Atypical Presentations of Exertional Collapse.

ABSTRACT: Exertional collapse associated with sickle trait (ECAST) is an underrecognized cause of exertional collapse triggered by complex mechanisms involving acidosis, rhabdomyolysis, and arrhythmias, all of which create sickling, vaso-occlusive problems, and ultimately end organ failure. Three cases are described in young athletes, as well as 12 other examples of ECAST noted in case reports and news sources. Exertional collapse associated with sickle trait can be differentiated from other common causes of collapse (exertional heat syndrome, acute cardiac events, and asthma) because it is a conscious collapse without neurological changes, occurs early in workout with only mildly elevated body temperature, and involves muscle pain and weakness but not cramping. Aggressive early management and transport to care facilities can reverse ECAST in certain cases. This article discusses tips for early recognition, initial treatment in the emergency department, and precautions that can be taken to prevent sickling collapse in athletes with sickle cell trait (SCT).

Ultrasound Diagnosis of Calf Injuries.

CONTEXT: The medial head of the gastrocnemius is the third most commonly strained muscle in elite athletes after the biceps femoris and rectus femoris. The differential diagnosis of posterior calf injury includes musculoskeletal and nonmusculoskeletal causes. Classically, delineation of these injuries from one another relied primarily on historical features and physical examination findings. The utilization of musculoskeletal ultrasound (sonography) has augmented the diagnosis of these injuries by providing dynamic, real-time confirmation. EVIDENCE ACQUISITION: A review of PubMed, OVID, and MD Consult prior to January 2016 was performed using search terms, including s oleus ultrasound, gastrocnemius ultrasound, and tennis leg. The references of the pertinent articles were further reviewed for other relevant sources. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: There have been few reviews to date of calf injuries and the use of sonography in their diagnosis. Prompt diagnosis utilizing ultrasound allows the clinician to focus management on gastrocnemius injury if present. Two-thirds of calf injuries occur at the junction of the fascia between the medial head of the gastrocnemius and the soleus. Injuries to the lateral head of the gastrocnemius occur in up to 14% of patients in some case series, but injury may occur anywhere from the proximal origin to the mid-belly to the fascial junction with the soleus. Numerous injuries to the posterior compartment can mimic gastrocnemius strain, and musculoskeletal ultrasound can aide in their diagnosis by incorporating real-time imaging into the grading of the injury and visual confirmation of physical examination findings. CONCLUSION: Acute injury to the posterior compartment of the lower extremity can represent a diagnostic challenge. Medial gastrocnemius strain represents the most common injury of the posterior compartment of the lower extremity. Ultrasound is a useful tool to assist the clinician in determining the specific cause of calf injury, estimate the severity of the injury, and monitor progress of healing. The vast majority of calf injuries can be diagnosed and managed without any additional imaging. Serial diagnostic ultrasound of an injured area allows for direct monitoring of tissue healing and may allow the clinician to more confidently assess response to treatment and help guide return-to-play decisions.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions.

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the centre of the controversy is the addition of a resting ECG to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcome-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs and resources. The decision to implement a cardiovascular screening programme, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

Muscular Calf Injuries in Runners.

Calf pain is a common complaint among runners of all ages but is most frequent in masters athletes. This article focuses on injuries to the triceps surae or true 'calf muscles.' The most common calf injury is a tear of the medial gastrocnemius muscle (Tennis Leg) but other structures including the lateral gastrocnemius, plantaris and soleus also may be the cause of muscular pain. This article looks at the presentation, evaluation, and treatment of these injuries. We also highlight some examples of musculoskeletal ultrasound which is a valuable tool for rapid diagnosis of the cause and extent of injury.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions.

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs, and resources. The decision to implement a cardiovascular screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence-base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations, and Future Directions.

Cardiovascular (CV) screening in young athletes is widely recommended and routinely performed before participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for CV screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation CV screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal CV screening strategy for all athletes including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate CV screening strategy unique to their athlete population, community needs, and resources. The decision to implement a CV screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. American Medical Society for Sports Medicine is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

Wheezing after respiratory tract infection in athletes.

Wheezing is a commonly encountered complaint by patients seen in sports medicine practice. Wheezes are a continuous musical sound heard best on expiration and can originate from one or more of several defined anatomical locations in the human airway. While common causes of wheezing include exercise-induced bronchoconstriction, postnasal drip, and asthma, wheezing also follows specific respiratory infections and can persist for months after the onset of symptoms. Abnormal lung physiology following pneumonia can persist for decades. These postinfectious pulmonary changes affect the ability of athletes to return to sports. In addition to history and physical examination, diagnosis may require pulmonary function testing and exercise challenge testing. The cornerstone to management is an accurate diagnosis and using lifestyle and pharmacologic intervention. Return to play should be gradual and allowed only after individuals demonstrate adequate pulmonary capacity to meet the demands of their sport. Providers also should be aware of governing body regulations regarding treatments and required therapeutic use exemptions.

Presence of automated external defibrillators in North Carolina public middle schools.

BACKGROUND: Automated external defibrillators (AEDs) have been used in the school setting to successfully resuscitate students, staff, and visitors. All public high schools in North Carolina have an AED. However, the number of North Carolina public middle schools with an AED is unknown. OBJECTIVE: The purpose of this study was to determine the presence of AEDs at public middle schools in North Carolina and to estimate the cost associated with providing an AED to all public middle schools currently without one. METHODS: All 547 middle schools in North Carolina's 117 public school systems were surveyed in 2009 via e-mail, fax, and, when necessary, telephone about whether an AED was present on site. For middle schools without AEDs, we estimated the cost of purchase and for 1 year of maintenance. RESULTS: A total 66.6% of public middle schools responded to 1 of 3 survey mailings. The remaining schools were contacted by telephone, so that 100% were included in data collection. At the time of the survey, at least 1 AED was present in 334 schools (61.1%). Of the 213 schools without AEDs, 57 (26.8%) were in school systems in which some middle schools had AEDs, and 156 (73.2%) were in systems in which no middle school had an AED. On the basis of a start-up cost of $1,200 per AED, the cost of providing an AED to each school without one is approximately $255,600. LIMITATIONS: These data are based on self-report, and we could not verify whether AEDs were functional. Cost estimates do not include charges for ongoing maintenance and staff training. CONCLUSIONS: Two hundred and thirteen North Carolina public middle schools (38.9%) do not have an AED on site.

Running injuries - changing trends and demographics.

Running injuries are common. Recently the demographic has changed, in that most runners in road races are older and injuries now include those more common in master runners. In particular, Achilles/calf injuries, iliotibial band injury, meniscus injury, and muscle injuries to the hamstrings and quadriceps represent higher percentages of the overall injury mix in recent epidemiologic studies compared with earlier ones. Evidence suggests that running mileage and previous injury are important predictors of running injury. Evidence-based research now helps guide the treatment of iliotibial band, patellofemoral syndrome, and Achilles tendinopathy. The use of topical nitroglycerin in tendinopathy and orthotics for the treatment of patellofemoral syndrome has moderate to strong evidence. Thus, more current knowledge about the changing demographics of runners and the application of research to guide treatment and, eventually, prevent running injury offers hope that clinicians can help reduce the high morbidity associated with long-distance running.

Prevention of running injuries.

Evidence for preventive strategies to lessen running injuries is needed as these occur in 40%-50% of runners on an annual basis. Many factors influence running injuries, but strong evidence for prevention only exists for training modification primarily by reducing weekly mileage. Two anatomical factors - cavus feet and leg length inequality - demonstrate a link to injury. Weak evidence suggests that orthotics may lessen risk of stress fracture, but no clear evidence proves they will reduce the risk of those athletes with leg length inequality or cavus feet. This article reviews other potential injury variables, including strength, biomechanics, stretching, warm-up, nutrition, psychological factors, and shoes. Additional research is needed to determine whether interventions to address any of these will help prevent running injury.

Peripheral nerve entrapment and injury in the upper extremity.

Peripheral nerve injury of the upper extremity commonly occurs in patients who participate in recreational (e.g., sports) and occupational activities. Nerve injury should be considered when a patient experiences pain, weakness, or paresthesias in the absence of a known bone, soft tissue, or vascular injury. The onset of symptoms may be acute or insidious. Nerve injury may mimic other common musculoskeletal disorders. For example, aching lateral elbow pain may be a symptom of lateral epicondylitis or radial tunnel syndrome; patients who have shoulder pain and weakness with overhead elevation may have a rotator cuff tear or a suprascapular nerve injury; and pain in the forearm that worsens with repetitive pronation activities may be from carpal tunnel syndrome or pronator syndrome. Specific history features are important, such as the type of activity that aggravates symptoms and the temporal relation of symptoms to activity (e.g., is there pain in the shoulder and neck every time the patient is hammering a nail, or just when hammering nails overhead?). Plain radiography and magnetic resonance imaging are usually not necessary for initial evaluation of a suspected nerve injury. When pain or weakness is refractory to conservative therapy, further evaluation (e.g., magnetic resonance imaging, electrodiagnostic testing) or surgical referral should be considered. Recovery of nerve function is more likely with a mild injury and a shorter duration of compression. Recovery is faster if the repetitive activities that exacerbate the injury can be decreased or ceased. Initial treatment for many nerve injuries is nonsurgical.

Diabetes in sports.

CONTEXT: Exercise is recommended for individuals with diabetes mellitus, and several facets of the disease must be considered when managing the diabetic athlete. The purpose of this article is to review diabetes care in the context of sports participation. EVIDENCE ACQUISITION: Relevant studies were identified through a literature search of MEDLINE and the Cochrane database, as well as manual review of reference lists of identified sources. RESULTS: Diabetics should be evaluated for complications of long-standing disease before beginning an exercise program, and exercise should be modified appropriately if complications are present. Athletes who use insulin or oral insulin secretogogues are at risk for exercise-induced immediate or delayed hypoglycemia. Diabetics are advised to engage in a combination of regular aerobic and resistance exercise. Insulin-dependent diabetics should supplement carbohydrate before and after exercise, as well as during exercise for events lasting longer than 1 hour. Adjustment of insulin dosing based on planned exercise intensity is another strategy to prevent hypoglycemia. Insulin-dependent athletes should monitor blood sugar closely before, during, and after exercise. Significant hyperglycemia before exercise should preclude exercise because the stress of exercise can paradoxically exacerbate hyperglycemia and lead to ketoacidosis. Athletes should be aware of hypoglycemia symptoms and have rapidly absorbable glucose available in case of hypoglycemia. CONCLUSION: Exercise is an important component of diabetes treatment, and most people with diabetes can safely participate in sports at recreational and elite levels with attention to appropriate precautions.

Evidence-based treatment of hamstring tears.

Hamstring tears are exceedingly common in a variety of athletic populations and contribute to a significant amount of morbidity and time lost from sport. Many modifiable and nonmodifiable risk factors have been identified with hamstring injury. There is strong evidence that Nordic hamstring exercises can decrease the risk of hamstring injury, limited evidence that sports specific anaerobic interval training and isokinetic strengthening can reduce injury rates, and limited evidence that daily static stretching after injury can increase recovery rate. The majority of medical, surgical, and rehabilitative intervention studies have limitations based on the total number of hamstring injuries included in a given study, reliance on retrospective cohort studies, and conclusions based on case series that limit the utility of the information. Most do not provide a level of evidence greater than expert opinion.

The effect of anabolic steroids on the gastrointestinal system, kidneys, and adrenal glands.

Over the past several decades we have seen an increase in the prevalence of anabolic steroid use by athletes. Because use of anabolic steroids is illicit, much of our knowledge of their side effects is derived from case reports, retrospective studies, or comparisons with studies in other similar patient groups. It has been shown that high-dose anabolic steroids have an effect on lowering high-density lipoprotein, increasing low-density lipoprotein, and increasing the atherogenic-promoting apolipoprotein A. Steroid abuse can also be hepatotoxic, promoting disturbances such as biliary stasis, peliosis hepatis, and even hepatomas, which are all usually reversible upon discontinuation. Suppression of the hypothalamic adrenal axis can also lead to profound adrenal changes that are also reversible with time. Although rare, renal side effects have also been documented, leading to acute renal failure and even Wilms' tumors in isolated cases. Much of our knowledge of these potentially severe but usually limited side effects is confounded by use of combinations of different steroid preparations and by the concomitant use with other substances. Physicians must target their efforts at counseling adolescents and other athletes about the potential harms of androgenic anabolic steroids and the legal options to improve strength and performance.

Basic biomechanics of the lower extremity.

This article describes common principles of biomechanics for running, jumping, and kicking. These activities form the basis for much of sports activity. Understanding human movement allows the physician to prescribe appropriate prevention, treatment, and rehabilitation to patients.