Sports Medicine

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[edit] Sports Medicine

Lisa Rowland Callahan

Michael F. Dillingham

Alex C. Lau

James L. McGuire✢

Deceased. An increasing awareness of the health benefits of fitness and of sports competition has also increased the demand for state-of-the-art sports medicine.An injured athlete desires a timely return to normal function.The primary care physician can provide not only treatment and rehabilitation, but also fitness evaluation, exercise programs, and injury prevention counseling.The office physician needs to evaluate and initially treat injuries, understand the sequelae of chronic injuries, and delineate the risks of overtraining.The physician should combine the best of current aggressive and conservative approaches to treatment of the athlete, with appropriate timing of subspecialty referral.

Physicians should be prepared to guide patients in three areas.First, a regular exercise program should be encouraged for its physiologic and psychologic benefits, such as better work performance and decreased stress levels.Second, nutritional advice is important, especially for weight maintenance or reduction through exercise.This is particularly true for young women who have not yet attained maximal bone mass.Third, cardiac and arthritic risk monitoring is also an important element of total care.

[edit] GUIDELINES FOR FITNESS TRAINING

[edit] Exercise

As with a medication, exercise should be prescribed properly to attain maximum benefit.During the history and physical examination the physician should consider the patient's current level of fitness, history of medical illnesses, medications, family history, and past injuries.Laboratory testing may be necessary, including lipid screening for cholesterol levels and electrocardiogram (ECG).Formal exercise testing is generally recommended for those with known or suspected cardiovascular or pulmonary disease and should at least be considered in any sedentary patient over age 35 before initiating an exercise program.On completion of the appropriate tests, exercise recommendations consider frequency, intensity, and duration of exercise; type of activity; and need for resistance training to achieve minimum fitness levels (Box 143-1).

Each exercise session should consist of three phases: warm-up, aerobic activity, and a cool-down period.The warm-up and cool-down may simply be the same aerobic activity performed with less intensity.The warm-up usually includes stretching and activation of the aerobic mechanism, and the cool-down attempts to minimize both postexercise myalgia and the risk of cardiac events.

The goals and methods for attaining fitness in children differ significantly from those for adults.Children have arelatively inefficient metabolism, less anaerobic capacity, and less heat tolerance.They are generally motivated by having fun rather than by increasing fitness.These factors should guide the physician's recommendations for achieving fitness in children.The type of exercise recommended should be determined by the child's interests and strengths.It is clear that the more active the child, the better the gain in bone density as young adulthood is reached.Weight training in children is controversial.Children probably can achieve increases in strength through resistance training.Much work still needs to be done for clear guidelines.Adolescents may generally use the same fitness training guidelines as adults.If an adolescent's goal is to achieve excellence in a particular sport, exercise prescription should focus particularly on developing skills relative to the chosen sport (e.g., drills to develop hand-eye coordination) in addition to achieving aerobic fitness and muscular strength and endurance.This idea of sport-specific conditioning is also applicable to adults.

The opportunity to prescribe appropriate exercise for the school-age athlete may come as a preparticipation physical examination.Growing numbers of children participate in organized athletics; physicians are often asked to screen these students for conditions that might limit participation or predispose to injury.This type of examination should consist of a directed history as well as medical and orthopedic evaluations.

[edit] Nutrition and Fluid Intake

Good nutrition is essential for good health as well as for athletic success.Since athletes frequently do not practice proper eating habits, the physician should review and explain sound nutrition principles.Generally, a healthy diet should consist of 60% to 70% carbohydrate, 20% to 30% fat, and approximately 10% to 15% protein.Some athletes are too restrictive with their diets, consuming minimal amounts of fats and calories.Athletes should be screened carefully for possible eating disorders, counseled in proper nutrition, and if necessary, referred for appropriate psychologic care.In contrast, young athletes, especially those engaged in vigorous activity, require high-caloric intakes to build and maintain appropriate muscle mass.For example, high-school football players training twice daily have caloric needs of 5000 to 6000 kcal per day.

Adequate fluid intake is an essential and frequently neglected aspect of sports nutrition.Exercise greatly increases heat production.The body's thermoregulatory system dissipates this excess heat primarily by evaporation of sweat.If the fluids and electrolytes lost through sweat are not replaced, the athlete will become dehydrated.This can lead to both cardiovascular and thermoregulatory compromise, which directly affects the athlete's health and performance.To prevent this, athletes should constantly drink fluids before, during, and after competition.Adequate intake can be estimated by having the athlete monitor weight and urine color.A pound of weight lost is equivalent to 2 cups of sweat and should be replaced accordingly.If the urine volume is low and the color becomes dark yellow, dehydration probably exists, and increased fluid intake either by mouth or intravenously is immediately warranted.

Questions concerning fluid replacement with water vs.sports drink often arise.In general, water is sufficient for the recreational athlete and exercise sessions lasting 90 minutes or less.For longer exercise sessions and endurance events, a sports drink or diluted fruit juice is recommended, since it provides both glucose (carbohydrate source) and electrolytes.Cold concentrations of 2% to 6% carbohydrate are absorbed most quickly.The physician should encourage the athlete not to rely on thirst as an indicator of fluid loss because enough body water lost can adversely affect performance before the athlete becomes thirsty.

[edit] Androgenic Steroids and Other Ergogenic Aids

Maximal athletic performance depends on a complex combination of physical and psychologic factors.Competitors have tried a variety of methods to enhance performance, including psychologic techniques, vitamins, food supplements, androgens, and illicit drugs.Currently, athletes are experimenting with anabolic steroids.Because these substances are banned by all official sporting organizations, the true prevalence of their use is difficult to quantify.Despite highly publicized suspensions and loss of Olympic medals, the use of anabolic steroids in certain sports continues to increase.Also, androgen use has extended beyond the well-publicized professional and world-class amateur athlete to the high-school and community health clubs.Physicians need to be aware of the extensive risks of androgen use so that they can convey these risks, especially because athletes believe that androgens provide a competitive advantage in some sports.

Although anabolic steroids improve muscle strength through increased lean muscle mass and exercise tolerance, many hormone-related side effects result from their use.Anabolic steroids, related to the naturally produced testosterone, are available in both injectable and oral forms.Androgenic effects in males include testicular atrophy, abnormal sperm counts, cystic acne, gynecomastia, decreased sex drive, liver adenomas, and aggressive behavior.In females, masculine secondary sexual characteristics develop and are thought to be largely irreversible.These include growth of facial hair, deepening of the voice, male pattern baldness, and enlargement of the clitoris.In prepubertal athletes, anabolic steroids may cause premature epiphyseal closure, leading to growth arrest.Chronic androgen use typically results in lower high-density lipoprotein (HDL) cholesterol levels, whereas exercise usually increases this beneficial cholesterol.These serious side effects, as well as psychologic and cardiac risks, underline the danger of steroid use in athletes.

The terms steroids, androgens, and anabolic steroids are used interchangeably by athletes, coaches, and some sports physicians, whereas for primary care physicians, the word steroids usually refers to glucocorticoids.

Creatine has become a popular supplementation used by athletes to enhance their strength and aerobic exercise capacity.The oral supplement increases total muscle creatine.Short-term supplementation appears to increase body mass, although this may be caused by a concomitant increase in water.Combined with exercise, creatine may enhance muscular and work performance.Initial reports with short-term use have not shown any major health risks, but with long-term use the risks are unknown.Creatine can be purchased over the counter and is currently legal for use by athletes.

Other substances used by athletes to enhance performance include human growth hormone (HGH) and erythropoietin (EPO), two naturally occurring hormones.Some users of HGH report an increase in muscular size and strength, but others do not.Endurance athletes use EPO to increase hemoglobin concentration and thus the amount of oxygen delivered to working muscles.As the concentration of red blood cells rises (enhanced also by dehydration), so does the risk of clot formation and stroke.Death after “blood doping,” as use of EPO is also known, has been reported.Androgens can be readily detected in urine, but illicit HGH and EPO injections may be difficult to detect in serum.

[edit] Specificity of Training

Proper conditioning demands specificity in training.The exercise done for the sporting contest should mimic the event itself in aspects of required endurance, motion, velocity, movement, and load.Weight training and other types of resistance training encourage development of metabolic systems that are specific to the overload and muscle size.Specificity of motion encourages neural coordination among muscle groups and within the muscles.Untrained persons cannot fully activate muscles, particularly their high-threshold muscle motor units.Specificity of training allows complete and coordinated activation of muscle with a specific task in mind.Given two muscles of equal size, the better coordinated muscle will be stronger.Thus muscular strength gains in any particular activity are achieved not only through hypertrophy of muscle, but also through better coordination of muscle activity.

[edit] Overtraining

Overtraining is a syndrome that affects athletes of all ages and abilities, resulting when an athlete's training program exceeds the body's ability to recover.Muscle growth occurs primarily as a response to muscle breakdown during bouts of exercise.Adequate rest and recovery are necessary, or muscular gains are not made.Exercise programs that emphasize endurance with high-frequency, low-resistance activity can be done every other day.Programs that focus on strength and building of muscle mass with low-repetition, high-load resistance training are generally done only every fourth day.This is true even for highly conditioned Olympic athletes.Overtraining, both in weight training and aerobic conditioning, is a common error made primarily by recreational athletes.

Overtraining manifests both psychologically and physiologically.Probably the most universal complaint is fatigue, which athletes often refer to as “staleness” or “burnout.” Apathy, sleep disturbances, loss of appetite, irritability, heavy legs, sore muscles, and decreased ability to concentrate are other common complaints.Physiologic changes include increased heart rate and blood pressure.The physician should distinguish this syndrome from other causes of medical conditions that accompany fatigue, such as depression, anemia, asthma, mononucleosis, or other viral illnesses.A complete history and physical examination should be performed.Screening complete blood counts and serum chemistries should be obtained.The physician should evaluate the training regimen and consult with the coach or athletic trainer if necessary.Rest is the best treatment for overtraining.Continued activity will prevent desired gains and may even cause more harm.

[edit] ATHLETIC INJURIES

[edit] Head Injuries

Most athletic injuries involve the musculoskeletal system.However, contact sports and many so-called noncontact sports (e.g., basketball, baseball, soccer) may cause head and thoracoabdominal injuries.The physician should examine the severely injured athlete for airway and hemodynamic stability and perform any necessary stabilization and resuscitation.With a head injury, associated neck injury must always be considered, especially with a concussion.

Although different methods exist for assessing and grading concussions, the most important indicator of severity is the athlete's level of consciousness.When a head injury has occurred, five historic points are pivotal to the evaluation: (1) loss of consciousness, (2) retrograde amnesia, (3) persistent headache, (4) nausea, and (5) blurring of vision.In general the athlete can return to competition if loss of consciousness lasted less than several minutes and the athlete can remember all events or plays before the injury.A headache after the head injury should not persist.The physical examination, especially the neuromuscular evaluation, should be normal.The athlete must be asymptomatic before returning to the game.If any of these symptoms is unresolved, magnetic resonance imaging (MRI) or computed tomography (CT) may be indicated.Postconcussion headaches, especially when exercising, may occur for several weeks after the injury.During an athletic contest the primary care physician may allow the patient to reenter the game if there is no retrograde amnesia and no headache with a normal neurologic examination.When any clinical doubt remains, the physician should not allow the athlete to resume play after a concussion (Fig.143-1).

Figure 143-1 Assessment of head injury without neck complaints.

[edit] Musculoskeletal Injuries

Evaluation of musculoskeletal injuries should include examination of bone and joint stability, deformity, and function.The most accurate examination is obtained if conducted as soon as possible after the injury.With time, muscle spasm, joint effusion, and discomfort increase, making ligamentous laxity more difficult to evaluate and dislocations more difficult to reduce.Therefore a primary care physician on the sidelines with knowledge of sports medicine can facilitate the athlete's return to play by providing an expedient and accurate assessment.

Ligamentous injury is usually called a sprain. Sprains are generally classified as mild, moderate, or severe, depending on the degree of disruption of the ligament's fibers: thegreater the disruption, the more severe and potentially unstable the injury.A simple grading system from I to III is used to signify the degree of instability (Fig.143-2).An injury to a musculotendinous unit is termed a strain. Strains are generally classified as acute or chronic, again with a grading system from I to III to describe the severity of the injury (Table 143-1).

Figure 143-2 Ligamentous sprains vary in severity. A, First degree. B, Second degree. C, Third-degree sprain, which indicates complete rupture.

Table 143-1 Classification of Musculoskeletal Injury

Athletic injuries may be acute (traumatic, e.g., anterior cruciate ligament tear in a football player), chronic, or related to overuse (e.g., stress fracture in a runner).A careful history delineates the type of injury.Medical illnesses, such as rheumatologic disease, may masquerade as an athletic injury.At the first manifestation of an acute or subacute rheumatic disease, patients often attribute their joint symptoms to a recent injury.At times there may be a cause-and-effect relationship.For example, the first manifestation of rheumatoid arthritis may follow a knee or ankle injury.Premature osteoarthritis is a well-established sequela of internal derangement of the knee.Other patients attribute the early phases of a pseudogout or gout attack to a strained knee or ankle, respectively.An adolescent may attribute a swollen knee to an athletic injury.A radiograph may demonstrate a more severe bony abnormality, such as infection or tumor.Thus the physician must consider all medical possibilities when diagnosing an athletic injury (Table 143-2).

Table 143-2 Common Athletic Injuries

Before examining the athlete with an acute musculoskeletal injury, the examiner asks about the mechanism of injury and if a pop or snap was heard or felt, if pain or swelling wasimmediate or delayed, if the athlete was able to continue activity, and if the patient has a history of injury.Ability to bear weight on an an injured leg and injury to the dominant arm are other considerations.

Radiographs can be useful when evaluating musculoskeletal injury.At least two views, anteroposterior (AP) and lateral, should always be obtained, since injuries are not always apparent on a single view.In some cases comparison views of the contralateral extremity are helpful, especially for children who may have injured their epiphyses and for subtle dislocations of carpal bones.Additional radiographs of a specific area sometimes require special views for the sports medicine specialist at referral (Box 143-2).Other radiographic techniques, including MRI, CT, and bone scan, are helpful in certain settings.

[edit] Overuse Injuries

Overuse syndromes result from repetitive microtrauma to bones, ligaments, and musculotendinous units.Intrinsic factors include structural (e.g., leg length discrepancy) or biomechanical (e.g., poor flexibility, muscular weakness, especially eccentric weakness) abnormalities.Extrinsic factors relate to equipment (e.g., worn-out running shoes) and training errors (e.g., increasing mileage too rapidly).Training schedules and techniques often provide the reason for injury.Specifically, the type, intensity, and duration of training workouts should be evaluated for the common “too much too soon” phenomenon, especially in unconditioned high-school and college athletes and recreational runners.Consideration of these factors usually reveals the etiology of the overuse injury.The physician can then treat the injury and counsel the athlete to prevent recurrence.

Bone constantly remodels and repairs itself, but if the degree of repetitive microtrauma exceeds this capability, an overuse injury occurs as a stress fracture.Stress fractures occur most often in the weight-bearing bones of the lower extremity (e.g., tibia, metatarsals) but have also been seen in the upper extremity of the throwing athlete.The athlete presents with pain in the area of the fracture and often gives a history compatible with overuse.The physician should ask specifically about training errors, such as changes in the length, intensity, or duration of exercise.The patient may have swelling and point tenderness in the area of the fracture.Radiographs may be negative initially, but the fracture maybe apparent on repeat radiographs in 2 weeks, when healing has begun.Although not usually part of the initial evaluation, a bone scan and special MRI (STIR sequences) may be positive before the radiograph.Treatment of the uncomplicated stress fracture consists of rest for a few weeks and therapy with nonsteroidal antiinflammatory drugs (NSAIDs) and ice.Athletes frequently have difficulty complying with rest; noncompliance may delay their return to the sport.As healing occurs, substituting another activity may help increase rest compliance (e.g., swimming instead of runningfor an athlete with a metatarsal stress fracture).After resolution of the stress fracture, a careful program is started to prevent overtraining and repetition of the injury.

Young athletes may develop the overuse syndrome known as traction apophysitis, which results from repeated stress at the insertion of a tendon into a growth plate center.It is most often seen at the insertion of the patellar tendon on the tibial tubercle, a condition known as Osgood-Schlatter disease. The young athlete presents with pain and swelling over the tubercle, which is usually enlarged and tender.Apophysitis frequently appears during rapid growth in association with tight hamstrings and quadriceps muscles.As in stress fractures, treatment is rest and NSAIDs.Prevention involves screening the athlete for contributing factors, such as tight muscles, and instruction in a stretching program, especially for the warm-up session.

Repetitive trauma at the site of tendon attachment to bone causes a common overuse syndrome of tendinitis. This probably results from the relatively poor blood supply of the tendon combined with tension overload.The patellar tendon, wrist flexors and extensors, and rotator cuff tendons are often affected.Ligaments may be the tissue affected by overuse, such as in breaststroker's knee, an overuse strain of the medial collateral ligament.Similarly, pitchers, golfers, andjavelin throwers experience overuse strains on the medial aspect of their elbow.A complete history should uncover contributing factors.Treatment is similar to that for other types of overuse syndromes, with a similar emphasis on prevention.Overuse injuries can occur in all sports (Box 143-3).

[edit] Running Injuries

Most injuries in runners are overuse rather than acute and can be attributed to training errors.Generally, injuries are seen in those who run more than 30 miles per week or increase their mileage by more than 10% per week.The type and grade of the running surface as well as fatigue and lack of strength may contribute to injuries.Other predisposing factors include muscle tightness and accelerated training schedules.

Tendinitis of the quadriceps, patellar, or Achilles tendon is a common running injury.With a strain of the hamstring muscle group, the runner complains of localized pain, which usually increases during the run.Pain is reproduced with palpation or contraction of the involved musculotendinous unit.Posterior leg or thigh pain may be radicular.Treatment is symptomatic, emphasizing rest.The patient should understand that acute tendinitis and strains respond most favorably to rest.If allowed to become chronic, these injuries often take months to resolve.

If the runner has anterior or medial knee pain, the physician should evaluate for patellofemoral syndrome with medial facet arthritis and a synovial plica (medial shelf).A plica is a remnant of an embryologic wall that divides the knee into compartments and remains present in an estimated 15% to 20% of adults.It may become symptomatic with repetitive flexion and extension of the knee, such as in running.Often bilateral, a plica is frequently the source of pain in runner's knee and growing pains.It causes medial parapatellar pain, often on palpation.In a minority of cases it is palpable in flexion and extension of the knee.Symptomatic treatment of a plica is often unsuccessful; therefore arthroscopic release may be needed.

Lateral patellofemoral pain results from joint overload and is a common cause of bilateral knee pain, especially in females.Risk factors include a relatively greater angle from hip to knee, called the Q angle(Fig.143-3).The Q angle increases the lateral forces on the patella, which then moves out of the normal femoral groove.The undersurface compresses against the femoral condyles in a reduced area, increasing stress.Biomechanical factors, including pes planus (flatfoot) and genu valgum (knock-knee), also contribute to the development of patellofemoral pain syndrome by increased lateralization.In a young athlete this may be caused by inflexibility.Physical findings are variable; the athlete may be apprehensive when gentle pressure is applied during lateral parapatellar palpation.Once the diagnosis is suspected and underlying causes identified, treatment generally involves NSAIDs and quadriceps stretching and strengthening.The rehabilitation program should stress eccentric strengthening and closed chain exercises.Specific knee braces and orthotic devices may also be helpful.Occasionally an arthroscopic lateral release or other procedure may be indicated.

Figure 143-3 Q angle.

The differential diagnosis of a runner with lateral knee pain includes iliotibial band syndrome. Common in cyclists and runners, this syndrome is an inflammatory condition caused by chronic friction of the iliotibial band with the bony prominence of the lateral femoral condyle.Runners with varus deformities (bowlegs) or those who run on sloped surfaces are likely to complain of lateral knee pain in association with a popping sensation.Again, treatment is symptomatic and emphasizes stretching, strengthening, and adequate warm-up exercises.

The runner complaining of foot pain should be evaluated for plantar fasciitis, an inflammation and strain at the origin of the plantar fascia on the calcaneus.Patients describe painon the bottom of the heel, especially on first awakening in the morning, which is relieved with activity.Frequently associated with tight heel cords of the foot and hyperpronation, plantar fasciitis can usually be controlled by heel cord stretching and orthoses.Recalcitrant cases may require injection or, rarely, surgical release.

Anterior lower leg pain is common in runners and is frequently diagnosed as shin splints. Shin splints refer to one of three syndromes: chronic compartment syndrome, chronic periostitis, or tibial stress fracture.Pain is generally at the medial distal tibia.Bone scan or MRI can differentiate between stress fracture and periostitis.Factors that predispose runners to shin splints include training errors, anatomic variations, and poor running techniques or equipment.Patients develop localized tenderness, which increases during running and subsides after activity.Treatment consists of rest, ice, stretching, careful warm-up, NSAIDs, and correction of predisposing factors (e.g., devices).Shin splints must be differentiated from stress fractures of the anterior tibia.

In addition to tibial stress fractures, other stress fractures are particularly common in runners.These overuse injuries are suggested when the runner complains of a persistent, dull pain while weight bearing.Although the metatarsals and tibia are probably the most common sites, the fibula, femoral neck, and pelvic bones may also sustain stress fracture.Any acute fracture should be evaluated to ensure the limb's neurovascular integrity, then splinted and the patient immediately transported to the hospital for further evaluation.Any open fracture is a surgical emergency.

[edit] Shoulder Injuries

Injuries to the shoulder are common in sports.Examination should include evaluation of the bony structures, musculotendinous units, and neurovascular system for deformity, limitation of function, and instability.Referred pain should be considered when movement of the affected joint does not change the symptom or does not elicit pain (e.g., amateur hockey player in a collision who complains of severe left shoulder pain with full range of motion).Causes of referred pain syndrome range from cervical disk herniation to a ruptured spleen with diaphragmatic irritation.

A sprain of the acromioclavicular (AC) joint is common in contact sports such as football and it often results from direct trauma to the shoulder, forcibly separating the acromion from the clavicle.The athlete usually complains of well-localized pain over the AC joint and has difficulty with cross-body adduction or abduction of the shoulder.In general, grade I (nondisplaced) and grade II (minimally displaced) reveal little or no deformity and are managed easily with NSAIDs and a sling for comfort.Athletes may return to play when their shoulder is asymptomatic, usually in 2 to 4 weeks.Grades III through VI should be placed in a sling initially, then referred to an orthopedist for further evaluation.

A fracture of the clavicle results from a direct blow to the bone and is suspected when the patient complains of pain directly over the clavicle.Radiographs confirm the diagnosis.This fracture can usually be managed with a figure-8 bandage or sling and pain medication.As with any fracture, follow-up should involve an orthopedist.Depending on the amount of displacement, most clavicular fractures heal in 6 to 8 weeks, when the athlete may return to play.

Impingement is an overuse condition often seen with overhead sports or with instability.It often results in rotator cuff tendinitis, with bursitis and compression of the cuff against the bony acromion causing pain.Depending on symptoms, impingement can be managed with NSAIDs, injections, physical therapy, and in refractory cases, surgery.Rotator cuff injuries may result from direct trauma or overuse, as seen with overhead sports.Patients complain of anterior or lateral shoulder pain and weakness.Rotator cuff tendinitis is initially managed with physical therapy and NSAIDs, but this injury is best managed by an orthopedist, potentially with surgical intervention.

Dislocation of the glenohumeral joint is also common, most often anterior dislocation resulting from an external rotation force on the abducted shoulder.The athlete complains of severe pain, limited motion of the shoulder, and a “squared off” deformity of the shoulder with anterior dislocations.The axillary nerve, which innervates the deltoid, should be evaluated before attempting reduction.The shoulder should be reduced as soon as possible, with before and after radiographs to assess for concomitant fracture.All shoulder dislocations should be managed initially with a sling and swathe for 2 to 3 weeks, then with exercises to strengthen the rotator cuff musculature.Athletes are allowed to return to play once therapy has restored their full motion and strength.Depending on the sport, specific equipment may aid in protection from the vulnerable abduction/external rotation force, which could cause a recurrent injury.The rate of redislocation is much higher in the younger athlete, who should be referred to the orthopedist for possible surgical stabilization.

[edit] Elbow, Wrist, and Hand Injuries

Most of the injuries to the elbow are from overuse, whereas wrist and hand injuries result from trauma.Fracture of the scaphoid of the wrist is often seen after a fall on theoutstretched hand and should be suspected in a patient with tenderness in the anatomic snuffbox of the radial wrist, along with a distal radius fracture.The patient may have no other physical findings, and radiographs may initially be negative.With suspected injury, the wrist should be splinted and the patient referred to an orthopedist.Scaphoid wrist fractures often take up to 3 months to heal.

Gamekeeper's or skier's thumb is an acute sprain or tear of the ulnar collateral ligament (UCL) of the thumb (see Chapter 126 ).The skier or other athlete falls and forces the thumb into abduction.The metacarpophalangeal joint may appear swollen, with tenderness over the UCL.If radiographs reveal no fracture, the examiner may assess stability by stressing the UCL and evaluating for laxity.Partial or complete tears should be referred to a hand specialist.For those with persistent wrist pain, a hand surgeon should evaluate for ligamentous injury.

[edit] Knee Injuries

The knee may be the most frequently injured joint confronting the primary care physician.Accurate diagnosis and treatment depend on working knowledge of the basic anatomy, function, and topography of the knee.As with the shoulder, the knee should be evaluated for deformity, loss or limitation of function, stability, and localization of tenderness.Assessment should also be made for effusion, although aspiration is rarely performed in the acute knee injury (see Chapter 129 ).

The anterior cruciate ligament (ACL) is often injured by a valgus stress with external rotation or by hyperextension and internal rotation.Most athletes are injured while pivoting about their knee and often hear an audible “pop” and feel immediate pain.The knee usually swells soon after the injury, and the patient cannot bear weight on the affected leg.It is advantageous to examine the patient before the swelling.Lachman's test is the most sensitive examination, and a pivot shift is confirmatory.These tests may be difficult to perform in the patient with a swollen knee and in pain.The patient must be as comfortable as possible while the injury is examined; a pillow under the knee encourages muscle relaxation.Radiographs should be performed to rule out fractures.If an ACL injury is suspected, ice, immobilization, crutches if needed, compression, and referral to an orthopedist are recommended.If a ligament reconstruction is performed, either bone and patellar tendon autografts or patellar and Achilles tendon allografts may be used.A few centers use hamstring tendons.Many athletes return to play 6 months after reconstruction.

An injury to the meniscus may accompany an ACL tear or may occur as an isolated injury.Meniscal tear frequently results from a twisting injury.Patients complain of swelling, pain, catching, locking, and sometimes “giving way.” Physical examination reveals joint line tenderness.Radiographs generally are not helpful.Arthroscopic surgery and possible repair are indicated for symptomatic athletes.Only certain meniscal tears are reparable, and partial menisectomies are performed to reduce the risk of osteoarthritis.Athletes can usually return to play in a few weeks.

Injuries to the medial (MCL) and lateral (LCL) collateral ligaments are also seen.The MCL is injured by a lateral (valgus) force to the knee, especially in sports such as football and soccer.The athlete complains of pain and swelling medially, and the ligament is tender to palpation at the site of injury.In comparison to the unaffected contralateral knee, application of a valgus stress to the knee in 30 degrees of flexion confirms laxity, along with tenderness over the MCL's origin and insertion.Radiographs may demonstrate an associated avulsion fracture if the sprain represents a complete tear.If the tear is grade I or II, protected immobilization in a brace, ice, and NSAIDs are indicated.Crutches may be used as needed.Severe tears require evaluation of other intraarticular pathology and may dictate whether surgery is required.Isolated LCL injuries are uncommon and usually associated with other ligamentous pathology.Virtually all clinically significant knee ligament injuries require physical therapy.Small tears can be protected using braces, with return to play in a few weeks.More severe tears may require 6 to 8 weeks to heal.

[edit] Foot and Ankle Injuries

One of the most common athletic injuries is the ankle sprain, and several other injuries may mimic this condition (see Chapter 130 ).A true sprain is a stretching or tearing of the ligaments.The most common type of ankle sprain is an inversion sprain, where the plantar surface of the foot rolls in, resulting in damage to the lateral ligaments, especially the anterior talofibular.This occurs frequently in running and jumping sports, such as basketball, where one player might jump for a rebound and land unevenly on another player's foot.The athlete complains of pain over the lateral ankle, and swelling usually develops quickly in the area anterior to the lateral malleolus.If there is prominent swelling or difficulty with weight bearing, radiographs should be obtained to evaluate for a fracture.On examination the most important finding is point tenderness over the injured ligament.Tests for stability, including the anterior drawer and talar tilt maneuvers, can be gently performed to aid in the diagnosis.Initial treatment should consist of elevation, ice, and compression.If the sprain is determined to be mild, this treatment, followed by appropriate rehabilitation, should be sufficient.More severe sprains, especially if unstable, require referral.Braces are available for use while a sprain is acute and also during rehabilitation.Any type of immobilization should effectively brace the injury while accommodating the patient's lifestyle.Three phases characterize subsequent rehabilitation to return to sport: immobilization and rest to control swelling and pain, training to increase strength and range of motion, and finally the athlete's return to the desired activity.

Less often, sprains to the deltoid ligament (medial) and tibiofibular ligaments (syndesmosis) occur.A deltoid injury usually is caused by an eversion injury, as opposed to the more common inversion injury.Depending on the sprain's severity, these injuries are treated similarly, with short-term immobilization and physical therapy.Syndesmosis injuries occur while the foot is planted and an external rotatory force is applied around the ankle.These patients have a positive squeeze test, which involves gently squeezing the tibia and fibula together.Tenderness is assessed over the proximal fibular area.The syndesmosis tear may have traveled proximally and caused a proximal fibular fracture.Full-length tibiofibular and ankle radiographs may reveal severe ligament or syndesmosis sprain, and orthopedic referral is warranted.

Similar to the ankle sprain affect an Achilles tendon injury may occur in a basketball or tennis player who forcefully pushes off the foot.Frequently the athlete hears a pop.Painmay be variable; the patient may infrequently continue walking but cannot stand on the toes with a complete tear.Thompson's test confirms the diagnosis.The athlete either sits with the leg dangling or lies prone while the examiner gently grasps and squeezes the calf muscle.If the tendon is intact, the foot passively plantar flexes; lack of passive flexion indicates Achilles tendon rupture.Immobilization with referral for further treatment is recommended.

Also mimicking an ankle sprain, subluxation of the peroneal tendon, which runs posteriorly to the lateral malleolus, occurs when the foot is fixed and the leg is forcibly rotated, as in cross-country skiing.The peroneal tendon tears free of its anchoring retinaculum and subluxates over the malleolus.If the examiner holds the foot in neutral position and asks the athlete to resist eversion, the peroneal tendon may subluxate, causing pain along its course.If the diagnosis is made promptly, before further damage occurs, several weeks of casting may be sufficient.If the diagnosis is delayed or the disorder recurs, surgery may be required.

The acute onset of pain in the middle to lower calf can represent a tear of the musculotendinous junction of the gastrocnemius, not of the Achilles tendon.The onset of sharp pain behind the knee may indicate rupture of the plantaris tendon.MRI can assist in the diagnosis.Both injuries are treated symptomatically.

In general, acute athletic injuries of the foot are much less common than overuse injuries.An exception is hyperextension injury of the metatarsophalangeal joint of the great toe, known as turf toe and often seen in football players playing on artificial turf.The athlete complains of pain; tenderness and swelling of the joint confirm the diagnosis.Radiographs are usually normal.Treatment is symptomatic with NSAIDs and rest; shoe inserts are useful in recurrent or severe cases.The midfoot sprain is often a partial subluxation of the tarsometatarsal joints requiring referral to a specialist for possible cast immobilization or surgery.Comparison between standing AP radiographs and MRI may be helpful.

[edit] Spinal Injuries

Athletic injuries of the spine fall into two major groups: the neck and lower back.Neck, or cervical spine, injuries are potentially the most serious and life-threatening athletic injuries.The most severe injuries occur with the neck in flexion, as in the now-banned tackling technique known as “spearing.” This can lead to quadriplegia and death.Any question of a possible severe neck injury should be treated as a medical emergency, even if this involves suspension of the athletic event until the neck can be protected and the patient safely transported (see Chapter 124 ).

An injury to the cervical spine can result in transient neurapraxia, most often seen in football.The athlete may complain of altered sensation and motor function in the upper extremity, although the lower extremity may also be involved.Radiographs are often negative but are required to rule out a fracture.The paresthesias resolve spontaneously, usually within minutes.Referral to a neurologist or an orthopedist is warranted.

The burner or stinger syndrome, often seen in contact sports, is a stretching injury of the brachial plexus or a compression of nerve roots at the foramen.The athlete has burning pain radiating into the shoulder, upper arm, and hand and associated with muscle weakness (e.g., deltoid, biceps).Symptoms generally resolve spontaneously over minutes or hours.The athlete should not return to play until normal strength and sensation have returned.

Myofascial sprains occur but are overdiagnosed.Many neck and trapezial pain syndromes are facet or neurogenic, with associated disk or root pathology.Frequently the mechanism of such injuries is hyperextension in contact athletes, who are treated symptomatically, usually with NSAIDs, rest, and physical therapy.Occasionally, electromyography (EMG) and MRI are useful in refractory cases.

The lumbar spine is frequently a site of pain and injury for both athletes and nonathletes.Participants in virtually every sport, including gymnastics, football, weightlifting, wrestling, and figure skating, are at risk for low back injury.Lumbar injury is frequently diagnosed as muscle strain; although muscle strain does occur, it is important to look for other common causes of pain.Disk herniation or annular tears have been reported in athletes of all ages and are frequently associated with radiculopathy.The patient may have pain on flexion or with midline palpation of the spine at the involved level.Patients with spondylolysis, a stress fracture of the pars interarticularis, may also present with low back pain.This is most common in teenage athletes involved in gymnastics, football, or weightlifting.The onset of pain is associated with a specific activity and is often nonradicular.Physical findings may include pain on spinal extension, while standing on the single leg on the side of the defect (positive one-legged hyperextension test), on rotation, and during palpation over the irritated area.Radiographs confirm a defect of the pars interarticularis in spondylolysis seen on oblique view (fracture of the neck of the “Scotty dog”).Rest is the treatment of choice; immobilization is occasionally required.If the defect has progressed to become a spondylolisthesis, consultation with a spine specialist is advised (see Chapter 127 ).

[edit] Hip and Thigh Injuries

Acute injuries to the hip and thigh are most often contusions or muscle strains.For example, a groin pull usually involves the adductors of the thigh, and a common contusion is the hip pointer, resulting from a direct blow to the ilium with pain and swelling.Examination may be difficult due to painful range of motion.The affected area is extremely tender.Treatment entails immediate application of pressure, then ice and rest. Osteitis pubis involves a combination of groin or abductor rectus strain, pubic ramus stress, and pubic symphysis osteolysis.Treatment consists of rest, NSAIDs, and orthopedic referral.Fractures of the pelvis and femur are rare in athletes (see Chapter 128 ).

[edit] REHABILITATION

Once an injury has occurred and the initial treatment plan has been instituted, the physician should plan for rehabilitation.If the injury results in time lost from activity, rehabilitation must be considered.The primary goal is to return the athlete to activity as soon and as safely as possible.In the initial 24 to 48 hours after injury, acute treatment is performed according to the mnemonic PRICE. Protection from further injury is accomplished by keeping the athlete from playing and using a splint for immobilization. Rest prevents further injury and allows healing to begin. Ice decreases swelling, pain, and muscle spasm and should be applied for 10 to 30 minutes, with an equal period without ice. Compression limits swelling and may provide somesupport to the injured tissue. Elevation helps to decrease swelling.

Rehabilitation should be sport and athlete specific, that is, individually designed for each athlete depending on the sport.When an athlete is injured, it is not a “knee injury” or “shoulder injury,” but rather an athlete with a specific knee injury or shoulder injury.Therefore general conditioning is important as well as local rehabilitation of the injured limb.Flexibility, strength, proprioception, and endurance must be addressed.Modalities include ice and heat, ultrasound, electric stimulation, and iontophoresis.An athlete's return to play depends on progress during rehabilitation and should be delayed until the athlete is symptom free and has regained confidence in the injured limb.

[edit] SPECIAL NEEDS

[edit] Female Athletes

Women are participating in athletics in increasing numbers.Considerable differences in the male and female anatomy and physiology affect exercise.Females have less dense bone, less muscle mass, a lower center of gravity, shorter limbs, and a gynecoid pelvis.These and other factors affect body mechanics and influence the ability to perform exercise.The female pelvis, because of its relative width, results in different running biomechanics than in males and has been associated with knee injury and overuse syndromes.Female bone is possibly at greater risk for stress fracture because it is less dense than male bone.

Back disorders such as spondylolysis and spondylolisthesis, as well as pubic ramus and femoral neck stress fractures, may be more prevalent in female athletes.ACL injuries occur four times more often in women than men, possibly because of intercondylar notch anatomy as well as muscle strength and training.Patellofemoral problems are common in the female athlete.

Nutritional considerations also differ for women.Because of menstruation, women have a greater need for iron than men.Competitive female athletes often restrict calories, leading in extreme cases to such complications as the female athlete triad, characterized by disordered eating, amenorrhea, and osteoporosis.Inadequate caloric intake reduces peripheral fat, which can result in decreased conversion of androgens to estrogen.This hypoestrogenic state contributes to amenorrhea and is associated with osteoporosis.Inadequate calcium intake exacerbates the effects of this syndrome.

The primary care physician should also be aware of the prevalence and appropriate treatment of eating disorders in athletes.Although most common in females, an estimated 5% of those with eating disorders are male.Between ages 10 and 20, young women must maintain sufficient caloric intake to ensure adequate bone density.Surveys indicate that about one third of female athletes have disordered eating and obsessions about food.An uninformed coach, especially in sports such as gymnastics, figure skating, and diving, which are scored in part on appearance, may contribute to the dietary problem and increase the athlete's risk of further psychologic and physiologic damage.

For the pregnant woman, exercise is generally regarded as safe, although controversy surrounds the degree of recommended endurance and intensity.Certain anatomic and physiologic changes may affect the pregnant athlete's ability to perform exercise, and therefore the physician should individualize the exercise prescription and consult the obstetrician as appropriate.In general, exercise should be carefully monitored for exacerbation of back pain, which is common in pregnant women.

[edit] Young Athletes

Children and adolescents have rapidly changing anatomic and physiologic characteristics that affect their ability to participate in various sports.The young athlete's skeletal immaturity predisposes to injuries not encountered in the older athlete.The epiphyseal plate, the cartilaginous growth center, is the weakest portion of growing bone and is often injured.Such injuries can affect growth and thus require careful evaluation.Physical examination should always include palpation of the epiphysis.Epiphyseal injuries are generally described by the Salter-Harris classification system.Depending on the type of and extent of epiphyseal injury, therapy ranges from closed reduction with excellent prognosis to open reduction and potential growth impairment.

In response to injury or trauma, young children and adults generally sustain ligament injuries, whereas adolescent patients usually have fractures.These injuries reflect the maturity of the musculoskeletal system and the relative strength of the ligament or epiphysis, not the patient's chronologic age (Box 143-4).As in the adult athlete population, tennis elbow, AC separations, and ACL tears are seen in athletic children.Certain fractures, however, such as those of the distal radius and clavicle, are seen more often in children.Developmental abnormalities, including patellofemoral dysplasia, Osgood-Schlatter disease, spondylolysis, and shoulder instability, can result in injuries or symptoms during participation in sports.Injury may precipitate these conditions, but there appears to be some predisposition based on preexisting abnormalities of growth and connective tissue, such as joint laxity in shoulders and patellar dislocations.

[edit] Older Athletes

The athlete over age 65 has the same injury profile as younger athletes, except in three areas.First, active weight-bearing exercise such as jogging is associated with better bone density in the general skeleton.This in turn offers someprotection against compression fractures of the vertebral spine and hip, especially compared with the risks of fracture in a sedentary age-matched group.However, fractures of the wrist and sprained ankles are more common in the geriatric running population because of falls.To avoid falls, patients should run on level surfaces, such as tracks, rather than on the side of the road.

Second, a warm-up period is mandatory for the older population to minimize tendon injuries.The combination of degenerative processes may predispose to higher rates of musculotendinous injuries than in younger athletes, particularly with sports involving sudden acceleration and deceleration (e.g., as tennis).The same degenerative predisposition probably accounts for some back injuries in golf.A complete warm-up is essential to facilitate injury prevention.

Third, exercise can aggravate existing osteoarthritis of the knee, hip, and lower spine in older patients.However, exercise-induced weight control and increased muscle strength usually offset this, ultimately protecting the joints.As discussed earlier, the cardiovascular system needs to be carefully evaluated before beginning any incremental exercise regimen.

[edit] Sports-specific Injuries

Primary care physicians may treat patients participating in a variety of sports (Table 143-3).The incidence of previous neck injuries in wrestlers, gymnasts, and football players is especially important.This information is most relevant during a preparticipation examination, when athletes can be screened for these injuries.Continued participation in sport might expose them to further neck injury.

Table 143-3 Approximate Frequency Distribution of Musculoskeletal Injuries in High-school Sports

[edit] MEDICAL CONSIDERATIONS

The primary care physician is in the position to integrate the athlete's care.Athletes are susceptible to the same illnesses as the general population but may require special treatment considerations.Communicability of an infectious disease, control of asthma and diabetes, and risks imposed by certain conditions (e.g., dysrhythmia) may have special implications for an athlete's health and subsequent return to safe participation.

[edit] Infectious Disease

A common infectious disease is acute febrile illness, such as an upper respiratory tract infection.Although treatment of an athlete's acute infection does not differ, the physician must address ability to practice and return to play.It is generally advisable to avoid strenuous activity while acutely ill, febrile, and experiencing myalgias, although the athlete does not need to be symptom free before returning to play.Adequate fluid intake is especially important for an athlete recovering from illness.The athlete with infectious mononucleosis should not resume contact sports until the spleen has returned to normal size.Resolution of splenomegaly can be confirmed with palpation.

In wrestlers, transmission of herpes simplex virus type I (HSV-I), known as herpes gladiatorum, occurs primarily through skin-to-skin contact.Coaches and parents should be advised to exclude any wrestlers with active skin lesions from competition or practice.Similarly, skin lesions of impetigo caused by streptococci should also preclude athletic participation.

The physician who treats athletes may be questioned about communicability of certain diseases, such as the human immunodeficiency virus (HIV).Patients must understand that the risk of contracting HIV through intact skin by infected blood or saliva is extremely low.Moreover, in the asymptomatic HIV-positive patient, no evidence indicates that exercise activates HIV into clinical acquired immunodeficiency syndrome (AIDS).The physician should stress safe sexual techniques through condom use in all sexually active patients.All health personnel, including trainers, should use universal precautions (e.g., gloves) when treating injured athletes, despite the extremely low risk of contracting HIV through intact skin.Regulatory agencies, including the National Collegiate Athletic Association (NCAA), are recommending the immediate changing of blood-stained uniforms in basketball.These highly publicized communicationsin the media urge physicians to transmit realistic information and precautionary guidelines to their patients.

[edit] Diabetes

Studies of diabetic athletes have shown the positive effects of fitness on diabetes.Training seems to improve glucose tolerance, aid in weight control, and decrease insulin requirements.Monitoring of glucose levels in insulin-dependent patients is crucial, since insulin requirements vary with exercise.The insulin-dependent athlete must be aware of hypoglycemia and have glucose readily available.Although exercise is generally beneficial, the poorly controlled diabetic patient may become more hyperglycemic and ketotic with activity.Therefore diabetes should be fairly well controlled with diet and insulin before initiating an exercise program.Rarely in the type II diabetic patient (adult onset) taking oral hypoglycemic agents, blood sugar will decrease during sustained exercise over hours, such as golf.Such patients should carry a glucose source when playing.

[edit] Asthma

Asthma is common among athletes, especially exercise- induced asthma (EIA).EIA does not interfere with ability to perform if precautions are followed.Patients with EIA develop cough, dyspnea, or wheezing after several minutes of moderately intense exercise.Symptoms are worse in cold, dry air but improve with warm, humid air.Swimming may therefore be more appropriate for a patient with EIA than running.In cold-weather sports such as downhill and cross-country skiing, cold-induced bronchospasm may occur, but its relationship to EIA is controversial.

Prophylaxis includes a warm-up period before vigorous exercise as well as medications.The two most important agents are the β-agonists and cromolyn, which should be administered 10 to 15 minutes before exertion.The physician must be careful to comply with prescribing and disclosure guidelines of the applicable athletic organization.The list of medicines that are allowed by the NCAA and the U.S.Olympic Committee (USOC) includes NSAIDs, antihistamines, antibiotics, insulin, topical steroids, and antiulcer medicines.

[edit] Cardiovascular Conditions

Interest in cardiac disease and the athlete has largely resulted from sudden deaths among high-profile athletes. Sudden death is defined as death that is unexpected, nontraumatic, and instantaneous.Over age 30 the most common etiology is coronary artery disease.Before age 30 the most common etiology is a congenital condition, such as abnormal coronary arteries, valve disease, or hypertrophic cardiomyopathy.Hypertrophic cardiomyopathy is suggested by a midsystolic crescendo-decrescendo murmur, heard best at the left sternal border and without an accompanying ejection sound, that increases in duration and intensity with tests that reduce ventricular filling (e.g., standing Valsalva's maneuver).The physician must also consider Marfan syndrome, which is associated with thoracic aortic aneurysm and dissection.Family history or typical physical features, including long limbs and fingers, may suggest the diagnosis.Although these entities are relatively uncommon, they are emphasized because of their potential for fatal outcomes.More common cardiac problems, such as mitral valve prolapse, can be associated with exercise-induced dysrhythmias.A history of troublesome palpitations, syncope, or presyncope should suggest a preexcitation syndrome, requiring a formal cardiac evaluation.The most important clues to a cardiac abnormality include history of syncope, chest pain, and family history of sudden death.

The condition known as athletic heart syndrome is a constellation of physiologic adaptations of the heart to exercise.It improves cardiac function and is a benign condition characterized by bradycardia, an irregular pulse, and a flow murmur.This asymptomatic syndrome is not associated with syncope or other ominous findings and does not place the athlete at risk for cardiac events.

[edit] Referral

Provision of high-quality care to address athetic injuries depends on timely and appropriate specialty referral.Individualized testing and exercises are important (Box 143-5).The trend toward a more complete approach to care of the injured athlete is an opportunity for primary care physicians to help patients make healthy lifestyle choices.

[edit] Acknowledgments

The authors would like to thank Kathryn M.Peuvrelle, Gerald P.Keane, MD, and George Thabit III, MD, of Sports, Orthopedic and Rehabilitation in Menlo Park, California, for their contributions to this chapter.

[edit] ADDITIONAL READINGS

• American College of Sports Medicine Position stand on the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med Sci Sports Exerc 1990; 22:265.
• American College of Sports Medicine Position stand on the use of anabolic-androgenic steroids in sports. Med Sci Sports Exerc 1987; 19:534.
• Belongia EA,et al.: An outbreak of herpes gladiatorum at a high school wrestling camp. N Engl J Med 1991; 325:906.
• Clark N: How to approach eating disorders among athletes. Top Clin Nutr 1990; 5:41.
• Fuentes RJ, Rosenberg JM, Davis A: Allen and Hanbury's Athletic drug reference '94 Durham NC: Glaxo; 1994:
• Grana WA Kalenak A Clinical sports medicine. Philadelphia: Saunders; 1991:
• Greenspan A: Orthopedic radiology: a practical approach ed 2. New York: Raven; 1992:
• Hoppenfeld S: Physical examination of the spine and extremities East Norwalk, Conn: Appleton-Century-Crofts; 1976:
• Johnston CCJr,et al.: Calcium supplementation and increases in bone mineral density in children. N Engl J Med 1992; 327:82.
• Lane NE,et al.: The risk of osteoarthritis with running and aging: a 5-year longitudinal study. J Rheumatol 1993; 20:461.
• Lane NE,et al.: Running, osteoarthritis and bone density: initial 2-year longitudinal study. Am J Med 1990; 88:452.
• Strauss RH Sports medicine. ed 2. Philadelphia: Saunders; 1991:
• Swander H, editor: Preparticipation physical evaluation, 1992.
• Teitz CC,et al.: The female athlete: evaluation and treatment of sports-related problems. J Am Acad Orthop Surg 1997; 5:87.
• Thabit GIII, Micheli L: Orthopedic disorders of the extremities. Burg FD Ingelfinger JR Wald ER Current pediatric therapy. Philadelphia: Saunders; 1993:
• Williams MH, JD Branch: Creatine supplementation and exercise performance: an update. J Am Coll Nutr 1998; 17:216.