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Darryl B. Thomas, MD. Chief, Orthopaedic Sports Medicine Service Scott & White University Medical Campus Round Rock, TX Assistant Professor of Surgery Texas A&M Health Science Center College of Medicine Temple, TX February 6,2010 - AAOS/AAPA Sports Medicine.

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slide1

Darryl B. Thomas, MD

Chief, Orthopaedic Sports Medicine Service

Scott & White University Medical Campus

Round Rock, TX

Assistant Professor of Surgery

Texas A&M Health Science Center College of Medicine

Temple, TX

February 6,2010 - AAOS/AAPA

Sports Medicine

darryl b thomas md education
Darryl B. Thomas, MD - Education
  • 1991 Princeton University (Army ROTC)
  • 1995 Johns Hopkins School of Medicine
  • 2000 Johns Hopkins Orthopaedic Residency
  • 2001 Sports Medicine Fellowship
    • US Military Academy, West Point, NY
    • Hospital for Special Surgery, New York, NY
    • Steadman Hawkins Clinic, Vail, CO
  • 2003 Chief Sports Medicine, BAMC
  • 2005 Orthopaedic Surgeon, Baghdad, Iraq
  • 2006 Private practice, Austin/Round Rock, TX
overview
OVERVIEW
  • Sports Medicine Specialty
  • Pre-participation Physical Exam (PPE)
  • The Collapsed Athlete
  • Sideline Medical Treatment for Common Conditions
  • Appropriate Referrals to Physicians
sports medicine
SPORTS MEDICINE

The study and practice of medical principles related to the science of sports, athletic performance, and exercise-related activity

  • Sports injury prevention
  • Sports injury diagnosis and treatment
  • Sports training and athletic performance
    • Exercise and workouts
    • Sports nutrition
    • Sports psychology
team doc
TEAM DOC

SPORTS MEDICINE PHYSICIAN

  • No residency in sports medicine
  • Typically complete a 1-yr fellowship after residency
    • Orthopaedic surgery
    • Primary Care
      • Family medicine
      • Pediatrics
  • At hospital or clinic associated with high school, collegiate, semi-pro, or professional teams
team doc1
TEAM DOC

SPORTS MEDICINE PHYSICIAN

  • Physician is ultimately responsible for the decisions regarding care for the athlete
  • Institution must vest the physician with the authority to make medical judgements relating to athletic participation
  • Important to be readily accessible
  • Keep in direct contact with the athletic trainer and / or coaches
slide7
PPE

PRE-PARTICIPATION PHYSICAL EXAM

  • Musculoskeletal Injuries
  • Cardiovascular disease
  • Neurologic conditions
    • convulsive / SZ disorders
  • Medical conditions
    • Exertional hyperthermia
    • Exertional rhabdomyolysis
    • Status asthmaticus - ∅ response to normal Tx
  • Leading causes of nontraumatic, non-cardiac sports death
musculoskeletal
MUSCULOSKELETAL

Orthopaedic Conditions

  • Most common disqualification from sports !
  • Knee injury > Ankle injury
    • stable ligamentous exam
    • no effusion, pain
    • 80-90% normal strength
  • Shoulder injury
    • No recent dislocation / subluxation
    • Resolved stingers / burners
  • Neck Injury
    • Free of neck or radicular pain, Full ROM

ACL Recon

c spine disqualifications
C-SPINE DISQUALIFICATIONS

No athletic participation

  • Congenital Conditions
    • Odontoid agenesis, hypoplasia
    • Atlanto-occipital fusion; Klippel-Feil
  • Developmental Conditions
    • Stenosis of the cervical spinal canal
      • neuropraxia, lig instability, + MRI
    • Spear Tackler’s Spine
      • stenosis, ∅ nl lordosis, post-traumatic X-ray ∆’s
  • Traumatic Conditions
    • Lig laxity, acute fx’s, certain healed fx’s (displ.)

Torg (Canal / Body) Ratio ≤ 0.8

slide10
HCM

Hypertrophic Cardiomyopathy

  • Heart muscle thickens making it more

difficult for blood to leave the heart ➔ heart

must work harder to pump blood

  • Estmated to affect 1/500 people in the US
  • Leading cause of sudden

cardiac death in the young

athlete, 12-32 yo

  • H.S. and college age
    • 1:200,000 - 1:300,000 / yr
    • AHA: 36% athletes who suffered SCD
slide11
HCM

History

  • HCM = heterogeneous group of disorders,

AD, incomplete penetration

  • Sx ➔➔ early adulthood
  • Hx reveals 64-78% of conditions
  • affecting participation in sports
  • More sensitive tool than PE !!!
  • Other conditions - Fam Hx:
    • Marfan syndrome ➔ aortic rupture
    • Premature atherosclerosis
    • Unexplained sudden death
slide12
HCM

Symptoms

  • Standard PPE’s not always able to detect
  • Often succum to SCD despite clearance !!!
  • Most athletes have prodromal Sx
    • Fainting / syncope during exercise
    • Lightheadedness after activity
    • Chest pain, palpitations, SOB
  • First Sx among many is sudden collapse

and possible death ➔ arrhythmias

slide13
HCM

Physical Exam

  • Systolic murmur on dynamic ascultation
    • ↑ w/ standing, or straining phase of Valsalva maneuver
      • ↓ preload
      • ↓ end diastolic
      • volume of LV
    • ↓ w/ squatting
      • ↑ preload
slide14
HCM

Physical Exam

  • Routine ECG screening not recommended

for routine PPE

    • too many false positives & negatives
    • not cost-effective on large-scale
  • Resting ECG rate is abnl

in 80-90% of pts w/ HCM

    • ST-segment ↑ in lateral leads
    • biphasic T-waves in V1 to V3
  • Order w/ Hx, Fam Hx, PE
cardiac disqualifications
CARDIAC DISQUALIFICATIONS

No athletic participation

  • HCM, Marfan syndrome
  • Rhythm and conduction abnl
  • Systemic hypertension
  • Valvular heart disease
  • Require cardiology clearance !!!
medical disqualifications
MEDICAL DISQUALIFICATIONS
  • Sickle Cell Disease
    • No contact or collision sports
    • SC Trait ➔ OK, but ↑ risk rhabdo
  • Solitary Organs
    • One paired organ ➔ controversial
      • No sports if diseased single organ
      • single eye ➔ only w/ protective eyewear
        • swimming, T&F, gymnastics
        • no boxing, wrestling, martial arts
      • single testicle ➔ protective cup
collapsed athlete
COLLAPSED ATHLETE
  • PRIMARY SURVEY
    • ABCDE
    • Sudden Cardiac Death
    • Arrythmias
    • Environmental Injury
  • SECONDARY SURVEY
    • Head / neck Injury
    • Electrolyte Imbalance
    • Anaphylactic reaction
primary survey
PRIMARY SURVEY
  • AIRWAY
    • Laryngeal fracture / edema
    • Foreign body
    • Oral trauma
  • BREATHING
    • Pneumo / hemothorax
    • Flail chest
    • Excercised induced asthma
    • Acute asthma exacerbation
primary survey1
PRIMARY SURVEY
  • CIRCULATION
    • Pulselessness:
      • VF until proven otherwise
    • Hypoxia
    • Shock (hypovolemic)
  • DEFIBRILLATE / DISABILITY
    • Dysrythmia
    • Head Injury (GCS, AVPU)
    • C-spine / Neck Injury - Neuro exam
primary survey2
PRIMARY SURVEY
  • EXPOSURE / ENVIRONMENT
    • Undress to expose all injuries
    • Remove from environment
      • Hyperthermia
      • Hypothermia
      • Lightning
  • Primary survey takes place on the field or immediate sideline - no time for training rm
  • Game is interrupted; Offical clock stopped
collapsed athlete1
COLLAPSED ATHLETE
  • CARDIAC CAUSES
    • Congenital cardiac anomalies
      • Hypertrophic cardiomyopathy
      • coronary artery anomalies
        • left main off right sinus
    • Myocarditis
    • Aortic rupture / dissection
    • Idiopathic left ventricular hypertrophy
collapsed athlete2
COLLAPSED ATHLETE
  • CARDIAC CAUSES (Cont’d)
    • Lethal arrythmias
      • arrythmogenic RV dysplasia
    • Aortic stenosis
    • Premature coronary artery disease
      • Ischemia
      • Myocardial Infaction
    • Commotio cordis
    • Recreational drug use
collapsed athlete3
COLLAPSED ATHLETE
  • METABOLIC EMERGENCIES
    • Symptomatic hyponatremia
    • Hypoglycemia
  • NEUROLOGIC CONDITIONS
    • CVA - stroke
    • Subarachnoid bleeding
    • Seizure
sudden cardiac death
SUDDEN CARDIAC DEATH
  • Sudden cessation of cardiac activity
    • Victim becomes unresponsive
    • Abnormal / absent breathing
    • No signs of circulation
  • Victim must receive immediate

CPR or they will die

  • Relatively uncommon
    • death rate in male athletes < 35 yrs of age
      • 0.75 per 100,000 participants per yr
    • H.S. cardiac arrest rate = 25-50 per yr
slide25
AED

Automatic External Defibrillator

  • Ventricular Fibrillation (V Fib)
  • ➔ Immediate CPR and defibrillation
    • Adhesive pads easy to attach
    • Anaylzes the rhythm
    • Determines if shock is needed
    • Charges to the appropriate
    • dose - voltage
    • Gives command to deliver
    • the shock
slide26
AED

Automatic External Defibrillator

  • Designed for use by anyone - lay people
  • Can be used on anyone > 1 yr old
  • Cost $1500 - $2500
  • Most schools and public facilities are now

equipped with AED’s

  • Victim’s survival chances drop by 10% for

every minute that passes

  • AED’s have been shown to increase

survival chances in SDA from 5 - 75%

commotio cordis
COMMOTIO CORDIS
  • Sudden disturbance of heart rhythm
  • Latin term for “commotion of the heart”
  • Refers to a functional effect of mechanical stimulation in the absence of structural damage - as opposed to mycardial contusion
  • Occurs as the result of a blunt,
  • non-penetrating impact to the
  • precordial region➔ impact of
  • ball, bat, or other projectile
  • Usually in boys or young men
  • George Boiardi, died 2004
commotio cordis1
COMMOTIO CORDIS
  • USA National Commotio Cordis Registry
    • 188 cases ‘96-’07, 1/2 during organized sports
    • 96% in males, mean age 14.7, < 1 in 5 survived
  • Timing of impact in relation to cardiac cycle
    • ascending phase of T-wave; repolariziation
      • 10-30 millisec portion
      • asystole to diastole
  • Causes an arrythmia
    • ectopic beat
    • ventricular tachycardia
    • ventricular fibrillation
commotio cordis2
COMMOTIO CORDIS

TREATMENT

  • Unfortunately, death is the most
  • common outcome → CPR and
  • AED must be initiated immediately
    • AED use w/ in 2 min ↑ survival rate 98%
    • delayed > 6 min ↓ survival rate to < 25%
  • Leading cause of fatalities in youth baseball
    • 2-3 deaths per year in the U.S.
  • AED’s recommended at all schools - on field
environmental injuries
ENVIRONMENTAL INJURIES

HYPERTHERMIA

  • 3rd most common cause of death in athletes
  • If temperature > 108º F (42º C)
  • ➔ mortality rate approaches 80%
  • Worse outcome with
  • delayed treatment
  • Spectrum of disease
    • heat cramps ➔ heat syncope
    • heat exhaustion ➔ heat stroke
    • ➔ death
hyperthermia
HYPERTHERMIA

HEAT CRAMPS

  • Can occur at any temperature
  • Loss of electrolytes, mainly salt

HEAT SYNCOPE

  • Core temp is normal or mildly elevated
  • Dehydration ➔ can lead to abrupt LOC
  • Occurs near end of exercise due to reduced

cardiac return and postural hypotension

  • Often happens at the beginning of the summer

season before the body acclimates

hyperthermia1
HYPERTHERMIA

HEAT EXHAUSTION

  • Unable to continue exercise in heat since the

CV system fails to respond to ↑ workload

  • Core temp 100.4º - 104º F (38º - 40º C)
  • Sx: muscle cramps, mild confusion, HA,

dizziness, nausea, often collapse

  • Treatment
    • As long as VSS, cool by removing
    • excess clothing and rest in shady place
    • Ice pack wrapped in towel → to neck, axilla, or groin
heat stroke
HEAT STROKE
  • Thermoregulatory failure with central nervous system (CNS) dysfunction
  • Usually core temp >104º F (40º C)
  • Absence of sweating can be present
  • Results is rhabdomyolysis,
  • renal failure, DIC, liver
  • failure and brain injury
  • Sx: tachycardia,
  • tachypneia, hypotension
heat stroke1
HEAT STROKE

TREATMENT

  • Immerse in tub of ice water as soon as

possible ➔ about 5-10 min, until core (rectal)

temp < 100.4º F (38º C) or pt starts to shiver

  • Or spray with cool water and place near fan,

include ice packs to neck, axilla, and groin

  • Hydrate with IVF and oral sports drinks
  • Avoid antipyretic agents for heat injuries
  • Benzodiazepines reserved for athletes who

have severe shivering or are having seizures

hypothermia
HYPOTHERMIA

Core temp ≤ 97º F (36.1º C)

  • CNS normal
  • Pt walks with or without assistance

Core temp ≤ 95º F (35º C)

  • CNS normal
  • Unable to walk or several muscle spasm

Core temp ≤ 90º F (32.2º C)

  • CNS changes ➔ profound hypothermia
  • Mild confusion and intense shivering
hypothermia1
HYPOTHERMIA

TREATMENT

  • Move indoors or to protected environment
  • Removing wet clothing
  • Passive warming with blankets, oral liquids

Core temp ≤ 80º F (30º C)

  • Critical hypothermia
  • Handle gently or can go into V Fib
  • May not respond to defibrillation
environmental injuries1
ENVIRONMENTAL INJURIES

TRANSFER TO HOSPITAL

  • Unstable vital signs
  • Core (rectal) temp < 90º F or > 104º F
  • Hyper- or hypothermia persisting > 30 min
  • Prolonged unconsciousness
  • Development of chest pain or arrythmias
electrolyte imbalances
ELECTROLYTE IMBALANCES

HYPONATREMIA

  • Endurance athletes at greater risk
  • 2003 Boston marathon, up to 13%
  • of runners experienced Sx hyponatremia
  • As athletes ingest excessive water ➔ serum

sodium levels fall ➔ confusion, nausea,

vomiting, ataxia, coma and potentially death

  • Consider IV access if signs of dehydration:

sunken eyes, parched lips, poor skin turgor

  • Hemodynamic instability, arrythmia ➔ IV !!!
rehydration iv fluid
REHYDRATION IV FLUID

CONTROVERSIAL !!!

  • ACSM - no official recommendation
  • Most commonly used: 5% dextrose in either

0.45% or 0.9% normal saline

    • Ironman Triathlon World Championship, HI
    • Marine Corps Marathon, DC
  • If athlete requires more than 2 L of IV fluid

without clinical improvement and/or

hemodynamic stabilization, transfer

to medical facility

hypoglycemia
HYPOGLYCEMIA
  • Relatively uncommon
  • Sx: body tremors, weakness, anxiety, sweating, slurred speech ➔ eventually coma
  • Treatment
    • administration of glucose
    • sports drinks, juice, candy,
    • or glucose tablets
    • unconscious / unresponsive
      • D50 IV or glucagon (IM)
      • Send to ER if no
      • improvement after 15-30 min
head injury
HEAD INJURY

DIFFUSE

  • Concussion
  • Second Impact Syndrome

FOCAL

  • Intracranial hemorrhage
    • Subdural hematoma (SDH)
    • Epidural hematoma
    • Subarachnoid hemorrhage (SAH)
  • Leading cause of death from athletic head injury
concussion
CONCUSSION

MILD BRAIN INJURY

MILD TRAUMATIC BRAIN INJURY (MTBI)

MINOR HEAD INJURY (MHI)

  • Most common head injury in sports
  • Trauma induced alteration in mental status
  • Transient loss in
  • brain function
  • Incidence as high as
  • 6 in 1000 people / yr
  • 300,000 athletes / yr
concussion1
CONCUSSION
  • ETIOLOGY
    • Blow to the head
    • Acceleration forces
    • without direct impact
  • MECHANISM
    • CSF not able to absorb forces associated with rapid acceleration
    • Angular and rotational forces affect midbrain disrupting nl cellular activity
    • impaired neurotransmission, deploarization
    • reduced cerebral blood flow → LOC
concussion sx
CONCUSSION - SX
  • PROBLEMS IN BRAIN FUNCTION
  • confused state, dazed look, vacant stare
  • memory loss (score, period, day)
  • HA, nausea, vomiting, blurred vision
  • SPEED OF BRAIN FUNCTION
  • slow response, reaction time, slurred speech
  • UNUSUALY BEHAVIOR
  • combative, aggressive, silly, restless, irritable
  • BALANCE & COORDINATION PROBLEMS
  • dizzy, clumsy, “drunk”, can’t walk straight
second impact syndrome
SECOND-IMPACT SYNDROME
  • An athlete sustains a head injury and then sustains a second head injury before the symptoms assoc w/ the first have cleared
  • Second blow can be remarkably minor
  • Within 2-5 minutes, athlete can die
    • → collapse, dilating pupils, ↓ eye mvt, respiratory failure
    • loss of autoregulation
    • → vascular engorgement, ↑ ICP, ➔ brian herniation
second impact syndrome1
SECOND-IMPACT SYNDROME
  • Mortality rate approaches 50%
    • kills 4 - 6 people < age 18 / yr
  • Morbidity rate near 100%
  • 35 cases reported b/w 1980 - 1992
  • 17 cases reported b/w 1992 - 1995 (CDC)
    • majority involved adolescent athletes or young adults (age 16 - 24)
  • Sports at most risk:
    • football, boxing, soccer, rugby, baseball
concussion grading
CONCUSSION - GRADING
  • GRADE I - MILD
  • No LOC
  • post-traumatic amnesia (PTA) < 30 min
  • post-concussive sx (PCSS) < 24 hrs
  • GRADE II - MODERATE
  • LOC < 1 min
  • PTA ≥ 30 min, but < 24 hrs
  • or PCSS ≥ 24 hrs, but < 7days
  • GRADE III - SEVERE
  • LOC ≥ 1 min or PTA ≥ 24 hrs
  • or PCSS > 7 days
  • Cantu grading system
concussion evaluation
CONCUSSION - EVALUATION
  • BLS; ? LOC occurred
  • Careful observation by MD, ATC
  • Question teammates, coaches
  • Neuro, mini-mental exam (MME)
    • CN’s, coordination, motor fcn
    • short- and long-term memory
      • 3-word memory (baseline exam)
      • coach asks specifics of plays
  • Sideline exertional testing before RTP
  • If no RTP, stick to decision
    • keep athlete’s essential equip: helmet, shoe
concussion mgmt
CONCUSSION - MGMT
  • GRADE I - MILD
  • #1 - may return to play (RTP) if ASx for 1 wk
  • #2 - may RTP in 2 wks if ASx for 1 wk
  • #3 - terminate season, but RTP following season if ASx
  • GRADE II - MODERATE
  • #1 - may RTP if ASx for 1 wk
  • #2 - 1 mo off sports, RTP if ASx but ? termination
  • #3 - terminate season, but RTP following season if ASx
  • GRADE III - SEVERE
  • #1 - 1 mo off sports, RTP if ASx but ? termination
  • #2 - terminate season, but RTP following season if ASx
  • #3 - no return to sports
c spine injury
C-SPINE INJURY
  • PPE - Identify those with h/o previous injury
  • Rules prohibiting “spearing” have eliminated the head as the initial contact point
    • significantly reduced incidence of injury
  • Note differences in helmets
  • and hardware needed to
  • remove the faceguard
  • Helmet and shoulder pads considered one unit
    • removing one takes airway out of neutral
    • if must remove for eval, put on collar
stinger burner
STINGER / BURNER
  • Transient weakness of the shoulder musculature and paresthesias into the upper extremity
  • Named for the “stinging or burning” pain that spreads from the shoulder into the hand
  • Neuropraxia or axonotmesis of a cervical nerve root or element of the brachial plexus
  • Mechanism unclear
    • traction
    • compression
    • extension compression
stinger burner1
STINGER / BURNER
  • Common injuries in contact sports
    • Football tackling or blocking
    • Fall onto head during wrestling takedown
  • Up to 70% of all college football players report having experienced a burner or stinger during their 4-yr careers
  • Recurrent injuries
    • 87% evid. of disc disease
    • 53% “developmentally”
    • narrow spinal canal
    • Levitz, Pelly, and Torg AJSM ‘97
stinger classification
STINGER CLASSIFICATION
  • NEUROPRAXIA
  • Transient dysesthesias & weakness
    • Mild: resolution in seconds - minutes
    • Moderate: resolution minutes - hours
    • Severe: Unresolved at 12 hours
  • NEUROPRAXIA / AXONOTMESIS
  • Motor, +/- sensory deficit > 2 wks
  • full recovery in 12-18 months
  • NEUROTOMESIS
  • No clinical improvement in 12-18 mo
stinger diagnosis
STINGER DIAGNOSIS
  • Establish Dx with accurate exam
  • Know brachial plexus anatomy
  • Differentiate from C-spine and nerve root injury
    • consider X-rays
    • MRI
    • bone scan
    • EMG’s
stinger mgmt
STINGER MGMT

TREATMENT

  • Sling if necessary
  • ROM exercises
  • Elect muscle stim

RTP ➔ COMPLETE RESOLUTION OF SX

  • Strength normal by manual muscle testing
  • Cybex isokinetic muscle testing
  • Go by exam ➔ little correlation b/w EMG and

clinical exam (normal EMG not criteria to RTP)

summary
SUMMARY
  • PPE: important screeing tool for athletic participation; don’t reveal all pre-existing conditions that may lead to sideline injury
  • Orthopaedic and CV conditions are the most common for sports disqualifcation
  • On-the-field injury mgmt begins with ABC’s
  • AED’s critical for collapsed athletes
  • Concussions & Stingers require full resolution of symptoms prior to return to play
references
REFERENCES
  • Head, Spine, and Plexus: Screening and Return to Play, John A Bergfeld, MD, AOSSM Annual Meeting 2008, IC 202.
  • The Preparticipation Athletic Evaluation, Kurt Kurowski, MD and Sangili CHandran, MD, AAFP Web Archive, May 1, 2000.
  • Killer Athlete Killers - SIdeline Management of the Collapsed Athlete, Neha P Raukar, MD, MS et al, AOSSM Annual Meeting 2008, IC 306.
  • UIL (University Interscholastic League) Extracurricular Activity Safety Training Program 2008-2009.
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