Tuesday, January 22, 2019

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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Keeping Athletes in the Game–At What Cost?

Thomas Degenhardt, MD, Gary Stein, MD, and Michael McDermott, MD

Injuries are an integral risk in competitive sports. Most injuries occur in contact sports, with football, hockey, soccer and basketball leading the lineup. As athletes compete and push themselves to improve, their sprains, strains, contusions and other injuries become part of the daily routine. In fact, recent statistics indicate that high school athletes account for an estimated 2 million injuries, 500,000 doctor visits, and 30,000 hospitalizations annually—all at a rate of 2.4 injuries per 1,000 athlete exposures, i.e., practices or competitions.[1]

Parents can occasionally lose sight of the big picture and become blinded by their offspring’s athletic achievements. Coaches, too, can become irrationally motivated and shortsighted. In contrast, trainers, physical therapists and physicians are able to emphasize prevention, treat injuries, and get athletes back in the game as quickly as is safe. 

In athletics, prevention and education are the best arsenal for keeping healthy athletes at peak performance. Partnerships between physicians and the athletic community in the form of sponsorships, educational programs and public workshops go a long way in serving the public health. Physicians play a significant role with school and community sports teams by keeping athletes healthy and their coaches well-informed. Prevention clinics can detect injuries in those involved in athletic programs and, when necessary, recommend courses of treatment to prevent further injury and return the athlete to optimal health. Athletic training programs are another important preventive tool. 

Common types of injuries sustained by athletes include muscle pulls, neck strain, frozen shoulder, lower back injuries, tennis elbow, runner’s knee, shin splints, sprained ankles, and concussions. This final type of injury has recently been the subject of much research and debate. 

Anyone who plays sports, professionally or otherwise, can suffer a head injury. Research has linked sports concussions with serious long-term effects. As the debate continues, athletes who play sports at any level should be aware of at least two key points about head injuries. 

First, there are two types of sports head injuries: sports concussion and epidural hematoma. A concussion, the most common type of sports head injury, results from a jarring or a blow to the head. An epidural hematoma occurs when an impact causes a blood clot to form and grow between the skull and the membrane surrounding the brain. If untreated, an epidural hematoma can be fatal. 

Second, identifying the groups most at risk for head injuries can lead to prevention and better treatment. A recent study, for example, found that in soccer 68% more concussions occur in girls than boys, and in basketball girls suffer concussions three times more frequently than boys.[2] Another recent study found that the athlete’s activity level after concussion affects symptoms and neurocognitive recovery.[3] The higher the level of post-injury activity, the worse the neurocognitive performance. Athletes who engage in moderate levels of activity typically achieve the best post-injury performance.

Researchers have made some significant progress in helping coaches, trainers and sports medicine teams determine when an athlete is ready to return to the game. For example, the University of Pittsburgh Sports Medicine Center has developed a computer program called Immediate Post-Concussion Assessment and Cognitive Testing, or ImPACT, which provides coaches with a more objective measure of whether the athlete is healthy enough to return to play after a head injury.[4]

Studies suggest the neurological consequences of cumulative mild traumatic brain injuries may be greater than once assumed. These consequences can lead to increased risk of depression, problems with memory, and other cognitive deficits.[5] Worse, the signs of a serious head injury aren’t always immediately apparent. Team management and sports medicine professionals must learn to spot head injury warning signs and know the basics of sports concussion first-aid treatment. As research reveals the true nature of sports concussions and other head injuries, the rules and regulations that govern professional and other sports are subject to change. In the meantime, coaches and team management should be armed with the latest information on prevention, including safety gear and athletic technique. 

The world of sports medicine is perpetually clouded with a dilemma: Where is the line between allowing injured athletes to play and restraining them to prevent further injury? Who draws that line? When is further competition harmful? How much can athletes withstand, and at what point does the physician or other professional say, “It’s time to rest”?

This situation can make the life of a team physician very challenging. When athletes are good enough to advance to the collegiate level, the complexity of these situations expands as expectations and demands increase. In big-revenue sports, such as football, hockey and basketball, the pressures mount for athletes to play through pain and injuries. For coaches and team management, the rewards for success are often enough motivation to keep MVPs in the game at all costs. Too many losses can be career-shattering. This institutionalized pressure to perform places a high premium on keeping athletes on the field. Athletes cannot win ball games in the training room. 

Can team physicians help athletes perform by helping them overcome pain and dysfunction with safe medical treatment while detecting when more serious injuries are present? For example, when is a partial ligament injury ready for a return to play and not at risk for further injury? 

In the high-stakes world of college sports, these pressures can mount as major games approach, with national rankings, television appearances, and all the rewards of college athletics possibly hanging in the balance. Can physicians protect the best interests of athletes in this powder-keg environment? College sports may be where physicians play the most important role, as the presence of parents diminishes but the athlete is not yet a mature adult.

At the next level of competition, that of professional sports, decisions seem to ease up for the medical team. For the most part, professional athletes are adults capable of making rational decisions. Although the pressures may be greater because of million-dollar contracts and high-powered agents, dealing with adult athletes, once they are adequately apprised of the risks and benefits, appears to be an easier task. Nonetheless, some professional athletes overestimate their ability to recover from injury and succumb to the irrational belief that they are immune from complications and side effects.

To meet these decision-making challenges at all levels of competition—high school, college and professional—team physicians must be adequately prepared, fully educated, and proficiently trained to use all the tools at their disposal for the benefit of the patient. To make sound medical decisions, the physician must fully understand the short- and long-term side effects and complications of medications, treatments and devices.

Physicians, trainers and physical therapists involved with sports medicine face two fundamental problems in their field. First, additional research is needed in many areas, such as the risks, benefits and problems associated with commonly used pain killers and anti-inflammatories. Second, even though these areas are frequent topics of informal discussion, they are rarely presented in forums or symposia at national meetings. 

This silence about certain topics suggests a dark side to sports medicine, which many athletic directors, coaches, and even physicians do not readily acknowledge. Where is the balance between athletes’ long-term health and industry pressure to perform? Do sports medicine professionals spend enough time examining the risks and side effects of what we do and recommend? What will long-term outcome studies suggest about these efforts? 

As coaches, educators, team managers and sports medicine professionals assimilate the growing body of knowledge surrounding sports injuries, they become better equipped to make the tough and often emotionally charged decisions about whether an athlete should sit on the sidelines or get back in the game.

  1. Powell JW, Barber-Foss KD, “Injury patterns in selected high school sports,” J Athletic Training, 34:277-284 (1999).
  2. Rechel JA, et al, “Epidemiologic comparison of high school sports injuries sustained in practice and competition,” J Athletic Training, 43:197-204 (2008).
  3. Majerske CW, et al, “Concussion in sports: Postconcussive activity levels, symptoms, and neurocognitive performance,” J Athletic Training, 43:265-274 (2008).
  4. www.impacttest.com 
  5. McCrory P, et al, “Consensus statement on concussion in sport,” Brit J Sports Med, 43:i76-84 (2009).

Drs. Degenhardt, Stein and McDermott are orthopaedic surgeons and co-directors of the Sports Medicine Center at Santa Rosa Orthopaedics. 

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