached to a helmet. head, face and eye protection and Materials (ASTM) Standard It comes with or without lenses, is should be certified by either F803 for selected sports (racket capable of being held securely in the Protective Eyewear Certifi- sports, basketball, women’s place, and may protect the face as cation Council (PECC — www. lacrosse, and field hockey). well as the eyes. Some forms can be protecteyes.org/), the Hockey b. Sports eyewear that is attached worn over regular glasses. Certification Council to a helmet or is designed for eye protectors are specially (HECC — www.hecc-hockey.org/), sports for which ASTM F803 designed, fracture-resistant units that the National Operating Committee on eyewear alone provides comply with the American Society Standards for Athletic Equipment insufficient protection. Those for for Testing and Materials (ASTM), (NOCSAE — www. which there are standard or the National Operating nocsae.org/), or the Canadian specifications include: skiing Committee on Standards for Standards Association (CSA — (ASTM 659), and ice hockey Athletic Equipment (NOCSAE) www.csa-international.org/). The (ASTM F513). Other protectors standards for specific sports. cited websites will have more with NOCSAE standards are specific information on these available for football and men’s Approximately one-third of all standards. Certification ensures that lacrosse. persons participating in sports the protective device has been require corrective lenses to achieve 2. Not appropriate for eye properly tested to current standards. the visual acuity necessary for protection in sports: proper and safe execution of their a. Streetwear (fashion) spectacles particular sports activity. Athletes Protective eyewear should be that conform to the requirements who need corrective eyewear for considered for all sports that have a of American National Standards participation should use lenses and projectile object (ball/stick) whose Institute (ANSI) Standard Z80.3. size and/or speed could potentially frames that meet the appropriate b. Safety eyewear that conforms to cause ocular damage. Eye safety standards. At this time, the requirements of ANSI Z87.1, protection is especially important polycarbonate plastic is the only mandated by OSHA for industrial for functionally one-eyed sports clear lens material that has been and educational safety eyewear. tested for sports and is participants (whose best corrected recommended for all sports with the vision in their weaker eye is 20/40 potential for impact. Other impact- or worse). Eye protection devices resistant lens materials may be are designed to significantly reduce available in the near future. Contact the risk of injury, but can never lenses are not capable of protecting provide a guarantee against such the eye from direct blows. Student- injuries. 96 Eye Safety in Sports

References

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

97 GUIDELINE 3c Mouthguards January 1986 • Revised August 2007

The NCAA Committee on 2. “Properly fitted mouthguards” Competitive Safeguards and could protect the lip and cheek Medical Aspects of Sports tissues from being impacted and acknowledges the significant input lacerated against tooth edges. of Dr. Jack Winters, past president of the Academy of Sports , 3. “Properly fitted mouthguards” in the revision of this guideline. could reduce the incidence of a fractured jaw caused by a blow The NCAA has mandatory delivered to the chin or head. equipment rules, including the use of mouthguards for selective 4. “Properly fitted mouthguards” sports. Various studies of could provide protection to “properly fitted mouthguards” toothless spaces, so support is indicate that they may reduce given to the missing dentition of dental injuries when blows to the the student-athlete. jaws or head are received. Stock, mouth-formed and custom- The American Dental Association fitted are three types of has urged the mandatory use of mouthguards recognized by the mouthguards for those engaged in American Dental Association. All athletics activities that involve need to be properly fitted for body contact and endorsed their maximum protection. Student- use “in sporting activities in which athletes should be advised as to a significant risk of oral injury may which “properly fitted occur.” It is important when mouthguard” is best for them and considering the optimum protection how it is best maintained to ensure for an athlete that a thorough the maximum fit and protection for medical history be taken and the daily practices and game-day wear. demands of his or her position and Medical staff personnel should sporting activity be considered. regularly oversee and observe the student-athletes and the “properly Specific objectives for the use of fitted mouthguards.” “properly fitted mouthguards” as protective devices in sports are In order to realize fully the benefits as follows: of wearing a mouthguard, the coach, student-athlete and medical 1. “Properly fitted mouthguards” staff need to be educated about the could reduce the potential chipping protective functions of a of tooth enamel surfaces and mouthguard and the game rules reduce fractures of teeth, roots regarding mouthguard use must or bones. be enforced. 98 Mouthguards

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

99 GUIDELINE 3d Use of the Head as a Weapon in Football and Other Contact Sports

January 1976 • Revised June 2002

Head and neck injuries causing brunt of contact in the teaching of inflicting instrument is illegal, and death, brain damage or paralysis blocking or tackling; should be strongly discouraged by occur each year in football and coaches and game officials. This other sports. While the number of 2. Self-propelled mechanical ap- concern is not only in football, but these injuries each year is relatively paratuses shall not be used in the also in other contact sports in which small, they are devastating occur- teaching of blocking and tackling; and helmets are used (e.g., ice hockey rences that have a great impact. and men’s lacrosse). Most of these catastrophic injuries 3. Greater emphasis by players, result from initiating contact with coaches and officials should be placed Football and all contact sports should the head. The injuries may not be on eliminating spearing. be concerned with the prevention of prevented due to the forces encoun- catastrophic head injuries. The rules Proper training in tackling and tered during collisions, but they can against butting, ramming and spearing be minimized by helmet manufac- blocking techniques, including a “see with the helmet are for the protection turers, coaches, players and officials what you hit approach,” constitutes of the helmeted player and the complying with accepted safety an important means of minimizing opponent. A player who does not standards and playing rules. the possibility of catastrophic injury. comply with these rules in any sport Using the helmet as an injury- is a candidate for a catastrophic injury. The American Football Coaches Association, emphasizing that the 1. NCAA Concussion Fact Sheets and Video helmet is for the protection of the Available at www.NCAA.org/health-safety. wearer and should not be used as a 2. Heads Up: Concussion Tool Kit weapon, addresses this point CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm. as follows: 3. Heads Up Video NATA. Streaming online at www.nata.org/consumer/headsup.htm. 1. The helmet shall not be used as the

References

1. Kleiner, D.M., Almquist, J.L., Bailes, 2. LaParade RF, Schnetzler KA, 4. Thomas BE, McCullen GM, Yuan HA: J., Burruss, P., Feurer, H., Griffin, L.Y., Broxterman RJ, Wentorf F, Wendland E, Cervical Spine Injuries in Football Herring, S., McAdam, C., Miller, D., Gilbert TJ: Cervical Spine Alignment in Players: J Am Acad Orthop Surg Sept- Thorson, D., Watkins, R.G., Weinstein, S. the Immobilized Ice Hockey Player: A Oct; 7 (5), 338-47, 1999. Prehospital Care of the Spine-Injured Computer Tomographic Analysis of the 5. Wojtys EM, Hovda D, Landry G, Athlete: A Document from the Inter- Effects of Helmet Removal: Am J Sports Boland A, Lovell M, McCrea M, Minkoff Association Task Force for Appropriate Med 27: 177-180, 1999. Care of the Spine-Injured Athlete. Dallas, J: Concussion in Sports: Am J Sports 100 National Athletic Trainers’ Association, 3. The Spine Injury Management Video Med 27: 676-687, 1999. March, 2001. Human Kinetics, Champaign, Illinois. GUIDELINE 3e Guidelines for Helmet Fitting and Removal in Athletics

June 1990 • Revised June 2006

Several sports, including football, between the medical staff and or turn the helmet with the wearer men’s lacrosse and ice hockey, emergency-transportation personnel resisting the movement. require wearing tight-fitting, should be maintained. It is similarly constructed helmets. The important that those involved in the With a properly fitted helmet, the following guidelines, while focused medical management of teams top of the head is separated from on football, are applicable to engaged in collision and contact the helmet shell by a uniform, periodic evaluation, fitting and sports, and the student-athlete be functional, shock-absorbing removal of protective helmets worn knowledgeable about the helmet. support lining. Daily evaluation of in any sport. These guidelines The student-athlete should be this support mechanism, including represent minimal standards of care instructed in the fitting, care and cheek and brow pads, for that are designed to assist use of the helmet. Helmet placement and resiliency should be physicians, coaches, athletic manufacturer guidelines should be taught to the student-athlete. Hel­ trainers, paramedics, EMTs and reviewed and followed for proper mets that require air inflation hospital personnel who care for fitting and care techniques.­ should be inflated and inspected student-athletes. daily by the student-athlete. Helmet The resilient plastic shell is shaped shells should be examined weekly Medical coverage of interscholastic spherically to deflect impacts. for cracking and be inspected and intercollegiate teams entails In­terior suspension pads are closely again if the face mask has many routine preventive and acute designed to match the skull contour been bent out of shape. All helmets health-care duties for dedicated to ensure a snug crown fit. Various need to be reconditioned and the practicing professionals; how­ever, rigid and removable jaw and brow attachments of the mask replaced an occasional, serious, on-the-field, pads, along with the chin strap, on a yearly basis. life-threatening head and/or neck help to hold the sides of the helmet injury poses a difficult challenge. It firmly against the mandible and the Although the helmet is designed is incumbent upon those forehead. When in place, the front for a stable fit for protection during individuals assigned to provide edge of the helmet should be play, removal of the helmet by medical coverage to be prepared to positioned about a finger’s breadth others is relatively difficult. In the handle each situation efficiently above the eyebrows. Pressure on case of a head or neck injury, and expertly. the helmet crown should be jostling and pulling during removal dissipated through the interior presents high potential for further Proper on-the-field management of suspension padding over the top of trauma. head and neck injuries is essential the head. to minimize sequelae, expedite Unless there are special emergency measures and to prepare The helmet should fit snugly circumstances such as for transportation. The action of without dependence on the chin respiratory distress coupled with those in attendance must not strap. The helmet should not an inability to access the airway, compound the problem. For this or slide when an examiner grasps the helmet should never be reason, clear communication the face mask and attempts to rock removed during the pre-hospital 101 Guidelines for Helmet Fitting and Removal in Athletics

care of the student-athlete with necessitating the use of PVC pipe • By rotating the helmet slightly a potential head/neck cutters, garden shears or a forward, it should now slide off the injury unless: screwdriver. Those involved in the occiput. If the helmet does not pre-hospital care of the injured move with this action, slight 1. The helmet does not hold the student-athlete should have readily traction can be applied to the head securely, such that available proper tools for easy helmet as it is carefully rocked immobilization of the helmet does facemask removal and should anteriorly and posteriorly, with not immobilize the head; frequently practice removal great care being taken not to move techniques for facemasks and the head/neck unit. 2. The design of the sport helmet is helmets. It should be noted that • The helmet should not be spread such that even after removal of the cold weather and old loops may apart by the earholes, as this facemask, the airway cannot be make cutting difficult. The chin maneuver only serves to tighten the controlled or ventilation provided; strap can be left in place unless helmet on the forehead and on the resuscitative efforts are necessary. occipital regions. 3. After a reasonable period of For resuscitation, the mouthpiece • All individuals participating in time, the facemask cannot be needs to be manually removed. this important maneuver must removed; or proceed with caution and Once the ABCs are stabilized, coordinate every move. 4. The helmet prevents transportation to an emergency facility should be conducted with immobilization for transportation If the injured student-athlete, after the head secure in the helmet and in an appropriate position. being rehabilitated fully, is allowed the neck immobilized by strapping, to participate in the sport again, When such helmet removal is taping and/or using lightweight refitting his/her helmet is necessary in any setting, it should bolsters on a spine board. When mandatory. Re-education about be performed only by personnel moving an athlete to the spine helmet use as protection should be trained in this procedure. board, the head and trunk should be conducted. Using the helmet as an moved as a unit, using the lift/slide offensive, injury-inflicting Ordinarily, it is not necessary to maneuver or a log-roll technique. instrument should be remove the helmet on the field to discouraged. evaluate the scalp. Also, the helmet At the emergency facility, can be left in place when satisfactory initial skull and evaluating an unconscious student-­ cervical X-rays usually can be athlete, an individual who obtained with the helmet in place. demonstrates transient or persistent Should removal of the helmet be neurological findings in his/her needed to initiate treatment or to extremities, or the student-athlete obtain special X-rays, the following who complains­ of continuous or protocol should be considered: transient neck pain. • With the head, neck and helmet manually stabilized, the chin strap Before the injured student-athlete can be cut. is moved, airway, breathing and • While maintaining stability, the circulation (ABCs) should be cheek pads can be removed by evaluated by looking, listening and slipping the flat blade of a palpation. To monitor breathing, screwdriver or bandage scissor care for facial injury, or before under the pad snaps and above the transport regardless of current inner surface of the shell. respiratory status, the facemask • If an air cell-padding system is should be removed by cutting or present, it can be deflated by unscrewing the loops that attach releasing the air at the external port the mask to the helmet. These with an inflation needle or large- loops may be difficult to cut, gauge hypodermic needle. 102 Guidelines for Helmet Fitting and Removal in Athletics

References

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

103 GUIDELINE 3f Use of Trampoline and Minitramp June 1978 • Revised June 2002

The NCAA recognizes that the persons controlling the safety and name of inspector, should be coaches and student-athletes in harness should have the kept on file. selected sports use the trampoline necessary strength, weight and and minitramp for developing training for that responsibility; Minitramp skills. The apparent safety record accompanying such use has been c. Skills being encouraged The minitramp, while different in good, but the use of the trampoline should be commensurate with nature and purpose from the can be dangerous. Therefore, these the readiness of the student- trampoline, shares its association guidelines should be followed in athlete, and direct observation with risk of spinal cord injury from those training activities in which should confirm that the student- poorly executed and/or spotted student-athletes use the trampoline: athlete is not exceeding his or tricks. Like the trampoline, the her readiness; and minitramp requires competent 1. Trampolines should be instruction and supervision, supervised by persons with d. Spotters are aware of the spotters trained for that purpose competence in the use of the particular skill or routine being (spotting somersaults on the practiced and are in an trampoline for developing athletics minitramp differs from the appropriate position to spot skills. This implies that: trampoline because of the running potential errors. Accurate action preceding the somersault), communication is important to a. Fellow coaches, student- emphasis on the danger of the successful use of these athletes, managers, etc., are somersaults and dive rolls, security techniques. trained in the principles and against unsupervised use, proper techniques of spotting with the erection and maintenance of the overhead harness, “bungee 2. Potential users of the trampoline should be taught proper procedures apparatus, a planned procedure for system” and/or hand spotting on emergency care should an accident the trampoline; for folding, unfolding, transporting, storing and locking the trampoline. occur, and documentation of participation and any accidents that b. New skills involving occur. In addition, no single or somersaults should be learned 3. The trampoline should be multiple somersault should be while wearing an overhead erected in accordance with attempted unless: safety harness. (Exception: Use manufacturer’s instructions. It of the overhead system is not should be inspected regularly and 1. The student-athlete has recommended for low-level maintained according to established demonstrated adequate progression salto activities such as saltos standards. All inspection reports, of skill before attempting any from the knees or back.) Those including the date of inspection

104 Use of Trampoline and Minitramp somersault (i.e., on the trampoline with a safety harness, off a diving board into a swimming pool or tumbling with appropriate spotting);

2. One or more competent spotters who know the skill being attempted are in position and are physically capable of spotting an improper execution;

3. The minitramp is secured reasonably or braced to prevent slipping at the time of execution in accordance with recommendations in the USA Gymnastics Safety Handbook; and

4. A mat is used that is sufficiently 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, related injuries. J Bone Joint Surg Am. Physical Education, Recreation and 1995; 77:1174-1178. Dance: The use of the trampoline for the 4. Trampolines at Home, School and development of competitive skills in Recreational Centers Policy Statement of sports. Journal of Physical Education, the American Academy of Pediatrics. Recreation and Dance 49(8):14, 1978. Pediatrics Vol. 103 (5) 1999 pp. 1053- 2. Hennessy JT: Trampoline safety and 1056. (www.aop.org/policy/re9844.html). diving programs. U.S. Diving Safety 5. USA Gymnastics: USA Gymnastics Manual. Indianapolis, IN: U.S. Diving Safety Handbook, 1994. (201 S. Capitol Publications, 1990. St., Ste. 300, Indianapolis, IN 46225) 3. Larson BJ, Davis JW. Trampoline- 105

Appendixes Also found on the NCAA website at: NCAA.org/health-safety Appendix A 2011-12 NCAA Banned Drugs

The NCAA bans the following classes of drugs: a. Stimulants; b. Anabolic Agents; c. Alcohol and Beta Blockers (banned for rifle only); d. Diuretics and Other Masking Agents; e. Street Drugs; f. Peptide Hormones and Analogues; g. Anti-Estrogens; and h. Beta-2 Agonists. Note: Any substance chemically related to these classes is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned-drug class regardless of whether they have been specifically identified.

Drugs and Procedures Subject to Restrictions: • Blood Doping. • Local Anesthetics (under some conditions). • Manipulation of Urine Samples. • Beta-2 Agonists permitted only by prescription and inhalation. • Caffeine – if concentrations in urine exceed 15 micrograms/ml.

NCAA Nutritional/Dietary Supplements Warning: • Before consuming any nutritional/dietary supplement product, review the product and its label with your athletics department staff! • Dietary supplements are not well regulated and may cause a positive drug test result. • Student-athletes have tested positive and lost their eligibility using dietary supplements. • Many dietary supplements are contaminated with banned drugs not listed on the label. • Any product containing a dietary supplement ingredient is taken at your own risk. Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting the Resource Exchange Center (REC) at 877/202-0769 or www. drugfreesport.com/rec (password ncaa1, ncaa2 or ncaa3).

108 Appendix B 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 2011-12 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 banned by the NCAA.

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

Effect on Eligibility 18.4.1.5 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 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 which (Div. II), the student-athlete is transferring. 13.1.1.2.6 (Div. III)

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

Athletics Department Resource 3.2.4.7 Institutions must designate an individual (or for Banned Drugs and Nutritional (Div. I) individuals) as an athletics department Supplements resource for questions related to NCAA banned drugs and nutitional supplements. 109 NCAA Legislation Involving Health and Safety Issues

Banned Drugs and Drug-Testing 18.4.1.5.2 NCAA Executive Committee is charged with Methods developing a list of banned substances and Drug approving all drug-testing procedures. Testing Consent Form: Content and Purpose 14.1.4.1 Consent must be signed before competition or practice or before the Monday of fourth week of classes. Failure to sign consent results in loss of eligibility.

Consent Form: Administration 14.1.4.2, Institution must administer consent form to 3.2.4.7 all student-athletes each academic year at the (Div. I); time the intercollegiate squads report for 14.1.4.2, practice. At this time, institutions must also 3.2.4.6 distribute to student-athletes the list of banned (Div. II); drug classes. 14.1.4.3, 3.2.4.6 (Div. III)

Consent Form: Exception, 14.1.4.3 Student-athletes who are trying out must sign 14-Day Grace Period (Div. I) the form within 14 days of the first athletics-­ 14.1.4.2 related activity or before they compete,­ (Div. II) whichever occurs first.

Effect of Non-NCAA Athletics 18.4.1.5.3 A student-athlete under a drug-test suspension Organization's Positive Drug Test from a national or international shall not compete in NCAA intercollegiate competition.

Failure To Properly Administer 14.1.4.4 Failure to properly administer drug-testing Drug-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 Drug Div. II), program. Rehabilitation 16.4 (Div. III)

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(g) Institution may provide only permissible Nutritional (Div. I), nutritional supplements that do not contain Supplements 16.5.1(h) any NCAA banned substances. See Bylaw (Div. II) for details.

110 NCAA Legislation Involving Health and Safety Issues

Restricted Advertising and Sponsorship 31.1.14.1 No tobacco advertisements in, or sponsorship Activities (Div. I), of, NCAA championships or regular-season Tobacco 31.1.12.1 events. Use (Div. II) 31.1.11.1 (Div. III)

Tobacco Use at Member Institution 11.1.5 (Div. I Use of tobacco products is prohibited by all and Div. II), game personnel and all student-athletes in all 17.1.8 (Div. I), sports during practice and competition. 17.1.9 (Div. II), 17.1.11 (Div. III)

Permissible Medical Expenses 16.4.1(Div. I Permissible medical expenses are outlined. If and Div. II), expense is not on the list, refer to Bylaw Medical 16.4 (Div. III) 16.12.1 for waiver procedure. Expenses Eating Disorders 16.4.1 Institution may cover expenses of counseling (Div. I and Div. II only) related to the treatment of eating disorders.

Transportation for Medical Treatment 16.4.1 Institution may cover or provide transportation (Div. I and Div. II only) to and from medical appointments.

Summer Conditioning - Football 13.2.7 Institution may finance medical expenses for a prospect who sustains an injury while Summer Conditioning - Sports other 13.2.8 participating in nonmandatory summer than Football (Div. I only) conditioning activities that are conducted by an institution's strength and conditioning coach.

Hardship Waiver 14.2.4 Under certain circumstances, a student-athlete (Div. I), may be awarded an additional season of Medical 14.2.5 competition to compensate for a season that Waivers (Div. II and was not completed due to incapacitating Div. III) injury or illness.

Five-Year/10-Semester Rule Waiver 14.2.1.5.1 Under certain circumstances, a student-athlete (Div. I), may be awarded an additional year of 14.2.2.3 eligibility if he or she was unable to participate (Div. II) in intercollegiate athletics due to incapacitating 14.2.2.4 physical or mental circumstances. (Div. III)

HIPAA/Buckley Amendment Consent 3.2.4.9, The authorization/consent form shall be Medical Forms 14.1.6 administered individually to each student- Records and (Div. I); athlete by the athletics director or the athletics Consent 3.2.4.7, director's designee before the student-athlete's Forms 14.1.5 participation in intercollegiate athletics each (Div. II); academic year. Signing the authorization/ 3.2.4.7, consent shall be voluntary and is not required 14.1.6 by the student-athlete's institution for medical (Div. III) treatment, payment for treatment, enrollment in a health plan or for any benefits (if applicable) and is not required for the student- athlete to be eligible to participate. Any signed authorization/consent forms shall be 111 kept on file by the director of athletics. NCAA Legislation Involving Health and Safety Issues

Time Restrictions on Athletics- 17.1.6 All NCAA sports are subject to the time Student-Athlete Related Activities limitations in Bylaw 17. Welfare and (Div. I and Div. II only) Safety 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 (Div. I and Div. II only) athletics-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-athletes Playing Season cannot engage in more than eight hours of (Div. I and Div. II only) 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) 17.1.6.2.3 student-athlete's eight hours of conditioning See Bylaws 17.1.6.2.2 and 17.1.6.2.3 (Div. I), activity may be skill-related instruction with (Div. I) for additional exceptions. 17.1.6.2, coaching staff. 17.1.6.2.1 (Div. II)

Required Day Off – Playing Season 17.1.6.4 During the playing season, each student- (Div. I and athlete must be provided with one day per Div. II), week on which no athletics-related activities 17.1.6 are scheduled. (Div. III)

Required Days Off – Outside Playing 17.1.6.5 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 13.11.3.8 Prospective student-athletes, who signed an NLI (Div. I only) (basketball) or enrolled in the institution's summer term prior to initial, full-time enrollment, may engage in voluntary summer workouts conducted by an institution's strength and conditioning coach with department-wide duties.

Voluntary Summer Conditioning 13.11.3.7 Prospective student-athletes, who signed an (Div. I only) (football) NLI or enrolled in the institution's summer term prior to initial, full-time enrollment, may engage in voluntary summer workouts conducted by an institution's strength and conditioning coach with department-wide duties (FBS) or a countable coach who is a certified strength and conditioning coach (FCS).

112 NCAA Legislation Involving Health and Safety Issues

Voluntary Summer 13.11.3.9 In sports other than football and basketball, a prospective student-athlete may engage in Student-Athlete Conditioning (Sports Other voluntary summer workouts conducted by Welfare and (Div. I only) Than Football an institution's strength and conditioning Safety and Basketball) coach with department-wide duties and may receive workout apparel (on an issuance and retrieval basis), provided he or she is enrolled in the institution's summer term prior to the student's initial full-time enrollment at the certifying institution. Such a prospective student-athlete may engage in such workouts only during the period of the institution's summer term or terms (opening day of classes through last day of final exams) in which he or she is enrolled.

Voluntary Weight-Training 13.11.3.9.4 A strength and conditioning coach who conducts or Conditioning Activities voluntary weight-training or conditioning (Div. I only) activities is required to maintain certification in first aid and cardiopulmonary resuscitation.

If a member of the institution's sports medicine staff (e.g., athletic trainer, physician) is present during voluntary conditioning activities conducted by a strength and conditioning coach, the sports medicine staff member must be empowered with the unchallengeable authority to cancel or modify the workout for health and safety reasons, as he or she deems appropriate.

Sports-Safety Training 11.1.6 Each head coach and all other coaches who (Div. II) are employed full time at an institution shall maintain current certification in first aid, cardiopulmonary resuscitation (CPR) and automatic external defibrillator (AED) use.

11.1.6 Each head coach shall maintain current (Div. III) certification in first aid, cardiopulmonary resuscitation (CPR) and automatic external defibrillator (AED) use.

Discretionary Time 17.02.14 Student-athletes may only participate in (Div. I only) athletics activities at their initiative during discretionary time.

Mandatory Medical 17.1.5 All student-athletes beginning their initial Examinations season of eligibility and students who are trying out for a team 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.

113 NCAA Legislation Involving Health and Safety Issues

Mandatory Medical 17.1.5.1 The examination or evaluation of student- Student-Athlete Examinations (Div. I) athletes who are beginning their initial season Welfare and of eligibility and students who are trying out Safety for a team shall include a sickle cell solubility test, unless documented results of a prior test are provided to the institution or the prospective student-athlete or student-athlete declines the test and signs a written release.

Five-Day Acclimatization Period – 17.9.2.3 Five-day acclimatization for conducting Football (Div. I), administrative and initial practices is required 17.9.2.2 for first-time participants (freshmen and (Div. II and transfers) and continuing student-athletes. Div. III)

Preseason Practice Activities – 17.9.2.4 Preseason practice time limitations and Football (Div. I), general­ regulations. 17.9.2.3 (Div. II and Div. III)

Out-of-Season Athletics-Related 17.9.6 Permissible summer conditioning activities. Football Activities (Div. I and Div. III), 17.9.8 (Div. II)

Sports-Specific Safety Exceptions 13.11.3.10 A coach may be present during voluntary (Equestrian; Fencing; Gymnastics; (Div. I); individual workouts in the institution’s regular Rifle; Women’s Rowing; Skiing; 17.6.7;17.7.7; practice facility (without the workouts being Swimming; Track and Field; 17.11.7; 17.14.7; considered as countable athletics-related Water Polo; and Wrestling.) 17.15.7 (Div. activities) when the student-athlete uses sport- (Div. I and Div. II only) I);17.15.9 (Div. specific equipment. The coach may provide II); 17.18.7; safety or skill instruction but cannot conduct 17.24.7 (Div. I); the individual’s workouts. 17.24.8 (Div. II); 17.26.8; 17.27.7 (Div. I and Div. II)

Playing Rules Oversight Panel 21.1.4 The panel shall be responsible for resolving issues involving player safety, financial impact or image of the game.

Concussion Management Plan 3.2.4.17 (Div. I Institutions must have a concussion and Div. II); management plan for student-athletes. See 3.2.4.16 (Div. III) Guideline 2i.

114 Appendix C NCAA Injury Surveillance Program Summary

The NCAA Injury Surveillance Surveillance Program supports rule Two easy ways Program was developed in 1982 to and policy changes that improve stu- to participate: provide current and reliable data on dent-athlete health and safety. In The Injury Surveillance Tool (IST) injury trends in intercollegiate athlet- addition, program participation pro- facilitates the workflow in the ath- ics. It collects injury and activity vides a number of benefits to athletic letic training room and supports an information in order to identify and trainers and their institutions: enhanced level of documentation highlight potential areas of concern Safer participation in collegiate and record keeping. The IST is and interest related to student- sports. In some cases, surveillance designed as a free injury incident athlete health and safety. information has led to a mitigation report, and allows documentation of of injuries and treatments (e.g., injuries. In doing so, the IST pro- Injury data are collected yearly by heat illness episodes). vides important injury information the Datalys Center from a sample of to the Datalys Center and helps to Resource Justification and NCAA member institutions, and the initiate a paper record keeping pro- resulting data summaries are Allocation. Surveillance informa- cess for the athletic trainer. reviewed by the NCAA Committee tion has been used in the NATA’s The Export Engine Program on Competitive Safeguards and Recommendations and Guidelines (EE) is a public data transmission Medical Aspects of Sports. The com- for Appropriate Medical Coverage standard that commercial vendors mittee’s goal continues to be to of Intercollegiate Athletics can voluntarily adopt. Through the reduce injury rates through suggested (AMCIA) document. Export Engine Program, athletic changes in rules, protective equip- Supports Clinical Best Practices. trainers can directly and easily sub- ment or coaching techniques, based Regional and national injury rate mit data from their vendor systems on the data. comparisons allow a university to to the Injury Surveillance Program. explore relevant clinical best prac- If you are considering a new sys- In some instances, the evaluation of tices with appropriate peer groups. tem, be sure to look for the Datalys the injury surveillance information Certified logo. Its certified vendors has led the NCAA to commission Supports Risk Management Best currently include ATS, Nextt research studies to better understand Practice. The electronic documen- Solutions and SIMS. the underlying factors that have con- tation of injuries (e.g., through an tributed to the observed surveillance Export Engine Certified vendor or Data Availability and Access. findings. To support the objective and the Injury Surveillance Tool) is a Injury surveillance data collected nature of the NCAA’s Injury recognized risk management best through the NCAA’s Injury Surveillance Program is available Surveillance Program – monitoring to practice. to the public through the Datalys identify areas of concern for potential Facilitates Paper Record Keeping further investigation – the Datalys Injury Statistics Clearinghouse Processes. For institutions manag- (DISC), a web-based research por- Center does not collect identifiable ing their health records via a paper tal. DISC provides a searchable information or treatment information. process, the Injury Surveillance Document Library for published Tool facilitates the workflow and reports and data on sports injuries. Program Benefits supports an enhanced level of doc- DISC also provides an interactive Participation in the NCAA’s Injury umentation and record keeping. Query Tool for public use that 115 NCAA Injury Surveillance System Summary

allows registered users to interac- tively query available datasets for summary information, such as national injury rates, injury rates by sports, and injury rates by type of injury. DISC will be launched in the fall of 2010 and can be found at www.disc. datalyscenter.org. Sampling Since its inception, the surveillance program has depended on a volun- teer “convenience sample” of reporting schools. Participation is available to the population of insti- tutions sponsoring a given sport. Schools qualifying for inclusion in the final sample are selected from the total participating schools for each NCAA sport, with the goal of representation of all three NCAA divisions. A school is selected as qualifying for the sample if they meet the minimum standards for data collection. It is important to recognize that this system does not identify every inju- ry that occurs at NCAA institutions in a particular sport. Rather, the Exposures (Activity) All Sports Figures emphasis is collecting all injuries An athlete exposure is defined as The following figures outline and exposures from schools that one athlete participating in one selected information from the voluntarily participate in the Injury practice or competition in which he sports currently reported by the Surveillance Program. The Injury or she is exposed to the possibility NCAA Injury Surveillance Program Surveillance Program attempts to of athletics injury. from 2004 to 2009. Complete sum- balance the dual needs of maintain- Injury Rate mary reports for each sport are ing a reasonably representative available online at www.disc. An injury rate is simply a ratio of cross-section of NCAA institutions datalyscenter.org. the number of injuries in a particu- while accommodating the needs of lar category to the number of ath- Any questions regarding the NCAA the voluntary participants. lete exposures in that category. Injury Surveillance Program or its Injuries This value is expressed as injuries data reports should be directed to: A reportable injury in the Injury per 1,000 athlete exposures. Megan McGrath, Manager of Surveillance Program is defined as Historical Data Collegiate Engagement, Datalys one that: The NCAA published 16 years of Center for Sports Injury Research 1. Occurs as a result of participa- injury data in 15 sports in the and Prevention, Indianapolis, tion in an organized intercollegiate Journal of Athletic Training Indiana (317/275-3665). practice or competition; and National Collegiate Athletic David Klossner, Director of Student- 2. Requires medical attention by a Association Injury Surveillance, Athlete Affairs, NCAA, P.O. Box team athletic trainer or physician 1988-1989 Through 2003-2004. J 6222, Indianapolis, Indiana 46206- 116 regardless of time loss. Athl Train. 2007;42(2). 6222 (317/917-6222). Figure 1 Competition and Practice Injury Rates Summary (25 Sports)

Competition Injury Rate Practice Injury Rate

Men’s Football 36.5 5.4

Men’s Wrestling 26.6 7.8

Men’s Soccer 16.9 5.1

Men’s Lacrosse 16.4 4.7 Figure illustrates the Men’s Ice Hockey 15.5 average injury rates 2.3 for 25 sports from Women’s Gymnastics 15.5 2004-05 to 2008-09 7.8 unless otherwise 14.4 Women’s Soccer noted below. 5.0 * Available data from Men’s Basketball 9.9 4.7 2005-06 to 2008-09 **Available data from Women’s Field Hockey 9.8 5.1 2006-07 to 2008-09

Men’s Indoor Track* 9.1 3.3 If a sport is not 9.0 included, it is Women’s Basketball 4.5 because there was not enough data Women’s Ice Hockey 7.5 2.1 collected to report 7.4 that sport. Women’s Cross Country* 3.3

Men’s Outdoor Track* 6.9 4.1 6.8 Women’s Lacrosse 2.8 5.9 Men’s Baseball 2.4 5.8 Women’s Outdoor Track* 3.2 5.7 Men’s Cross Country* 2.7 5.1 Women’s Tennis* 2.4 4.3 Women’s Softball 3.2 4.2 Women’s Volleyball 4.4 3.5 Women’s Indoor Track* 2.8 2.4 Men’s Tennis* 2.5 1.4 Women’s Swimming & Diving** 1.1 1.3 Men’s Swimming& Diving** .8 0 5 10 15 20 25 30 35 40 Injury Rate (per 1,000 athlete-exposures) 117 Figure 2 Percentage of All Injuries Occurring in Practices and Competition

Competition Injuries Practice Injuries

Men’s Ice Hockey 66.8 33.2

Men’s Baseball 55.1 44.9

Women’s Ice Hockey 53.2 46.8

Women’s Soccer 48.6 51.5

Women’s Softball 48.5 51.5 Figure represents the national estimates of Men’s Soccer 48.3 51.7 injury percentages for 25 sports from 2004 Women’s Tennis* 42.5 57.4 to 2009 unless otherwise noted Men’s Lacrosse 39.9 60.1 below.

Women’s Field Hockey 39.2 60.8 * Sports with data from 2005-06 to Men’s Football 38.6 61.4 2008-09 (4 years only). Women’s Lacrosse 37.6 62.4 **Sports with data Women’s Basketball 36.5 63.5 from 2006-07 to 2008-09 (3 years Men’s Basketball 34.7 65.3 only).

Men’s Wrestling 31.6 68.4 If a sport is not included in the gure, it is because there Women’s Volleyball 29.1 70.9 was not enough data collected to report on Women’s Outdoor Track* 24.3 75.7 that sport.

Men’s Tennis* 23.6 76.4

Men’s Indoor Track* 23.1 76.9

Men’s Outdoor Track* 21.9 78.1

Women’s Gymnastics 19.5 80.6

Women’s Cross Country* 16.7 83.3

Men’s Swimming & Diving** 15.7 84.3

Men’s Cross Country* 14.9 85.1

Women’s Swimming & Diving** 13.5 86.5

Women’s Indoor Track* 13.4 86.6

0 20 40 60 80 100 Percentage of All Injuries 118 Appendix D Acknowledgements

From 1974 to 2011, 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 Marino H. Casem Paul W. Gikas, M.D. Western Athletic Conference Southern University, Baton Rouge University of Michigan Ken Akizuki Nicholas J. Cassissi, M.D. Pamela Gill-Fisher University of San Francisco University of Florida University of California, Davis Jeffrey Anderson Rita Castagna Gordon L. Graham University of Connecticut Assumption College Minnesota State University Mankato James R. Andrews, M.D. Charles Cavagnaro Gary A. Green, M.D. Troy University University of Memphis University of California, Elizabeth Arendt, M.D. Kathy D. Clark Los Angeles University of Minnesota, University of Idaho Letha Griffin, M.D. Twin Cities Kenneth S. Clarke Georgia State University William F. Arnet Pennsylvania State University Eric Hall University of Missouri, Columbia Priscilla M. Clarkson Elon University James A. Arnold University of Massachusetts, Eric Hamilton University of Arkansas, Amherst The College of New Jersey Fayetteville Bob Colgate Kim Harmon Janet Kay Bailey National Federation of State High University of Washington Glenville State College School Associations Richard J. Hazelton Dewayne Barnes Donald Cooper, M.D. Trinity College (Connecticut) Whittier College Oklahoma State University Larry Holstad Amy Barr Kip Corrington Winona State University Eastern Illinois University Texas A&M University, College Maria J. Hutsick Fred L. Behling Station Boston University Stanford University Lauren Costello, M.D. Nell C. Jackson Daphne Benas Princeton University Binghamton University Yale University Ron Courson John K. Johnston John S. Biddiscombe University of Georgia Princeton University Wesleyan University (Connecticut) Carmen Cozza Don Kaverman Carl S. Blyth Yale University Southeast Missouri State University University of North Carolina, Scot Dapp Janet R. Kittell Chapel Hill Moravian College California State University, Chico Cindy D. Brauck Bernie DePalma Fran Koenig Missouri Western State University Cornell University Central Michigan University Donald Bunce, M.D. Jerry L. Diehl Olav B. Kollevoll Stanford University National Federation of State High Lafayette College Elsworth R. Buskirk School Associations Jerry Koloskie Pennsylvania State University Randy Eichner University of Nevada, Las Vegas Peter D. Carlon University of Oklahoma Roy F. Kramer University of Texas, Arlington Brenna Ellis Vanderbilt University Gene A. Carpenter University of Texas Michael Krauss, M.D. Millersville University of at San Antonio Purdue University Pennsylvania Larry Fitzgerald Carl F. Krein Frank Carr Southern Connecticut State Central Connecticut State Earlham College University University 119 Acknowledgements

Russell M. Lane, M.D. Joseph V. Paterno Willie G. Shaw Amherst College Pennsylvania State University North Carolina Central University Kelsey Logan Marc Paul Jen Palancia Shipp The Ohio State University University of Nevada, Reno University of North Carolina, John Lombardo, M.D. Daniel Pepicelli Greensboro The Ohio State University St. John Fisher College Gary Skrinar Scott Lynch Frank Pettrone, M.D. Boston University Pennsylvania State University George Mason University Andrew Smith William B. Manlove Jr. Marcus L. Plant Canisius College Delaware Valley College University of Michigan Bryan W. Smith, M.D. Jeff Martinez Sourav Poddar University of North Carolina, University of Redlands University of Colorado, Boulder Chapel Hill Lois Mattice Nicole Porter Michael Storey California State University, Shippensburg University Bridgewater State University Sacramento of Pennsylvania Grant Teaff Arnold Mazur, M.D. James C. Puffer, M.D. Baylor University Boston College University of California, Carol C. Teitz, M.D. Chris McGrew, M.D. Los Angeles University of Washington University of New Margot Putukian Patricia Thomas William D. McHenry Princeton University Georgetown University Washington and Lee University Ann Quinn-Zobeck Susan S. True Malcolm C. McInnis Jr. University of Northern Colorado National Federation of State High University of Tennessee, Knoxville Tracy Ray School Associations Laurie Turner Douglas B. McKeag, M.D. Samford University University of California, San Diego Michigan State University Butch Raymond Christopher Ummer Kathleen M. McNally Northern Sun Intercollegiate Lyndon State College La Salle University Conference Jerry Weber Robin Meiggs Joy L. Reighn University of Nebraska, Lincoln Humboldt State University Rowan University Christine Wells Dale P. Mildenberger Frank J. Remington Arizona State University Utah State University University of Wisconsin, Madison Kevin M. White Melinda L. Millard-Stafford Rochel Rittgers Tulane University Georgia Institute of Technology Augustana College (Illinois) Robert C. White Fred L. Miller Darryl D. Rogers Wayne State University Arizona State University Southern Connecticut State (Michigan) Matthew Mitten University Sue Williams Marquette University Yvette Rooks University of California, Davis James Morgan University of Maryland, Charlie Wilson California State University, Chico College Park Olivet College Frederick O. Mueller Debra Runkle G. Dennis Wilson University of North Carolina, University of Dubuque Auburn University Chapel Hill Felix Savoie Mary Wisniewski David M. Nelson Tulane University University of Chicago University of Delaware Richard D. Schindler Glenn Wong William E. Newell National Federation of State High University of Massachusetts, Purdue University School Associations Amherst Jeffrey O’Connell Kathy Schniedwind Joseph P. Zabilski University of Virginia Illinois State University Northeastern University Roderick Paige Brian J. Sharkey Connee Zotos Texas Southern University University of Montana Drew University

120 The NCAA salutes the more than 400,000 student-athletes participating in 23 sports at more than 1,000 member institutions

NCAA 81688-7/11 MD 11