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Sports Medicine
Symposium on Common Orthopedic Problems
Sports Medicine James G. Garrick, M.D.*
There are few "orthopedic diseases" that prompt more physician visits than the problems resulting from sport and recreational activities. Rather than being the exclusive domain of high school boys, organized athletics are now available to boys and girls of almost any age, thus the potential patient population is a large one indeed. If nothing else, merely certifying these children as fit for athletic participation is a monumental medical undertaking to say nothing of supervising the maintenance of that level of fitness. Although few athletic injuries are truly emergencies, nearly every one is accompanied by a sense of urgency by the child, parent, and coach. None of these individuals is the least bit reluctant to inform the physician that the decisions regarding the particular injury will probably influence the child's well-being, the team's success, the likelihood of someone receiving a college scholarship, and so on. Often this places the physician in an anxiety-surrounded situation to which he is unaccustomed. Too often the physician overreacts to the plight of the injured athlete. If the physician is unsure of the diagnosis or the demands of the sport, overtreatment may result and the athlete needlessly may miss a season of play. On the other hand, expedient treatment may be given by a physician'unaware of the long-term problems resulting from the injury or, perhaps, too willing to accede to the demands of the youthful competitor wishing to return to play. More familiarity with the demands of various sports and the resulting injuries will enable the physician to make decisions truly in the long-term best interests of the patient.
Evaluating the Risks A sport requires a certain amount of organization before its safety characteristics can be examined. Most competitive sports have some semblance of organization - if nothing else someone has to schedule matches and keep score-and thus can be studied. Other individual noncompetitive sports, such as hunting, fishing, scuba diving, water
*Associate
Professor of Orthopedic Surgery, University of Washington School of Medicine, Seattle, Washington
Pediatric Clinics of North America- Vol. 24, No.4, November 1977
737
738
JAMES G. GARRICK
90
1
FOOT TBALL
80
• WRESTLING
70 2 yr rate: ~ Male © Female
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1st yr eo 2nd yr
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'-
30 20
CROSS COUNTRY
t •
~
BALL© BASKET BALL
CROSS COUNTRY
SOCCER .,
BASKET BALL
VOLLEYBALL
10
8 FIELD!
tt
G~M
~ © BADMINTON
TRACK
1 TRACKT 8 FIELD
fBASEBALL
SWIMMIN~ SWIMMING
TENNIS TENNIS
A
~
O~----------~------~~~----------~~--------Figure 1. Distribution of sports injuries in a study of 3049 students who participated in 19 sports and sustained 1197 injuries. See text for details.
skiing, and swimming, while surely dangerous in some cases, are nearly impossible to evaluate systematically. Also, in order to study the injury problems within a sport there must be someone available to decide "who is hurt." Although this sounds naIve, a large proportion (if not a majority) of athletic injuries that ultimately limit participation go initially unrecognized by those responsible for the conduct of the practice or game. DUring two school years we attempted to resolve the problem by hiring athletic trainers to identify injuries in four high school athletic programs. An injury was defined as "a traumatic medical incident resulting in removal from a practice or a game and/or missing a subsequent practice or game." During the study 3049 students participated in 19 sports and sustained 1197 injuries-or 39 injuries per 100 participants (Fig. 1). Nearly two-thirds of the injuries identified in these high school athletes were strains and sprains. Over half of the injuries were to the lower extremities with the thigh, knee, and ankle being involved almost equally. Although it is difficult to study the injury problems in extrascholastic sports, investigations with a number of age group programs such as soccer, skiing, football, and hockey would suggest that types and loca-
SPORTS MEDICINE
739
tions of injuries are reasonably consistent within sports, but rates vary with age and experience. For example, it would appear that the injury rate for football players under 12 years of age is about one-quarter to one-sixth that of high school players, although the type and locations of the injuries are not too dissimilar. What may be a devastating injury in one sport may be of little or no significance in another. The wide receiver in football with a sprained ankle is lost so long as he has appreciable symptoms. Were he a side-horse specialist in gymnastics, however, it might not affect his capabilities in the least.
The Pre-Season Examination The pre-participation examination is much likethe elephant being examined by blind men-it appears differently depending upon how it is approached. To the school administrator it fulfills the school's legal and insurance requirements. To the coach it is theoretically a means of starting the season with athletes who have some common level of health and fitness. To the idealist it may be a means of attempting to prevent injuries. To the physician it should be an opportunity to discover "treatable" conditions or conditions that will interfere with or be worsened by athletic participation. In reality, it is probably an annual period of frustration, unkept office appointments, and frantic phone calls the day before the first turnout. A child athlete offers the most potential for accomplishing something meaningful in the pre-participation examination. As athletes become more experienced, one is less likely to discover significant medical problems during the course of an examination. Thus the first few pre-participation eXlilminations uncover conditions that will preclude speCific athletic activities. Later in the athlete's career one usually looks for (and finds) only the residuals of previous injuries. For the experienced athlete, the examination serves primarily as a quality control of treatment and rehabilitation of previous injuries. Realistically, save for requiring complete rehabilitation from prior injuries, the pre-season examination offers little opportunity for preventing injuries. Generally we know little about the factors predisposing to injury. Commonly advocated conditioning programs that stress stretching and strengthening are better justified in enhancing performance than in preventing injury due to the absence of any evidence of injury reduction associated with their use. Most conditions generally regarded as disqualifying - apparently so considered because they would appreciably increase the risk of injury or the consequences of injury were one to occur or worsen health-are so obvious that there would be little question of partiCipation because the athlete would be under active medical care.~' The keys to a successful pre-participation examination program are planning and adequate assistance. The physician is required for a small portion of the process. Those responsible for the conduct of the sport 'The disqualifying conditions listed in the· American Medical Association's Medical Evaluation of the Athlete-A Guide, have been the most extensively promulgated. While possibly unrealistic, they undoubtedly constitute the standard to which one will be held.
740
JAMES G. GARRICK
(coaches, school administrators, etc.) must assume the responsibility for organizing and providing personnel for the examination. The following plan was developed, tested, and utilized over a two-year period by the Division of Sports Medicine, University of Washington, in both high school and college settings. DUring that period we have not (subsequent to the examination) been faced with medical problems that "could have been picked up" (on the initial examination). Location The examination is most efficiently carried out in a large room (gymnasium or all-purpose room) with two adjacent offices or screened off areas (coach's office). Although a clinic or physician's office may be used, it decreases the number of athletes that can be examined in a specified time by approximately 20 per cent. Examiners The number of examiners and their interests and skills are the most important variables determining how many athletes can be seen in a given period of time. Assuming 30 or more athletes are to be examined, the ideal team consists of nine members including a mandatory two physicians and at least two others with medical or paramedical training - nurses, physician assistants, or athletic trainers. Five student managers, trainers, or assistant coaches are needed as well as a head coach to act as traffic director and disciplinarian. Athletes The athletes must be dressed in gym shorts or a swimming suit (two piece suits for girls) at least 10 minutes prior to the examination. They all must be there for the beginning of the examination even though some will have to wait for their actual examination. Examination Stations The stations should be numbered so they can be easily seen and each station should have a desk or writing surface available for the examiner. The history station requires a place for the historian to sit and write. Equipment Provided by the school: 1. Assembly and examination areas (above). 2. Station number cards-1 through 9. 3. ExaInination tables, one each for cardiovascular, abdominal, and orthopedic examiners. 4. Snellen visual acuity chart. 5. Black pencils, one for each athlete; red pencils, one for each examiner. 6. Paper cups, one per athlete. 7. Tongue depressors, one per athlete. 8. Lab-Stix for urine examination, one per athlete. 9. Flashlight. 10. History and examination forms. Provided by the physician: 1. Oto-ophthalmoscope 2. Stethoscopes (2) 3. Sphygmomanometer 4. Reflex hammer 5. Tape measure 6. Pin
SPORTS MEDICINE
741
Conduct of Examination History: Undressed athletes are seated and each is given a history/physical form and a black pencil. The physician, nurse, or athletic trainer reads and explains each question on the history form; athletes answer on their sheets. When all the questions have been answered the black pencils should be taken away from the athletes. Athletes with all "No" answers on their form line up for the beginning of the examination starting with Station No.2; athletes with any "Yes" answers line up at Station No.1 to have an individual history taken.* Station No. I-Individual History: All "Yes" items in general history are probed in detail adequate to determine if they constitute a risk when coupled with athletic participation. Station No.2-Blood Pressure: Student trainer or manager. Right arm, sitting. Diastolic greater than 90. t Station No.3-Snellen vision: Student trainer or manager. Vision less than 20/40. Station No.4-Skin, Mouth, Eyes: Physician, nurse, or athletic trainer. Pustular acne, herpes, athletes' foot, dental prostheses, severe caries, or pupil inequality. Station No.5-Chest: Physician. Murmurs, abnormal rhythm or heart enlargement, incomplete (lung) filling, or wheezes. Station No.6-Lymphatics, Abdomen, Genitalia (Males): Physician. Cervical or axillary adenopathy, organomegaly, penile or testicular lesions, undescended testes, or hernia. Station No. 7 - Orthopedic (Table 1): Physician or athletic trainer. Asymmetry, scoliosis, swelling or deformity, decreased range of motion or strength. . Station No. 8- Urinalysis: Athlete picks up paper cup, goes to restroom, fills it and gives it to student trainer manager in restroom who tests urine. Positive test on Lab-Stix. Station No.9-Review: Physician. One of the following decisions must be made and checked (on the form) for every athlete: 1. No athletic participation. 2. Limited participation (e.g., "no participation in football, hockey, etc."). Specific sports must be listed. 3. Clearance withheld (until additional tests, exaInination or rehabilitation is completed). Must list precise conditions to be met before clearance can be given. 4. Full, unliInited participation. Form must then be signed and dated.
Disposition of Forms Original for the school records, copy for parents, and a copy for the personal physician.
The limiting factor regarding the speed with which the examination can be conducted is Station No.5 (chest). With two physicians at this station, examinations can be accomplished at the rate of 20 to 25 per hour. 'One must assume that major historical items will be forgotten or ignored. Part of the purpose of the physical examination is to serve as a "quality control" for the history. tltems in italics require physician's judgment regarding disqualification.
742
JAMES G. GARRICK
Table 1.
Orthopedic Screening Examination':'
ATHLETIC ACTIVITY (INSTRUCTIONS)
Stand facing examiner Look at ceiling, floor, over both shoulders; touch ears to shoulders Shrug shoulders (examiner resists) Abduct shoulders 90" (examiner resists at 90") Full external rotation of arms Flex and extend elbows Arms at sides, elbows 90" flexed; pronate and supinate wrists Spread fingers; make fist Tighten (contract) quadriceps; relax quadriceps "Duck walk" 4 steps (away from examiner with buttocks on heels) Back to examiner Knees straight, touch toes Raise up on toes, heels
OBSERVATIONS
Acromio-clavicular joints: general habitus Cervical spine motion Trapezius strength Deltoid strength Shoulder motion Elbow motion Elbow and wrist motion Hand or finger motion and deformities Symmetry and knee effusion; ankle effusion Hip, knee and ankle motion Shoulder symmetry; scoliosis Scoliosis, hip motion, hamstring tightness Calf symmetry, leg strength
*May require reflex hammer, tape measure, pin and examination table.
Sideline Decisions One of the most disquieting thoughts of most team physicians is that of having to decide wh'ether an athlete can continue playing after sustaining an injury. Although making such a decision in a championship game in front of 10,000 people may indeed be difficult, such a situation rarely occurs. About 65 to 75 per cent of injuries occur during practice. Thus it is probably more appropriate to teach the coach how to deal with an injury decision (during practices) and then to "teach by example" during games using the same decision model. Athletes should not be allowed to return to participation until the following conditions have been satisfied: (1) The injury has been diagnosed. A definitive diagnosis must be made. It is not enough to say "swollen ankle"; one must state "ankle sprain" and by doing so rule out other possibilities such as a fracture or contusion. (2) The examiner is sure the injury will not worsen with continued play. (3) The examiner is sure continued participation (with the injury) will not result in another injury (for example, the post-concussion wrestler sustaining additional injury due to inability to protect himself). This decision requires a fair degree of sophisticated knowledge of both the injury and the sport in question. About which conditions should these questions be asked? In other words, what constitutes an injury? The following is a list of signs or symptoms which generally preclude further participation unless the three preceding questions can be answered completely or until they have been completely evaluated. 1. Unconsciousness, however brief. 2. "Dazed" or inappropriate responses for greater than 10 seconds as a result of being struck on the head.
743
SPORTS MEDICINE
3. Any complaint of neurologic abnormalities such as numbness or tingling. 4. Obvious swelling- except occasionally that involving the fingers. Swelling obvious to the coach or lay person generally merits attention regardless of its location. 5. Limited range of motion (compared with the opposite side). 6. Pain within the normal range of motion. 7. Decreased strength through the normal range of motion. 8. Obvious bleeding. 9. An injury the examiner does not know how to handle. 10. Obvious loss of some normal function. 11. Requirement of the athlete to have assistance to get off the mat, field, or court at some time earlier in the practice or the game. 12. Any time an athlete says he or she is injured and cannot participate-regardless of what the examiner thinks of the injury.
At first glance the above seem too extensive, resulting in excessively conservative decisions. In the context of common athletic injuries, however, it becomes apparent to a physician that those decisions would all be fairly obvious and the list is merely a means of practically applying an appreciable body of medical knowledge. The commonest of athletic injuries - the lateral ankle sprain - might serve as an example of the use of this system: In nearly half of the instances the athlete will be unable to get off the court or field without assistance or obvious disability. The ankle will be obviously swollen. The extremes of dorsiflexion, plantar flexion, and any inversion will be painful and thus normal motion will be lost. This picture would result in the cessation of participation in every conceivable instance for the child athlete, if for no other reason he or she cannot perform very well under those circumstances. Three weeks later after: (1) the x-rays have revealed no fracture or epiphyseal injury, (2) examination reveals intact ligaments and normal strength, and (3) normal motion has been reestablished, there still may be some residual swelling, but now the three initial questions can be answered: (1) the diagnosis is a "grade I sprain of the anterior talofibular ligament," (2) the injury will not worsen with participation, as the athlete can now run and start/cut/stop normally without pain and will be supported by taping, and (3) because he or she can function normally there is no increased risk of another injury. Hence participation is permitted.
Thus we find that the initial scheme of evaluating initial injuries is also appropriate for determining whether or not patients can return to athletic participation.
SPECIFIC INJURIES A few sports injuries are unique to the athletic environment. An ankle sprain is an ankle sprain whether it occurs on the basketball court or next door in a vacant lot. The biggest difference between the two is that the "basketball ankle sprain" should receive ideal first aid (ice, compression, elevation, and rest) because no athletic team should be allowed to play or practice without someone present who at least has a basic knowledge of first aid. Two major categories of orthopedic problems in sports are acute injuries and overuse syndromes. N early three-quarters of the acute injuries involve the lower extremities and about two-thirds are sprains
744
JAMES G. GARRICK
or strains. Sprains are generally more common in team and contact sports, and strains in individual and running sports. There are, however, a few acute injuries that occur frequently in sports (but rarely elsewhere) that merit mention here. Costochondral Separation and Subluxation This is an injury common among wrestlers, football players, and occasionally gymnasts, usually involving the costochondral junction of one of the lower five or six ribs. A result of a deforming force applied to the chest, the injury occurs suddenly with severe, well localized pain accompanied by a "slipping out" or snapping sensation and often an audible "pop." Over the first few days post injury, certain motions may result in painful popping crepitation. This will be obvious if the athlete can be convinced to allow the examiner to palpate the often exquisitely tender area. Management is aimed at relief of symptoms, consisting initially of application of ice and use of analgesics. An elastic rib belt should be tried but will give relief in only about half of the cases. The athlete will not return to effective partiCipation until he is almost totally asymptomatic (three to four weeks in wrestling injuries). As a general rule, return to participation too soon results in recurrence of the injury and appreciably lengthens healing time. No evidence exists that healing time can be lessened by heroic measures such as injecting medications of any sort into the costochondral junction, large doses of vitamins, various physiotherapy modalities, and so on. Quadriceps Contusion, Myositis Ossificans, and "Charlie Horse" Contusions in athletes, especially in team and contact sports, are exceedingly common. Because the quadriceps mechanism is among the largest muscle masses in the body, one would expect it to be struck and injured with some frequency. Most quadriceps contusions involve the anterior or anterolateral portion of the muscle, as the medial portion is protected by the other leg. Although a football thigh pad that is struck "dead center" may dissipate enough force to prevent injury, opponents often thoughtlessly strike at the periphery of the pad, driving the pad edge ahead of their foot or helmet forcing it to function as a secondary missile. Thigh contusions are almost universally misunderstood by coaches ("it's just a bruise"). Because their severity is nearly always underestimated, the requirement for medical assistance is used as an indicator of a lack of "manliness:"-'" The problem is worsened because the injury is often sustained by running backs, the individuals upon whose shoulders rest the fortunes of the team. A patient with a significant quadriceps contusion may present at the time of injury, within an hour of the injury when the period of rest *1 have yet to meet a coach below the college level who was not incredulous when an athlete was removed from participation as a result of a thigh contusion.
SPORTS MEDICINE
745
has allowed the knee to stiffen up, or the following day. He mayor may not have a palpable hematoma in the thigh. Ecchymosis is rarely seen in the first 24 to 48 hours. Severity is best determined 24 hours following the injury. During that first 24 hours the thigh should be iced intermittently (30 minutes every three to four hours) and compression wrapped. Unless the athlete has a normal painless gait he should be on crutches or at bed rest. At 24 hour:s the athlete is placed prone on an examining table, told to relax, and the knee is passively flexed. If painless flexion beyond 90° is possible, rehabilitation can be started so long as it can be done painlessly. Isometric quadriceps contractions followed by active rangeof-motion exercises and isotonic weight lifting will all occur in the period of a few days, and the return to full, painless participation should occur within a week. If passive knee flexion is limited to less than 90°, the period of disability will be increased and the likelihood of myositis ossificans greater. As a general rule, the less the knee flexion, the longer will be the period of disability. Definitive treatment of the thigh contusion and/or myositis ossificans involves reestablishment of full range of motion and normal strength in a painless manner. Rehabilitation programs that are painful may best be viewed as "re-injuries"-the common denominator of most cases of myositis ossificans. Return to participation should not be allowed until motion is full and the strength of both knee flexors and extensors is equal to the opposite side. Overuse Syndromes Overuse syndromes in athletes are among the most difficult medical problems with which to deal. Their insidious onset and initially benign character, as opposed to the dramatic onset of the usual athletic injury, do not seem to demand prompt medical attention. Thus generally the athlete with an overuse syndrome presents for treatment only when his performance is suffering badly and there is no other choice. Early in their course, overuse syndromes are related to specific athletic activities (such as excessive running, pitching, or swimming), and stopping the particular activjty alleviates the problem. Often the athlete has already discovered this: "The only time it hurts is when I run." However it is for this very reason that he has sought medical help; only stopping the activity gives him relief and he is unwilling to do this. Treatment of overuse syndromes follows one of two courses: convincing the athlete that he must stop the activity (temporarily) and then resume it gradually or attempting to balance the symptoms and the activity in order to allow continued participation. If dealt with early, overuse syndromes rarely progress to significant medical problems or permanent disability. The intraarticular changes of "little league elbow" do not occur overnight nor do the lesions resulting in activity-related spondylolysis in gymnasts. Treatment by the athlete or parent and coach, however, is the rule and by the time the physician is consulted, permanent changes may have resulted.
746
JAMES G. GARRICK
Most overuse syndromes have names related to specific sports. Although the two examples used below involve bone, the syndromes usually originate in soft tissue, most often the musculotendinous units. Examples can be found in any sport that involves repetitive activity and include involvement of the rotator cuff in pitcher's, gymnast's or swimmer's shoulder, the common extensor origin in tennis elbow, the patellar or quadriceps tendon in jumper's knee, the medial collateral ligament in swimmer's knee, and the Achilles tendon in jogger's heel. A few general rules apply to overuse syndromes: (1) precipitating activity must be discontinued to allow for an interval free from disability and pain; (2) resumption of athletic activity must be gradual and the fervor of the activity determined by the presence (or absence) of symptoms; (3) appropriate rehabilitation must precede resumption of activity; and (4) the athlete must be watched carefully (and given definite guidelines) for recurrence. Osgood-Schlatter's disease, which more appropriately may be termed traumatic apophysitis, is an overuse syndrome. The patient invariably presents with a red, swollen tibial tuberosity that is tender and boggy to palpation and painful, with quadriceps. contractions. It has usually resulted in a limp and significantly diminished athletic prowess. The athlete is restricted from precipitating activities for a short period of time, usually less than 7 to 10 days, until an average nonathletic day is painless. It is important to inform athletes and parents that cessation of athletic activities is not permanent but rather is a means of getting the patient symptom-free so that the treatment might be started. When normal activities are painless, an isometric quadriceps strengthening program is begun. A period of favoring the extremity (limping) will undoubtedly have resulted in quadriceps atrophy and, in some patients, subsequently those symptoms that accompany chondromalacia. The isometric exercises should be painless. A horseshoeshaped pad is then worn during athletic activities and participation is gradually resumed. The parents are told that as long as the athlete does not experience pain and there is no evidence of disability (a limp), he may continue athletic participation. Stress fracture of distal tibia or fibula, usually the result of distance running, constitutes an overuse syndrome. The patient often presents with a swollen tender area in the region of the stress fracture, a limp, and often evidence of new bone formation on x-rays. (The better athlete who is more body conscious may report stress fractures very early in their course-too early for any changes to be seen on standard x-rays.) The first order of treatment is to decrease the athlete's activities until normal nonathletic activities are painless. This may require three to four days on crutches or cast immobilization; however, these means are used sparingly so as not to increase muscular atrophy.
SPORTS MEDICINE
747
If painless, re-strengthening exercises of muscle groups crossing adjacent joints should be started immediately These serve not only to prepare the athlete for resumption of the athletic activity, but also to allow him to play an active role in his treatment preferable to just "resting." After 7 to 10 days elapse with no symptoms, the previously provoking activity (usually running) may be resumed. Running should be started on soft surfaces at no more than a quarter of a mile the first day, increasing the distance by an eighth of a mile a day so long as the individual remains completely asymptomatic. All of this assumes, of course, that the original injury (stress fracture) was not the result of a secondary cause such as a gait alteration from incomplete rehabilitation. 333 East Virginia Avenue Suite 101 Phoenix, Arizona 85004
Sports Medicine James G. Garrick, M.D.*
There are few "orthopedic diseases" that prompt more physician visits than the problems resulting from sport and recreational activities. Rather than being the exclusive domain of high school boys, organized athletics are now available to boys and girls of almost any age, thus the potential patient population is a large one indeed. If nothing else, merely certifying these children as fit for athletic participation is a monumental medical undertaking to say nothing of supervising the maintenance of that level of fitness. Although few athletic injuries are truly emergencies, nearly every one is accompanied by a sense of urgency by the child, parent, and coach. None of these individuals is the least bit reluctant to inform the physician that the decisions regarding the particular injury will probably influence the child's well-being, the team's success, the likelihood of someone receiving a college scholarship, and so on. Often this places the physician in an anxiety-surrounded situation to which he is unaccustomed. Too often the physician overreacts to the plight of the injured athlete. If the physician is unsure of the diagnosis or the demands of the sport, overtreatment may result and the athlete needlessly may miss a season of play. On the other hand, expedient treatment may be given by a physician'unaware of the long-term problems resulting from the injury or, perhaps, too willing to accede to the demands of the youthful competitor wishing to return to play. More familiarity with the demands of various sports and the resulting injuries will enable the physician to make decisions truly in the long-term best interests of the patient.
Evaluating the Risks A sport requires a certain amount of organization before its safety characteristics can be examined. Most competitive sports have some semblance of organization - if nothing else someone has to schedule matches and keep score-and thus can be studied. Other individual noncompetitive sports, such as hunting, fishing, scuba diving, water
*Associate
Professor of Orthopedic Surgery, University of Washington School of Medicine, Seattle, Washington
Pediatric Clinics of North America- Vol. 24, No.4, November 1977
737
738
JAMES G. GARRICK
90
1
FOOT TBALL
80
• WRESTLING
70 2 yr rate: ~ Male © Female
<::~'"
.~
~
60
1st yr eo 2nd yr
Jr./';.
'~
c:...
(J (J
--"-
'">:::
50 SOFT
'I>
.'i::'"
40
'-
30 20
CROSS COUNTRY
t •
~
BALL© BASKET BALL
CROSS COUNTRY
SOCCER .,
BASKET BALL
VOLLEYBALL
10
8 FIELD!
tt
G~M
~ © BADMINTON
TRACK
1 TRACKT 8 FIELD
fBASEBALL
SWIMMIN~ SWIMMING
TENNIS TENNIS
A
~
O~----------~------~~~----------~~--------Figure 1. Distribution of sports injuries in a study of 3049 students who participated in 19 sports and sustained 1197 injuries. See text for details.
skiing, and swimming, while surely dangerous in some cases, are nearly impossible to evaluate systematically. Also, in order to study the injury problems within a sport there must be someone available to decide "who is hurt." Although this sounds naIve, a large proportion (if not a majority) of athletic injuries that ultimately limit participation go initially unrecognized by those responsible for the conduct of the practice or game. DUring two school years we attempted to resolve the problem by hiring athletic trainers to identify injuries in four high school athletic programs. An injury was defined as "a traumatic medical incident resulting in removal from a practice or a game and/or missing a subsequent practice or game." During the study 3049 students participated in 19 sports and sustained 1197 injuries-or 39 injuries per 100 participants (Fig. 1). Nearly two-thirds of the injuries identified in these high school athletes were strains and sprains. Over half of the injuries were to the lower extremities with the thigh, knee, and ankle being involved almost equally. Although it is difficult to study the injury problems in extrascholastic sports, investigations with a number of age group programs such as soccer, skiing, football, and hockey would suggest that types and loca-
SPORTS MEDICINE
739
tions of injuries are reasonably consistent within sports, but rates vary with age and experience. For example, it would appear that the injury rate for football players under 12 years of age is about one-quarter to one-sixth that of high school players, although the type and locations of the injuries are not too dissimilar. What may be a devastating injury in one sport may be of little or no significance in another. The wide receiver in football with a sprained ankle is lost so long as he has appreciable symptoms. Were he a side-horse specialist in gymnastics, however, it might not affect his capabilities in the least.
The Pre-Season Examination The pre-participation examination is much likethe elephant being examined by blind men-it appears differently depending upon how it is approached. To the school administrator it fulfills the school's legal and insurance requirements. To the coach it is theoretically a means of starting the season with athletes who have some common level of health and fitness. To the idealist it may be a means of attempting to prevent injuries. To the physician it should be an opportunity to discover "treatable" conditions or conditions that will interfere with or be worsened by athletic participation. In reality, it is probably an annual period of frustration, unkept office appointments, and frantic phone calls the day before the first turnout. A child athlete offers the most potential for accomplishing something meaningful in the pre-participation examination. As athletes become more experienced, one is less likely to discover significant medical problems during the course of an examination. Thus the first few pre-participation eXlilminations uncover conditions that will preclude speCific athletic activities. Later in the athlete's career one usually looks for (and finds) only the residuals of previous injuries. For the experienced athlete, the examination serves primarily as a quality control of treatment and rehabilitation of previous injuries. Realistically, save for requiring complete rehabilitation from prior injuries, the pre-season examination offers little opportunity for preventing injuries. Generally we know little about the factors predisposing to injury. Commonly advocated conditioning programs that stress stretching and strengthening are better justified in enhancing performance than in preventing injury due to the absence of any evidence of injury reduction associated with their use. Most conditions generally regarded as disqualifying - apparently so considered because they would appreciably increase the risk of injury or the consequences of injury were one to occur or worsen health-are so obvious that there would be little question of partiCipation because the athlete would be under active medical care.~' The keys to a successful pre-participation examination program are planning and adequate assistance. The physician is required for a small portion of the process. Those responsible for the conduct of the sport 'The disqualifying conditions listed in the· American Medical Association's Medical Evaluation of the Athlete-A Guide, have been the most extensively promulgated. While possibly unrealistic, they undoubtedly constitute the standard to which one will be held.
740
JAMES G. GARRICK
(coaches, school administrators, etc.) must assume the responsibility for organizing and providing personnel for the examination. The following plan was developed, tested, and utilized over a two-year period by the Division of Sports Medicine, University of Washington, in both high school and college settings. DUring that period we have not (subsequent to the examination) been faced with medical problems that "could have been picked up" (on the initial examination). Location The examination is most efficiently carried out in a large room (gymnasium or all-purpose room) with two adjacent offices or screened off areas (coach's office). Although a clinic or physician's office may be used, it decreases the number of athletes that can be examined in a specified time by approximately 20 per cent. Examiners The number of examiners and their interests and skills are the most important variables determining how many athletes can be seen in a given period of time. Assuming 30 or more athletes are to be examined, the ideal team consists of nine members including a mandatory two physicians and at least two others with medical or paramedical training - nurses, physician assistants, or athletic trainers. Five student managers, trainers, or assistant coaches are needed as well as a head coach to act as traffic director and disciplinarian. Athletes The athletes must be dressed in gym shorts or a swimming suit (two piece suits for girls) at least 10 minutes prior to the examination. They all must be there for the beginning of the examination even though some will have to wait for their actual examination. Examination Stations The stations should be numbered so they can be easily seen and each station should have a desk or writing surface available for the examiner. The history station requires a place for the historian to sit and write. Equipment Provided by the school: 1. Assembly and examination areas (above). 2. Station number cards-1 through 9. 3. ExaInination tables, one each for cardiovascular, abdominal, and orthopedic examiners. 4. Snellen visual acuity chart. 5. Black pencils, one for each athlete; red pencils, one for each examiner. 6. Paper cups, one per athlete. 7. Tongue depressors, one per athlete. 8. Lab-Stix for urine examination, one per athlete. 9. Flashlight. 10. History and examination forms. Provided by the physician: 1. Oto-ophthalmoscope 2. Stethoscopes (2) 3. Sphygmomanometer 4. Reflex hammer 5. Tape measure 6. Pin
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Conduct of Examination History: Undressed athletes are seated and each is given a history/physical form and a black pencil. The physician, nurse, or athletic trainer reads and explains each question on the history form; athletes answer on their sheets. When all the questions have been answered the black pencils should be taken away from the athletes. Athletes with all "No" answers on their form line up for the beginning of the examination starting with Station No.2; athletes with any "Yes" answers line up at Station No.1 to have an individual history taken.* Station No. I-Individual History: All "Yes" items in general history are probed in detail adequate to determine if they constitute a risk when coupled with athletic participation. Station No.2-Blood Pressure: Student trainer or manager. Right arm, sitting. Diastolic greater than 90. t Station No.3-Snellen vision: Student trainer or manager. Vision less than 20/40. Station No.4-Skin, Mouth, Eyes: Physician, nurse, or athletic trainer. Pustular acne, herpes, athletes' foot, dental prostheses, severe caries, or pupil inequality. Station No.5-Chest: Physician. Murmurs, abnormal rhythm or heart enlargement, incomplete (lung) filling, or wheezes. Station No.6-Lymphatics, Abdomen, Genitalia (Males): Physician. Cervical or axillary adenopathy, organomegaly, penile or testicular lesions, undescended testes, or hernia. Station No. 7 - Orthopedic (Table 1): Physician or athletic trainer. Asymmetry, scoliosis, swelling or deformity, decreased range of motion or strength. . Station No. 8- Urinalysis: Athlete picks up paper cup, goes to restroom, fills it and gives it to student trainer manager in restroom who tests urine. Positive test on Lab-Stix. Station No.9-Review: Physician. One of the following decisions must be made and checked (on the form) for every athlete: 1. No athletic participation. 2. Limited participation (e.g., "no participation in football, hockey, etc."). Specific sports must be listed. 3. Clearance withheld (until additional tests, exaInination or rehabilitation is completed). Must list precise conditions to be met before clearance can be given. 4. Full, unliInited participation. Form must then be signed and dated.
Disposition of Forms Original for the school records, copy for parents, and a copy for the personal physician.
The limiting factor regarding the speed with which the examination can be conducted is Station No.5 (chest). With two physicians at this station, examinations can be accomplished at the rate of 20 to 25 per hour. 'One must assume that major historical items will be forgotten or ignored. Part of the purpose of the physical examination is to serve as a "quality control" for the history. tltems in italics require physician's judgment regarding disqualification.
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Table 1.
Orthopedic Screening Examination':'
ATHLETIC ACTIVITY (INSTRUCTIONS)
Stand facing examiner Look at ceiling, floor, over both shoulders; touch ears to shoulders Shrug shoulders (examiner resists) Abduct shoulders 90" (examiner resists at 90") Full external rotation of arms Flex and extend elbows Arms at sides, elbows 90" flexed; pronate and supinate wrists Spread fingers; make fist Tighten (contract) quadriceps; relax quadriceps "Duck walk" 4 steps (away from examiner with buttocks on heels) Back to examiner Knees straight, touch toes Raise up on toes, heels
OBSERVATIONS
Acromio-clavicular joints: general habitus Cervical spine motion Trapezius strength Deltoid strength Shoulder motion Elbow motion Elbow and wrist motion Hand or finger motion and deformities Symmetry and knee effusion; ankle effusion Hip, knee and ankle motion Shoulder symmetry; scoliosis Scoliosis, hip motion, hamstring tightness Calf symmetry, leg strength
*May require reflex hammer, tape measure, pin and examination table.
Sideline Decisions One of the most disquieting thoughts of most team physicians is that of having to decide wh'ether an athlete can continue playing after sustaining an injury. Although making such a decision in a championship game in front of 10,000 people may indeed be difficult, such a situation rarely occurs. About 65 to 75 per cent of injuries occur during practice. Thus it is probably more appropriate to teach the coach how to deal with an injury decision (during practices) and then to "teach by example" during games using the same decision model. Athletes should not be allowed to return to participation until the following conditions have been satisfied: (1) The injury has been diagnosed. A definitive diagnosis must be made. It is not enough to say "swollen ankle"; one must state "ankle sprain" and by doing so rule out other possibilities such as a fracture or contusion. (2) The examiner is sure the injury will not worsen with continued play. (3) The examiner is sure continued participation (with the injury) will not result in another injury (for example, the post-concussion wrestler sustaining additional injury due to inability to protect himself). This decision requires a fair degree of sophisticated knowledge of both the injury and the sport in question. About which conditions should these questions be asked? In other words, what constitutes an injury? The following is a list of signs or symptoms which generally preclude further participation unless the three preceding questions can be answered completely or until they have been completely evaluated. 1. Unconsciousness, however brief. 2. "Dazed" or inappropriate responses for greater than 10 seconds as a result of being struck on the head.
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3. Any complaint of neurologic abnormalities such as numbness or tingling. 4. Obvious swelling- except occasionally that involving the fingers. Swelling obvious to the coach or lay person generally merits attention regardless of its location. 5. Limited range of motion (compared with the opposite side). 6. Pain within the normal range of motion. 7. Decreased strength through the normal range of motion. 8. Obvious bleeding. 9. An injury the examiner does not know how to handle. 10. Obvious loss of some normal function. 11. Requirement of the athlete to have assistance to get off the mat, field, or court at some time earlier in the practice or the game. 12. Any time an athlete says he or she is injured and cannot participate-regardless of what the examiner thinks of the injury.
At first glance the above seem too extensive, resulting in excessively conservative decisions. In the context of common athletic injuries, however, it becomes apparent to a physician that those decisions would all be fairly obvious and the list is merely a means of practically applying an appreciable body of medical knowledge. The commonest of athletic injuries - the lateral ankle sprain - might serve as an example of the use of this system: In nearly half of the instances the athlete will be unable to get off the court or field without assistance or obvious disability. The ankle will be obviously swollen. The extremes of dorsiflexion, plantar flexion, and any inversion will be painful and thus normal motion will be lost. This picture would result in the cessation of participation in every conceivable instance for the child athlete, if for no other reason he or she cannot perform very well under those circumstances. Three weeks later after: (1) the x-rays have revealed no fracture or epiphyseal injury, (2) examination reveals intact ligaments and normal strength, and (3) normal motion has been reestablished, there still may be some residual swelling, but now the three initial questions can be answered: (1) the diagnosis is a "grade I sprain of the anterior talofibular ligament," (2) the injury will not worsen with participation, as the athlete can now run and start/cut/stop normally without pain and will be supported by taping, and (3) because he or she can function normally there is no increased risk of another injury. Hence participation is permitted.
Thus we find that the initial scheme of evaluating initial injuries is also appropriate for determining whether or not patients can return to athletic participation.
SPECIFIC INJURIES A few sports injuries are unique to the athletic environment. An ankle sprain is an ankle sprain whether it occurs on the basketball court or next door in a vacant lot. The biggest difference between the two is that the "basketball ankle sprain" should receive ideal first aid (ice, compression, elevation, and rest) because no athletic team should be allowed to play or practice without someone present who at least has a basic knowledge of first aid. Two major categories of orthopedic problems in sports are acute injuries and overuse syndromes. N early three-quarters of the acute injuries involve the lower extremities and about two-thirds are sprains
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or strains. Sprains are generally more common in team and contact sports, and strains in individual and running sports. There are, however, a few acute injuries that occur frequently in sports (but rarely elsewhere) that merit mention here. Costochondral Separation and Subluxation This is an injury common among wrestlers, football players, and occasionally gymnasts, usually involving the costochondral junction of one of the lower five or six ribs. A result of a deforming force applied to the chest, the injury occurs suddenly with severe, well localized pain accompanied by a "slipping out" or snapping sensation and often an audible "pop." Over the first few days post injury, certain motions may result in painful popping crepitation. This will be obvious if the athlete can be convinced to allow the examiner to palpate the often exquisitely tender area. Management is aimed at relief of symptoms, consisting initially of application of ice and use of analgesics. An elastic rib belt should be tried but will give relief in only about half of the cases. The athlete will not return to effective partiCipation until he is almost totally asymptomatic (three to four weeks in wrestling injuries). As a general rule, return to participation too soon results in recurrence of the injury and appreciably lengthens healing time. No evidence exists that healing time can be lessened by heroic measures such as injecting medications of any sort into the costochondral junction, large doses of vitamins, various physiotherapy modalities, and so on. Quadriceps Contusion, Myositis Ossificans, and "Charlie Horse" Contusions in athletes, especially in team and contact sports, are exceedingly common. Because the quadriceps mechanism is among the largest muscle masses in the body, one would expect it to be struck and injured with some frequency. Most quadriceps contusions involve the anterior or anterolateral portion of the muscle, as the medial portion is protected by the other leg. Although a football thigh pad that is struck "dead center" may dissipate enough force to prevent injury, opponents often thoughtlessly strike at the periphery of the pad, driving the pad edge ahead of their foot or helmet forcing it to function as a secondary missile. Thigh contusions are almost universally misunderstood by coaches ("it's just a bruise"). Because their severity is nearly always underestimated, the requirement for medical assistance is used as an indicator of a lack of "manliness:"-'" The problem is worsened because the injury is often sustained by running backs, the individuals upon whose shoulders rest the fortunes of the team. A patient with a significant quadriceps contusion may present at the time of injury, within an hour of the injury when the period of rest *1 have yet to meet a coach below the college level who was not incredulous when an athlete was removed from participation as a result of a thigh contusion.
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has allowed the knee to stiffen up, or the following day. He mayor may not have a palpable hematoma in the thigh. Ecchymosis is rarely seen in the first 24 to 48 hours. Severity is best determined 24 hours following the injury. During that first 24 hours the thigh should be iced intermittently (30 minutes every three to four hours) and compression wrapped. Unless the athlete has a normal painless gait he should be on crutches or at bed rest. At 24 hour:s the athlete is placed prone on an examining table, told to relax, and the knee is passively flexed. If painless flexion beyond 90° is possible, rehabilitation can be started so long as it can be done painlessly. Isometric quadriceps contractions followed by active rangeof-motion exercises and isotonic weight lifting will all occur in the period of a few days, and the return to full, painless participation should occur within a week. If passive knee flexion is limited to less than 90°, the period of disability will be increased and the likelihood of myositis ossificans greater. As a general rule, the less the knee flexion, the longer will be the period of disability. Definitive treatment of the thigh contusion and/or myositis ossificans involves reestablishment of full range of motion and normal strength in a painless manner. Rehabilitation programs that are painful may best be viewed as "re-injuries"-the common denominator of most cases of myositis ossificans. Return to participation should not be allowed until motion is full and the strength of both knee flexors and extensors is equal to the opposite side. Overuse Syndromes Overuse syndromes in athletes are among the most difficult medical problems with which to deal. Their insidious onset and initially benign character, as opposed to the dramatic onset of the usual athletic injury, do not seem to demand prompt medical attention. Thus generally the athlete with an overuse syndrome presents for treatment only when his performance is suffering badly and there is no other choice. Early in their course, overuse syndromes are related to specific athletic activities (such as excessive running, pitching, or swimming), and stopping the particular activjty alleviates the problem. Often the athlete has already discovered this: "The only time it hurts is when I run." However it is for this very reason that he has sought medical help; only stopping the activity gives him relief and he is unwilling to do this. Treatment of overuse syndromes follows one of two courses: convincing the athlete that he must stop the activity (temporarily) and then resume it gradually or attempting to balance the symptoms and the activity in order to allow continued participation. If dealt with early, overuse syndromes rarely progress to significant medical problems or permanent disability. The intraarticular changes of "little league elbow" do not occur overnight nor do the lesions resulting in activity-related spondylolysis in gymnasts. Treatment by the athlete or parent and coach, however, is the rule and by the time the physician is consulted, permanent changes may have resulted.
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Most overuse syndromes have names related to specific sports. Although the two examples used below involve bone, the syndromes usually originate in soft tissue, most often the musculotendinous units. Examples can be found in any sport that involves repetitive activity and include involvement of the rotator cuff in pitcher's, gymnast's or swimmer's shoulder, the common extensor origin in tennis elbow, the patellar or quadriceps tendon in jumper's knee, the medial collateral ligament in swimmer's knee, and the Achilles tendon in jogger's heel. A few general rules apply to overuse syndromes: (1) precipitating activity must be discontinued to allow for an interval free from disability and pain; (2) resumption of athletic activity must be gradual and the fervor of the activity determined by the presence (or absence) of symptoms; (3) appropriate rehabilitation must precede resumption of activity; and (4) the athlete must be watched carefully (and given definite guidelines) for recurrence. Osgood-Schlatter's disease, which more appropriately may be termed traumatic apophysitis, is an overuse syndrome. The patient invariably presents with a red, swollen tibial tuberosity that is tender and boggy to palpation and painful, with quadriceps. contractions. It has usually resulted in a limp and significantly diminished athletic prowess. The athlete is restricted from precipitating activities for a short period of time, usually less than 7 to 10 days, until an average nonathletic day is painless. It is important to inform athletes and parents that cessation of athletic activities is not permanent but rather is a means of getting the patient symptom-free so that the treatment might be started. When normal activities are painless, an isometric quadriceps strengthening program is begun. A period of favoring the extremity (limping) will undoubtedly have resulted in quadriceps atrophy and, in some patients, subsequently those symptoms that accompany chondromalacia. The isometric exercises should be painless. A horseshoeshaped pad is then worn during athletic activities and participation is gradually resumed. The parents are told that as long as the athlete does not experience pain and there is no evidence of disability (a limp), he may continue athletic participation. Stress fracture of distal tibia or fibula, usually the result of distance running, constitutes an overuse syndrome. The patient often presents with a swollen tender area in the region of the stress fracture, a limp, and often evidence of new bone formation on x-rays. (The better athlete who is more body conscious may report stress fractures very early in their course-too early for any changes to be seen on standard x-rays.) The first order of treatment is to decrease the athlete's activities until normal nonathletic activities are painless. This may require three to four days on crutches or cast immobilization; however, these means are used sparingly so as not to increase muscular atrophy.
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If painless, re-strengthening exercises of muscle groups crossing adjacent joints should be started immediately These serve not only to prepare the athlete for resumption of the athletic activity, but also to allow him to play an active role in his treatment preferable to just "resting." After 7 to 10 days elapse with no symptoms, the previously provoking activity (usually running) may be resumed. Running should be started on soft surfaces at no more than a quarter of a mile the first day, increasing the distance by an eighth of a mile a day so long as the individual remains completely asymptomatic. All of this assumes, of course, that the original injury (stress fracture) was not the result of a secondary cause such as a gait alteration from incomplete rehabilitation. 333 East Virginia Avenue Suite 101 Phoenix, Arizona 85004