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Military Sports Medicine Fellowship. The Challenged Athlete. “Every Warrior an Athlete”. Kevin deWeber, MD, FAAFP Director, Primary Care Sports Medicine Fellowship Acknowledgments to Dr. Mark Williams. Objectives. Review classifications of disabilities Describe PPE requirements

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the challenged athlete


Sports Medicine


The Challenged Athlete

“Every Warrior an Athlete”

Kevin deWeber, MD, FAAFP


Primary Care Sports Medicine Fellowship

Acknowledgments to Dr. Mark Williams

  • Review classifications of disabilities
  • Describe PPE requirements
  • Discuss epidemiology of injury and illness
  • Describe unique medical issues
  • Prepare for medical coverage of Special Olympics events
types of disabilities challenges
Types of disabilities (challenges)
  • Physical challenges
  • Intellectual disabilities
    • Subaverage intellectual functioning and marked impairment in adaptive behavior
  • Sometimes both coexist
physical disability classification
Physical Disability Classification
  • Wheelchair athletes
  • Cerebral palsy
  • “Les autres” (“the others”)
  • Limb deficiencies
  • Hearing impairment
  • Vision impairment
u s paralympics
U.S. Paralympics
  • Governing body for sporting competition in those with physical disabilities
  • “U.S. Paralympics, a division of the U.S. Olympic Committee, is dedicated to becoming the world leader in the Paralympic sports movement, and promoting excellence in the lives of persons with physical disabilities.” U.S. Paralympics website
paralympic sports














Skiing (alpine and Nordic)

Sled Hockey



Table Tennis


Track & Field


Paralympic Sports
mental retardation
Mental Retardation
  • In the United States:
    • 100,000 born each year with mental retardation
    • 7 times more prevalent than blindness
    • 7 times more prevalent than deafness
    • 10 times more prevalent than physical disability
    • 12 times more prevalent than cerebral palsy
    • 35 times more prevalent than muscular dystrophy
“Special Olympics is an international nonprofit organization dedicated to empowering individuals with intellectual disabilities to become physically fit, productive and respected members of society through sports training and competition. Special Olympics offers children and adults with intellectual disabilities year-round training and competition in 30 Olympic-type summer and winter sports.” Special Olympics website
  • To provide sports training and competition for persons with mental retardation age 8 through adulthood
  • Children ages 5-8 may participate in training, but not compete
special olympics activities
Special Olympics activities
  • Sports training and competition for children and adults exist in each state of the U.S.
    • Clinics, camps,
  • Games held at local, regional, state, national, and international levels
special olympics games
Special Olympics Games
  • First International Special Olympics - 1968
  • 2005 Special Olympics World Winter Games
    • 1,800 athletes, 84 countries
  • 2003 World Summer Games
    • 6,500 athletes, 150 countries
  • Over 2.2 million athletes worldwide
  • Physical fitness
  • Social development
  • Acceptance into larger society
  • Identified by an agency or professional as having mental retardation OR
  • Have a cognitive delay as determined by standardized measures OR
  • Have significant learning or vocational problems due to cognitive delay which require specially designed instruction
levels of participation
Levels of Participation
  • Divisioning:
    • Gender
    • Age
      • 8-11, 12-15, 16-21, 22-29, 30+
    • Ability
      • Athletes scored based on ability in specific skills
      • Goal: 3-8 participants/teams of similar ability in each event
official sports winter and demonstration
Alpine skiing

Cross country skiing

Figure skating

Floor hockey

Speed skating




Table tennis

Team handball

Official SportsWinter and Demonstration
official sports summer
Aquatics (swimming and diving)

Track and field






Roller skating





Official SportsSummer
preparticipation physical evaluation requirements
PreparticipationPhysical EvaluationRequirements
  • History and physical exam required on entry
  • Update every 1-3 years, depending on state
    • Requirements not standardized
    • Special Olympic Games: PPE < 12 months
  • New exam required when a new problem develops that could pose a risk for the athlete during sports participation
preparticipation evaluation
Preparticipation Evaluation
  • PPE must be tailored to address their special needs
  • Office-based exam preferred
    • Frequency of abnormal findings
    • Diagnoses often associated with clusters of abnormal findings
    • Enhanced interpersonal communication
additional history needed
Level of independence


Motor impairment

Prosthetic equipment

H/O autonomic dysreflexia

Testicle (absence?)

Kidney (absence ?)

Urinary catheters?

Communication issues

Additional History Needed
ppe special concerns
PPE: Special Concerns
  • Communication
    • Many Special Olympics athletes have expressive and receptive language deficiencies
    • 5% of athletes are non-verbal
    • May be unable to describe symptoms clearly
    • Utility of PPE Questionnaire at events:
      • Available to medical provider for review
      • Must be kept updated and brought to all competitions
exam abnormalities in non disabled athletes vs special olympians
Exam Abnormalities in Non-Disabled Athletes vs Special Olympians
  • Nondisabled athletes: 0.3 – 3% have disqualifying abnormalities
  • Special Olympians- 39% have abnormalities
    • Not necessarily all disqualifying.
sports significant disabilities
Sports Significant Disabilities
  • McCormick, Ivey, et al 1988
  • 80 athletes in Special Olympics sports PPE
  • 39% had sports significant abnormalities
    • Vision worse than 20/40 13%
    • Seizures 13%
    • Cardiac arrhythmia
    • Cyanotic heart disease
sports significant disabilities1
Sports Significant Disabilities
  • Hudson (Physician & Sportsmedicine 1988)
  • 176 Preparticipation Physical Exams
  • Age = 5-20 years
    • Visual acuity of 20/30 or worse 40%
    • Decreased LE Flexibility 31%
    • Clonus 12%
    • Spasticity 8%
    • Heart murmur 5%
    • Scoliosis 3%
sports significant disabilities hudson physician sportsmedicine 1988 medical diagnoses in history
Seizure 23

Down Syndrome 16

Cerebral Palsy 15

Hydrocephaly 4

Meningomyelocele 4

Multifocal leukoencephalopathy 1

Progressive Sz d/o 1

Sickle Cell dz 1

Muscular Dystrophy 1

Renal anomalies 1

Sports Significant DisabilitiesHudson (Physician & Sportsmedicine 1988)Medical Diagnoses in History (#)
Down Syndrome 417

Epilepsy 239

Cardiac lesion 88

Cerebral palsy 33

Asthma 24

Hypothroidism 22

Hemiparesis 11

Severe vision dist 11

Diabetes 10

Hydrocephalus 9

Ataxia 7

Microcephaly 6

Paraplegia 5

Phenylketonuria 3

Conditions Encountered on Pregame Medical Exam of 1512 Competitors at U.K. Special Olympics,1989Robson, Br. J. Sports Med. 24:225,1990
physical exam
Height and Weight

Blood pressure

Visual Acuity

Eye,ear, nose, throat

Cardiorespiratory auscultation

Abdominal, including hernia and testicular check

Screening orthopedic, including scoliosis

Focused orthopedic

Screening neurologic

Physical Exam
visual exam
Visual Exam
  • About 1/3 will have abnormality
    • Poor visual acuity most common
    • Others:
      • Refractive errors
      • Astigmatism
      • strabismus
physical exam1
Physical Exam
  • Routine general exam
  • Focus on areas that most often reveal problems
    • Musculoskeletal
    • Cardiovascular
    • Neurological
    • Derm (wheelchair, prosthetics)
    • Functional Assessment
musculoskeletal examination
Musculoskeletal Examination
  • Wheelchair athlete: attention to shoulder, wrist and hand
  • Amputees: attention to back and lower extremities
  • Downs:
    • attention to c-spine exam
    • Hip and knee exam, instability common
  • Cerebral palsy:
    • contractures, strength, muscle imbalances; attention to hips,
    • knees, ankles and feet which have high rates of overuse injuries.
down syndrome major musculoskeletal disorders
Down SyndromeMajor Musculoskeletal Disorders
  • Metatarsus Primus Varus
    • Problem with shoe fit
  • Hallux Valgus
  • Patellar Instability
  • Scoliosis
  • Slipped Capital Femoral Epiphysis

Most due to defect in collagen synthesis, resulting in generalized ligamentous laxity

down syndrome cervical spine abnormalities
Down Syndrome Cervical Spine Abnormalities
  • Atlantoaxial Instability
  • Occiput-C1 Instability
  • Odontoid Dysplasia (6% of Down patients)
  • Hypoplasia of posterior arch of C1
  • Spondylolysis and Spondylolisthesis of midcervical vertebrae
  • Precocious Arthritis of C4-C6
atlantoaxial instability aai
Atlantoaxial Instability (AAI)
  • Up to 15% of Down syndrome have a laxity of the transverse ligament of C-1 (atlas) which stabilizes the articulation of the odontoid process of C-2 (axis) with C-1
  • If excessively lax, C-1 may spontaneously sublux forward on C-2 resulting in compression of the cervical spinal cord
atlantoaxial instability
Atlantoaxial Instability
  • 10%- 20% of Down syndrome individuals have asymptomatic AAI
  • 1-2% have symptomatic AAI
atlantoaxial instability diagnosis
Atlantoaxial Instability: Diagnosis
  • Lateral x-ray of the cervical spine in flexion, neutral, and extension
  • Look at Atlas-Dens Interval (ADI)
    • Distance between anterior ramus of C-1 and the dens of C-2
    • Should not exceed 4.0mm
  • All Down syndrome athletes must receive a diagnostic x-ray of the c-spine before entering Special Olympics participation

Normal ADI in neutral


Increased ADI in


cardiovascular exam
Cardiovascular Exam
  • Cardiac murmurs are common
    • Grade2/6 or softer and systolic = no further evaluation
    • Diastolic murmur or systolic 3/6 or louder = further evaluation
  • Blood pressure
down syndrome cardiac lesions
Down SyndromeCardiac Lesions
  • Endocardial Cushion Defect
  • Ventricular Septal Defect
  • Less Commonly
    • Secundum Atrial Septal Defect
    • Tetralogy of Fallot
    • Patent Ductus Arteriosus
  • 36th Bethesda Conference standards apply
ventricular septal defect
Ventricular Septal Defect
  • History of failure to thrive and dyspnea on exertion
  • Murmur = holosystolic and loudest in the 3rd and 4th left interspaces
  • Work-up and any necessary intervention prior to participation
    • Fairly common in Down Syndrome
    • May cause problems during Sports events
endocardial cushion defect
Endocardial Cushion Defect
  • Embryologic precursors of the atrioventricular canal, mitral and tricuspid valves
  • Defects of valves
neurologic examination
Neurologic examination
  • Nerve entrapment disorders
    • Especially common in wheelchair athletes
  • Cerebral palsy: evaluate sport-specific movements
  • MS: check for ataxia, weakness, fatigue, spasticity, sensory function
  • Downs: signs of AAI
    • Abnormal gait, incoordination , sensory deficits, spasticity, hyperreflexia, clonus, UMN or posterior column deficits
skin examination
Skin Examination
  • Wheelchair athletes prone to skin injuries
    • Abrasion, blisters, pressure ulcers (look in those difficult places)
  • Amputees: remove prostheses, look for abrasions, blisters, rashes, pressure ulcers
functional assessment
Functional Assessment
  • Overall mobility
  • Use of prosthetics
  • Use of wheelchair
  • Evaluate sport-specific tasks
lab tests and x rays
Lab Tests and X-rays
  • Down Syndrome- lateral C-spine in neutral, flexion, and extension
  • Seizure disorders- monitor therapeutic drug levels
    • Risk in swimming, diving, gymnastics, skiing, speed skating, and equestrian events
  • Other tests as indicated by each condition
minimize risk maximize participation
Minimize RiskMaximize Participation
  • Many benefits of athletics and competition
  • Must identify potential problems
  • Must encourage physical activity for individuals with disabilities
  • If an athlete is disqualified from chosen sport, help determine alternate sport
  • Provide positive reinforcement and encourage a healthy lifestyle
atlantoaxial instability and athletics
Atlantoaxial Instability and Athletics
  • Sports related collision or contact may lead to subluxation or dislocation at the atlantoaxial joint
  • Spinal cord compression can lead to fatigue when ambulating, or to upper motor neuron and posterior column signs
    • Gait disturbances, progressive loss of coordination, spasticity, hyperreflexia, clonus, or toe-extensor reflex

Atlantoaxial Instability and Athletics

  • Refer for neurosurgical consultation
  • Avoid activities at risk for hyperextension, radical flexion, or direct pressure on the neck or upper spine
    • butterfly stroke, diving, pentathlon, high jump, equestrian sports, gymnastics, soccer, squat lift, alpine skiing, and any warm-up exercise placing undue stress on the head and neck
  • Non-contact sports OK with parental consent
injury rates for team usa at the first international special olympics winter games 1993
Injury rates for Team USA at the First International Special Olympics Winter Games, 1993
  • Alpine skiing 20/28 = 71%
  • Floor hockey 11/35 = 31%
  • Speed skating 7/28 = 25%
  • Figure skating 3/29 = 10%
  • Cross country skiing 1/28 = 4%
international summer special olympics 1983 2150 athletes
Heat illness 302

Abrasion/lac 287

Sprain /strain 280

GI illness 115

Respiratory illness 70

Behavior/psych 26

Seizure 22

Dental injury 15

Closed head/ neck 12

Fracture/dislocation 8

International Summer Special Olympics, 1983 (2150 Athletes)
hawaii special olympics summer games 1993 96
Hawaii Special Olympics Summer Games, 1993-96
  • Batts, Glorioso, Williams.The Medical Demands of the Special Athlete. Clin J Sport Med 1998; 8:22-25.
  • Medical attention rate of 3.87% per year
    • 58% injuries
    • 42% medical conditions
hawaii special olympics summer games injuries n 52 medical cond n 38
Abrasion 16

Muscle cramp 14

Sprain/strain 8

Contusion 7

Laceration 4

Blister 2

Nail avulsion 1

GI complaint 6

Heat injury 5

Epistaxis 5

Infection 5

Seizure 4

Headache 4

Injection 3

Hawaii Special Olympics Summer GamesINJURIES (n=52) MEDICAL COND (n=38)
hawaii special olympics summer games injury sites
Hawaii Special Olympics Summer GamesINJURY SITES
  • Lower extremity 50% (knee = 13)
  • Upper extremity 30%
  • Chest/Abd 8%
  • Face 6%
  • No site listed 6%
hawaii special olympics summer games
Hawaii Special Olympics Summer Games
  • Track and Field 55.6%
  • Softball 35.6%
  • Aquatics, dance, training 8.8%

No reported injuries for wheelchair events, powerlifting, or tee ball

study comparison

Study Comparison


Time 2yr 1yr 1yr 4yr

Athlete 2056 777 1512 2326

Treated 4.2% 3.5% 13% 3.8%

disabled athlete injury rates
Disabled AthleteInjury Rates
  • Hoeberigs (1990) Wheelchair 47.5%
  • Richter (1991) Paralympics 60%
  • Ferrara (1992) Wheelchair, Blind and Cerebral palsy 32%
able bodied athlete injury rates
Able-Bodied AthleteInjury Rates
  • Zacicznyj (1980) 6% school aged child
  • Backx (1989) 10.6% school aged child
  • Garrick (1981) 39% high school athletes
  • Requa (1981) 85% high school track and field injuries to the lower extremity
hawaii special olympics winter games unpublished
Hawaii Special Olympics Winter Games (unpublished)
  • Approx. 3.2 % injury rate
  • 66% of injuries in Basketball
  • 15% of injuries from non-sports
  • 56% of injuries either strain/sprain or abrasions
  • No injuries in ice skating
medical coverage of special olympic events
Medical Coverage of Special Olympic Events
  • Medical professionals
    • Physicians, nurses, EMT’s, physical therapists, athletic trainers
  • Equipment- Basic first aid, ACLS, oxygen
  • Medical Aid Stations
  • Communication
  • Transportation
    • Ambulance, golf carts
medical coverage safety precautions
Medical Coverage Safety Precautions
  • Protect from the heat and sun
  • Environment and weather
    • Acclimate to altitude, temperature, humidity
  • Fluids
    • Encouraged by coaches, volunteers, health care teams
  • Personal medications available
medical coverage prevention
Medical Coverage Prevention
  • Training- muscular and cardiovascular conditioning
  • Protective gear - eyewear
  • Seizure precautions
    • A seizure while in or around water
    • Equestrian events, gymnastics, alpine skiing
  • Prior knowledge of injury patterns experienced by Special Olympians will improve medical coverage of games
  • The spirit with which these athletes compete is no different than that of a true Olympians
  • Although injury rates are higher in disabled athletes and able-bodied athletes, the types of injuries sustained by the special athlete are similar
  • Sport specific injuries are similar to all athletes