The new graduate, or the licensed physical therapist with general orthopedic experience, is not qualified to provide sideline coverage at athletic events. Additional or advanced training in emergency care is essential to provide aid in acute situations. Completion of the First Responder certification prepares an individual to react appropriately to any emergency on the sidelines, in the clinic, or in the community. The highest qualification that a physical therapist can attain to ensure adequate preparation for the practice of Sports Physical therapy is the ABPTS Sports Certified Specialist (SCS) designation. This professional designation indicates that this individual is highly qualified to care for athletes at any level, from on the sidelines, through rehabilitation and return to play, regardless of the injury, age of the athlete, or skill level.
Emergency care; sideline coverage; sports physical therapist
Serious abdominal injuries in athletics, including liver trauma, are relatively rare. When they do occur, the athletic trainer and the team physician must be able to recognize the signs and symptoms and employ the appropriate first aid and follow-up care. In this paper, we present a case study of a football player who suffered a lacerated liver as a result of a forceful blow to the right side of the chest. Although his case was typical of most isolated liver injuries and he did not experience massive internal bleeding, the potential for life-threatening exsanguination exists and must be recognized by by sports health care practitioners. Most isolated liver injuries can be treated nonsurgically. However, those patients with multiple organ trauma, deteriorating vital signs, or diminishing hemodynamic stability generally require immediate surgery. Athletes with persistent right upper quadrant pain, especially when accompanied by referred pain to the right shoulder, abdominal rigidity, guarding, or rebound pain should be considered to have a liver injury until ruled out by CT scan and liver enzyme studies. Our subject was typical of most athletic liver patients and he was able to resume light exercise after 5 weeks and full activity after 3 months.
Injuries to the distal femoral epiphysis are not common, but when they do occur, at least half of them occur in sports. Many athletic trainers work with skeletally immature athletes, thereby increasing the likelihood that they will face this type of injury. The case of a 14-year-old football player who sustained a Salter-Harris III fracture of his medial femoral condyle is presented to illustrate the classic natural history and prognosis of this injury. To properly evaluate this injury, the athletic trainer must understand the anatomy of the immature skeleton and be able to recognize signs that epiphyseal injury has occurred. These injuries frequently result in long-term complications such as leg-length discrepancy, although this and other complications can be minimized or eliminated through proper immediate treatment. Athletic trainers must be aware of these injuries and include them in their differential evaluation, since immediate treatment can mean the difference between permanent leg-length discrepancy or deformity and an uncomplicated recovery with the athlete returning to full athletic activity.
To present a protocol for the initial assessment and documentation of mild brain injury, a protocol that is used within the Department of Physical Education at the United States Military Academy.
Recently, much attention has been given to the assessment and management of mild brain injury by the sports medicine community. Although the classification of and management strategies for mild brain injury have been well disputed, most experts agree on the essentials of the sideline or initial evaluation. According to leading experts, if an athlete has experienced an episode of mild brain injury, the initial signs and symptoms, as well as the course of those signs and symptoms, should be documented.
Although many athletic training texts formerly discussed techniques for evaluating an episode of mild brain injury, few present an objective protocol to follow. Our protocol includes 3 components. The first component is the initial evaluation, which incorporates serial observations during the first 20 minutes after injury, with neurologic checks every 5 minutes. The second component includes a take-home sheet for athletes not referred to a physician for further evaluation. The third part of the protocol is a 24-hour postinjury follow-up examination for any signs or symptoms of postconcussion syndrome. Finally, we present the indications for referral to a physician for further evaluation.
Using a standard protocol to guide evaluation and to document the initial course of signs and symptoms after mild brain injury allows the sports medicine staff to make better management decisions. In addition, patient instructions and the course of follow-up evaluations can be improved if a standard protocol is employed. Our protocol has been developed to meet the needs both of athletes who are exposed to mild brain injury on a daily basis and of the certified athletic trainers who initially evaluate them; the protocol can be adapted to the individual needs of each athletic training setting.
concussion; sideline; neurologic
Sports dentistry is one of the most recent and upcoming field in dentistry. It mainly includes the prevention and management of athletics-related orofacial injuries and associated oral diseases. The sports or team dentist assists athletes in the prevention, treatment, and diagnosis of oral injuries. The most significant aspect in preventing sports-related orofacial injuries is wearing basic protective devices such as properly-fitting helmets, face masks and/or mouth guards. Dental injuries are the most common type of orofacial injury sustained during participation in sports. Many athletes are not aware of the health implications of a traumatic injury to the mouth or of the potential for incurring severe head and orofacial injuries while playing. The dentist can play an imperative role in informing athletes, coaches and patients about the importance of preventing orofacial injuries in sports. The aim of this paper is to increase professional awareness and interest for orientation toward sports dentistry.
Dental injury; sports; mouth gaurd
An integral part of the responsibilities of the sports physical therapist is emergency care that is provided on the sidelines and courtside during athletic events. Often times, the sports physical therapist is the “most medical” individual present at athletic events, especially at high school, middle school, and club level events. The sports physical therapist is looked upon to provide appropriate care in the event of an injury to or sudden illness of an athlete, or in the event of an unexpected medical emergency that arises in members of the coaching staff, officials, and fans.
Objective: To present guidelines for the recognition, prophylaxis, and management of asthma that lead to improvement in the quality of care certified athletic trainers and other heath care providers can offer to athletes with asthma, especially exercise-induced asthma.
Background: Many athletes have difficulty breathing during or after athletic events and practices. Although a wide variety of conditions can predispose an athlete to breathing difficulties, the most common cause is undiagnosed or uncontrolled asthma. At least 15% to 25% of athletes may have signs and symptoms suggestive of asthma, including exercise-induced asthma. Athletic trainers are in a unique position to recognize breathing difficulties caused by undiagnosed or uncontrolled asthma, particularly when asthma follows exercise. Once the diagnosis of asthma is made, the athletic trainer should play a pivotal role in supervising therapies to prevent and control asthma symptoms. It is also important for the athletic trainer to recognize when asthma is not the underlying cause for respiratory difficulties, so that the athlete can be evaluated and treated properly.
Recommendations: The recommendations contained in this position statement describe a structured approach for the diagnosis and management of asthma in an exercising population. Athletic trainers should be educated to recognize asthma symptoms in order to identify patients who might benefit from better management and should understand the management of asthma, especially exercise-induced asthma, to participate as active members of the asthma care team.
airway hyperresponsiveness; airway obstruction; exercise-induced asthma; exercise-induced bronchospasm; pulmonary function tests; certified athletic trainer
To present a new approach in the evaluation and management of concussion from the athletic trainer's perspective.
The evaluation and management of concussion continues to be a controversial topic among sports medicine professionals. Inconsistent management, lack of objective data, and confusion concerning assessment techniques may lead to inappropriate decisions regarding when to return an athlete to competition after concussion. In this article, we provide recommendations and considerations for the certified athletic trainer in the management of concussion. We also present a quantifiable assessment technique that provides more information on which return-to-play decisions can be made; this technique can be used during the initial sideline examination as well as during subsequent follow-up examinations.
Certified athletic trainers and team physicians should consistently use appropriate grading scales. Assessment of concussion should include a symptom checklist, the Balance Error Scoring System, and the Standardized Assessment of Concussion, and the results should be compared with the athlete's normal baseline scores. Follow-up neuropsychological and postural stability testing is recommended. Return-to-play decisions should be based on the grade of concussion, scores on objective tests, and presence of concussive symptoms during exertional activities.
mild head injury; neuropsychological testing; postural stability testing; grading scales
Health care providers must be prepared to manage all potential spine injuries as if they are unstable. Therefore, most sport teams devote resources to training for sideline cervical spine (C-spine) emergencies.
To determine (1) how accurately rescuers and simulated patients can assess motion during C-spine stabilization practice and (2) whether providing performance feedback to rescuers influences their choice of stabilization technique.
Patients or Other Participants:
Athletic trainers, athletic therapists, and physiotherapists experienced at managing suspected C-spine injuries.
Twelve lead rescuers (at the patient's head) performed both the head-squeeze and trap-squeeze C-spine stabilization maneuvers during 4 test scenarios: lift-and-slide and log-roll placement on a spine board and confused patient trying to sit up or rotate the head.
Main Outcome Measure(s):
Interrater reliability between rescuer and simulated patient quality scores for subjective evaluation of C-spine stabilization during trials (0 = best, 10 = worst), correlation between rescuers' quality scores and objective measures of motion with inertial measurement units, and frequency of change in preference for the head-squeeze versus trap-squeeze maneuver.
Although the weighted κ value for interrater reliability was acceptable (0.71–0.74), scores varied by 2 points or more between rescuers and simulated patients for approximately 10% to 15% of trials. Rescuers' scores correlated with objective measures, but variability was large: 38% of trials scored as 0 or 1 by the rescuer involved more than 10° of motion in at least 1 direction. Feedback did not affect the preference for the lift-and-slide placement. For the log-roll placement, 6 of 8 participants who preferred the head squeeze at baseline preferred the trap squeeze after feedback. For the confused patient, 5 of 5 participants initially preferred the head squeeze but preferred the trap squeeze after feedback.
Rescuers and simulated patients could not adequately assess performance during C-spine stabilization maneuvers without objective measures. Providing immediate feedback in this context is a promising tool for changing behavior preferences and improving training.
head squeeze; trap squeeze; spine board placement; head motion; inertial measurements; self-reports; training; feedback; spine injuries; spine immobilization; neck injuries
The acute anterior dislocation of the glenohumeral joint (GHJ) poses a challenge to sports medicine providers at all levels and in all settings. This macrotraumatic injury occurs in athletes who participate in a wide variety of sports, most typically as a result of contact or collision mechanisms. Quick and effective relocation of the GHJ is an important skill for on the sideline or on the field management of this type of dislocation when appropriate and allowable by facility protocol. This clinical suggestion describes one possible technique for athlete self‐reduction that may be appropriate in some circumstances. This is in contrast to forcible reduction by the health professional, which is outside of the scope of this clinical commentary.
Level of Evidence:
Anterior glenohumeral joint dislocation; self‐reduction technique
The vast differences between individual athletes makes identifying and evaluating sports-related concussion one of the most complex and perplexing injuries faced by medical personnel.
This review summarizes the existing literature supporting the use of a multifaceted approach to concussion evaluation on the sideline of the athletic field. Information was drawn from a PubMed search (MEDLINE) for the terms sport concussion for the most recent and relevant literature.
By using a standardized clinical examination that is supported by objective measures of concussion-related symptoms, mental status, and postural control, the medical professional becomes well equipped to make an informed diagnosis.
mild traumatic brain injury; symptoms; postural control; neurocognitive status
Injuries to the head and neck are the most frequent catastrophic sports injury, and head injuries are the most common direct athletic cause of death. Although direct compressive forces may injure the brain, neural tissue is particularly susceptible to injury from shearing stresses, which are most likely to occur when rotational forces are applied to the head. The most common athletic head injury is concussion, which may very widely in severity. Intracranial haemorrhage is the leading cause of head injury death in sports, making rapid initial assessment and appropriate follow up mandatory after a head injury. Diffuse cerebral swelling is another serious condition that may be found in the child or adolescent athlete, and the second impact syndrome is a major concern in adult athletes. Many head injuries in athletes are the result of improper playing techniques and can be reduced by teaching proper skills and enforcing safety promoting rules. Improved conditioning (particularly of the neck), protective headgear, and careful medical supervision of athletes will also minimise this type of injury.
Because sports injuries in men form most of the available statistics, the reportage of injuries in female athletes is sparse. We describe exertion injuries and disorders in 281 women athletes, all of which hampered athletic training or performances. Sixty per cent of the injuries occurred to girls ages between 12-19 years, and about forty-eight per cent were track and field athletes. The most common sites of injury were the ankle, foot, heel and leg. Osteochondritic disorders were the most typical injuries in the series, and the chronic medical tibial syndrome was the injury that needed surgical treatment most frequently. Overuse injuries seem to differ very little from each other in the events included in this survey.
Objectives: To educate athletic trainers and others about the need for emergency planning, to provide guidelines in the development of emergency plans, and to advocate documentation of emergency planning.
Background: Most injuries sustained during athletics or other physical activity are relatively minor. However, potentially limb-threatening or life-threatening emergencies in athletics and physical activity are unpredictable and occur without warning. Proper management of these injuries is critical and should be carried out by trained health services personnel to minimize risk to the injured participant. The organization or institution and its personnel can be placed at risk by the lack of an emergency plan, which may be the foundation of a legal claim.
Recommendations: The National Athletic Trainers' Association recommends that each organization or institution that sponsors athletic activities or events develop and implement a written emergency plan. Emergency plans should be developed by organizational or institutional personnel in consultation with the local emergency medical services. Components of the emergency plan include identification of the personnel involved, specification of the equipment needed to respond to the emergency, and establishment of a communication system to summon emergency care. Additional components of the emergency plan are identification of the mode of emergency transport, specification of the venue or activity location, and incorporation of emergency service personnel into the development and implementation process. Emergency plans should be reviewed and rehearsed annually, with written documentation of any modifications. The plan should identify responsibility for documentation of actions taken during the emergency, evaluation of the emergency response, institutional personnel training, and equipment maintenance. Further, training of the involved personnel should include automatic external defibrillation, cardiopulmonary resuscitation, first aid, and prevention of disease transmission.
policies and procedures; athletics; planning; catastrophic
To describe the pathomechanics, diagnostic procedures, classification, and conservative management of the osteitis pubis syndrome in the elite soccer athlete.
Groin injuries can be the most difficult sport injuries to accurately diagnose and treat. Osteitis pubis is a painful, chronic syndrome that affects the symphysis pubis, adductor and abdominal muscles, and surrounding fascia. If misdiagnosed or mismanaged, osteitis pubis can run a prolonged and disabling course. The abdominal and adductor muscles have attachments to the symphysis pubis but act antagonistically to each other, predisposing the symphysis pubis to mechanical traction microtrauma and resulting in osteitis pubis. These antagonistic forces are most prevalent in kicking sports, such as soccer or football.
We provide a retrospective review of the demographics, diagnostic criteria and procedures, and conservative management of osteitis pubis in a professional soccer team. Osteitis pubis represented 3% to 5% of all injuries sustained by our professional soccer team between 1989 and 1997; 71.4% of those presenting with osteitis pubis were classified as having stage I disease, with a mean recovery time of 26.7 days. Midfielders were most affected by the syndrome (42.8%), whereas defenders and forwards exhibited equal incidences (25.7%) of osteitis pubis. Conservative management included nonsteroidal anti-inflammatory medication, electric stimulation, ultrasound, laser, cryomassage, and a progressive rehabilitation program.
Athletes who participated in this conservative management program appeared to return to full sport participation earlier and with fewer restrictions than the current literature seems to suggest. A 4-stage diagnostic criteria system was helpful in determining the course of treatment.
groin pain; soccer injuries; pubic symphysis; rehabilitation; diagnosis
Chest injuries in contact and collision sports are relatively rare, particularly those that are life threatening. However, as with every sports related injury, one must initially consider life threatening situations that may occur as a result of collision with another player, a stationary object, or being struck with some type of object (missile). In other words, as is the case in all acute sports injury assessment, the mechanism of injury must be considered when evaluating the injured athlete on the field as well as on the sidelines. The Sports Physical Therapist (PT) must look for several initial life threatening conditions as well as be aware of and monitor for the development of these symptoms during the subsequent evaluation of the athlete. The purpose of this clinical commentary is to review the presentation and management of several emergent conditions associated with injuries to the chest and thorax.
Chest injury; commotio cordis; flail chest; pneumothorax
To identify the types of injuries the human brain incurs as a result of traumatic forces applied to the cranium. In athletic events and endeavors, the full spectrum of intracranial hemorrhages in various compartments, raised intracranial pressure, and diffuse nonhemorrhagic damage may be seen. In this review, we describe these serious injuries and the more common mild traumatic brain injury in their clinical presentations and relate concussion classification to the overall picture of traumatic brain injury.
Our cumulative experience with athletic injuries, both at the catastrophic and mild traumatic brain injury levels, has led us to a management paradigm that serves to guide us in the classification and treatment of these athletes.
The occurrence of intracranial injuries in sports has now been well documented. Intracranial hematomas (epidural, subdural, and parenchymal) and cerebral contusions can result from head injury. Many patients sustain a diffuse brain injury, resulting in elevated intracranial pressures, without a blood clot or mass lesion. The classification of concussion and the use of concussion guidelines are not uniform. However, the major emphases are agreed upon: the close and careful scrutiny of the athlete, an expeditious but reliable neurologic examination, and proper on-field management. Return-to-play decisions are based on many factors that affect normal functioning, both on and off the playing field.
Sufficient knowledge now exists to allow us to carefully evaluate the injured athlete, to place him or her in the management scheme to minimize the potential for permanent cerebral dysfunction, and to know when the athlete can safely return to contact sport participation.
diffuse brain injury; hematoma
Bleeding or open wounds of the integumentary system occur frequently in athletics. Integumentary wounds vary from minor scrapes, blisters, and small punctures to more serious lacerations and arterial wounds that could threaten the life of the athlete. The Sports physical therapist (PT) must realize that integumentary wounds and subsequent bleeding can occur in many sports, and assessment and care of such trauma is an essential skill. The purpose of this “On the Sidelines” clinical commentary is to review types of integumentary wounds that may occur in sport and their acute management.
Level of Evidence:
Athletes; bleeding; integument; wounds
Sports injuries involving the hand and wrist are common and, as a result, many different practitioners (athletic trainers, physical therapists, primary care physicians, general orthopedic surgeons) will encounter these injuries. In addition to thorough evaluation, an understanding of typical pathologies seen in the athlete enhances diagnosis and facilitates appropriate, expedient management. These injuries are complex because they can be either acute traumatic or repetitive in origin and often involve both the bony skeleton and soft tissues. This article provides a review of athletic injuries to the wrist with particular focus on physical evaluation and management of the most common and challenging fractures and soft tissue injuries.
Sports injuries; Wrist; Scaphoid fracture; Scapholunate ligament tear; Triangular fibrocartilaginous complex (TFCC) tear; Hamate hook fracture; Pisiform fracture; Extensor carpi ulnaris (ECU)
Duodenal injury is an uncommon finding, accounting for about about 3 – 5% of abdominal trauma, mainly resulting from both penetrating and blunt trauma, and is associated with significant mortality (6 - 25%) and morbidity (30 - 60%).
Patients and Methods:
Retrospective analysis was performed in terms of presentation, management, morbidity and mortality on 14 patients of duodenal injuries out of a total of 172 patients of abdominal trauma attending Subharti Medical College.
Epigastric pain (100%) along with vomiting (100%) is the usual presentation of duodenal injuries in blunt abdominal trauma, especially to the upper abdomen. Computed tomography (CT) was diagnostic in all cases. Isolated duodenal injury is a rare finding and the second part is mostly affected.
Duodenal injury should always be suspected in blunt upper abdominal trauma, especially in those presenting with epigastric pain and vomiting. Investigation by CT and early surgical intervention in these patients are valuable tools to reduce the morbidity and mortality.
Blunt trauma abdomen; duodenal injury; pancreatico-duodenal injury
Abdominal trauma is a major public health problem for all nations and all socioeconomic strata.
This study was designed to determine the incidence and patterns of abdominal injuries in trauma patients.
Materials and Methods:
We classified and identified the incidence and subtype of abdominal injuries and associated trauma, and identified variables related to morbidity and mortality.
Abdominal trauma was present in 248 of 300 cases; 172 patients with blunt abdominal trauma and 76 with penetrating. The most frequent type of abdominal trauma was blunt trauma; its most common cause was motor vehicle accident. Among patients with penetrating abdominal trauma, the most common cause was stabbing. Most abdominal trauma patients presented with other injuries, especially patients with blunt abdominal trauma. Mortality was higher among penetrating abdominal trauma patients.
Type of abdominal trauma, associated injuries, and Revised Trauma Score are independent risk factors for mortality in abdominal trauma patients.
Abdominal injuries; Incidence; Mortality; Patterns; Trauma
This paper describes a case of C7 radiculopathy in a professional rugby league player after repeated cervical spine trauma. The report outlines the management of the patient following an acute cervical hyperflexion injury with chiropractic manipulation and soft tissue therapies. It also presents a change in approach to include distractive techniques on presentation of a neurological deficit following re-injury. The clinical outcomes, while good, were very dependent upon the athlete restricting himself from further trauma during games, which is a challenge for a professional athlete.
A 30-year old male front row Australian rugby league player presented complaining of neck pain after a hyperflexion and compressive injury during a game. Repeated trauma over a four month period resulted in radicular pain. Radiographs revealed decreased disc height at the C5-C6 and C6-C7 levels and mild calcification within the anterior longitudinal ligament at the C6-C7 level. MRI revealed a right postero-lateral disc protrusion at the C6-C7 level causing a C7 nerve root compression.
Recommendations from the available literature at the present time suggest that conservative management of cervical discogenic pain and disc protrusion, including chiropractic manipulation and ancillary therapies, can be successful in the absence of progressive neurological deficit. The current case highlights the initial successful management of a football athlete, and the later unsuccessful management. This case highlights the issues involvement in the management of a collision sport athlete with a serious neck injury.
manipulation, chiropractic; non operative treatment; cervical, radiculopathy; sport, injury; rugby league
Injury or weakness of lower abdominal attachments and the posterior inguinal wall can be symptoms of a “sports hernia” and an underlying source of groin pain. Although several authors note conservative treatment as the initial step in the management of this condition, very little has been written on the specific description of non-surgical measures. Most published articles favoring operative care describe poor results related to conservative management; however they fail to report what treatment techniques comprise non-operative management.
The subject of this case report is a professional ice hockey player who sustained an abdominal injury in a game, which was diagnosed as a sports hernia. Following the injury, structured conservative treatment emphasized core control and stability with progressive peripheral demand challenges. Intrinsic core control emphasis continued throughout the treatment progression and during the functional training prior to return to sport.
The player completed his recovery with return to full competition seven weeks post injury, and continues to compete in the NHL seven years later.
Surgical intervention has been shown to be effective in the treatment of the “sports hernia.” However it is the authors' opinion that conservative care emphasizing evaluation of intrinsic core muscular deficits and rehabilitation directed at addressing these deficits is an appropriate option, and should be considered prior to surgical intervention.
groin pain; non-surgical treatment; sports hernia
To present an uncommon athletic soft tissue wound and its proper management.
Soft tissue wounds are common in athletic competition. However, the subcategory of puncture wounds due to impalement by foreign bodies is quite rare. Although initial observation of a puncture wound may show minimal injury and blood loss, one must be concerned about damage to underlying structures and risk of infection.
Fracture, tendon injury, neurovascular compromise, soft tissue injury.
When dealing with an impaled foreign object, it is vital to stabilize the injured area and leave the object in place. Prompt evaluation and removal by a physician is necessary. Also, the risk of infection is significant after a puncture wound, and prophylactic antibiotics should be considered.
Impalement by foreign objects is rare in sports, particularly hockey. Incorrect management of athletes with this injury could lead to additional morbidity.
Although puncture wounds and impalement by foreign objects are not frequently seen in athletes, proper recognition, treatment, and management are essential to avoid complications and loss of function.
puncture wounds; impalement by foreign objects; impalement by foreign bodies
To provide an overview of the general legal principles of negligence for sports medicine professionals and apply these principles to situations involving athletes with head injury.
Case law dating back to 1976 and recent studies of sport-related concussion.
One of the most difficult problems facing athletic trainers and team physicians is the recognition and treatment of sport-related concussion. Providing medical clearance for sports participation and treatment of athletic injuries involves legal as well as medical issues. The threat of lawsuits exists for the sports medicine professional, whether the athlete is allowed to play or not. In general, established medical malpractice principles govern claims by athletes for injury or death caused by improper treatment by health care providers. The elements of negligence are examined, as well as the primary defenses an athletic trainer would use in court and risk management techniques to avoid litigation.
Athletic trainers may protect themselves from liability by including standardized cognitive or postural stability testing in preparticipation examinations, using objective tests rather than subjective judgement to evaluate athletes who have sport-related concussion, working closely with physicians, and keeping excellent records.
negligence; duty; breach; causation; damage; reasonable person standard