Chief, Orthopaedic Sports Medicine Service Scott & White University Medical Campus Round Rock, TX

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

2. Darryl B. Thomas, MD - Education • 1991 Princeton University (Army ROTC) • 1995 Johns Hopkins School of Medicine • 2000 Johns Hopkins Orthopaedic Residency • 2001 Sports Medicine Fellowship • US Military Academy, West Point, NY • Hospital for Special Surgery, New York, NY • Steadman Hawkins Clinic, Vail, CO • 2003 Chief Sports Medicine, BAMC • 2005 Orthopaedic Surgeon, Baghdad, Iraq • 2006 Private practice, Austin/Round Rock, TX

3. OVERVIEW • Sports Medicine Specialty • Pre-participation Physical Exam (PPE) • The Collapsed Athlete • Sideline Medical Treatment for Common Conditions • Appropriate Referrals to Physicians

4. SPORTS MEDICINE The study and practice of medical principles related to the science of sports, athletic performance, and exercise-related activity • Sports injury prevention • Sports injury diagnosis and treatment • Sports training and athletic performance • Exercise and workouts • Sports nutrition • Sports psychology

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

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

7. PPE PRE-PARTICIPATION PHYSICAL EXAM • Musculoskeletal Injuries • Cardiovascular disease • Neurologic conditions • convulsive / SZ disorders • Medical conditions • Exertional hyperthermia • Exertional rhabdomyolysis • Status asthmaticus - ∅ response to normal Tx • Leading causes of nontraumatic, non-cardiac sports death

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

9. C-SPINE DISQUALIFICATIONS No athletic participation • Congenital Conditions • Odontoid agenesis, hypoplasia • Atlanto-occipital fusion; Klippel-Feil • Developmental Conditions • Stenosis of the cervical spinal canal • neuropraxia, lig instability, + MRI • Spear Tackler’s Spine • stenosis, ∅ nl lordosis, post-traumatic X-ray ∆’s • Traumatic Conditions • Lig laxity, acute fx’s, certain healed fx’s (displ.) Torg (Canal / Body) Ratio ≤ 0.8

10. HCM Hypertrophic Cardiomyopathy • Heart muscle thickens making it more difficult for blood to leave the heart ➔ heart must work harder to pump blood • Estmated to affect 1/500 people in the US • Leading cause of sudden cardiac death in the young athlete, 12-32 yo • H.S. and college age • 1:200,000 - 1:300,000 / yr • AHA: 36% athletes who suffered SCD

11. HCM History • HCM = heterogeneous group of disorders, AD, incomplete penetration • Sx ➔➔ early adulthood • Hx reveals 64-78% of conditions • affecting participation in sports • More sensitive tool than PE !!! • Other conditions - Fam Hx: • Marfan syndrome ➔ aortic rupture • Premature atherosclerosis • Unexplained sudden death

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

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

14. HCM Physical Exam • Routine ECG screening not recommended for routine PPE • too many false positives & negatives • not cost-effective on large-scale • Resting ECG rate is abnl in 80-90% of pts w/ HCM • ST-segment ↑ in lateral leads • biphasic T-waves in V1 to V3 • Order w/ Hx, Fam Hx, PE

15. CARDIAC DISQUALIFICATIONS No athletic participation • HCM, Marfan syndrome • Rhythm and conduction abnl • Systemic hypertension • Valvular heart disease • Require cardiology clearance !!!

16. MEDICAL DISQUALIFICATIONS • Sickle Cell Disease • No contact or collision sports • SC Trait ➔ OK, but ↑ risk rhabdo • Solitary Organs • One paired organ ➔ controversial • No sports if diseased single organ • single eye ➔ only w/ protective eyewear • swimming, T&F, gymnastics • no boxing, wrestling, martial arts • single testicle ➔ protective cup

17. COLLAPSED ATHLETE • PRIMARY SURVEY • ABCDE • Sudden Cardiac Death • Arrythmias • Environmental Injury • SECONDARY SURVEY • Head / neck Injury • Electrolyte Imbalance • Anaphylactic reaction

18. PRIMARY SURVEY • AIRWAY • Laryngeal fracture / edema • Foreign body • Oral trauma • BREATHING • Pneumo / hemothorax • Flail chest • Excercised induced asthma • Acute asthma exacerbation

19. PRIMARY SURVEY • CIRCULATION • Pulselessness: • VF until proven otherwise • Hypoxia • Shock (hypovolemic) • DEFIBRILLATE / DISABILITY • Dysrythmia • Head Injury (GCS, AVPU) • C-spine / Neck Injury - Neuro exam

20. PRIMARY SURVEY • EXPOSURE / ENVIRONMENT • Undress to expose all injuries • Remove from environment • Hyperthermia • Hypothermia • Lightning • Primary survey takes place on the field or immediate sideline - no time for training rm • Game is interrupted; Offical clock stopped

21. COLLAPSED ATHLETE • CARDIAC CAUSES • Congenital cardiac anomalies • Hypertrophic cardiomyopathy • coronary artery anomalies • left main off right sinus • Myocarditis • Aortic rupture / dissection • Idiopathic left ventricular hypertrophy

22. COLLAPSED ATHLETE • CARDIAC CAUSES (Cont’d) • Lethal arrythmias • arrythmogenic RV dysplasia • Aortic stenosis • Premature coronary artery disease • Ischemia • Myocardial Infaction • Commotio cordis • Recreational drug use

23. COLLAPSED ATHLETE • METABOLIC EMERGENCIES • Symptomatic hyponatremia • Hypoglycemia • NEUROLOGIC CONDITIONS • CVA - stroke • Subarachnoid bleeding • Seizure

24. SUDDEN CARDIAC DEATH • Sudden cessation of cardiac activity • Victim becomes unresponsive • Abnormal / absent breathing • No signs of circulation • Victim must receive immediate CPR or they will die • Relatively uncommon • death rate in male athletes < 35 yrs of age • 0.75 per 100,000 participants per yr • H.S. cardiac arrest rate = 25-50 per yr

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

26. AED Automatic External Defibrillator • Designed for use by anyone - lay people • Can be used on anyone > 1 yr old • Cost $1500 - $2500 • Most schools and public facilities are now equipped with AED’s • Victim’s survival chances drop by 10% for every minute that passes • AED’s have been shown to increase survival chances in SDA from 5 - 75%

27. COMMOTIO CORDIS • Sudden disturbance of heart rhythm • Latin term for “commotion of the heart” • Refers to a functional effect of mechanical stimulation in the absence of structural damage - as opposed to mycardial contusion • Occurs as the result of a blunt, • non-penetrating impact to the • precordial region➔ impact of • ball, bat, or other projectile • Usually in boys or young men • George Boiardi, died 2004

28. COMMOTIO CORDIS • USA National Commotio Cordis Registry • 188 cases ‘96-’07, 1/2 during organized sports • 96% in males, mean age 14.7, < 1 in 5 survived • Timing of impact in relation to cardiac cycle • ascending phase of T-wave; repolariziation • 10-30 millisec portion • asystole to diastole • Causes an arrythmia • ectopic beat • ventricular tachycardia • ventricular fibrillation

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

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

31. HYPERTHERMIA HEAT CRAMPS • Can occur at any temperature • Loss of electrolytes, mainly salt HEAT SYNCOPE • Core temp is normal or mildly elevated • Dehydration ➔ can lead to abrupt LOC • Occurs near end of exercise due to reduced cardiac return and postural hypotension • Often happens at the beginning of the summer season before the body acclimates

32. HYPERTHERMIA HEAT EXHAUSTION • Unable to continue exercise in heat since the CV system fails to respond to ↑ workload • Core temp 100.4º - 104º F (38º - 40º C) • Sx: muscle cramps, mild confusion, HA, dizziness, nausea, often collapse • Treatment • As long as VSS, cool by removing • excess clothing and rest in shady place • Ice pack wrapped in towel → to neck, axilla, or groin

33. HEAT STROKE • Thermoregulatory failure with central nervous system (CNS) dysfunction • Usually core temp >104º F (40º C) • Absence of sweating can be present • Results is rhabdomyolysis, • renal failure, DIC, liver • failure and brain injury • Sx: tachycardia, • tachypneia, hypotension

34. HEAT STROKE TREATMENT • Immerse in tub of ice water as soon as possible ➔ about 5-10 min, until core (rectal) temp < 100.4º F (38º C) or pt starts to shiver • Or spray with cool water and place near fan, include ice packs to neck, axilla, and groin • Hydrate with IVF and oral sports drinks • Avoid antipyretic agents for heat injuries • Benzodiazepines reserved for athletes who have severe shivering or are having seizures

35. HYPOTHERMIA Core temp ≤ 97º F (36.1º C) • CNS normal • Pt walks with or without assistance Core temp ≤ 95º F (35º C) • CNS normal • Unable to walk or several muscle spasm Core temp ≤ 90º F (32.2º C) • CNS changes ➔ profound hypothermia • Mild confusion and intense shivering

36. HYPOTHERMIA TREATMENT • Move indoors or to protected environment • Removing wet clothing • Passive warming with blankets, oral liquids Core temp ≤ 80º F (30º C) • Critical hypothermia • Handle gently or can go into V Fib • May not respond to defibrillation

37. ENVIRONMENTAL INJURIES TRANSFER TO HOSPITAL • Unstable vital signs • Core (rectal) temp < 90º F or > 104º F • Hyper- or hypothermia persisting > 30 min • Prolonged unconsciousness • Development of chest pain or arrythmias

38. ELECTROLYTE IMBALANCES HYPONATREMIA • Endurance athletes at greater risk • 2003 Boston marathon, up to 13% • of runners experienced Sx hyponatremia • As athletes ingest excessive water ➔ serum sodium levels fall ➔ confusion, nausea, vomiting, ataxia, coma and potentially death • Consider IV access if signs of dehydration: sunken eyes, parched lips, poor skin turgor • Hemodynamic instability, arrythmia ➔ IV !!!

39. REHYDRATION IV FLUID CONTROVERSIAL !!! • ACSM - no official recommendation • Most commonly used: 5% dextrose in either 0.45% or 0.9% normal saline • Ironman Triathlon World Championship, HI • Marine Corps Marathon, DC • If athlete requires more than 2 L of IV fluid without clinical improvement and/or hemodynamic stabilization, transfer to medical facility

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

41. HEAD INJURY DIFFUSE • Concussion • Second Impact Syndrome FOCAL • Intracranial hemorrhage • Subdural hematoma (SDH) • Epidural hematoma • Subarachnoid hemorrhage (SAH) • Leading cause of death from athletic head injury

42. CONCUSSION MILD BRAIN INJURY MILD TRAUMATIC BRAIN INJURY (MTBI) MINOR HEAD INJURY (MHI) • Most common head injury in sports • Trauma induced alteration in mental status • Transient loss in • brain function • Incidence as high as • 6 in 1000 people / yr • 300,000 athletes / yr

43. CONCUSSION • ETIOLOGY • Blow to the head • Acceleration forces • without direct impact • MECHANISM • CSF not able to absorb forces associated with rapid acceleration • Angular and rotational forces affect midbrain disrupting nl cellular activity • impaired neurotransmission, deploarization • reduced cerebral blood flow → LOC

44. CONCUSSION - SX • PROBLEMS IN BRAIN FUNCTION • confused state, dazed look, vacant stare • memory loss (score, period, day) • HA, nausea, vomiting, blurred vision • SPEED OF BRAIN FUNCTION • slow response, reaction time, slurred speech • UNUSUALY BEHAVIOR • combative, aggressive, silly, restless, irritable • BALANCE & COORDINATION PROBLEMS • dizzy, clumsy, “drunk”, can’t walk straight

45. SECOND-IMPACT SYNDROME • An athlete sustains a head injury and then sustains a second head injury before the symptoms assoc w/ the first have cleared • Second blow can be remarkably minor • Within 2-5 minutes, athlete can die • → collapse, dilating pupils, ↓ eye mvt, respiratory failure • loss of autoregulation • → vascular engorgement, ↑ ICP, ➔ brian herniation

46. SECOND-IMPACT SYNDROME • Mortality rate approaches 50% • kills 4 - 6 people < age 18 / yr • Morbidity rate near 100% • 35 cases reported b/w 1980 - 1992 • 17 cases reported b/w 1992 - 1995 (CDC) • majority involved adolescent athletes or young adults (age 16 - 24) • Sports at most risk: • football, boxing, soccer, rugby, baseball

47. CONCUSSION - GRADING • GRADE I - MILD • No LOC • post-traumatic amnesia (PTA) < 30 min • post-concussive sx (PCSS) < 24 hrs • GRADE II - MODERATE • LOC < 1 min • PTA ≥ 30 min, but < 24 hrs • or PCSS ≥ 24 hrs, but < 7days • GRADE III - SEVERE • LOC ≥ 1 min or PTA ≥ 24 hrs • or PCSS > 7 days • Cantu grading system

48. CONCUSSION - EVALUATION • BLS; ? LOC occurred • Careful observation by MD, ATC • Question teammates, coaches • Neuro, mini-mental exam (MME) • CN’s, coordination, motor fcn • short- and long-term memory • 3-word memory (baseline exam) • coach asks specifics of plays • Sideline exertional testing before RTP • If no RTP, stick to decision • keep athlete’s essential equip: helmet, shoe

49. CONCUSSION - MGMT • GRADE I - MILD • #1 - may return to play (RTP) if ASx for 1 wk • #2 - may RTP in 2 wks if ASx for 1 wk • #3 - terminate season, but RTP following season if ASx • GRADE II - MODERATE • #1 - may RTP if ASx for 1 wk • #2 - 1 mo off sports, RTP if ASx but ? termination • #3 - terminate season, but RTP following season if ASx • GRADE III - SEVERE • #1 - 1 mo off sports, RTP if ASx but ? termination • #2 - terminate season, but RTP following season if ASx • #3 - no return to sports

50. C-SPINE INJURY • PPE - Identify those with h/o previous injury • Rules prohibiting “spearing” have eliminated the head as the initial contact point • significantly reduced incidence of injury • Note differences in helmets • and hardware needed to • remove the faceguard • Helmet and shoulder pads considered one unit • removing one takes airway out of neutral • if must remove for eval, put on collar