When is playing a bad idea?

1. When is playing a bad idea? Sara Mackenzie, MD, MPH and Gary Strokosch, MD Regional Health Specialists November 8, 2012

2. After this presentation, you will be able to: • Describe common components of a sports physical • Describe red flags that need further evaluation prior to sports clearance • List common sports-related injuries • Identify common treatments for sports-related injuries

3. Can I get a sense of who is on call? • Center physician? • Health and wellness manager? • Center nurse or LPN? • TEAP/CMHC? • Recreation specialists? • Other?

4. Pre-participation physical purpose: • Detect potentially life threatening or disabling medical or musculoskeletal conditions • Identify pre-existing conditions that may predispose to injury • Satisfy administrative requirements • Promote health and safety • General health assessment

5. Why discuss? • Regulatory reasons – Job Corps and broader • 50 of 51 states require pre-participation sports physicals for high school students prior to competitive sports participation • American Heart Association recommends for competitive athletes to detect underlying cardiac abnormalities in an attempt to reduce risk of sudden death

6. Job Corps PRH 6.11 R2 • All students participating in organized contact or rigorous sports shall be medically cleared • Physical exam at entry within 1 year of organized sport activity can fulfill requirement • Repeat annually • Staff member trained in CPR/first aid must be present at all organized contact and rigorous sports activities, including practice and sports events

7. Identification of life threatening conditions: • Sudden cardiac death – leading cause of death in young athletes • Stimulates discussion about appropriate screening and preparation at events • Range from 1/50,000 to 1/200,000 high school athletes/year • 1/70,000 college athletes/year • Due to lack reporting—likely underestimated rates

8. Causes of sudden cardiac death: • Under age 35: • Cardiomyopathy or structural–genetic link • Primary electrical disease–genetic link • Acquired heart disease/myocarditis • Congenital heart disease • Over age 35: • Coronary artery disease

10. Hypertrophic Cardiomyopathy • Leading cause SCD in U.S. • Autosomal dominant with variable expression (over 10 genes isolated and >200 mutations identified) • Symptoms can include: exertion chest pain, shortness of breath, palpitations, fatigue, dizziness, near syncope or syncope • Most athletes are asymptomatic • Some will be identified by family history or murmur on exam

11. Cardiac Exam • If present, harsh systolic murmur due to left ventricular outflow obstruction • Murmur increases with decreased systolic return (so louder murmur when standing, valsalva; softer murmur when squatting)

12. What is standard of care? • No universally accepted standards for what constitutes appropriate sports screening • Usually some level of history and physical

14. History: • Most critical component – required part of entry exam for all students • Detection of previous and current medical issues or injuries is key • Key areas in relations to sports: • History of concussion • History of dizziness or collapse with exertion • Family history of exercise related death or unexplained death <age 50 • History of asthma • History of loss or dysfunction of paired organs

15. Physical: • Most components already included in routine required entry physical • Height, weight, blood pressure, vision • Skin exam – infection • Heart exam – sitting and supine • Lung exam • Abdominal exam • Genital exam – males, controversial • Musculoskeletal

16. Draft Job Corps specific history and physical forms: • Proposed to replace SF 88 and SF 93 • Incorporate recommended sports screening questions • Should help identify those at increased risk

17. DRAFT History form

18. DRAFT History form

19. DRAFT History form

20. Syncope or dizziness during exercise: • Prior history of exertional syncope or near syncope found in 17% to 23% of SCD (1) • Of 6.4% athletes reporting syncope only 1.3% related to exertion and 33% of those had structural disease known to cause SCD on exam (2) • Work up—EKG, ECHO; possible stress test 1) Maron, JAMA, 1996 2) Colivicchi, Epidemiology and prognostic implications of syncope in young, competitive athletes. European Heart Journal, 2004

21. DRAFT History form

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

23. Common musculoskeletal conditions: • Knee • Osgood Schlatter • Knee Injuries • ACL, PCL, MCL • Meniscus tear • Anterior knee pain • Ankle

24. Osgood-Schlatter Condition • Painful condition of the knee(s) • Located at the tibial tuberosity, the bump where the ligament from the patella is inserted into the tibia • Characterized by tiny, microfractures of the tibial tuberosity that occur primarily during a growth spurt

25. Osgood-Schlatter Condition

26. Osgood-Schlatter Condition • More likely to affect junior high and high school age athletes • Found in athletes of either sex who are active in games requiring substantial running and/or jumping • It is an overuse condition • Requires rest and restraint from further strenuous activity for periods of time • It usually clears by late adolescence

27. Osgood-Schlatter Condition • It does not require an x-ray to diagnose • Tenderness and swelling at one or both tibialtuberosities • The swelling persists into adulthood, long after the tenderness is resolved • Most athletes will want to play through the pain, try anti-inflammatory medication, or ice and rest for periods of time

28. Knee • It is the largest joint in the body • The upper and lower bones are separated by 2 discs (menisci) • The distal femur and proximal tibia and fibula are connected by ligaments and tendons • The surface of the bones inside the knee joint is covered by articular cartilage • Injuries of one of these structures are the most common knee problems

29. Knee Injuries • Caused by direct blow to the knee, abnormal twisting or bending the knee, or falling on the knee – these lead to pain, bruising and swelling • Injuries most commonly include ligament sprain, tendon strain, meniscus tear, ligament tears (anterior cruciate or medial collateral), fracture (distal femur, proximal tibia or fibula, or patella) and dislocation of the patella

30. Anterior CruciateLigament Tear • A tear usually occurs when a force is applied to the knee while the foot is firmly planted on the ground or upon landing • Pain and swelling start quickly and student may report hearing a popping or cracking sound at the time of injury • Pain occurs in the knee or calf region and student feels instability of joint (giving way)

31. Posterior Cruciate Ligament Tear • Injured less than ACL and is thicker/stronger • From direct impact to the front of tibia, usually when the knee is bent • Pain, swelling in the back of knee and instability of the joint (giving way)

32. Medical Collateral Ligament TearLateral Collateral Ligament Tear • They connect the femur and tibia on the medical and lateral side of the knee • They protect a force from the opposite side • MCL is torn more frequently from lateral trauma forces on the knee • Pain, stiffness, swelling and tenderness along the side of the knee • The knee may feel unsteady or it may lock or catch

33. Meniscus Tear • The injury usually occurs with forcefully rotating knee while bearing weight • Pain occurs, especially when the leg is straightened • Swelling usually occurs • May report an audible click or pop and the knee may lock or feel weak

34. Treatment of Knee Injury • RICE treatment as first aid as outlined above • NB: The injury is more severe if • there is/was a popping sound • the knee gives out • the pain is severe • cannot move the knee • cannot bear weight of any kind

35. Anterior Knee Pain • Anterior knee pain that occurs at the front and center of the knee • Also known as: • Patellofemoral Syndrome • Chondromalacia Patella • Runner’s Knee • Patellar Tendonitis • Jumper’s Knee

36. Etiology (?) • Patellofemoralmalalignment • Quadriceps tightness • Overuse of jumping or twisting, running, skiing, playing soccer or bicycling • Obesity • Flat feet • Adolescent or young adult

37. Findings • The knee may be tender and mildly swollen • Examiner may feel a grinding sensation below patella with flexion • Pressing the patella when straightened may be painful • X-rays or scans are not helpful

38. Treatments • Rest and anti-inflammatory meds • Strengthen and stretch the hamstrings and quadriceps • Lose weight if needed • Orthotics for flat feet • Good quality sports or running shoes

39. Ankle Injuries • The ankle is where 3 bones meet: the tibia and fibula of the lower leg with the talus of the foot • These 3 bones are held together by ligaments • Tendons attach muscles to the bones to do the work of moving the ankle and foot and help keep the joints stable

40. Ankle Injuries • A fracture describes a break in one or more of the bones • A sprain is the term that describes damage to ligaments when they are stretched beyond their normal range of motion and can range from many microscopic tears in the fibers to a complete tear or rupture • Muscle or tendon strains from over stretching commonly affect the peroneal tendons

41. ANKLE

42. Ankle Injuries • Most injuries occur when the ankle joint is twisted too far out of its normal position, mostly during sports activities • Symptoms include pain, swelling, bruising, inability to walk or bear weight, stiffness, tenderness, and deformed or out of place. NB: The latter two may suggest a fracture

43. R.I.C.E. • Rest: this helps prevent further damage and keep weight of ankle • Ice: this helps slow or reduce swelling and may numb the pain • Compression: wrapping the injured ankle with elastic bandage helps keep it immobile and supported • Elevate: this may reduce swelling and pain

44. Examination and Re-examination • This is usually to determine if x-rays are needed for the uncommon finding of a fracture – tenderness, deformity or lack of improvement over time • With conservative management, re-examination is suggested to be certain that improvement is occurring with sprains or strains • However, students often continue sports activities with an injury and prevent healing and/or injure the ankle further

45. Ankle Sprains • Mild (grade 1): several days of RICE • Moderate (grade 2): RICE for longer period of time and immobilization of ankle • Severe (grade 3): Immobilization of joint for a much longer period of time to allow healing

46. Ankle Treatment Time • The initial treatment of a sprain includes resting and protecting the ankle until the swelling goes down for about one week • That is followed by one to two weeks of exercise to restore range of motion, strength and flexibility • Complete healing may take several more weeks to several months to return to normal activities

47. Concussion • A disturbance in brain function following trauma to the head • An athlete in a contact sport has a 19% chance of experiencing a concussion each season

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

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

50. Assessment • Note any signs and symptoms from two previous slides • Especially, determine if there was any loss of consciousness • X-rays and neuroimaging tests not helpful • Monitor over time – next 24 hours