Selected Issues in Injury and Illness Prevention and the Team Physician: a Consensus Statement

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SPECIAL COMMUNICATIONS Team Physician Consensus Statement Selected Issues in Injury and Illness Prevention and the Team Physician: A Consensus Statement

DEFINITION developed by a collaboration of six major professional asso- ciations concerned about clinical sports medicine issues. Prevention of injury and illness associated with athletic They have committed to forming an ongoing project-based activity is one of the roles of the team physician (10,15). alliance to bring together sports medicine organizations to This process involves understanding the pathophysiology of best serve active people and athletes. The organizations are the the injury or illness, evaluating the known risk factors that American Academy of Family Physicians, American Acad- influence the incidence of injury or illness, implementing emy of Orthopaedic Surgeons, American College of Sports interventions to minimize the influence of the risk factors, Medicine, American Medical Society for Sports Medicine, and recording the outcomes of the interventions. American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. GOAL The goal of this document is to help the team physician EXPERT PANEL improve the care of the athlete by understanding and prac- ticing methods of injury and illness prevention in specific Executive Committee sports medicine problems. To accomplish this goal, the team Stanley A. Herring, M.D., Chair, Seattle, WA physician should have knowledge of general strategies of W. Ben Kibler, M.D., Lexington, KY injury and illness prevention and implement these strategies Margot Putukian, M.D., Princeton, NJ for the following: Committee: Joel Brenner, M.D., MPH, Norfolk, VA Musculoskeletal injuries to the ankle, knee, elbow, Katherine Dec, M.D., Richmond, VA and shoulder R. Robert Franks, D.O., Marlton, NJ Concussion and cervical spine injuries Timothy Hosea, M.D., Somerset, NJ Cardiovascular issues Peter Indelicato, M.D., Gainesville, FL Heat-related illness Anthony Johnson, M.D., San Antonio, TX Skin infection Patrick Leary, D.O., Erie, PA Equipment issues Jason Matuszak, M.D., Buffalo, NY Bradley Nelson, M.D., Minneapolis, MN SUMMARY This document provides an overview of selected medical CONSULTANTS issues that are important to team physicians who are re- Andrew Gregory, M.D., Nashville, TN sponsible for the care and treatment of athletes. It is not Zachary Kerr, Ph.D., MPH, Indianapolis, IN intended as a standard of care and should not be interpreted John Parsons, Ph.D., ATC, Indianapolis, IN as such. This document is only a guide and, as such, is of a general nature, consistent with the reasonable, objective practice of the health-care profession. Adequate insurance GENERAL CONCEPTS IN RISK FACTORS AND should be in place to help protect the physician, the athlete, PREVENTION STRATEGIES and the sponsoring organization. This statement was The incidence of injury in sports medicine may be influenced by the presence of risk factors. Intrinsic factors 0195-9131/16/4801-0159/0 may be physiological, biomechanical, anatomical, or genetic

MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ and may include previous injury, muscle weakness, inflexi- Copyright Ó 2015 by the American College of Sports Medicine bility, imbalance, or kinetic chain breakage (injuries or other DOI: 10.1249/MSS.0000000000000827 alterations in distant parts of the body, which affect function

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. in the local joint). They may also include psychological restriction of the athletes_ participation for one or more days factors, which have been addressed in the Team Physician (24) although concussions, dental injuries, fractures, and heat- Consensus Conference series (13). related events are included regardless of time loss. Extrinsic risk factors may be related to the inherent de- A source of consistent and systematic data of injuries mands of the sport, such as the intensity and duration of sustained in collegiate sports from September 2008 to 2013/ play, or factors, such as environmental, conditioning, or 2014 is from ISP (23). High school data are available from equipment issues. They may influence the process of June 2005 through 2013/2014 (24). chronic injury or illness development, or they may influence From these data, the following issues have been identified: the occurrence of an acute injury or illness. Specific programs that affect the intrinsic and extrinsic risk factors to Across most sports, reported injury rates continue to be alter or prevent illness and injury are limited. Of the pro- significantly higher in competition than in practice. grams that do exist, implementation is often a challenge. Non–time loss injuries account for more than half of However, current studies have shown that a strategy of risk all injuries. factor identification and process implementation to modify Lower-extremity injuries account for 49% and 46% of SPECIAL COMMUNICATIONS risk factors before athletic competition may reduce the in- all practice and game injuries at the collegiate level and cidence of some injuries or illnesses. These studies show 51% and 48% at the high school level (21) ) that the prevention strategies should be as specific as pos- Ankle sprains account for 21% of lower-extremity sible to the injury or illness, athletic activity, or sport and injuries at the collegiate level and 16% at the high need to be continued as long as the athlete is competing. A school level (21) ) general format of prevention and risk factor modification Anterior cruciate ligament (ACL) injuries are rela- strategies includes the following: tively infrequent (3% of all reported injuries) but are associated with significant loss of time from play. Understanding the pathophysiology of the injury or illness. h At both high school and collegiate level, women_s Understanding and implementing procedures for iden- soccer, women_sbasketball,andmen_s football had tifying risk factors. the highest rates of ACL injury, with football re- Implementing interventional processes to modify the porting the greatest absolute number (24). risk factors to improve outcome. h Patellofemoral pain and tendinopathy are frequent injuries, particularly in women. Assessing medical history, family history, and exertional symptoms is relevant in developing prevention strategies in medical conditions Upper-extremity injuries account for approximately It is essential the team physician 19% and 24% of all practice and game injuries at the Understand basic concepts of injury and illness prevention. collegiate level and 26% and 27% of all practice and game injuries at the high school level (21) It is desirable the team physician ) Shoulder injuries account for 27% of upper-extremity Set up policies and procedures to identify risk factors, injuries at the collegiate level and 24% at the high implement intervention strategies, and quantify outcomes. school level (21). Work with the athletic care network (see [15]) to educate athletes, parents, and coaches on the principles and Head and neck injuries account for approximately 8% practices of injury and illness prevention. and 12% of all practice and game injuries at the collegiate level and 8% and 14% of all practice and game EPIDEMIOLOGY injuries at the high school level (21) ) Concussions account for 6% of all injuries at the Injuries collegiate level and 4% of all injuries at the high The type of injury and its related risk factors present vari- school level (21). Overall, rates have increased dur- ous opportunities and methods of prevention. The National ing the sample period. Collegiate Athletic Association (NCAA) Injury Surveillance ) At the collegiate level, men_s wrestling, men_sice Program (ISP) defines a reportable injury as one that occurs as hockey, men_s football, women_s soccer, and women_s a result of participation in an organized intercollegiate prac- basketball had the highest rates of concussion. At the tice or competition and requires medical attention by a team high school level, boys_ football and ice hockey and athletic trainer or physician regardless of time loss (23). girls_ soccer and lacrosse had the highest rates of At the high school level, the National Athletic Trainer In- concussion (24). jury and Outcomes Network provides injury data that uses the ) Both the number and the rate of concussions have same definition of injury as the NCAA (21). Additional high increased over the last 3 years. This may be due to school data are available from High School Reporting Infor- improved diagnostic strategies and increased disclo- mation Online, which defines injury as that which results in sure by student athletes.

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. ) Caution must be taken when interpreting differences be- ) Ruptured aortic aneurysm (Marfan_s syndrome) (3% COMMUNICATIONS SPECIAL tween the collegiate and high school data as study periods of athletes) and distributions of reporting sports programs vary. ) Myocarditis ) Arrhythmias Most head, neck, and spine injuries do not have catastrophic consequences. Heat illness is sport- and environment-specific, most ) Reported concussion rates are increasing at all levels commonly occurring during preseason practices with the of participation. highest prevalence in football. ) Twelve thousand spinal cord injuries occur each Milder forms of heat illness are more common but may year in the United States; 10% are related to be underreported; more serious forms of heat-related athletic events. illness are less common. According to the National Center for Catastrophic One of the leading causes of death in the high school Sports Injury Research, football, gymnastics, ice and college athlete. hockey, wrestling, and cheerleading have the highest Race and ethnicity appear to be risk factors. risk of catastrophic injury. ) Forty-one total catastrophic injuries occurred in Skin Infections high school and collegiate sports in 2012/2013 (29 high school; 12 college) representing 0.53/100,000 Skin infections account for 21% of health conditions participants. and injuries in collegiate sports and 8.5% in high ) Over a period of 31 years (Fall 1982–Spring 2013), school sports. 2101 catastrophic sports-related injury and illnesses In collegiate athletics, skin infections account for 1% to were recorded; 80.8% occurred at the high school 2% of all time-loss injuries. ) level and were directly attributed to activities of the In college wrestling, the most common skin sport (22). infections are Herpes gladiatorum (41%), fungal (22%), impetigo (14%), and bacterial, including Medical Conditions methacillin-resistant Staphylococcus aureus (MRSA) (11%) (23). Sudden cardiac death (SCD) is a rare occurrence. Responsible for 16% of death among college athletes MUSCULOSKELETAL INJURY PREVENTION (8). Other causes of death included accidents (51%), suicide (9%), cancer (7%), homicide (6%), sickle cell Inversion Ankle Sprains (2%), and heat stroke (1%). Pathophysiology, including risk factors: Incidence of SCD in exercising high school and collegiate athletes is 2.3 to 4.4/100,000 per year in the United States. Traumatic inversion injury upon landing (variable amount ) The highest rate of SCD occurs in Division 1 men_s of injury to all structures) basketball (8,9). Although inversion ankle sprains are well recognized to ) Men and African American and Caribbean athletes cause injury to the anterior talofibular and calcaneofibular are most at risk. ligaments (ATFL and CFL), other injuries may occur and require particular attention, including the following: Causes in young athletes include the following: ) Lateral or medial malleolus fracture, especially at the ) Hypertrophic cardiomyopathy (HCM) is the most physis in the young athlete common cause of sudden death in high school and ) Peroneal tendons dislocation and/or retinaculum tear college athletes and occurs more frequently in men ) Talar dome osteochondral injury and all African American athletes. ) Anterior tibio-fibular ligament injury ) Commotio cordis is the second most common cause ) Fifth metatarsal avulsion injury of sudden death in the youth athlete. h Most commonly occurs in baseball, lacrosse, ice High rate of recurrent injury hockey, softball, and other sports, as well as rec- Risk factors include the following: reational activities involving projectile or direct ) Previous ankle injury blows to the chest. h Ligamentous instability h Most commonly reported in boys between ages 7 and h Incomplete rehabilitation, decreased ankle dorsifle- 16 years. xion, and/or poor proprioception h Fifty-three percent occur in competitive sports; 24% ) Peroneal muscle weakness in injured or noninjured occur in recreational sports/activities. ankles. Other causes of SCD include the following: ) Heel varus ) Coronary artery anomalies (12% to 33% of athletes) ) Increased body mass index (BMI)

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. Injury Risk Reduction and Modification Evaluation: In high school sports, football has the highest rate of ACL injury. In collegiate sports, women_s soccer has Athletes in running, landing, and cutting sports should the highest rate of ACL injury. have an evaluation, including the following: In sports with the same rules, female subjects have a higher ) History of previous ankle injury incidence of ACL injury than their male counterparts. ) Ankle ligament evaluation Causes of noncontact ACL injuries are multifactorial (11). ) Heel alignment Risk factors include the following: ) Ankle muscle strength and flexibility testing ) Neuromuscular variables (e.g., core and lower ex- ) Balance and core muscle control tremity strength, balance, flexibility, and muscle acti- ) Body mass index (BMI) vation patterns) Injury Risk Reduction and Modification Interventions: ) Biomechanics (landing position) ) Implement an education program and sport/activity Environment (e.g., playing surface, shoe interface) ) conditioning program with periodization (10,17), in- Female ) Anatomy SPECIAL COMMUNICATIONS cluding the following: ) ) Local muscle strengthening with eccentric emphasis Family history ) ) Improve dorsiflexion range of motion Increased BMI ) Motor control (including balance and core muscle Noncontact ACL injuries occur commonly during de- control) celeration, landing, or cutting. At-risk body positions Ankle bracing is effective for both primary and sec- during these maneuvers include the following: ondary prevention (19). ) Hip adduction and extension ) Ankle bracing is superior to and more cost effective ) Knee extension than neuromuscular training for secondary preven- ) Knee valgus position tion (18). ) Flat foot landing ) Ankle taping is effective for secondary prevention but ) Off-balance body position may be less effective for primary prevention. Injury Reduction and Modification Evaluation Proprioceptive training is effective for both primary Athletes in running, landing, and cutting sports should and secondary prevention of ankle sprain (27) and have an evaluation (10), including the following: recommended in combination with ankle bracing or taping. ) History of previous personal or family ACL injury It is essential the team physician understand the following: ) Lower extremity alignment (e.g., knee valgus) ) Motor control (including core and lower extremity Mechanism of inversion ankle sprains strength, balance, and flexibility) Structures other than ATFL and CFL may be injured. The usefulness of taping or bracing as well as propri- Other evaluation techniques may include the following: oceptive training in primary and secondary prevention. ) Review of training surface and shoe type The role of rehabilitation to decrease the risk of sub- ) Screening biomechanical analysis of jumping and sequent ankle sprains. landing It is desirable the team physician Injury Reduction and Modification Interventions Identify previous ankle injury and assess status of re- Implement a sport-specific conditioning program habilitation (10,17). with periodization (10), including these elements Coordinate the implementation of a preseason condi- that have been shown to have efficacy in specific tioning program including balance training for all ath- populations: letes in running, landing, and cutting sports (10,17). ) Motor control (including core and lower extremity ) Risk awareness education (e.g., increased BMI as a strength, balance, and flexibility) modifiable risk factor) ) Technique training to include landing and sport- Work with the athletic care network to educate players, specific athletic skills programs parents, and coaches on the principles and practices of ) Risk awareness education ankle injury prevention. Knee bracing is ineffective for primary and secondary Knee Injuries: ACL prevention of ACL injury. Proper care of playing surfaces Pathophysiology, including risk factors: Sport- and surface-specific selection of shoe type ACL injuries may occur in contact or noncontact inju- It is essential the team physician understand the following: ries. Risk reduction and intervention strategies are more effective for noncontact injuries. The multifactorial nature of ACL injury mechanisms.

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. Neuromuscular and educational interventions decrease ) Patellar hypermobility COMMUNICATIONS SPECIAL risk of ACL injury. ) Early sport-specific specialization Female subjects are more at risk than male subjects in ) Abnormal kinematics with jumping and landing soccer and basketball. ) Patellofemoral hypoplasia In high school sports, football has the highest risk of ) Increased femoral anteversion ACL injury. The contribution of static and/or dynamic malalignment It is desirable the team physician of the pelvis, hip, knee, ankle, and foot to anterior knee pain is less clear. Identify previous ACL injury and assess status of rehabilitation. Injury Reduction and Modification Evaluation: Evaluate for core stability, lower extremity strength, and motor control. Athletes should have an evaluation (10), including the Coordinate the implementation of a sport-specific following: ) conditioning program, including the following: History of previous lower extremity injury and ) Motor control (including core and lower extremity rehabilitation ) strength, balance, and flexibility) Present and anticipated volume of training and ) Technique training to include landing and sport- participation ) specific athletic skill programs Patellar and peri-patellar examination ) ) Risk awareness education (e.g., increased BMI as a Lower extremity alignment (e.g., femoral anteversion, modifiable risk factor) knee valgus, and foot pronation) ) Hip abduction, quadriceps, and hamstring strength Coordinate the evaluation of the playing surface ) Quadriceps, hamstring, and iliotibial band flexibility Advise on the selection of shoe type Work with the athletic care network to educate athletes, Other evaluation techniques may include the following: ) parents, and coaches on the principles and practices of Review of training surface and shoe type ) ACL injury prevention. Screening biomechanical analysis of jumping and landing

Other Knee Injuries Injury Reduction and Modifications Interventions: Patellofemoral Pain. Patellofemoral pain and dysfunc- Implement sport- and activity-specific conditioning tion are multifactorial including malalignment, articular car- program with periodization (10), emphasizing hip ab- tilage lesions, instability, soft tissue factors, and psychosocial duction; quadriceps and hamstring strengthening; and issues (13). Few intervention programs for alteration and quadriceps, hamstring, and iliotibial band flexibility. prevention have been shown to be effective. Other interventions include evaluation of playing sur- Pathophysiology: faces and shoe type. As a secondary prevention strategy, avoid patellofemoral Patellofemoral pain may occur in what seems to be an compression exercises (e.g., lunges, deep squats) anatomically normal knee. Chondromalacia means degenerative cartilage and may It is essential the team physician have no relationship to symptoms of anterior knee pain. Understand the role of multiple risk factors and possi- Structures in the anterior knee that may be involved ble sites of pain in athletes with patellofemoral pain. include the following: Perform an examination that includes evaluation of ) Patellar subchondral bone quadriceps, hamstrings, hip abductors, and iliotibial band. ) Fat pad and synovium ) Medial plica It is desirable the team physician ) Retinaculum Identify history of patellofemoral pain and assess status Other structures that may cause anterior knee pain: of rehabilitation. ) Patellar tendon Evaluate for core stability and lower-extremity ) Apophyses (e.g., tibial tubercle, inferior patella) strength, flexibility, and alignment. ) Hip pathology Coordinate the implementation of a strength and condi- Risk factors include the following: tioning program (10) for the core and lower extremity. ) Muscle weakness and/or imbalance and inflexibility, Recommend shoe type for anticipated activity. including hamstrings, quadriceps hip abductors, and Discuss surface selection for training and conditioning. iliotibial band Work with the athletic care network to educate athletes, ) Trauma, overuse, training errors, and/or previous parents, and coaches on the principles and practices of injury patellofemoral prevention.

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. NONCONTACT SHOULDER INJURIES Examination of shoulder, including the scapula and IN THROWERS AND OTHER OVERHEAD kinetic chain ATHLETES When possible, coordinate the evaluation of the throwing, hitting, or serving mechanics, including the ki- Few intervention programs for the alteration and prevention netic chain. of specific shoulder injuries have been shown to be effective. Injury Reduction and Modification Interventions: The ‘‘Disabled Throwing Shoulder’’ (DTS) Educate athletes, coaches, and parents of the importance of the cause of overload injury and rest (10). Pathophysiology, including risk factors Address identified deficits in the glenohumeral joint, DTS is a concept that describes findings associated scapula, and kinetic chain. with injury, pain, and/or decreased function in throwers In youth baseball, emphasize recommended pitch vol- and other overhead athletes. These findings include the ume per game and per season and oversight of number following: of games played. SPECIAL COMMUNICATIONS ) Anatomical injuries Assessment for and encouragement of proper throwing h Superior labral anterior to posterior (SLAP) tears or serving mechanics and biceps tendon pathology It is essential the team physician understand the folowing: h Other labral injuries h Rotator cuff pathology The importance of overload as a risk factor in shoulder h Capsular injuries injury and addressing load and rest in injury reduction and modification ) Physiological deficits The importance of altered shoulder rotation and scap- h Posterior rotator cuff weakness or fatigue ular dyskinesis as most prominent risk factors for DTS. h Altered shoulder rotation: isolated loss of internal Youth baseball players and other overhead athletes re- rotation (glenohumeral internal rotation deficit or quire specific oversight, including pitch volume. loss of total range of internal/external rotation h Pectoralis minor inflexibility It is desirable the team physician h Scapular muscle weakness inhibition or injury Identify previous shoulder injury and assess status of h Kinetic chain changes in core strength or rehabilitation. flexibility Recognize multiple anatomic, physiologic and biome- ) Alterations of biomechanical motions chanical factors may exist and contribute to DTS. h Abnormal arm position in the overhead motion Assess shoulder rotation, scapular function, and kinetic sequence chain status. h Scapular dyskinesis: alteration of scapular static Assess throwing, hitting, or serving mechanics and in- position or dynamic motion teract with coaches to optimize the motion. h Alteration in coordinated kinetic chain segment Implement a program for evaluation and conditioning. motion, including altered timing of coordinated Work with the athletic care network to educate athletes, activation parents, and coaches on the principles and best practices of shoulder injury reduction and modification. ) Volume and intensity of overhead activity and throwing ) Lack of adequate rest between throwing episodes Elbow ) Previous injury in the shoulder or other parts of the Elbow injuries are becoming more recognized, especially kinetic chain in youth/adolescent overhead athletes. A point of specific ) Shoulder muscle imbalance, most commonly concern is the increasing recognition of valgus overload in- posterior shoulder, muscle weakness, fatigue, or juries, resulting in ulnar collateral ligament (UCL) tears and inflexibility subsequent reconstructions. Few intervention programs for ) Alteration of hip motion, especially the loss of internal the alteration and prevention of UCL injuries have been rotation shown to be effective. ) In youth baseball, increased number of pitches per Pathophysiology: game, innings pitched per season, months pitched per year. Partial or complete disruption of the anterior band of ) In youth baseball, pitching while fatigued the UCL Clinical presentation may be an acute injury or an acute Injury Reduction and Modification Evaluation exacerbation of a chronic injury History of any previous injury in the shoulder and rel- Other important causes of elbow pain: evant parts of the kinetic chain. ) Medial epicondylitis, apophysitis, and avulsion Volume and intensity of training ) Osteochrondritis dessicans of the capitellum

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. Risk factors include the following: Assess shoulder rotation, scapular function, and kinetic COMMUNICATIONS SPECIAL ) Volume and intensity of overhead activity chain status. h Pitches, hits, or serves Assess throwing, hitting, or serving mechanics and in- h Events, games, or tournaments teract with coaches to optimize the motion. h Multiple leagues and/or teams Implement a program for evaluation and conditioning. h Length of season Work with the athletic care network to educate athletes, parents, and coaches on the principles and best prac- ) Poor throwing, hitting, or serving mechanics tices of elbow injury reduction and modification. ) Tight or weak pronator and elbow flexor muscles ) Shoulder and scapular dysfunction ) Kinetic chain deficits, including hip muscle weakness MEDICAL INJURY PREVENTION and hamstring or quadriceps muscle tightness Cardiovascular Issues ) Performing while fatigued ) Early single-sport specialization Hypertrophic cardiomyopathy Pathophysiology: Injury Reduction and Modification Evaluation: Genetic mutations in beta-myosin heavy chain gene, Review of playing and throwing history to determine cardiac troponin gene, or alpha-tropomyosin gene risk factors Autosomal dominant pattern of inheritance History of elbow, shoulder, and kinetic chain injury and Characterized by left ventricular hypertrophy (LVH) rehabilitation status ) With or without left ventricle (LV) outflow tract Examination of the elbow, including the shoulder and obstruction kinetic chain Myocardial disarray on histology When possible, coordinate the evaluation of the Sudden death most often secondary to arrhythmia is usually throwing, hitting, or serving mechanics, including the ventricular tachycardia (VT) or ventricular fibrillation (VF) kinetic chain. Diagnosis made by electrocardiography (ECG) and Injury Reduction and Modification Interventions: echocardiography, cardiac magnetic resonance imaging (MRI). More than 90% demonstrate abnormal Educate athletes, coaches, and parents of the impor- resting ECG. tance of the cause of overload injury and the importance of rest (10). Risk factors for sudden death: Address elbow flexibility and strength deficits Family history of one or more HCM-related sudden Address identified deficits in the glenohumeral joint, cardiac deaths scapula and kinetic chain. One or more episodes of unexplained syncope Implement a sport/activity-specific conditioning pro- LVH greater than 30 mm gram with periodization of activity and incorporating Nonsustained VT on Holter ECGs. rest intervals (10) Hypotensive or attenuated blood pressure response to In youth baseball, emphasize recommended pitch vol- exercise. ume per game and per season as well as oversight of Other possible risk factors: number of games played. ) In youth baseball, monitor fatigue. Akinetic thin-wall LV apical aneurysms ) Assessment for and encouragement of proper throwing Delayed enhancement ) or serving mechanics Large ventricular septal scars It is essential the team physician understand the following: Arrhythmogenic right ventricular cardiomyopathy. Five-fold risk of sudden cardiac death with arrhythmogenic Overload as a risk factor in UCL injury and addressing right ventricular cardiomyopathy in competitive sports loadandrestininjuryreductionandmodification. Pathophysiology: Other common injuries associated with valgus overload in the young athlete. Inherited myocardial disease due to gene mutations Altered shoulder rotation and scapular dyskinesis as encoding cardiac desmosomal proteins common risk factors for UCL injury. Focal myocarditis with healing leads to fibrofatty re- Avoidance of throwing, pitching or serving while fatigued. placement of myocardium and predisposition to VT or VF Youth baseball players and other overhead athletes Risk factors for sudden death: require specific oversight. Previous cardiac arrest It is desirable the team physician Unexplained syncope Identify previous elbow injury and assess status of VT with hemodynamic compromise rehabilitation. Extensive structural disease including LV involvement

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. Coronary artery anomalies exertional chest pain, and excessive exertional short- Pathophysiology: ness of breath Physical examination of pulses, heart murmurs, blood Ischemia and/or arrhythmia, secondary to abnormal pressure, heart rhythm, and stigmata of Marfan_s anatomy syndrome Most common in SCD are left coronary artery origins in the right sinus of Valsalva and right coronary artery Illness prevention interventions of hypertrophic cardiomy- origins in the left sinus of Valsalva opathy, arrhythmias, coronary artery anomalies, arrhythmogenic Screening EKG is usually normal right ventricular cardiomyopathy, and ruptured aortic aneurysm (Marfan_ssyndrome): Risk factors for sudden death: Screening essentials include personal history, family Vigorous exercise history, and physical exam (20) Additional testing and/or consultation Ruptured aortic aneurysm (Marfan_s syndrome) SPECIAL COMMUNICATIONS Controversy exists for EKG screening in asymptomatic Pathophysiology: athletes. A growing number of organizations are including Autosomal dominant disease of collagen due to genetic EKG screening. Specific EKG interpretation criteria have mutation encoding fibrillin causing weakening of the been developed. ) aortic wall (cystic medial necrosis), leading ultimately CertaincausesofSCDcanbeidentifiedbyEKG to aortic dissection/rupture. screening, including HCM, ARVD, long QT syn- _ Physical stigmata (3) drome, Brugada s syndrome, and Wolf-Parkinson- White syndrome. Risk factors for sudden death: ) Screening asymptomatic athletes has consequences, including the cost of the screening, cost of additional Vigorous exercise testing and expertise, false positives (no significant Aortic root dilatation cardiac disease identified), and false negatives.

Arrhythmias Modification or preclusion of activity in those with Pathophysiology: identified disease Emergency action plan for all practices and competition Abnormalities in atrial or ventricular rhythm include the following: It is essential the team physician understand the following: ) Congenital causes such as Wolfe-Parkinson-White syndrome, long Q-T syndrome, Brugada_s syndrome, The major causes of and risk factors for SCD. exercise-induced VT, and catecholaminergic polymor- The role of preparticipation examination in screening phic VT for cardiac conditions. ) Acquired causes such as electrolyte disturbance, med- The importance of an emergency action plan for all ications or drug use, myocarditis, and other cardio- practices and competition (16). myopathies. Exertional symptoms are particularly worrisome. Despite screening, SCD may be the initial presentation. Risk factors for sudden death: It is desirable the team physician Vigorous exercise Coordinate, evaluate, and review the preparticipation Chest wall trauma examination. Unexplained palpitations Implement an emergency action plan that includes the Sudden change in environment (i.e., sudden immersion on-site availability of an automated external defibrillator. in cold water) Work with the athletic care network to educate athletes, Family history of juvenile sudden death or stress- parents, and coaches regarding the common causes of induced syncope sudden cardiac death. Illness reduction and modification evaluation of HCM, arrhythmias, coronary artery anomalies, arrhythmogenic Commotio Cordis right ventricular cardiomyopathy, and ruptured aortic aneu- Pathophysiology: rysm (Marfan_s syndrome): Blunt chest trauma over the cardiac silhouette during a Family history of premature sudden death, especially first- vulnerable period of the cardiac cycle, producing ar- degree relatives, and heart disease in surviving relatives rhythmia in an otherwise normal heart. Personal history of heart murmur, hypertension, ex- Dramatic increase in survival with early defibrillation cessive fatigue, syncope or near syncope with exertion, (within 3 minutes).

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. In animal studies, the hardness of the ball correlates to Practice and play modifications (e.g., limiting contact COMMUNICATIONS SPECIAL induction of ventricular fibrillation. exposure in practice) Almost 30% of fatal events occur in organized com- Programs to improve neck strength and preparation for petitive sports where athletes are already wearing impact (28) chest protectors. Concussion policies and laws Athletes with signs and/or symptoms of concussion Risk factors for sudden death: should not continue participation. Rigid helmets are designed to prevent skull fracture and Age (majority younger than 16 years) major head trauma; they have not been proven to pre- Competitive sport vent concussion. Recreational sport Head gear, helmet modifications, and mouth guards Illness Reduction and Modification Evaluation: have also not been proven to prevent concussion. Educate athletes, parents, and coaches on the impor- No known tests tance of reporting symptoms of concussion. Illness Reduction and Modification Intervention: It is essential the team physician understand the following: Emergency action plan in place The recognition and management principles of concussion. Age-specific safety balls Treatment should be individualized to limit the risk of Educate coaches and athletes that athletes should avoid subsequent concussions. taking a direct blow to the chest (e.g., stepping in front ) Manage young athletes more conservatively than of the shot) adults. Educate coaches and health-care providers to recognize There is no equipment proven to prevent concussion. commotio cordis Concussion policies and laws Chest protectors have not been shown to prevent commotio cordis. It is desirable the team physician It is essential the team physician understand the following: Coordinate the implementation of concussion awareness and education programs for medical staff, athletes, The clinical presentation of commotio cordis. parents, coaches, administrators, and officials, with The importance of having an emergency action plan. emphasis on the importance of reporting concussion. The importance of age-specific safety balls for sports at Work with coaches and administrators to implement a risk for commotio cordis. concussion reduction and modification program and policy. Chest protectors do not prevent commotio cordis. Discuss and advocate for rule enforcement and changes, It is desirable the team physician fair play, practice and play modifications, and legislative action. Implement an emergency action plan that includes the Provide postinjury instructions to athletes and others. on-site availability of an automated external defibrillator. Educate athletes, parents, and coaches about commotio cordis. Cervical Spine Injury Few intervention programs for the alteration and preven- HEAD AND NECK tion of cervical spine (c-spine) injuries have been shown to be effective. Concussion Pathophysiology, including risk factors: See the ‘‘Concussion (Mild Traumatic Brain Injury) and Axial loading of the slightly flexed c-spine is the the Team Physician: A Consensus Statement’’ (14). Since its mechanism that most often causes permanent or tran- publication, some studies have shown that in addition to sient spinal cord injury in sport. functional changes, there are microscopic structural changes Transient quadriparesis is a c-spine injury associated on advanced imaging. The greatest challenge remains in with sensory and/or motor changes in all four extrem- primary concussion prevention. There are some injury re- ities. Some cases present only with bilateral upper ex- duction and modification strategies for limiting primary and tremity sensory and/or motor changes. Risk factors subsequent concussions. include the following: Injury Reduction and Modification Interventions: ) Previous episode of transient quadriparesis ) C-spine instability, stenosis, and spinal cord changes Enforcement of existing rules and consideration of rule ) Improper technique (e.g., spearing/axial load) changes Promotion of fair play (2,25,29–31) ‘‘Stingers’’ are compression or distraction injuries of Technique modification (e.g., tackling, checking) the cervical nerve root or brachial plexus that produce

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. transient unilateral radiating pain, burning, paresthe- Heat production during exercise is 15–20 times greater sias, and occasionally weakness in the upper extremity. than at rest. ) They usually involve either the C5 and/or C6 nerve Mechanisms to dissipate heat include primarily evap- roots, or the upper trunk of the brachial plexus. oration, as well as conduction, convection, and radia- ) Previous episode of a stinger is a risk factor (6,7) tion. Evaporation is more efficient in acclimatized individuals. Congenital and surgical spinal fusion, depending on Risk factors: level and number of levels fused, may alter participa- ) Extrinsic tion in collision/contact sports h Environment Injury Reduction and Modification Evaluation h Excessive physical exertion and multiple same-day sessions Athletes should have an evaluation including the following: h Inadequate rest and access to hydration ) History of c-spine injury or abnormality h Equipment (e.g., helmets, pads) ) C-spine and neurological examination h Tight-fitting, dark, and nonbreathable clothing SPECIAL COMMUNICATIONS ) Consideration of additional testing and/or consultation h Medications (e.g., antidepressants, diuretics, anti- Injury Reduction and Modification Interventions hypertensives, and antihistamines, attention deficit hyperactivity disorder drugs) Sport-specific techniques to prevent c-spine injury h Supplements and energy drinks (stimulants such (e.g., Heads Up Tackling technique in football) as caffeine) Enforcement of existing rules (e.g., spearing in foot- h Alcohol ball, checking from behind in ice hockey, stunting in cheerleading) ) Intrinsic Management of the downed athlete h Previous history of heat illness ) Initiate the emergency action plan (16) h Increased BMI ) Immobilization of suspected c-spine injured athletes. h Dehydration ) Be aware of modified EMS guidelines and protocols h Medical conditions (e.g., illness and fever) in the local jurisdiction. h Lack of acclimatization h Low fitness Comprehensive rehabilitation may limit risk of subse- h Sickle cell trait quent stingers (17) h Spinal cord–injured athlete The role of shoulder pad modification and neck rolls in football in preventing cervical stingers is unclear Recent data demonstrates young athletes do not have a Education of coaches, parents, and athletes regarding higher risk for heat illness when adequate hydration is the importance of rules and techniques maintained.

It is essential the team physician understand the following: Injury Reduction and Modification Evaluation: Mechanisms and risk factors for c-spine injury Athletes should have a thorough preseason evaluation, The importance of having an emergency action plan including the following: Local EMS guidelines and protocols ) History of risk factors ) It is desirable the team physician Evaluation of fluid intake ) Evaluation of present and anticipated volume/ Coordinate emergency action plan. intensity of training and participation Incorporate local EMS providers in at least one annual ) Evaluation of athlete_s state of acclimatization practice of emergency action plan. ) Screening for sickle cell trait Work with the athletic care network to educate athletes, parents, and coaches on prevention principles and Monitor prepractice and postpractice weight of athletes practices for sports where c-spine injury is possible. Emergency action planning to include access to on-site cooling Address clothing and equipment HEAT ILLNESS Monitor on-site wet bulb globe temperature and/or heat stress index (12). Physiology/Pathophysiology: Injury Prevention Interventions: Heat illness occurs on a spectrum, with the most severe form being heat stroke, which may be life threatening. Review practice parameters (i.e., time of day, intensity, ) May occur anytime, but most likely to occur in hot, duration, and frequency). humid weather. Optimize acclimatization and hydration strategies for ) Results from an inability to dissipate heat. practice and competition (4,12).

168 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. Allow sufficient recovery between repeated exercise Based on laboratory data, age-specific safety balls are COMMUNICATIONS SPECIAL bouts or closely scheduled same-day training sessions recommended for prevention of commotio cordis. or rounds of sports competition. Wrist guards have been shown to reduce wrist injuries Modify and/or cancel sport-specific activities based on in snowboarding and skating sports (26). environmental conditions. Prophylactic knee bracing has not been shown to pre- Review medication/supplement use. vent ACL injury. Its efficacy is unclear in preventing Implement sport/activity conditioning program with medial collateral ligament injury. periodization (10). Shin guards decrease the incidence of tibia fractures in Optimize clothing (loose-fitting, light colors, breath- soccer. able fabrics for exercise in the heat) and equipment Taping or bracing is useful for primary and secondary (minimizing equipment on days with excessive heat). prevention of inversion ankle sprains. It is essential the team physician Breakaway bases decrease the incidence of ankle injuries/ fractures in softball and baseball. Recognize the spectrum of heat illness and at-risk individuals. Establish a reliable method to assess ambient tempera- Skin Infections ture and humidity. Understand the need for rapid, on-site cooling with cold Pathophysiology: water immersion (1). Increasing frequency of antimicrobial resistance among Understand the importance of modifying work/rest infectious organisms is of great concern. ratios. The recent emergence of MRSA is of particular con- Recognize the early warning signs of heat illness. cern. It is increasingly reported in wrestling, fencing, It is desirable the team physician and football. Although the overall incidence of skin infections is Establish an emergency action plan to manage acute heat illness (16). small, prevention is possible. Infections are spread by direct physical contact or trans- Screen athletes at the time of preseason evaluation for fer of infection from one part of body to another, fomites risk factors for heat illness. (equipment, mats), and compromised skin barrier. Oversee acclimatization recovery and hydration practices. Assist in scheduling practices and events around times Risk factors: of increased potential for heat illness. Implement mechanism for rapid, on-site cooling. Cool Previous history of infection first, transport second. Compromised host immune status Work with coaches in modifying work/rest ratios dur- Sports with close contact ing activity Poor personal hygiene Educate athletes, parents, and coaches regarding the Body shaving early warning signs of heat illness. Overuse of antibiotics Sharing towels, razors, and equipment Facility cleanliness

EQUIPMENT AND INJURY REDUCTION Illness Reduction and Modification Evaluation AND MODIFICATION Athletes should have an evaluation before participation Equipment selections and modifications have been shown including the following: to reduce and/or modify injury. History of previous communicable skin lesions and treatment Rigid helmets are designed to prevent skull fracture and Comprehensive assessment for skin breaks and wounds ) major head trauma; they have not been proven to pre- Identification of type and location of current com- vent concussion. municable skin lesions and treatment Head gear, helmet modifications, and mouth guards Hygiene practices should be assessed both in the athlete have also not been proven to prevent concussion. and in facilities. Mouth guards decrease the risk of dental and facial Illness Reduction and Modification Interventions injury. Faceshields provide protection from facial injuries and Routine surveillance is recommended in all sports, lacerations. especially high-risk sports (e.g., wrestling, football, Protective eye wear in women_s lacrosse is associated and rugby). with decreased incidence of eye injuries. To decrease transmission, withhold athletes with bacterial, Chest protectors have not been shown to prevent viral, and fungal infections from practice/competition commotio cordis. until adequately treated (23).

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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited. Promote good hygiene with regular bathing and nail It is essential the team physician trimming, emphasizing showering as soon as possible. Understand management principles and risk factors for Immediate laundering of uniforms, towels, and equipment. common skin infections. Instruct athletes to dry area of lesion last before dis- Recognize common skin infections that may be conta- carding towel. gious or become secondarily infected. Wash hands regularly with soap and water or use alcohol-based hand gel. Is it desirable the team physician Avoid sharing equipment, uniforms, towels, clothing, Understand return-to-play guidelines for common in- bedding, bar soap, razors, and toothbrushes. fections and infestations. Coverage alone is never appropriate as a primary treat- Maintain accurate and complete records of type, loca- ment or prevention of spread of disease. tion, and treatment for each lesion. ) Coverage of skin lesions only after they are non- Coordinate hygiene practice guidelines for practice and infectious to prevent secondary infection. competition, travel, and the training room.

SPECIAL COMMUNICATIONS Prophylactic medications should be considered for Understand the role and use of drug prophylaxis for in- those with frequent outbreaks. season athletes with recurrent infections. Cleaning of equipment and other environmental surfaces Understand the efficacy of treating potential MRSA with which multiple athletes have bare skin contact. carriers to prevent spread of infection is inconclusive (5). Encourage student athletes to report skin wounds and Work with the athletic care network or to educate ath- lesions. letes, coaches, officials, parents, and other health-care Education of coaches, officials, and health-care practi- practitioners on recognizing and reporting, identifying, tioners regarding common skin infections. treating, and documenting skin lesions in athletes.

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