Selected Issues in Injury and Illness Prevention and the Team Physician

DEFINITION Prevention of injury and illness associated with athletic activity is one of the roles of the team physician (see (1) and (3)). This process involves understanding the pathophysiology of the injury or illness, evaluating the known risk factors that influence the incidence of injury or illness, implementing interventions to minimize the influence of the risk factors, and recording the outcomes of the interventions. GOAL The goal of this document is to help the team physician improve the care of the athlete by understanding and practicing methods of injury and illness prevention in specific sports medicine problems. To accomplish this goal, the team physician should have knowledge of general strategies of injury and illness prevention, and implement these strategies regarding: Musculoskeletal injuries to the ankle, knee and shoulder Head and neck injuries Cardiac illness Heat related illness Skin Issues Equipment issues SUMMARY This document provides an overview of selected medical issues that are important to team physicians who are responsible for the care and treatment of athletes. It is not intended as a standard of care, and should not be interpreted as such. This document is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the healthcare profession. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization. This statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. EXPERT PANEL Stanley A. Herring, M.D., Chair, Seattle, Washington David T. Bernhardt, M.D., Madison, Wisconsin Lori Boyajian-O'Neill, D.O., Kansas City, Missouri Peter Gerbino, M.D., Monterey, California Rebecca Jaffe, M.D., Wilmington, Delaware Susan M. Joy, M.D., Cleveland, Ohio W. Ben Kibler, M.D., Lexington, Kentucky Walter Lowe, M.D., Houston, Texas Margot Putukian, M.D., Princeton, New Jersey Stephen Weber, M.D., Sacramento, California Marcia Whalen, D.O., Newport Beach, California CONSULTANT Randy Dick, NCAA, Indianapolis, Indiana GENERAL CONCEPTS IN RISK FACTORS AND PREVENTION STRATEGIES The incidence of injury in sports medicine may be influenced by the presence of risk factors. Intrinsic factors may be physiological, biomechanical, anatomical or genetic, and may include prior injury, muscle weakness, inflexibility, imbalance or kinetic chain breakage (injuries or other alterations in distant parts of the body which affect function in the local joint). They may also include psychological factors, which have been addressed in the Team Physician Consensus Conference series (see (7)). Extrinsic risk factors may be related to the inherent demands of the sport, such as the intensity and duration of play, or factors such as environmental, conditioning, or equipment issues. They may influence the process of chronic injury or illness development, or they may influence the occurrence of an acute injury or illness. Studies have shown that a strategy of identification of risk factors and implementation of processes to modify the risk factors prior to athletic competition may reduce the incidence of some injuries or illnesses. These studies show that the prevention strategies should be as specific as possible to the injury or illness, athletic activity, or sport, and need to be continued as long as the athlete is competing. A general format of prevention strategies includes: Understanding the pathophysiology of the injury or illness. Understanding and implementing procedures for identifying risk factors. Implementing interventional processes to modify the risk factors. Assessing medical history, family history, and exertional symptoms is relevant in developing prevention strategies in medical conditions. It is essential the team physician: Understand basic concepts of injury and illness prevention. It is desirable the team physician: Set up policies and procedures to identify risk factors, implement intervention strategies, and quantify outcomes. Work with the athletic care network (see (3)) to educate athletes, parents, and coaches on the principles and practices of injury and illness prevention. EPIDEMIOLOGY Injuries The type of injury and its related risk factors present various opportunities and methods of prevention. A source of consistent and systematic data is from the National Collegiate Athletic Association (NCAA) Injury Surveillance System (8) of injuries sustained in collegiate sports from 1988 to 2003. From this data, the following issues have been identified: Across all sports, injury rates are significantly higher in games than in practices. Lower extremity accounts for more than 50 percent of all practice and game injuries. Ankle sprains account for 14 percent of lower extremity injuries. Anterior cruciate ligament (ACL) injuries are relatively infrequent (three percent of all reported injuries) but are associated with significant loss of time from play. At the collegiate level, football has the greatest number of ACL injuries. At the collegiate level, women's gymnastics, women's basketball and women's soccer have the highest rates of ACL injury. Patellofemoral pain and tendinopathy are frequent injuries, particularly in women. Upper extremity accounts for approximately 20 percent of all practice and game injuries. Shoulder injuries account for 10 percent of upper extremity injuries, including both contact (football, ice hockey) and noncontact (baseball, tennis) mechanisms. Noncontact mechanisms are more amenable to prevention strategies. Head and neck injuries account for approximately 12 percent of all practice and game injuries. Concussions account for five percent of all injuries; rates have nearly doubled during the sample period. In collegiate athletics, football and men's and women's ice hockey, lacrosse and soccer have the highest risk of concussion. Self-report data suggests significantly higher incidence of concussion (see (6)). Most head, neck and spine injuries do not have catastrophic consequences. According to the National Center for Catastrophic Sports Injury Research, football, gymnastics, ice hockey, wrestling, and cheerleading have the highest risk of catastrophic injury. Concussion rates are increasing at all levels of participation. Ten-thousand spinal cord injuries occur each year in the United States; 10 percent are related to athletic events. Medical Conditions Sudden cardiac death is a rare occurrence. Causes in young athletes include: Hypertrophic cardiomyopathy Condition occurs more frequently in men and African-American ethnicity Arrhythmias Coronary artery anomalies Myocarditis Ruptured aortic aneurysm (Marfan's Syndrome) Commotio Cordis Most commonly occurs in baseball, lacrosse, ice hockey, softball, and other sports as well as recreational activities involving projectile or direct blow to chest Most commonly reported in boys, between ages 7 and 16 Fifty percent occur in recreational sports/activities Heat illness is sport- and environment-specific, most commonly occurring during preseason practices with its highest prevalence in football. Milder forms of heat illness are more common, but may be underreported; more serious forms of heat related illness are less common. Third leading cause of death in the high school athlete. Race and ethnicity appear to be risk factors for heat injury. Skin Infections In collegiate athletics, skin infections account for one to two percent of all time loss injuries. In wrestling, skin infections have increased threefold over the past 10 years and account for 16 to 20 percent of time loss injuries. Herpes gladiatorum, fungal infections and impetigo are the most common skin infections in wrestling. MUSCULOSKELETAL INJURY PREVENTION Inversion Ankle Sprains Pathophysiology, including risk factors: Traumatic inversion injury upon landing (variable amount of injury to all structures) High rate of recurrent injury Reported risk factors include: Previous ankle injury Ligamentous instability Incomplete rehabilitation, including balance Peroneal muscle weakness and/or decreased ankle dorsiflexion Heel varus Increased body mass index (BMI) Injury Prevention Evaluation: Athletes in running, landing and cutting sports should have a thorough evaluation, including: History of previous ankle injury Ankle ligament evaluation Heel alignment Ankle muscle strength and flexibility testing Balance and core control Injury Prevention Interventions: Implement an education program and sport/activity conditioning program with periodization (see (3)), including: Local muscle strengthening with eccentric emphasis Improve dorsiflexion range of motion Motor control (including balance and core control) Taping or bracing in athletes with a history of a previous ankle injury; the role of taping or bracing for injury prevention in a normal ankle is less clear. It is essential the team physician understand: Mechanism of inversion ankle sprains. The usefulness of taping or bracing in an athlete with a previous inversion ankle sprain. The role of rehabilitation to decrease the risk of subsequent ankle sprains. It is desirable the team physician: Implement a thorough preseason conditioning program including balance training for all athletes in running, landing, and cutting sports (see (3)). Work with the athletic care network to educate players, parents, and coaches on the principles and practices of ankle injury prevention. Knee Injuries ACL Pathophysiology, including risk factors: Most ACL injuries are noncontact injuries. College data shows more ACL injuries in football to be contact injuries. Causes of noncontact ACL injuries are multifactorial (see (4)). Reported risk factors include: Environment (turf and shoe-surface interface) Anatomy Hormonal status Biomechanics (landing position) Neuromuscular variables (e.g., core and lower extremity strength, balance, flexibility and muscle activation patterns) Family history Increased BMI Noncontact ACL injuries occur commonly during deceleration, landing or cutting. At-risk positions during these maneuvers include: Hip and knee extension Knee valgus or knee varus Flat foot landing Off-balance body position Injury Prevention Evaluation: Athletes in running, landing, and cutting sports should have a thorough evaluation (see (3)), including: History of previous personal or family ACL injury Lower extremity alignment Motor control (including core and lower extremity strength, balance and flexibility) Other evaluation techniques may include: Evaluation of the playing surface and shoe type Screening biomechanical analysis of jumping and landing Injury Prevention Interventions: Implement a sport-specific conditioning program with periodization (see (3) and (4)), including these elements that have been shown to have efficacy in specific populations: Motor control (including core and lower extremity strength, balance and flexibility) Technique training to include landing and sport-specific athletic skills programs Risk awareness education Proper care of playing surfaces, and selection of shoe wear It is essential the team physician understand: The multifactorial nature of ACL injury mechanisms. Modifying neuromuscular factors may decrease risk of ACL injury. It is desirable the team physician: Evaluate for core stability, lower extremity strength, and motor control. Implement a sport-specific conditioning program, including: Motor control (including core and lower extremity strength, balance, and flexibility) Technique training to include landing and sport-specific athletic skills programs Risk awareness education Evaluate the playing surface and shoe type Work with the athletic care network to educate players, parents, and coaches on the principles and practices of ACL injury prevention. Other Knee Injuries Patellofemoral Pain and Tendinopathy Pathophysiology, including risk factors: Patellofemoral pain and dysfunction are multifactorial, including malalignment, articular cartilage lesions, instability, soft tissue factors, and psychosocial issues (see (4)). Sites of pain generation in the anterior knee include: Patellar subchondral bone Fat pads and synovium Medial plica Retinaculum Patellar tendon Reported risk factors include: Muscle weakness and/or imbalance and inflexibility, including quadriceps shortening Trauma, overuse, training errors and/or previous injury Patellar hypermobility Hip muscle weakness Patellofemoral pain may occur in what appears to be a structurally intact knee. Chondromalacia means degenerative cartilage and may have no relationship to symptoms of anterior knee pain. The contribution of static and/or dynamic malalignment of the pelvis, hip, knee, ankle, and foot to anterior knee pain is less clear. Injury Prevention Evaluation: Athletes should have a thorough evaluation (see (3)), including: History of any previous lower extremity injury and rehabilitation Present and anticipated volume/intensity of training and participation Patellar and peri-patellar examination Lower extremity alignment (e.g., Q-angle, foot pronation) Core stability, especially hip external rotator strength, as well as quadriceps strength and hamstring flexibility Training surface and shoe type Injury Prevention Interventions: Implement sport/activity conditioning program with periodization (see (3)), emphasizing the proven interventions of quadriceps strengthening and increasing hamstring flexibility. Other interventions may include core and lower extremity strengthening, hip abductor and external rotator strengthening, and improving motor control. It is essential the team physician: Understand the role of multiple risk factors in patellofemoral pain and tendinopathy. Evaluate the patella and peri-patellar soft tissues, quadriceps strength and hamstring flexibility. It is desirable the team physician: Evaluate for core stability, lower extremity strength and flexibility, motor control, and postural alignment. Implement a thorough program for evaluation and conditioning (see (3)) for core stability, lower extremity strength, and motor control. Recommend shoe selection for anticipated activity. Work with the athletic care network to educate players, parents, and coaches on the principles and practices of patellofemoral and tendon injury prevention. NONCONTACT SHOULDER INJURIES IN THROWERS AND OTHER OVERHEAD ATHLETES The Disabled Throwing Shoulder Pathophysiology, including risk factors: The "disabled throwing shoulder"; describes the proven findings that create pain and/or decreased function in throwers and other overhead athletes. These findings are: Anatomical injuries: superior labral tears, partial rotator cuff tear, and capsular attenuation. Physiological deficits: posterior rotator cuff weakness, decreased internal rotation, pectoralis minor inflexibility, scapular muscle weakness, and kinetic chain changes in core strength or flexibility. Alterations of biomechanical motions: abnormal humeral head translation on the glenoid, alteration of arm position, and scapular dyskinesis. Risk factors include: Volume and intensity of overhead activity and throwing History of previous injury in other parts of the kinetic chain Gleno-Humeral Internal Rotation Deficit (GIRD): side-to-side asymmetry of total range of shoulder internal/external rotation measured with the arm in 90-degree abduction and in the scapular plane. GIRD may be present in asymptomatic shoulders and may predispose the shoulder to injury. alteration of scapular static position or dynamic motion that be as on clinical shoulder weakness of internal and external range of motion of the hip In baseball, increased number of game and and in athletes. Injury Prevention Evaluation: should have a thorough evaluation (see (3)), including: History of any previous injury and rehabilitation Present and anticipated volume/intensity of training and participation of for labral tears, instability, and strength for scapular for core strength and and kinetic chain function Injury Prevention Interventions: including GIRD and scapular core strength, motor control and kinetic chain Implement sport/activity conditioning program with periodization (see (3)) of game and and of in athletes It is essential the team physician understand: The of GIRD as a risk for the throwing alterations in the throwing throwing athletes specific It is desirable the team physician: Implement a thorough program for evaluation and conditioning (see (3)). to Work with the athletic care network to educate players, parents, and coaches on the principles and practices of shoulder injury prevention. INJURY PREVENTION Issues Hypertrophic cardiomyopathy in chain cardiac or or and/or dysfunction Sudden death most to Reported risk factors for history of cardiac death from cardiac Family history of cardiac death History of on on Arrhythmias in or include: such as such as or and other Risk factors for Coronary artery anomalies and/or to abnormal Risk factors for Ruptured aortic aneurysm (Marfan's Syndrome) of of the aortic leading to Risk factors for Prevention Evaluation of artery anomalies and aortic aneurysm (Marfan's evaluation including: Family history of especially and in history of or exertional chest and exertional of examination of and of Prevention of artery anomalies and aortic aneurysm (Marfan's testing and/or or of activity. Screening evaluation for prevention of illness in family for all practices and It is essential the team physician understand: The major of and risk factors for cardiac The role of examination in for cardiac conditions. symptoms are particularly an for all practices and competition (see cardiac death may be the only It is desirable the team physician: and the Implement an that the of an external Work with the athletic care network to educate players, parents, and coaches the common of cardiac Commotio Cordis chest over the cardiac during of cardiac in with In of to of percent of occur in sports athletes are chest Risk factors for 16 years Prevention Evaluation: known Prevention in place coaches and that should a direct blow to the chest (e.g., in of chest have not been shown to It is essential the team physician understand: The clinical of The of an The of for sports at risk for The of chest in It is desirable the team physician: Implement an that the of an Work with athletic care to educate players, parents, and coaches on the principles and practices for sports is AND Concussion Pathophysiology, including risk factors: the by direct or biomechanical (see (6)). of head injury a of and may be of concussion on biomechanical or other symptoms than injury. may the of clinical may be a to head in young athletes. Risk factors include: concussion history, including and Injury Prevention Evaluation: Athletes should have a thorough evaluation including: history of including and of testing Injury Prevention Interventions: athletes, parents, and coaches on the of symptoms of concussion. Athletes with and/or symptoms of concussion should not participation. the incidence of and major head but not and may the incidence of concussion. of the head and of or equipment may the risk of concussion. are to head injury (e.g., leading with the the of to decrease the risk of and injury, the they to concussion risk is It is essential the team physician understand: The and principles of concussion. should be to the risk of subsequent It is desirable the team physician: to athletes and Implement concussion awareness and education program for medical athletes, parents, and in developing changes to reduce head injury. Work with the athletic care network to educate players, parents, and coaches the risk of concussion. Injury Pathophysiology, including risk factors: of the spine is the that most spinal cord injury in is a spine injury associated with and/or motor changes in all present only with upper and/or motor are or injuries of the or that and weakness in the upper They the and/or or the upper of the Risk factors include: Previous of spinal on and number of levels spine findings including instability, spinal cord and Injury Prevention Evaluation: Athletes should have a thorough evaluation including: History of spine injury or spine and examination of testing and/or Injury Prevention Interventions: rehabilitation to risk of subsequent techniques to spine injury (e.g., what in of (e.g., in football, from in ice hockey) of parents, and athletes the of and techniques The role of shoulder and neck in football in is of the athlete It is essential the team physician and risk factors for spine injury. The of an It is desirable the team Work with the athletic care network to educate players, parents, and coaches on prevention principles and practices for sports spine injury is Risk Heat may occur but most to occur in Heat occur as the of the to Heat occur on a with the most heat which may be Heat during is than at to heat include and and are more in Risk factors: BMI of history of heat illness (e.g., and Deficit such as and and of equipment Injury Prevention Evaluation: Athletes should have a thorough preseason evaluation, including: History of risk factors Evaluation of Evaluation of present and anticipated volume/intensity of training and participation Evaluation of of Screening for and of athletes and equipment and/or heat index (see Injury Prevention Interventions: to 10 on activity, and strategies for practice and competition (see core and Implement sport/activity conditioning program with periodization (see (3)). for in the and equipment equipment on with and/or sport-specific activities on conditions. It is essential the team physician: the of and a means by which to and/or an to acute heat illness (see It is desirable the team physician: athletes at the time of preseason evaluation for risk factors for heat illness. and practices. in practices and of increased for heat illness. Implement for Work with the athletic care network to educate players, parents, and coaches on the principles and practices of heat illness prevention. AND INJURY PREVENTION are equipment and that have been to injury. the incidence of and major head but not and may the incidence of concussion. from injuries and protect from injury; is they protect concussion. decrease the incidence of in decrease the incidence of ankle in and wear in women's lacrosse is associated with decreased incidence of injuries. Taping or bracing in athletes with a history of a previous ankle inversion the risk of recurrent injury; the role of taping or bracing for injury prevention in a normal ankle is less clear. ligament bracing has not been shown to injury and may risk of knee soccer is associated with a decrease in It is essential the team physician understand: of and for It is desirable the team physician: Work with the athletic care network to educate players, parents, and coaches on the role of equipment in injury prevention. Pathophysiology, including risk factors: of is of is the of is reported in wrestling, and football. the incidence of skin infections is this is an prevention is Infections are by direct contact or Risk factors: Previous history of status personal Prevention Evaluation: Athletes should have a thorough evaluation prior to participation including: history of skin History of prior or treatment practices should be in practice and training Prevention Interventions: is in To decrease athletes with and skin infections from practice or with contact with from skin of other with and or Equipment and of skin of equipment and other with which multiple athletes have skin contact to skin coaches common skin It is essential the team physician: Understand principles common skin skin infections that may be or activity as It is desirable the team physician: practice for practice and Work with the athletic care network to educate athletes, and on and skin