Care of The Older Fighter: Position Statement of the Association of Ringside Physicians.

Older Fighters are defined as combat sports athletes older than 35 years, based on heightened medical risks and historical classification. Age-related changes to the neurological, cardiopulmonary, endocrinological, thermoregulatory, osmoregulatory, and musculoskeletal systems increase these athletes' risks for injury and may prolong their recovery. These age-related risks warrant special considerations for competition, licensure, prefight medical clearance, in-fight supervision, post-fight examination, and counseling regarding training practices and retirement from combat sports. Neurological considerations include increased risk of intracranial lesions, intracranial hemorrhage, and sequelae from traumatic brain injury (TBI), warranting more comprehensive neurological evaluation and neuroimaging. Increased risk of myocardial ischemia and infarction warrant careful assessment of cardiac risk factors and scrutiny of cardiovascular fitness. Older fighters may take longer time to recover from musculoskeletal injury; post-injury clearance should be individualized.

Transgender competition in combat sports: Position statement of the Association of ringside physicians.

The Association of Ringside Physicians (ARP) is committed to the concept of fair competition. It advocates for two equally skilled and matched athletes to keep bouts fair, competitive, entertaining, and, most importantly, safe for all combatants. Numerous studies have proven that transgender women may have a competitive athletic advantage against otherwise matched cis-gender women. Likewise, transgender men may suffer a competitive disadvantage against cis-gender men. These differences - both anatomic and physiologic - persist despite normalization of sex hormone levels and create disparities in competitive abilities that are not compatible with the spirit of fair competition. More importantly, allowing transgender athletes to compete against cisgender athletes in combat sports, which already involve significant risk of serious injury, unnecessarily raises the risk of injury due to these differences. Hence the ARP does not support transgender athlete competition against cisgender athletes in combat sports.

Headguard use in combat sports: position statement of the Association of Ringside Physicians.

Headguard use is appropriate during some combat sports activities where the risks of injury to the face and ears are elevated. Headguards are highly effective in reducing the incidence of facial lacerations in studies of amateur boxers and are just as effective in other striking sports. They should be used in scenarios - especially sparring prior to competitions - where avoidance of laceration and subsequent exposure to potential blood-borne pathogens is important. Headguards are appropriate where avoidance of auricular injury is deemed important; limited data show a marked reduction in incidence of auricular injury in wrestlers wearing headguards.Headguards should not be relied upon to reduce the risk of concussion or other traumatic brain injury. They have not been shown to prevent these types of injuries in combat sports or other sports, and human studies on the effect of headguards on concussive injury are lacking. While biomechanical studies suggest they reduce linear and rotational acceleration of the cranium, changes in athlete behavior to more risk-taking when wearing headguards may offset any risk reduction. In the absence of high-quality studies on headguard use, the Association of Ringside Physicians recommends that further research be conducted to clarify the role of headguards in all combat sports, at all ages of participation. Furthermore, in the absence of data on gender differences, policies should be standardized for men and women.

Pre-bout hypertension in the combat sports athlete: clearance recommendations.

Hypertension is one of the most prevalent medical disorders in the world and is associated with significant cerebrovascular and cardiovascular morbidity. Pre-bout blood pressure (BP) elevation is extremely common, and ringside physicians must accurately assess the accompanying risk of adverse cerebrovascular and cardiovascular events in the decision to allow participation in combat sports. It is strongly recommended that a ringside physician consider disqualifying a combat sports athlete with severe pre-bout hypertension (systolic BP ≥160 mm Hg and/or diastolic BP ≥100 mm Hg, or stage 2 hypertension in children when indexed by gender, age, and height) from that bout, if it persists despite rest and repeated measurement with accurate equipment. This recommendation is congruent with that of the American College of Sports Medicine, the American College of Cardiology, and the American Heart Association, which recommend non-clearance for sports or exercise testing when BP exceeds those thresholds. Severely elevated BP, as defined above, confers markedly increased risk of morbidity and mortality. Exercise further raises BP markedly. The combination of severely elevated blood pressure and cranial trauma during combat sports is a risk factor for intracranial hemorrhage with a direct impact on the morbidity and mortality associated with ringside combat sports events. Combat sports athletes with SBP ≥130 or DBP ≥90 - and their coaches and families, if available and the athlete consents - should be educated on the causes of hypertension, its acute and chronic risks, and the possible future implications for bout clearance, and the athletes should be referred for evaluation and management.

Cutaneous infections in wrestlers.

CONTEXT: Cutaneous infections are common in wrestlers. Although many are simply a nuisance in the everyday population, they can be problematic to wrestlers because such infections may result in disqualification from practice or competition. Prompt diagnosis and treatment are therefore important. EVIDENCE ACQUISITION: Medline and PubMed databases, the Cochrane Database of Systematic Reviews, and UpToDate were searched through 2012 with the following keywords in various combinations: skin infections, cutaneous infections, wrestlers, athletes, methicillin-resistant Staphylococcus aureus, skin and soft tissue infections, tinea corporis, tinea capitis, herpes simplex, varicella zoster, molluscum contagiosum, verruca vulgaris, warts, scabies, and pediculosis. Relevant articles found in the primary search, and selected references from those articles were reviewed for pertinent clinical information. RESULTS: The most commonly reported cutaneous infections in wrestlers are herpes simplex virus infections (herpes gladiatorum), bacterial skin and soft tissue infections, and dermatophyte infections (tinea gladiatorum). The clinical appearance of these infections can be different in wrestlers than in the community at large. CONCLUSION: For most cutaneous infections, diagnosis and management options in wrestlers are similar to those in the community at large. With atypical presentations, testing methods are recommended to confirm the diagnosis of herpes gladiatorum and tinea gladiatorum. There is evidence to support the use of prophylactic medications to prevent recurrence of herpes simplex virus and reduce the incidence of dermatophyte infections in wrestlers.

Knuckle cracking and hand osteoarthritis.

BACKGROUND: Previous studies have not shown a correlation between knuckle cracking (KC) and hand osteoarthritis (OA). However, one study showed an inverse correlation between KC and metacarpophalangeal joint OA. METHODS: We conducted a retrospective case-control study among persons aged 50 to 89 years who received a radiograph of the right hand during the last 5 years. Patients had radiographically proven hand OA, and controls did not. Participants indicated frequency, duration, and details of their KC behavior and known risk factors for hand OA. RESULTS: The prevalence of KC among 215 respondents (135 patients, 80 controls) was 20%. When examined in aggregate, the prevalence of OA in any joint was similar among those who crack knuckles (18.1%) and those who do not (21.5%; P = .548). When examined by joint type, KC was not a risk for OA in that joint. Total past duration (in years) and volume (daily frequency × years) of KC of each joint type also was not significantly correlated with OA at the respective joint. CONCLUSIONS: A history of habitual KC-including the total duration and total cumulative exposure-does not seem to be a risk factor for hand OA.

The athlete and high altitude.

Expanding athlete participation in high-altitude environments highlights the importance for a sports physician to have a good understanding of the high-altitude illness (HAI) syndromes: acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). All may occur in the setting of acute altitude exposure higher than 2500 m; incidence and severity increases as altitudes or ascent rates increase. Once HAI is recognized, proven therapies should be instituted to alleviate symptoms and avert the possibility of critical illness. Allowing for acclimatization is the best strategy for preventing HAI. Acetazolamide and dexamethasone are additional preventive measures for AMS/HACE; nifedipine, salmeterol, and phosphodiesterase inhibitors are useful in preventing HAPE. Along with the immediate hazards of HAI with altitude exposure, the sport physician also should be familiar with altitude/hypoxic training practices used by athletes to enhance fitness and performance.

Return to activity at altitude after high-altitude illness.

CONTEXT: Sports and other activities at high altitude are popular, yet they pose the unique risk for high-altitude illness (HAI). Once those who have suffered from a HAI recover, they commonly desire or need to perform the same activity at altitude in the immediate or distant future. EVIDENCE ACQUISITION: As based on key text references and peer-reviewed journal articles from a Medline search, this article reviews the pathophysiology and general treatment principles of HAI. RESULTS: In addition to the type of HAI experienced and the current level of recovery, factors needing consideration in the return-to-play plan include physical activity requirements, flexibility of the activity schedule, and available medical equipment and facilities. Most important, adherence to prudent acclimatization protocols and gradual ascent recommendations (when above 3000 m, no more than 600-m net elevation gain per day, and 1 rest day every 1 to 2 ascent days) is powerful in its preventive value and thus strongly recommended. When these are not practical, prophylactic medications (acetazolamide, dexamethasone, salmeterol, nifedipine, or phosphodiesterase inhibitors, depending on the type of prior HAI) may be prescribed and can reduce the risk of illness. Athletes with HAI should be counseled that physical and mental performance may be adversely affected if activity at altitude continues before recovery is complete and that there is a risk of progression to a more serious HAI. CONCLUSION: With a thoughtful plan, most recurrent HAI in athletes can be prevented.