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Whether you are a primary care physician, an orthopedic surgeon, an athletic trainer or a physical therapist pursuing further in-depth sports medicine knowledge, we sincerely hope you find this reference all it is meant to be.
Thompson Netter’s Concise Orthopaedic Anatomy, 2nd Edition 978-1-4160-5987-5 Greene Netter’s Orthopaedics 978-1-929007-02-8 Hart & Miller Netter’s Musculoskeletal Flash Cards 978-1-4160-4630-1 Runge & Greganti Netter’s Internal Medicine, 2nd Edition 978-1-4160-4417-8 View more Netter titles and other great Elsevier resources at www.elsevierhealth.com! Gain a better view of read more..
These state-of-the-art resources from Elsevier complement Netter’s Sports Medicine, providing all the know-how you need to meet your daily clinical challenges! DeLee, Drez, & Miller DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, 3rd Edition Expert Consult — Online and Print (2 Volumes) ISBN: 978-1-4160-3143-7. Noyes Noyes Knee Disorders: Surgery, read more..
Netter’s Sports Medicine Illustrations by Frank H. Netter, MD CONTRIBUTING ILLUSTRATORS Carlos A. G. Machado, MD John A. Craig, MD James A. Perkins, MS, MFA Kristen Wienandt Marzejon, MS, MFA CHRISTOPHER C. MADDEN, MD MARGOT PUTUKIAN, MD, FACSM CRAIG C. YOUNG, MD read more..
1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 NETTER’S SPORTS MEDICINE ISBN: 978-1-4160-4922-7 Copyright © 2010 by Saunders, an imprint of Elsevier Inc. ISBN (online): 978-1-4160-5924-0 All rights reserved. No part of this book may be produced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording read more..
Netter’s Sports Medicine is dedicated to the Team Physician’s Handbook and to the many thousands of sports medicine physicians and health professionals who have loyally followed and evolved with its content over three spectacular editions. Netter’s Sports Medicine is the formal heir to the Team Physician’s Handbook and all that the text has embodied for sports read more..
Editors Christopher C. Madden, MD Assistant Clinical Professor University of Colorado Health Sciences Center Department of Family Medicine Sports and Family Medicine Physician, Private Practice Longs Peak Family Practice Longmont, Colorado Team Physician Niwot High School Niwot, Colorado Margot Putukian, MD, FACSM read more..
Craig C. Young, MD, is a professor and the Medical Director of Sports Medicine at the Medical College of Wisconsin. He received a BS degree (cum laude) in Biological Sciences from the University of California, Irvine. He is a graduate of the University of Califor- nia, San Diego School of Medicine. He completed a residency in family medicine at UCLA and a sports read more..
The Netter illustrations are appreciated not only for their aes- thetic qualities, but more importantly, for their intellectual con- tent. As Dr. Netter wrote in 1949 “… clariﬁ cation of a subject is the aim and goal of illustration. No matter how beautifully painted, how delicately and subtly rendered a subject may be, it is of little value as a medical read more..
Contributors Joanne B. “Anne” Allen, MD, FAAPMR, FACSM Orthopedic Specialist Clinical Adjunct Faculty University of North Carolina at Wilmington Wilmington, North Carolina Annunziato Amendola, MD Director UI Sports Medicine Department of Orthopaedics and Rehabilitation University of Iowa Health Care Iowa City, Iowa read more..
Stephanie M. Chu, DO Thomas O. Clanton, MD University of Texas Medical School–Houston Department of Orthopaedic Surgery Team Physician Houston Rockets and Rice University Orthopaedic Consultant Houston Texans Houston, Texas Steven J. Collina, MD Division Chief of Sports Medicine Director read more..
Scott Escher, MD Department of Family Medicine Division of Sports Medicine Gundersen Lutheran Medical Center LaCrosse, Wisconsin John E. Femino, MD Chief of Foot and Ankle Service Department of Orthopaedics and Rehabilitation University of Iowa Health Care Iowa City, Iowa Karl B. Fields, MD read more..
Kevin M. Honig, MD Orthopedic Sports Medicine and Shoulder Fellow Department of Orthopaedics University of Colorado School of Medicine Denver, Colorado Thomas Howard, MD Director Sports Medicine Fellowship Program Fairfax Family Medicine Fairfax, Virginia Brian A. Jacobs, MD Team Physician Marian High read more..
Edward Josiah Lewis, MD Sports Medicine Fellow Fairfax Family Medicine Fairfax, Virginia Cheryl Lindly, MA, ATC, PA-C Alegen Health Family Care Clinic Omaha, Nebraska Colin G. Looney, MD Orthopaedic Surgery/Sports Medicine The Bone and Joint Clinic Franklin, Tennessee Robert E. read more..
Charles S. Peterson, MD Instructor of Family Medicine Mayo College of Medicine Arizona Sports Medicine Center Gilbert, Arizona David J. Petron, MD Assistant Professor Department of Orthopaedics Director Primary Care Sports Medicine, Associate Director Primary Care Fellowship University of Utah Salt Lake City, Utah read more..
Deborah Saint-Phard, MD Director Active Women’s Health CU Sports Medicine Program Associate Professor Department of Physical Medicine and Rehabilitation University of Colorado Denver School of Medicine Aurora, Colorado Robert C. Schenck, Jr., MD Professor and Chairman Division Chief Sports Medicine Section Head Team read more..
Nathan van Zeeland, MD Chief Resident Vanderbilt University Department of Orthopaedics and Rehabilitation Vanderbilt Orthopaedics Institute Nashville, Tennessee Carole S. Vetter, MD Associate Professor Orthopaedic Surgery Associate Program Director Orthopaedic Surgery Residency Division of Sports Medicine Medical College of Wisconsin read more..
champion, and backcountry mountainside to Super Bowl ﬁ eld. The book is designed to serve as a comprehensive sports medicine re- source and a ready reference in the busy outpatient ofﬁ ce, in the training room, on the sideline, and in the long, quiet hours of prepa- ration for sports medicine board certiﬁ cation. Insightful, expert, an- ecdotal experience ﬁ read more..
SECTION IV Environment 17 Exercise in the Heat and Heat Illness ............139 Jon Divine • Josh Takagishi 18 Exercise in the Cold and Cold Injuries ...........149 Christopher C. Madden 19 High-Altitude Training and Competition ........158 Benjamin D. Levine • James Stray-Gundersen SECTION V Behavioral and Psychological Problems 20 The Role of Sport Psychology and Psychiatry read more..
35 Connective Tissue and Rheumatologic Conditions in Sports ......................................285 Mark E. Lavallee SECTION VII Injury Prevention, Diagnosis, and Treatment 36 Musculoskeletal Injuries in Sports .................299 Eric C. McCarty 37 Comprehensive Rehabilitation of the Athlete ................................................304 Kevin E. Wilk • Charles D. Simpson II 38 Physical Modalities read more..
xx CONTENTS 78 Boxing ..........................................................650 Brian A. Jacobs • Jessica Ellis 79 Dance ...........................................................657 Craig C. Young • Selina Shah • Laura M. Gottschlich 80 Mass Participation Endurance Events ............663 William O. Roberts 81 Field Hockey .................................................671 Cherie B. Miner 82 Lacrosse read more..
I Medical Care and Supervision of the Athlete 1 The Team Physician 2 The Certiﬁ ed Athletic Trainer and the Athletic Training Room 3 The Preparticipation Physical Evaluation 4 Sideline Preparedness and Emergencies on the Field 5 Sports Nutrition 6 Sports Supplements 7 Sports Pharmacology of Pain and Inﬂ ammation Control in Athletes read more..
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BEING A TEAM PHYSICIAN: A SPECIAL PRIVILEGE, AN AWESOME CHALLENGE Special Role Team physicians have a unique responsibility for important decisions. They are expected by athletes, parents, and school, community league, or professional team administrators to make major decisions about athletes’ health, qualiﬁ cations to join the team, and ability to participate read more..
4 SECTION I • Medical Care and Supervision of the Athlete To protect from possible future liability: Team physicians need to be ready to serve as mindful guides when the agenda of a coach or team is not supportive of appropriate health care deci- sions for an injured athlete. Responsibilities to the Institution To facilitate success read more..
1 • The Team Physician 5 Employer of Team Physicians The athletic director, athletic trainer, business manager or other ofﬁ cer of the professional team hires or obtains the services of the team physician. Standard of quality guidelines for selecting a team physician are suggested in a 2005 AOSSM publication: • The selection of a team physician read more..
6 SECTION I • Medical Care and Supervision of the Athlete ROLES AND FUNCTIONS OF THE TEAM PHYSICIAN Medical Supervision of Athletes The traditional function of a team physician, which has now been greatly expanded, includes the following roles and functions: Prevention • The team physician is responsible for the preparticipation read more..
1 • The Team Physician 7 • Regarding malpractice insurance, make sure physician cov- erage extends to the sideline, training room, and team setting. Coverage is frequently more expensive with professional and high-level sports. Communication/Liaison The ideal team physician is a skilled communicator who can often resolve conﬂ icts or read more..
HOW THE CERTIFIED ATHLETIC TRAINER AND PHYSICIAN FUNCTION AS A TEAM Standing Orders • By law, ATCs function under the auspices of a physician. As such, the physician under whom an ATC is practicing should have standing orders to help guide the ATC. The National Athletic Trainers’ Association website ( www.nata. org ) has several guidelines read more..
2 • The Certiﬁ ed Athletic Trainer and the Athletic Training Room 9 Immediate Care • Necessary equipment available • Communication procedures for emergency situations— scenarios and procedures rehearsed by entire staff • Prompt, accurate triage Treatment, Rehabilitation, and Reconditioning • read more..
PREPARTICIPATION PHYSICAL EVALUATION (PPPE) • History and physical examination performed before participa- tion in sport that meets several objectives and is one of the most important functions provided by the sports medicine physician. • Often the ﬁ rst interaction between the physician and the ath- lete; for many young adults, it is the ﬁ read more..
3 • The Preparticipation Physical Evaluation 11 • The 2005 Preparticipation Physical Evaluation monograph (see “Recommended Readings”) considers the “gymnasium ex- amination” to be inadequate to achieve the goals and objec- tives of the PPPE process. Personnel Physicians • The PPPE should be performed by an MD or DO read more..
• Nutritional issues: ﬂ uids, game-day nutrition, general nutrition • Supplements and performance-enhancing agents • Sexuality concerns: pregnancy, sexually transmitted diseases, sexual orientation (best addressed in private setting) • Recreational drugs and alcohol use • Preventive medicine: seat belts, helmets, self read more..
BOX 3-1 The 12-Element American Heart Association Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes 3 • ThePreparticipationPhysicalEvaluation 13 • Hypertension (95th-99th percentile for age, sex, and height) • Severe hypertension (.99th percentile for age, sex, and height) Palpate radial and femoral pulses: • Decreasedornonpalpablefemoralpulsesraisesuspicionfor read more..
Hypertrophic cardiomyopathy (HCM) Long Q T syndrome Brugada syndrome Rate = 71/min Structural congenital abnormalities Channelopathies Ventricular tachycardia (VT) is common in patients with HCM and asymmetric septal hypertrophy. HCM is usually inherited as an autosomal dominant trait with incomplete penetrance. Patients with family history of syncope or sudden cardiac death are at particularly high read more..
3 • The Preparticipation Physical Evaluation 15 • Asthma screening (e.g., exercise challenge test) has been sug- gested but is impractical in most preparticipation settings. Abdominal/Gastrointestinal Assessment Should be performed with athlete in supine position. Problems requiring further evaluation before participation include organo- megaly (liver and read more..
16 SECTION I • Medical Care and Supervision of the Athlete Table 3-2 CLASSIFICATION OF HYPERTENSION (HTN) Age and phase 90th-95th percentile † High normal * Prehypertensive ‡ 95th-99th percentile † Signiﬁ cant HTN * Stage 1 HTN ‡ 99th percentile † Severe HTN * Stage 2 HTN ‡ 6-9 yr Systolic † 104-121 read more..
3 • The Preparticipation Physical Evaluation 17 • Female: routine exam not recommended; if warranted by his- tory or other ﬁ ndings, examine in private setting. • Tanner staging no longer recommended in PPPE monograph because of controversy over using it for injury prevention and psychological beneﬁ ts; may be useful for counseling on read more..
18 SECTION I • Medical Care and Supervision of the Athlete Umbilicus Medial malleolus A A’ B Gauging trunk alignment with plumb line Measurement of rib hump with scoliometer Estimation of rib hump and evaluation of curve unwinding as patient turns trunk from side to side Older sister, severe curve Younger sister, mild curve Examination of all siblings to detect early scoliosis read more..
Atlas fused to base of skull. Dens projects into foramen magnum well above McGregor’s line. 70% of patients with occipitalization of atlas and fusion of C2–3 develop C1–2 instability. When neck is flexed, space available for spinal cord may be considerably reduced as atlas-dens interval increases. Fusion of C2–3 accentuates instability. Space for spinal cord reduced Atlas-dens read more..
20 SECTION I • Medical Care and Supervision of the Athlete • Differentiation of categories is important. • Familiarity with demands of speciﬁ c sport is essential; use of classiﬁ cation system for sports by contact and strenuousness is helpful in this regard ( Tables 3-3 and 3-4 ). • Published guidelines read more..
3 • The Preparticipation Physical Evaluation 21 Table 3-5 MEDICAL CONDITIONS AND SPORTS PARTICIPATION Condition May participate Atlantoaxial instability (instability of joint between cervical vertebrae 1 and 2) Explanation: Athlete needs evaluation to assess risk of spinal cord injury during sports participation. Qualiﬁ ed yes Bleeding disorder read more..
22 SECTION I • Medical Care and Supervision of the Athlete Condition May participate Convulsive disorder, well controlled Explanation: Risk of convulsion during participation is minimal. Yes Convulsive disorder, poorly controlled Explanation: Athlete needs individual assessment for collision/contact or limited contact sports. Avoid the read more..
3 • The Preparticipation Physical Evaluation 23 2. American Academy of Pediatrics Committee on Sports Medicine and Fitness : Athletic participation by children and adolescents who have systemic hypertension . Pediatrics 99 ( 4 ): 637 - 638 , 1997 . 3. American Academy of Pediatrics Committee on Sports Medicine and Fitness : read more..
PREPARATION Training • Many different health care professionals may cover sporting events. This chapter is directed to physician coverage of events. • Physicians of any specialty may cover events ranging from high level (professional, Olympic, college) to informal games played by their children or in the neighborhood. • The read more..
4 • Sideline Preparedness and Emergencies on the Field 25 parents (if athlete is a minor) is obtained to maintain conﬁ - dentiality. Athletic Director • The athletic director or venue director needs to be involved in the emergency action plan to assure that adequate medical care can be provided to the athlete. • The read more..
26 SECTION I • Medical Care and Supervision of the Athlete • There are often inherent delays in getting emergency re- sponse to sporting venues (trafﬁ c patterns, security issues, venue access), and an early activation means an early re- sponse. • Keep in mind, however, that it is difﬁ cult to cancel an EMS response once 911 read more..
4 • Sideline Preparedness and Emergencies on the Field 27 • Transport to appropriate medical facility for deﬁ nitive care and observation. Asthma • Check airway. Administer oxygen. • Administer albuterol via inhaler (two puffs via AeroChamber). • Monitor for improvement. Transport if not read more..
28 SECTION I • Medical Care and Supervision of the Athlete Dental • Many dental injuries can be prevented by proper use of well- ﬁ tted mouth guards. The team physician should make certain that the players are wearing their mouth guards. To keep them functional and prevent them from obstructing the airway if an athlete were to lose read more..
4 • Sideline Preparedness and Emergencies on the Field 29 • Needle decompression is performed by inserting a large bore needle (14 gauge or 16 gauge) into the second inter- costals space on the affected side. The needle should be inserted just above the third rib at the midclavicular line. There should be a release of air once the area is entered. read more..
30 SECTION I • Medical Care and Supervision of the Athlete • The splint should be securely applied, but with caution not to put it on too tightly. Extremities will swell and a tight wrap could increase the risk of compartment syndrome devel- oping. • Always check neurovascular status before and after application of splint. Monitor neurovascular read more..
GOALS OF A NUTRITION AND PERFORMANCE PLAN Both team and individualized nutrition strategies should strive to promote performance and well-being ( Fig. 5-1 ). Individualize! Certainly generalizations can be made about the diets of athletes, but it is paramount to gain an understanding of an individual athlete’s eating behaviors, food preferences, cur- rent read more..
32 SECTION I • Medical Care and Supervision of the Athlete lasting 5 to 6 seconds (e.g., power lifting, short all-out sprinting such as 50 or 100 m). Creatine is derived from animal food sources such as meat, ﬁ sh, and poultry. • The short-term system: Human cells’ capacity for gly- colysis remains crucial during physical activities that re- quire read more..
5 • Sports Nutrition 33 lean body mass, maximizes positive training adaptations, and protects immune and reproductive function. Regulation of human energy intake: The factors that regulate human energy intake and expenditure are complex, and include both physiological and psychosocial factors. • Physiological signals: Intake is regulated by the hypothala- read more..
34 SECTION I • Medical Care and Supervision of the Athlete 4 kcal/g and can become a signiﬁ cant energy source under cer- tain circumstances, such as in a low-carbohydrate condition or during prolonged exercise. Recommendation: In general, athletes’ protein requirements are greater than those of their sedentary counterparts and are most accurately determined read more..
5 • Sports Nutrition 35 Micronutrients • Micronutrients play a speciﬁ c role in facilitating energy trans- fer and tissue synthesis—two functions very important to the overall performance and recovery of athletes. • Generally, if an athlete meets overall energy needs and incor- porates a wide variety of nutrient-dense foods, read more..
36 SECTION I • Medical Care and Supervision of the Athlete drinks”) can help prompt better overall ﬂ uid intake as well as help maintain blood glucose and delay fatigue during intense activities lasting more than 45 to 60 minutes as well as longer endurance events lasting several hours. Practical means to maintain and monitor hydration status: • read more..
5 • Sports Nutrition 37 Guidelines for Lean Tissue Gain • Progressive resistance training and adequate calories are criti- cal for weight gain. However, genetic predisposition, somato- type, maturity level, and compliance determine progress. • Initially increase caloric intake by 500 to 700 kcal per day: • read more..
PRODUCT OVERSIGHT AND MARKETING Dietary Supplement Health and Education Act of 1994 (DSHEA) Food and Drug Administration (FDA): The FDA regulates di- etary supplements. This is done under separate regulations from those that cover “conventional” foods and drug products (pre- scription and over-the-counter). Under DSHEA, the dietary supplement manufacturer is read more..
6 • Sports Supplements 39 tric oxide production but deﬁ nitive studies need to be com- pleted. Studies have shown that arginine’s effects on muscle protein synthesis are likely a net effect in combination with ni- tric oxide as well as concurrent elevation of other amino acids. Side effects: None reported in short-duration studies. Dosage: 3 read more..
40 SECTION I • Medical Care and Supervision of the Athlete Efﬁ cacy: Numerous studies have examined the effect of creatine supplementation on athletic performance. Despite some disagree- ment, general consensus is that creatine supplementation has a small, but real, beneﬁ cial effect on anaerobic activity, speciﬁ cally short-duration, repetitive, high-intensity read more..
6 • Sports Supplements 41 enhance immune function. Glutamine has been shown to reduce upper respiratory infections in athletes after vigorous exercise, but more data are needed to conﬁ rm this ﬁ nding. It may be ef- fective in treating chemotherapy-induced stomatitis. In general, reliable data are insufﬁ cient to support effectiveness of gluta- mine for most of its read more..
42 SECTION I • Medical Care and Supervision of the Athlete proper oral hydration, proper acclimatization, and good sense during exercise in extreme conditions. Side effects: Isolated reports of headache, bloating, and nausea after oral ingestion. Otherwise data about side effects are lim- ited. Dosage: Typically 1 to 1.2 g/kg mixed with 1.5 L of ﬂ read more..
6 • Sports Supplements 43 2 hours on the ﬁ rst day of illness, followed by three times a day for the remainder of the illness; E. purpurea extract tablets, two tablets three times daily; and herbal compound tea, 5 to 6 cups on ﬁ rst day of illness followed by titration to 1 cup a day. Evening Primrose Claims: Evening read more..
44 SECTION I • Medical Care and Supervision of the Athlete theoretical concern about interference with gonadal develop- ment in children and adolescents. Melatonin can also cause ir- ritability, dysphoria, dizziness, and abdominal cramping. The data concerning long-term use is insufﬁ cient. Dosage: Typical dosing for jet lag: 5 mg at nighttime for 3 days before ﬂ read more..
6 • Sports Supplements 45 Side effects: Side effects are uncommon and dose-related. Hyper- oxaluria, hematuria, crystalluria, hyperuricosuria, and predispo- sition to urinary stone formation may be related to intake greater than 1 g/day. Other side effects include intestinal ob- struction, other GI distress, headache, insomnia, fatigue, and ﬂ ushing. Dosage: read more..
46 SECTION I • Medical Care and Supervision of the Athlete RECOMMENDED READINGS 1. American College of Sports Medicine, American Dietetic Associa- tion, and Dietitians of Canada : Joint position statement on nutrition and athletic performance . Med Sci Sports Exerc 32 : 2130 - 2145 , 2000 . 2. Bemben MG, Lamont HS : read more..
OVERVIEW The pharmacology of pain management in the athletic arena can be a critical component in returning an athlete to play. Several op- tions exist and choosing an appropriate medication should involve careful consideration of the goals of treatment and potential ad- verse reactions. This chapter will review some commonly used formulations in greater detail. read more..
48 SECTION I • Medical Care and Supervision of the Athlete NH2 NH2 NH2 NH2 NH2 NH2 Heme group Heme Heme Ile 523 Val 523 Hydrophobic channel Hydrophilic “side pocket” Endoplasmic reticulum Cyclooxygenase (COX enzyme) dimer COX-1 Isoform COX-2 Isoform Hydrophobic drug-binding channel Ibuprofen Celecoxib Rofecoxib Aspirin NSAIDs: Mechanism of Action NSAIDs Coxibs COX-1 COX-2 Coxibs: Mechanism of Action COX-1 read more..
7 • Sports Pharmacology of Pain and Inﬂ ammation Control in Athletes 49 • Finally, NSAIDs block constitutive prostaglandins necessary for proper kidney function. • NSAIDs decrease sodium excretion and increase free water retention. This is more of an issue with long-term use, al- though care should be taken regarding use during endur- ance read more..
50 SECTION I • Medical Care and Supervision of the Athlete tion via an increased concentration of hyaluronic acid in the joint. Types The original corticosteroid used for intra-articular injection was hydrocortisone (thus the familiarity with the term “cortisone” in- jection by many patients). Subsequent research helped develop formulations with longer durations of read more..
7 • Sports Pharmacology of Pain and Inﬂ ammation Control in Athletes 51 VISCOSUPPLEMENTATION Background • The use of intra-articular viscosupplementation, or hyal- uronic acid (HA), injections in pain management in lower extremity osteoarthritis (speciﬁ cally knee and more recently ankle) has been established. • A normal read more..
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II Conditioning 8 The Pediatric Athlete 9 The High School Athlete: Setting Up a High School Sports Medicine Program 10 The Female Athlete 11 The Senior Athlete 12 The Physically Challenged Athlete read more..
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GENERAL PRINCIPLES • The pediatric athlete can be any child of any age (although usually younger than 18 years old) who participates regularly in sports activities. • Type of activity, skill level, and motivation for sport par- ticipation varies greatly at different ages and different levels of maturity. Therefore, it is best to understand young read more..
56 SECTION II • Conditioning • Recommendations for overuse injury prevention include the following: • Limit one sporting activity to 5 days per week. • Provide one day of rest from organized activity. • Take 2 to 3 months off per year from a single sport. • Vary workout routines to maintain read more..
8 • The Pediatric Athlete 57 Implications for Sport Participation in Youth Athletes • Coach and parent reaction with appropriate feedback to young athletes is crucial in sport development. • Conﬁ dence, self-esteem, and body awareness are all de- veloping. • Young athletes should be taught to think along read more..
58 SECTION II • Conditioning searchers feel that the skills required for weightlifting and powerlifting make it almost impossible to lift too much weight too soon. • More research is needed in these areas and is ongoing. • It is important to note that many sports use intrinsic strength techniques to perform sport-speciﬁ c exercises, such as read more..
8 • The Pediatric Athlete 59 • Return to play varies from approximately 3 weeks to 12 weeks or more. In general, immobilization lasts 3 to 6 weeks because physeal injuries heal quickly. • General return-to-play criteria should apply, including an as- sessment of range of motion, strength, and ability to perform sport-speciﬁ c exercises with read more..
60 SECTION II • Conditioning chanical symptoms. Gait abnormalities may be seen in knee OCD patients and include walking with the tibia externally ro- tated to decrease pressure on the lesion. Diagnosis: Often made on plain radiographs. • Knee: AP, notch or skier’s, lateral, and sunrise views should be obtained. Often, the lesion in the read more..
8 • The Pediatric Athlete 61 • Braces are unlikely to signiﬁ cantly limit extension; rather, ef- ﬁ cacy may be achieved via a proprioceptive mechanism. Prognosis: Unilateral pars defects have a better prognosis for heal- ing without long-term complications than do bilateral defects. Nevertheless, there is a low rate of bony healing read more..
62 SECTION II • Conditioning Best diagnostic in physical examination. With patient supine, as thigh is flexed it rolls into external rotation and abduction. Frog-leg view Frog-leg view Frog-leg view Grade I (<33%) Classification Grade II (33% – 50%) Grade III (>50%) Antero- posterior view Antero- posterior view Antero- posterior view Slipped capital femoral epiphysis not readily read more..
8 • The Pediatric Athlete 63 Physical examination: Findings often include a leg length dis- crepancy, tenderness at the medial tibial physis, and tibial tor- sion associated with the tibia vara. Instability to valgus stress testing may be present. Gait is usually antalgic and is notable for a varus thrust. Diagnosis: Radiographs of the knee often read more..
64 SECTION II • Conditioning Postoperative radiograph Rigid, painful flatfoot (pes planus) with hind part of foot in valgus position, characteristic of tarsal coalition Prominence of peroneus longus and brevis tendons. These muscles contract on forced inversion of foot. Navicular Calcaneo- navicular bar Head Body Talus Calcaneus Calcaneonavicular coalition Tarsal Coalition Calcaneonavicular bar read more..
GENERAL PRINCIPLES Reasons Athletic Health Care Is Well Established at College and Professional Levels • Awareness of needs and obligation to meet responsibilities • Commitment to solve “problem” by meeting responsibilities • Risk management and loss control are central concerns to organization • Well-being and health read more..
66 SECTION II • Conditioning • Seek assistance of medical community • Know what is desired from physicians, physical therapists, and clinics. • Ask your entire medical community to get involved. Desig- nate a head team physician. • Seek broad assistance and coverage for all sports: prepar- ticipation physical exams, as read more..
9 • The High School Athlete: Setting Up a High School Sports Medicine Program 67 • Role of team physician in school without athletic trainer • Understand history and culture of school • Assess strengths and weaknesses of how athletic care is and was provided • Greater challenge to meet responsibilities read more..
68 SECTION II • Conditioning • Course for “soldiers on the front lines every day” • Sensitivity of coaches • Toward injuries and injured athletes • Old school—“no pain, no gain”; no practice, no play • New school—recognize injury, treat, and fully rehabili- tate; pain-free participation only read more..
9 • The High School Athlete: Setting Up a High School Sports Medicine Program 69 • Severe fracture • Major muscle contusion • Eye trauma • Finger tendon rupture • Cauliﬂ ower ear • Limb threatening—major dislocation or severe fracture • Common sports injuries read more..
70 SECTION II • Conditioning • Injury data — injury surveillance • Tabulate data, determine injury rates • Numerator—number of injuries, body part or injury type • Denominator (measure of risk)—number of participants or athletic exposures • Follow year-to-year trends within school and sports read more..
9 • The High School Athlete: Setting Up a High School Sports Medicine Program 71 4. France R : Today’s athletic training: Built on tomorrow’s needs . The First Aider 61 ( 1 ): 6 , 1991 . 5. Herring SA et al : Team Physician Consensus Statement . American Academy of Family Physicians, American Academy of read more..
GENERAL PRINCIPLES • Female athlete issues can be divided into health concerns ex- clusive to women and those more common in women. • Menstruation and pregnancy are conditions speciﬁ c to young women and inﬂ uence exercise performance and sport. • The female athlete triad is a condition that describes the rela- tionship read more..
10 • The Female Athlete 73 strual disorders like oligomenorrhea or amenorrhea, premen- strual symptoms, and time-shifting of the menstrual cycle. • Despite the widespread use of the OCP, the literature in this area is scarce. Given the proliferation of OCPs into monopha- sic combination pills consisting of various doses of ﬁ xed com- binations of estrogen and read more..
74 SECTION II • Conditioning progestin-only pills, injectables, or implantable forms, gener- alizations from the limited research cannot be drawn. The effect of OCPs on physical ﬁ tness parameters and athletic performance is still unclear. • Athletic performance may be improved by controlling pre- menstrual symptoms (fatigue, ﬂ uid retention, etc.) with OCPs. read more..
10 • The Female Athlete 75 in female athletes it is 6% to 69%, depending on the type of sport, level of competition, body weight, and age. Sports em- phasizing leanness have reported prevalence rates of amenor- rhea as high as 69% in dancers and 65% in long-distance runners. Prevalence of amenorrhea in distance runners went from 3% to 60% with mileage increases from read more..
76 SECTION II • Conditioning • Purging activities: self-induced vomiting, laxatives, diuret- ics, excessive exercise • Weight: current, ideal, most and least in past year; level of satisfaction with current weight • Menstrual history: onset of menarche, last menstrual period, number of menstrual periods in past year read more..
10 • The Female Athlete 77 • Complete physical examination including pelvic examination in women with menstrual dysfunction • Physical signs of eating-disordered athletes ( Box 10-3 ) Laboratory and Diagnostic Tests • Complete blood count with differential (anemia) • Electrolytes (abnormalities read more..
78 SECTION II • Conditioning • Hormonal studies—follicle-stimulating hormone (FSH), es- tradiol (amenorrhea) • Bone density evaluation—dual-energy X-ray absorptiometry (if more than 6 months of disordered eating, menstrual dys- function, or stress fracture) • Nutritional assessment Treatment PRINCIPLES • read more..
10 • The Female Athlete 79 OLIGOMENORRHEA • Menstrual cycle length greater than 35 days. • May be anovulatory. ANOVULATION • Absence of ovulation. • Estrogen and progesterone levels are low, therefore follicular development is impaired. • Often there is sufﬁ read more..
80 SECTION II • Conditioning LABORATORY AND DIAGNOSTIC TESTS • Urine pregnancy test, thyroid-stimulating hormone (TSH), prolactin, FSH and LH • Progestin challenge test: • Administer medroxyprogesterone acetate (Provera) 10 mg orally daily for 7 to 10 days. • Two to 7 days after challenge, if read more..
10 • The Female Athlete 81 HORMONE REPLACEMENT TREATMENT • American Academy of Pediatrics recommends OCP use for treatment of amenorrhea if athlete is over the age of 16 years or if she is 3 years post menarche. • Additional beneﬁ ts of OCP use include decreases in dysmen- orrhea, premenstrual syndrome, read more..
82 SECTION II • Conditioning time. Severe undernutrition and menstrual dysfunction im- pairs skeletal health. • Menstrual disorders with a hypoestrogenic state result in ac- celerated bone resorption, because of the loss of the suppress- ing effect of estrogen on osteoclast activity. • Low energy availability may also be a factor, as indicated in read more..
10 • The Female Athlete 83 hydroxyvitamin D3; celiac sprue autoantibodies, and 24-hour urinary calcium excretion. Treatment of Low Bone Mineral Density • Important to initiate treatment within ﬁ rst year of onset of amenorrhea when rapid bone loss occurs. • Baseline BMD is useful to measure response to treatment. • read more..
84 Section ii • conditioning EXERCISEANDPREGNANCY GeneralConcepts • Exerciseduringanormal pregnancyshouldbeencouraged as part of a healthy lifestyle during pregnancy. For normal pregnancies, moderate-intensity exercise on a regular basis hasnoriskstothefetusandhasmaternalbenefits. • Goals of exercise during pregnancy should be to exercise safelywhilemaintainingmaternalfitnesslevelsandminimiz- ingrisktodevelopingfetus. read more..
10 • The Female Athlete 85 3. American Psychiatric Association Working Group on Eating Disor- ders : Treatment of patients with eating disorders , third edition . Am J Psychiatry 163 : 4 - 54 , 2006 . 4. Artal R, O’Toole M : Guidelines of the American College of Obstetri- cians and Gynecologists for exercise read more..
GENERAL CONSIDERATIONS Demographics • In Western society, the population of older adults is growing both in size and in proportion to the total population. • It is estimated that by year 2030, the number of people older than 65 will approach 70 million in the United States. • People over the age of 85 are expected read more..
11 • The Senior Athlete 87 Neurologic:decreasesinspinalmotorneurons(contributingfac- tortodecreasedmusclestrength),reactiontimes,coordination, balance,andproprioception. Metabolic: decreases in basic metabolic rate and glucose toler- ance; increases in plasma triglycerides, total cholesterol, and low-densitylipoproteinconcentrations. BENEFITS OF EXERCISE IN OLDER ADULTS • read more..
88 SEcTion ii • conditioning • Previousjointinjuriesandunderlyingosteoarthritis,whichis more common in older adults, are risk factors for activity- relatedinjury. • Sensory impairment, such as alterations in vision, hearing, vestibularfunction,andproprioception,mayincreasesuscep- tibilitytoaccidentsandfalls. • Overuseinjuriesremainthemostcommoncauseofathletic disabilityinathletesolderthan50. • read more..
11 • The Senior Athlete 89 tus tendon near its insertion; Achilles tendon 4 to 5 cm proximal to calcaneal insertion). MENISCAL CARTILAGE INJURIES • Acute meniscal tears often occur as a result of a twisting injury or knee hyperﬂ exion. • Individuals with degenerative meniscal tears often have a his- tory of read more..
Ischemic heart disease and SCD The pathogenic electrical event leading to sudden cardiac death is likely ventricular tachycardia (VT) followed by ventricular fibrillation (VF) and eventually asystole. Myocardial infarction causes fatal arrhythmias by two distinct mechanisms—the first is VT or VF in ischemic setting (acute MI). The second is propensity of myocardial scars to act as foci read more..
11 • The Senior Athlete 91 • Other cardiovascular conditions that pose exercise-related risks include valvular heart disease, uncontrolled hyperten- sion, cardiomyopathies, cardiac arrhythmias, and decompen- sated heart failure. • Medical problems commonly seen in older adults, such as dia- betes mellitus and obesity, may negatively affect cardiovascu- lar read more..
92 SECTION II • Conditioning geal reﬂ ux; certain agents (e.g., verapamil) may impair heart rate response to exercise. • Statins (3-hydroxy-3-methyl-glutaryl coenzyme A [HMG- CoA] reductase inhibitors) can produce a variety of skeletal muscle disorders including myositis, rhabdomyolysis, mild serum creatinine kinase (CK) elevations, myalgia with and without elevated read more..
94 SEcTion ii • conditioning • Studieshavedemonstratedthatthetotalamountofcoronary calciumpredictscoronarydiseaseeventsbeyondstandardrisk factors. • Ahighcalciumscore(.100)isassociatedwithahighrisk ofacardiaceventinthenext2to5years. • A negative test is associated with an extremely low risk (0.1%peryear)ofacardiovasculareventinthenext2to 5years. • Itisunknownwhethertheriskofcoronaryeventsduringin- tense exercise is increased in read more..
11 • The Senior Athlete 95 Myocardial Ischemia, Demonstrated by Stress Test At rest Exercise Incline and speed of treadmill progressively increased Myocardium ischemic due to increased demand for coronary flow with exercise Coronary artery narrowed by 70% of luminal cross section Heart rate normal for resting state Normal ECG. No ST- segment depressions. ST-segment depressions in leads read more..
11 • The Senior Athlete 95 Myocardial Ischemia, Demonstrated by Stress Test At rest Exercise Incline and speed of treadmill progressively increased Myocardium ischemic due to increased demand for coronary flow with exercise Coronary artery narrowed by 70% of luminal cross section Heart rate normal for resting state Normal ECG. No ST- segment depressions. ST-segment depressions in leads read more..
96 SECTION II • Conditioning • Using a well-designed implant. • Creating a properly balanced soft-tissue envelope. • Other issues to consider when advising patients about partici- pation in sports after joint replacement include: • Experience of the participant • Preoperative athletic activity is a critical read more..
11 • The Senior Athlete 97 • Attaininghighskilllevelsinasportafterarthroplastycan be quite challenging for patients who have not partici- patedinthisactivitypreoperatively. • Participationinanewathleticactivityafterjointreplace- mentmayresultinanincreasedriskofinjury. • Thetypeofathleticactivityandtheextentofparticipation • Repetitivemotionandjointloadingcanacceleratejoint- bearingsurfacewear. • read more..
98 SEcTion ii • conditioning • Delay in appropriate evaluation may contribute to injury chronicity,complicatedrehabilitation,anddelayedrecovery. • Initialmanagementofacutemusculoskeletalinjuriesisbased on the PRICE regimen: protection, rest, ice, compression, and elevation. Subsequent Treatment Principles • Somereportssuggestthathealingofmusculoskeletalinjuries isslowerinolderathletes,butresultsfromotherstudiesare read more..
11 • The Senior Athlete 99 • Adequate nutrition must be maintained (see “Nutrition in Older Athletes”). NUTRITION IN OLDER ATHLETES General Considerations • Regardless of age, proper nutrition is essential for optimal health and athletic performance. • All athletes need adequate energy intake to fuel working read more..
100 SECTION II • Conditioning 12. Healy WL, Iorio R, Lemos MJ : Athletic activity after joint replace- ment . Am J Sports Med 29 : 377 - 388 , 2001 . 13. Kallinen M, Markku A : Aging, physical activity and sports injuries: An overview of common sports injuries in the elderly . Sports Med 20 : 41 - read more..
GENERAL CONSIDERATIONS Deﬁ nitions Physically challenged: combines all groups of athletes competing in international competition such as Paralympics. Athletes have an impairment that restricts or decreases their ability to partici- pate in athletic arenas within manner considered “normal” for deﬁ ned sport. Impairment: any loss or abnormality read more..
102 SECTION II • Conditioning GENERAL CONSIDERATIONS FOR TREATMENT OF ATHLETE • Cognitive age differences: coping with impairment • Adult: potential concurrent medical issues, social isolation • Management of comorbid diabetes, arthritis, other disease • Youth: peer interaction, relationships • read more..
12 • The Physically Challenged Athlete 103 • Medications: antiepileptics, antispasmodics, tricyclic antide- pressants, anticholinergics, baclofen pumps, pain medicines, other medicines for comorbid conditions • Comorbid medical issues: • Related to impairment: e.g., pressure sore, type and success of bowel/bladder management program; recurring urinary read more..
104 SECTION II • Conditioning Urinary Tract Infection • Potential comorbid issue because of bladder management op- tions • Long-term use of indwelling catheters leads to higher risk for UTI • Symptoms can be masked because of lack of feeling below SCI level: patient won’t feel typical urinary urgency, dysuria, or ﬂ read more..
12 • The Physically Challenged Athlete 105 • Medications: antispasmodics, tricyclic antidepressants, pain medicines (may affect cognition), other medicines for comor- bid conditions • Comorbid medical issues: • Related to impairment: e.g., skin breakdown from pros- thesis • Related to concurrent illness: e.g., traumatic brain read more..
106 SECTION II • Conditioning • Require good strength, balance on limb, to better adapt to prosthetic component mismatch • Quadriceps and hip abductors and adductors important for success with prosthesis LEA Secondary Issues • Low back pain: found in greater than 50% of lower extremity amputees • read more..
12 • The Physically Challenged Athlete 107 Glossary in Cerebral Palsy Spastic CP: most common form; affects 70% to 80%; increased muscle tone and stiffness. Spasticity increases with excessive fa- tigue or anxiety. Athetosis CP: four limbs, trunk, and sometimes face. Athetonia is a slow, writhing involuntary muscle movement. Muscle tone read more..
108 SECTION II • Conditioning Physical Considerations in Athlete Spasticity, neurogenic bowel or bladder, seizure, joint contracture, pulmonary issues are caused by muscle weakness. Short Stature Syndrome Two general types: • Disproportionate • Average-size torsos, unusually short limbs. • Causes: skeletal dysplasia read more..
12 • The Physically Challenged Athlete 109 RECOMMENDED READINGS 1. Adams RC, McCubbin JA : Games, Sports, and Exercises for the Physically Disabled , 4th ed . Philadelphia : Lea & Febiger , 1991 . 2. Bizzarini E, Sccavini M, Lipanje F , et al : Exercise prescription in sub- jects with spinal cord injuries . read more..
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III Special Consideration for Athlete Populations 13 Exercise Prescription and Physiology 14 Aerobic Training 15 Resistance Training 16 Flexibility read more..
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EXERCISE PHYSIOLOGY Exercise can be deﬁ ned as “bodily exertion, especially for the sake of training, recreation, or ﬁ tness.” Exercise Physiology • Exercise physiology is the science of the processes and mech- anisms of skeletal muscle contraction and the corresponding interaction of other body systems that facilitate and respond to skeletal read more..
114 SECTION III • Special Consideration for Athlete Populations Adaptations to Chronic Exercise (“Training”) • Musculoskeletal and cardiorespiratory systems are highly adaptable to regularly performed exercise. • Adaptation to repetitive exercise can be understood in terms of several factors, which can be represented by the mnemonic read more..
13 • Exercise Prescription and Physiology 115 Implement As Part of Clinical Practice • Identify individuals who would beneﬁ t from exercise prescrip- tion. • Identify conditions amenable to exercise therapy. • Assess patient’s activity level. • Educate patient about the beneﬁ ts of exercise. read more..
116 SECTION III • Special Consideration for Athlete Populations Collaterals to respiratory centers from motor pathways for muscle activation Rise in body temperature accounts for a small part of elevation Respiratory neurons seem to be more responsive to changes in chemoreceptor activity. Centers may be more sensitive to fluctuation than to absolute values of PaO 2, PaCO 2, or pH Lactic read more..
13 • Exercise Prescription and Physiology 117 • Asymptomatic men older than 45 years or women older than 55 years with two or more risk factors who plan to start a vigorous exercise program ( see Table 13-3 and Box 13-1 ) • American College of Cardiology/American Heart Association (ACC/AHA) recommends screening exercise stress read more..
118 SECTION III • Special Consideration for Athlete Populations • Exercise induces a spike in endogenous insulin secretion so individuals may develop hypoglycemia relatively early in exercise. • Delay exercise if glucose is greater than 250 and ketonuria is present. EXERCISE IMPROVES INSULIN SENSITIVITY • read more..
13 • Exercise Prescription and Physiology 119 • Moderate intensity exercise is safe (including in the elderly). • Increases in exercise intensity should be kept to a minimum during ﬂ are-ups of OA • Isometric exercises are particularly helpful in lower extremity OA. • Walking, biking, swimming, and read more..
INTRODUCTION • In the early days of sporting events coaches and athletes learned through trial and error that they could not develop maximal endurance and maximal power simultaneously. They found that by ﬁ rst establishing an aerobic endurance base and later by adding faster training they could peak at the proper times. • It was not read more..
14 • Aerobic Training 121 RA RV LV LA Volume distribution Distribution of vascular resistance Lungs High-pressure system (supply function) Low-pressure system (reservoir function) Pulmonary arterial pressure: 25/10 mm Hg (mean pressure: 15 mm Hg) Lungs (9%) Small arteries and arterioles (8%) Small arteries and arterioles (47%) Aortic pressure: 120/80 mm Hg (mean pressure: 95 mm Hg) Veins (64%) Large read more..
122 SECTION III • Special Consideration for Athlete Populations lactate threshold at 70% of his or her VO 2 max, and the oth- er’s lactate threshold is 90% of his or her VO 2 max, the latter runner has a signiﬁ cant physiologic advantage in a head-to- head endurance race ( Table 14-2 ). • Compared to aerobic capacity, which is primarily read more..
14 • Aerobic Training 123 prove that the body is in an oxygen debt (anaerobic), only that a signiﬁ cant amount of glycolysis is necessary to keep up with the energy needs of the muscle. • To further compound the problem of rising lactic acid levels, sometimes there is not enough oxygen supplied to the muscles during high-intensity exercise. When read more..
124 SECTION III • Special Consideration for Athlete Populations race-like—maximum intensity. Ten minutes into the time trial (20 minutes to go) press the “lap” button on your heart rate monitor so that when you ﬁ nish you have your average heart rate for the last 20 minutes. This number is an approximation of your LTHR. • Pay attention to your heart read more..
14 • Aerobic Training 125 Intensity • Frequency and duration are much easier to quantify than in- tensity. Intensity is often referred to as volume or workload, or simply, “hardness” of a workout. Poor understanding of intensity is the primary cause of ineffective training pro- grams. If you are performing your workouts with precise read more..
126 SECTION III • Special Consideration for Athlete Populations or intensity, and peak and/or race ( Fig. 14-11 ). Periodization takes place from cycle to cycle (micro and macro). • The basic premise of all periodization programs is that train- ing should progress from general to speciﬁ c. Early in the season, training is focused on maintaining weight, read more..
14 • Aerobic Training 127 8. Knehr CA et al : Training and its effects on man at rest and at work . Am J Physiol 136 : 148 - 156 , 1942 . 9. Koppo K et al : Effects of training status and exercise intensity on phase II V O 2 kinetics . Med Sci Sports Exerc 36 ( 2 ): 225 - 232 read more..
GENERAL PRINCIPLES • As physiologic demands of sports become greater and greater, prevention of injury becomes one of the most important as- pects of sports performance. Physical conditioning of athletes plays an important role in preventing injury and improving athletic performance. • Changes are mediated by increasing the athlete’s physical read more..
15 • Resistance Training 129 • Velocity of movement typically is associated with type of re- sistance used, choice of exercise, and exercise modality. Terms such as speed strength and power relate to rapid development of force at high speeds of movement. Continuum of velocities is used in conventional resistance training, from very slow con- centric read more..
130 SECTION III • Special Consideration for Athlete Populations intensity and more effective training stimulus for all muscles involved. • Another consideration is to place exercises that are being taught or practiced (especially those involving complex move- ments) at the beginning of the session. • Ordering of exercises also involves ordering of read more..
15 • Resistance Training 131 Periodized training cycles use variations in training frequency to alter exercise stimulus, thus allowing recovery and enhanc- ing the effect of exercise stimulus. • Athletes may train twice daily to reduce volume within a sin- gle workout so that quality (intensity) of workout can be maintained at the highest level. Twice-daily read more..
132 SECTION III • Special Consideration for Athlete Populations • Each 16-week program is called a mesocycle (made up of microcycles), and 1-year training programs typically are com- posed of several mesocycles. Each mesocycle attempts to in- crease muscle hypertrophy, strength, local muscular endur- ance, and/or power toward the athlete’s theoretical genetic read more..
15 • Resistance Training 133 5. Kraemer WJ, Fleck SJ : Optimizing Strength Training: Designing Nonlinear Periodization Workouts . Champaign, Ill : Human Kinetics , 2007 . 6. Kraemer WJ, Fleck SJ : Strength Training for Young Athletes , 2nd ed . Champaign, Ill : Human Kinetics , 2005 . 7. read more..
GENERAL PRINCIPLES • The term ﬂ exibility is often used clinically as a synonym for range of motion (ROM) around a joint. • Both muscles and ligaments can limit ROM. • When ligaments limit ROM, it is referred to as a decrease in mobility; ﬂ exibility is usually reserved to refer to limited ROM caused by read more..
16 • Flexibility 135 weaker. Similarly, but perhaps through a different mechanism, muscles are also weaker after stretching. This would not be expected to reduce injury risk and most studies have shown no change in injury risk when a stretching intervention is started. • Regular stretching: If a person does weightlifting over weeks to months, the muscles read more..
136 SECTION III • Special Consideration for Athlete Populations PERSONALIZING A STRETCHING PROGRAM Objectives • As with any intervention, one must clearly understand the objectives. Is the objective to reduce injury, improve tests of performance, improve performance, or something else? Do not confuse tests of performance (e.g., force read more..
IV Environment 17 Exercise in the Heat and Heat Illness 18 Exercise in the Cold and Cold Injuries 19 High-Altitude Training and Competition read more..
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HEAT PRODUCTION Exercise: The Body’s Furnace • Thermodynamics Law #1: energy can neither be created nor destroyed • Contraction is directly related to and limited to muscle blood ﬂ ow • “Incoming” energy is transformed into: • Energy-rich chemical compounds: phosphates • Mechanical contraction read more..
140 SECTION IV • Environment • Early in exercise, • Heat production is greater than heat loss, resulting in in- creased core temperature. • The rate of core temperature elevation increases even more in a hot environment. • Rise in core temperature is sensed and centrally regulated primarily by thermo detectors read more..
17 • Exercise in the Heat and Heat Illness 141 Convection Heat Loss • Convection heat loss is heat transfer as a result of forced ﬂ uid ﬂ ow (usually cooler) across a warmer, relatively stationary surface . • Newton’s Law of Cooling states that the rate of heat transferred is directly related to the read more..
142 SECTION IV • Environment • Magnesium sulfate • Dantrolene (if malignant hyperthermia suspected) • Prevention: Conditioning and heat acclimatization. Recurrent crampers, particularly “salty sweaters,” may beneﬁ t from liberal use of salt within their diet, especially in hotter climates. • Complications: read more..
17 • Exercise in the Heat and Heat Illness 143 • Pronounced mental status changes (irritability, ataxia, confu- sion, disorientation, syncope, hysterical or psychotic behavior, seizure, and/or coma). • Diminished peripheral cooling ability (cessation of sweating, hot skin). • Signs of life-threatening disseminated intravascular coagula- tion read more..
144 SECTION IV • Environment • Place intravenous line and measure serum sodium. • May be difﬁ cult because of peripheral vasoconstriction. • Do not delay efforts to cool down the athlete while waiting to place an IV. • Keep in mind: Cooling techniques cause peripheral vasocon- striction, read more..
17 • Exercise in the Heat and Heat Illness 145 • Age-related limitation to full heat acclimation is a result of reduced vasodilator response, which may begin as early as age 50. • Decreased maximum heart rate with age leads to decreased maximum cardiac output. • Reduced thirst response after water deprivation, which re- sults read more..
146 SECTION IV • Environment increased maximum sweating capacity, lower sweat sodium concentration. • Increased cardiovascular efﬁ ciency: increased basal plasma volume, decreased heart rate at given workload and heat stress. • Thermal effects: increased exercise capacity in heat, lower core and skin temperature at given workload and heat stress, read more..
17 • Exercise in the Heat and Heat illness 147 Proper Clothing for Exercise in the Heat • Short-sleeved,loosefitting,open-weaveormeshjerseysallow betterevaporation. • Evidence to support or discourage the wearing of newer, sweat-“wicking” shirts (made of fabric that absorbs sweat awayfromtheskintotheoutersurfacetopromoteevapo- rativecooling)toreducetheriskofheatillnessislacking. • Wearing no shirt read more..
148 SECTION IV • Environment RECOMMENDED READINGS 1. American Academy of Pediatrics Committee on Sports Medicine and Fitness : Climatic heat stress and the exercising child and adolescent . Pediatrics 106 ( 1 ): 158 - 159 , 2000 . 2. American College of Sports Medicine : Position stand on exercise and ﬂ uid read more..
GENERAL PRINCIPALS Physiology of Cold Exposure Mechanisms of Heat Loss RADIATION • Radiation involves direct emission or absorption of heat en- ergy from the body (mostly infrared radiation). • Radiation is the largest source of heat loss from the body. • Clothed, sedentary individuals in a calm, temperate read more..
150 SECTION IV • Environment Thermoregulation and Physiologic Adaptations • The hypothalamus is the thermoregulatory center for mainte- nance of body temperature and physiologic response to cold. • The body needs to stay between 34° C and 40.5° C (95° F and 105° F) to maintain normal organ function; core tem- perature normally hovers read more..
18 • Exercise in the Cold and Cold Injuries 151 • Most versatile cold weather clothing systems are usually com- posed of three layers: • Inner hydrobic polyester fabric (e.g., Capilene, Coolmax, Thermax, Thermolite, Thermostat) that allows wicking of moisture away from the body. Avoid cotton. • Middle insulating material can be second read more..
152 SECTION IV • Environment • Adequately warm-up before exercising in cold conditions (may warm-up indoors, or use insulated, protective clothing if outdoors). EXTERNAL WARMING SOURCES See Treatment discussion in the following “Accidental Hypother- mia” section. SPECIFIC INJURIES Systemic Cold Injury Accidental read more..
18 • Exercise in the Cold and Cold Injuries 153 • Some practitioners advocate the use of active external warm- ing measures (see following discussion) or noninvasive inter- nal rewarming in the ﬁ eld with heated humidiﬁ ed oxygen. • These rewarming measures do not likely signiﬁ cantly in- crease core temperature and are controversial read more..
154 SECTION IV • Environment arterial blood gas) should be drawn and close serial moni- toring is required. Serum potassium greater than 10 mEq/L in the presence of hypothermia is a strong marker for death. ECG and chest x-ray should be performed. • Some experts believe that limiting the application of exter- nal heat to the trunk may minimize the read more..
18 • Exercise in the Cold and Cold Injuries 155 • The affected body part may also appear yellowish, mottled blue, and waxy. • Initial tissue pliability may indicate superﬁ cial frostbite, whereas frozen-solid tissue without pliability usually indicates deep frostbite. • As tissue thaws with rewarming, signs and symptoms read more..
156 SECTION IV • Environment • Affected extremities should be adequately padded. • Oral hydration should be encouraged. • If equipment is available, some experts feel that rapid rewarm- ing may be performed during transport if transport time to a deﬁ nitive treatment facility is minimal. • Avoid tissue massage and read more..
18 • Exercise in the Cold and Cold Injuries 157 RAYNAUD ’S PHENOMENON Description: Vasospastic disorder characterized by initial pallor (ischemia secondary to vasoconstriction) followed by hyperemia (rebound vasodilation) of the digits (ﬁ ngers most common) after cold exposure and/or emotional stress. Pathophysiology: May be primary read more..
HIGH-ALTITUDE ENVIRONMENT • Athletes must cope with hypoxia, cold, and dehydration, yet maintain maximal performance. • Timing of altitude exposure and degree of acclimatization are critical to successful outcome. • Physiologic adaptation to high altitude may be beneﬁ cial; altitude training is frequently used by elite athletes in at- read more..
19 • High-Altitude Training and Competition 159 different in men than in women, and the ﬁ nal effect of alti- tude on substrate utilization depends on whether the same absolute or relative workload is being compared to sea level, whether the fuel utilization is corrected for energy expen- diture, and whether or not weight loss has occurred. • read more..
160 SECTION IV • Environment • Overtraining may be precipitated by: • Inappropriately hard workouts: Base pace too fast be- cause of narrowed training zones and/or athlete inexperi- ence, intervals too hard—run at maximal speed rather than 105% race pace, recovery exercise too hard (i.e., no recov- ery pace). • Inadequate read more..
19 • High-Altitude Training and Competition 161 report improvement in performance. Finnish and French inves- tigators reported results similar to ﬁ eld environments with 14 to 16 hours daily, which include some easy exercise in hypoxic en- vironment. Optimal dose of such environments has yet to be determined, though a minimum of 12 to 16 hours appears neces- sary. read more..
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V Behavioral and Psychological Problems 20 The Role of Sport Psychology and Psychiatry 21 Drugs and Doping in Athletes 22 Eating Disorders in Athletes 23 Overtraining read more..
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WHAT IS SPORT PSYCHOLOGY (SP)? Deﬁ nitions • The American Psychological Association (APA) Division 47 Exercise and Sport Psychology deﬁ nes sport psychology as: • Helping athletes apply psychological principles to achieve improved or optimal sport performance and mental health. • Increasing knowledge regarding the impact of read more..
166 SECTION V • Behavioral and Psychological Problems • Athletes are not immune from mental health problems. However, it has been shown that physical activity and orga- nized sports participation decreases depression. • Psychological treatment from a licensed mental health professional (and possibly psychotropic medication eval- uation) is usually read more..
20 • The Role of Sport Psychology and Psychiatry 167 • Decreased need for sleep • Grandiose notions • Increased talking • Racing thoughts • Increased sexual desire • Greatly increased energy • Poor judgment • Inappropriate social behavior • read more..
168 SECTION V • Behavioral and Psychological Problems • Education of athletes regarding eating disorders can be help- ful, but understand that athlete culture may help camouﬂ age the eating issues and/or be offering mixed messages. • In many, if not most cases, depression or anxiety symptoms coexist with eating disorder behavior (e.g., through read more..
20 • The Role of Sport Psychology and Psychiatry 169 and enhancing functional levels; these chronic disorders may ﬂ uctuate but their complexity usually suggests long-term therapeutic interventions. PSYCHOLOGICAL ASPECTS OF INJURY • Psychological aspects of injury can be an important area in which a sport psychologist makes signiﬁ cant read more..
170 SECTION V • Behavioral and Psychological Problems to handle pressure (arousal control) and develop relaxation skills, in order to ﬁ nd the level of arousal associated with optimal performance. Visualization or imagery skills are useful in improving control and focus. • Concentration is crucial for successful performance. This skill involves not only the read more..
DEFINITION • According to the World Anti-Doping Agency (WADA) Code, doping is deﬁ ned as the occurrence of one or more of the fol- lowing anti-doping rule violations: • The presence of a prohibited substance or its metabolites or markers in an athlete’s bodily specimen. • Use or attempted use of a prohibited substance or read more..
172 SECTION V • Behavioral and Psychological Problems States Anti-Doping Agency [USADA]) to ensure compliance. WADA is composed and funded equally by the sports move- ment and governments of the world. • Beginning in 2003, the Bay Area Lab Cooperative (BALCO) has been at the center of a scandal in sports involving the company’s role in developing read more..
21 • Drugs and Doping in Athletes 173 for muscular exercise, giving an unfair advantage to those who are willing to risk the potential side effects to achieve gains in athletic performance. • Steroids have been associated with adverse side effects in therapeutic trials and in limited research on athletes. • A well-conducted study by read more..
174 SECTION V • Behavioral and Psychological Problems and cerebrovascular accident. Testosterone may contribute to myocardial ischemia through imbalance between myocardial oxygen supply and demand. Psychological effects: Changes in libido, mood swings, aggres- sive behavior, exacerbation of underlying mental illness, addic- tion to the appearance on AAS, suicide attempts. Dependence read more..
21 • Drugs and Doping in Athletes 175 • Use of hGH in adults who are not deﬁ cient in growth hor- mone has not been established. • Creutzfeldt-Jakob disease has resulted from use of hGH derived from cadaveric pituitary glands. Although use of synthetic hGH eliminates this problem, athletes often obtain substances from black market read more..
176 SECTION V • Behavioral and Psychological Problems priced free base (“crack”) cocaine has led to epidemic smoking in urban areas. The effect of crack is rapid and lasts only 5 to 10 minutes. The half-life of cocaine is 2 to 6 hours; it can be detected in urine for 3 to 5 days. Adverse reactions: • Cardiovascular: Increased levels of read more..
21 • Drugs and Doping in Athletes 177 Prevalence: Sympathomimetic amines appear in various cold remedies, common nasal and ophthalmologic decongestants, and most asthma preparations. After passage of the Dietary Supplement Health and Education Act in 1994, ephedrine ap- peared in various over-the-counter dietary supplements for weight loss and energy and was often read more..
178 SECTION V • Behavioral and Psychological Problems • A study by Urbano-Marquez and colleagues concluded that al- cohol is toxic to striated muscle in a dose-dependent manner. • Arrests for driving while impaired substantially increase the risk of eventual death in an alcohol-related crash. Detection: Except for shooting events read more..
21 • Drugs and Doping in Athletes 179 Dosage: The THC content of marijuana in the United States ranges from 0.5% to 11%; serum concentration depends on smoking technique. Adverse reactions: Renaud and Cormier found the following ef- fects on exercise performance: reduction of maximal exercise performance with premature achievement of V O 2 max; read more..
180 SECTION V • Behavioral and Psychological Problems tic transmission and regulation have been demonstrated. GHB facilitates slow wave sleep, which is associated with growth hor- mone release. It is postulated that this may increase muscle mass. Potential therapeutic uses: GHB is a Schedule I drug and be- cause of its ability to increase cerebral dopamine levels, read more..
21 • Drugs and Doping in Athletes 181 with 1.1% being 13 C (an isotope that contains an additional neutron). The ratio of 13 C to 12 C can be measured with high accuracy and precision by an isotope ratio mass spectrometer. Very small differences in the abundance of 13 C can be detected to allow differentiation of carbon sources. The IRMS values for read more..
182 SECTION V • Behavioral and Psychological Problems testing was not signiﬁ cant, and the government had a legiti- mate interest in deterring drug use. Guidelines for drug testing: The NCAA has suggested guide- lines for member institutions considering a drug-testing proto- col. Although not obligated to institute separate programs, the university must follow read more..
21 • Drugs and Doping in Athletes 183 16. Parkinson AB, Evans NA : Anabolic androgenic steroids: A survey of 500 users . Med Sci Sports Exerc 38 : 644 - 651 , 2006 . 17. Pope HG, Katz DL : Affective and psychotic symptoms associated with anabolic steroid use . Am J Psychiatry 145 : 487 - 490 , read more..
ANOREXIA NERVOSA (AN) DSM Criteria • Essential features and diagnostic criteria for anorexia nervosa ( Fig. 22-1 ): • Individual refuses to maintain a minimally normal body weight, is intensely afraid of gaining weight, and exhibits a signiﬁ cant disturbance in perception of the shape or size of his or her body. • read more..
22 • Eating Disorders in Athletes 185 Endocrine and Metabolic: • Amenorrhea: Results from disorders in the hypothalamic- pituitary-ovarian axis ( Fig. 22-3 ). Levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are low de- spite low levels of estrogen. Amenorrhea persists in 5% to 44% of patients in whom weight read more..
186 SECTION V • Behavioral and Psychological Problems Gastrointestinal: Constipation, delayed gastric emptying, de- creased intestinal motility. Hematologic: Anemia, leucopenia, thrombocytopenia. Integumentary: Dry skin and hair, lanugo, nail fragility. Neurologic: Cerebral atrophy, ventricular enlargement. Reproductive: read more..
22 • Eating Disorders in Athletes 187 BOX 22-1 Laboratory Assessments for Patients with Eating Disorders Laboratory studies CBC with differential Complete metabolic panel Liver function tests Thyroid function tests HCG, FSH, LH, prolactin, estradiol ESR Drug screen Urinalysis Amylase (if purging) Other studies read more..
188 SECTION V • Behavioral and Psychological Problems RECOMMENDED READINGS 1. American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders , 4th ed , Text Revision . Washington, DC : American Psychiatric Association , 2000 . 2. American Psychiatric Association : Practice Guidelines for the Treat- ment read more..
OVERVIEW Introduction • Overtraining syndrome is a medical disorder of athletes that is complicated by many diagnostic and therapeutic challenges. Current research in this area is limited by a small number of studies and inconsistent results. Several researchers have con- cluded the following: there are poorly established diagnostic criteria; there are read more..
190 SECTION V • Behavioral and Psychological Problems BOX 23-1 Autonomic Dysfunction Symptomatology Sympathetic/Basedowian symptoms Agitation or jitteriness Increased heart rate and BP Weight loss Insomnia Parasympathetic/Addisonoid symptoms Depression Fatigue Decreased libido Hypersomnolence Somatic symptoms (myalgias) read more..
23 • Overtraining 191 • Suppressed free testosterone-to-cortisol ratio • Decreased prolactin secretion • Increased norepinephrine and epinephrine levels • The multiple endocrine abnormalities associated with over- training syndrome have yet to be completely elucidated and likely vary along the continuum of overtraining read more..
192 SECTION V • Behavioral and Psychological Problems Musculoskeletal Features • Muscular fatigue at previously tolerated exercise levels • Decreased performance • Persistent soreness Immune Features • Demonstrated increase in the rate of upper respiratory infec- tions in endurance athletes read more..
Infectious Mononucleosis Pharyngitis Fever Typical presentation of infectious mononucleosis (Epstein-Barr virus) Should be alert to possibility of airway compromise in children Neurologic Complications (rare) Encephalitis Transverse myelitis Guillian-Barré syndrome Splenomegaly (common) Cholestatic hepatitis Bone marrow (rare) Hemolytic anemia ITP Potential complications and associated findings Lymphadenopathy Periorbital read more..
194 SECTION V • Behavioral and Psychological Problems Not improved Improved Athletic fatigue TSH, POMS, chest x-ray, nutrition consultation Modify schedule/periodization Visit 1 Visit 2 (2–3 weeks later) Review results Review training over past 2–3 weeks Review results Review training over past 2–3 weeks History Physical examination Dietary evaluation Training diary review Lab: CBC, read more..
VI General Medical Problems in Athletes 24 Infections in Athletes 25 Gastrointestinal Problems 26 Hematologic Problems in Athletes 27 Renal and Genitourinary Problems 28 The Athlete with Diabetes 29 The Athlete’s Heart and Sudden Cardiac Death 30 The Hypertensive Athlete 31 Exercise-Induced Bronchospasm, Anaphylaxis, and Urticaria 32 Neurologic Problems in the Athlete 33 read more..
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INTRODUCTION • With millions of people in the United States participating in athletics recreationally or at the high school, college, or pro- fessional levels, there is growing interest in infectious disease outbreaks in competitive sports. • These diseases can easily spread among athletic teams and can result in decrease in performance, morbidity, read more..
198 SECTION VI • General Medical Problems in Athletes Symptoms: Sore throat, fever, lethargy, malaise, lymphadenopa- thy, and splenomegaly ( Fig. 24-1 ). Potential complications: Splenic rupture, airway obstruction, Guillain-Barré syndrome, meningitis, DIC, aplastic anemia, hemolytic-uremic syndrome. Treatment: Symptomatic. Return to play: It read more..
24 • Infections in Athletes 199 Symptoms: Firm, rough papules or nodules with punctuate black dots within the lesion. Treatment: Salicylic acid, freezing with liquid nitrogen, or tri- chloroacetic acid (painless treatment of plantar warts). Tinea Infections Etiology: Various fungi. Epidemiology: Sweat-soaked clothing, read more..
200 SECTION VI • General Medical Problems in Athletes for screening in males; however, it is prudent for team physicians to discuss screening with male athletes at risk. Encourage con- dom use. Gonorrhea Etiology: The bacterium Neisseria gonorrhoeae. Epidemiology: There were 115.6 reported cases of gonorrhea per 100,000 population in read more..
24 • Infections in Athletes 201 COMMON INFECTIONS: MYOCARDITIS Myocarditis Etiology: Usually viral: enteroviruses, particularly the Coxsackie B viruses, respiratory viruses, such as inﬂ uenza A and B viruses and cytomegalovirus, herpes simplex viruses, human herpes virus 6, parvovirus B19, Epstein-Barr viruses, and hepatitis C virus. HIV-induced read more..
202 SECTION VI • General Medical Problems in Athletes environments. They should have a follow-up skin test 8 to 10 weeks after returning to the United States. The American College of Health Association recommends screening for col- lege students who have signs or symptoms of active TB, are HIV-positive, inject drugs, have had close contact with another person with TB, have read more..
24 • Infections in Athletes 203 Infectious mycobacteria preserved in darkness and moisture from hours to months Sterilized by sunlight and/or dispersed by winds Droplets remain suspended in air for an hour or two Expulsion Droplets containing M. tuberculosis coughed or sneezed into air Implantation Intestine (most commonly in lower ileum and cecum). Drainage to mesenteric lymph node Tonsil read more..
INTRODUCTION Competitive athletes frequently experience gastrointestinal (GI) problems, many of which are related to training or competition. Surveys of serious runners have shown that up to 80% have expe- rienced GI symptoms, mostly in the lower tract, before, during, or after competition. The problems are more common, and perhaps more severe, at higher levels of training read more..
25 • Gastrointestinal Problems 205 • There may be some protective effect from increases in lower esophageal sphincter tone that have been demon- strated with moderate exercise. • Treatment: H 2 -blockers or proton pump inhibitors 4 hours before exercise, standard medical management for reﬂ ux, alteration of oral intake (avoid symptom- triggering read more..
206 SECTION VI • General Medical Problems in Athletes • Other data: 30% to 42% of serious runners have urge to defecate; 14% to 30% report running-induced diarrhea; di- rect relationship between severity of symptoms and level of physical exertion; diarrhea more common in running than in other sports. Lower GI Bleeding • read more..
25 • Gastrointestinal Problems 207 • No clear diagnostic criteria and no imaging modality predict response to surgery. • Most common in young people, people with recent weight loss, and women. • Pain may be sharp, dull, steady, or crampy and may worsen after meals, weight loss, or position changes. • Loud read more..
208 SECTION VI • General Medical Problems in Athletes • Surgery involving division of obstructing diaphragmatic ﬁ bers and denervation of celiac ganglion may beneﬁ t patients with celiac compression syndrome but is controversial. EXERCISE AND THE LIVER Normal liver: No signiﬁ cant changes in function are associated with read more..
SPORTS/DILUTIONAL ANEMIA Description: Known as dilutional anemia or pseudoanemia. Epidemiology: The most common cause of anemia found in the athletic population. Dilutional pseudoanemia is not pathologic but rather an adaptation to endurance training and normalizes after training cessation. It is hypothesized that the dilutional anemia enhances the efﬁ read more..
210 SECTION VI • General Medical Problems in Athletes mean corpuscular volume below 75 fL, a peripheral smear that is hypochromic and microcytic, low serum iron with high total iron-binding capacity, and a serum ferritin below 12 g/L. Treatment: Oral iron therapy in the form of elemental iron, 50 mg three times daily as ferrous gluconate, sulfate, or read more..
26 • Hematologic Problems in Athletes 211 RECOMMENDED READINGS 1. Banﬁ G, Dolci A : Preanalytical phase of sport biochemistry and hae- matology . J Sports Med Phys Fitness 43 ( 2 ): 223 - 230 , 2003 . 2. El-Sayed MS, Ali N, El-Sayed AZ : Haemorheology in exercise and training . Sports Med 35 ( 8 read more..
ANATOMY Genitourinary system: Composed of internal and external organs of the urinary system and genital organs. Both systems are con- tained in lower abdomen and pelvic region. Urinary system: Comprised of kidneys, ureters, urinary bladder, and urethra. Genital system: Male (penis, testicles), female (ovaries, Fallopian tubes, uterus, vagina, read more..
27 • Renal and Genitourinary Problems 213 HEMATURIA • Can be macroscopic, gross, or microscopic ( Fig. 27-3 ). • Microscopic generally deﬁ ned as more than 3 RBC per high power ﬁ eld. • In athletes, rates of hematuria can be as high as 75% to 80%; it occurs in both contact and noncontact read more..
214 SECTION VI • General Medical Problems in Athletes Causes • Direct kidney injury • Renal vein kinking • Bladder contusion • Preexisting pathology • Nephrolithiasis • Urinary tract infection • Drug or medication use (including penicillin, cephalexin, thiazides, read more..
27 • Renal and Genitourinary Problems 215 • Exertional hematuria is a diagnosis of exclusion. Must be related temporally to exertion and must resolve within 3 to 5 days of discontinuing or reducing activity. PROTEINURIA • Occurs in many sports; present in up to 70% of athletes after exertion and in 5% to 85% of read more..
216 SECTION VI • General Medical Problems in Athletes • McArdle’s syndrome—familial lack of muscle phosphorylase • Sickle cell trait • Acute renal failure with rhabdomyolysis may also be associ- ated with: • Disseminated intravascular coagulation • Hyperkalemia, hyperphosphatemia, hyperuricemia • read more..
27 • Renal and Genitourinary Problems 217 • Creatine monohydrate increases muscle stores of creatine, theoretically leading to greater ATP resynthesis. • End product of creatine is creatinine, which is ﬁ ltered in glomeruli and excreted. • In healthy individuals, there is no link between creatine ingestion and renal dysfunction if read more..
218 SECTION VI • General Medical Problems in Athletes • CT scan is the recommended method for initial evaluation of suspected renal trauma, if available. • Can establish contusion, which IVP cannot • Localization of injury if surgery needed Five Classes of Renal Injury See Figure 27-8 . Grade read more..
27 • Renal and Genitourinary Problems 219 • Intrinsic urethral sphincter composed of type I (slow- twitch) muscle ﬁ bers innervated by pudendal and sympa- thetic nerves. • External urethral sphincter composed of type II striated mus- cle innervated by perineal branches of the pudendal nerve. • Treatment options • read more..
220 SECTION VI • General Medical Problems in Athletes • Extravaginal torsion occurs if tunica vaginalis is loosely at- tached to scrotal lining: • Allows spermatic cord to rotate above testis • Not common • Occurs almost exclusively in neonates • Intravaginal torsion occurs if tunica vaginalis is read more..
27 • Renal and Genitourinary Problems 221 • Dysuria and obstruction with voiding • Chronic bacterial prostatitis common cause of recurrent uri- nary tract infection • Need to examine both urine and prostatic ﬂ uid Benign Prostatic Hypertrophy • Symptoms primarily related to bladder outlet read more..
222 SECTION VI • General Medical Problems in Athletes dal neuropathy, and etiology is thought to be neurovascular. Central saddle cutouts have not proven to decrease incidence. Consider adjustments in handlebar height and saddle position Male infertility: Some evidence of decreased sperm motility dur- ing season in elite cyclists. No direct causal evidence exists. read more..
GENERAL CONSIDERATIONS • Exercise is one component of the treatment triad (medication, medical nutritional therapy, exercise) for diabetes mellitus. Position statements of the American Diabetes Association support exercise for persons with type 1 and type 2 diabetes. • Short-term effects of exercise in both types of diabetes are well understood, read more..
224 SECTION VI • General Medical Problems in Athletes • Examine feet daily and keep them well lubricated with an oil, cream, or ointment. Autonomic neuropathy with decreased sweating predisposes to dry skin. Trim nails care- fully; avoid blisters, corns, and calluses; and wear properly ﬁ tting shoes and socks. • Treat foot injuries read more..
28 • The Athlete with Diabetes 225 • Patients with macular edema, nonproliferative diabetic retinopathy, and proliferative diabetic retinopathy should be evaluated by an ophthalmologist prior to exercise. Some patients with controlled disease states listed earlier may safely exercise. EXERCISE GUIDELINES • Good blood glucose read more..
226 SECTION VI • General Medical Problems in Athletes • Increases muscle and liver glycogen stores, allowing athlete to be active for much longer time before needing supple- mental carbohydrate. • Hypoglycemia is more likely to occur during exercise in the evening and least likely to occur in morning exercise because of diurnal variation read more..
28 • The Athlete with Diabetes 227 • Hypoglycemia occurs during and after exercise more fre- quently and severely in those who have had type 1 diabetes for 10 years or more. Patients in good glycemic control may suf- fer more episodes of hypoglycemia if there are no alterations in the management plan. Frequent exposure to hypoglycemia promotes hypoglycemic read more..
228 SECTION VI • General Medical Problems in Athletes 14. Mayer-Davis EJ, D’Agostino R, Karter AJ , et al : Intensity and amount of physical activity in relation to insulin sensitivity . JAMA 279 : 669 - 674 , 1998 . 15. Pavan P, Sarto P , et al .: Metabolic and cardiovascular parameters in type 1 read more..
THE ATHLETE’S HEART Deﬁ nition Intense regular physical exercise can induce physiologic and morpho- logic cardiac changes known as athlete’s heart. Theses adaptations are considered a normal response to repetitive exercise training. Increased Vagal Tone • As stroke volume increases in response to regular exercise training, the resting heart read more..
230 SECTION VI • General Medical Problems in Athletes Young Athletes Registry (a nonmandatory surveillance sys- tem) has documented about 120 deaths per year in young competitive athletes in the United States, or approximately 1 in 50,000 per year, or one death every 3 days. • SCD in athletes occurs more commonly in males, with a male-to-female ratio ranging read more..
29 • The Athlete’s Heart and Sudden Cardiac Death 231 wall thickness ( 16 mm) and LV diastolic dysfunction. MRI has additional value in identifying segmental hypertrophy in the anterolateral LV free wall or at the apex, and can help differenti- ate HCM from athlete’s heart with serial MRIs after an interval of deconditioning. Return to play: The 36th read more..
232 SECTION VI • General Medical Problems in Athletes Symptoms: Characteristic symptoms include a prodromal viral illness followed by progressive exercise intolerance and conges- tive symptoms of dyspnea, cough, and orthopnea. Physical exam ﬁ ndings: S3 gallop; signs of heart failure (edema, pulmonary rales). Diagnostic tests: ECG may show read more..
29 • The Athlete’s Heart and Sudden Cardiac Death 233 Genetics: Primary mitral valve prolapse can be inherited as an autosomal dominant condition with incomplete penetrance. The prevalence of the disease in ﬁ rst-degree relatives ranges from 30% to 50%. Symptoms: No reliable indicators of MVP. Physical exam ﬁ ndings: Midsystolic read more..
234 SECTION VI • General Medical Problems in Athletes Genetics: Patients with congenital AS are slightly more likely to have offspring with congenital heart disease. Symptoms: Usually asymptomatic; less than 5% develop chest pain, angina, or syncope. Physical exam ﬁ ndings: Systolic ejection murmur at upper right sternal border and apical read more..
29 • The Athlete’s Heart and Sudden Cardiac Death 235 that deﬁ ne the syndrome. Risk of sudden death in WPW is es- timated at 1 per 1000 patient years. Pathologic features: A tachyarrhythmia caused by an accessory pathway (the Bundle of Kent) which directly connects the atria and ventricles and bypasses the AV node. The arrhythmia can be read more..
236 SECTION VI • General Medical Problems in Athletes or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias. • A physical exam assessing for a heart murmur (auscultation standing, supine, and with Valsalva), femoral pulses to exclude coarctation of the aorta, recognition of the physical stigmata of Marfan syndrome, and measurement of read more..
29 • The Athlete’s Heart and Sudden Cardiac Death 237 • The EAP should be speciﬁ c to each individual athletic venue and provide plans for: • Communication: a communication system should be in place to activate the emergency medical services (EMS) system and to alert local/school responders and expedite transfer of emergency equipment (e.g., read more..
INTRODUCTION • Fifty million U.S. adults have hypertension. • Hypertension (HTN) is the most common cardiovascular condition observed in competitive athletes. • Athletes are usually considered to be free of cardiovascular disease because of their apparent high level of ﬁ tness. • Overall incidence of HTN in athletes read more..
30 • The Hypertensive Athlete 239 Essential hypertension Renal disorders Adrenal disorders Neurogenic disorders Hematologic disorders Parathyroid or thyroid disorders Coarctation of aorta Toxemia of pregnancy Drug- or diet-induced Increased left ventricular stroke volume Decreased aortic distensibility Unknown etiology Parenchymal renal disease Renovascular disease Cortical Mineralocorticoid excess (primary or idiopathic read more..
240 SECTION VI • General Medical Problems in Athletes • Metabolic factors • Obesity • Glucose intolerance • Endocrine disorders (see “ Causes ”) • Stress • Environmental • Social • Leads to chronic neurogenic activation of the sympathetic nervous read more..
30 • The Hypertensive Athlete 241 CLINICAL EVALUATION History • Cardiovascular risk factors: • Smoking • Family history of cardiac disease in men younger than 55 and women younger than 65 • Obesity • Physical inactivity • Diabetes • Dyslipidemia read more..
242 SECTION VI • General Medical Problems in Athletes Dietary Interventions ELECTROLYTES • Na • A reduction in sodium can result in signiﬁ cant decrease in blood pressure. • Fast food and lunch meats provide 75% of sodium in typical American diet. • 2.3 g per day (6 g NaCl) is read more..
30 • The Hypertensive Athlete 243 weather. Cramping may occur despite normal serum potassium. • Increases in plasma cholesterol, glucose, uric acid (higher doses). • Higher incidence of sexual dysfunction in males. • Thiazides are the preferred ﬁ rst step in therapy for casual exercisers, active elderly, and African-Americans. read more..
244 SECTION VI • General Medical Problems in Athletes • Often ﬁ rst-line agent for hypertension in active athletes • Concomitant use of NSAIDs may increase potassium-sparing effect and potentially cause hyperkalemia • Women of childbearing age need contraception because this class is contraindicated in pregnancy read more..
30 • The Hypertensive Athlete 245 • CO gradually returns to baseline over next 5 years because of increased SV • TPR remains decreased 15% to 20% • Exercise hemodynamics return to normal Calcium Channel Blockers • Include the dihydropyridines (e.g., amlodipine, nifedipine, nicardipine, felodipine, read more..
246 SECTION VI • General Medical Problems in Athletes • An even greater reduction is seen with exercise at 75% of maximal oxygen uptake. • Monitor blood pressure every 2 to 4 months to monitor im- pact of exercise. • Prescribing exercise—“FITT” • Frequency: ﬁ ve to six sessions per week. read more..
30 • The Hypertensive Athlete 247 7. Neter JE, Stam BE, Kok FJ , et al : Inﬂ uence of weight reduction on blood pressure: A meta-analysis of randomized controlled trials . Hy- pertension 42 ( 5 ): 878 - 884 , 2003 . 8. Sachs FM, Swetkey LP, Vollmer WM, et al, for the DASH-Sodium Collaborative Research Group read more..
EXERCISE-INDUCED BRONCHOSPASM Deﬁ nitions: Exercise-induced bronchospasm (EIB) is deﬁ ned as a decline in forced expiratory volume in 1 second (FEV 1 ) or peak expiratory ﬂ ow rate (PEFR) shortly after onset or cessation of exercise. The terms exercise-induced asthma (EIA) and exercise- induced bronchospasm are often used interchangeably; however, read more..
31 • Exercise-Induced Bronchospasm, Anaphylaxis, and Urticaria 249 • Special testing • At present, the International Olympic Committee (IOC) requires prior notiﬁ cation for the use of a beta-2 agonist. The notiﬁ cation must be accompanied by objective evi- dence that justiﬁ es the need for the medication. The IOC accepts the read more..
250 SECTION VI • General Medical Problems in Athletes • Avoid hyperventilation. • Cold weather may exacerbate EIB, so dressing appropri- ately may help. Also, in cold weather a scarf may help retain warmer and more humid air, thus reducing EIB symp- toms. • Avoid exercising in areas that have high pollen counts or heavy read more..
31 • Exercise-Induced Bronchospasm, Anaphylaxis, and Urticaria 251 Studies have also shown mast cell degeneration on skin biopsies done after attacks. May be a priming phenomenon at work where one stimuli acts as a cofactor for the reaction to occur. The food, medication, etc., may act as the primer, and exercise then triggers the event. Clinical signs and read more..
EPILEPSY AND SEIZURE ACTIVITY IN ATHLETES Deﬁ nition • Seizure: a transient occurrence of signs and/or symptoms re- sulting from abnormal excessive or synchronous neuronal activity in the brain. • Epilepsy: an enduring predisposition to generate epileptic seizures. Prevalence is approximately 8.2 per 1000 of the gen- eral population read more..
32 • Neurologic Problems in the Athlete 253 ery, any history of status epilepticus, current anticonvulsant use including side effects and medication adherence, and history of head trauma. On-Field Treatment • Standard guidelines for management of airway, breathing, and circulation should be followed. • Assist the patient to the ground read more..
254 SECTION VI • General Medical Problems in Athletes cervical pain or limited range of motion (ROM), cervical spine magnetic resonance imaging (MRI) should be strongly consid- ered before return to play (RTP). Up to 10% have neurologic deﬁ cit lasting from hours to weeks. Physical exam: Athletes frequently leave the ﬁ eld shaking their arm and hand and read more..
32 • Neurologic Problems in the Athlete 255 Opinions range from considering this a relative contraindication to an absolute contraindication. Multiple episodes without doc- umented stenosis should prompt serious consideration of stop- ping contact sports. COMPLEX REGIONAL PAIN SYNDROME (CRPS) Overview: A regional pain syndrome of unclear etiology generally read more..
256 SECTION VI • General Medical Problems in Athletes meral circumﬂ ex artery and axillary nerve as they pass though the quadrilateral space. Compression is believed to be caused by ﬁ brotic bands within the space or by hypertrophy of the muscles that form the borders but the exact etiology is un- clear. • Iatrogenic (e.g., rotator cuff surgery). read more..
32 • Neurologic Problems in the Athlete 257 natus with sensory branches to the acromioclavicular and glenohu- meral joints. Sensory innervation of the proximal-lateral arm is reported in 15% of patients. The nerve is the most frequently in- jured peripheral branch of the brachial plexus in athletes. Common sports for injury: volleyball, baseball, basketball, tennis/ read more..
258 SECTION VI • General Medical Problems in Athletes mechanics. Others may complain of shoulder, neck, and/or scapu- lar area pain lasting up to a few weeks followed by insidious weak- ness with overhead activities or forward elevation. Differential diagnosis: Cervical disc disease, rotator cuff pathol- ogy, brachial neuritis (Parsonage-Turner syndrome), adhesive capsulitis, read more..
32 • Neurologic Problems in the Athlete 259 • The radial tunnel is the area between the lateral epicondyle and the supinator muscle, which exists as a potential space with numerous sites of compression. • Posterior interosseous nerve compression syndrome (PIN): The same structures are compressed as with RTS but symp- toms are predominantly read more..
260 SECTION VI • General Medical Problems in Athletes anterior interosseous nerve (anterior interosseous syndrome) ( Fig. 32-7 ). Symptoms: • Carpal tunnel syndrome (CTS): Paresthesias and weakness in the radial three and a half digits of the hand. Increased symp- toms with repetitive movements. Pain may radiate proximally. Nighttime symptoms are read more..
32 • Neurologic Problems in the Athlete 261 • AIS: Frequently resolves with conservative management. Good prognosis if surgical intervention required. ULNAR NERVE INJURY Overview: The ulnar nerve arises from the C8 and T1 roots. Con- tribution from C7 is not uncommon. It descends distally, just medial to axillary artery. read more..
262 SECTION VI • General Medical Problems in Athletes the wrist (carpal tunnel view). MRI studies and angiograms may reveal occult hamate fracture and/or ulnar artery thrombosis. Nerve conduction velocities and electromyography (EMG) may help localize the injury and monitor recovery, though utility at Guyon’s canal is limited because of the technical difﬁ culty of the exam. read more..
32 • Neurologic Problems in the Athlete 263 • Two-point discrimination test on medial and lateral sides of the foot may localize lesions. Diagnostics: Plain radiographs may reveal fracture or osteo- phytes. MRI to rule out mass lesions. Nerve conduction veloci- ties and electromyography (EMG) may show prolonged con- duction. Treatment: read more..
264 SECTION VI • General Medical Problems in Athletes Differential diagnosis: Varies depending on symptoms. Physical exam: Visual inspection in chronic cases may display at- rophy in the anterior and lateral compartments of the leg. Ob- servation of the patient ambulating may reveal steppage gate or hip hiking. Physical inspection should include read more..
GENERAL PRINCIPLES • Headache is one of the most common disorders and symptoms reported to primary care, emergency depart- ment, and team physicians. • Complaint of headache accounts for 1% to 4% of primary care ofﬁ ce and emergency department visits. • In the general population, the prevalence of headache in a 1- year read more..
266 SECTION VI • General Medical Problems in Athletes • Conduct neurologic examination to assess for motor, sensory, reﬂ ex response. Also include evaluation of gait. • Check for evidence of systemic illness (assess abnormalities in the cardiovascular, respiratory, gastrointestinal [GI] systems). Additional Investigation read more..
33 • Headache in the Athlete 267 • Sensory disturbances (pins and needles sensation, numb- ness) • Speech disturbances (dysphasia) • Motor deﬁ cits (rare) • Resolution (postdrome) symptoms: These are symptoms that follow headache that may include some premonitory symptoms. • Exhaustion read more..
268 SECTION VI • General Medical Problems in Athletes • Favorable side effect proﬁ le when compared to ergotamine. (Minimal cardiovascular effects and nausea; no rebound head- ache; nausea/vomiting, GI upset, and muscle cramping have been reported.) • DHE-45 is a vasoconstrictor and is therefore contraindicated in patients with cerebrovascular, read more..
33 • Headache in the Athlete 269 • Sumatriptan (Imitrex): 5-HT1D receptor agonist. The ﬁ rst triptan developed, it is available in injectable, oral, and intra- nasal spray forms. • Injectable dosage: 4 to 6 mg SQ initially; may repeat in 1 hour (maximum of two 6-mg injections in 24 hours). Recommended initial dose is 6 mg. • read more..
270 SECTION VI • General Medical Problems in Athletes • Both episodic and chronic TTH may exhibit photophobia and phonophobia, but nausea is usually isolated to chronic TTH. • Chronic tension-type headache (CTTH): deﬁ ned by IHS as headache present for more than 15 days per month for more than 3 months. • CTTH prevalence read more..
33 • Headache in the Athlete 271 followed by remission periods. Pain is always unilateral and is of a severe, penetrating, stabbing nature. The location of these headaches is orbital, periorbital, or temporal ( Fig. 33-4 ). • Most important differentiating feature of cluster headaches is the presence of transient autonomic symptoms. • read more..
272 SECTION VI • General Medical Problems in Athletes are severe, unilateral, throbbing, and last 4 to 72 hours) and are brought on by exercise. Those who experience exercise/ effort-induced migraines usually have a history of non– exercise-related migraines. • In one study, high-intensity bicycling for a duration of 30 seconds was shown to precipitate a typical read more..
33 • Headache in the Athlete 273 • Location, severity, and pain characteristics vary considerably. Most studies show that PTH is less common when the head trauma is more severe. • Tension-type headache is the most common PTH. • Women have a higher risk for developing PTH. • In a study of 443 high read more..
274 SECTION VI • General Medical Problems in Athletes proper acclimation to one altitude before climbing to a higher altitude. Pharmacologic treatments include: • Pretreatment with aspirin: Raises headache threshold; associated with less pronounced cardiorespiratory response to short-term exercise at altitude; can prevent headache. • Ibuprofen: More read more..
GENERAL CONSIDERATIONS Although athletes are probably as susceptible to most dermatologic disorders as the general population, there are some disorders that are more common in athletes. Table 34-1 describes common der- matologic lesions and gives examples of each. PROBLEMS CAUSED BY FRICTION AND PRESSURE Blisters Overview: Fluid-ﬁ lled read more..
276 SECTION VI • General Medical Problems in Athletes Diagnosis: Diagnosis is made through typical history and character- istic location over pressure points (differential diagnosis includes plantar warts [lack “black dots” of warts], bunions, and psoriasis). Treatment: The athlete may use a pumice stone to reduce the bulk of the callus or the read more..
34 • Skin Problems in the Athlete 277 Abrasions Overview: Also called road rash, turf burn, raspberry (term may be applied to both a fresh injury and the scar tissue left by an old one). Denuded epidermis and superﬁ cial dermis with punctuate bleeding and exudate. Presentation: Skin and subcutaneous tissue injury caused by read more..
278 SECTION VI • General Medical Problems in Athletes burns, oral ﬂ uids, maintain integrity of the overlying skin; oral and topical steroids may be required for moderate to severe burns to control inﬂ ammation and discomfort. Prevention: Sunscreen and sunblock (sweatproof/waterproof), protective clothing and hats, avoid midday sun from 10 a.m . to 4 read more..
34 • Skin Problems in the Athlete 279 Diagnosis: Appropriate history and physical ﬁ ndings. Treatment: Aluminum chloride (Certain Dry, Drysol, etc.) ap- plied before bed; after several weeks, may need application only once or twice a week. Iontophoresis units can be very useful. Return to play: As tolerated. Erythema read more..
280 SECTION VI • General Medical Problems in Athletes Diagnosis: Diagnose by typical clinical presentation, skin KOH scrapings, or fungal cultures. Treatment: • Over-the-counter preparations: Lotrimin Ultra (butenaﬁ ne) or LamisilAT (terbinaﬁ ne) are fungicidal against both derma- tophytes and yeasts, but need to be used twice daily for 2 read more..
34 • Skin Problems in the Athlete 281 Physical exam: Macular hypopigmented or hyperpigmented le- sions that start on the nape of the neck and may extend onto the shoulders, trunk, and arms in a fan-shaped pattern. Diagnosis: By typical lesions and/or pathopneumonic spaghetti- and-meatball appearance on KOH scrapings. Treatment: • read more..
282 SECTION VI • General Medical Problems in Athletes ated. Close follow-up to assess response to treatment and insure clinical cure. Return to play: Avoid contact with other players, shared equip- ment, and mats until no longer infective (dry with no dis- charge). Occlusive Folliculitis (Bikini Bottom) Overview: Common infection of the read more..
34 • Skin Problems in the Athlete 283 Viral Infections Verruca Vulgaris (Warts) Overview: Caused by human papilloma viral infection of the epi- dermis. May occur anywhere on the body; appears as a rough hyperkeratotic area that can become quite large. Presentation: Athletes may present with a painless lesion most often seen read more..
284 SECTION VI • General Medical Problems in Athletes including the areola and nipple. Burrows may be seen on the hands, feet, and groin. Diagnosis: Suspected when burrows are found or when a patient has typical symptoms with characteristic lesions and distribu- tion. Deﬁ nitive diagnosis is made with microscopically identi- ﬁ ed mites, eggs, egg casings, read more..
CONNECTIVE TISSUE DISORDERS Marfan Syndrome Overview: Inheritable autosomal-dominant genetic condition af- fecting the processing of ﬁ brillin. Caused by more than 400 mutations in the gene encoding ﬁ brillin-1 (FBN-1) located on chromosome 15 at q21 loci. Incidence is 1 in 3000 to 10,000 live births; an estimated 200,000 Americans have Marfan read more..
286 SECTION VI • General Medical Problems in Athletes • Prevention: Annual evaluation of eyes (ectopic lentis or lens dislocation), heart (valvular issues, aortic root dilatation or dissection), imaging of chest and abdomen (identifying/ following aortic dissections, aneurysms, or dilatation). • Vascular: Monitor any changes in aorta with annual echocar- read more..
35 • Connective Tissue and Rheumatologic Conditions in Sports 287 Ehlers-Danlos Syndrome (EDS) Overview: Group of inheritable genetic conditions that affect connective tissue, especially collagen in joints, vessels, skin, and internal organs. Variable severity seen within each type and within the same family of pedigree. The defect in the genes read more..
288 SECTION VI • General Medical Problems in Athletes Treatment: • General: Healthy lifestyle that includes exercise and diet to control lipids and systemic blood pressure. Medic-alert bracelet/necklace stating condition. • Prevention: Periodic evaluation of heart (e.g., valvular issues) and chest/abdomen (e.g., identifying/following aortic dissec- read more..
35 • Connective Tissue and Rheumatologic Conditions in Sports 289 ity of condition. Joint and bone protection is crucial both in activities of daily life and in selection of athletic and recreational activities. No cardiovascular limitation noted by the 36th Bethesda Guidelines. Allowed once fracture(s) have healed and matured both clinically and radiographically. read more..
290 SECTION VI • General Medical Problems in Athletes Treatment: • Discontinue smoking because it can accelerate lung scarring and decrease pulmonary functioning. • TNF-blockers: • Adalimumab 40 mg SC every other week • Etanercept 25 mg SC twice weekly • Inﬂ iximab 5 mg/kg IV read more..
35 • Connective Tissue and Rheumatologic Conditions in Sports 291 Diagnostic: History and physical exam. Radiographs (weight- bearing preferred in lower extremity). Bone scan will show moderate to severe arthritic changes in all joints of the body. Treatment: • Pain control (acetaminophen, tramadol, NSAIDs). • Physical read more..
292 SECTION VI • General Medical Problems in Athletes • Physical therapy • Physical activity and healthy lifestyle • Orthotics for foot deformities/pain • Joint replacement surgery, when conservative measures fail Prognosis: Depends on severity, responsiveness to medicines, ju- venile versus adult onset. read more..
35 • Connective Tissue and Rheumatologic Conditions in Sports 293 Diagnostic: • Common hematologic abnormalities: • Leukopenia (white blood count below 4500 cells 10 3 /mL in 43% to 66% of cases) • Mild anemia • Thrombocytopenia • Elevated sedimentation rate. • ANA read more..
294 SECTION VI • General Medical Problems in Athletes • Arterial angiography • Early ﬁ ndings: consistent with claudication • Late ﬁ ndings: show multiple ﬁ ne “cork-screw” shaped branches of distal arteries that end abruptly Treatment: • Eliminate contact with all tobacco products. read more..
35 • Connective Tissue and Rheumatologic Conditions in Sports 295 Return to play: Once a patient has been indentiﬁ ed and appropri- ately treated, there are relatively little contraindications for par- ticipation outside of those issues associated with chronic steroid use (e.g., weight gain, glucose intolerance, osteoporosis, etc.). RECOMMENDED READINGS read more..
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VII Injury Prevention, Diagnosis, and Treatment 36 Musculoskeletal Injuries in Sports 37 Comprehensive Rehabilitation of the Athlete 38 Physical Modalities in Sports Medicine 39 Head Injuries 40 Neck Injuries 41 Eye Injuries in Sports 42 Maxillofacial Injuries 43 Shoulder Injuries 44 Elbow Injuries 45 Hand and Wrist Injuries 46 Thorax and Abdominal Injuries 47 Thoracic and Lumbosacral Spine read more..
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GENERAL CLASSIFICATION OF MUSCULOSKELETAL SPORTS INJURIES Musculoskeletal sports injuries can be classiﬁ ed as traumatic inju- ries or overuse injuries. Traumatic Injuries Description: Result from speciﬁ c episode(s) of trauma, whether recent (acute) or in the more distant past (subacute or chronic). Bone Description: read more..
300 SECTION VII • Injury Prevention, Diagnosis, and Treatment EXERTIONAL RHABDOMYOLYSIS Description: Breakdown of skeletal muscle cells with leakage of cellular contents, including myoglobin, creatine kinase (CK), and aldolase through damaged sarcolemma into serum as result of prolonged, heavy, or repetitious exercise. read more..
36 • Musculoskeletal Injuries in Sports 301 with swelling, warmth, pain, and, occasionally, redness. Some synovitis is more localized (e.g., synovial plica of knee, peripatel- lar synovitis in extensor mechanism malalignment of knee; see Chapter 49 ). Ligament Description: There are few examples of pure overuse injuries to ligaments. Theoretically, read more..
302 SECTION VII • Injury Prevention, Diagnosis, and Treatment ply forces across adjacent joints, but athletes are generally able to support adjacent joints adequately, thus allowing examiner to apply more force to area in question. Strength is usually graded on a 0 to 5 scale (0 zero, 1 trace, 2 poor, 3 fair, 4 good, 5 normal). Most athletic applications read more..
36 • Musculoskeletal Injuries in Sports 303 • Poor posture, poor body mechanics, anatomic abnor- malities, poorly designed or sized workstation (especially computer worksite) • Disease (rheumatoid arthritis, multiple sclerosis) • Mental: fatigue, anxiety/stress, depression • Palpation of trigger points: read more..
INTRODUCTION The overall goal of rehabilitation is to enhance recovery of injured tissues and avoid stresses that may prove deleterious to the healing process. This is accomplished by understanding normal function, pathomechanics, and the healing processes of speciﬁ c tissues. Cur- rent research and scientiﬁ c evidence must establish guidelines for rehabilitation. read more..
37 • Comprehensive Rehabilitation of the Athlete 305 • The science of rehabilitation should be applied to all injuries and surgeries, especially rotator cuff repairs, SLAP (superior labral anterior posterior) repairs, meniscus repairs, and re- lated procedures. Prevent the Deleterious Eﬀ ects of Immobilization • Restriction of motion read more..
306 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Biofeedback can also be used to enhance voluntary control of injured musculature. • Clinically, NMES is used following injury or surgery while the patient performs isometric and isotonic extremity exercises. • NMES is typically used prior to biofeedback when the read more..
37 • Comprehensive Rehabilitation of the Athlete 307 • The rehabilitation specialist can also challenge the athlete by providing manual perturbations by striking the tilt board with his or her foot to create a sudden disturbance in the static support of the lower extremity; this requires the pa- tient to stabilize the board with dynamic muscular contrac- tions. read more..
308 SECTION VII • Injury Prevention, Diagnosis, and Treatment Gradually Restore Muscular Strength and Endurance • Gradually restore muscular strength after volitional muscle activity is achieved. • Baseline levels of muscular strength are needed before the athlete can progress to the later stages of rehabilitation. • read more..
37 • Comprehensive Rehabilitation of the Athlete 309 peripheral afferent stimulation with reﬂ exive and prepro- grammed muscle control and coactivation. • Drills may be modiﬁ ed based on speciﬁ c functional move- ment patterns that are unique to the patient’s sport. • Sport-speciﬁ c training can include side-to-side shufﬂ e, read more..
310 SECTION VII • Injury Prevention, Diagnosis, and Treatment • At approximately week 6 to 7, the Thrower’s Ten program is initiated; this program places emphasis on external rotator and scapula strengthening. • No isolated biceps strengthening should be performed for the ﬁ rst 8 weeks to protect the healing biceps attachment into the read more..
37 • Comprehensive Rehabilitation of the Athlete 311 7. Snyder-Mackler L, Ladin Z, Schepsis AA, Young JC : Electrical stimu- lation of the thigh muscles after reconstructing the anterior cruciate ligament: Effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles . J Bone read more..
INTRODUCTION Modalities are best thought of as an adjunct to the body’s own re- covery process. It would be a mistake to think of them as all that any patient needs to rehabilitate. However, they do have a role in therapy, especially in sports medicine, where any tool that hastens the return to play is valuable. Some may claim that certain mo- dalities are read more..
38 • Physical Modalities in Sports Medicine 313 • Injuries in which pain is the predominant symptom • Postoperative conditions • Preexisting injuries (immediately following activity) • Problems in which pain inhibits activity or therapy • Situations in which anesthesia is desired • read more..
314 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Increased cellular activity • Increased blood ﬂ ow • Increased tissue extensibility • Reduced muscle spasm • Reduced pain • Nonthermal effects • Acoustic streaming—movement of ﬂ uids along cell mem- read more..
38 • Physical Modalities in Sports Medicine 315 Interferential Current • Interferential current is another variation of EMS used for pain relief. • Main advantage is deeper penetration. • Uses four electrodes (two pairs of slightly different medium frequencies). • Arrange electrode pairs diagonally so read more..
316 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Muscle tissue has more dipoles and thus greater capacitance and requires more current to achieve desired effect • Fatty tissue and skin tissue have fewer dipoles and so have greatest heating • Inductance technique • Electromagnetic ﬁ eld generated read more..
GENERAL PRINCIPLES • Head injuries in sports are comparatively mild compared with those in high-velocity motor vehicle accidents, yet remain signiﬁ cant and important injuries for team physicians to evaluate and manage. • Concussion is the most common head injury in sports. Infor- mation is evolving regarding pathophysiology, diagnosis, nat- read more..
318 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Look at epidemiology when considering injury preven- tion. Before making rule or equipment change, consider inci- dence of injury and how change may affect sport. • Use of helmet in women’s lacrosse and ﬁ eld hockey may decrease incidence of facial lacerations, nasal read more..
39 • Head Injuries 319 • No current objective neuroanatomic or neurophysiologic measurements can be used practically and reliably to deter- mine if athlete has concussion. See “Diagnostic Testing.” • After concussion brain cells may be in state of injury-induced vulnerability; second injury during this time of heightened vulnerability may read more..
320 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Presentation: Decreased level of consciousness followed by lucid interval, deteriorating mental status with eventual loss of consciousness, headache, confusion, sleepiness, nausea, vom- iting. Only one third present classically with loss of conscious- ness followed by lucid interval and focal deﬁ cits. read more..
39 • Head Injuries 321 of consciousness ( 50%), headache, confusion, nausea, vom- iting, focal deﬁ cits (affected areas) (see Fig. 39-3 ). Symptoms may develop over hours or days. • Treatment: Many require emergent intervention to lower ICP and/or stop bleeding; depends on severity of clinical pre- sentation, bleed, and associated pathology. read more..
322 SECTION VII • Injury Prevention, Diagnosis, and Treatment Early Evaluation of Head Injuries • On ﬁ eld and sideline • A irway, b reathing, c irculation, d isability, e xposure (ABCDE) • Glasgow Coma Scale; evaluates best eye, verbal and motar response. Useful for predicting prognosis in severe head read more..
39 • Head Injuries 323 • Pay particular attention to repeat concussions with lesser impact forces and/or increasing duration of symptoms. • Assessment of other risk factors: intoxication, childhood and adolescence (to age 18), learning disability, use of anti- coagulants, hemophilia, inadequate postinjury supervision. • Close read more..
324 SECTION VII • Injury Prevention, Diagnosis, and Treatment same-day RTP can be considered in the adult athlete when symptoms are limited, resolve quickly, and a comprehensive evaluation by an individual with knowledge regarding sports concussion and one that includes normal cognitive and bal- ance testing is performed, with no additional modiﬁ ers pres- ent. All agree that read more..
39 • Head Injuries 325 • Treat each injury individually based on several factors including burden and duration of symptoms, age of athlete, prior history of concussions and sport, mismatch between force of impact, and subsequent injury ( see Appendix C ). • No athlete who is symptomatic (at rest or with exertion) after head injury read more..
INTRODUCTION Cervical spine injuries are most often seen in football and hockey but have occurred in wrestling, rugby, baseball, lacrosse, and mountain biking. Anatomy • There are seven cervical vertebrae and eight cervical nerves. • Spinal nerves exit above the vertebral body for which they are named; for example, the sixth cervical read more..
40 • Neck Injuries 327 • Six persons, who have practiced the maneuver prior to injury, must logroll the athlete onto a spine board and transport the athlete safely to the sidelines. • Helmet should not be removed but the airway must be pro- tected and maintained. • The patient with only pain is examined with palpation. read more..
328 SECTION VII • Injury Prevention, Diagnosis, and Treatment tional Collegiate Athletic Association (NCAA) has banned the use of hitting with the crown of the head. After this technique was banned there was a drop in the rate of catastrophic cervical injuries. Diagnostics: X-rays may show cervical stenosis with a positive Torg ratio ( 0.8). There is usually a read more..
40 • Neck Injuries 329 Diagnostics: Plain ﬁ lms and CT scan should be diagnostic. Treatment: This is an unstable injury and referral to an orthope- dic spine surgeon or neurosurgeon should be performed. Prognosis and return to play: This player will likely not be al- lowed to return to play. C2 Fractures read more..
330 SECTION VII • Injury Prevention, Diagnosis, and Treatment eral facet dislocation. Greater than 3.5 mm of displacement of the posterior vertebral line of one vertebra compared to the other vertebral body denotes instability. CT scans should be performed as well, which will pick up fractures of the facets and give an overall indication of the force and treatment pattern. read more..
40 • Neck Injuries 331 9. Sherbondy PS, Hertel JN, Sebastianelli WJ : The effect of protective equipment on cervical spine alignment in collegiate lacrosse players . Am J Sports Med 34 : 1675 - 1679 , 2006 . 10. Tarazi F, Dvorak MFS, Wing PC : Spinal injuries in skiers and snow- boarders . Am J Sports Med read more..
INTRODUCTION • More than 42,000 sports and recreation-related eye injuries were reported in 2000. Seventy-two percent occurred in individuals younger than 25 years; 43% in people younger than 15. • About 1.5% of all sports injuries involve the eye or ocular adnexa; these injuries have a high morbidity rate. • In the United read more..
41 • Eye Injuries in Sports 333 • Over-the-glasses protector that conforms to the appropri- ate ASTM standard. CERTIFICATION AND SELECTION OF EYEWEAR • Several organizations certify sports protective eyewear. These include the Protective Eyewear Certiﬁ cation Council (PECC), Canadian Standards Association (CSA), Hockey Equipment read more..
334 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Confrontational visual ﬁ eld testing: Examiner tests visual ﬁ elds in all four quadrants of each eye using his or her own eye as a control. • Inspection: Look for signs of external trauma, bruising, full- ness, or subcutaneous emphysema. Mild external trauma can be a sign read more..
41 • Eye Injuries in Sports 335 such as Voltaren or Acular are modestly useful in reducing pain. • Generally, avoid topical corticosteroid preparations except in complicated cases, because they can encourage fungal and vi- ral infections. • In corneal abrasions in contact lens wearers, patients need gram-negative antibiotic coverage. An read more..
336 SECTION VII • Injury Prevention, Diagnosis, and Treatment sudden pressure increases transmitted to eye from surrounding orbital tissue. Blunt Trauma to Orbit RUPTURED GLOBE Description: Occurs when the full thickness of the cornea or sclera is breached. The potential for serious morbidity of the eye is present with this injury. read more..
41 • Eye Injuries in Sports 337 obvious interruption or herniation of orbital tissue, there is no need to delay deﬁ nitive repair. Prognosis: Varies depending on degree of injury. Prognosis is best when orbital tissue damage is minimal. Prolonged tissue entrap- ment and inﬂ ammation can result in ﬁ brosis and contractures, which can lead to permanent read more..
338 SECTION VII • Injury Prevention, Diagnosis, and Treatment for sleep may enhance settling of the hemorrhage. Emergent con- sultation is required if hemorrhage resulted from trauma. Prognosis: Varies depending on location, extent, and severity of involvement. A chance for recovery of good central vision is gen- erally poor if retina becomes detached in the area read more..
41 • Eye Injuries in Sports 339 Full face protector: Designed for use in conjunction with eye protectors for high-risk sports that do not require protection for brain: fencing, some positions in baseball and softball. Helmet with separate eye protectors: For use in sports with low risk for injuries to lower face and neck: cycling, snowmobiling, read more..
INTRODUCTION General Considerations Epidemiology • 3% to 29% of facial injuries are a result of sporting activity. • 60% to 90% of facial injuries in sports occur in males between the ages of 10 and 29. • Approximately 75% of facial fractures occur in the zygoma, mandible, or nose. • The most read more..
42 • Maxillofacial Injuries 341 Imaging Studies Conventional Radiography • Conventional radiography is rarely used for nasal bone evalu- ation because imaging adds little to clinical exam; however, if needed, most common x-rays of the nose include right and left lateral, superoinferior axial occlusal, and Waters’ views. read more..
342 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Attempt to minimize sutures in cartilage. • Use undyed absorbable 6-0 suture for cartilage and perichon- drium. Otitis Externa (“Swimmer’s Ear”) Mechanism of injury: Anything that injures the thin ear canal skin, especially in athletes with water in the read more..
42 • Maxillofacial Injuries 343 Return to play: Facial protection can be purchased off the shelf or individually fabricated for athletes in contact or collision sports such as basketball or soccer. Athletes can return to contact/ collision sports with the facemask in approximately 4 weeks. Many athletes return earlier than 4 weeks with the understand- ing that read more..
344 SECTION VII • Injury Prevention, Diagnosis, and Treatment teeth) or bone plating. With wiring, the jaw is immobilized for 4 to 6 weeks; with bone plating, can move jaw immediately but chewing is limited for approximately 4 weeks. With bone plat- ing, airway issues, oral hygiene, and diet are less problematic. Infection, unfortunately, is not uncommon. read more..
42 • Maxillofacial Injuries 345 Zygoma Fractures Mechanism of injury: Usually from direct force to cheek. Often associated with orbital ﬂ oor fracture. Can affect root of maxil- lary teeth. Affects the anterior wall of the maxillary sinus. Also known as tripod fractures, tetrapod fractures, and malar complex fractures. Examination: read more..
HISTORY • A careful history will help establish the diagnosis and formu- late a treatment plan. • Important factors include the chief complaint, mechanism of injury, hand dominance, what sport the athlete plays, and prior treatments. • Common complaints are “pain with overhead activities,” “pain at night when I lie on that read more..
43 • Shoulder Injuries 347 ation of the humeral head that is then reduced with a “jerk” when extending the arm (see Fig. 43-2 ). Multidirectional Sulcus sign: Traction is applied to the arm in an inferior direction by grasping the elbow while observing the area lateral to the acromion for a “sulcus.” Presence of a sulcus indicates read more..
348 SECTION VII • Injury Prevention, Diagnosis, and Treatment Cross-arm adduction test: The arm is ﬂ exed 90 degrees and then adducted across chest. A positive test causes pain at the AC joint (see Fig. 43-2 ). O’Brien’s test: Can cause pain localized to the AC joint and should be distinguished from pain deep within the shoulder. read more..
43 • Shoulder Injuries 349 True AP (Grashey view): Taken in plane of scapula. Provides true anteroposterior (AP) view of glenohumeral (GH) joint by angling beam approximately 45 degrees in medial-to-lateral direction or by rotating patient and placing scapula ﬂ at on x-ray cassette. Axillary view: Important for evaluating dislocations. Useful for read more..
350 SECTION VII • Injury Prevention, Diagnosis, and Treatment Treatment: • Acute anterior dislocations require reduction. Several reduc- tion methods have been described. The Stimson technique is a relatively atraumatic technique. The patient is placed prone and weights are placed on the affected wrist (see Fig. 43-3 ). A variation of this read more..
43 • Shoulder Injuries 351 objects at one’s side is indicative of instability in the inferior di- rection. Physical exam: Look for signs of generalized laxity, such as hyper- extension of the elbows or ability to bring the thumb to the forearm. A positive sulcus sign indicates inferior instability. Ap- ply the tests described earlier to evaluate for read more..
352 SECTION VII • Injury Prevention, Diagnosis, and Treatment pression injury occurs when falling onto an outstretched slightly abducted arm. Classiﬁ cation: The original classiﬁ cation by Snyder described four types of lesions. Many additional types have since been added. The original four types are described below. Type II lesions are the most common read more..
43 • Shoulder Injuries 353 • Jobe relocation test: Initially described for anterior instability. Patients with internal impingement report posterior-superior shoulder pain with the arm abducted and externally rotated. This pain improves when applying a posteriorly directed force on the humerus, effectively centering the humeral head on the glenoid and reducing the read more..
354 SECTION VII • Injury Prevention, Diagnosis, and Treatment Differential diagnosis: Impingement, AC joint arthritis, biceps pathology, GH instability, adhesive capsulitis, cervical radicu- lopathy. Diagnostics: • X-rays: AP to look for proximal migration of the humeral head, which would indicate a chronic tear. • MRI: read more..
43 • Shoulder Injuries 355 Differential diagnosis: Rotator cuff disease, infection, hyperpara- thyroidism, clavicle fracture, AC separation. Diagnostics: • Zanca view reveals osteopenia and expansion of the distal clavicle. Joint space widening and cysts may be present as well. • Bone scan is sensitive and is useful in cases in read more..
356 SECTION VII • Injury Prevention, Diagnosis, and Treatment tions should be withheld from sports for 6 to 8 weeks. Those with posterior dislocations should be withheld for a longer dura- tion to allow for complete ligament healing, given the potential complications associated with a recurrent posterior dislocation. Little Leaguer’s Shoulder read more..
43 • Shoulder Injuries 357 pain around chest, axilla, and upper arm associated with weak- ness and painful limited motion. Physical exam: Acutely, swelling and ecchymosis will be present over anterior chest wall and upper arm (if distal injury). Weak- ness will be evident with resisted adduction and internal rota- tion. Distal injuries will often have a palpable read more..
358 SECTION VII • Injury Prevention, Diagnosis, and Treatment Mechanism of injury: Sports-related fractures are usually caused by a high-energy impact or are avulsion fractures of the greater or lesser tuberosity associated with a dislocation. Fractures in the older population result from a fall onto the shoulder or out- stretched arm. Presentation: Pain, read more..
43 • Shoulder Injuries 359 Treatment to address this intra-articular pathology also success- fully decompresses the cyst. Prognosis and Return to Play: Once near normal strength and motion has returned. Scapular Dyskinesia Description: Abnormal motion of the scapula in relation to the thoracic cage and a visible altered position of read more..
GENERAL PRINCIPLES History and Physical Exam History: Hand dominance, location/type of pain, duration, mech- anism of injury, alleviating/exacerbating factors, history of previ- ous injuries, treatments rendered, recent changes in technique or training regimen, results of previous treatment. Physical exam: • Inspection: Compare to uninjured read more..
44 • Elbow Injuries 361 Prognosis and return to play: Usually a season-ending injury; patients treated early can be expected to have full return of power and function. Pronator Syndrome (Median Nerve Entrapment) Description: Compression of the median nerve at the level of the elbow with resultant nerve irritation ( Fig. 44-3 read more..
362 SECTION VII • Injury Prevention, Diagnosis, and Treatment often have tenderness to palpation 4 cm distal to the anterior el- bow skin fold in addition to painful resisted pronation; if the nerve is compressed by the ﬂ exor digitorum superﬁ cialis (FDS) arch, patients can have pain with resisted middle ﬁ nger ﬂ exion. Differential diagnosis: read more..
44 • Elbow Injuries 363 Presentation: Less common in adult throwers than adolescents and children; patients usually report gradual onset of pain in the posterior or lateral elbow that occurs during the acceleration phase of throwing. Physical exam: Normal neurovascular exam and range of motion; focal point tenderness to palpation over olecranon without read more..
364 SECTION VII • Injury Prevention, Diagnosis, and Treatment Flexor-Pronator Strain Description: Acute injury to the ﬂ exor-pronator mass immediately distal to the common tendon origin at the medial epicondyle. Mechanism of injury: Can occur with a valgus stress to the elbow causing partial rupture/microrupture of the ﬂ exor read more..
44 • Elbow Injuries 365 Ulnar Nerve Compression Syndrome Description: Also known as cubital tunnel syndrome; compres- sion of the ulnar nerve as it crosses the elbow joint. Mechanism of injury: May be incited by trauma, cubitus valgus deformity, or subluxing ulnar nerve at the medial epicondyle. Also seen in weightlifters read more..
366 SECTION VII • Injury Prevention, Diagnosis, and Treatment Prognosis and return to play: Nonoperative treatment is suc- cessful in 80% to 90%; 6 to 12 week course. Of surgical cases, 85% returned to full activity by 6 months. Radiocapitellar Chondrosis Description: Damage to the articular cartilage of the radius and capitellum read more..
44 • Elbow Injuries 367 Prognosis and return to play: Nonoperative management usually successful (80%); full return to sports usually by 4 to 8 weeks; surgical release highly effective (90%), return 6 to 8 weeks. DISLOCATIONS AND FRACTURE- DISLOCATIONS Description: Fracture of the radius, ulna, or humerus, with or with- out read more..
GENERAL PRINCIPLES AND EVALUATION Overview • Fortunately, most sports-related hand and wrist injuries, when addressed in a timely manner, do not represent a signiﬁ cant threat to limb viability, long-term function, or eventual return to sport. • Perhaps the greatest morbidity from these injuries results from delayed presentations or missed read more..
45 • Hand and Wrist Injuries 369 irrigated, and the nail matrix repaired with 6-0 or 7-0 resorbable suture. The adjacent skin rip is repaired with 5-0 nylon. Under- lying phalangeal tuft fracture is managed nonoperatively. Associ- ated displaced fracture of the distal phalangeal shaft, however, requires washout and perhaps surgical stabilization. Prognosis and return to read more..
370 SECTION VII • Injury Prevention, Diagnosis, and Treatment the level of proximal retraction. Bony avulsions tend to become incarcerated along the ﬂ exor sheath (often at the A4 pulley over the middle phalanx). Loss of active DIP joint ﬂ exion is most speciﬁ c ﬁ nding. Differential diagnosis: Distal phalanx fracture, DIP joint dis- location. read more..
45 • Hand and Wrist Injuries 371 Presentation: Usually same as PIP dislocation; can be difﬁ cult to differentiate from dislocation clinically. Physical exam : Swelling, deformity at PIP joint, point tenderness and crepitance at PIP joint. Differential diagnosis: Volar plate injury without dislocation, PIP dislocation or shaft fracture of read more..
372 SECTION VII • Injury Prevention, Diagnosis, and Treatment slight ﬂ exion (see Fig. 45-6 ). However, in the immediate phase, the patient may be able to maintain PIP extension through the lateral bands, which have not yet migrated palmarly. Physical exam: Palpate for tenderness directly over the central slip insertion on the dorsal middle phalangeal base. read more..
45 • Hand and Wrist Injuries 373 Prognosis and return to play: Flexor tendon rehabilitation requires 6 to 8 weeks of extensive ROM therapy and up to 12 weeks for strengthening before returning to sports that re- quire gripping and grasping. Phalangeal Fractures Description: May occur as simple transverse patterns with mini- mal read more..
374 SECTION VII • Injury Prevention, Diagnosis, and Treatment Presentation: Painful, impaired grip. MP joint usually diffusely swollen in the subacute phase; resting angular deformity may or may not be visible at the MP joint. In RCL injuries, as swelling subsides, metacarpal head may appear prominent because of “sagging” of the radial aspect of the joint from read more..
45 • Hand and Wrist Injuries 375 Diagnostics: Physical examination is the mainstay in initial diag- nosis. AP, lateral, and oblique radiographs are required, because up to 50% of such injuries have an associated fracture. Simple dislocation will demonstrate the proximal phalanx hyperex- tended 90 degrees; complex dislocation may demonstrate exces- sive joint read more..
376 SECTION VII • Injury Prevention, Diagnosis, and Treatment proximal pole should be assessed by palpation at the scapholu- nate joint just distal to the dorsal radial tubercle. The distal scaphoid pole can be palpated at the scaphotrapezial joint, deep to the intersection of the ﬂ exor carpi radialis tendon and wrist ﬂ exion crease. Forced passive wrist extension read more..
45 • Hand and Wrist Injuries 377 offering treatment at the time of diagnosis. Isolated deep tears of the TFCC insertion may not be visible on arthroscopic evalu- ation and may be better seen with an MR arthrogram. Treatment: Many TFCC tears, both traumatic and degenerative, may be minimally symptomatic and not require treatment. If the athlete is in season read more..
378 SECTION VII • Injury Prevention, Diagnosis, and Treatment can occur in combination, however, and tenderness over the scaphoid as well as the radius should lead to assessment with appropriate plain ﬁ lms. Diagnostics: PA and lateral plain ﬁ lms usually sufﬁ cient. CT scan- ning may be useful for surgical planning for fractures with intra- articular read more..
INTRODUCTION General Overview • Injuries to the thorax and abdomen are more often seen in sports involving sudden deceleration and impact (football, ice hockey, skiing, and snowboarding). • Early recognition and management of these potentially life- threatening injuries is imperative. Repeated assessment and a high index of suspicion are read more..
380 SECTION VII • Injury Prevention, Diagnosis, and Treatment pain have no signiﬁ cant abdominal injury. Always examine the chest and spine when evaluating an abdominal complaint, and consider examining the inguinal and pelvic regions. • Frequent monitoring of vital signs, including orthostatics, is important to gauge the cardiovascular status, and the respira- tory read more..
46 • Thorax and Abdominal Injuries 381 Diagnostics: Obtain plain x-rays with 40-degree cephalic tilt view (“serendipity” view). Tube distance for children, 45 inches; for thicker-chested athletes, 60 inches. CXR to rule out pneumo- thorax. Axial CT images (3-mm cuts) have greater sensitivity and speciﬁ city and are imaging modality of choice for the SCJ; can read more..
382 SECTION VII • Injury Prevention, Diagnosis, and Treatment Physical exam: Localized tenderness, ecchymosis, and edema; crepitus over fracture site; palpable deformity of rib if fracture displaced; shallow, rapid breathing; with anteroposterior and transverse compression of rib cage, pain at site of suspected in- jury; subcutaneous emphysema with pleural injury. read more..
46 • Thorax and Abdominal Injuries 383 rotation, ﬂ exion, and adduction of arm on affected side; defor- mity of chest wall and palpable muscle bulge with resisted ad- duction; with abduction, defect in anterior axillary fold if tendon is avulsed at its insertion. Shoulder ROM limited by pain. Differential diagnosis/associated injuries: Pectoralis muscle read more..
384 SECTION VII • Injury Prevention, Diagnosis, and Treatment Prognosis and return to play : No sport-speciﬁ c guidelines exist for return to play. With mild pulmonary contusion and no CXR ﬁ nd- ings, gradual return to progressive activity after symptoms resolve (between 2 and 10 days). Traumatic pseudocysts can develop fol- lowing a contusion; follow-up read more..
46 • Thorax and Abdominal Injuries 385 Presentation: Rapidly increasing shortness of breath, asymmetry of respiration (see Fig. 46-4 ). Physical exam: Distended neck veins, cyanosis, hypotension and tachycardia, dyspnea and tachypnea, shift of the trachea away from the injured side, absent breath sounds on involved side; hyper-resonance on percussion of read more..
386 SECTION VII • Injury Prevention, Diagnosis, and Treatment venous inﬂ ow and diastolic ﬁ lling, and cardiac output is dimin- ished ( Fig. 46-5 ). Shock and death can rapidly evolve without early recognition and treatment. Mechanism of injury: Blunt trauma to chest, most commonly from high-energy collisions. Presentation: Symptoms can be read more..
46 • Thorax and Abdominal Injuries 387 tal. Return to play decisions should be made with consultation of cardiologist and/or cardiothoracic surgeon. Thoracic Outlet Syndrome Description: Spectrum of signs and symptoms resulting from com- pression of neurovascular bundle (brachial plexus and subclavian and axillary arteries and veins) in interval between read more..
388 SECTION VII • Injury Prevention, Diagnosis, and Treatment including trapezius and suboccipital region. People who sleep with arms above head may awaken with symptoms at night. • Arterial compression symptoms: Hand feels cold, arm be- comes numb and fatigued with rapid overhead movement. • Venous compression symptoms: Swelling and read more..
46 • Thorax and Abdominal Injuries 389 MRI or CT scan may be used to assist in differentiation between intra-abdominal injury and hematoma ( Fig. 46-7 ). Treatment: Ice, activity modiﬁ cation, and NSAIDs; local heat after 48 to 72 hours. Avoid activities that require rotation, stretching, or ﬂ exion of trunk or lower extremities. Rehabilita- tion read more..
390 SECTION VII • Injury Prevention, Diagnosis, and Treatment rapid respirations suggest internal bleeding. Fixed dullness in left ﬂ ank (Ballance’s sign). Differential diagnosis/associated injuries: Left-sided 11th and 12th rib fractures, abdominal contusions. Diagnostics: Imaging studies: Flat-plate abdominal x-rays may show fading splenic outline and read more..
46 • Thorax and Abdominal Injuries 391 Prognosis and return to play: Higher morbidity and mortality when pancreatic injuries are not recognized in ﬁ rst 24 hours. No return to play guidelines; progressive return to play following anatomic and functional healing. Hernias Description: Three most common hernias in adults are indirect read more..
392 SECTION VII • Injury Prevention, Diagnosis, and Treatment ioinguinal nerve is occasionally trapped in scar tissue within torn aponeurosis. • Other: Muscular strain, hydrocele, or varicocele. Treatment: Prompt surgical repair for large or symptomatic her- nias. Surgical exploration and repair for chronic groin pain with inability to perform sport read more..
INTRODUCTION General Principles • With an increased number of adults and adolescents partici- pating in ﬁ tness programs and competitive sports there has been an increase in thoracic and lumbar spinal problems. • Most injuries are soft tissue injuries and proper training and avoidance of aggravating activities may allow participation while read more..
394 SECTION VII • Injury Prevention, Diagnosis, and Treatment History and Physical Examination History Information obtained in the history and physical examination is critical. The following questions are particularly relevant. When and how did your symptoms start? Mechanism of injury can help locate the damage. Onset can be telling read more..
47 • Thoracic and Lumbosacral Spine Injuries 395 Physical Examination Should address inspection, palpation, and percussion and identify: • Exact location of tenderness, dysesthesias, or numbness • Maneuvers that reproduce the pain • Presence of neural tension signs • Deﬁ cits in range of motion read more..
396 SECTION VII • Injury Prevention, Diagnosis, and Treatment Special Tests Pain from Neural Source Straight leg raise test (SLR): Tension test that indicates nerve irritation in the sciatic nerve if positive with radicular pain at less than 60 to 70 degrees of leg elevation ( Fig. 47-3 ). SLR with foot dorsiﬂ read more..
47 • Thoracic and Lumbosacral Spine Injuries 397 Differential diagnosis: Cervical and lumbar herniated discs, tu- mors (benign, primary, metastatic, neural, bone, malignant), fractures (both stress and traumatic), spine or rib ( Fig. 47-5 ). Diagnostics: Diagnosis is conﬁ rmed with MRI or myelogram with CT. Treatment: Nonoperative read more..
398 SECTION VII • Injury Prevention, Diagnosis, and Treatment Presentation: Acute onset, back pain, no neurologic complaints. Physical exam: Localized tenderness, with or without spasm. Differential diagnosis: Stress reaction or fracture, SI joint pain. Diagnostics: X-rays may not be required by history or exam but will be normal read more..
47 • Thoracic and Lumbosacral Spine Injuries 399 tests are positive and a neurologic exam may reveal numbness and weakness. Differential diagnosis: Stress fracture to lumbar spine, sacrum, or pelvis, anular tear with referred pain, plexopathy, peripheral neuropathy or nerve injury, SI joint pain, fracture (see Figs. 47-6 and 47-7 ). Diagnostics: Plain read more..
400 SECTION VII • Injury Prevention, Diagnosis, and Treatment one or both sides, worse with motion or running. Often has onset in strength and conditioning workouts. Physical exam: Extension and one-legged extension tests are positive. Neurologic exam is negative; tension tests are negative. Pain may occur with rotation or side bending. Differential read more..
47 • Thoracic and Lumbosacral Spine Injuries 401 Spondylolisthesis Description: One vertebral body is slipping relative to another (spondylo spine, listhesis slippage) (see Fig. 47-9 ). Usually the upper body is slipping forward on the body below, resulting in a kyphotic deformity at the slip and a reactive lordosis above. • read more..
402 SECTION VII • Injury Prevention, Diagnosis, and Treatment Treatment: Varies from observation to bracing to surgery, de- pending on age and type of curve. If the curvature is less than 20 degrees, then no active treatment is required but reassess- ment should be every 4 to 6 months until skeletally mature. If the curve is 25 degrees or more or if read more..
47 • Thoracic and Lumbosacral Spine Injuries 403 strong and allow limited motion while constrained with strong anterior and posterior ligaments; possess a synovial membrane. Mechanism of injury: Injury, contracture, or inﬂ ammation of the SI joint. Presentation: Patients may present with a traumatic history or they may be involved in jumping sports read more..
GENERAL PRINCIPLES Overview The last decade has brought a pronounced increased awareness and understanding of disorders around the hip and pelvis. More accurate diagnoses have led to more speciﬁ c treatment strategies. Proper management can allow athletes to successfully recover and resume their activities. Anatomy The constrained bony architecture of the read more..
48 • Pelvis, Hip, and Thigh Injuries 405 • The deep layer includes posterior, lateral, anterior, and medial groups (see Fig. 48-1 ). • The lower extremity receives its innervation from the lumbo- sacral plexus, which forms the sciatic femoral and obturator nerves as well as various smaller branches. • The hip receives read more..
406 SECTION VII • Injury Prevention, Diagnosis, and Treatment History and Physical Examination Onset of Symptoms • A history of signiﬁ cant trauma is a more favorable indicator of a potentially correctable problem. • Insidious or gradual onset symptoms reﬂ ect underlying de- generative disease or predisposition to read more..
48 • Pelvis, Hip, and Thigh Injuries 407 • Patrick, or FABER (ﬂ exion, abduction, external rotation), test may provoke symptoms from either the hip or the SI joint. • Straight leg raise test is used to assess tension signs associated with lumbar nerve root irritation. An active straight leg raise, or leg raise against resistance, may read more..
408 SECTION VII • Injury Prevention, Diagnosis, and Treatment Adductor Strain Description: “Pulled groin muscle”; adductor injuries are espe- cially common in ice hockey and soccer. The adductor longus is the most frequently injured (see Fig. 48-1 ). Adductor involve- ment may be a component of athletic pubalgia (see “ Athletic Pubalgia ”). read more..
48 • Pelvis, Hip, and Thigh Injuries 409 Presentation: Anterior hip and groin pain. Physical exam: Localized tenderness to palpation is usually pres- ent. Pain with resisted hip ﬂ exion is usually present, but variable. Absence of signiﬁ cant discomfort with passive hip ﬂ exion with internal rotation distinguishes this from an irritable hip read more..
410 SECTION VII • Injury Prevention, Diagnosis, and Treatment Prognosis and return to play: Participation to tolerance is ap- propriate and successful return has been reported following surgical release. Pudendal Nerve Description: Common in cyclists; reported as a complication of hip arthroscopy. Mechanism of injury: Caused by read more..
48 • Pelvis, Hip, and Thigh Injuries 411 Diagnostics: Imaging studies are rarely beneﬁ cial in substantiat- ing the diagnosis of iliotibial band, but may be useful to rule out other causes. Treatment: It is difﬁ cult to cure the snapping, but modiﬁ cation of offending training activities may be beneﬁ cial in diminishing the read more..
412 SECTION VII • Injury Prevention, Diagnosis, and Treatment irritability and can be difﬁ cult to distinguish from intra- articular pathology. Differential diagnosis: Intra-articular pathology, muscle strain, avascular necrosis (AVN), or neoplasm. Diagnostics: Radiographs are important but may fail to detect a lesion in almost half of cases. Radionuclide read more..
48 • Pelvis, Hip, and Thigh Injuries 413 drogens. Sites of involvement in order of decreasing frequency include the anterior superior iliac spine, ischium, lesser trochanter, anterior inferior iliac spine, iliac crest, and greater trochanter. Mechanism of injury: As with strains, the injury is usually the result of a sudden ballistic maneuver with accompanying read more..
414 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Disrupted ﬁ bers of the ligamentum teres can be selectively debrided (see Fig. 48-7 ). • Careful evaluation must be performed to assess for associated etiologic factors such as impingement or dysplasia, which may need to be addressed. Prognosis and return to read more..
48 • Pelvis, Hip, and Thigh Injuries 415 mal forces created by the altered morphology. With cam im- pingement, the bump on the anterolateral femoral head glides underneath the labrum, engaging the articular surface, resulting in delamination with a variable amount of associated labral pa- thology. With pincer impingement, the labrum becomes crushed against the neck of the femur, read more..
416 SECTION VII • Injury Prevention, Diagnosis, and Treatment Prognosis and return to play: Surgical intervention has a high success rate at diminishing symptoms. However, returning to the rigors of competitive sports is more variable and is dictated by the severity of damage at the time of surgery. Whether or not these procedures alter the natural read more..
PHYSICAL EXAMINATION Anatomy of the Knee See Figure 49-1 . Observation and Measurement Standing Alignment of lower extremities: View patient from front, side, and back. Angular and rotational deformities: Excessive valgus, varus, re- curvatum, ﬂ exion contracture, femoral or tibial torsion. Foot alignment and read more..
418 SECTION VII • Injury Prevention, Diagnosis, and Treatment Vastus medialis obliquus/vastus lateralis (VMO/VL) relation- ship: With patient’s knees held actively at 45 degrees of ﬂ exion ( Fig. 49-2 ), distal one-third of vastus medialis normally should present as substantial muscle from adductor tubercle inserting into upper one-third to one-half of medial read more..
49 • Knee Injuries 419 joint line opening. Perform at 30 degrees of ﬂ exion and then at full possible extension or hyperextension (see Fig. 49-3 ). External rotation recurvatum test: Patient is supine and relaxed. Lift entire lower extremity by ﬁ rst toe. Observe for excessive recurvatum and external rotation of proximal tibia (tibial tuber- osity) and read more..
420 SECTION VII • Injury Prevention, Diagnosis, and Treatment KNEE LIGAMENT INJURIES Medial Ligaments Description: Injury to medial (tibial) collateral ligament and/or medial capsular ligament ( Fig. 49-4 ). Mechanism of injury: Valgus force applied to knee with external tibial rotation; may be noncontact twist or a read more..
49 • Knee Injuries 421 Examination: Positive valgus stress test at 30 degrees ﬂ exion. Compare with opposite knee. An injured medial collateral liga- ment (MCL) along with disrupted ACL or PCL will result in more gap occurring with a valgus stress test, particularly notice- able when knee is tested in extension. Frequently, but not al- ways, positive read more..
422 SECTION VII • Injury Prevention, Diagnosis, and Treatment Examination: Acute, large hemarthrosis, positive Lachman test. Chronic, positive Lachman test, positive pivot shift test or jerk test. Perhaps positive anterior drawer sign, but not reliable. Do not rely on anterior drawer sign. Imaging: Lateral capsular sign; avulsion of tibial spine may be read more..
49 • Knee Injuries 423 Imaging: Unusual to ﬁ nd patella still dislocated on x-ray, because positioning on x-ray table usually reduces dislocation. Infrapa- tellar view may show avulsion of medial edge of patella. Large osteochondral fracture may be visible. Important to take in- frapatellar view with knee ﬂ exed only 30 to 45 degrees, rather than read more..
424 SECTION VII • Injury Prevention, Diagnosis, and Treatment there has been an acute injury on symptomatic side. Mild effu- sion; positive hypermobility and apprehension test. Imaging: Infrapatellar x-ray view must be done with proper tech- nique and knee ﬂ exed only 30 to 45 degrees; may show lateral tilt and/or lateral subluxation or be normal in appearance. read more..
49 • Knee Injuries 425 Examination: Findings predisposing to extensor mechanism prob- lems in both legs; pain on patellofemoral compression test; crepitation about patella on range of motion; tenderness to pal- pation around patella. Mild effusion may be present. Foot mal- alignment or leg length inequality may aggravate symptoms. Imaging: Same as for read more..
426 SECTION VII • Injury Prevention, Diagnosis, and Treatment superolateral pole of patella or VMO insertion into superome- dial pole of patella. Rupture of the quadriceps mechanism may occur with or without a history of tendonitis following forceful knee ﬂ exion against resistance (see Fig. 49-6 ). Mechanism of injury: Same as for patellar tendinitis. read more..
49 • Knee Injuries 427 Mechanism of injury: Usually overuse; much less commonly, single episode of strain. Popliteus tendinitis is usually running injury. Predisposing factors: For semimembranosus, pes anserinus, or biceps femoris tendinitis, hamstring tightness predisposes. Presentation: Complaints of pain over appropriate tendon area; for popliteus read more..
428 SECTION VII • Injury Prevention, Diagnosis, and Treatment 10. Majewski M, Susanne H, Klaus S : Epidemiology of athletic knee inju- ries: A 10-year study . Knee 13 ( 3 ): 184 - 188 , 2006 . 11. Quarles JD, Hosey RG : Medial and lateral collateral injuries: Progno- sis and treatment . Prim Care 31 ( 4 read more..
GENERAL PRINCIPLES OF EVALUATION • Leg and ankle are structurally and functionally united and evaluation of one must include the other ( Fig. 50-1 ). • Leg is composed of four fascial compartments that are in continuity with the ankle and foot via tendons, nerves, and blood vessels. • Acute injuries to the leg that read more..
430 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Determine the type of shoe wear and any orthoses that have been used leading up to and just after the onset of symptoms. PHYSICAL EXAMINATION Inspection • Evaluate skin for abrasions or lacerations; check for any bleeding that has fat globules that read more..
50 • Ankle and Leg Injuries 431 Superficial fibular (peroneal) nerve (cut) Fibularis (peroneus) longus tendon Fibularis (peroneus) brevis muscle and tendon Extensor digitorum longus muscle and tendon Fibula Perforating branch of fibular (peroneal) artery Anterior lateral malleolar artery Lateral malleolus Lateral branch of deep peroneal nerve (to muscles of dorsum of foot) and lateral read more..
432 SECTION VII • Injury Prevention, Diagnosis, and Treatment an acute injury, the pressure measurement is an important part of the evaluation, but it is not the sole determinant. Pain in ex- cess of what would be expected with the injury, palpation of a hard and tender muscle compartment, and severe pain with pas- sive motion of the suspected muscles are strong clinical read more..
50 • Ankle and Leg Injuries 433 Acute Fibular Shaft Fractures Description: Associated with tibial fractures and are more likely with higher energy injuries. Fibula bears only 15% to 20% of the weight and alignment is often achieved with satisfactory alignment of the tibia. A seemingly low-energy ﬁ bular shaft fracture can be associated with read more..
434 SECTION VII • Injury Prevention, Diagnosis, and Treatment maintained anatomically reduced are well treated with cast im- mobilization. Transition to full weight bearing and a functional brace or removable cast can usually begin within 2 to 3 weeks, depending on the injury. Chronic Exercise-Induced Leg Pain Tibial Stress Fractures Description: read more..
50 • Ankle and Leg Injuries 435 dures, with no technique having clear superiority. Postoperative physical therapy and rehabilitation are critical to outcome. Achilles Tendinopathy (Noninsertional) Description: Peritendinitis is a thickening and inﬂ ammation of the peritendinous tissue and is associated with acute pain; tendi- nosis is a degenerative read more..
436 SECTION VII • Injury Prevention, Diagnosis, and Treatment Presentation: May include recent trauma, but this is not always the case in chronic peroneal tendon problems. Examination: Some have suggested that the cavovarus foot pos- ture is a risk factor for developing peroneal tendon pathology. Pain in the lateral retromalleolar region that is read more..
50 • Ankle and Leg Injuries 437 as the ankle dorsiﬂ exes; medially the same occurs but the ante- rior band of the deltoid ligament is torn with the capsule and synovium to create an impingement lesion. Examination: Physical examination can be very speciﬁ c in repro- ducing the pain. Imaging: MRI and arthrograms may suggest the lesion but read more..
GENERAL PRINCIPLES Articular Cartilage • Functions to decrease joint friction and distribute load across the joint; also referred to as hyaline cartilage. • Composition: Water (65% to 80%), collagen (10% to 20%), proteoglycans (10% to 15%), and chondrocytes (5%). Pri- mary collagen is type II collagen ( Fig. 51-1 ). • read more..
51 • Cartilage Problems in Sports 439 • These injuries may not be initially identiﬁ ed, however, and oc- casionally are only diagnosed after persistence of symptoms. • Chronic symptoms may also be secondary to the various os- teochondroses. Physical Examination • Few, if any, physical examination tests are read more..
440 SECTION VII • Injury Prevention, Diagnosis, and Treatment Diagnostics: Radiographs helpful in ruling out other conditions in the differential. MRI may demonstrate localized defect or subchondral edema. Treatment: Arthroscopic chondroplasty, drilling, or microfrac- ture for localized lesions. Excision of unstable or loose frag- ments to alleviate mechanical read more..
51 • Cartilage Problems in Sports 441 Differential diagnosis: Meniscus tear, focal chondral defect, intra-articular loose body of other etiology (e.g., subsequent to patellar dislocation). Diagnostics: Tunnel (notch) view best demonstrates OCD lesions on radiographs (see Fig. 51-3 ). MRI better delineates size and stability of the lesion. Synovial ﬂ read more..
442 SECTION VII • Injury Prevention, Diagnosis, and Treatment Mechanism of injury: Traction apophysitis secondary to me- chanical stress from the extensor mechanism. Overuse injuries. Presentation: Activity-related anterior knee pain. Physical examination: Localized tenderness, prominent tibial tuberosity, pain with resisted knee extension. read more..
51 • Cartilage Problems in Sports 443 Presentation: Skeletally immature patient with activity-related posterior heel pain. Bilateral in up to 50% of cases. Physical examination: Localized tenderness of the posterior heel, pain with medial-lateral compression, tight heel cords. Differential diagnosis: Achilles tendonitis, retrocalcaneal bursi- tis, read more..
444 SECTION VII • Injury Prevention, Diagnosis, and Treatment Wrist Kienboöck’s Disease Description: Avascular necrosis and collapse of the lunate. Mechanism of injury: Associated with overuse and repetitive compressive loading of the wrist as well as ulnar negative wrist variance. Presentation: Chronic wrist pain, read more..
TRANSPORTATION OF THE ATHLETE WITH FRACTURE OR DISLOCATION • Transportation of the injured athlete is determined upon pri- mary and secondary evaluations by the ﬁ rst responder, and contingent upon the extent of the injury; must always be ex- ecuted so that further injury is prevented. • Planning the mode of transport and necessary read more..
446 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Splints and braces are prescribed after a fracture to protect a partially healed fracture, or to prevent the pain that occurs with motion. • A cast is a stress-sharing device, allowing callus formation and rapid secondary bone healing. Both joints, above and below the fracture, must read more..
52 • Acute Fractures and Dislocations in Athletes 447 Distal Humerus Fractures • Fractures that have minimal displacement and are in near ana- tomical alignment can be treated with casting or splinting. • Cast or splint treatment of these injuries should allow no mo- tion at the elbow. • The cast should be read more..
448 SECTION VII • Injury Prevention, Diagnosis, and Treatment • The cast should be trimmed to the proximal palmar crease volarly and the metacarpophalangeal prominences dorsally to allow for free ﬁ nger movement. The cast should be trimmed to allow the thumb full opposition with the small ﬁ nger. • Distal fractures requiring open read more..
52 • Acute Fractures and Dislocations in Athletes 449 Initial on-ﬁ eld management: Injured extremity should be stabi- lized with a splint and the athlete taken off the ﬁ eld for further evaluation. Evaluation: • Inspection: Determine if the fracture is open or closed. • Palpation: Assess both the elbow and read more..
450 SECTION VII • Injury Prevention, Diagnosis, and Treatment Prognosis and return to play: Long-term results following hip dislocations are poor, even if reduction is prompt and appropri- ate. Athletes who sustain a dislocation of the hip with or without a fracture should be counseled that they may have sustained a career-ending injury. read more..
52 • Acute Fractures and Dislocations in Athletes 451 Initial on-ﬁ eld management and evaluation: • Gross deformity may be apparent. There is associated swell- ing and guarding on physical examination. • Palpation: The knee joint, leg, and thigh should be palpated to assess for possible fracture or associated soft tissue injury. read more..
452 SECTION VII • Injury Prevention, Diagnosis, and Treatment Tibial Shaft Fractures Description: Generally low- to medium-energy fractures. Despite the lower energy mechanism, fracture can be a devastating career-ending injury to an athlete. Early fracture stabilization with a well-supervised rehabilitation program is paramount to a good outcome . read more..
52 • Acute Fractures and Dislocations in Athletes 453 clear space (distance between the lateral wall of the medial malleolus and medial wall of the talus) greater than 4 mm and the distal tibioﬁ bular space (distance between the posterior border of the tibia and the inner border of the ﬁ bula) greater than 6 mm. However, injury may not be apparent radiograph- read more..
454 SECTION VII • Injury Prevention, Diagnosis, and Treatment Prognosis and return to play: Prognosis for a severe open frac- ture is driven by both the type of fracture and the open wound. It may be a career-ending injury, and the athlete and coach need to understand that. However, with aggressive treatment and in- corporating contemporary treatment read more..
GENERAL OVERVIEW Deﬁ nition Stress fractures are fatigue-failure injuries of bone and are consid- ered the ultimate overuse injury affecting physically active peo- ple, including military recruits, track and ﬁ eld athletes, and ballet dancers. With increased evidence supporting positive role of exer- cise for elderly people and patients with chronic disease, read more..
456 SECTION VII • Injury Prevention, Diagnosis, and Treatment PROTECTIVE AND RISK FACTORS See Table 53-2 . Bone Characteristics • Composition: Mineral deposition around collagen matrix. Bone resists compression; collagen matrix (connective tissue) resists tension. • Bone remodels in response to stress (Wolff’s read more..
53 • Stress Fractures 457 History • Maintain high index of suspicion when evaluating frequency, intensity, and duration of activity. • Some affected anatomic areas are particularly challenging to diagnose. • Recall of speciﬁ c detailed historical facts may be challenging for athletes. • Recent change in read more..
458 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Gradually add impact activity, altering surface or equip- ment if possible. Run short distances on grass or soft sur- faces and gradually increase running time. • Resume sports-speciﬁ c training in noncompetitive setting. • Work out on alternating days and maximize rest read more..
53 • Stress Fractures 459 Ribs Description: First rib most commonly seen in baseball pitchers and basketball players; reported in weightlifting, tennis, table tennis, rugby, judo, gymnastics, and ballet. Other rib fractures seen in softball (pitchers), golf, tennis, and rowing. Diagnosis often delayed because misdiagnosed as back strain. Typically read more..
460 SECTION VII • Injury Prevention, Diagnosis, and Treatment nonunion, varus deformity, and chronic pain. Superior neck fractures are under tension and are a high-risk area for pro- gression to complete fracture. Inferior neck fractures are compression-sided and are often managed conservatively. History: Earliest sign: 87% report inguinal or anterior groin pain. read more..
53 • Stress Fractures 461 Tibial Shaft Stress Fractures Description: Need to differentiate between compression stress fracture and tension stress fracture (“dreaded black line”). • Compression stress fractures: MRI suggests continuum between medial tibial stress syndrome and stress fracture, with varying degrees of periosteal edema. read more..
462 SECTION VII • Injury Prevention, Diagnosis, and Treatment History: Insidious onset forefoot/midfoot pain, especially with running and jumping. Pain occasionally mild and usually re- lieved with rest. Examination: Pain at “N spot” (dorsal aspect of the navicular). Pain may be diffuse rather than localized. Radiographic studies: X-rays read more..
53 • Stress Fractures 463 Examination: Pain to palpation, pain with resisted ﬁ rst toe plan- tarﬂ exion, pain over sesamoids with stretch into extreme of dorsiﬂ exion. Radiographic studies: Diagnosis of sesamoid stress fracture by x-ray is challenging, and additional imaging (e.g., bone scan, MRI) is often required to differentiate stress read more..
NORMAL ANATOMY AND PHYSICAL EXAMINATION Observation and Measurement Standing Alignment of the lower extremities: View patient from front and back. Angular and rotational deformities: Check for pelvis, patellae, and tibial tubercles, pelvic tilt and leg length discrepancy; varus, valgus, ﬂ exion, extension, and rotational abnormalities of the read more..
54 • Foot Problems 465 version, and supination of the foot. Observe the medial arch during stance. Palpation Ligament attachments: Calcaneoﬁ bular ligament, anterior talo- ﬁ bular ligament, superﬁ cial deltoid ligament, plantar fascia. Tendons: Posterior tibialis, ﬂ exor hallucis longus, anterior tibialis, peroneal brevis and read more..
466 SECTION VII • Injury Prevention, Diagnosis, and Treatment Differential diagnosis: Entrapment of the ﬁ rst branch of the lat- eral plantar nerve (thought by some to be component of plantar fasciitis syndrome); plantar fascial rupture; tarsal tunnel syn- drome; calcaneal stress fracture; heel pad atrophy. Treatment: Early intervention more efﬁ read more..
54 • Foot Problems 467 tivity and improves with rest, tender to palpation at or just ante- rior to Achilles insertion. Positive “squeeze” test: compression of medial and lateral aspects of calcaneal apophysis produces pain. Positive “Sever’s test”: heel pain aggravated by standing on tip-toes. Imaging: Radiographs characterized by fragmentation, sclerosis, and increased density read more..
468 SECTION VII • Injury Prevention, Diagnosis, and Treatment Table 54-3 INFLAMMATORY CONDITIONS Type Signs and symptoms Treatment Posterior tibial tendinitis Medial arch pain, swelling, pain with resisted inver- sion, painful or unable to single heel rise, medial arch collapse, “too many toes sign”: when viewed from behind, abducted forefoot allows more read more..
54 • Foot Problems 469 increased with running, incline training, and wearing shoes with elevated heel ( Fig. 54-9 ). Imaging: WB AP, lateral, oblique; may be normal initially; non- uniform narrowing of ﬁ rst MTPJ with widening and ﬂ attening of the metatarsal head, loose body, marginal osteophytes; dorsal exostosis of ﬁ rst metatarsal is the read more..
470 SECTION VII • Injury Prevention, Diagnosis, and Treatment surgical (open reduction, internal ﬁ xation [ORIF], if possible), otherwise excision of fragment(s). Calcaneus Fractures Etiology: Traumatic, rare; s tress, more common; usually related to endurance sports ( Fig. 54-11 ). Symptoms/signs: Localized pain in heel, read more..
54 • Foot Problems 471 Midfoot Fractures Lisfranc Injury Etiology: Traumatic; 3 common mechanisms: twisting of forefoot (e.g., equestrian foot caught in stirrup during fall); axial load with foot in equinus (e.g., football, soccer); crush injury ( Fig. 54-12 ). Lisfranc ligament runs from plantar-medial cuneiform to the base of the read more..
472 SECTION VII • Injury Prevention, Diagnosis, and Treatment Navicular Stress Fracture Etiology: Common in running and jumping athletes; repetitive cyclic loading, explosive push-off. Unique vascular anatomy re- sults in relatively avascular central one-third. Frequently missed, delay in diagnosis up to 4 to 7 months reported. Symptoms/signs: read more..
54 • Foot Problems 473 Treatment: Generally cast for 4 to 6 weeks followed by 4 to 6 weeks in walking boot. Approximately 75% will heal with nonoperative treatment but 30% to 50% will refracture. Indica- tions for surgical stabilization with intramedullary screw are controversial but considered for acute fracture in athletes, non- union, refracture, and cavovarus read more..
474 SECTION VII • Injury Prevention, Diagnosis, and Treatment Radiographic assessment: Usually negative; evaluate for stress fracture, compression from exostosis. Treatment: Initial: NSAIDs, metatarsal pads, wide toe-box shoes, lower heel, corticosteroid injection. Chronic: Surgical excision; patient left with permanent anesthesia between involved toes, but no read more..
TEAM PHYSICIAN’S ROLE IN TAPING AND BRACING • Determine appropriateness of taping/bracing. • Facilitate selection process. • Identify available options. • Communicate with treatment team: certiﬁ ed athletic trainer, coach, athlete. • Evaluate effectiveness of selected support. read more..
476 SECTION VII • Injury Prevention, Diagnosis, and Treatment Application • Requires skill; proﬁ ciency results from practice. • Elements of proper taping technique: • Tearing tape is basic skill; tape must be torn often. • Every piece of tape should have distinct purpose. • read more..
55 • Taping and Bracing 477 Anterior Cruciate Ligament Taping Performance of custom-ﬁ tted and off-the-shelf braces far exceeds that of taping. Taping requires skilled practitioner. Medial or Lateral Knee Taping Common indication: Collateral ligament sprain. Materials: 11⁄2-inch or 2-inch cloth tape, or 3-inch elastic tape. read more..
478 SECTION VII • Injury Prevention, Diagnosis, and Treatment BRACING Comparisons of Bracing to Taping • Advantages of bracing • Does not require skilled application. • Sometimes more cost-effective (tape underwrap ad- herent time $). • Increased convenience. • Less read more..
55 • Taping and Bracing 479 Considerations of Brace Prescription • Brace market full of unsubstantiated claims and disclaim- ers of liability. • Need to be knowledgeable about and critical of new devices. • Often need to evaluate a currently used or “borrowed” device. • read more..
480 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Use of audiovisual aids (e.g., videotapes, instruction, posters) supplied by manufacturers to teach players proper application and daily reminders. • Daily check of positioning by coaches and certiﬁ ed athletic trainers or other skilled person. • Weekly check on upkeep by read more..
55 • Taping and Bracing 481 RECOMMENDED READINGS 1. Albright JP, Powell JW, Smith W , et al : Medial collateral ligament sprains in college football: Brace wear preference and injury risk . Am J Sports Med 22 ( 1 ):2, 1994 . 2. Albright JP, Powell JW, Smith W , et al : Medial collateral ligament read more..
GENERAL OVERVIEW • Knowledge of anatomy is essential to performing injections safely and effectively. • Use of local anesthetic injections in athletes may reduce the number of games missed because of injury but carries a theo- retical risk of worsening the injury. • Corticosteroid injections are widely used in the treatment of read more..
56 • Injections in the Athlete 483 Corticosteroids • Interfere with inﬂ ammatory cell-to-cell adhesion and migra- tion through the vascular endothelium. • Inhibit the synthesis of cyclooxygenase-2 (COX-2) and vari- ous proinﬂ ammatory cytokines. • Stimulate gluconeogenesis and catabolic activity in muscle, skin, read more..
Coracoacromial ligament Acromion Supraspinatus tendon (fused to capsule) Subdeltoid bursa Infraspinatus tendon (fused to capsule) Glenoid cavity (cartilage) Teres minor tendon (fused to capsule) Synovial membrane (cut edge) Opening of subtendinous bursa of subscapularis A. The subacromial bursa lies deep to the acromion and superficial to the rotator cuff. The glenohumeral joint is approached read more..
56 • Injections in the Athlete 485 Acromioclavicular (AC) Joint Indications: AC joint sprain, grades I and II AC joint separation, AC joint arthropathy, distal clavicle osteolysis. Technique: • Identify the lateral border of the acromion anteriorly and palpate medially to identify the superior aspect of the AC joint (see read more..
486 SECTION VII • Injury Prevention, Diagnosis, and Treatment LOWER EXTREMITY INJECTIONS Hip Trochanteric Bursa Indications: Trochanteric bursitis, bone contusion. Technique: • Place patient in lateral decubitus position with hip and knee ﬂ exed. • Insert the needle perpendicular to the skin at read more..
56 • Injections in the Athlete 487 • Palpate the soft spot at the midpoint between the inferolateral border of the patella and the lateral joint line (see Fig. 56-2 ). • Direct the needle toward the notch approximately 0.5 to 1 cm lateral to the patellar tendon. Considerations: The lateral suprapatellar approach may read more..
488 SECTION VII • Injury Prevention, Diagnosis, and Treatment • Palpate the lateral epicondyle of the femur. The bursa lies deep to the iliotibial band in the region of the lateral epicon- dyle (see Fig. 56-2 ). • Insert the needle perpendicular to the skin at the point of maximum tenderness and inject. Considerations: read more..
VIII Speciﬁ c Sports 57 Football 58 Volleyball 59 Soccer 60 Basketball 61 Wrestling 62 Swimming and Diving 63 Scuba Diving 64 Baseball 65 Track and Field 66 Gymnastics 67 Road Biking 68 Mountain Biking 69 Tennis 70 Alpine Skiing 71 Cross-Country Skiing 72 Snowboarding 73 Ice Hockey 74 Ice Skating 75 Sailing 76 Rock Climbing 77 Martial Arts 78 Boxing 79 Dance 80 Mass Participation read more..
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OVERVIEW • Approximately 1.5 million athletes participate in American football in the United States. • It has been played at the college level competitively for more than 100 years. The “ﬂ ying wedge” was a V-shaped formation used by Harvard in a game against Yale in 1892 and was felt to be associated with signiﬁ cant read more..
492 SECTION VIII • Speciﬁ c Sports • For games, knee internal derangements, ankle ligament sprains, and concussions account for the majority of injuries (17.8%, 15.6%, and 6.8%, respectively). For fall practices, knee internal derangements, ankle ligament sprains, and up- per leg muscle-tendon injuries account for the majority of injuries (12%, 11.8%, and 10.7%, read more..
57 • Football 493 • Infectious mononucleosis is additional consideration for splenic rupture. Caused by Epstein-Barr Virus (EBV). No activity for initial 3 to 4 weeks of symptoms, then dependent on athlete’s clinical condition and presence or absence of sple- nomegaly, which is present in majority of cases of EBV. Ab- dominal ultrasound useful for accurate read more..
494 SECTION VIII • Speciﬁ c Sports Return-to-Play Criteria after Cervical Injury • Absolute contraindications to return to collision sports • Congenital: Odontoid hypoplasia, atlanto-occipital fusion, Klippel-Feil anomaly with occipital-cervical involvement or mass fusion. • Developmental • Spinal read more..
57 • Football 495 • Acute injury should be treated with gentle reduction, which can be performed on ﬁ eld by experienced physician; immo- bilization following acute injury is controversial. Early reha- bilitation is important and bracing can control abduction- external rotation moments (the position at risk) and allow early return to play ( Fig. 57-3 ). read more..
496 SECTION VIII • Speciﬁ c Sports • Aspiration for persistent or large collection; consider scleros- ing agent or excision with recurrence. • Return to play with protective pad. WRIST AND HAND Wrist Sprains and Fractures • Injuries of wrist must be evaluated carefully for location of tenderness and read more..
57 • Football 497 • Mallet ﬁ ngers should be treated with continuous extension of DIP joint with splint, free range of motion of proximal interphalangeal (PIP) joint, early return to play. • Extensor tendon avulsions of central slip (insertion into proximal aspect of middle phalanx) also occur by “jamming” ﬁ nger and are read more..
498 SECTION VIII • Speciﬁ c Sports • Clinical progress more reliable indicator than x-rays, which often do not demonstrate bony healing even when patient becomes symptom free. • Known presence of spondylolysis or spondylolisthesis in asymptomatic player is not contraindication to play. • Symptomatic, skeletally immature patient with read more..
57 • Football 499 • Return to play with extra thigh padding when full strength, function, and range of motion are achieved. Hamstring Injuries • Sudden pain in posterior thigh with rapid hamstring contrac- tion; associated with fatigue, poor conditioning, inadequate stretching. Short head of biceps is most common. • read more..
500 SECTION VIII • Speciﬁ c Sports ﬁ nally eccentric training when asymptomatic during other therapy. FAT PAD SYNDROME (HOFFA’S DISEASE ) • Seen frequently secondary to contusions and resultant irrita- tion to anterior aspect of knee. • Tenderness to palpation usually present medial and lateral to patellar tendon read more..
57 • Football 501 Midfoot Sprains • Usually indirect injuries from forceful foot abduction when foot in ﬁ xed position or foot forced into severe plantarﬂ exion. • Patient demonstrates pain or tenderness in midfoot region, unable to tiptoe, may have ﬂ attening of longitudinal arch. • Lateral read more..
502 SECTION VIII • Speciﬁ c Sports RECOMMENDED READINGS 1. Boden B, Tacchetti RL, Cantu RC , et al : Catastrophic cervical spine injuries in high school and college football players . Am J Sports Med 34 : 1223 - 1232 , 2006 . • Modiﬁ cations depend on position and preference (e.g., linebackers and other players read more..
GENERAL PRINCIPLES Overview • Volleyball is played by an estimated 200 million people world- wide and is growing in popularity. • The game is played from the recreational to Olympic level. • The focus is to hit a powerful, unreturnable ball into the op- ponent’s court. • Achieved by complex setting and read more..
504 SECTION VIII • Speciﬁ c Sports • Fewer ﬁ nger injuries than in indoor volleyball because (1) fewer blocks are performed in beach volleyball and (2) the ball is softer. Prevention of Injuries • Shock-absorbent playing surface; wood is softer than concrete or linoleum. • Sweat on the ﬂ oor read more..
58 • Volleyball 505 • Sprain of the collateral ligament of the thumb metacarpopha- langeal joint is a common injury in volleyball. • Partial tears may be stabilized with thumb spica taping, al- lowing earlier resumption of play (see Fig. 58-4 ). • Injuries to the thumb, index, and middle ﬁ ngers are especially read more..
506 SECTION VIII • Speciﬁ c Sports Shoulder Impingement (Primary) • Tends to occur in the older athlete. • Often concomitant with rotator cuff muscle weakness. • Tendinitis and bursitis tend to accompany impingement. • Occasionally there is degeneration and tears of the rotator cuff tendons. read more..
58 • Volleyball 507 • Playing on a hard surface rather than shock-absorbing sur- face • Having higher vertical leap • Differential diagnosis for anterior knee pain: • Patellofemoral syndrome (see following section) • Osgood-Schlatter disease (in early teens) Patellofemoral read more..
RULES OF THE GAME • Game lasts 90 minutes; divided into two 45-minute halves. • Eleven players on the ﬁ eld (generally 10 ﬁ eld players and 1 goalkeeper). • Ball cannot be played by hands (except goalkeeper), but all other surfaces of body can be used. • Goal scored by hitting ball into opposing read more..
59 • Soccer 509 Prevention of Heat Injury • Modiﬁ cations can be made that decrease risk of heat injury; more water breaks, change game times, shorten length of play. • Thermoregulation potentially improved with hyperhydra- tion. • Several factors increase risk for development of heat illness (preexisting medical read more..
510 SECTION VIII • Speciﬁ c Sports • Amount of time each player spent walking, jogging, sprint- ing, or cruising measured by video analysis in both halves of game. • Players spent same amount of time walking and jogging in ﬁ rst and second halves and same amount of time in cruising or sprinting in ﬁ rst half, but players given read more..
59 • Soccer 511 • ACL injury rates for women and men from 1988-1989 through 2002-2003 were 0.28 and 0.28 per 1000 AE, respec- tively. These data conﬁ rm increased rate of knee and, speciﬁ cally, ACL injuries in women. • Concussion rate for women and men from 1988-1989 through 2002-2003 were 0.41 and 0.28 per 1000 AE, read more..
512 SECTION VIII • Speciﬁ c Sports • Reinjury is major factor in developing myositis ossiﬁ cans. • Deﬁ ned as new bone formation in muscle after injury; also called heterotopic (ectopic) ossiﬁ cation. • Occurs in 9% to 20% all quadriceps contusions; average time of disability is 73 days. read more..
59 • Soccer 513 • Sportsman’s hernia: musculotendinous disruption with torn external oblique aponeurosis, torn conjoined tendon, conjoin tendon torn from pubic tubercle, dehiscence be- tween conjoined tendon and inguinal ligament, no hernia. • 90% male, 70% insidious onset, 30% report injury. • Affects soccer, rugby, track, read more..
514 SECTION VIII • Speciﬁ c Sports • Accelerometer data measuring ball speed at 15.5 meters per second (35 mph) demonstrated head acceleration forces of approximately 20 gravity, with peak forces of 1200 Nm. • Greater than forces in boxing, in which punch generates head acceleration at 100 gravity. Forces in soccer tend to be linear, read more..
59 • Soccer 515 players achieved higher educational level, higher number of anesthesias, lower alcohol use. • 54% of soccer players had one or more sport-related con- cussions with or without LOC, 79% sustained one or more head-to-head collisions (with or without concussion). • Median of 50 soccer matches per year; median amateur and professional read more..
516 SECTION VIII • Speciﬁ c Sports • Prophylactic taping or bracing for ankle laxity. • Further evaluation and strength testing for knee laxity, ortho- pedic consultation. • Optimize sport-speciﬁ c cardiovascular training; endurance and intermittent sprints. • Proper warm-up before practice and game; no shooting on read more..
INTRODUCTION • Basketball has one of the highest overall injury rates among noncollision sports. • It is a contact sport and is a fast and aggressive game. • High-risk sports have been deﬁ ned to involve contact, a high jump rate, and indoor participation. EPIDEMIOLOGY See Table 60-1 . read more..
518 SECTION VIII • Speciﬁ c Sports • Do not return symptomatic player to competition. • Preparedness for severe concussions: • Use emergency resuscitative measures if necessary. Equipment should be readily available. • Transport to designated medical facility. • Document neurologic deﬁ cits at all times. read more..
60 • Basketball 519 • Treatment: Strict immobilization with splint for 6 weeks. Compliance is poor. Surgical repair may be required. Con- sider percutaneous pinning of mallet ﬁ nger injuries to ensure maintenance of reduction, allow skin care, and facilitate ear- lier return to play. Quadriceps and Hamstring Injuries • read more..
520 SECTION VIII • Speciﬁ c Sports • Players that do not stretch before participation may be 2.5 times more likely to sprain their ankle. • Mechanism of injury: Usually inversion injury—player frequently lands on foot of another player and inverts (rolls) the ankle. Another frequent mechanism is sudden lateral movement in the read more..
GENERAL CONSIDERATIONS Wrestling Styles Greco-Roman wrestling: Grew out of a form of 19th-century show-wrestling characterized by upper-body throws. The use of legs is prohibited in this style and points are often scored during frequent throws. Takedown points are awarded based on the degree of skill exhibited in throwing an opponent to the mat, with more read more..
522 SECTION VIII • Speciﬁ c Sports Table 61-1 U.S. AGE DIVISIONS AND WEIGHT CLASSES FOR WRESTLING, 2008 USA kids division (pounds) Bantam (born 2000-2001) Midget (born 1998-1999) Novice (born 1996- 1997) School boy/girl (born 1994-1995) FILA cadet (born 1991-1993) Boys/Girls Boys/Girls Boys/Girls Boys Girls Men Women 40 45 50 read more..
61 • Wrestling 523 Corneal Abrasions Description: Can occur when a wrestler is poked or scratched in the eye. Treatment: Consideration should be given to empiric topical an- tibiotics. More severe lacerations, especially those that do not heal overnight, should be evaluated by an eye specialist with a slit lamp. read more..
524 SECTION VIII • Speciﬁ c Sports Diagnosis: Dyspnea, tenderness, and pain, mostly associated with inhalation, trunk motion, or chest compression; x-ray examina- tion is helpful for identifying fractures. Treatment: Rib injuries may be quite painful. Although further injury is unlikely, participation may be limited by pain. • Rest, ice, read more..
61 • Wrestling 525 Knee Injuries Description: Most common wrestling injury and account for nearly 25% of all wrestling injuries. Certain maneuvers place extreme stress on the knee structures. Etiology: Although exact pathomechanics of meniscal injuries are not always identiﬁ ed, Wroble and colleagues have cited the following read more..
526 SECTION VIII • Speciﬁ c Sports Epistaxis: Epistaxis treatment during competition does not count against the injury time allowed. Rules regarding treatment: • Taping is permissible during injury time-outs, but must allow normal joint motion. • Use of braces or devices that limit normal joint range of mo- tion prevent read more..
61 • Wrestling 527 mouth, throat, and eyes. Offending wrestler is penalized with a point deduction. • Potentially dangerous holds are those that force a limb to the limit of the normal range of motion, and such holds may be stopped by the referee. No penalty is assessed be- cause potentially dangerous holds are usually unintentional. Wrestling is then read more..
528 SECTION VIII • Speciﬁ c Sports • Mandatory NCAA ofﬁ cial weigh-in form, generated by the National Wrestling Coaches Association web site ( www. NWCAonline.com ) must be used for all competitions. • Weigh-ins must occur 1-hour or less before the ﬁ rst match for dual, triangular, and quadrangular meets; 2 hours or less on the read more..
SWIMMING General Overview • One of the largest recreational and competitive sports in the United States. • U.S. Swimming registered 280,000 athletes in 1999; 287,480 in 2006. • Provides liability and accident insurance for club members and coaches. • Requires coach education, training, and certiﬁ cation in ﬁ read more..
530 SECTION VIII • Speciﬁ c Sports • Overtraining • Low carbohydrate diets can lead to chronic muscle fatigue. Marked by decreased urinary norepinephrine and decreased plasma glutamine 2 to 4 weeks before fatigue develops. • Periodization, progression, adaptation, recovery, and taper techniques are of beneﬁ t. read more..
62 • Swimming and Diving 531 Physical examination: Tenderness over acromion, positive im- pingement tests (Hawkins, Neer), instability to anterior and posterior stresses with reproduction of symptoms. Radiographs: Normal x-ray. Magnetic resonance imaging (MRI) or MRI arthrogram may show tear of the glenoid labrum or an abnormal rotator cuff. read more..
532 SECTION VIII • Speciﬁ c Sports • Various provocative tests help with the diagnosis: • Wright’s test: Hyperabduct the arm so the arm is brought over the head with the elbow and arm in the coronal plain. Have the patient extend and rotate the neck away from the arm and take in a breath. Check for changes in the pulse during read more..
62 • Swimming and Diving 533 • Labs/diagnostic tests; chest x-ray and thoracic outlet MRI to evaluate anatomical area of impingement. Urgent vascular studies such as d -dimer, magnetic resonance angiogram (MRA), or upper extremity Doppler ultrasound indicated if concern for thrombus. • Double crush theory: Proximal nerve compression will read more..
534 SECTION VIII • Speciﬁ c Sports • Chondromalacia or patellofemoral pain • Repetitive quadriceps contraction in the ﬂ utter kick • Push-off from the wall • Medial patella facet pain or medial joint synovitis • Associated with abnormal whip kick. • Hips held in wide abduction read more..
62 • Swimming and Diving 535 • Iliotibial band tendonitis • Lateral patellar subluxation Ankle Injuries • Overuse from ﬂ utter kicks. • Extensor retinaculum injury. • Change stroke pattern for treatment. Groin Injuries • More common with the breast read more..
536 SECTION VIII • Speciﬁ c Sports Cervical Spine Injuries • Occur in recreation diving from lack of formal training, inad- equate water depth, inadequate supervision, and alcohol in- gestion. • Competitive diving • In more than 100 years of competition in the United States, no fatality from cervical injury has read more..
62 • Swimming and Diving 537 • Pulmonary contusion: usually self-limiting within 48 hours • Pneumothorax • Scalp lacerations • Splenic rupture with underlying splenomegaly • Dehydration and malnutrition 6. Johnson JN, Houchin G : Adolescent athlete’s shoulder: A case read more..
GENERAL PRINCIPLES Overview • Diving is an activity done in a different environment. • Technology allows people to enjoy the underwater experience. • It is estimated that there are more than 1 million dives in the United States each year. • People dive for various reasons including the ability to ex- read more..
63 • Scuba Diving 539 • Oxygen toxicity can occur if the partial pressure is too high for too long. • Effects can include nausea, disorientation, visual changes, and seizures that can be life threatening if experienced underwater • Enriched air mixtures have different concentrations of oxygen and different depth limits due to the read more..
540 SECTION VIII • Speciﬁ c Sports • Important to evaluate underlying ﬁ tness for activities in a predive physical. • A predive physical may only occur once in a person’s lifetime so it is important to educate the diver about ongoing monitor- ing of his or her health. SPECIFIC INJURIES Pressure-Related Diving read more..
63 • Scuba Diving 541 dizziness, anxiety, and headache and progress rapidly to loss of consciousness, seizures, shock, and death. Often difﬁ cult to dif- ferentiate AGE from central nervous system (CNS) type 2 DCS. Treatment is similar—recompression and oxygenation. AGE can occur with any dive. DCS injuries often involve longer, deeper dives in which tissue saturation read more..
542 SECTION VIII • Speciﬁ c Sports • Local inﬂ ammatory response with pain and erythema is the main problem. • Neurologic and respiratory depression has been seen along with nausea, vomiting, and abdominal pain from stings of certain species such as the Portuguese man-o- war. • Initial treatment is to remove the individual read more..
63 • Scuba Diving 543 with an implantable cardio deﬁ brillator (ICD) is not recom- mended. Syncope: Contraindication to diving if triggers unknown or if triggers may be encountered during a dive or during dive- related activities. Peripheral artery disease (PAD): Claudication can be worsened during a dive because of vasoconstriction from the dive read more..
544 SECTION VIII • Speciﬁ c Sports • 30 minutes predive: 120 to 250 • immediately predive: 150 to 250 • If too low or dropping faster than 20 mg/dL per hour, diver should eat a snack, delay the dive, recheck blood glucose. • If too high and no ketones, may treat with insulin and/or de- lay read more..
63 • Scuba Diving 545 3. Bennett PB : Assessment of Diving Medical Fitness for Scuba Divers and Instructors . Flagstaff, Ariz : Best Publishing , 2006 . 4. Bove AA : Bove and Davis’ Diving Medicine , 4th ed . Philadelphia : W. B. Saunders , 2004 . 5. Bove AA : Medical aspects of read more..
546 SECTION VIII • Speciﬁ c Sports GENERAL OVERVIEW History • Baseball, the great American pastime, was ﬁ rst described by Abner Doubleday in 1839. • The game evolved considerably in the early years, but it was with the advent of the overhand pitching motion in the 1880s, that shoulder and elbow problems become a familiar read more..
64 • Baseball 547 by overloading the shoulder, resulting in a possible rotator cuff strain. • If stride is off line to the ﬁ rst base side (right-handed pitcher), the torso will be ahead of the shoulder, resulting in “opening” too soon and stressing the anterior capsule. This may result in shoulder instability. • If stride is off read more..
548 SECTION VIII • Speciﬁ c Sports throwing activity to shifting the player’s position (e.g., playing ﬁ rst base instead of pitching). • Physical therapy • Rotator cuff strengthening • Thera-Bands with elbow at side. • Advance to pulleys with arm in throwing position (shoul- der abducted 90 degrees with arm read more..
64 • Baseball 549 • Increased laxity with valgus stress. • Soft endpoint with valgus stress. • Pain with milking maneuver (valgus stress applied with the elbow ﬂ exed 90 degrees and the forearm in maximum pro- nation ( Fig. 64-4 ). • With increased laxity, traction to the ulnar nerve may occur, resulting read more..
550 SECTION VIII • Speciﬁ c Sports Common Flexor Strain Description: Dynamic medial stabilizer for the elbow. Must dif- ferentiate from a UCL sprain. Diagnosis: Pain anterior and lateral to medial epicondyle, not over the UCL; pain with resisted wrist ﬂ exion/pronation; nega- tive milking maneuver. read more..
64 • Baseball 551 RECOMMENDED READINGS 1. Altchek D, Levinson M : Shoulder injury in the throwing athlete . Phys Med Rehab Clin North Am 11 : 745 - 754 , 2000 . 2. Andrews JR, Timmerman LA, Wilk KE : Baseball . In Pettrone (ed): Athletic Injuries of the Shoulder . New York : McGraw-Hill , read more..
552 SECTION VIII • Speciﬁ c Sports GENERAL INFORMATION Overview • Track and ﬁ eld often attracts multisport athletes. • The sport involves year-round competition and training. • Differing athletic events subject athletes to differing demands. For example: • The shot put demands explosive power. read more..
65 • Track and Field 553 • Speciﬁ city of training, including periodization, to demands based on types of energy pathways used. Strengthening and Conditioning • Key in track and ﬁ eld is sport speciﬁ city in training. This differs for each event. Much of training continues year round. Need to emphasize read more..
554 SECTION VIII • Speciﬁ c Sports assess iron intake. Minimizing this potential deﬁ cit may minimize potential fatigue, and diet-related conditions. • Voluntary protein intake, along with fat and total energy in- take, has been shown to be lower in athletes with menstrual irregularities than in normally menstruating athletes. • read more..
65 • Track and Field 555 • Dehydration can incur physiologic changes; increase in core body temperature of 0.3° C, increase in heart rate of 8 beats per minute, and decrease in cardiac output of 1 L per minute, for every liter of water (2.2 pounds) lost while exercising in the heat. • Proper rehydration essential during, after, and between read more..
556 SECTION VIII • Speciﬁ c Sports • Important to initiate workup and treatment because of long- range consequences of menstrual dysfunction. Treatment must be individualized. • “Progesterone challenge” helpful in functionally differentiat- ing estrogen-deﬁ cient state from estrogen- and progesterone- deﬁ cient state. • If read more..
65 • Track and Field 557 Diarrhea: Typically self-limited and physiologic, tending not to cause dehydration or electrolyte imbalances. Antidiarrheal med- ications should be avoided whenever possible. Celiac sprue (gluten sensitive enteropathy): Can lead to de- creased bone mass secondary to poor absorption of calcium. Athletes will typically complain of read more..
558 SECTION VIII • Speciﬁ c Sports • Type 1: pain after activity • Type 2: pain during activity, not restricting activity • Type 3: pain during activity, restricting activity, which re- stricts performance • Type 4: chronic, unremitting pain SPECIFIC MUSCULOSKELETAL INJURIES Upper Extremity read more..
65 • Track and Field 559 Examination: Reveals tenderness at or below the inferior pole of the patella, often worse with passive, ballistic hyperextension. Treatment: Patellar taping, often by compressing the fat pad even further. Meniscal Lesions Description: Most common acute mechanism is twisting injury in association with read more..
560 SECTION VIII • Speciﬁ c Sports tor strain include relative adductor weakness and decreased hip abduction range of motion. Presentation: Sudden pain in belly of affected muscle. Athletes often describe “pulling” or “tearing” sensation. Athletes often run through initial discomfort only to experience increasing pain and disability later. Examination: read more..
65 • Track and Field 561 OTHER STRESS FRACTURES Description: Runners account for 69% of all stress fractures be- cause of increased stresses on normal bone and normal to in- creased stresses on weakened bone. Occur throughout the lower extremity: tibia (34%), ﬁ bula (24%), metatarsals (18%), femur (14%), pelvis (6%). read more..
562 SECTION VIII • Speciﬁ c Sports duced, implies a syndesmotic injury (“high ankle sprain”). Radio- graphs should be obtained based on the Ottawa ankle rules. Acute treatment: Ice, elevation, compression wrap, immobiliza- tion (if severe), NSAIDs, weight-bearing as tolerated by pain as long as normal gait biomechanics maintained. X-rays, in- cluding mortise read more..
65 • Track and Field 563 hol use, drugs (tricyclic antidepressants, amphetamines, LSD, PCP, cocaine, anticholinergics (previously discussed), antihistamines, diuretics, beta-blockers); increased humidity, temperature, no clouds, no wind; poor physical conditioning; acute febrile illness. Treatment: Focuses on rapid cooling and timely transport to medical facility. If rectal read more..
564 SECTION VIII • Speciﬁ c Sports • Safety issues • Poles can break during take-off or from contact with vault- ing box. • Landing mats should cover vaulting box on all sides. • Thickness of mat should range from 28 to 36 inches. • Risk of injury to cervical spine or head and read more..
OVERVIEW • Types of gymnastics: acrobatic, artistic, rhythmic, tumbling, and trampoline ( Tables 66-1 to 66-4 ). • More than 88,000 competitive gymnasts in the United States register yearly with USA Gymnastics; there are up to 3 mil- lion recreational gymnasts in the United States. • Injury epidemiology: read more..
566 SECTION VIII • Speciﬁ c Sports blocks and make injury worse and make it more difﬁ cult to removal the athlete. Gently placing a mat into the pit and then using this as a means to reach the athlete is one method to minimize disturbing the foam blocks. Shoulder Injuries Anterior Dislocation and Multidirectional Instability read more..
66 • Gymnastics 567 Evaluation and treatment: Appropriate for type of fracture(s). Prevention: • Regular replacement of grips as the leather stretches out over time. • Gymnasts or coaches should make routine checks to ensure that grips are not long enough to overlap around bar. • Avoid sharing of grips read more..
568 SECTION VIII • Speciﬁ c Sports Pelvic Apophyseal Injuries Deﬁ nitions: Apophysis: Growth plate that adds contour and shape to bone without contributing to bone length ( Table 66-6 ). Apophysitis: Irritation of apophysis. Areas include ASIS, AIIS, ischial tuberosity, lesser trochanter, greater trochanter, and the iliac crest read more..
66 • Gymnastics 569 History and physical exam: Often fails conservative treatment; practices are very limited because of pain. Pain with plantar ﬂ exion, pain increases with skills that require gymnast to be on 3⁄4 pointe or requires rebounding off 3⁄4 pointe. Tenderness to palpation over posterior talus, posterior tibioﬁ bular ligament, or os read more..
570 SECTION VIII • Speciﬁ c Sports 10. Matzkin E, Singer D : Scaphoid stress fracture in a 13-year-old gym- nast: A case report . J Hand Surg 25 ( 4 ): 710 - 713 , 2000 . 11. McCrory P, Johnston K , et al : Summary and agreement statement of the 2nd International Conference on Concussion in Sport , read more..
GENERAL PRINCIPLES Races Road Racing Stage races: Multiday races on consecutive days with daily stage winners and overall winner based on cumulative time; mass start races where the athletes ride in a pack, or pelenton. Grand tours: Tour de France, Giro d’Italia, and Vuelta de España; in- clude prologue, ﬂ at stages for read more..
572 SECTION VIII • Speciﬁ c Sports only. Write name, contact information, and medical infor- mation in helmet for emergencies. • Other protective clothing: gloves, snug-ﬁ tting cycling wear, chamois padding in shorts, sunglasses. Biomechanical Principles Bicycle Anatomy ROAD BICYCLE • Key frame measurements read more..
67 • Road Biking 573 • Handlebar tilt is a personal preference, but most cyclists prefer the lower curve and brake hoods to be slightly ele- vated. • Stem length or extension • A rider’s reach is determined by the top tube length, stem length, and stem angle or rise (see Fig. 67-1 ). • read more..
574 SECTION VIII • Speciﬁ c Sports efﬁ cient at shuttling lactate for utilization to other parts of the body. V O2 max test: Ramp protocol of increasing load of 25 watts at 1 minute increments until failure to maintain set cadence. Mea- sures oxygen consumption and heart rate (HR) at differing workloads. Maximum aerobic power test with read more..
67 • Road Biking 575 • Although low cadences (50 to 60 rpm) have been found to be more economical/efﬁ cient (lower V O 2 ), most cyclists prefer to pedal at high cadences. Improved blood ﬂ ow and reduced muscular stress are possible advantages at higher cadences. • Blood ﬂ ow oxygenation to the vastus lateralis is signiﬁ read more..
576 SECTION VIII • Speciﬁ c Sports • Bicycle factors: saddle tilt too high, saddle level too high, handlebars too low or too far forward; too much saddle pad- ding, narrow saddle, prolonged seated riding in one position; riding on rollers worse than riding on a stationary bicycle worse than riding on the road. • Diagnosis: Clinically, may read more..
67 • Road Biking 577 best. Peroxide can inhibit healing. Local anesthetic may be used. • The wound should not be left open to the air to heal because large scabs may form. • Traditional method: Cover wound with a nonadherent dress- ing with antibiotic ointment or silver sulfadiazine, pad with gauze, wrap with stretch gauze, and cover read more..
578 SECTION VIII • Speciﬁ c Sports donitis” in etiology and treatment. Limit use of cortisone injection. • Prepatellar bursitis: Swelling overlying patella. Caused by direct trauma or repetitive overuse. Treatment as above, occasional aspiration. • Pes anserine bursitis: Swelling and pain at pes anserine insertion. Cortisone and treatment read more..
67 • Road Biking 579 2) Treatment of excessive length with shortening, 3) Treat- ment of endoﬁ brosis with endoﬁ brosectomy with venous or arterial closing angioplasty, polyester patch angioplasty, or saphenous bypass surgery, 4) Inguinal ligament release, 5. NOT recommended: angioplasty, stent. • Medical treatment: Vitamin B1, B6, and folates when minor read more..
580 SECTION VIII • Speciﬁ c Sports • Overtraining should be discussed not only under the clinical aspect, but more under the aspect of training content. • Late diagnosis may result in loss of months of racing. • Cycling treatment: Complete time off the bike weeks to months; return slowly with no hills or hard efforts for read more..
GENERAL OVERVIEW Deﬁ nitions • Mountain biking broadly refers to riding bikes with speciﬁ c design characteristics in various off-road settings. • Mountain bikes generally differ from road bikes in several ways: smaller frame, stronger rims, larger range of gears, wider ﬂ at or upright handlebar, stronger brakes, suspension, wider, read more..
582 SECTION VIII • Speciﬁ c Sports DH bottom bracket may be lower than FR; powerful, large disc brakes; longest travel suspension (6 to 10 inches), always front and rear; platform (FR DH) or clipless (DH FR) ped- als (sometimes with clipless on large platform). • “Slopestyle” riding is a variation of FR that combines big air freeride stunts with BMX read more..
68 • Mountain Biking 583 Gloves: Varying thickness, shell protection (dorsal ﬁ ngers and hand), and padding. Eyewear: Ultraviolet protection, shatterproof, changeable light- reducing and colored lenses for varying conditions; goggles in DH and extreme cold. Mountain Bike Fit • Directly applicable to overuse, indirectly read more..
584 SECTION VIII • Speciﬁ c Sports tain foot stability on pedal, but more versatility for small adjustments over rough terrain. • Set initial rotational cleat position (center of ﬂ oat; toe-in, neutral, or out) to individual foot mechanics: may estimate by observing foot rotation of rider sitting on table with legs dangling (hip and knees at 90 read more..
68 • Mountain Biking 585 • Start has fundamental importance to entire race; XC riders race to the narrows (where trail becomes singletrack) to achieve good position; fast starts and early steep climbs lead to high intensity and max HR early in race. • Anaerobic energy systems taxed, especially during steep climbs (require high power output: read more..
586 SECTION VIII • Speciﬁ c Sports • Rear falls • Common causes are forceful wheelie, preload jump too early. • Reported injuries are soft tissue, upper extremity (especially hand and wrist), head, spine and torso, tailbone. Collisions • Collisions with other cyclists common in XC. read more..
68 • Mountain Biking 587 warm-up, wrong shoes, not enough training (inadequate pre- season conditioning), cold weather. • Treatment and prevention focuses on training and ﬁ t. Knee May be most common joint affected by overuse; affects 30% to 40% of mountain bikers. PATELLOFEMORAL PAIN (BIKER’S KNEE , PATELLAR TENDONITIS , read more..
588 SECTION VIII • Speciﬁ c Sports Treatment: Hydrate with appropriate electrolyte drinks (espe- cially when hot), decrease riding intensity slightly, soften sus- pension, appropriate training volume, stretching. Low Back Pain Description: 37% affected, one of most common overuse com- plaints, may be as common as knee pain. read more..
68 • Mountain Biking 589 • Causes and risk factors (see “Mechanisms of Injury and Risk Factors”): Often multifactorial, some connection to ﬁ t (re- lated to bike control), falls/unscheduled dismounts, collisions, problems releasing from pedals (inexperience and release ad- justments for some pedals similar to ski bindings; avoid pull- ing up and off pedal), read more..
590 SECTION VIII • Speciﬁ c Sports Spine • Cervical and lumbar fractures reported. • Cervical most common site of injury, followed by thoracic, then lumbar. • Most common cervical spine injury caused by fall over bars and landing on head. • Cord injuries reported in FR (24% total spine read more..
68 • Mountain Biking 591 BOX 68-1 Basic Mountain Biking Skills • Mounting and dismounting in various situations • Braking • Cornering • Wheelies and hops • Drops (slow and fast) • Jumping • Line selection and ﬂ ow • Pedaling efﬁ read more..
GENERAL OVERVIEW Description • More than 20 million people in the United States participate in tennis at least once a year. • Five million people play tennis at least twice a month. • More than 500,000 adolescents participate in tennis. • Roughly 650,000 people in the United States play at the com- read more..
69 • Tennis 593 impact (see Fig. 69-1 ). High muscular activity is noted with peak activity prior to ball impact as energy is transferred along the kinetic chain. Internal rotation of the humerus is responsible for 40% of the racket speed at impact. Fluid motion through the kinetic chain is crucial. Injury to one segment will lead to a loss of power and place read more..
594 SECTION VIII • Speciﬁ c Sports backhand. This is attributed to not using the trunk and shoul- der musculature properly, placing more stress across the el- bow joint, and from hitting the ball with the wrist in ﬂ exion (versus extension). Players should strive to hit the ball in front of their body to reduce injury to the elbow. • Using a read more..
69 • Tennis 595 Strengthen weak muscles; external rotators tend to be weaker than internal rotators. Increased rotator cuff strength is associ- ated with increased velocity of serve. Additionally, strengthen latissimus dorsi, serratus anterior for all strokes, deltoid for overhead and backhand strokes, and rhomboids to counter drooping of the shoulder girdle. Maintaining ﬂ read more..
596 SECTION VIII • Speciﬁ c Sports Wrist/Hand De Quervain’s stenosing tenosynovitis: Irritation to the abduc- tor pollicis brevis and extensor pollicis brevis rubbing over the radial styloid with excessive ulnar deviation of the hand during grasping and swing of the racket ( Fig. 69-4 ). Triangular ﬁ brocartilage complex read more..
69 • Tennis 597 Peroneal tendinitis: Frequently encountered in tennis players due to pivoting and rapid change in direction. Players should use tennis shoes appropriate for the surface of the court. Stabilize the ankle with braces, elastic bandaging, tape, or high-top ath- letic shoes. Strengthen peroneal muscles by eversion against resistance. Perform proprioceptive read more..
598 SECTION VIII • Speciﬁ c Sports Lumbar strain: Onset of symptoms often correlated to a change in intensity/duration of play. Repetitive trunk rotation and hy- perextension place the erector spinae and multiﬁ dius muscles at risk for injury. When the player serves the ball, tossing the ball slightly ahead of the service line and use of the lower read more..
69 • Tennis 599 Traction to the apophysis at the greater/lesser tuberosity of the humerus: Akin to Little Leaguer’s shoulder. Rest and activ- ity modiﬁ cation are the mainstays of treatment. Upon return to play, the player should start with ground strokes only. High vol- leys and serves should be gradually incorporated. Humeral medial epicondyle read more..
GENERAL PRINCIPALS Background • Alpine skiing is an immensely popular sport worldwide, with upward of 200 million participants per year. • Alpine skiing involves high speeds, variable terrain, and weather conditions that combined with equipment can create signiﬁ cant opportunity for injury. • Equipment changes have changed read more..
70 • Alpine Skiing 601 • Highest prevalence of lower extremity injuries has changed from ankle/tibia to knee; this is likely due to equipment changes including stiffer boot materials and the advent of re- lease bindings. • Rates of injury and severe injury are similar with snowboard- ing, although snowboarders have a higher rate of upper ex- read more..
602 SECTION VIII • Speciﬁ c Sports • The topic of efﬁ cacy of helmets in preventing head injury is difﬁ cult to study due to many confounding variables, in- cluding rates of helmet use, terrain, weather, conditions, skill level, etc. A. Mechanism of ACL injuries B. Mechanisms of knee sprains C. External rotation-abduction fractures Mild grade III read more..
70 • Alpine Skiing 603 Thoracoabdominal Trauma • Minor chest wall, back, and abdominal trauma is relatively common in skiing and is generally not life threatening. • Because of the high speeds involved, however, physicians should always be aware of the possibility of severe trauma, particularly in cases of collisions. read more..
GENERAL PRINCIPLES • Cross-country, or nordic, skiing is a multifaceted sport that can be pursued either as a simple recreational outdoor activity or as a vigorous competitive endurance sport. • Cross-country skiing serves as an excellent means to develop and maintain cardiovascular ﬁ tness; most large muscle groups of the upper and lower read more..
71 • Cross-Country Skiing 605 Ski Base Preparation Ski glide: Considerable effort is directed at maximizing ski glide during cross-country ski competitions. Most elite skiers carry several different pairs of skis with variable base compositions and stone ground patterns, or “grinds,” each best suited to a particular snow condition. A “rill” pattern may read more..
606 SECTION VIII • Speciﬁ c Sports • Mean V O 2 max levels of male Finnish and Swedish national skiers during the 1990s was 85 to 90 mL/kg per minute, with the gold medalists in the low 90 mL/kg per minute range. • Elite Swedish women had mean V O 2 max levels in the mid 70 mL/kg per minute range. • read more..
71 • Cross-Country Skiing 607 • Medical complaints such as dehydration, cold injury, gastroin- testinal problems, and bronchospasm are also common. • Exercise-induced bronchospasm is estimated to occur in more than 30% of participants. • Cross-country skiing is a winter sport that occurs when the risk of viral upper respiratory illness read more..
608 SECTION VIII • Speciﬁ c Sports [MCL] and anterior cruciate ligament [ACL]), meniscal tear, patellar dislocation, tibial and ﬁ bular fractures, ankle sprains, ankle fractures, calf strain, and plantar fascia rupture. Trunk and head: Soft tissue trauma may cause contusions and lacerations. Direct blows to the head can result in mild traumatic brain injury read more..
GENERAL PRINCIPLES Overview • Snowboarding was developed in the 1970s and popularized in the 1980s. • Snowboarding is one of the fastest growing sports worldwide, and there are more than 6 million riders in the United States. • Snowboarders range in age from 4 to seniors. • Typical riders are males in read more..
610 SECTION VIII • Speciﬁ c Sports • Snowboarders are two and a half times more likely to sustain a fracture than skiers. Risk Factors • Snowboarding has a fast learning curve, which predisposes beginners, especially ﬁ rst-day riders, to injury. It is estimated that approximately half of all injuries occur in beginner read more..
72 • Snowboarding 611 • Ankle injuries comprise approximately 15% to 20% of all snowboarding injuries. Approximately half of all ankle injuries are fractures. A common fracture type involves the lateral process of the talus (15% of all ankle injuries sustained while snowboarding). This fracture is frequently seen in riders wearing soft boots that allow increased read more..
612 SECTION VIII • Speciﬁ c Sports pressing the ankle in a cephalad direction and holding the lower leg in external rotation (see Fig. 72-2B ). The LPT is compressed against the posterior calcaneal facet with this maneuver. Differential diagnosis: Similar clinical presentations are seen with a lateral ligamentous sprain, subluxed peroneal tendon, lateral read more..
72 • Snowboarding 613 12. Matsumoto K, Sumi H, Sumi Y, Shimizu K : Wrist fractures from snowboarding: A prospective study for 3 seasons from 1998 to 2001 . Clin J Sport Med 14 : 64 - 71 , 2004 . 13. Nakaguchi H, Tsutsumi K : Mechanisms of snowboarding-related se- vere head injury: Shear strain induced by the read more..
HOCKEY ORGANIZATION AND PARTICIPATION • USA Hockey, located in Colorado Springs, Colorado, is na- tional governing body for ice hockey in the United States and ofﬁ cial representative of U.S. Olympic Committee and Inter- national Ice Hockey Federation. It works with National Hockey League (NHL) and National Collegiate Athletic As- sociation (NCAA). read more..
73 • Ice Hockey 615 • Face masks • Full face masks required at youth and high school levels in 1975; Eastern Collegiate Athletic Conference mandated use in 1977; NCAA required use in 1980. Helmets required in NHL but face masks remain optional. This level of play accounts for most serious eye injuries. • Effects of full read more..
616 SECTION VIII • Speciﬁ c Sports Muscle Glycogen Stores (Energy Source) • Glycogen stores decline by average of 60% for forwards and defensemen after one game. • All muscle ﬁ bers (types I, IIa, and IIb) contribute glycogen; type I depletes (contributes) most. • Twofold increase in plasma free fatty read more..
73 • Ice Hockey 617 • Collegiate injuries ( Table 73-2 ) • Age group differences • Age 11 to 14: 1 injury/100 hours playing time. • Age 15 to 18: 1 injury/16 hours playing time. • Age 19 to 21: 1 injury/11 hours playing time. • Professional: 1 injury/7 hours playing time. read more..
618 SECTION VIII • Speciﬁ c Sports • Severity • Minor ( 7 days’ absence): 61% to 73% (46% of all minor injuries caused by body checks). • Moderate (8 to 30 days’ absence): 19% to 22%. • Severe ( 30 days’ absence): 8% (75% of all severe inju- ries caused by body checks). read more..
73 • Ice Hockey 619 hockey were reported. First published report in Canadian literature occurred in 1984. Between 1981 and 1985, 15 major cervical spine injuries reported each year attribut- able to hockey. Currently, an average of 17 severe spinal in- juries are reported each year. • Mechanism of serious injury: axial load of cervical spine with read more..
620 SECTION VIII • Speciﬁ c Sports surgical reinforcement has been necessary to permit athletes to return to skating. • NHL experience (1991-1992 to 1996-1997) • Injuries per 1000 player hours: 1991-1992, 12.99; 1996- 1997, 19.87. • Preseason injury rate 5 times greater than regular season, 20 times greater than postseason play. read more..
73 • Ice Hockey 621 6. Cox MH, Miles DS, Verde TJ, Rhodes EC : Applied physiology of ice hockey . Sports Med 19 ( 3 ): 184 - 201 , 1995 . 7. Delaney JS, Al-Kashmiri A : Neck injuries presenting to emergency departments in the United States from 1990 to 1999 for ice hockey, soccer, and American football . read more..
FIGURE SKATING History • Figure skating is a sport that focuses on a unique combination of athleticism, strength, endurance, gracefulness, and artistry on ice. • It is an evolving sport that began in the early 1800s, when the sport consisted of complicated ﬁ gures traced on the ice. • Jumps and spins were read more..
74 • Ice Skating 623 • Patellar compression injuries arise from repetitive falling, al- though actual patellar fractures are rare. These injuries are seen with increased frequency when performing more difﬁ - cult jumps and with increased jump frequency. • Patellar tendonitis is less common in ﬁ gure skating than in other jumping sports, read more..
624 SECTION VIII • Speciﬁ c Sports coaches, because the onset of puberty is often accompanied by the accumulation of additional body fat and mass that must be lifted into the air with each jump, as well as wider hips that contribute to decreased rotational speed. • Osteoporosis has not frequently been found in women skat- ers; however, physicians caring read more..
74 • Ice Skating 625 • The blades are extremely sharp and are bent in at an arc that mirrors the direction of the turn to better grip the ice. • The blades are also placed off-center to the left to keep the boot from rubbing the ice when leaning into the left turn at high speed. • The walls of the read more..
626 SECTION VIII • Speciﬁ c Sports RECOMMENDED READINGS 1. Brown TD, Varney TE, Micheli LJ : Malleolar bursitis in ﬁ gure skat- ers . Am Orthop Soc Sports Med 28 : 109 - 111 , 2000 . 2. Dubravcic-Simunjak S, Pecina M, Kuipers H , et al : The incidence of injuries in elite junior ﬁ gure skaters . read more..
GENERAL OVERVIEW History of Sailing • Sailing has been a vital mode of transportation and trade since the dawn of history when boats were built by the Phoenicians, Egyptians, Greeks, and Romans. • The earliest representation of a ship under sail appears on an Egyptian vase from about 3500 bc . • From the read more..
628 SECTION VIII • Speciﬁ c Sports • Though a jury is often present to interpret the rules in case of protests, sailing is considered a Corinthian sport in which the participants are expected to abide by the rules and take their penalties when appropriate. • Many sailboat races are similar to race car driving; the boat that completes read more..
75 • Sailing 629 need a bathing suit, hiking shorts, sailing gloves, boat shoes, a hat, some sunscreen, and a lifejacket. • Constant debate occurs over the “requirement” of wearing lifejackets/personal ﬂ otation devices (PFDs) in regattas. • For the most part, the decision to wear PFDs is primarily the responsibility of the sailor, though the read more..
630 SECTION VIII • Speciﬁ c Sports cluding proper clothing, adequate nutrition, and safety mea- sures are recommended. Physiology of Sailing • Research addressing the biomechanics and physiology in the sport of sailing has been recently increasing as more scientists are analyzing the performance of the sailboat racer. • In read more..
75 • Sailing 631 • The biomechanics of hiking in Paralympic sailing may change the dynamics, due to different force couples when using pros- thetic legs for example, and should be considered when work- ing with athletes with disabilities (see Fig. 75-7 ). Training for the Sport • With physical ﬁ tness joining boat read more..
632 SECTION VIII • Speciﬁ c Sports • America’s Cup sailors have been found to average 56 kcal per kg of body weight in daily energy expenditure. • Dehydration can hamper performance, including increasing cognitive impairment and increasing risk of injuries. • General guidelines for hydration in sports apply to sailors. read more..
75 • Sailing 633 one place for a prolonged time period can lead to overuse problems for these drivers. • Grinders: Attention to the grip size and angle of rotation on winch handles, and to the height and angle of pedestal winches, may also help prevent other overuse injuries such as lateral epicondylitis, often referred to as “grinder’s elbow” (see read more..
GENERAL PRINCIPLES Climbing Overview • Climbing requires endurance, strength, and agility. • Athletes must be in good cardiovascular shape to climb. • Climbing-speciﬁ c training reduces injury and enhances ability. • Safety and equipment advances have made climbing much safer. • Climbers must read more..
76 • Rock Climbing 635 • Illness or injury related to environment, remoteness • Minor injury can lead to death in remote locale • Environment-related • Hypothermia • Altitude sickness • Falling rocks Bouldering • Indoor and outdoor (see Fig. read more..
636 SECTION VIII • Speciﬁ c Sports • Shoes (see Fig. 76-2 ) • Glovelike and tight-ﬁ tting, but should be bearable; smaller than normal shoe • Creates a “hoof effect” of the foot to provide strength and grip, protection from the rock • Shoe types range from general use to slipper-like supple read more..
76 • Rock Climbing 637 Epidemiology and Injury • Type of climb • Indoor safer, more controlled • Proper use of pro, condition of bolts and chains • Equipment condition, inspection • Risk for death and serious injury greater with mountaineer- ing ( Table 76-1 ) read more..
638 SECTION VIII • Speciﬁ c Sports • Foot supinated in small shoes (dorsiﬂ exion, plantarﬂ exion- inversion) • Bouldering falls from up to 3 meters, reduced risk with adequate mats • Falling into climbing surface or tangling into ropes on overhang • Foot • Neurologic symptoms of read more..
76 • Rock Climbing 639 • Falls and harness can contribute to strains, contusion, but less likely when harness properly ﬁ tting and applied Head • Impact • Falls, concussion • Rocks from above • Helmet for climber and belayer • Eye • read more..
640 SECTION VIII • Speciﬁ c Sports if milder injury but must be pain-free and climbing 2 to 3 levels below normal, with diminished frequency and intensity. Physical therapy highly beneﬁ cial, but requires experienced physiothera- pist. Modality care, oral anti-inﬂ ammatories for inﬂ ammation and pain. Strengthening of opposing muscle groups. Complete ruptures should be read more..
76 • Rock Climbing 641 Table 76-4 TREATMENT OF PULLEY INJURIES Grade 1 Grade 2 Grade 3 Grade 4 Injury Pulley strain Complete rupture of A4 or partial rupture of A2 or A3 Complete rupture of or A3 Multiple ruptures, such as A2/A3, A2/A3/A4, or single rupture (A2 or A3) combined with lumbricalis muscle or ligament damage Therapy read more..
642 SECTION VIII • Speciﬁ c Sports ment. Length of restricted activity depends on the severity of injury and resolution of symptoms. INJURY PREVENTION, DIAGNOSIS, AND TREATMENT Medical Care of Climbers • Physician inexperience or misconception • “What do you expect when you climb?” • Diagnosis and read more..
GENERAL OVERVIEW Deﬁ nition • Martial arts, also known as ﬁ ghting systems, are bodies of codiﬁ ed practices or traditions of training for unarmed and armed combat, usually without the use of guns and other modern weapons. • People study martial arts for various reasons including im- proving ﬁ tness, self-realization read more..
644 SECTION VIII • Speciﬁ c Sports celeration forces (see Fig. 77-1 ). Padding may lead to decreased inhibition and poorer control of striking, which may lead to a greater number of blows with a larger amount of force. Hand and foot padding are thought to decrease the amount of super- ﬁ cial injuries, such as lacerations and abrasions, to both the at- tacker read more..
77 • Martial Arts 645 Spear thrust: Open hand technique during which contact is made with the ﬁ ngertips of the second, third, and fourth ﬁ ngers, most often targeting the eyes and throat. Hammer ﬁ st: Closed hand strike with the ulnar aspect of the ﬁ st. Spinning back ﬁ st: The attacker swivels 360 degrees read more..
646 SECTION VIII • Speciﬁ c Sports Joint Locks/Manipulation Arm bar: A joint lock that hyperextends the elbow joint by placing the opponent’s extended arm over a fulcrum such as an arm, leg, or hip (see Fig. 77-2 ). The opponent is controlled in this posi- tion and if they do not tap out then continued force will result in read more..
77 • Martial Arts 647 Tae Kwon Do (“The Way of the Feet and Fist”) • Founder: unknown • Country of origin: Korea • Emphasis • Kicking techniques are emphasized because the leg is the longest and strongest limb in the body and thus has the potential to deliver the most read more..
648 SECTION VIII • Speciﬁ c Sports • Emphasis • Striking art. • Forms or techniques that demonstrate combat principles. • Techniques must be performed with excellent control and good form. • Injuring an opponent may result in a point deduction. • Light contact is permitted and read more..
77 • Martial Arts 649 • Mixed martial arts (MMA) has grown to be the most popular combative spectator sport in the United States and is arguably safer than boxing because match stoppage is not solely from knockout. • Participation in martial arts training continues to grow in part because of the emphasis on personal growth and improved read more..
HISTORY • Origins • Boxing is one of the most ancient of sports. • Drawings of matches are preserved on the walls of Beni Hasan in Egypt dating back between 1500 bc and 2000 bc . • Boxing became an Olympic sport for the ﬁ rst time in 688 bc , with Onomastos of Smyrna garnering the ﬁ read more..
78 • Boxing 651 tion, and through monitoring the recovery from previous in- juries. Physician Approval, Qualiﬁ cation, and Disqualiﬁ cation • Athletes are required to have approval from their physician prior to competing. • The physical exam must certify that the athlete is free from any injury, disability, or infection read more..
652 SECTION VIII • Speciﬁ c Sports the safety and ability of the boxer, precluding further partici- pation. Disqualifying During Competition • The following injuries disqualify initial or further competition: • Excessive swelling of the face or eyes that impairs vision • Active herpetic lesions of the face read more..
78 • Boxing 653 • If the ﬁ ght is stopped because of concern of concussion or other head injury, the designation is RSC (H), indicating that the ﬁ ght has been stopped due to head injury. • In this instance, the ﬁ ghter will then be evaluated immediately after the ﬁ ght has been declared RSC (H). read more..
654 SECTION VIII • Speciﬁ c Sports the ground, rapidly dilating pupils, a ﬁ xed gaze, and imminent respiratory failure. • This injury is usually catastrophic, and death follows, the re- sult of rapidly developing brain edema with herniation of the brainstem. • The pathophysiology is suspected to be a loss of autoregula- tion of the read more..
78 • Boxing 655 MONITORING BOXERS FOR CHRONIC BRAIN INJURY • When considering chronic brain injury, it is imperative that the evaluating physician be attuned to subtle signs such as loss of skill or alterations of behavior. • Maintain a high index of suspicion for this injury. An experi- enced and skilled ﬁ read more..
656 SECTION VIII • Speciﬁ c Sports ebellum and other areas of the brain, degeneration of the substantia nigra, and regional appearance of neuroﬁ brillary tangles. • However, according to other studies, there is no clear infor- mation regarding the persistence of the CSP in the general population at any time after the neonatal period. • read more..
GENERAL OVERVIEW Description • Dance is an activity that is found in most cultures and dates back to ancient times. • Although many sports medicine physicians think of dance medicine as ballet medicine, there are many other forms of dance, including ballroom, folk, jazz, and modern. • Each of these forms has unique read more..
658 SECTION VIII • Speciﬁ c Sports Jazz • Jazz dance originated from the African-American dances of late 1800s and has beget tap dancing and some forms of ball- room (e.g., swing and Lindy). • Traditional jazz shoes—soft leather with small heel. • Jazz sneakers—soft leather/canvas with padded sole to in- read more..
79 • Dance 659 • Shoes consist of a soft leather, lace-up slipper (soft, or reel, shoes) and a leather shoe with ﬁ berglass tips and heels (hard, or jig, shoes) (see Fig. 79-2 ). • Shoes are purchased to be extremely snug to give a tight toe appearance in plantar ﬂ exion. • Competition • Compete read more..
660 SECTION VIII • Speciﬁ c Sports • Intrinsic risk factors for injury: anatomic structure, inadequate strength and ﬂ exibility, improper technique, nutrition, previ- ous injury, fatigue. • Extrinsic risk factors for injury: choreography, cold environ- ment. • Students in summer intensive programs at high risk for in- jury. read more..
79 • Dance 661 • Subtalar coalition • Bony connection that is between the calcaneus and either the navicular or the talus. • Limits foot motion. • May cause mechanical pain. • Usually affects young dancers. • Navicular stress fractures • Lisfranc joint read more..
662 SECTION VIII • Speciﬁ c Sports • Dancers may use different ﬂ oors in the class area, as op- posed to performance areas. • Dancers in smaller programs and folk dancers are much less likely to have the luxury of dancing on sprung ﬂ oors. • Evaluate footwear worn when dancer is not dancing. read more..
GENERAL CONSIDERATIONS Overview • This chapter develops an algorithm for management of mass participation endurance events. • Medical director is safety and health advocate for athletes who participate in race. • Safety of athletes is primary purpose of race medical opera- tion. Events • Road read more..
664 SECTION VIII • Speciﬁ c Sports • Examples: emergency department transfer, hospital admis- sion, rehabilitation center. PREPARATION Race Scheduling • Location (latitude and longitude) • Season of year • Safest start and ﬁ nish times (if average high temperature is 60° F , read more..
80 • Mass Participation Endurance Events 665 • Give runner number to ensure that dispatched ambulance responds to the correct person. Notify central dispatch of pickup and disposition. Fluids and Fuel • Type: water, carbohydrate-electrolyte solutions, high- carbohydrate foods. • Location: start, aid stations, ﬁ nish read more..
666 SECTION VIII • Speciﬁ c Sports • Toilet • Point of care lab measuring devices for serum sodium, BUN, potassium, hematocrit, glucose, oxygen saturation (if available) Supplies • Medical • Trauma • Intravenous ﬂ uids (normal saline [NS] or 5% dextrose in NS) • read more..
80 • Mass Participation Endurance Events 667 MEDICAL PROTOCOLS • First aid: do no harm; stay within training level. • Basic problems: exercise-associated collapse, low-frequency medical emergencies, trauma, repetitive use, and skin injury. • Initial assessment of collapsed athlete (ABCDE): a irway read more..
668 SECTION VIII • Speciﬁ c Sports hypothermic patient because cold liver does not metabolize lactate). • IV access uses (invasive procedure that should be used for set criteria) • Medication access. • Measure serum electrolytes, BUN, glucose, and hematocrit. • Fluid replacement in participants with normal or read more..
80 • Mass Participation Endurance Events 669 • Instruct in ﬂ uid and food replacement. • Reevaluate if change in status. • Recommend follow-up exam for severe cases. LOW-FREQUENCY MEDICAL EMERGENCIES Cardiac Arrest • Equipment and supplies: automatic or manual deﬁ brillators, read more..
670 SECTION VIII • Speciﬁ c Sports • Deﬁ nitive ﬁ eld care: temperature maintenance, pain con- trol, splint, other. • Transport to emergency medical facility or race medical facility, if equipped and staffed to care for trauma. POSTRACE REVIEW • What went right (and can it be improved)? read more..
RULES OF THE GAME • Two halves, 35 minutes each in collegiate and international play, 30 minutes in high school play. • Eleven players per side, including goalkeeper. • Pitch may be grass or artiﬁ cial turf and is 100 yards long and 60 yards wide, divided by centerline and 25-yard line on each side of the ﬁ read more..
Table 81-2 1988-2003 NCAA INJURY SURVEILLANCE SYSTEM * Practice injuries Game injuries Injuries Lower extremity 60% • Upper leg strains 26.9% • Ankle sprains 15% • Pelvis/hip muscle strains 9.9% • Knee internal derangement 7.8% Trunk/back injuries 16.2% Head/neck 8.4% with read more..
81 • Field Hockey 673 Cold weather issues: Frost nip, chill blains, frostbite, hypother- mia. Wear appropriate clothing, gloves for prevention. Fluid considerations: Prevent and manage dehydration. Frequent water breaks during play. Postworkout body weight should equal preworkout body weight. Athletes need to rehydrate prior to continued play. Grass read more..
GENERAL PRINCIPLES History • The sport of lacrosse derives its name from the netted stick, or crosse, which resembles a crosier, a staff with a hook- shaped curve at one end, used by religious ﬁ gures. • Lacrosse is a true American sport that has its roots in Native American Indian culture. Basics of the Game read more..
82 • Lacrosse 675 WOMEN’S FIELD LACROSSE • Women’s lacrosse is a noncontact sport, although controlled checking with the stick is allowed. • There are 12 players per side: one goalie, four attackers, four defenders, and three midﬁ elders with similar functions as in the men’s game. • Traditionally there read more..
676 SECTION VIII • Speciﬁ c Sports Chest • Commotio cordis is a rare cause of sudden cardiac death. • It is seen in sports where a projectile is used and is most com- mon in baseball. • Commotio cordis occurs when the ball impacts over the car- diac silhouette in a speciﬁ c phase of the cardiac read more..
82 • Lacrosse 677 Typical hand fractures associated with lacrosse Oblique fracture of proximal phalanx with shortening. Fragment must be pulled out to avoid leaving volar spike that limits flexion of proximal interphalangeal joint. Protective, articulated, plastic covering over thumb pad of goalie glove. Intra-articular fractures of phalanx that are non-displaced and stable may be treated read more..
678 SECTION VIII • Speciﬁ c Sports Anterior subluxation of talus Anterior talofibular ligament–torn Arthroscopic image of torn anterior cruciate ligament. Lateral ankle sprain MRI of torn anterior cruciate ligament. Calcaneofibular ligament–torn Ligament tear Anterior talofibular ligament–torn Posterior cruciate ligament Anterior cruciate ligament (ruptured) Arthroscopic view. Figure 82-5 read more..
GENERAL OVERVIEW • As a competitive sport, rowing dates back several hundred years, and was one of the original sports in the modern Olym- pic Games. • Rowing was the ﬁ rst intercollegiate sport in the United States, the ﬁ rst U.S. race being held in 1852 between Harvard and Yale. • Since Title IX regulations read more..
680 SECTION VIII • Speciﬁ c Sports APPROACH TO INJURY EVALUATION • Vast majority for competitive rowers of all ages and abilities are chronic overuse injuries, due to repetitive nature of the sport. • Improper stroke mechanics and asymmetries can predispose a rower to injury. • Other factors include poor read more..
83 • Rowing 681 Types of injury: • Muscle strain: Most common injury. Pain in low back, in- volving erector spinae muscles and/or sacroiliac joint region. • Sacroiliac joint dysfunction: May result in pain over but- tock, lateral thigh, anterior pelvis, and groin. Contributing factors may include leg length discrepancies, underlying read more..
682 SECTION VIII • Speciﬁ c Sports 23%; higher incidence in female rowers. Most common in anterolateral and posterolateral aspects of ﬁ fth through ninth ribs. • Costochondritis and costovertebral joint subluxation: Poorly understood condition, most likely to occur during sweep rowing because of excessive rotation. • Intercostal, rhomboid, read more..
83 • Rowing 683 buckle or pop up slightly at ﬁ nish. If athlete cannot fully ex- tend at the ﬁ nish, vastus medialis muscle will be prevented from normal function; the three remaining muscles of quad- riceps are strengthened during stroke and the imbalance will lead to lateral tracking of patella. Some female rowers may be predisposed to patellofemoral pain because read more..
684 SECTION VIII • Speciﬁ c Sports • Tenosynovitis of wrist extensors or “sculler’s thumb”: Swelling over dorsal aspect of forearm, cause by hypertrophy of abductor pollicis longus and extensor pollicis brevis muscle bellies. May be due to improper use of thumb to feather the oar at the ﬁ nish or by allowing palm to slide down the handle read more..
83 • Rowing 685 hard plastic, foam, etc.), although some rowers opt to use ten- nis racket grip, which they tape on themselves. However, in most cases some blistering will be unavoidable. Ensure scrub- bing of oar handle after each use if shared among crew. Case study of spread of hand warts caused by oar sharing among crew. • Track bites: Use read more..
IN-LINE SKATING History • The existence of in-line skates dates to 1849 when Louis Legrange crafted a pair with wooden wheels to simulate ice skates for a scene in Giacomo Meyerbeer’s opera La Prophète. • In the 1970s in-line skating was principally limited to hockey players looking for a way to practice during the summers. read more..
84 • In-line Skating, Skateboarding, and Bicycle Motocross 687 Location • Approximately two-thirds of the injuries occur in the upper ex- tremity, with the wrist being the most common locus of injury. • Wrist and forearm are the most frequent sites of injury, especially of the more severe injuries (e.g., fractures and dis- read more..
688 SECTION VIII • Speciﬁ c Sports Injury Patterns Risk Factors • Male: Consumer Products Safety Commission (CPSC) re- viewed 11 years of injury data and found approximately 87% of injured skaters were male. • Age: 10- to 14-year-olds are the group most often injured. Among CPSC age groups, 5- to 14-year-olds have read more..
84 • In-line Skating, Skateboarding, and Bicycle Motocross 689 • The disciplines or styles may overlap to some extent, and as new styles of riding are developed the current may change as with skateboarding. • Disciplines • Street: Riding on streets or public property; allows for cre- ativity, as almost anything can be used as an read more..
GENERAL INFORMATION • Rugby is an internationally played sport, second only to soc- cer in popularity. • It originally derived from soccer in 1823 when Englishman William Webb Ellis, “in a ﬁ ne disregard for the rules,” picked up the ball and ran with it. • Today, rugby is one of the most popular club sports and read more..
85 • Rugby 691 • Flanker: Also known as “wing-forward” or “loose-for- ward,” these players on the outside of the third row attempt to push forward during scrums as well as break away from the pack if they are needed to make defensive tackles. • Eight man: The middle player of the third row whose job it is to push during read more..
692 SECTION VIII • Speciﬁ c Sports • There have been several organizational rule changes that have helped decrease the incidence of cervical spine injury. • There is unequivocal evidence to show that mouth guards reduce the incidence of dental injury; however, only approxi- mately 60% of professional and 80% of youths wear them. • read more..
GENERAL INFORMATION • History • Cheerleading originated at a Minnesota University football game on November 2, 1898. • Over the next century cheerleaders functioned primarily in a supportive role at athletic competitions. • Since the 1980s, cheerleading has evolved into an activity demanding high levels of dance, read more..
694 SECTION VIII • Speciﬁ c Sports • Retrospective analysis of cheerleading-related injuries in chil- dren noted a greater number of injuries per 1000 participants sustained in the 12- to 17-year-old group compared with 6- to 11-year-old group, reﬂ ecting the greater level of performance difﬁ culty. • Studies have demonstrated that read more..
86 • Cheerleading 695 • Proper ceiling height. • Appropriate ﬂ oors, mats, lighting, and padding of objects. • Current surveys have demonstrated up to 10% of cheer- leading practices occur in the cafeteria or hallway at the school. • Proper stunt progression • See AACCA manual for acceptable read more..
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The duties for which the team physician has ultimate responsi- bility include the following: Medical management of the athlete □ Coordinate pre-participation screening, examination, and evaluation □ Manage injuries on the ﬁ eld □ Provide for medical management of injury and illness □ Coordinate rehabilitation read more..
American Medical Society for Sports Medicine (AMSSM) 11639 Earnshaw Overland Park, KS 66210 (943) 327-1415 American Orthopaedic Society for Sports Medicine (AOSSM) 6300 N. River Rd. Suite 200 Rosemont, IL 60018 (847) 292-4900 American Osteopathic Academy of Sports Medicine 7611 Elmwood Ave., read more..
Administrative Protocol It is essential for the team physician to coordinate: • Assessment of environmental concerns and playing condi- tions • Presence of medical personnel at the competition site with sufﬁ cient time for all pre-game preparations • Plan with the medical staff of the opposing team for medical care read more..
Administrative Protocol It is essential for the team physician to coordinate: • Review and modiﬁ cation of current medical and administra- tive protocols In addition, it is desirable for the team physician to coordinate: • Compilation of injury and illness data Conclusion This Consensus Statement outlines read more..
return-to-play, home with observation, or transport to hos- pital). • Provide post-event instructions to the athlete and others (e.g., regarding alcohol, medications, physical exertion and medical follow-up). In addition, it is desirable for the team physician to: On Field • Have a plan to protect access to the injured player read more..
• Previous concussions (number, severity, proximity) • Signiﬁ cant injury in response to a minor blow • Age (developing brain may react differently to trauma than mature brain) • Sport • Learning disabilities • Understand contraindications for return to sport (e.g., abnor- mal read more..
Collins MW, Iverson GL, Lovell MR , et al : On-ﬁ eld predictors of neuro- psychological and symptom deﬁ cit following sports-related concus- sion . Clin J Sport Med 13 : 222 - 229 , 2003 . Collins MW, Lovell M, Iverson G , et al : Cumulative effects of concussion in high school athletes . Neurosurgery 51 : 1175 - 1179 read more..
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A Abdomen assessment of, 15 trauma to, 29 Abdominal injuries, 379-392 anatomy and physiology of, 379, 389f auscultation of, 380 diaphragm rupture, 389-392, 389f epidemiology of, 379 hernias, 391-392, 391f history-taking, 379-380 in ice hockey, read more..
706 Index opioids, 49, 49f tramadol, 49 Anaphylaxis, 26-27 exercise-induced, 250-251 local anesthetics-related, 483 Anemia dilutional, 209 evaluative algorithm for, 209f iron-deﬁ ciency, 209f sports, 209 Anger control issues, 168 Angiotensin II receptor read more..
Index 707 Avulsed teeth, 342 Avulsion fractures, 299, 412-413 Axillary nerve injury, 255-256, 256f, 349 Axillary vein injury, 388 Axis, 326f B Baclofen, 107 Baker’s cyst, 426f, 427 Ballance’s sign, 389-390 Ballet, 657, 658f, 659-660 read more..
708 Index Bunions, 467, 470f, 661 Burners, 327 Bursitis, 408-409 deﬁ nition of, 301 greater trochanteric, 558, 559f iliopectineal, 391 iliopsoas, 391, 408-409 ischial, 409 knee, 426, 426f olecranon, 363, 363f prepatellar, 525, read more..
Index 709 Cold agglutinin disease, 157 Cold baths, 313 Cold exposure physiologic responses to, 150 physiology of, 149-150 Cold injury, 279 bronchospasm, 156 chilblains, 156, 279 in cross-country skiing, 606 frostbite, 154-156, 155f, 279, 279f frostnip, read more..
710 Index DASH diet, 242 de Quervain’s tenosynovitis, 505, 587, 596, 596f, 683f Decompression illness, 540-541 Deep venous thrombosis, 103 Deﬁ brillation, 25 Degenerative arthropathy, 290-291 Degenerative disc disease, 399 Degenerative hypertrophic spondylitis, 89f read more..
Index 711 clinical, 75, 76b diagnostic criteria for, 76b etiology of, 77f, 186 in ﬁ gure skating, 623-624 hospitalization for, 187, 187b not otherwise speciﬁ ed, 76, 186 prevalence of, 186 prevention of, 187 psychotherapy for, 187 risk factors read more..
712 Index elements of, 115 in hypertension, 118, 245-246, 246f implementation of, 115 in obesity, 119 in osteoarthritis, 118-119 principles of, 115 Exercise program initiation of, 115 risk associated with, 116t safety of, 115 Exercise stress testing, for read more..
Index 713 Fibrocartilage, 438 Fibular fractures distal physeal, 568 stress, 461 Field hockey, 671-673 equipment used in, 671 eye protection in, 333t fouls in, 671 fractures in, 672, 673f heat-related issues in, 672 helmet protections, 317t, 318 read more..
714 Index epiphyseal, 299 evaluation of, 29 femoral neck, 449 femur, 450, 450f ﬁ bular shaft, 433, 461 in ﬁ eld hockey, 672, 673f ﬁ fth metatarsal, 462, 462f, 501, 520, 560 foot, 449, 450f calcaneus, 461, 462f stress, read more..
Index 715 Groin injuries in ice hockey, 619-620 in soccer, 512-513 in swimming, 535 Groin pain, 411 Groin pull. See Adductor strain Groin taping, 476 Gross mechanical efﬁ ciency, 574 Growth and maturation of female athletes, 72 of pediatric athletes, 56-57 read more..
716 Index Heat injury in older adults, 89 in soccer, 509-510 in track and ﬁ eld, 562-563 Heat loss, 149 conductive, 140, 149 convection, 141, 149 decreases in, 150-151 evaporative, 141, 149 layering of clothing to prevent, 150-151 nonevaporative, read more..
Index 717 management of, 241-245 alpha 1 receptor blockers, 244 alpha/beta blocker combination, 244-245, 245f angiotensin II receptor blockers, 244-245 angiotensin-converting enzyme inhibitors, 243-244, 243f beta blockers, 244, 244t, 245f calcium, 242 calcium channel blockers, 245 read more..
718 Index sterile technique for, 482 subacromial space, 483, 484f tarsal tunnel, 488 trochanteric bursa, 486, 486f upper extremity, 483-485 wrist joint, 485 Injuries. See also speciﬁ c injuries data regarding, 70, 70t ﬂ exibility’s role in prevention of, read more..
Index 719 eyelid, 335, 335f ﬂ exor tendon, 372-373, 372f liver, 390 in martial arts, 646 maxillofacial, 341 scalp, 321 skin, 29 in wrestling, 521 Lachman test, 419, 420f Lacrosse, 674-678 eye protection in, 333t fouls in, read more..
720 Index Mania, 166-167 Marfan syndrome, 233, 233t, 285-286, 285f, 286t, 386 Marfan syndrome stigmata, 13, 16f Marijuana, 178-179 Marketing of supplements, 38 Martial arts, 643-649 aikido, 647 chokeholds in, 645, 645f deﬁ nition of, 643 read more..
Index 721 environmental, 590 epidemiology of, 585 evaluation of, 586 falls, 585-586 fractures, 589 hand, 587 hip, 587 iliotibial band friction syndrome, 587 knee, 587 low back pain, 588 lower extremity, 589 mechanism of, 585-586 muscle read more..
722 Index Norbolethone, 173 Nutrients carbohydrates, 32f, 33 fats. See Fats protein. See Protein requirements, 32-35 timing of, 36 Nutrition goals of, 31, 31f high altitude training, 161 precompetition, 36 for road biking, 580 in read more..
Index 723 Patellofemoral tracking, 418 Patent airways, 26f Patent foramen ovale, 542 Patrick’s test, 396, 406f, 407 Peak expiratory ﬂ ow rates, 74 Pectoralis major rupture of, 382-383, 497 tear of, 356-357 Pediatric athlete. See also Children endurance read more..
724 Index frequency of, 10 group, 10 guidelines for, 10 in high school athletes, 68 “Italian Experience,” 18-19 legal considerations, 236 medical history, 11-12 methodology of, 10-11 objectives of, 10 personnel involved in, 11 physical examination. See read more..
Index 725 Respiratory system exercise responses by, 116f hypothermia effects on, 151t Rest periods, 130 Resting heat production, 139 Resting metabolic rate, 33 Restrictive lung disease, 109 Retina detachment of, 337-338 edema of, 334 hemorrhage of, 337-338 read more..
726 Index Sailing, 627-629 boardsailing, 633 competitive, 627 crew positions for, 632f environmental considerations, 629-630, 630f equipment used in, 628 hiking, 630-631, 633 history of, 627 illnesses, 629-630 injuries associated with, 632-633 nutrition for, read more..
Index 727 sternoclavicular joint, 355-356, 355f subscapularis testing, 346 suprascapular nerve entrapment, 358-359 supraspinatus testing, 346 swimmer’s shoulder, 530 in tennis, 594-595, 594f in volleyball, 505-506 in wrestling, 524 x-ray evaluations, 348-349 Shoulder pads, read more..
728 Index sheriff, 24 team physician. See Team physician Sports participation clearance for, 19-20 guidelines for, 21t medicolegal issues, 20 by older adults, 86 restriction of, 236 Sports pharmacology, 172 Sports psychiatrists, 170 Sports psychologist, 165 read more..
Index 729 creatine, 39-40 dietary, 37 echinacea, 42-43 ephedra, 38 evening primrose, 43 ﬂ uid replacement beverages, 40 Food and Drug Administration regulation of, 38 garlic, 43 general health, 42-46 Ginkgo biloba, 43 ginseng, 41 glucosamine, read more..
730 Index Tension pneumothorax, 384-385, 385f, 540, 540f Tension-type headache, 265, 269-270 beta blockers for, 270 characteristics of, 266t deﬁ nition of, 269 diagnostic criteria for, 270t signs and symptoms of, 270f treatment of, 270, 274t Teratocarcinoma, read more..
Index 731 seizures after, 252 sudden cardiac death caused by, 235 testicular, 219, 219f thoracic spine, 396, 397f thoracoabdominal, 603 Traumatic brain injury, 252 acute, 653-654, 655f in boxing, 653-656 chronic, 325, 654-656 mild, 317-318, 318t, read more..
732 Index neck, 523 patterns of, 521 prepatellar bursitis, 525 rib, 523-524 septic bursitis, 525 shoulder, 524 thumb, 524 treatment guidelines for, 525-526 wrist, 524 intercollegiate, 521, 527t interscholastic, 527t NCAA Wrestling Weight Certiﬁ read more..
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