Medical Care of the Athlete David H.
\s=b\ Athletics involve many health hazards for children. The possibility for injury is present and participation means a calculated risk. To justify the risks, the benefits must outweigh the dangers. Sports, suitably engaged in, promote both physical and mental health. As pediatricians we become involved on two occasions: during the preseason examination to determine the child's fitness to participate, and when injury has occurred. Adequate examining means an understanding of what is involved to participate, promoting safety standards, and equitable competitive situations. (Am J Dis Child 132:181-187, 1978)
Athletics have been accepted as an important part of the process of general education since the 16th century. At first predominantly intra¬ mural, they have become during the last half-century increasingly com¬ petitive and extramural. Team sports, particularly those involving body con¬ tact, have become very popular. As a consequence, injuries have increased. The ferocity and level of intensity attributed to football can best be described by paraphrasing a state¬ ment by the late Vincent Lombardi: "Kissing is a contact sport, football is ¿X.
From the Department of Pediatrics, State University of New York, Upstate Medical Center, Syracuse. Dr Adamkin is now with the Department of Pediatrics, Louisville General Hospital. Reprint requests to Department of Pediatrics, Louisville General Hospital, 323 E Chestnut,
Louisville, KY 40202 (Dr Adamkin).
Adamkin, MD
collision sport." Not too long ago, treatment of inju¬ ries was believed to be the responsi¬ bility of the competitor and his parents, with first aid to be rendered by teammates and the coach. Medical attention was considered only for more serious injuries. The greatest impetus toward the provision of medical supervision for athletes came from the advent of acci¬ dent insurance programs that re¬ quires medical reports, and the increasing tendency of the courts to assign responsibility to the spon¬ soring institutions. Educational institutions now uni¬ versally acknowledge their responsi¬ a
bility to provide medical supervision, but they vary considerably in their interpretation of what constitutes adequate supervision. They must con¬ sider not only the physical welfare of
the student but also ensure that he is able to continue his studies without serious interruption while participat¬ ing in the athletic program. The risk of converting a minor injury into a major disability by continuing in athletic competition, often taken as a matter of course by the professional athlete, should not be permitted for the school athlete. The institution must accept this responsibility and make certain that all of its employees who are respon¬ sible for the supervision of athletes are deeply committed to their welfare. When the winning of a particular game, or establishing an unbeaten
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season, assumes a higher priority, the stage is set for trouble. The director of
athletics, coach, trainer, and others who deal with the athlete must give first priority to prevention of injury and to the proper treatment of the
injured player. If injuries are such a matter of concern, why should we allow children compete in athletics at all? Those who have themselves been involved in competitive sports appreciate the role that athletics can have in developing skills useful in our lives. A quote from Supreme Court Justice Byron (Whizzer) White, an All-American and AllProfessional football player and a Rhodes Scholar, illustrates this point: to
This business of performing under some kind of pressure and being able to face upward to requirements, proves its utility in other activities in life. In athletics, espe¬ cially competitive athletics, whether team or individual, you get in the habit of train¬ ing, planning, and working for some kind of excellence.1
The subject of medical supervision of athletics is an important aspect of public health because of the number of persons involved, its role in the educa¬ tional aspect of health maintenance, as well as its potential effect on the future of the community, many of whose leaders will come from the ranks of school and college athletics. AUTHORITY TO DETERMINE FITNESS
Responsibility for the health of the athlete must be delegated to a
competent medical advisor, who alone should determine
competition.
physical fitness
The usual physical examination given to schoolchildren is not ade¬ quate for those participating in com¬
petitive sports, particularly sports involving body contact and unusual endurance.
When
the
athlete
is
injured during competition, the physi¬ cian in attendance must finally decide
whether he should continue, be rested, or be removed for the day. The physi¬ cian may seek the advice of coach and trainer but the final decision is his. He would be foolish to ignore their expe¬ rience in matters of conditioning, timing, and coordination. He must resist the natural desire of the competitor to return to action before being physically able to do so. A Bill of Rights, designed to safe¬ guard the health of the high school athlete, has been issued jointly by the American Medical Association and the National Federation of State High School Athletic Associations.2 This Bill of Rights appears in Table 1. The examining physician should be familiar with the requirements and hazards of the sports offered by the school. If the examination is per¬ formed at school, the medical history should be obtained from the child's physician and/or parent in advance by use of a checklist. This form should list those medical conditions that might exclude a child from athletics or lead to acceptance for limited activity. Adequate time must be provided by the institution and physician for the examination. No physician examining 30 or 40 scantily dressed boys stand¬ ing in line in a two-hour period can derive information of value to either school or athlete. Materials for urine testing and hemoglobin determina¬ tions are needed. Table 2 lists medical causes for disqualification from par¬ ticipation in athletics.3 PHYSICAL EXAMINATION
The
physical
significant portions examination
are
Table 1.—The Athlete's Bill of
for
of the listed in
Table 3.3 MATCHING THE COMPETITORS An attempt to match competitors by size limits led to football programs
Rights*
Proper conditioning helps to prevent injuries by hardening the body and increasing resistance to fatigue. 1. Are prospective players given directions and activities for preseason conditioning? 2. Is there a minimum of two weeks of practice before the first game or contest? 3. Is each player required to warm up thoroughly prior to participation? 4. Are substitutions made without hesitation when players evidence disability? Careful coaching leads to skillful performance, which lowers the Incidence of Injuries. 1. Is emphasis given to safety in teaching techniques and elements of play? 2. Are Injuries carefully analyzed to determine causes and suggest preventive programs? 3. Are tactics discouraged that may increase the hazards and thus the incidence of injuries? 4. Are practice periods carefully planned and of reasonable duration? Good officiating promotes enjoyment of the game as well as the protection of players. 1. Are players as well as coaches thoroughly schooled in the rules of the games? 2. Are rules and regulations strictly enforced in practice periods as well as in games? 3. Are officials employed who are qualified both emotionally and technically for their responsibilities? Right equipment and facilities serve a unique purpose in protection of players. 1. Is the best protective equipment provided for contact sports? 2. Is careful attention given to proper fitting and adjustment of equipment? 3. Is equipment properly maintained, and are worn and outmoded Items discarded? 4. Are proper areas for play provided and carefully maintained? Adequate medicai care is a necessity in the prevention and control of athletic injuries. 1. Is there a thorough preseason health history and medical examination? 2. Is a physician present at contests and readily available during practice sessions? 3. Does the physician make the decision as to whether an athlete should return to play following injury during games? 4. Is authority from a physician required before an athlete can return to practice after being out of play because of disabling injury? 5. Is the care given athletes by coach or trainer limited to first aid and medically prescribed services? "From Hein.2
Table 2.—Medical Causes for
Disqualification*
Hepatitis: restrict for three months after apparent return to good health Infectious mononucleosis: until spleen is back to normal size Acute nephritis: until urine returns to normal Nephrotlc syndrome: long period (minimum of six months) without a relapse Acute rheumatic myocarditis: restrict for six months after complete recovery Tuberculosis: arrested disease and no loss of pulmonary function from extensive scarring, six months after arrest is judged complete
Diabetes mellitus: hazards for young athletes are twofold: 1. Exercise may result in either increased insulin production or increased peripheral utilization of glucose and hence precipitate hypoglycémie shock 2. Acidosis may result from dehydration caused by heavy exercise in warm weather The diabetic must be as well regulated as possible, taking these factors into account for competition. Orange juice should be available at all times. a paired organ (kidney, eye). Hypertension (blood pressure > 140/90 mm Hg): should be evaluated and recorded frequently; Individualize restrictions if necessary Cardiac conditions: Data are now being collected at many cardiac centers to help make recommendations for both recreational and occupational activity."
Loss of
"Modified from Ryan.3
colleges in which participa¬ tion is restricted by the maximum weight limit of 68 kg. This tends to be unpopular with parents, athletes, fans, and coaches, but if it results in a substantial reduction in the oc¬ currence of injury it should be contin¬ ued. Division by age alone, as in the Little League, has often produced inequitable situations. An article by Hafner5 illustrates the dilemma of two athletes. The first, a 13-year-old at many
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in ninth grade, wanted to play football, but his school had only varsity squad and one modified team. According to his age, he should have played on the modified team, yet he was 184 cm tall and weighed 102 kg. He was kept off the team because the rest of the squad was 34 kg lighter and
boy
several centimeters shorter. The sec¬ ond youngster is an eighth grader, New York's 1975 "Pee Wee" wrestling champ, who weighs only 41 kg. At age
Table 3.—The
Physical
Examination of the Potential
Sports Participant*
Height, weight, blood pressure, visual acuity, chest and waist measurement, hearing test Skin Infections: contagious disease, chronic infections Scars: evidence of previous surgery or trauma Color of skin and conjunctiva, jaundice especially Head Eyes: if visual acuity is less than 20/30, corrective lenses may be needed Nose: deformity may limit endurance Mouth: teeth repair or removal; impacted third molar should be removed before participa¬ tion in contact sports since its presence is often associated with severe injuries to the mandible Neck Any limitation of normal motion should be noted for future reference in case some injury to this part should occur; stiffness or muscle spasm should be viewed with suspicion and subject to further investigation Chest Murmurs, wheezing, etc, obviously important Abdomen
Organomegaly, Inguinal Genitalia Absence of one
or
hernia
failure of descent of
one or
both testes is
a
contraindication to
participation; hydrocele should be corrected before contact sports are allowed; varicocele may be aggravated by strenuous physical exercise Female pelvic examination, If indicated by history of periodic cramping with amenorrhea or chronic lower abdominal pain or secondary amenorrhea Extremities Any abnormal mobility requires special individual consideration Important muscles from the standpoint of protection against injury are the quadriceps and biceps femoris groups: although the ankle can be reasonably well protected against injury by wrapping and taping to the point that mobility in the tibiofibular and tibiofibulartalar joints is greatly limited without interfering with function, the knee cannot; application of conventional protective taping around and over the knee joint may limit Its efficiency for running as much as 50% and still not limit lateral mobility of the joint more than this amount, if as much; protection of the ligaments and cartilages of the knee joint must therefore depend primarily on the strength of the thigh muscle whose tendons cross the
joint
Urine
Glucose, acetone, protein Hemoglobin/hematocrit Hemoglobin standards: prepubertal, 11.5 gm/100 ml; postpubertal males, 14 gm/100 ml; postpubertal females, 12 gm/100 mi" Values falling below these standards should be evaluated; participation need not be restricted after satisfactorily ruling out severe anemia or disease "From Ryan.3
13 he had exceptional strength, endur¬ ance, and motor skills. He was so
superior to other 13-year-olds that the
athletic director and coach took him off the team for fear he would injure his own teammates in practice. Al¬ though a student's age is an inad¬
measure of physical maturity, most athletic programs still group athletes by age alone, ignoring their stage of development. The result is a high athletic injury rate. At age 13, as Hafner points out, "Boys can physi¬ cally vary from 90 lbs of baby fat and peach fuzz to 225 lbs of muscle and moustache."3 In short, matching youngsters of similar maturity and skill is likely to reduce injuries and improve competition. In 1973, Hafner began an experiment in which ath¬ letes in grades 7 through 12 (aged 12
equate
matched. In 1974, a sampling of 200 of these players showed that only three suf¬ fered injuries, and these were termed to
19)
were so
random
insignificant. By comparison, 700,000
of the nation's 1.4 million boys matched by age to play football in
1974 were injured severely enough to keep them out of play for one week or
pensive screening method has been devised. For girls, it is quite simple. All girls are considered to be at approximately the same stage of physical development at menarche, and two girls of the same chronolog¬ ical age. For this test, all girls are considered to have a development age
of 12V2 years (the average menarcheal age in the United States) at the time of their first menstrual period, re¬ gardless of chronologic age. By using the scale listed in Fig 1, the physician can quickly determine the stage of female adolescent development by calculating postmenarcheal age and converting it to a developmental age. The method for boys is more complex, since no single event iden¬ tifies a definite stage of maturation. School physicians are provided with a series of drawings (Fig 2) to help them grade facial, axillary, and pubic hair growth on a scale from 1 to 5. When these test scores are entered into a master log, the result is a scheme that allows physicians, athletic directors, and coaches to channel athletes into a level of competition with others at the same stage of maturity. MOUTH PROTECTORS
Injuries to the mouth, including fractures and loss of teeth, can be serious and are not confined to contact sports. Such injuries are often perma¬ nent. Fractures of the jaws, and inju¬ ries to lips, cheeks, and nose, are addi¬ tional hazards that can be prevented by suitable protection. Injuries to the mouth in football are common and account for 50% of all sports injuries."-7 These hazards are greatest in unorganized play, and in touch foot¬ ball, where protective equipment is likely to be inadequate or nonexis¬
more.3
tent.8
The Selection Classification Age Maturity Program utilizes five crite¬ ria to match athletes (Table 4). Accurate determination of physical maturity used to present a problem. Formerly, the most accepted method was to obtain a roentgenogram of the hand and wrist for assessment of bone age but this is too expensive for schools that deal with large numbers of youngsters. Now a quick and inex-
Every season, a football player who is not wearing a mouth protector has one chance in ten of receiving an injury to his teeth. If he plays ten seasons, which he may do, considering pre-high school, high school, and college, his risk of tooth injury approaches 100%.8 In 1960, all high school football teams were required for the first time by the National Federation of State
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High School Associations to wear face guards. Many believed that face guards would be adequate to afford mouth protection, but they were found to reduce mouth injuries by only 50%.9 The face guard provides protection primarily from direct blows to the mouth, nose, and other facial struc¬ tures. It does not
protect the mouth
from blows under the chin delivered by forearm blocking, knees, and kicks, nor does it protect the top of the head from blows that may cause the jaws to snap shut. Since 1962 the National Football Alliance (NFA), which includes most high school and junior colleges, has had a rule making it mandatory that their football players wear mouth protectors. It was not until 1973 that the National Collegiate Athletic Asso¬ ciation (NCAA) developed a similar rule. The professional leagues still do not have such a rule. In hockey, where the risks are the highest, only a few teams require mouth protectors. It is important for physicians to realize that such protection is not automati¬ cally provided, and he should join with parents and dentists in demanding that protectors are provided. It is also recommended that mouth protection be used in practice sessions. More injuries occur in practice than in games, perhaps because more time is spent in practice and more players are involved, including those less capable and less well coordinated. The less skilled and inexperienced individual is most likely to be injured. It is a fallacy to think that the blows delivered by younger players are of lesser magni¬ tude and, therefore, that fewer inju¬ ries result. In particular, this is not true of dental injuries. The mouth protector rule has all but eliminated the remaining 50% of mouth injuries. The actual figures from high school insurance programs show that mouth injuries account for between 0.035% and 0.045% of all sports injury claims. This result has been achieved even without quality
control. Considering previous injury figures, this probably means that at least 100,000 oral injuries per year are prevented for more than 1 million players in the NFA and NCAA.8
Table 4.—Selection Classification
Age Maturity Program Criteria*
as strenuous, moderately strenuous, nonstrenuous, and then subdivided into contact, limited contact, or noncontact: Football, ice hockey: strenuous, contact Basketball, soccer: strenuous, limited contact Tennis: strenuous, noncontact Volleyball: moderately strenuous, noncontact Riflery: nonstrenuous, noncontact_ Categorization according to level at which athlete should compete on basis of age: junior high, freshman, junior varsity, or varsity squads Test for agility, strength, speed, and endurance: raw scores for each test are converted into an achievement level based on norms for grades 7 to 12, then ranked on a scale from 1 (underdeveloped) to 10 (superior)t Agility: sidesteps measure agility: starting from a center line, participant sidesteps left and then right across two outside lines that are eight feet apart; fitness score is the total number of lines alternately crossed in ten seconds Strength: number of slt-ups in two minutes Speed: timed 90- or 120-yard dashes Endurance: number of squat thrusts in one minute_ Evaluation of the athlete by coaches for proficiency in the sport he or she wants to play Physical examination that also determines the athlete's level of maturity
1. The
sport the athlete wants to pursue Is categorized
or
2. 3.
4. 5.
"From Banks." tStandards available from New York State Public High School Athletic Association, Ine, Albany.
Developmental age
12Vj 13 Poetmenarche age
14
15
12
16
17
J
3
4
18
5
6
Fig 1 .—To determine girl's developmental age, physician fills in form with date of birth (in this case, Nov 6, 1960), year and month menstruation began (March 1971), and examination date (March 1,1975). Number of elapsed years and months between onset of menstruation and examination date (four years) is plotted on lower line, and arrow drawn from that point to top line. This gives girl's developmental age (top line), in this case I6V2 years. By comparison, her chronological age is 14 years and 4 months.5 is now imposed football team whose players do not have mouth protectors. However, enforcement of this recommendation of mandatory mouth protectors in fact rests with the coaches and school offi¬ cials. Physicians should be urged to refuse to provide medical coverage to any team whose players do not have mouth protectors. There is some evidence that mouth protectors can also help prevent concussions. Some schools have re¬ ported that when mouth protectors are in place the incidence of concus¬ sions is reduced to nearly zero! The results of a five-year study at the University of Kentucky1" and Notre Dame" support this premise. The report also shows a dramatic reduc¬ tion of neck injuries, which the inves¬ tigators attribute largely to the use of A
15-yard penalty
on a
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protectors. The Kentucky study reported that mouth protectors, by cushioning blows to the chin, reduced cranial deformation injuries by 50%. mouth
SEIZURE DISORDERS
For years there has been a wide¬ that epileptic children and young adults should be restricted from vigorous athletics. Livingston1states that there is danger even for those who have been seizure free for two or three years after termination of drug therapy. However, he observes that in his experience the incidence of withdrawal seizures in patients who participate in athletics is no different than in those who do not. He would consider restricting uncontrolled epi¬ leptics, regardless of the in frequency of their seizures, from participating in
spread belief
Fig 2.—To determine boy's stage of maturity, physician uses drawings of five stages of facial (top), axillary (center), and pubic (bottom) hair growth.5 activities such
horseback riding, and other sports that may be associated with a significant risk of injury. Vigorous physical activity does not adversely affect the epileptic disorder, so changes in drug dosages are not necessary, nor is there any evidence that vigorous physical activity alters the body's metabolism of the antiepi-
climbing
to
as
high altitudes,
leptic drugs. Livingston
also states that he encourages his young patients (aged 6 to 9 years) whose seizures are adequately controlled to participate in
sports appropriate for age. He ex¬ plains to the parents that even though
their child may have an occasional seizure, there is no valid reason for major restriction of normal childhood activities. There is a risk for injury in athletic activities for everyone, epilep¬ tic or nonepileptic, and because of the possibility of a seizure occurring
during physical activity, particularly a
sport, the risk may be greater for the child with epilepsy; however, parents should weigh this small risk of injury against the much greater risk of instilling in their child an attitude contact
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of
inferiority.13-15
In August 1974, the AMA commit¬ tee on the Medical Aspects of Sports revised its policy and revoked the
prohibition against participation of epileptic patients in body contact sports. It stated that there was ample evidence to show that patients will not be affected adversely by indulging in any sport, including football, provided the normal safeguards for sports participation are followed.1317 The difficult question is whether athletes whose epileptic disorders are unequivocally the result of previous
head trauma should be allowed to participate in contact sports. At pres¬ ent there are no data on the long-term follow-up of such athletes, but it would seem prudent to restrict them for competition in contact sports such as
boxing, football, hockey, or rugby.
LIFE-THREATENING INJURIES
Life-threatening no means
common;
situations
are
however, they
by can
In 1970, forty-three deaths were associated with football, and there are an average of 25 to 35 deaths yearly. Six situations can immediately threaten the life of an athlete: airway
occur.
obstruction, respiratory failure,
car¬
diac arrest, heat injury, craniocerebral injury, and cervical spine injury.18
Airway Obstruction This
can occur
in the unconscious
athlete, who may experience a tran¬ sient apneic episode. When one is in
supine position, relaxation of the oropharyngeal musculature can allow
the
the tongue to fall back and occlude the airway. In this situation immediate action must be taken to reestablish the airway. This is accomplished by simply supporting the neck with one hand and tilting the head back with the other. If this maneuver does not work, the next step is to grasp the mandible firmly and pull it forward, again with the head tilted backward. When a cervical spine injury is suspected, care must be taken not to forcibly manipulate the cervical spine. The initial evaluation of the uncon¬ scious player is to determine if he is breathing and has a pulse. Considera¬ tion then should be given to the possi¬ bility of an associated neck injury.
Respiratory An
Failure
example of this is simple syncopal apnea, which may occur in the physician's office when the athlete faces some diagnostic or therapeutic procedure like arthrocentesis. Follow¬ ing the apneic episode, such patients usually start breathing spontaneously. Players with craniocerebral injuries may have apneic episodes complicated by obstruction of the airway because of transient paralysis of the oropha¬ ryngeal musculature. Oral airways and reinflatable breathing bags
should be available in case respiration must be supported for a prolonged
period.
A basic rule for dealing with the unconscious player is that the helmet should not be removed prior to medical evaluation. Head injuries are often associated with injuries to the cervical spine, and this possibility must be considered until the patient regains consciousness or until roentgeno¬ grams prove otherwise. Forced ma¬ nipulation of the cervical spine to remove the helmet may cause irre¬ versible damage to the spinal cord. If a player has respiratory problems, his face mask should be removed and the helmet left in place.
Cardiac Arrest
Arrhythmias are the usual cause. Cardiopulmonary resuscitation should be begun in the absence of the pulse.1" Heat
Injuries
Heat exhaustion and heat stroke are two life-threatening situations. Signs of heat injury include muscle cramps, excessive fatigue or weak¬ ness, loss of coordination, a slowing of reaction time, headache, decreased nausea and vomiting, and dizziness. Heat exhaustion occurs when an individual is exposed to a high environmental temperature and sweats excessively without salt and fluid replacement. This is followed by collapse and circulatory failure. The patient will respond to intravenous fluids containing salt, cooling, and rest, but death may result if the condi¬ tion is not recognized and treated
comprehension,
immediately.
Heat stroke occurs when a unacclimatized individual is exposed to a high environmental temperature. The thermal regulatory mechanism fails, sweating stops, and body temperature rises. Brain damage may occur at temperatures above 41 C and death may follow. The diagnostic key is the presence of a high body temperature in the absence of sweating. The athlete with these signs should be undressed, packed in ice, and hospital¬ ized immediately. To prevent heat injuries, the athlete fresh from vacation in a cool climate
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should be allowed 14 to 21 days of acclimatization before exposure to a competitive situation at a location where the temperature is high. Initial practices should be arranged for cooler hours of the day. Clothing should be such as to allow moisture to evaporate. Above all, players should be given free access to water and salt (3 to 5 gm/day). Weight charts are a good way to monitor the daily weight loss, so that the exact fluid loss can be determined. It is not unusual for an athlete to lose 3.5 kg in eight hours. To prevent heat injury, several basic rules should be followed. First, unlimited fluids should be provided before, during, and after practices and games. Conditioning by dehydra¬ tion is contraindicated. Second, on hot days players should be given four to eight 650-mg salt tablets daily and allowed liberal use of table salt as well. Too much salt, however, can be dangerous. With an intake of more than 15 gm daily, there is a danger of ^
rhabdomyolysis.™
Intracranial
Injuries
These include concussion, skull frac¬
ture, subdural and epidural hema¬ toma, and intracerebral hemorrhage.
The symptoms of concussion range from slight mental confusion and possible memory loss, tinnitus, and dizziness to profound mental confu¬ sion and prolonged loss of conscious¬ ness. The high school player who has any degree of concussion should not be allowed to continue. Signs and symp¬ toms that demand emergency action in any athlete who has sustained a blow to the head are increasing head¬ ache, nausea and vomiting, inequality of the pupils, disorientation, and progressive impairment of conscious¬ ness.
Cervical
Spine Injuries
Fracture, dislocation, and fracture dislocation of the cervical spine are the most disastrous traumatic insults. When such an injury occurs or is suspected, it is imperative that the victim be protected from further injury to the neural elements. Neck trauma precaution should be taken
also for those who have severe, unre¬ mitting neck pain, with or without paralysis. The basic principle in mov¬ ing an unconscious player or one suspected of having a significant cervical spine injury is to roll him like a log so that once on the fracture board a log-like alignment of the head and neck with the axial skeleton is maintained.
both
physical and mental health. Those who are responsible for orga¬ nized sports, including the players,
SUMMARY
Sports involve many health hazards. possibility of physical injury is always present, and those who engage in sport? deliberately run a calculated The
coaches, trainers, and athletic depart¬ ment, are also responsible for mini¬ mizing the risks. We as pediatricians
risk in order to obtain a beneficial To justify the risks, the benefits must outweigh the dangers. Sports suitably engaged in certainly promote
must become part of this team to extend our goal—the well-being of children.
goal.
References 1. Hayes W: You Win With People. Columbus, Ohio, Typographic Printing Company, 1973, p 14. 2. Hein F: Safeguarding the health of the high school athlete, in Ryan A: Medical Care of the Athlete. New York, McGraw-Hill Book Co Inc, 1962, pp 16-17. 3. Ryan A: Medical Care of the Athlete. New York, McGraw-Hill Book Co Inc, 1962, pp 34-43. 4. Nathan DC, Oski FA: Hematology of Infancy and Childhood. Philadelphia, WB Saunders Co, 1974, p 98. 5. Hafner J: Problems in matching young athletes: Baby fat, peach fuzz, muscle and moustache. Sports Med 3:96-98, 1975. 6. Banks 0: The Occurrence of Dental Injuries Resulting From Varsity Football During the Football Season of 1959-60 Academic Year, thesis. Kansas State University, Manhattan, 1961. 7. Cathcat JF: Mouth protectors for contact sports. Dental Digest 57:346, 1951. 8. Heintz W: The case for mandatory mouth
Sports Med 3:61-63, 1975. 9. Report of a Study of Face Guards and Mouth Protectors. Marinette, Wisconsin Interscholastic Athletic Association, 1956. 10. Hickey JC, Morris AL, Carlson LD, et al: The relation of mouth protectors to cranial pressure and deformation. J Am Dent Assoc 74:735, 1967. 11. Stenger JM, Lawson EA, Wright JM, et al: Mouthguards: Protection against shock to head, neck and teeth. J Am Dent Assoc 69:273, 1964. 12. Livingston S: Should epileptics be athletes? Sports Med 3:67-72, 1975. 13. Livingston S: Living With Epileptic Seizures. Springfield, Ill, Charles C Thomas Publisher, 1963, p 87. 14. Livingston S: Comprehensive Management of Epilepsy in Infancy, Childhood, and Adolescence. Springfield, Ill, Charles C Thomas Publisher, 1972, p 147. 15. Aisenson MR: Accidental injuries in epileptic children. Pediatrics 2:85-88, 1948.
16. Convulsive disorders and
protectors.
Livingston S: Convulsive disorders and participation in sports and physical education.
JAMA 206:1291, 1968. 18. Torg JS, Quedenfeld TC, Newell W, et al: When the athlete's life is threatened. Sports Med 3:54-60, 1975. 19. Standards for cardiopulmonary resuscitation and emergency cardiac care, American Heart Association Committee on CPB and ECC. JAMA 227:837-868, 1974. 20. Brodine C: The adverse effects of salt loading: A potential problem of salt supplementation. Read before the Ramsay B. Thomas Symposium, Bethesda, Md, May 4, 1974. 21. Policy Statement: Cardiac Evaluation for Participation in Sports. Evanston, Ill, American Academy of Pediatrics, 1977.
Errors in Table.\p=m-\In the article titled "Gonorrhea: Diagnosis by Gram Stain in the Female
Table are inverted and should correctly read Smear Positive/Culture Positive and Smear Negative/Culture Negative. The number of female patients should be 121. The corrected Table is shown below.
No. of
Smear Positive/
and Culture Results
Sensitivity,*
Smear
Negative/
Specificity."
_Patients_Culture Positive_%_Culture Negative_%_ 121 Female
Male
"Percentage
tPercentage
29
22/34 23/23
65
in the
1968. 17.
Adolescent," published in the October Journal (131:1094-1096,1977), two headings in the
Interpretation
on
Medical Aspects of Sports and Committee on Exercise and Physical Fitness. JAMA 206:1291,
CORRECTION
Correlation of Smear
participation
sports and physical education, Committee
86/87
ÎÔÔ
of culture-positive specimens correctly identified by Gram stain. of culture negative specimens correctly identified by Gram stain.
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ß
99
..,
\s=b\ Athletics involve many health hazards for children. The possibility for injury is present and participation means a calculated risk. To justify the risks, the benefits must outweigh the dangers. Sports, suitably engaged in, promote both physical and mental health. As pediatricians we become involved on two occasions: during the preseason examination to determine the child's fitness to participate, and when injury has occurred. Adequate examining means an understanding of what is involved to participate, promoting safety standards, and equitable competitive situations. (Am J Dis Child 132:181-187, 1978)
Athletics have been accepted as an important part of the process of general education since the 16th century. At first predominantly intra¬ mural, they have become during the last half-century increasingly com¬ petitive and extramural. Team sports, particularly those involving body con¬ tact, have become very popular. As a consequence, injuries have increased. The ferocity and level of intensity attributed to football can best be described by paraphrasing a state¬ ment by the late Vincent Lombardi: "Kissing is a contact sport, football is ¿X.
From the Department of Pediatrics, State University of New York, Upstate Medical Center, Syracuse. Dr Adamkin is now with the Department of Pediatrics, Louisville General Hospital. Reprint requests to Department of Pediatrics, Louisville General Hospital, 323 E Chestnut,
Louisville, KY 40202 (Dr Adamkin).
Adamkin, MD
collision sport." Not too long ago, treatment of inju¬ ries was believed to be the responsi¬ bility of the competitor and his parents, with first aid to be rendered by teammates and the coach. Medical attention was considered only for more serious injuries. The greatest impetus toward the provision of medical supervision for athletes came from the advent of acci¬ dent insurance programs that re¬ quires medical reports, and the increasing tendency of the courts to assign responsibility to the spon¬ soring institutions. Educational institutions now uni¬ versally acknowledge their responsi¬ a
bility to provide medical supervision, but they vary considerably in their interpretation of what constitutes adequate supervision. They must con¬ sider not only the physical welfare of
the student but also ensure that he is able to continue his studies without serious interruption while participat¬ ing in the athletic program. The risk of converting a minor injury into a major disability by continuing in athletic competition, often taken as a matter of course by the professional athlete, should not be permitted for the school athlete. The institution must accept this responsibility and make certain that all of its employees who are respon¬ sible for the supervision of athletes are deeply committed to their welfare. When the winning of a particular game, or establishing an unbeaten
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season, assumes a higher priority, the stage is set for trouble. The director of
athletics, coach, trainer, and others who deal with the athlete must give first priority to prevention of injury and to the proper treatment of the
injured player. If injuries are such a matter of concern, why should we allow children compete in athletics at all? Those who have themselves been involved in competitive sports appreciate the role that athletics can have in developing skills useful in our lives. A quote from Supreme Court Justice Byron (Whizzer) White, an All-American and AllProfessional football player and a Rhodes Scholar, illustrates this point: to
This business of performing under some kind of pressure and being able to face upward to requirements, proves its utility in other activities in life. In athletics, espe¬ cially competitive athletics, whether team or individual, you get in the habit of train¬ ing, planning, and working for some kind of excellence.1
The subject of medical supervision of athletics is an important aspect of public health because of the number of persons involved, its role in the educa¬ tional aspect of health maintenance, as well as its potential effect on the future of the community, many of whose leaders will come from the ranks of school and college athletics. AUTHORITY TO DETERMINE FITNESS
Responsibility for the health of the athlete must be delegated to a
competent medical advisor, who alone should determine
competition.
physical fitness
The usual physical examination given to schoolchildren is not ade¬ quate for those participating in com¬
petitive sports, particularly sports involving body contact and unusual endurance.
When
the
athlete
is
injured during competition, the physi¬ cian in attendance must finally decide
whether he should continue, be rested, or be removed for the day. The physi¬ cian may seek the advice of coach and trainer but the final decision is his. He would be foolish to ignore their expe¬ rience in matters of conditioning, timing, and coordination. He must resist the natural desire of the competitor to return to action before being physically able to do so. A Bill of Rights, designed to safe¬ guard the health of the high school athlete, has been issued jointly by the American Medical Association and the National Federation of State High School Athletic Associations.2 This Bill of Rights appears in Table 1. The examining physician should be familiar with the requirements and hazards of the sports offered by the school. If the examination is per¬ formed at school, the medical history should be obtained from the child's physician and/or parent in advance by use of a checklist. This form should list those medical conditions that might exclude a child from athletics or lead to acceptance for limited activity. Adequate time must be provided by the institution and physician for the examination. No physician examining 30 or 40 scantily dressed boys stand¬ ing in line in a two-hour period can derive information of value to either school or athlete. Materials for urine testing and hemoglobin determina¬ tions are needed. Table 2 lists medical causes for disqualification from par¬ ticipation in athletics.3 PHYSICAL EXAMINATION
The
physical
significant portions examination
are
Table 1.—The Athlete's Bill of
for
of the listed in
Table 3.3 MATCHING THE COMPETITORS An attempt to match competitors by size limits led to football programs
Rights*
Proper conditioning helps to prevent injuries by hardening the body and increasing resistance to fatigue. 1. Are prospective players given directions and activities for preseason conditioning? 2. Is there a minimum of two weeks of practice before the first game or contest? 3. Is each player required to warm up thoroughly prior to participation? 4. Are substitutions made without hesitation when players evidence disability? Careful coaching leads to skillful performance, which lowers the Incidence of Injuries. 1. Is emphasis given to safety in teaching techniques and elements of play? 2. Are Injuries carefully analyzed to determine causes and suggest preventive programs? 3. Are tactics discouraged that may increase the hazards and thus the incidence of injuries? 4. Are practice periods carefully planned and of reasonable duration? Good officiating promotes enjoyment of the game as well as the protection of players. 1. Are players as well as coaches thoroughly schooled in the rules of the games? 2. Are rules and regulations strictly enforced in practice periods as well as in games? 3. Are officials employed who are qualified both emotionally and technically for their responsibilities? Right equipment and facilities serve a unique purpose in protection of players. 1. Is the best protective equipment provided for contact sports? 2. Is careful attention given to proper fitting and adjustment of equipment? 3. Is equipment properly maintained, and are worn and outmoded Items discarded? 4. Are proper areas for play provided and carefully maintained? Adequate medicai care is a necessity in the prevention and control of athletic injuries. 1. Is there a thorough preseason health history and medical examination? 2. Is a physician present at contests and readily available during practice sessions? 3. Does the physician make the decision as to whether an athlete should return to play following injury during games? 4. Is authority from a physician required before an athlete can return to practice after being out of play because of disabling injury? 5. Is the care given athletes by coach or trainer limited to first aid and medically prescribed services? "From Hein.2
Table 2.—Medical Causes for
Disqualification*
Hepatitis: restrict for three months after apparent return to good health Infectious mononucleosis: until spleen is back to normal size Acute nephritis: until urine returns to normal Nephrotlc syndrome: long period (minimum of six months) without a relapse Acute rheumatic myocarditis: restrict for six months after complete recovery Tuberculosis: arrested disease and no loss of pulmonary function from extensive scarring, six months after arrest is judged complete
Diabetes mellitus: hazards for young athletes are twofold: 1. Exercise may result in either increased insulin production or increased peripheral utilization of glucose and hence precipitate hypoglycémie shock 2. Acidosis may result from dehydration caused by heavy exercise in warm weather The diabetic must be as well regulated as possible, taking these factors into account for competition. Orange juice should be available at all times. a paired organ (kidney, eye). Hypertension (blood pressure > 140/90 mm Hg): should be evaluated and recorded frequently; Individualize restrictions if necessary Cardiac conditions: Data are now being collected at many cardiac centers to help make recommendations for both recreational and occupational activity."
Loss of
"Modified from Ryan.3
colleges in which participa¬ tion is restricted by the maximum weight limit of 68 kg. This tends to be unpopular with parents, athletes, fans, and coaches, but if it results in a substantial reduction in the oc¬ currence of injury it should be contin¬ ued. Division by age alone, as in the Little League, has often produced inequitable situations. An article by Hafner5 illustrates the dilemma of two athletes. The first, a 13-year-old at many
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in ninth grade, wanted to play football, but his school had only varsity squad and one modified team. According to his age, he should have played on the modified team, yet he was 184 cm tall and weighed 102 kg. He was kept off the team because the rest of the squad was 34 kg lighter and
boy
several centimeters shorter. The sec¬ ond youngster is an eighth grader, New York's 1975 "Pee Wee" wrestling champ, who weighs only 41 kg. At age
Table 3.—The
Physical
Examination of the Potential
Sports Participant*
Height, weight, blood pressure, visual acuity, chest and waist measurement, hearing test Skin Infections: contagious disease, chronic infections Scars: evidence of previous surgery or trauma Color of skin and conjunctiva, jaundice especially Head Eyes: if visual acuity is less than 20/30, corrective lenses may be needed Nose: deformity may limit endurance Mouth: teeth repair or removal; impacted third molar should be removed before participa¬ tion in contact sports since its presence is often associated with severe injuries to the mandible Neck Any limitation of normal motion should be noted for future reference in case some injury to this part should occur; stiffness or muscle spasm should be viewed with suspicion and subject to further investigation Chest Murmurs, wheezing, etc, obviously important Abdomen
Organomegaly, Inguinal Genitalia Absence of one
or
hernia
failure of descent of
one or
both testes is
a
contraindication to
participation; hydrocele should be corrected before contact sports are allowed; varicocele may be aggravated by strenuous physical exercise Female pelvic examination, If indicated by history of periodic cramping with amenorrhea or chronic lower abdominal pain or secondary amenorrhea Extremities Any abnormal mobility requires special individual consideration Important muscles from the standpoint of protection against injury are the quadriceps and biceps femoris groups: although the ankle can be reasonably well protected against injury by wrapping and taping to the point that mobility in the tibiofibular and tibiofibulartalar joints is greatly limited without interfering with function, the knee cannot; application of conventional protective taping around and over the knee joint may limit Its efficiency for running as much as 50% and still not limit lateral mobility of the joint more than this amount, if as much; protection of the ligaments and cartilages of the knee joint must therefore depend primarily on the strength of the thigh muscle whose tendons cross the
joint
Urine
Glucose, acetone, protein Hemoglobin/hematocrit Hemoglobin standards: prepubertal, 11.5 gm/100 ml; postpubertal males, 14 gm/100 ml; postpubertal females, 12 gm/100 mi" Values falling below these standards should be evaluated; participation need not be restricted after satisfactorily ruling out severe anemia or disease "From Ryan.3
13 he had exceptional strength, endur¬ ance, and motor skills. He was so
superior to other 13-year-olds that the
athletic director and coach took him off the team for fear he would injure his own teammates in practice. Al¬ though a student's age is an inad¬
measure of physical maturity, most athletic programs still group athletes by age alone, ignoring their stage of development. The result is a high athletic injury rate. At age 13, as Hafner points out, "Boys can physi¬ cally vary from 90 lbs of baby fat and peach fuzz to 225 lbs of muscle and moustache."3 In short, matching youngsters of similar maturity and skill is likely to reduce injuries and improve competition. In 1973, Hafner began an experiment in which ath¬ letes in grades 7 through 12 (aged 12
equate
matched. In 1974, a sampling of 200 of these players showed that only three suf¬ fered injuries, and these were termed to
19)
were so
random
insignificant. By comparison, 700,000
of the nation's 1.4 million boys matched by age to play football in
1974 were injured severely enough to keep them out of play for one week or
pensive screening method has been devised. For girls, it is quite simple. All girls are considered to be at approximately the same stage of physical development at menarche, and two girls of the same chronolog¬ ical age. For this test, all girls are considered to have a development age
of 12V2 years (the average menarcheal age in the United States) at the time of their first menstrual period, re¬ gardless of chronologic age. By using the scale listed in Fig 1, the physician can quickly determine the stage of female adolescent development by calculating postmenarcheal age and converting it to a developmental age. The method for boys is more complex, since no single event iden¬ tifies a definite stage of maturation. School physicians are provided with a series of drawings (Fig 2) to help them grade facial, axillary, and pubic hair growth on a scale from 1 to 5. When these test scores are entered into a master log, the result is a scheme that allows physicians, athletic directors, and coaches to channel athletes into a level of competition with others at the same stage of maturity. MOUTH PROTECTORS
Injuries to the mouth, including fractures and loss of teeth, can be serious and are not confined to contact sports. Such injuries are often perma¬ nent. Fractures of the jaws, and inju¬ ries to lips, cheeks, and nose, are addi¬ tional hazards that can be prevented by suitable protection. Injuries to the mouth in football are common and account for 50% of all sports injuries."-7 These hazards are greatest in unorganized play, and in touch foot¬ ball, where protective equipment is likely to be inadequate or nonexis¬
more.3
tent.8
The Selection Classification Age Maturity Program utilizes five crite¬ ria to match athletes (Table 4). Accurate determination of physical maturity used to present a problem. Formerly, the most accepted method was to obtain a roentgenogram of the hand and wrist for assessment of bone age but this is too expensive for schools that deal with large numbers of youngsters. Now a quick and inex-
Every season, a football player who is not wearing a mouth protector has one chance in ten of receiving an injury to his teeth. If he plays ten seasons, which he may do, considering pre-high school, high school, and college, his risk of tooth injury approaches 100%.8 In 1960, all high school football teams were required for the first time by the National Federation of State
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High School Associations to wear face guards. Many believed that face guards would be adequate to afford mouth protection, but they were found to reduce mouth injuries by only 50%.9 The face guard provides protection primarily from direct blows to the mouth, nose, and other facial struc¬ tures. It does not
protect the mouth
from blows under the chin delivered by forearm blocking, knees, and kicks, nor does it protect the top of the head from blows that may cause the jaws to snap shut. Since 1962 the National Football Alliance (NFA), which includes most high school and junior colleges, has had a rule making it mandatory that their football players wear mouth protectors. It was not until 1973 that the National Collegiate Athletic Asso¬ ciation (NCAA) developed a similar rule. The professional leagues still do not have such a rule. In hockey, where the risks are the highest, only a few teams require mouth protectors. It is important for physicians to realize that such protection is not automati¬ cally provided, and he should join with parents and dentists in demanding that protectors are provided. It is also recommended that mouth protection be used in practice sessions. More injuries occur in practice than in games, perhaps because more time is spent in practice and more players are involved, including those less capable and less well coordinated. The less skilled and inexperienced individual is most likely to be injured. It is a fallacy to think that the blows delivered by younger players are of lesser magni¬ tude and, therefore, that fewer inju¬ ries result. In particular, this is not true of dental injuries. The mouth protector rule has all but eliminated the remaining 50% of mouth injuries. The actual figures from high school insurance programs show that mouth injuries account for between 0.035% and 0.045% of all sports injury claims. This result has been achieved even without quality
control. Considering previous injury figures, this probably means that at least 100,000 oral injuries per year are prevented for more than 1 million players in the NFA and NCAA.8
Table 4.—Selection Classification
Age Maturity Program Criteria*
as strenuous, moderately strenuous, nonstrenuous, and then subdivided into contact, limited contact, or noncontact: Football, ice hockey: strenuous, contact Basketball, soccer: strenuous, limited contact Tennis: strenuous, noncontact Volleyball: moderately strenuous, noncontact Riflery: nonstrenuous, noncontact_ Categorization according to level at which athlete should compete on basis of age: junior high, freshman, junior varsity, or varsity squads Test for agility, strength, speed, and endurance: raw scores for each test are converted into an achievement level based on norms for grades 7 to 12, then ranked on a scale from 1 (underdeveloped) to 10 (superior)t Agility: sidesteps measure agility: starting from a center line, participant sidesteps left and then right across two outside lines that are eight feet apart; fitness score is the total number of lines alternately crossed in ten seconds Strength: number of slt-ups in two minutes Speed: timed 90- or 120-yard dashes Endurance: number of squat thrusts in one minute_ Evaluation of the athlete by coaches for proficiency in the sport he or she wants to play Physical examination that also determines the athlete's level of maturity
1. The
sport the athlete wants to pursue Is categorized
or
2. 3.
4. 5.
"From Banks." tStandards available from New York State Public High School Athletic Association, Ine, Albany.
Developmental age
12Vj 13 Poetmenarche age
14
15
12
16
17
J
3
4
18
5
6
Fig 1 .—To determine girl's developmental age, physician fills in form with date of birth (in this case, Nov 6, 1960), year and month menstruation began (March 1971), and examination date (March 1,1975). Number of elapsed years and months between onset of menstruation and examination date (four years) is plotted on lower line, and arrow drawn from that point to top line. This gives girl's developmental age (top line), in this case I6V2 years. By comparison, her chronological age is 14 years and 4 months.5 is now imposed football team whose players do not have mouth protectors. However, enforcement of this recommendation of mandatory mouth protectors in fact rests with the coaches and school offi¬ cials. Physicians should be urged to refuse to provide medical coverage to any team whose players do not have mouth protectors. There is some evidence that mouth protectors can also help prevent concussions. Some schools have re¬ ported that when mouth protectors are in place the incidence of concus¬ sions is reduced to nearly zero! The results of a five-year study at the University of Kentucky1" and Notre Dame" support this premise. The report also shows a dramatic reduc¬ tion of neck injuries, which the inves¬ tigators attribute largely to the use of A
15-yard penalty
on a
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protectors. The Kentucky study reported that mouth protectors, by cushioning blows to the chin, reduced cranial deformation injuries by 50%. mouth
SEIZURE DISORDERS
For years there has been a wide¬ that epileptic children and young adults should be restricted from vigorous athletics. Livingston1states that there is danger even for those who have been seizure free for two or three years after termination of drug therapy. However, he observes that in his experience the incidence of withdrawal seizures in patients who participate in athletics is no different than in those who do not. He would consider restricting uncontrolled epi¬ leptics, regardless of the in frequency of their seizures, from participating in
spread belief
Fig 2.—To determine boy's stage of maturity, physician uses drawings of five stages of facial (top), axillary (center), and pubic (bottom) hair growth.5 activities such
horseback riding, and other sports that may be associated with a significant risk of injury. Vigorous physical activity does not adversely affect the epileptic disorder, so changes in drug dosages are not necessary, nor is there any evidence that vigorous physical activity alters the body's metabolism of the antiepi-
climbing
to
as
high altitudes,
leptic drugs. Livingston
also states that he encourages his young patients (aged 6 to 9 years) whose seizures are adequately controlled to participate in
sports appropriate for age. He ex¬ plains to the parents that even though
their child may have an occasional seizure, there is no valid reason for major restriction of normal childhood activities. There is a risk for injury in athletic activities for everyone, epilep¬ tic or nonepileptic, and because of the possibility of a seizure occurring
during physical activity, particularly a
sport, the risk may be greater for the child with epilepsy; however, parents should weigh this small risk of injury against the much greater risk of instilling in their child an attitude contact
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of
inferiority.13-15
In August 1974, the AMA commit¬ tee on the Medical Aspects of Sports revised its policy and revoked the
prohibition against participation of epileptic patients in body contact sports. It stated that there was ample evidence to show that patients will not be affected adversely by indulging in any sport, including football, provided the normal safeguards for sports participation are followed.1317 The difficult question is whether athletes whose epileptic disorders are unequivocally the result of previous
head trauma should be allowed to participate in contact sports. At pres¬ ent there are no data on the long-term follow-up of such athletes, but it would seem prudent to restrict them for competition in contact sports such as
boxing, football, hockey, or rugby.
LIFE-THREATENING INJURIES
Life-threatening no means
common;
situations
are
however, they
by can
In 1970, forty-three deaths were associated with football, and there are an average of 25 to 35 deaths yearly. Six situations can immediately threaten the life of an athlete: airway
occur.
obstruction, respiratory failure,
car¬
diac arrest, heat injury, craniocerebral injury, and cervical spine injury.18
Airway Obstruction This
can occur
in the unconscious
athlete, who may experience a tran¬ sient apneic episode. When one is in
supine position, relaxation of the oropharyngeal musculature can allow
the
the tongue to fall back and occlude the airway. In this situation immediate action must be taken to reestablish the airway. This is accomplished by simply supporting the neck with one hand and tilting the head back with the other. If this maneuver does not work, the next step is to grasp the mandible firmly and pull it forward, again with the head tilted backward. When a cervical spine injury is suspected, care must be taken not to forcibly manipulate the cervical spine. The initial evaluation of the uncon¬ scious player is to determine if he is breathing and has a pulse. Considera¬ tion then should be given to the possi¬ bility of an associated neck injury.
Respiratory An
Failure
example of this is simple syncopal apnea, which may occur in the physician's office when the athlete faces some diagnostic or therapeutic procedure like arthrocentesis. Follow¬ ing the apneic episode, such patients usually start breathing spontaneously. Players with craniocerebral injuries may have apneic episodes complicated by obstruction of the airway because of transient paralysis of the oropha¬ ryngeal musculature. Oral airways and reinflatable breathing bags
should be available in case respiration must be supported for a prolonged
period.
A basic rule for dealing with the unconscious player is that the helmet should not be removed prior to medical evaluation. Head injuries are often associated with injuries to the cervical spine, and this possibility must be considered until the patient regains consciousness or until roentgeno¬ grams prove otherwise. Forced ma¬ nipulation of the cervical spine to remove the helmet may cause irre¬ versible damage to the spinal cord. If a player has respiratory problems, his face mask should be removed and the helmet left in place.
Cardiac Arrest
Arrhythmias are the usual cause. Cardiopulmonary resuscitation should be begun in the absence of the pulse.1" Heat
Injuries
Heat exhaustion and heat stroke are two life-threatening situations. Signs of heat injury include muscle cramps, excessive fatigue or weak¬ ness, loss of coordination, a slowing of reaction time, headache, decreased nausea and vomiting, and dizziness. Heat exhaustion occurs when an individual is exposed to a high environmental temperature and sweats excessively without salt and fluid replacement. This is followed by collapse and circulatory failure. The patient will respond to intravenous fluids containing salt, cooling, and rest, but death may result if the condi¬ tion is not recognized and treated
comprehension,
immediately.
Heat stroke occurs when a unacclimatized individual is exposed to a high environmental temperature. The thermal regulatory mechanism fails, sweating stops, and body temperature rises. Brain damage may occur at temperatures above 41 C and death may follow. The diagnostic key is the presence of a high body temperature in the absence of sweating. The athlete with these signs should be undressed, packed in ice, and hospital¬ ized immediately. To prevent heat injuries, the athlete fresh from vacation in a cool climate
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should be allowed 14 to 21 days of acclimatization before exposure to a competitive situation at a location where the temperature is high. Initial practices should be arranged for cooler hours of the day. Clothing should be such as to allow moisture to evaporate. Above all, players should be given free access to water and salt (3 to 5 gm/day). Weight charts are a good way to monitor the daily weight loss, so that the exact fluid loss can be determined. It is not unusual for an athlete to lose 3.5 kg in eight hours. To prevent heat injury, several basic rules should be followed. First, unlimited fluids should be provided before, during, and after practices and games. Conditioning by dehydra¬ tion is contraindicated. Second, on hot days players should be given four to eight 650-mg salt tablets daily and allowed liberal use of table salt as well. Too much salt, however, can be dangerous. With an intake of more than 15 gm daily, there is a danger of ^
rhabdomyolysis.™
Intracranial
Injuries
These include concussion, skull frac¬
ture, subdural and epidural hema¬ toma, and intracerebral hemorrhage.
The symptoms of concussion range from slight mental confusion and possible memory loss, tinnitus, and dizziness to profound mental confu¬ sion and prolonged loss of conscious¬ ness. The high school player who has any degree of concussion should not be allowed to continue. Signs and symp¬ toms that demand emergency action in any athlete who has sustained a blow to the head are increasing head¬ ache, nausea and vomiting, inequality of the pupils, disorientation, and progressive impairment of conscious¬ ness.
Cervical
Spine Injuries
Fracture, dislocation, and fracture dislocation of the cervical spine are the most disastrous traumatic insults. When such an injury occurs or is suspected, it is imperative that the victim be protected from further injury to the neural elements. Neck trauma precaution should be taken
also for those who have severe, unre¬ mitting neck pain, with or without paralysis. The basic principle in mov¬ ing an unconscious player or one suspected of having a significant cervical spine injury is to roll him like a log so that once on the fracture board a log-like alignment of the head and neck with the axial skeleton is maintained.
both
physical and mental health. Those who are responsible for orga¬ nized sports, including the players,
SUMMARY
Sports involve many health hazards. possibility of physical injury is always present, and those who engage in sport? deliberately run a calculated The
coaches, trainers, and athletic depart¬ ment, are also responsible for mini¬ mizing the risks. We as pediatricians
risk in order to obtain a beneficial To justify the risks, the benefits must outweigh the dangers. Sports suitably engaged in certainly promote
must become part of this team to extend our goal—the well-being of children.
goal.
References 1. Hayes W: You Win With People. Columbus, Ohio, Typographic Printing Company, 1973, p 14. 2. Hein F: Safeguarding the health of the high school athlete, in Ryan A: Medical Care of the Athlete. New York, McGraw-Hill Book Co Inc, 1962, pp 16-17. 3. Ryan A: Medical Care of the Athlete. New York, McGraw-Hill Book Co Inc, 1962, pp 34-43. 4. Nathan DC, Oski FA: Hematology of Infancy and Childhood. Philadelphia, WB Saunders Co, 1974, p 98. 5. Hafner J: Problems in matching young athletes: Baby fat, peach fuzz, muscle and moustache. Sports Med 3:96-98, 1975. 6. Banks 0: The Occurrence of Dental Injuries Resulting From Varsity Football During the Football Season of 1959-60 Academic Year, thesis. Kansas State University, Manhattan, 1961. 7. Cathcat JF: Mouth protectors for contact sports. Dental Digest 57:346, 1951. 8. Heintz W: The case for mandatory mouth
Sports Med 3:61-63, 1975. 9. Report of a Study of Face Guards and Mouth Protectors. Marinette, Wisconsin Interscholastic Athletic Association, 1956. 10. Hickey JC, Morris AL, Carlson LD, et al: The relation of mouth protectors to cranial pressure and deformation. J Am Dent Assoc 74:735, 1967. 11. Stenger JM, Lawson EA, Wright JM, et al: Mouthguards: Protection against shock to head, neck and teeth. J Am Dent Assoc 69:273, 1964. 12. Livingston S: Should epileptics be athletes? Sports Med 3:67-72, 1975. 13. Livingston S: Living With Epileptic Seizures. Springfield, Ill, Charles C Thomas Publisher, 1963, p 87. 14. Livingston S: Comprehensive Management of Epilepsy in Infancy, Childhood, and Adolescence. Springfield, Ill, Charles C Thomas Publisher, 1972, p 147. 15. Aisenson MR: Accidental injuries in epileptic children. Pediatrics 2:85-88, 1948.
16. Convulsive disorders and
protectors.
Livingston S: Convulsive disorders and participation in sports and physical education.
JAMA 206:1291, 1968. 18. Torg JS, Quedenfeld TC, Newell W, et al: When the athlete's life is threatened. Sports Med 3:54-60, 1975. 19. Standards for cardiopulmonary resuscitation and emergency cardiac care, American Heart Association Committee on CPB and ECC. JAMA 227:837-868, 1974. 20. Brodine C: The adverse effects of salt loading: A potential problem of salt supplementation. Read before the Ramsay B. Thomas Symposium, Bethesda, Md, May 4, 1974. 21. Policy Statement: Cardiac Evaluation for Participation in Sports. Evanston, Ill, American Academy of Pediatrics, 1977.
Errors in Table.\p=m-\In the article titled "Gonorrhea: Diagnosis by Gram Stain in the Female
Table are inverted and should correctly read Smear Positive/Culture Positive and Smear Negative/Culture Negative. The number of female patients should be 121. The corrected Table is shown below.
No. of
Smear Positive/
and Culture Results
Sensitivity,*
Smear
Negative/
Specificity."
_Patients_Culture Positive_%_Culture Negative_%_ 121 Female
Male
"Percentage
tPercentage
29
22/34 23/23
65
in the
1968. 17.
Adolescent," published in the October Journal (131:1094-1096,1977), two headings in the
Interpretation
on
Medical Aspects of Sports and Committee on Exercise and Physical Fitness. JAMA 206:1291,
CORRECTION
Correlation of Smear
participation
sports and physical education, Committee
86/87
ÎÔÔ
of culture-positive specimens correctly identified by Gram stain. of culture negative specimens correctly identified by Gram stain.
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ß
99
..,
