Selected Issues in Injury and Illness Prevention and the Team Physician

DEFINITION Prevention of injury and illness associated with athletic activity is one of the roles of the team physician (10,15). This process involves understanding the pathophysiology of the injury or illness, evaluating the known risk factors that influence the incidence of injury or illness, implementing interventions to minimize the influence of the risk factors, and recording the outcomes of the interventions. GOAL The goal of this document is to help the team physician improve the care of the athlete by understanding and practicing methods of injury and illness prevention in specific sports medicine problems. To accomplish this goal, the team physician should have knowledge of general strategies of injury and illness prevention and implement these strategies for the following: Musculoskeletal injuries to the ankle, knee, elbow, and shoulder Concussion and cervical spine injuries Cardiovascular issues Heat-related illness Skin infection Equipment issues SUMMARY This document provides an overview of selected medical issues that are important to team physicians who are responsible for the care and treatment of athletes. It is not intended as a standard of care and should not be interpreted as such. This document is only a guide and, as such, is of a general nature, consistent with the reasonable, objective practice of the health-care profession. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization. This statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues. They have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are the American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. EXPERT PANEL Executive Committee Stanley A. Herring, M.D., Chair, Seattle, WA W. Ben Kibler, M.D., Lexington, KY Margot Putukian, M.D., Princeton, NJ Committee: Joel Brenner, M.D., MPH, Norfolk, VA Katherine Dec, M.D., Richmond, VA R. Robert Franks, D.O., Marlton, NJ Timothy Hosea, M.D., Somerset, NJ Peter Indelicato, M.D., Gainesville, FL Anthony Johnson, M.D., San Antonio, TX Patrick Leary, D.O., Erie, PA Jason Matuszak, M.D., Buffalo, NY Bradley Nelson, M.D., Minneapolis, MN CONSULTANTS Andrew Gregory, M.D., Nashville, TN Zachary Kerr, Ph.D., MPH, Indianapolis, IN John Parsons, Ph.D., ATC, Indianapolis, IN GENERAL CONCEPTS IN RISK FACTORS AND PREVENTION STRATEGIES The incidence of injury in sports medicine may be influenced by the presence of risk factors. Intrinsic factors may be physiological, biomechanical, anatomical, or genetic and may include previous injury, muscle weakness, inflexibility, imbalance, or kinetic chain breakage (injuries or other alterations in distant parts of the body, which affect function in the local joint). They may also include psychological factors, which have been addressed in the Team Physician Consensus Conference series (13). Extrinsic risk factors may be related to the inherent demands of the sport, such as the intensity and duration of play, or factors, such as environmental, conditioning, or equipment issues. They may influence the process of chronic injury or illness development, or they may influence the occurrence of an acute injury or illness. Specific programs that affect the intrinsic and extrinsic risk factors to alter or prevent illness and injury are limited. Of the programs that do exist, implementation is often a challenge. However, current studies have shown that a strategy of risk factor identification and process implementation to modify risk factors before athletic competition may reduce the incidence of some injuries or illnesses. These studies show that the prevention strategies should be as specific as possible to the injury or illness, athletic activity, or sport and need to be continued as long as the athlete is competing. A general format of prevention and risk factor modification strategies includes the following: Understanding the pathophysiology of the injury or illness. Understanding and implementing procedures for identifying risk factors. Implementing interventional processes to modify the risk factors to improve outcome. Assessing medical history, family history, and exertional symptoms is relevant in developing prevention strategies in medical conditions It is essential the team physician Understand basic concepts of injury and illness prevention. It is desirable the team physician Set up policies and procedures to identify risk factors, implement intervention strategies, and quantify outcomes. Work with the athletic care network (see [15]) to educate athletes, parents, and coaches on the principles and practices of injury and illness prevention. EPIDEMIOLOGY Injuries The type of injury and its related risk factors present various opportunities and methods of prevention. The National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) defines a reportable injury as one that occurs as a result of participation in an organized intercollegiate practice or competition and requires medical attention by a team athletic trainer or physician regardless of time loss (23). At the high school level, the National Athletic Trainer Injury and Outcomes Network provides injury data that uses the same definition of injury as the NCAA (21). Additional high school data are available from High School Reporting Information Online, which defines injury as that which results in restriction of the athletes’ participation for one or more days (24) although concussions, dental injuries, fractures, and heat-related events are included regardless of time loss. A source of consistent and systematic data of injuries sustained in collegiate sports from September 2008 to 2013/2014 is from ISP (23). High school data are available from June 2005 through 2013/2014 (24). From these data, the following issues have been identified: Across most sports, reported injury rates continue to be significantly higher in competition than in practice. Non–time loss injuries account for more than half of all injuries. Lower-extremity injuries account for 49% and 46% of all practice and game injuries at the collegiate level and 51% and 48% at the high school level (21) ○ Ankle sprains account for 21% of lower-extremity injuries at the collegiate level and 16% at the high school level (21) ○ Anterior cruciate ligament (ACL) injuries are relatively infrequent (3% of all reported injuries) but are associated with significant loss of time from play. ▪ At both high school and collegiate level, women’s soccer, women’s basketball, and men’s football had the highest rates of ACL injury, with football reporting the greatest absolute number (24). ▪ Patellofemoral pain and tendinopathy are frequent injuries, particularly in women. Upper-extremity injuries account for approximately 19% and 24% of all practice and game injuries at the collegiate level and 26% and 27% of all practice and game injuries at the high school level (21) ○ Shoulder injuries account for 27% of upper-extremity injuries at the collegiate level and 24% at the high school level (21). Head and neck injuries account for approximately 8% and 12% of all practice and game injuries at the collegiate level and 8% and 14% of all practice and game injuries at the high school level (21) ○ Concussions account for 6% of all injuries at the collegiate level and 4% of all injuries at the high school level (21). Overall, rates have increased during the sample period. ○ At the collegiate level, men’s wrestling, men’s ice hockey, men’s football, women’s soccer, and women’s basketball had the highest rates of concussion. At the high school level, boys’ football and ice hockey and girls’ soccer and lacrosse had the highest rates of concussion (24). ○ Both the number and the rate of concussions have increased over the last 3 years. This may be due to improved diagnostic strategies and increased disclosure by student athletes. ○ Caution must be taken when interpreting differences between the collegiate and high school data as study periods and distributions of reporting sports programs vary. Most head, neck, and spine injuries do not have catastrophic consequences. ○ Reported concussion rates are increasing at all levels of participation. ○ Twelve thousand spinal cord injuries occur each year in the United States; 10% are related to athletic events. According to the National Center for Catastrophic Sports Injury Research, football, gymnastics, ice hockey, wrestling, and cheerleading have the highest risk of catastrophic injury. ○ Forty-one total catastrophic injuries occurred in high school and collegiate sports in 2012/2013 (29 high school; 12 college) representing 0.53/100,000 participants. ○ Over a period of 31 years (Fall 1982–Spring 2013), 2101 catastrophic sports-related injury and illnesses were recorded; 80.8% occurred at the high school level and were directly attributed to activities of the sport (22). Medical Conditions Sudden cardiac death (SCD) is a rare occurrence. Responsible for 16% of death among college athletes (8). Other causes of death included accidents (51%), suicide (9%), cancer (7%), homicide (6%), sickle cell (2%), and heat stroke (1%). Incidence of SCD in exercising high school and collegiate athletes is 2.3 to 4.4/100,000 per year in the United States. ○ The highest rate of SCD occurs in Division 1 men’s basketball (8,9). ○ Men and African American and Caribbean athletes are most at risk. Causes in young athletes include the following: ○ Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden death in high school and college athletes and occurs more frequently in men and all African American athletes. ○ Commotio cordis is the second most common cause of sudden death in the youth athlete. ▪ Most commonly occurs in baseball, lacrosse, ice hockey, softball, and other sports, as well as recreational activities involving or to the ▪ Most commonly reported in between and years. ▪ occur in 24% occur in recreational Other causes of SCD include the following: ○ to of ○ (3% of ○ ○ illness is and most commonly during practices with the highest in of heat illness are more common but may be more of heat-related illness are of the causes of death in the high school and college athlete. and to be risk factors. Skin Skin account for 21% of conditions and injuries in collegiate sports and in high school collegiate account for to of all injuries. ○ college wrestling, the most common are and (23). PREVENTION Ankle risk injury of injury to all sprains are well to cause injury to the and and other injuries may occur and the following: ○ or at the in the young athlete ○ ○ injury ○ Anterior ligament injury ○ injury High rate of injury factors include the following: ○ injury ▪ ▪ ○ muscle in or ○ ○ Injury and in and sports should have an the following: ○ of previous injury ○ Ankle ligament ○ ○ Ankle muscle and ○ and muscle ○ Injury and an and with the following: ○ muscle with ○ of ○ and muscle Ankle is for both and prevention ○ Ankle is to and more than for prevention ○ Ankle is for prevention but may be for prevention. is for both and prevention of and in with or It is essential the team physician the following: of sprains other than and may be The of or as well as in and prevention. The of to the risk of It is desirable the team physician previous injury and of the implementation of a for all athletes in and sports ○ increased as a risk Work with the athletic care network to educate parents, and coaches on the principles and practices of injury prevention. ACL risk ACL injuries may occur in or injuries. and intervention strategies are more for injuries. high school sports, football the highest rate of ACL injury. collegiate sports, women’s soccer the highest rate of ACL injury. sports with the same have a higher incidence of ACL injury than Causes of ACL injuries are factors include the following: ○ and and muscle ○ ○ ○ ○ ○ Family ○ ACL injuries occur commonly during or during these include the following: ○ and ○ ○ ○ ○ Injury and in and sports should have an the following: ○ of previous or family ACL injury ○ ○ and and Other may include the following: ○ of and type ○ of and Injury and a with these that have been shown to have in specific ○ and and ○ to include and athletic programs ○ is for and prevention of ACL injury. care of and of type It is essential the team physician the following: The of ACL injury and interventions risk of ACL injury. are more at risk than in soccer and high school sports, football the highest risk of ACL injury. It is desirable the team physician previous ACL injury and of for and the implementation of a the following: ○ and and ○ to include and athletic programs ○ increased as a risk the of the on the of type Work with the athletic care network to educate athletes, parents, and coaches on the principles and practices of ACL injury prevention. Other Injuries Patellofemoral Patellofemoral pain and are factors, and issues (13). intervention programs for and prevention have been shown to be Patellofemoral pain may occur in to be an and may have to symptoms of in the that may be include the following: ○ ○ and ○ ○ Other that may cause ○ ○ ○ factors include the following: ○ and inflexibility, and ○ previous injury ○ ○ ○ with and ○ Patellofemoral ○ The of of the knee, ankle, and to pain is Injury and should have an the following: ○ of previous injury and ○ and of and participation ○ and ○ and ○ and ○ and Other may include the following: ○ of and type ○ of and Injury and and with and and and Other interventions include of and a prevention It is essential the team physician Understand the of risk factors and possible of pain in athletes with an that includes of and It is desirable the team physician of pain and of for and lower-extremity and the implementation of a and for the and type for for and Work with the athletic care network to educate athletes, parents, and coaches on the principles and practices of prevention. IN AND intervention programs for the and prevention of specific shoulder injuries have been shown to be The risk factors is a that associated with injury, function in and other athletes. These include the following: ○ injuries ▪ to and ▪ Other injuries ▪ ▪ injuries ○ ▪ or ▪ shoulder loss of or loss of total of ▪ ▪ muscle or injury ▪ chain in or ○ of ▪ in the ▪ of or ▪ in kinetic chain of ○ and intensity of activity and ○ of between ○ injury in the shoulder or other parts of the kinetic chain ○ Shoulder muscle imbalance, most commonly muscle weakness, or ○ of the loss of ○ youth baseball, increased number of per per per ○ youth baseball, Injury and of previous injury in the shoulder and relevant parts of the kinetic and intensity of of the and kinetic chain the of the or the kinetic Injury and athletes, and of the of the cause of injury and in the and kinetic youth baseball, per game and per and of number of for and of or It is essential the team physician the The of as a risk factor in shoulder injury and and in injury and modification The of shoulder and as most risk factors for and other athletes specific It is desirable the team physician previous shoulder injury and of and factors may and to shoulder and kinetic chain or and with coaches to the a for and Work with the athletic care network to educate athletes, parents, and coaches on the principles and best practices of shoulder injury and injuries are more in athletes. A of specific is the increasing of injuries, in ligament and intervention programs for the and prevention of injuries have been shown to be or of the of the may be an acute injury or an acute of a chronic injury Other important causes of ○ and ○ of the factors include the following: ○ and intensity of activity ▪ or ▪ or ▪ ▪ of ○ or ○ or and ○ Shoulder and ○ chain muscle and or muscle ○ ○ Injury and of and to risk factors of elbow, and kinetic chain injury and of the elbow, the shoulder and kinetic chain the of the or the kinetic Injury and athletes, and of the of the cause of injury and the of and in the and kinetic a with of activity and youth baseball, per game and per as well as of number of youth baseball, for and of or It is essential the team physician the following: as a risk factor in injury and and in injury and Other common injuries associated with in the young athlete. shoulder and as common risk factors for injury. of or and other athletes specific It is desirable the team physician previous injury and of shoulder and kinetic chain or and with coaches to the a for and Work with the athletic care network to educate athletes, parents, and coaches on the principles and best practices of injury and PREVENTION Cardiovascular Hypertrophic cardiomyopathy in chain cardiac or of by ○ or on Sudden death most often to is or by and cardiac than factors for sudden Family of one or more sudden cardiac or more of than on or to Other possible risk ○ ○ ○ cardiomyopathy risk of sudden cardiac death with cardiomyopathy in sports due to cardiac with to of and to or factors for sudden cardiac with to Most common in SCD are in the of and in the of is factors for sudden of due to genetic of the to factors for sudden in or include the following: ○ causes such as long and ○ causes such as or and other factors for sudden Sudden in sudden in Family of sudden death or and modification of and Family of sudden and in of or with exertional and exertional of of and of prevention interventions of and include history, family history, and Additional for in athletes. A number of organizations are Specific have been ○ causes of SCD be by long and ○ athletes the of the of and significant cardiac and or of activity in with for all practices and competition It is essential the team physician the following: The major causes of and risk factors for The of in for cardiac The of an for all practices and competition symptoms are particularly SCD may be the It is desirable the team physician and the an that includes the of an Work with the athletic care network to educate athletes, parents, and coaches the common causes of sudden cardiac Commotio over the cardiac during a period of the cardiac in an in with 3 the of the to of of events occur in organized sports athletes are factors for sudden than sport sport and known and in place coaches and athletes that athletes should a to the in of the coaches and health-care to cordis have not been shown to prevent It is essential the team physician the following: The clinical of The of an The of for sports at risk for do not prevent It is desirable the team physician an that includes the of an athletes, parents, and coaches about AND Concussion the and the Team A Consensus its some studies have shown that in to are on The greatest in concussion prevention. are some injury and modification strategies for and Injury and of and of of modification and in to improve neck and for Concussion policies and with symptoms of concussion should not continue participation. are to prevent and major they have not been to prevent concussion. Head and have also not been to prevent concussion. athletes, parents, and coaches on the of reporting symptoms of concussion. It is essential the team physician the following: The and principles of concussion. should be to the risk of ○ young athletes more than is equipment to prevent concussion. Concussion policies and It is desirable the team physician the implementation of concussion and programs for medical athletes, parents, and with on the of reporting concussion. Work with coaches and to implement a concussion and modification and and for and play, practice and and to athletes and Injury intervention programs for the and prevention of cervical spine injuries have been shown to be risk of the is the that most often causes or spinal cord injury in is a injury associated with in all present only with factors include the following: ○ of ○ and spinal cord ○ are or injuries of the cervical or that and in the ○ They the or the of the ○ of a is a risk factor and spinal on level and number of levels may alter participation in sports Injury and should have an the following: ○ of injury or ○ and ○ of Injury and to prevent injury in of in football, from in ice hockey, in of the athlete ○ the ○ of athletes. ○ of and in the local may risk of The of shoulder modification and neck in football in cervical is of parents, and athletes the of and It is essential the team physician the following: and risk factors for injury The of an and It is desirable the team physician local in at one practice of Work with the athletic care network to educate athletes, parents, and coaches on prevention principles and practices for sports injury is illness occurs on a with the most heat which may be ○ occur but most to occur in ○ from an to during is than at to heat include as well as and is more in ○ Extrinsic ▪ ▪ and ▪ and to ▪ Equipment ▪ and ▪ and attention ▪ and such as ▪ ○ Intrinsic ▪ of heat illness ▪ ▪ ▪ Medical conditions illness and ▪ of ▪ ▪ cell ▪ athlete data young athletes do not have a higher risk for heat illness when is Injury and should have a the following: ○ of risk factors ○ of ○ of present and of and participation ○ of of ○ for sickle cell and of athletes to include to and equipment heat Injury Prevention practice time of and and strategies for practice and competition between or or of sports activities on with for in the and equipment equipment on days with It is essential the team physician the of heat illness and a to and Understand the need for with Understand the of the of heat illness. It is desirable the team physician an to acute heat illness athletes at the time of for risk factors for heat illness. and in practices and events of increased for heat illness. for Work with coaches in during activity athletes, parents, and coaches the of heat illness. AND AND Equipment and have been shown to reduce modify injury. are to prevent and major they have not been to prevent concussion. Head and have also not been to prevent concussion. the risk of dental and injury. from injuries and in women’s lacrosse is associated with incidence of injuries. have not been shown to prevent on data, are for prevention of have been shown to reduce injuries in and sports not been shown to prevent ACL injury. is in ligament injury. the incidence of in or is for and prevention of the incidence of in and Skin of among is of The of is of It is reported in wrestling, and the incidence of is prevention is are by or of infection from one of to and of infection Sports with of and equipment and should have an before participation the following: of previous and treatment for and ○ of type and of current and treatment practices should be both in the athlete and in and is in all sports, sports wrestling, football, and To athletes with and from (23). with and as as of and athletes to of last before with and or and is as a treatment or prevention of of ○ of only they are to prevent should be for with frequent of equipment and other with which athletes have student athletes to and of and health-care common It is essential the team physician Understand principles and risk factors for common common that may be or desirable the team physician Understand for common and and of and treatment for each practice for practice and and the Understand the and of for athletes with Understand the of to prevent of infection is Work with the athletic care network or to educate athletes, parents, and other health-care on and and in athletes.