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Chiropractic Sports Physician

The Role of the Chiropractic Sports Physician

The Chiropractic Sports Physician (CSP) performs diverse and multifaceted roles to include the following;

1. Athlete examination prior to sports participation.

2. Testing to determine the athletes fitness level.

3. Creation and implementation of exercise strength training protocols.

4. On field assessment of athletic injuries.

5. On field trauma care / provision of therapeutic measures during the period between the time of the injury until the arrival of emergency medical personnel.

6. Medical decision making regarding the injured athlete's ability to return to athletic competition.

7. Interpersonal relationships with individual athletes, parents, coaches, athletic trainers, school administrators and other medical personnel.

8. Diagnosis of sports related injuries.

9. Utilization of appropriate rehabilitation treatment methodologies to enhance the return to active sports participation

10. Documentation and record keeping.

The demand for qualified CSP's has increased commensurate with the increased number of people participating in sports and fitness endeavors and the increased number of sports related injuries.

Athletic Participation / Injury Statistics For the U.S.

· 40 million Americans play tennis.

· 25 million Americans jog on a regular basis.

· 14 million people play racquetball. [1]

· 70% of all sports injuries happen to athletes between the ages of ten and twenty - four.

· 40% of all sports injuries happen to children under 15 years of age.

· 63,000 people are injured yearly in golf.

· 84,000 people are injured yearly in bowling.

· 250,000 people are injured playing volleyball. [2]

· Over 100,000 people seek emergency room treatment for skateboard-related injuries per year. [3]

Chiropractic Sports Physician Interactions

Relationship With The Athlete

· It is imperative to develop a comfort level with the athlete. Become familiar with the demands which are placed upon the athlete (demands relative to their position, and training, as well as familial and academic demands.)

· Clearly explain to the athlete your sports and educational background.

· Offer the athlete information regarding the chiropractic profession.

· Discuss with the athlete the array of treatment services that you are capable of offering and the efficacy of chiropractic treatment.

· Assure the athlete that as the CSP you possess the authority to make the final clinical determination regarding their return to sports participation following an injury.

· Get the athlete's consent to evaluate and treat them. In the case of a minor, get the parents consent for treatment.

· Advise the athlete / or the athlete's parents as to the status of their child's injury, diagnosis, treatment plan, prognosis and expected date of return to competition.

· Be on the alert for signs of drug use such as anabolic steroids and ephedrine, which influence the cardiac and respiratory systems and psychotonic stimulants, such as amphetamines, which effect the central nervous system. Council the athlete regarding the adverse physical effects of drug usage.

· Familiarize yourself with the diagnosis and treatment of infectious disease.

Relationship With The Coach

· Prior to becoming a team's physician, clearly discuss with the coach and come to an agreement regarding your clinical decision making authority relative to clearing an athlete for sports participation, treatment, exercise protocol planning and monitoring and the eventual return to athletic competition following injury.

· Make clear to the coach that your primary concern is the health and well being of the athlete.

· Give the coach general guidelines regarding the healing process, duration of care and timeframes for return to competition following specific injuries. For example, a mild bicep strain may not necessitate removal from a game while a moderate ankle sprain may require the absence from competition for 2-4 weeks and intensive rehabilitative therapy.

· Familiarize the coach regarding your athletic history and educational background. Illustrate the efficacy of chiropractic treatment.

· Ascertain the authority to order a conference with the coach, athlete, and parents of the minor athlete to discuss treatment, return to competition and suspected drug use.

· Become familiar with coaching principles and the demands placed upon the coach.

· Develop a strong working relationship with the coach predicated on trust and respect.

Relationship With The Team

· Educate yourself regarding team dynamics, such as "the star system", the roles of starters verses substitutes, position competition, team camaraderie, team jealousies, team bonding and cliques, team perception of the coaching staff, school administration and athletic facilities.

· Be consistent and treat each team member fairly and equally regardless if they are the star athlete or a substitute role player.

· Always maintain your position of authority.

Relationship With Other Health Care Providers Affiliated with the Team

· Determine each of the team physicians and trainers roles and responsibilities. Determine whether the trainer or the Chiropractic Sports Physician is responsible for taping the athlete, fitting the athlete with athletic equipment and supports and prescribing / providing treatment.

· Ascertain who possesses the ultimate authority to determine the athlete's ability to participate in a contest and the date of return to competition following injury.

· Work in unison with the other health care providers and affiliated staff. Develop unified treatment goals, plans and guidelines.

Chiropractic Sports Physician Experience

The vast majority of CSP's will gain experience as team physicians working with youth leagues, junior high school and high school teams. Since these teams have small or no operating budgets at all, they would readily embrace having the CSP on staff on a voluntary basis. Working with these teams allows the CSP to gain valuable, practical team physician experience.

Some CSP's will have the opportunity to receive compensation from high school, college and professional teams for their services. The level of compensation is often negotiable depending upon budgetary constraints and the Chiropractic Sports Physician's level of expertise. These paid positions are not as easy to come by voluntary positions. Often the paid team physician positions are required to have personal contacts with team officials responsible for health care staffing. Remember, a large percentage of the college and professional teams have contracts with large medical conglomerates (such as the Philadelphia Eagles and Nova Care), who dictate team physician operations. Some of these medical conglomerates have a bias against chiropractic and will not use the services of a CSP. Others will offer the CSP a limited role in their organization. Very few, offer unlimited access and equality as the teams physician.

Preparticipation Examination Of The Athlete

· Unlike patient examinations which take place in your chiropractic office, the athletic examination typically involves a healthy individual. The purpose of the athletic examination is to determine the athletes health status, preparedness for participation in a particular sport, and their performance potential. The athlete examination is performed to garner information regarding the athletes present health status which can then be used for comparison with subsequent examination findings. The examination is further performed to rule out or detect conditions that would preclude or restrict their participation in sports.

· Be cognizant of the athlete who attempts to withhold medical information or down play previous injuries for fear that this information will prevent sports participation.

· In the athlete examination, more focus and greater emphasis is placed on morphological measurements, strength, cardiovascular fitness, flexibility, agility and coordination testing.

· The ultimate question which must be answered by the athlete examination is whether or not the athlete is ready to play.

Synopsis of the Preparticipation Athletic Examination

· Case history taking with emphasis on the athletes sports history (sport played, position played, previous injuries etc.)

· Vital signs (blood pressure, (120/80); pulse (72 beats per minute); temperature (98.6°); and respirations (14-18 respirations per minute).

· Height and weight.

· Morphologic determination (ectomorph (thin); endormorph (obese) and mesomorph (muscular).

· Head, neck, chest, waist, thigh, knee, calf, ankle, upper and lower arm and wrist measurements. This is valuable information if the CSP is responsible for fitting the athlete with equipment.

· Muscle strength testing.

· Range of motion testing using inclinometry.

· Gait assessment (foot flair / pronation / supination/ eversion / inversion; coxa and genu valgum / varum; anatomical variants such as Morton's Foot and hallux valgus.) Morton's Foot is characterized by the second toe being longer than the big toe. As a result the inner border of the foot bears weight longer than normal in the support phase of the foot strike, causing over-pronation of the foot. Hallux valgus is a deformity in which the big toe points away from the midline of the body towards the outside of the foot. The second toe overrides the big toe causing over-pronation. More than 50% of all joggers have pronation abnormalities due to over use.

· Other Foot Conditions

1. Pes Planus (low arched or flat feet).

2. Pes Cavus (high-arched feet).

The cavus foot is more common in women, is relatively rigid and inflexible and is not well suited to the demands of certain running sports like distance running. Distance running can require tens of thousands of foot strikes per training session. It is not uncommon for these athletes to run hundreds of miles per week. The demands of distance running combined with foot abnormalities can easily lead to overuse injuries.

· Orthopedic Evaluation

· Neurological Evaluation

Cerebrum: alert, orientated to time and space, cooperative, emotionally labile or unstable.

Cerebellum: ataxia (a blocked ability to coordinate movements; a staggering walk and poor balance which may be caused by damage to the spinal cord or brain.); dysmetria (an abnormal condition that prevents the affected person from properly estimating distances linked to muscular movements, such as reaching for an object); dyskinesia (impaired ability to make voluntary movements).

Mensuration: thigh (6 inches above the pole of the knee), calf (4 inches below the pole the knee), leg length, inspiration/expiration.

Deep tendon reflexes: bicep (C5, 6-musculocutaneous nerve); tricep (C 6, 7, 8-radial nerve);brachioradialis (C 5, 6-radial nerve); knee/patellar (L 2, 3, 4-femoral nerve); ankle (S 1, 2-tibial nerve).

Superficial reflexes: upper/lower abdominal (T 8--12); plantar response (L 4, 5, S 1 and 2).

Muscle strength grading: hip flexors (L 2, 3); hip extensors (L 4, 5); knee extensors ( L 3, 4); knee flexors (L 5, S 1); ankle extensors (L 4, 5); ankle flexors (S 1, 2).

Pathological reflexes—Babinski-the single most important pathological sign in neurology. Stroke the sole of the foot. With a positive Babinski you will see extension of the big toe and fanning of the toes. The following tests will elicit a Babinski sign; Chaddock-Stroke the lateral malleolus; Oppenheim- Stroke downward on the anterior tibia; Gordons-Squeeze the calf muscle; Schaffers – Squeeze the achilles tendon.

Rossolimo’s-Tap the ball of the foot. A positive Rossolimo test will cause dorsiflexion of the big toe and flexion of the toes.

Sensory appreciation to: light touch, pin prick, vibration, heat/cold, two point discrimination and proprioception.

Cranial Nerves

I. Olfactory Nerve — smell

II. Optic Nerve — sensory. The light reflex. A light shined on the retina causes reflex pupillary constriction of that eye (direct light reflex) and also of the opposite eye (consensual light reflex). Accommodation is the process by which a clear visual image is maintained as the gaze is shifted from a distant to near point. The three components of the reaction are:

1. Convergence of the eyes.

2. Pupillary constriction.

3. Thickening of the lens through contraction of the ciliary muscles.

Only the first two are visible to the examiner.

III. Oculomotor Nerve — test with CN4 and CN6

IV. Trochlear Nerve — test with abducens (CN6) and oculomotor (CN3) motor extraocular movement — 6 cardinal fields of gaze, identifying paralysis, weakness, nystagmus, conjugate movement (eyes moving together).

V. Trigeminal Nerve — sensory/motor — touch, pain, temperature, muscles of mastication, the trigeminal nerve has three branches including:

1. Ophthalmic.

2. Maxillary

3. Mandibular.

Testing of trigeminal nerve through palpation, i.e., jaw jerk reflex or sensation w/ a cotton wisp in the three branches.

VI. Abducens Nerve — motor

VII. Facial Nerve — sensory/motor — taste (anterior two thirds) and facial expression — corneal reflex, using a cotton wisp against the cornea, the ability to feel is assessed by the trigeminal nerve. The blinking would be an assessment of the facial nerve.

VIII. Vestibulo/Cochlear Nerve, i.e., balance and hearing

IX. Glossopharyngeal — sensory/motor — taste, posterior 1/3 of tongue and muscles of swallowing

X. Vagus Nerve — sensory/motor — gag reflex — assessed by having the patient swallow and identifying dysphagia.

XI. Spinal Accessory Nerve — sensory/motor — trapezius — SCM, test by having the patient turn head and shrug shoulders against resistance.

XII. Hypoglossal Nerve — motor — musculature of the tongue.

· Vascular Screening (check pulses and perform George's and Thoracic Outlet Tests (Allen's Arterial Occlusion; Adson's Scalenus Anticus; Eden's Costoclavicular; and Wright's Hyperabduction Tests)

· Examine the eyes, ears, nose, throat, skin, hair, nails, heart, lungs, abdomen and genatalia.

· Check for inguinal hernias - a bulge that appears on straining suggests a hernia.

A. Indirect Inguinal Hernia - most common; all ages; both sexes; most often in children; the point of origin is above the inguinal ligament near its midpoint extending often into the scrotum. With the examining finger in the inguinal canal during straining or coughing the hernia comes down the inguinal canal and touches the examiners fingertip.

B. Direct Inguinal Hernia - less common than the indirect; usually seen in men over 40; rare in women; found near the pubic tubercle near the external inguinal ring; rarely courses into the scrotum. While examining, this hernia bulges anteriorly and pushes the examiners fingertip forward.

C. Femoral Hernia - least common type; more common in women then men; found below the inguinal ligament and more lateral than an inguinal hernia; easily confused with lymph nodes; never courses into the scrotum. While examining, the inguinal canal is empty.

· If your findings suggest a hernia, gently try to reduce it by returning it to the abdominal cavity by sustained pressure with your finger. A hernia is incarcerated when its contents cannot be returned to the abdominal cavity. A hernia is strangulated when the blood supply to the entrapped contents is compromised. The presence of tenderness, nausea and vomiting suggests a strangulated hernia.

· Perform routine urinalysis. Conversely, x-rays are not considered a part of a routine preparticipation athlete examination.[4]

Physical Fitness Testing Components

Physical fitness components include: cardiorespiratory capacity, muscular strength, muscular endurance, and flexibility

Cardiorespiratory Capacity

Cardiorespiratory capacity can be defined as the functional efficiency of the heart and lungs.

Activities which exercise the large muscles of the trunk and legs are the most effective way to develop cardiorespiratory capacity.

Heart-lung capacity is the most important component of physical fitness and physical work capacity. The transport of oxygen to the cells maintains life, and increased cardiorespiratory capacity improves the ability to concentrate. A high state of cardiorespiratory training may prevent decreases in mental acuity due to aging. Older runners averaging 42 miles weekly do not show the decreased reaction time usually seen in the aged.

Cardiorespiratory capacity, also referred to as cardiovascular, circulatory, or circulo-respiratory fitness, can be measured in several ways:

with a treadmill, a stepping bench, or a stationary bicycle. These methods measure the heart rate during exercise.

Other methods, such as the Cooper 12-minute run, measure the distance traveled in a given amount of time or the time required to run a certain distance as in Cooper's 1.5-mile test. Although some tests of cardiorespiratory capacity are not strenuous, others involve maximal effort, such as running to exhaustion on a treadmill.

Sports specific exercise training is required for most sports, including tennis, long-distance running, sprinting, football, baseball, wrestling, and swimming. Being trained for one sport does not guarantee fitness for other activities. Typically, long-distance runners perform exceptionally well on tests of cardiorespiratory capacity, but have weak, arm, chest and shoulder strength. Conversely, weight lifters and body builders exhibit low cardiorespiratory fitness but excel in tests of muscular strength and endurance.

Muscular Strength

Muscular strength is the maximum amount of force that a muscle or muscle group can exert. It can be measured by observing the maximum amount of weight lifted with a specific movement for one repetition or the amount of tension developed when exerting against a strain gauge. The first type of muscular contraction is a measure of isotonic strength and the amount of weight lifted once is referred to as the one repetition maximum. Isometric strength is measured by strain gauges such as the back and leg or grip dynamometers, or the cable tensiometer, which record the amount of force exerted in a maximal effort.

Muscular strength can be developed by progressive resistance exercise strength training methodologies.

Muscular Endurance

Muscular endurance is the capacity of a muscle or muscle group to perform repeated contractions or to maintain an isometric contraction for an extended period of time. Endurance training is aimed at gradually increasing the number of repetitions or the amount of time an isometric contraction is held, rather than increasing the amount of resistance or weight. Exercises such as push-ups, pull-ups, and sit-ups develop muscular endurance. Lifting light weights for a greater number of repetitions than is required to develop strength will also improve muscular endurance.

Flexibility

Flexibility refers to the range of joint motion and is defined as that quality of the muscles, ligaments, and tendons that enables them to move easily through a complete range of movement. Joints which are exercised regularly through a full range of motion will exhibit more flexibility than unexercised joints.

Flexibility can be measured by devices like the goniometer or by direct linear measurement. There are two fundamental types of flexibility or stretching exercises. Active stretching is characterized by bouncing and is sometimes referred to as ballistic or dynamic stretching. Passive stretching is achieved by holding a muscle at greater than resting length. The recent trend in athletic training is to have the athlete perform a combination of stretching techniques. Passive stretching is recommended for pre-competition training sessions while active, dynamic, sports specific stretching immediately prior to competition enhances sports performance. Example of dynamic stretching maneuvers include windmill arm and high step movements.

Athletic Ability

Athletic ability (motor ability) is the level of efficiency someone exhibits when he or she learns and performs motor skills. Superior athletic ability is a compilation of genetics and learned behaviors.

Factors contributing to successful motor performance include depth perception, ability to visualize spatial relationships, arm control, sensory rhythm, timing, and motor rhythm. Motor ability is a combination of coordination, agility, power, balance, reaction time, and speed.

BALANCE

Balance is a specific kind of coordination which permits someone to maintain equilibrium while moving (dynamic balance) or in a stationary position (static balance).

POWER

Power involves muscular strength and refers to the exertion of muscular force for a brief period of time, or explosive muscular contraction. Powerful movements are useful in most sports: the dunk in basketball, the tackle in football, the knockout punch in boxing, the sprinter's start, and the home run in baseball. Explosive power is enhanced by plyometric training.

AGILITY

Agility is the ability to change direction while moving at or near full speed. Agility is especially important in soccer, ice hockey, judo, football, and basketball.

SPEED

Speed is the capacity to move quickly through short distances from point A to point B. Timed 40, 60, 100 yard dashes are common tests of speed.

REACTION TIME

Reaction time is that brief period required for voluntarily responding to a sound stimulus such as a whistle, a horn or a buzzer. Reaction time is important in activities where quick starts are important such as sprinting, defensive baseball play and wrestling.

COORDINATION

Coordination is the smooth flow of movement during the performance of motor tasks. Coordination involves the combined use of the eyes with the head, hands, and feet as required in hitting, throwing, catching, striking, and kicking balls.

Athletic Ability Testing

Flexibility Test Norms

1. Trunk Extension - In the prone position, the legs are held firmly by a partner. With the fingers laced behind the neck, raise the head and chest upward and backward. Measure the distance from the floor to the chin. Twenty (20) inches is a pass.

2. Trunk Flexion - Bend forward from a sitting position with the heels 18 inches apart. Keep the knees locked. To pass, the forehead must reach a point 8 inches or less from the floor.

3. Shoulder Flexion - In the prone position with chin touching the floor and a ruler grasped by both hands, raise the hands as high as possible from the floor - 18 inches is a passing performance.

4. Back Flexion - Kneeling and with the toes pointed back, lean back as far as possible. This test is passed by touching the head to the mat.

5. Back and Leg Stretch - Place the hands palm down at the side while lying in the supine position. Take the feet back over the head and touch your toes to the mat.

If you can touch your knees to the mat beside your ears, you have above average flexibility.

.

Strength Tests Norms

1. Squat Hand Balance - Assume a squatting position. Place the palms flat on the floor and the elbows touching inside your legs just below the knees. Balance your body on the hands by leaning forward and raising the toes from the floor. Holding this position for 20 seconds is indicative of having above average strength.

2. Extension Press-up. Lying face downward (prone) with the arms extended forward and elbows and knees rigid, lift your body by pressing on the hands and feet and contracting the small back muscles. The abdomen should be raised 4 inches from the floor at least once. A superior rating is given for 15 repetitions. Women can use their forearms, not the palms. Holding for 20 seconds suggests above average strength.

3. Head or Neck Bridge - Lie on back, arms folded across chest or hands on thighs, and arch back so body is supported by feet and head. The ability to hold for 60 seconds suggests above average strength.

4. Stick Body - Lie in the back leaning rest position with your head on partner's knee and feet on floor. Place the hands on the hips and hold. Holding for 30 seconds equals above average strength.

5. Back or Reverse Push-up - Assume the neck bridge position with hands on the mat beside the ears. Push up to a position where the elbows are locked. One repetition is sufficient. The capacity to perform 20 or more can be a measure of muscular endurance. This movement also involves a flexibility component.

6. One Hand Pull-up - Grip the chinning bar with one hand, palm facing away from the body, and place the other hand around the wrist of the hand holding the bar. Repeat with the other arm. Another pull-up test of strength: grasp the bar with both hands facing away and pull-up to a position where the head is in front of the bar behind the neck pull-up). Superior strength 20 or more pull ups; average strength 10-15; poor strength 4 or less.

7. Push up Test - The most reliable measure of absolute strength is not surprisingly, the maximum amount of weight you can lift once. Push-ups are a safe test of strength. Assume the standard position, with your arms locked and your body straight. Bending your arms, touch your nose to the ground, then press yourself back up. Do as many as you can without bouncing, resting, or losing your form.

How Do You Measure Up?

Age	20-29	30-39	40-49	50-59	60-69
Excellent	>40	>31	>24	>23	>23
Good	30-40	24-31	19-24	14-23	11-23
Average	24-29	19-23	13-18	10-13	9-10
Fair	18-23	14-18	10-12	7-9	6-8
Poor	<18	<14	<10	<7	<6

[5]

8. Sit up Test.

Coordination Tests

In a standing position, with eyes closed, extend your right arm horizontally to the side. Touch the tip of your nose three times in succession with your right index finger, returning your arm to your side between trials. Repeat the same movements with your left index finger. Then extend both arms horizontally to the sides. Bring the index fingers together three times at arm's length in front of your body, returning your arms to your sides between trials. Next, sit on a chair with both feet on the floor. Touch the heel of your right foot to your left knee cap three times in succession, returning your foot to the floor between trials. Repeat these movements with your left foot and right knee cap. Each successful touch is a hit and each failure is a "miss." You must score eight or more "hits" to pass this test.

Agility Tests

1. Timed agility runs around cones (Illinois agility run)

2. Six Count Agility Test - From a standing position, squat with the hands between the legs. Thrust the legs to the rear, assuming a front leaning rest position. Then swing the legs to the side and forward, assuming a back leaning rest position. Turn over, return to the squat position, and then stand up. Four complete repetitions must be completed in 20 seconds to pass. A variation for women does not include step 3, thus making the movement a squat thrust. Must be completed in 10 seconds for a pass.

3. Kneeling Jump - Spring to the feet and hold balance for 3 seconds.

4. Jack Spring - Touch hands to toes at least waist high 5 times in succession.

Balance Tests

The foot-and-toe test and Diver's Stance Test are two other frequently used tests of balance. For the foot-and-toe test of balance, stand flat on one foot for ten seconds, then rise up to a toe-stand for ten seconds. You may keep your eyes open and move your hands at will to maintain your balance. For the Diver's Stance Test, stand on tiptoe with your heels together and your hands held horizontally forward. Close your eyes and hold the position for 20 seconds without shifting your feet or hands.

Tests of Power

A. Basketball Throw - The throwing position is on a mat with the knees parallel and the lower legs perpendicular to the throwing line. The non-throwing hand can be used to steady the ball when preparing to throw. The Floor or mat cannot be touched during or after a throw. Three trials are taken with each being measured to the center of ball impact.

· 75 or more feet = superior strength (men)

· 54 ft. or less = poor strength (men)

B. Standing Long Jump - Spring from a standing position with no prior foot movement. Three trials are taken with jumping distance being measured from the starting line to the rearmost point of heel contact. Average power in a child is being able to long jump a distance equal to their height.

Test Norms

Test	Rope-Skip	Pull-up	Flexed Arm Hang	Bent-Knee Sit-Up		Basketball Throw		Standing Long Jump		Illinois Agility Run
Measure	Rotations, 1 Minute	Reps	Seconds	Repetitions, 1 Minute		Feet		Feet, Inches		Secs.
		Men	Women	Men	Women	Men	Women	Men	Women
Superior	171 or more	20 or more	40 or more	52 or more	40 or more	75 or more	50 or more	8' or more	6'11" or more	15.5 or less
Above Average	157-170	16-19	30-39	47-51	35-39	67-74	46-49	7'6"-7'11"	6'7"-6'10"	16-17.5
Average	138-156	10-15	23-29	41-46	29-34	61-66	40-45	7'1"-7'5"	6'1"-6'6"	18-21
Below Average	125-137	5-9	18-22	36-40	24-28	55-60	36-41	6'9"-7'1"	5'10"-6'	21.5-23
Poor	124 or less	4 or less	17 or less	34 or less	23 or less	54 or less	35 or less	6'8" or less	5'9" or less	23.5 or more

[6]

Rating of Sports and Activates for Physical Fitness

Physical Fitness	Jogging	Bicycling	Swimming	Skating(Ice, Roller)	Handball / Squash	Skiing (Nordic)	Basketball	Skiing (Alpine)	Tennis	Calisthenics	Walking	Golf	Softball	Bowling
Cardiorespira-tory endurance (Stamina)	21	19	21	18	19	19	19	16	16	10	13	8	6	5
Muscular Endurance	20	18	20	17	18	19	17	18	16	13	14	8	8	5
Muscular Strength	17	16	14	15	15	15	15	15	14	16	11	9	7	5
Flexibility	9	9	15	13	16	14	13	14	14	19	7	8	9	7
Weight Control	21	20	15	17	19	17	19	15	16	12	13	6	7	5

Ratings were calculated on the basis of regular (minimum four time weekly) and vigorous (30 to 60 minutes per session) participation in each activity. The maximum possible score is 21, with 0 to 3 points awarded for each fitness component. Ratings for golf are based on the fact that many Americans ride a golf cart. The physical fitness value moves up appreciably for golfers who walk. [7]

1.5 Mile and 12 Minute Walk / Run Test Norms

		1.5 Mile Test (time)	12 Minute Walk / Run (distance, miles)
Superior	Men Women	<8:37 <11:50	>1.87 >1.52
Excellent	Men Women	8:37-9:40 12:29-11:50	1.73-1.86 1.44-1.86
Good	Men Women	9:41-10:48 14:30-12:30	1.57-1.72 1.30-1.43
Fair	Men Women	10:49-12:10 16:54-14:31	1.38-1.56 1.19-1.29
Poor	Men Women	12:11-15:30 18:30-16:55	1.30-1.37 1.00-1.18
Very Poor	Men Women	>15:31 >18:31	<1:30 <1.00

[8]

Conditions Which May Preclude Athletic Participation

· Acute and chronic disease processes.

· Hernia.

· Systolic blood pressure over 140 and diastolic pressure over 90.

· Heart arrythmias (tachycardia and bradycardia).

· Recurring injuries, such as joint dislocations.

· Repetitive concussions.

· Surgical losses of a major organ such as a kidney.

· Emotional or mental problems.

· Infectious skin diseases.

· Impaired vision.

· Heart disease

· Joint fusions.

· Epilepsy

· Spina bifida

· Disc herniation

· Structural deformities.

· Fractures, surgically repaired utilizing pins, and screws etc.

· Fever / inner ear conditions / vertigo / tinnitis / dizziness and fainting.

Before excluding an athlete from competition, due to an injury or condition, the CSP must determine the following;

1. Given the requirements of the sport, will participation risk further injury or result in a permanent injury.

2. Are there training methods available, such as bracing, taping etc. which would compensate for the injury and allow for participation.

3. Are there medical treatment methods available, provided by the teams medical personnel, such as pain medication, which would allow for participation (controversial issue).

4. Would the presenting condition or injury generally be considered a legitimate, clinical reason for excluding the athlete from participation.

5. Is there medical possibility or probability that the injury will adversely affect the athletes performance or place other team members at risk.

Injuries

Three general types of injuries are sustained during physical activity:

· Direct injury.

· Indirect injury.

· Overuse injury.[9]

Direct Injuries

Injuries caused by direct physical contact, such as fractures and concussions are examples of direct injuries. This type of injury occurs most frequently in contact and collision sports such as football, basketball, baseball, rugby, soccer, wrestling and boxing. Initial treatment for these injuries (bruises or contusions) is essentially the same as for indirect injuries-rest, ice, compression and elevation.

Indirect Injuries

Indirect injuries are caused by violent forces not involving physical contact, mostly strains, sprains, and muscle tears. A strain is a tear in a muscle-tendon complex (tendons attach muscles to bones) and is graded first-, second-, or third-degree depending on the severity of the injury. A first-degree strain heals readily and permits an early return to activity. Second-and third-degree injuries, however, require careful treatment. Returning to activity too quickly will delay healing and promote the formation of scar tissue, which in turn will decrease strength and flexibility.

A torn ligament (ligaments bind bones together at the joints) is referred to as a sprain. Similarly, sprains are classified as first-, second- or third degree. First- and second-degree lateral ankle sprains are the kind most commonly seen in active people. Most third-degree sprains require surgery. In third-degree sprains, it's imperative that the injured area be completely immobilized.

First-degree sprains should be treated with rest, as many as five 20-minute ice applications, a compression bandage, and elevation during the first 24 to 48 hours following injury. This treatment, sometimes referred to as RICE or ICE, should also be accompanied by two or three days rest or the use of alternative physical activities (swimming or stationary bicycling, for example). Second- and third-degree sprains are treated the same way, but may require casting or surgery and up to six weeks or more for recovery.

Overuse Injuries

Overuse injuries can occur as the result of excessive repetitive movements. Common overuse injuries include rotator cuff tendonitis, medial and lateral epicondylitis (medial-Little Leaguers elbow; lateral-tennis elbow), chondromalacia patella (patellar tracking dysfunction) and shin splints.

Jogging requires as many as 5,000 foot strikes per hour and one million or more annually for regular joggers. Runner's World magazine surveyed 4,000 runners; almost 70% of them indicated that they had been limited by running-related injuries in the preceding year. [10]

Shin Splints

The term shin splints refers to several conditions in front of or along side the shin bone which usually are not serious but can be: inflammation of a tendon (tendinitis), muscle tears or strains, or stress fractures of the tibia (shin bone) or fibula. These conditions are caused by one of the following reasons or a combination of them: inadequate or no warm-up, running or jumping on hard surfaces or uneven ground, poor shoes, the sudden addition of sprinting to a workout or training program, introducing hill training to a jogging program (including downhill), and jogging with ankle weight.

The soreness caused by a muscle tear is thought to be associated with a slight tearing of the connective tissue attaching it to the shin bone. The pain may be accompanied by reduced ankle flexibility. Shin splints can be prevented by avoiding excessively heavy early training and wearing well fitting and adequately cushioned shoes.

Five Most Common Overuse Injuries of Runners and Some Preventive Measures

INJURY SUGGESTED PREVENTATIVE MEASURES	CAUSES	SUGGESTED PREVENTIVE MEASURES
Knee (chondromalacia patellae)	Irritation of the kneecap as the result of excessive knee rotation with foot strike.	Heel and/or arch supports, quadriceps strengthening exercises.
Achilles tendon	Short Achilles (additional tightness acquired with running, accompanied by irritation and inflammation).	Quarter-inch thick heel lift, calf stretching exercises.
Shin splints	Poor ankle flexibility, weak shin muscles, stiff shoes. Frequently occurs in sedentary individuals who initiate an exercise program too vigorously.	Shoes with flexible forefoot and heel lifts; stretching and shin strengthening exercises.
Ankle	Stepping on un-even surfaces, chronic ankle problems can be caused by excessively worn shoe heels and/or too widely flared heels.	Shoes without excessively wide heels, shoe heels not worn down more than a quarter inch; ankle strengthening exercises.
Heel	Inadequate padding under heel to absorb impact of foot strikes, heel instability, irritation from shoe back.	Shoes with wide heel base and a good heel lift; calf stretching and shin strengthening exercises.

Adapted from: Henderson, J. First-aid for the injured. Runner's World 12:57,1977 (July).[11]

Other Conditions Affecting the Athlete

Illnesses Affecting the Athlete

1) Asthma

· Bronchial asthma affects approximately nine million Americans and may be responsible for more than 2,000 deaths annually. It's the number-one chronic illness of childhood as well as the greatest cause of school absenteeism in those 17 years old and younger. Asthmatics suffer from chronic fatigue, which leads to inattention in school and they can become socially maladjusted if they don't participate in physical activities or active games.

· Many asthmatics suffer from increased airway obstruction after exercise. This condition is referred to as either exercise-induced asthma or exercise-induced bronchoconstriction.

· Exercise-induced asthma attacks are similar to those induced by other types of asthma. It's usually most extreme 5 to 10 minutes after the completion of exercise; breathing may not return to normal for up to an hour.

· Swimming is the exercise of choice for asthmatics and the one most frequently prescribed by physicians. Patients in a five-month swimming training program demonstrated a significant decrease both in the number of asthma attacks and their medication requirements. In addition, they improved cardiovascular fitness.

· In swimming, the horizontal position and the effects of water pressure may reduce the incidence and severity of asthma attacks. The rhythmic breathing required during swimming is probably another inhibiting factor. Also, inhaling moisture-saturated air appears to reduce or prevent exercise-induced bronchoconstriction. Asthmatics should swim for exercise unless it increases asthmatic symptoms or causes respiratory tract complications.

· 15% to 20% of chronic asthmatics have eczema which can be aggravated by exposure to chlorinated water.

· Those with severe asthma should avoid contact sports.

· For those asthmatics requiring medication, bronchoconstriction can be modified effectively with theophylline, theophylline ephedrine combinations, or cromolyn sodium. Cromolyn sodium and aerosol terbutaline either singly or in combination are the preferred medications for preventing or reducing asthma attacks in competitive athletics. Oral formulations taken 30 to 60 minutes prior to exercise are preferred.

· Short intervals of exercise (one to two minutes) promote lung ventilation in asthmatics, but periods of four to twelve minutes appear to cause wheezing, especially in those who are deconditioned or inactive. For this reason, interval training is usually more effective than continuous exercise

2) Diabetes

· Many diabetics have reduced or eliminated their insulin requirements by exercising, following a careful diet, not smoking, and controlling their weight. Diabetes can also be controlled with regular exercise, to include vigorous, rhythmic, cardiovascular exercise. Insulin injected into the leg is absorbed more quickly when the leg is exercised. This accelerated absorption may cause hypoglycemia (low blood sugar) and dizziness and other problems. The use of a non-exercised injection site (the arm or abdominal area) appears to remedy this reaction. Diabetics can decrease their insulin requirements by exercising moderately after meals.

· Diabetes Insipidus - an uncommon form of diabetes marked by extreme thirst and heavy urination (as much as 2 1/2 gallons per 24 hrs.) Caused by an insufficient amount of the hormone ADH (Antidiuretic Hormone) which regulates the amount of urine produced in the kidney.

· Diabetes Mellitus - caused by either a failure of the pancreas to produce / release enough insulin into the body (Type I) or a defect in the parts of cells that accept the insulin (Types II, III, & IV).

· Type I - insulin dependent diabetes mellitus / Juvenile diabetes. This is the most serious form of diabetes. Islet cell antibodies limit the production of insulin by the pancreas. Primarily found in children but can also be found in adults.

· Type II - noninsulin dependent diabetes mellitus - patients are not dependent on insulin to preserve life but may be treated with insulin. 60-90% of these diabetics are obese.

· Type III - gestational diabetes mellitus - glucose intolerance which occurs during pregnancy.

· Type IV - diabetes mellitus attributable to diseases of the pancreas, hormonal changes, genetic defects or drug use.

3) Convulsive Disorders (Epilepsy)

Decisions to allow epileptics to participate in sports and physical activity should be influenced by three factors;

1. The effectiveness of medication in controlling seizures.

2. The possibility of endangering the participant's welfare.

3. The patient's cooperativeness and impulsiveness. Past responses to competition can be an indicator.

· In 1974, the American Medical Association's Committee on the Medical Aspects of Sports concluded that an epileptic whose seizures are under reasonable control would not be endangered by participation in any sport, including football. This was revised in 1976 to recommend that epileptics with incompletely controlled seizures should be excluded from collision sports; football, hockey, lacrosse, rugby; contact sports; baseball, basketball, soccer, wrestling, and non-contact sports: crew, cross-country, swimming, tennis, track, volleyball. Following some controversy, the 1974 guidelines were re-instituted with a qualification - that epileptics whose conditions are not completely controlled by medication forego competition in archery, discus, javelin, shot put and riflery.

· More than two million Americans are affected by epilepsy.[12]

Other Common Conditions Affecting the Athlete

1) Stitch

A stitch is a stabbing pain usually felt at the bottom of the rib cage during vigorous activity. Although the exact cause is not known, there are several theories:

1. Excessive gas in the large intestine. This may be the result of eating highly spiced food or an individual intolerance to foods such as milk due to an absence of certain intestinal enzymes which prepare them for digestion. Avoiding these foods and consuming alternative sources of the nutrients they provide may solve the problem. Cramps can be relieved by bending forward and gently squeezing the site of the pain to push the gas along.

2. Distended liver capsule. The increased cardiac output during exercise may cause the liver to be distended. The resultant pressure causes pain.

3. Diaphragm, rib, or abdominal muscle cramping is caused by lack of oxygen. The pain usually subsides when the intensity of the activity is reduced. Abdominal muscle conditioning may help prevent this problem.

2) Blisters

Foot blisters are burns produced by friction. To reduce friction:

1. Buy good shoes that fit well.

2. Never wear new shoes for a long workout or race.

3. Smear your feet with petroleum jelly or other lubricants to reduce "hot spots."

Blood blisters can be serious. An infected blister can kill. Redness, swelling or pain, and other signs such as red streaks may indicate the infection is spreading. Check for swollen glands behind the knee or in the groin area.

Drain simple blisters after you wash your hands and clean the affected area. Puncture the blister sac with a sterilized needle and carefully drain it. Do not remove the outer skin if possible; (blisters heal better when the skin is left in place) Clean the area with an antiseptic and cover with a sterile dressing.

3) Athlete's Foot and Jock Itch

"Athlete's foot" is a synonym for the itchy, runny, and scaly ringworm infections between the toes to which active people are particularly prone. These infections may be stimulated by exercise, hot weather, sweating, and tight shoes. Ringworm infections can also occur in the armpits and crotch ("jock itch").

To prevent or treat the infection be careful to thoroughly dry the armpits, crotch, and feet-especially between the toes. Treat the feet with a medicated powder after each training session and every shower. At the first sign of an itch, treat the area by drying it, exposing it to sunlight, and applying a powder or spray medication. A highly recommended medication agent is aluminum chloride.

Cerebral Concussion

A cerebral concussion is a clinical syndrome characterized by immediate, instant onset due to a mechanical force injury to the head. Cerebral concussion can result in transient impairment of neural function, such as disturbances of consciousness, visual disturbances, altered equilibrium, tinnitus, memory loss, and muscular weakness or flaccidity.

Additional Signs and Symptoms of Concussion

· Headache

· Nausea

· Vomiting

· Inability or difficulty communicating.

· Decreased pulse rate.

· Confusion.

· Inappropriate behavior.

The presence of a concussion does not require loss of consciousness. Following a blow to the head, the athletes reporting of seeing stars, a flash of light or blacking out, accompanied by dizziness, confusion, or loss of memory is highly suggestive of a concussion.

· Concussion is the most common athletic head injury. 20% of high school football players suffer a concussion during a football season.

· Patient does not need to lose full consciousness.

· Following a blow to the head the athlete may not have immediate symptoms.

· Repeated brain injuries can result in patterns of brain damage and steady decline in information processing.

· Repeated head injuries are cumulative.

Chronic effects of repeated head trauma causes traumatic encephalopathy characterized by:

A. Slow appearance of a fatuous or euphoric dementia.

B. Emotional lability.

C. The victim may be unaware of their deterioration.

D. Deterioration of memory and speech.

American College of Sports Medicine

Concussion Classifications

First Degree

A. No actual loss of consciousness.

B. Blurring of consciousness (bell rung) lasting less than 10-20 seconds. Minimal or no signs are present.

C. The only neurologic deficit is a brief period of post-traumatic amnesia lasting less than 30 minutes.

D. EEG, CT or MRI is usually not necessary after a mild concussion. If post-concussion syndrome occurs, these studies should be done.

Second Degree:

A. Blurring or loss of consciousness lasting 20 seconds to 1-2 minutes. Minimal to moderate symptoms and signs present.

B. Will rarely occur without a loss of consciousness. Typically there will be a protracted period of post-traumatic amnesia lasting over 30 minutes and less than 24 hours.

C. Generally overnight admission for observation and CT scan if necessary.

Third Degree:

A. Loss of consciousness lasting more than five minutes.

B. There will be loss of consciousness with a sustained period of post-traumatic amnesia lasting longer than 24 hours.[13]

Guidelines for the Management of Concussion in Sports

Sports Medicine Committee, Colorado Medical Society

Grading Scale for Concussion in Sports

I. Grade I Concussion - Most common yet most difficult form of concussion to recognize. Characteristics include:

· Confusion without amnesia.

· No loss of consciousness (athlete complains of having his bell rung).

· Remove the athlete from event pending on-site evaluation prior to return to the game.

II. Grade II Concussion:

· No loss of consciousness.

· Confusion.

· Amnesia following the impact (Post Traumatic Amnesia).

Treatment for a Grade II concussion:

1. Remove the athlete from the game.

2. Perform a thorough neurological examination.

3. Athlete is evaluated frequently over the next 24 hours for signs of evolving intracranial pathology.

III. Grade III Concussion:

· Loss of Consciousness.

· Amnesia.

Treatment Considerations

1. Suspect cervical spine injury.

2. Treat for shock.

3. Thorough neurological examination is required.

4. CT or MRI scanning is usually appropriate.

5. Hospital confinement is indicated if any signs of pathology are detected or if the mental status of the athlete remains abnormal.

6. If findings at hospital are normal, explicit written instructions may be give to the family for overnight observation. Neurological status should be assessed daily until all symptoms have resolved.

Testing Amnesia

A. Questions of Immediate Memory

1. Simple arithmetic.

2. Reverse spelling.

B. Questions of Recent Experiences

1. Events of the game.

2. Last play.

3. Opponents name.

4. Athlete's play assignments etc.

C. Questions of Memory Recall and Orientation to Time

1. Their name, School's name, Coaches name.

2. Orientation to time.

3. President's name.

4. Today's date.

Postconcussion Syndrome

Late effects of concussion:

· Headache, often with exertion.

· Dizziness.

· Fatigue.

· Irritability.

· Impaired memory and concentration.

The athlete should have a CT scan and neurological testing when symptoms persist. Also, the athlete should not return to activity until symptoms abate and / or diagnostic tests are normal.

Return to Play Considerations Following Concussion

The CSP's decision to return an athlete to competition following a cerebral concussion is dependent upon the grade of concussion and the athletes history of concussive events.

Concussion Scenarios

Grade 1

· Grade 1 concussion, (first event) -if the signs of concussion abate quickly and there are no symptoms during rest, the athlete may be able to return to the game. If symptoms persist during the game, do not allow return to the game. The athlete then must be asymptomatic at rest and during exertion for a period of one week before returning to play.

· Grade 1 concussion, (second event) - the athlete must be asymptomatic at rest and during exertion for two weeks before returning to play.

· Grade 1 concussion, (third-event) -disallow return to play for the season. Neurological evaluation and diagnostic testing clearance should be considered before allowing a return to play the following season.

Grade 2

· Grade 2 concussion, (first event) - the athlete should not return to play the day of the concussion. If the athlete remains asymptomatic at rest and during exertion for one week they may be able to return to play at that time.

· Grade 2 concussion, (second event) - the athlete should be removed from the game and should be excluded from competition for approximately four weeks. Return is dependent upon the athlete being asymptomatic at rest and during exertion for four weeks.

· Grade 2 concussion, (third event) - the athlete should be taken out of competition for the season. Medical clearance is required to return the following season.

Grade 3

· Grade 3 concussion, (first event) - the athlete is incapable of returning to the game and should not return for at least one month. Return is dependent upon the athlete being asymptomatic at rest and during exertion for four weeks.

· Grade 3 concussion, (second event) - the athlete should be out for the season. Medical clearance is required before returning and competing the following season.

· Grade 3 concussion, (third event) - the athlete should be advised to consider a sporting endeavor that does not have a risk of head injury.

· Many state athletic commissions have developed clearly defined rules relative to the sport of boxing, regarding return to competition following a concussion. For example, the New York State Athletic Commission stated that if a boxer is knocked unconscious, they can not return to boxing for 90 days.

Return to Competition Following a Neck Injury

Prior to authorizing a return to competition following a neck injury, examination of the athlete must demonstrate;

· Minimal or no neck complaints

· Full cervical range of motion with minimal pain.

· Normal muscle strength / reflexes and sensation.

On - Field Evaluation of an Injured Athlete

Level of Consciousness

Upon reaching the injured athlete perform the following fundamental survey:

Determine their state of consciousness - fully alert and responsive; slight disorientation; confused; in a stuperous sleep but awaken quickly; coma (some responses); deep coma (no response).

Glascow Coma Scale

Eyes	Open	Spontaneously	4
		To verbal command	3
		To pain	2
		No response	1
Best Motor Response	To verbal command	Obeys	6
	To painful stimulus	Localizes pain	5
		Flexion - withdrawal	4
	Cognitive function	Flexion - abnormal (decorticate rigidity)	3
	Spontaneous function	Extension (decerebrate rigidity)	2
		No response	1
Best Verbal Responses		Oriented and Converses	5
		Disoriented and converses	4
		Inappropriate words	3
		Incomprehensible sounds	2
		No response	1
Total			3-15

[14]

A grade of 12 or lower suggests the presence of a relatively severe injury.

· If the athlete is conscious, ask them if they want you to help them, explain what you will do for them and ask for their cooperation. Their affirmative response and cooperation is informed consent.

· If the athlete is unresponsive, immediately check their airway, breathing and circulation.

· If the athlete is unresponsive in a prone position, turn them over using a log roll maneuver making sure that the body moves as a unit to prevent aggravating a spinal injury.

Check the Airway

With the athlete supine check their airway and position their head to maintain an open airway. If there is no suspicion of spinal injury, hyperextend the head and lift the chin to open the airway. An alternate to this is the tongue, jaw lift maneuver. If you suspect spinal injury, do not hyperextend the neck. To open the airway in this case use the modified jaw thrust maneuver or the thumbscrew maneuver.

Modified Jaw Thrust Maneuver

Kneel at the head of the person far enough back so you can lean forward and rest your elbows on the ground. Place your fingers at the jaw angle and stabilize the head with your forearms. Then lift the jaw to open the airway. Do not tilt or rotate the person's head. Approximate and cross the thumb and first finger and put them in the person's mouth. Then open the fingers and pull the jaw forward (upward). Sweep the mouth clear of any material in the mouth.

Check Breathing

Look to see if their chest is moving.

Place your ear at the athletes mouth and listen and feel for breathing.

Wait 5-10 seconds as respiration may be slow.

If there is no breathing perform pulmonary resuscitation.

Lift the chin with one hand to maintain an open airway.

With the other hand stabilize the head & pinch the nose shut.

Take a deep breath and place your mouth over the athlete's forming a seal.

Exhale into the mouth until you see the chest rise and you feel resistance from the expanding lungs.

Stop when you see the chest rise.

Once ventilation has occurred remove your mouth and allow the athlete to exhale passively. Allow for deflation before the next ventilation (each ventilation should take one to one and a half seconds).

Frequently check the carotid pulse. If there is a pulse but no breathing continue the ventilation.

Adult - ventilate once every five seconds.

Child - ventilate once every four seconds.

Check Circulation

Check the carotid artery pulse.

Check for bleeding.

If the initial A(airway), B (breathing) and C (Circulation) check is negative, then the Chiropractic Sports Physician should check the following:

· Athlete's general appearance.

· Vital signs (blood pressure, pulse, respiration and temperature).

· Mental status.

· Check the head for bleeding or skull deformation.

· Check the ears for fluid loss (blood or cerebral spinal fluid).

· Check the spine.

· Check the abdomen.

· Check the extremities.

Quick Assessment of the Extremities

Upper Extremity Sensory Assessment

· Radial Nerve - dorsum of the thumb and index webspace.

· Ulnar Nerve - tip of fifth digit.

· Median Nerve - top of second and/or third digit.

· Musculocutaneous Nerve - extensor aspect of the forearm.

· Auxillary Nerve - lateral aspect of upper arm.

Upper Extremity Motor Assessment

· Radial Nerve - extension of the thumb.

· Ulnar Nerve - Adduction of the thumb, i.e., thumb to little finger.

· Median Nerve - flexion of the first joint of the thumb.

Lower Extremity Sensory Assessment

· Peroneal Nerve - dorsum of the foot.

· Tibial Nerve - back of heel.

· Saphenous Nerve (from the femoral) - medial malleolus.

Lower Extremity Motor Assessment

· Peroneal Nerve - dorsiflexion of the great toe. (L-5 root nerve root).

· Tibial Nerve - plantar flexion of the great toe.

On-Field Evaluation of a Football Player With a Potentially Serious Neck Injury

If The Athlete Is Conscious

· Ask the athlete where the injury is and if he has difficulty breathing, neck pain, any problem moving his limbs, and numbness, tingling or burning in his limbs.

· If the athletes response to the above questions are all negative, ask the athlete to perform cervical ranges of motion checking for complaints of pain, numbness, tingling or burning.

· If any of the athletes responses to the above questions are positive, suspect a neck injury. Remove the athlete from the field on a spine board with his head and neck stabilized. Do not remove the helmet. Assist the EMT's with removing the player from the field to the ambulance. If you have coverage at the field, proceed with the injured player to the emergency room.

If The Athlete is Unconscious

· Always assume the unconscious athlete has a fracture of the cervical spine.

· Assess level of consciousness.

· Check the airway / breathing. If the airway is compromised, remove the face mask from the helmet. Do not remove the helmet. Stabilize the head and neck making sure not to hyperextend the neck. Bring the jaw forward, clean the mouth of material. Supply oxygen.

· Check pulse - the pulse is not present commence CPR.

· Check blood pressure.

· Check pupils size and reactivity.

· Remove from the field on a spine board. Assist EMT's in removing the player from the field.

American College of Sports Medicine

Emergency Sports Assessment Of the Injured Football Player[15]

Call for assistance

1 2 3 4 5 6

How to Determine A Brachial Plexus Lesion From A Nerve Root Lesion

Characteristics of a Brachial Plexus Lesion

1. Numbness and burning of entire arm, hand and fingers.

2. Sensation loss over two to four dermatomes.

3. Complete transient paralysis of arm.

4. Tenderness over the posterior neck.

5. Increase in symptoms with passive movement of head and neck to opposite side.

6. Symptoms do not occur with downward pressure on head with chin in supraclavicular fossa on same side as lesion.

Characteristics of a Nerve Root Lesion

1. Numbness and burning are confined to one or more definable dermatomes.

2. Sensation loss is confined to a definable dermatome.

3. Partial transient paralysis of arm.

4. No tenderness over brachial plexus.

5. Tenderness over the posterior neck.

6. Hyperflexion, extension, or lateral flexion of neck to same side as the symptoms causes symptoms.

7. Symptoms occur with downward pressure on head.

American College of Sports Medicine / Dr. Robert Cantu

Mechanisms of Brain and Spinal Injuries

Force can generate 3 types of stresses:

1) compressive 2) tensile (opposite of compressive) 3) shearing

· Coup Force - head is not accelerated.

Blow to head injury (direct trauma).

· Contrecoup Force-head in motion and brain lags behind.

Cerebral spinal fluid is pooled at the impact site leaving the opposite area of the brain vulnerable (the cerebral spinal fluid acts as a shock absorber).

Skull Fracture

· Linear transient displacement of bone.

· Depressed structures.

Neck

· Neck muscles tensed at time of impact causes less injury (forces are distributed over a greater mass).

· Axial loading (with flexion of 20 degrees)-most serious of c-spine injuries (compressive/burst type fractures are possible results).

· Hyperflexion Injury-anterior elements compressed.

Posterior elements distracted.

· Hyperextension Injury-anterior elements distracted.

Posterior elements compressed.

1. Extradural Hematoma

‾ Outside covering of brain.

‾ Rapidly progressing hematoma.

‾ Common cause is a temporal bone fracture.

2. Subdural Hematoma

‾ Between surface of brain and dural covering of brain.

‾ Most common fatal athletic head injury.

‾ Unconsciousness occurs at the instant of injury with rapid deterioration.

3. Intracerebral Hematoma

‾ Usually the result of ruptures of congenital vascular lesions eg. aneurysm or a arteriovenous malformation.

‾ Blood clot in the substance of brain itself.

‾ Not common.

4. Subarachnoid Hematoma

‾ Surface of brain with disruption of tiny blood vessels.

‾ "Brain bruise".

‾ Occasionally may be due to rupture of a arteriovenous malformation or a new aneurysm.

In pediatric athletes, head injury can cause the brain to swell causing Malignant Brain Edema Syndrome (MBES)

Malignant Brain Edema Syndrome is:

· Lesion characterized by hyperemia of the brain i.e., vascular engorgement caused by pathologic loss of auto regulation of blood flow.

· Characterized by rapid neurologic deterioration from an alert conscious state to coma and death within a few hours.

Second Impact Syndrome

· The adult variant of MBES because its effects are also caused by hyperemia from loss of auto regulation of blood flow.

· Seen in athletes with symptoms from previous head injury who sustain a second acceleration head injury.

· Rapid progression.

· Critical-even when with prompt treatment. High morbidity and mortality rate.

Neck And Spinal Injuries

Cervical Sprain

· Most common neck injury.

Spinal Cord Concussion

· Single violent impact to the spinal cord..

· Transient loss of motor or sensory cord function below the level of injury.

· Symptoms last from seconds to minutes (most clear within 24 hours). Tommy Maddox, the quarterback of the Pittsburgh Steelers, suffered this injury in 2002.

Spinal Cord Contusion

· Greater loss of motor or sensory function in upper extremity compared with lower extremity.

· Usually caused by hyperextension.

· Evaluate with MRI or CT.

· High likelihood of either spinal stenosis or disc rupture.

· Discontinuation of contact sports.

Lateral Pinch / Burners Syndrome

· Pain and burning paraesthesias radiating from neck down one arm to base of the thumb.

· Symptoms last several minutes or less.

Treatment of Head and Neck Injuries

· Elements of CNS cannot regenerate.

· Never allow an athlete who suffered head or spinal injury to continue play without being examined.

· If concussion is expected-remove from competition and do an exam on the bench.

· Following concussion, the physician should work with the coaching staff to search for underlying correctable causes such as improperly fitted head gear, improper technique and inadequately conditioned neck muscles.

Assessing Neck Injury

Three criteria should be met before return to competition:

1. Full ROM - Spurling's Maneuver (chin flexed and laterally flex and extend the neck). The patient should have no pain.

2. Neuro exam must be normal.

Injury Prevention

1. Rule changes.

2. Coaching technique changes.

3. Improved conditioning (especially neck muscles).

4. Improved equipment.

5. Improved medical supervision of the game.

American College of Sports Medicine / Dr. Cantu [16]

Environmental Factors Affecting Sports Performance

Heat, cold, pollution, and altitude all affect sports performance.

Heat

Four physical processes remove excess heat from the body: radiation, conduction, evaporation, and convection. Since body temperature is usually higher than air temperature, the human body radiates heat rays to the environment. But during the warmer days of summer, heat is absorbed by the body through radiation.

There are two kinds of heat loss through conduction (to the air and to objects). With the exception of swimmers losing body heat to the water, very little heat is lost through conduction during exercise.

Convection is the term applied to air movement (wind). It plays a major role in heat loss by both conduction and evaporation. During exercise sweat conducts an enormous amount of heat from within the body to the skin surface. The heat dissipates when the convection currents (wind) evaporate the sweat.

In the presence of high environmental temperatures, evaporation and convection provide the only relief from heat stress. On hot days when the humidity is high and there is little or no wind, evaporation is greatly reduced. Metabolic heat generated during exercise is denied release and the body temperature rises, sometimes resulting in heat sickness. Heat exhaustion, (a less serious form of heat ailment), may be accompanied by decreased motor ability. Coast Guard studies have shown that three hours of sun exposure can slow reaction time just as drunkeness can.

To avoid heat sickness, drink plenty of fluids, six to eight glasses a day, including 13 to 17 ounces just before an exercise session.

Train in the morning or evening to avoid the heat of the day (before 9 A.M. and after 6 P.M.). The body usually becomes acclimated to heat and humidity within two weeks.

The athletes cardiovascular system is able to dissipate heat more efficiently, and they tolerate heat better than the unfit. They also become acclimated more quickly. Losing weight will increase heat tolerance. Overweight individuals suffer more in heat and humidity because their fat insulates them and interferes with heat loss.

Heat Sickness: Symptoms and First Aid

Disorder	Cause	Symptoms	First Aid
Heat cramps	Excessive loss of salt in sweat.	Pain and muscle spasm; body temperature normal	Rest. Administer salt and water.
Heat exhaustion	Cardiovascular inadequacy dehydration	Headache; dizziness; fainting; rapid and weak pulse; cold, pale, clammy skin; small rise in temperature; possible vomiting.	Rest in shade in recumbent position. Administer fluids.
Heat stroke	Failure of temperature regulatory center due to excessive high body temperature.	High body temperature; profound prostration; delirium; hot, dry, flushed skin; sweating diminished or absent.	Requires immediate immersion in cold water, application of ice packs or alcohol spray. Medical emergency requiring a physician; meanwhile administer fluids if conscious, but no stimulants.

[17]

COLD

Two common cold related conditions include:

a) Hypothermia (abnormally low body temperature). Hypothermia should always be treated before frostbite. First, warm a suspected hypothermia victim. Rewarming may be accompanied by coronary dysrhythmia (irregular heartbeat) that can progress to fibrillation and cardiac arrest (arrhythmia), the usual cause of death in hypothermia.

b) Frostbite - Frostbite is the destruction of body tissue by freezing. Ice crystals form in the fluid surrounding cells and frozen blood vessels prevent blood from circulating. Frostbitten skin appears red, feels warm, burns and stings, then progresses to numbness and a white, waxen appearance. This condition is accompanied by poor hand and foot coordination. With frostbite attempt to thaw the frozen tissue only when you reach shelter and can prevent the frostbitten area from being refrozen. Refreezing poses a greater risk of severe injury. Protect the frozen part. Do not rub it, especially with snow. Massaging increases the injury. If possible, avoid walking on frostbitten feet. Immerse the frozen area in l00-110⁰F water.

· Avoid alcoholic beverages. By dilating surface blood vessels, alcohol promotes heat loss. Smoking constricts blood vessels in the hands and feet, increasing the chance of frostbite by reducing the flow of warm blood to these areas

American College Of Sports Medicine Position Statements

The Recommended Quantity And Quality Of Exercise For Developing And Maintaining Fitness In Healthy Adults

1. Frequency of training: 3 to 5 days per week.

2. Intensity of training: 60 per cent to 90 per cent of maximum heart rate reserve or, 50 per cent to 85 per cent of maximum oxygen uptake (VO₂max).

3. Duration of training: 15-60 minutes of continuous aerobic activity. Duration is dependent on the intensity of the activity, thus lower intensity activity should be conducted over a longer period of time. Because of the importance of the 'total fitness' effect and the fact that it is more readily attained in longer duration programs, and because of the potential hazards and compliance problems associated with high intensity activity, lower to moderate intensity activity of longer duration is recommended for the nonathletic adult.

4. Mode of activity: Any activity that uses large muscle groups, that can be maintained continuously, and is rhythmical and aerobic in nature (e.g., running, jogging. walking-hiking, swimming, skating, bicycling, rowing. cross-country skiing, rope skipping, and various endurance game activities.

[18]

The Use Of Alcohol In Sports

1. The acute ingestion of alcohol can exert a deleterious effect upon a wide variety of psychomotor skills such as reaction time; hand-eye coordination, accuracy, balance, and complex coordination.

2. Acute ingestion of alcohol will not substantially influence metabolic or physiological functions essential to physical performance such as energy metabolism, maximal oxygen consumption (VO₂max), heart rate, stroke volume, cardiac output, muscle blood flow, arteriovenous oxygen difference, or respiratory dynamics. Alcohol consumption may impair body temperature regulation during prolonged exercise in a cold environment.

3. Acute alcohol ingestion will not improve and may decrease strength, power, local muscular endurance, speed, and cardiovascular endurance.

4. Alcohol is the most abused drug in the United States and is a major contributing factor to accidents and their consequences. Also, it has been documented widely that prolonged excessive alcohol consumption can elicit pathological changes in the liver, heart, brain, and muscle, which can lead to disability and death.

5. Serious and continuing efforts should be made to educate athletes, coaches, health and physical educators, physicians, trainers, the sports media, and the general public regarding the effects of acute alcohol ingestion upon human physical performance and on the potential acute and chronic problems of excessive alcohol consumption.[19]

Proper And Improper Weight Loss Programs

1. Prolonged fasting and diet programs that severely restrict caloric intake are scientifically undesirable and can be medically dangerous.

2. Fasting and diet programs that severely restrict caloric intake result in the loss of large amounts of water, electrolytes, minerals, glycogen stores, and other fat-free tissue (including proteins within fat-free tissues), with minimal amounts of fat loss.

3. Mild calorie restriction (500-1000 kcal less than the usual daily intake) results in a smaller loss of water, electrolytes, minerals, and other fat-free tissue, and is less likely to cause malnutrition.

4. Dynamic exercise of large muscles helps to maintain fat-free tissue, including muscle mass and bone density, and results in losses of body weight. Weight loss resulting from an increase in energy expenditure is primarily in the form of fat weight.

5. A nutritionally sound diet resulting in mild calorie restriction coupled with an endurance exercise program along with behavioral modification of existing eating habits is recommended for weight reduction. The rate of sustained weight loss should not exceed 1 kg (2 lb) per week.[20]

Weight Loss In Wrestlers

It is the position of the American College of Sports Medicine that the potential health hazards created by the procedures used to "make weight" by wrestlers can be eliminated if state and national organizations will:

1. Assess the body composition of each wrestler several weeks in advance of the competitive season. Individuals with a fat content less than five percent of their certified body weight should receive medical clearance before being allowed to compete.

2. Emphasize the fact that the daily calorie requirements of wrestlers should be obtained from a balanced diet and determined on the basis of age, body surface area, growth and physical activity levels. The minimal calorie needs of wrestlers in high schools and colleges will range from 1200 to 2400 kcal/day; therefore, it is the responsibility of coaches, school officials, physicians and parents to discourage wrestlers from securing less than their minimal needs without prior medical approval.

3. Discourage the practice of fluid deprivation and dehydration. This can be accomplished by:

a. Educating the coaches and wrestlers on the physiological consequences and medical complications that can occur as a result of these practices.

b. Prohibiting the single or combined use of rubber suits, steam rooms, hot boxes, saunas, laxatives, and diuretics to "make weight".

c. Scheduling weigh-ins just prior to competition.

d. Scheduling more official weigh-ins between team matches.

4. Permit more participants to compete in those weight classes (119-145 pounds) which have the highest percentages of wrestlers certified for competition.

5. Standardize regulations concerning the eligibility rules at championship tournaments so that individuals can only participate in those weight classes in which they had the highest frequencies of matches throughout the season. Encourage local and county organizations to systematically collect data on the hydration state of wrestlers and its relationship to growth and development.[21]

The Use And Abuse Of Anabolic-Androgenic Steroids In Sports

Based on a comprehensive survey of the world literature and a careful analysis of the claims made for and against the efficacy of anabolic-androgenic steroids in improving human physical performance, it is the position of the American College of Sports Medicine that:

1. The administration of anabolic-androgenic steroids to healthy humans below age 50 in medically approved therapeutic doses often does not of itself bring about any significant improvements in strength, aerobic endurance, lean body mass or body weight. There is no conclusive scientific evidence that extremely large doses of anabolic-androgenic steroids either aid or hinder athletic performance.

2. The prolonged use of oral anabolic-androgenic steroids (C₁₇ alkylated derivatives of testosterone) has resulted in liver disorders in some persons. Some of these disorders are apparently reversible with the cessation of drug usage, but others are not.

3. The administration of anabolic-androgenic steroids to male humans may result in a decrease in testicular size and function and a decrease in sperm production. Although these effects appear to be reversible when small doses of steroids are used for short periods of time, the reversibility of the effects of large doses over extended periods of time is unclear.

4. Serious and continuing effort should be made to educate male and female athletes, coaches, physical educators, physicians, trainers, and the general public regarding the inconsistent effects of anabolic-androgenic steroids on improvement of human physical performance and the potential dangers of taking certain forms of these substances, especially in large doses, for prolonged periods.[22]

Overtraining Syndrome Signs

1. Mild leg stiffness and soreness.

2. Decreased coordination.

3. Chronic fatigue; excessive tiredness has been associated with the development of mononucleosis.

4. Lowered general resistance, colds, headaches, and fever.

5. Poor appetite.

6. Weight loss.

7. Irritability.

8. Sleep disturbances

When signs of overtraining are present dramatically reduce or temporarily halt exercise training.

Chiropractic Sports Physician Medical-Legal Considerations

General Rule of Thumb

Prior to advertising yourself as a sports injury specialist, the Chiropractic Sports Physician should first undergo specialized training and receive certification in the treatment of sports injuries. The certification should be recognized and sponsored by an accredited chiropractic college. In a court of law, when you claim specialty credentials above and beyond that of a Doctor of Chiropractic, anyone in that specialty, regardless of their profession, can testify against you.

What is Risk Management?

Risk Management is the development of practice strategies to prevent patient harm and practitioner liability. This is achieved through the development of clearly defined practice guidelines intended to reduce and prevent malpractice actions. Properly implemented risk strategies will decrease the potential for malpractice claims and increase the quality of care for patients.

What is Malpractice?

Malpractice is a dereliction from professional duty or a failure to exercise an accepted degree of professional skill or learning by a physician rendering professional services which results in injury, loss or damage. Malpractice is further defined as an injurious, negligent or improper practice.[23]

How is Malpractice Proven?

There are four primary components necessary to successfully prosecute a malpractice claim: 1) Duty; 2) Dereliction of Duty; 3) Direct Causation and 4) Damage.

In Depth Analysis of the Four Components of Malpractice

Duty-something that one is expected or required to do by moral or legal obligation. Duty is further defined as an action or task required by one's position or occupation.[24] The primary element of a successful malpractice action is proving that the physician owed some duty to the claimant. It must be determined that a doctor--patient relationship had been established.

In an emergency situation the Chiropractic Sports Physician has a duty to know the following;

1. What emergency medical team has the duty to act(public or municipal ambulance or private ambulance service).

2. What is the response and skill level of the emergency medical team.

3. What is the average response time.

4. Know the name and phone number of the Category I emergency medical facilities in proximity to the playing field. A Category I facility is capable of providing comprehensive intensive medical care in an intensive care unit.

5. Develop a working relationship with the Category I emergency medical facility staff.

6. Be cognizant of the medical equipment that the team possesses (first aid equipment, oxygen, splints and supports).

Dereliction of Duty - any actions or tasks that do not meet the requirements of one's position or profession involving a deviation from standards of care.

Direct Causation - it must be proven that a negligent act occurred which directly caused the patient injury.

Negligence--failure to exercise the care that a prudent person usually exercises. [25] In a malpractice action it must be proven that the doctor failed to perform his duty with reasonable skill and or performed a procedure that was outside of his scope of practice, expertise and training.

In order to successfully prove malpractice, the plaintiff's attorney must prove causation to a reasonable degree of medical probability. This implies that it is more probable than not, (i.e., there is more than 50% probability) that a certain condition was caused by a negligent action by the accused doctor.

Damage - is a loss sustained by a party for which recovery is sought in a malpractice lawsuit.

If any of the four elements necessary to prove malpractice are absent (Duty, Dereliction of Duty, Direct Causation or Damage) then the accused doctors chances of winning the lawsuit are greatly increased. In short, a doctor can lose a malpractice claim if the plaintiffs attorney can prove the doctor had a duty, was derelict in his duty, and his actions or inactions directly caused damage to the claimant.

Error--an act or condition of ignorance or imprudent deviation from a code of behavior. Errors fall into two categories; 1) Errors of Omission--an example would be the failure to diagnose. Diagnosis is the art or act of identifying a disease from its signs and symptoms and distinguishing one disease from another. 2) Errors of Commission--the performance of an act which results in injury. An example of an error of commission would be fracturing a rib while adjusting a thoracic vertebra.

Errors of Omission

1) Failure to perform any physical examination or the appropriate examination given the history and patient complaints. For example, due to philosophy, some DC's will perform chiropractic analysis (palpation and leg length checks etc, but do not perform review of systems, orthopedic or neurological evaluation. A protective, risk management strategy is to perform chiropractic analysis, orthopedic and neurologic examination testing procedures.

2) Failure to correlate examination findings and render an accurate diagnosis. Failure to diagnose cancer is a primary risk management concern.

3) Failure to appropriately refer a patient.

Patient Consent for Treatment

Consent--Compliance in or approval of what is done or proposed by another. [26] Consent falls into two categories; Informed Consent and Implied Consent.

1) Informed Consent--Involves a verbal interaction between the doctor and patient. Essential elements of informed consent include discussion of the patients condition, identification and explanation of proposed treatment, warning of the risks or consequences of treatment, disclosure of alternative treatment options and their risks and the probability of success or failure of the proposed treatment. Informed consent should be discussed with the patient before care begins. Having the patient sign a written consent form is a prudent risk management strategy.

"Where there is risk of significant harm from the treatment proposed, this risk must be disclosed, understood, and accepted by the patent. Such informed consent is required for ethical and legal reasons.

Informed Consent and Emergency Medical Care

· Emergency medical care requires the consent of the person you are attending. This consent should be informed (explain what treatment is to be done, the risks of treatment and the risks of non-treatment).

· Checking the injured persons consciousness and coherency is a part of trauma triage. Use that check to get informed consent from the individual. Keep informing the injured person what you are going to do so that those standing nearby, such as coaches, trainers, and referees hear you. (They may one day be called as a witness in a malpractice case).

· If the injured individual is a minor, consent must be obtained from a parent or guardian. Get a signed consent from the parent prior to the season.

2) Implied Consent--This form of consent is granted by the patient's voluntary presentation for treatment. Implied consent occurs on each visit to the doctor's office. In general, implied consent takes place after informed consent with the patient having full knowledge of the proposed care plan and the treatment methods to be employed.

The prudent physician should never breach the doctor--patient relationship contract by exceeding the consent given by the patient. Patients can limit the scope of consent given for treatment. Consent limitations expressed by the patient become an integral part of the contract for services. The unauthorized touching of another is actionable in itself as a battery. The commission of a battery can result in both civil and criminal causes of action.

If and injured person is unconscious then the consent for emergency care is said to be implied. Research your states laws regarding implied consent and emergency care.

Emergency Care Legal Considerations

Good Samaritan legislation, is a series of laws, adopted by most states, which provides limited legal protection to health care professionals and citizens when they administer emergency care. The Good Samaritan laws vary from state to state as to whom they offer limited legal protection to. These laws require an individual to act in good faith, provider care to the best of their knowledge, ability and skill level, support life and prevent further injury.

In most states, the degree of liability protection given to the licensed health care professional (E.M.T., nurse, physician) is much less than the protection given to the average citizen. Professionals are held to higher level of accountability due to their supposed knowledge of emergency care. The average citizen conversely is typically not held liable for civil damages as the result of any act or failure to act in providing emergency care. The Chiropractic Sports Physician should become familiar with the Good Samaritan laws in their state.

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[1] Morehouse, L.E. and A.T. Miller, Exercise, Heat, And Body Temperature. In: Physiology of Exercise. St. Louis, C.V. Mosby, 1967.

[2] Marley, W.P., S Study Of Attitude And Opinion, Health And Physical Fitness Knowledge, And Physical Fitness In PE 100, North Carolina State University, 1975.

[3] Marley, W.P., S Study Of Attitude And Opinion, Health And Physical Fitness Knowledge, And Physical Fitness In PE 100, North Carolina State University, 1975.

[4] Bates, Barbara, M.D. A Guide to Physical Examination, Third Edition. 1983. J.B. Lippincott Co., Philadelphia, Pg 266.

[5] Mens Journal, 2002.

[6] Marley, W.P., S Study Of Attitude And Opinion, Health And Physical Fitness Knowledge, And Physical Fitness In PE 100, North Carolina State University, 1975.

[7]Conrad, C,C. How Different Sports Rate in Promoting Physical Fitness. Medical Times104:65, 1999 (May)

[8] Cooper, K.H. The Aerobics Way, New York, M.Evans and Co., 1977, pp.88, 89.

[9] Marley, W.P., S Study Of Attitude And Opinion, Health And Physical Fitness Knowledge, And Physical Fitness In PE 100, North Carolina State University, 1975.

[10] www.runnersworld.com

[11] Henderson, J. First-Aid For The Injured, Runners's World 12:57, 1977 (July).

[12] American Medical Association's Committee on the Medical Aspects of Sports (1974, 1976).

[13] www.americancollegeofsportsmedicine.com

[14] www.AmericanCollegeofSportrsMedicine.com

[15] www.AmericanCollegeofSportsMedicine.com

[16] www.AmericanCollegeofSportsMedicine.com

[17] Morehouse, L.E. Marley, W.P., S Study Of Attitude And Opinion, Health And Physical Fitness Knowledge, And Physical Fitness In PE 100, North Carolina State University, 1975. and A.T. Miller, Exercise, Heat, And Body Temperature. In: Physiology of Exercise. St. Louis, C.V. Mosby, 1967.

1.Medical Science Sports 3 vii-ix 1978.

[19]. Medical Science Sports 14(6) IX-XI 1982

[20] Medical Science Sports 11(4) IX-XI 1979

[21] Medical Science Sports 8(2) XI-XIII 1976.

[22] Medical Science Sports 8(2) XI-XIII 1976.

[23] Webster's New Collegiate Dictionary, C&C Merriam Company, Springfield, Mass., 1976, page 697.

[24] Webster's New Collegiate Dictionary, C&C Merriam Company, Springfield, Mass., 1976, page 411.

[25] Webster's New Collegiate Dictionary, C&C Merriam Company, Springfield, Mass., 1976, page 769.

[26] Webster's New Collegiate Dictionary, G & C Merriam Co., Springfield, Mass, 1976, page 241.