Jeffrey A. Zlotnick, MD CAQ FAAFP DABFP
Family & Sports Medicine
Asst. Clinical Professor Family and Primary Care Sports Medicine
Rutgers - Robert Wood Johnson Medical School
Rutgers - New Jersey Medical School
Philadelphia College of Osteopathic Medicine
Medical Consultant – “Healthy Athletes Initiative”
Special Olympics New Jersey
New Jersey Academy of Family Physicians

 Primary Goal is the Health and Safety of the athlete
 Objective is to be INCLUSIVE, not to try to exclude participation
 NOT a substitute for the regular health examinations by the Primary Care Physician
Jeffrey A. Zlotnick, MD CAQ New Jersey Academy of Family Physicians

 Detect conditions that may limit participation
 Atlanto-axial instability in Down’s
 Heart murmurs: Innocent vs. HCM
 Detect conditions that may lead to injury
 Lack of physical conditioning, weak muscles
 Poor exercise tolerance, heat intolerance
 High amount of major joint problems ex;
“Miserable Misalignment Syndrome”
 Meet legal and insurance requirements
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Assess the general health of the athlete
 May be the ONLY opportunity you will have to see this patient
& go into issues such as immunizations, substance abuse, birth control
 Counsel the athlete on health related issues
 Assess growth & development
– Tanner staging can be helpful where less mature athlete is playing against a more mature athlete: HIGH risk for injury in contact sports (Exam can be embarrassing)
 Assess fitness level & performance
 Help identify weaknesses that may increase chances of injury ex; Swimmers with weak pectoral muscles
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Best done at a MINIMUM of SIX weeks prior to the start of practices
 Gives time to identify & correct problems that were noted on the exam
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Vary from before each season to every
“few” years (“few” is variable)
 Optional: short interval history and go after specific changes or problems
 Once yearly is the most popular
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Private office by Primary Care Physician
 Multi-station exam with different providers of various types (physicians, nurses, PA’s)
 Each type has its advantages and disadvantages
 In-school physical
– Currently not in NJ to get athletes to have a “Medical
Home”. However, there are exceptions
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 PCP knows the PMHx, the FHx, Immunizations
 Less likely to overlook problems
 Young athlete will be more willing to discuss sensitive issues with a known person
 Easier/Less embarrassing to do GU exam
(if indicated)
 Less chance that abnormalities found will be overlooked and not followed up on
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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Many athletes don’t have a PCP
 Limited time for appointments: Time consuming
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Varying levels of knowledge and interest in sport specific problems
–
Must be well versed in Sports-specific demands
Greater cost: Many can’t afford
– Higher income athletes will tend to go to different specialists for each problem found
 Tendency for poor communication between the PCP and the school athletic staff
– Many un-indicated disallowed athletes
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Cost-effective and easy to screen large numbers of athletes
 Specialized personnel at each station
 Usually 5-6 stations
 Good communication with the school athletic staff since the Coach & AT’s are usually part of the team
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Requires a large amount of space
 Hurried, noisy, with minimal privacy
 Difficult for GU exam, Heart murmurs
 Continuity of care easily lost, problems noted are NOT followed up upon
 Lack of communication with parents
 Particular consultant may put unreasonable demands on an athlete
 Varying level of training of school physicians
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

Station
 Sign-in, Ht/Wt, Vital signs, Vision
 History review,
Physical (medical, orthopedic, & neurological) assessment/clearance
Personnel
 Coach, Trainer, Nurse, volunteer
 Physician
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

Station
 Specific orthopedic exam
 Flexibility
 Body composition
 Strength
 Speed, agility, power, endurance, balance
Personnel
 Physician
 Trainer or therapist
 Physiologist
 Trainer, coach, therapist, physiologist
 Trainer, coach, physiologist
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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 Medicine & Science in Sports & Exercise: Volume 31(12) December 1999p 1727
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

Need to be asked or put on a questionnaire that is reviewed

 Important to know number and severity of
Traumatic Brain Injuries (concussions)
 Determine if certain medical conditions are under control enough to allow or limit participation
 Diabetes, Asthma
 Has enough time been allowed to heal and rehabilitate from surgery?
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians


History of Rx’s important to assess control
 Diabetes, Asthma
 Does the athlete require any emergency drugs that the coach/AT will need to know about AND how to use them!
 Get information on birth control measures, menstrual history
 Amenorrhea in women athletes can lead to a high risk of stress fractures (Female Athletic Triad)

Good way to introduce talk on STD’s
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Get information on OTC use as athletes tend to abuse these:
–
OTC asthma, decongestants, diet pills can cause increased heart rate and arrhythmia's
– NSAID’s can cause increased bleeding, renal damage
–
Laxatives (wrestlers) can cause electrolyte abnormalities
 Try to get history of illicit drug use
–
Alcohol, tobacco, marijuana, steroids
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Drugs
– Know what can and CAN’T be given in case of an emergency
 Bees, Insects - important in outdoor sports
–
Need to carry an EpiPen?
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Mainly looking for herpes, scabies, lice, molluscum contagiosum
 Impetigo, herpes and others can be spread by mats, helmets, towels
 Acne and other atopic conditions can be exacerbated by clothing or equipment
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Seizure history (epilepsy?)
 LOC & HA Hx important to determine ability to resist Traumatic Brain Injury & risk for Second
Impact Syndrome
 Burners/stingers are Brachial plexus injuries
 Usually resolve but are occasionally permanent
 Cervical cord neuropraxia w/ transient quadriplegia:
Rare!
–
Associated w/ cervical stenosis, congenital fusions, cervical instability, disc problems
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 1.6 to 3.8 million sports-related TBIs occur each year
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Concussion accounts for 6-10% of all sport related injuries
– Higher risk among high school athletes in contact sports
 Langlois, 2006
TBI can be cumulative
– Cognitive Function (“Punch Drunk”)
– Memory
– Ability to learn
– Reaction time
Increased risk of Second Impact Syndrome
– Primarily younger (pre-adolescent) athletes
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 History of dizziness or passing out during activities in the heat
 Determines ability to tolerate heat or prolonged events
– Marathons
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 During or after activity?
 Seasonal: allergies vs. asthma
 Also could be cardiac
– HCM
–
Valvular disease
– Arrhythmia's
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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Is athlete “single-eyed”
– Less than 20/50 as best in one eye
 Hx of orbital fractures
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Medical problem or injury since last evaluation (periodic exam)
 Immunizations up to date?
–
Td, Hep B, MMR, Meningitis
 Women: 1st menses, last menses, Longest time between menses
 Family use of tobacco, alcohol, street drugs
– “How about yourself??”
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Ever passed out or became significantly dizzy during/after exercise?
 Ever have chest pain during/after exercise?
 Do you tire more quickly than your peers?
 Hx of increased BP, heart murmur?
 Hx of heart racing/skipping beats?
 FHx of sudden death before age 50?
 Hx of concussion
(Traumatic Brain Injury)
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 90% of sudden death in athletes <30 y/o is cardiovascular
Oxford Journals Medicine Cardiovascular Research Volume 50, Issue 2 Pp. 399-408
 Syncope or near-syncope may be a sign of underlying hypertrophic cardiomyopathy
 Chest pain may be atherosclerotic
 Dyspnea on exertion may be asthma, valvular disease, or coronary artery disease
 Palpitations may be arrhythmia, WPW
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Compare to growth charts for age/sex
– Body fat: male 5-10%, female 12-15%
 Very thin: Ask about diet, weight loss, body image (r/o anorexia, bulimia)
 Optional: Body composition:
 Skin fold calipers easiest
 Electronic scales
 Total immersion more accurate
 Good time to discuss weight in athletes where weight is important
 Wrestling, Ice Skating, Gymnastics

 Absence of 1 eye or vision >20/50 in the best eye: AVOID COLLISION SPORTS!
 Anisicoria: slight/baseline is normal and should be noted (1-2mm)
 Large difference needs neurological workup first!
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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BP: Use correct size cuff!!
The strongest risk factor for primary hypertension in children is elevated body mass index.
– The USPSTF found inadequate evidence on the diagnostic accuracy of screening for primary hypertension. The USPSTF also found inadequate evidence on the effectiveness of treatment and the harms of screening or treatment. http://www.uspreventiveservicestaskforce.org/
Check pulses: Symmetrical femoral and radial pulse is a good screen for Coarctation of the aorta
Murmurs: deep inspiration, valsalva, squatting
– Innocent, Mitral valve prolapse, Hypertrophic cardiomyopathy,
Aortic sclerosis
Arrhythmia: EKG to evaluate
– 24 hour monitor
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Baseline testing: Neuropsych testing
– Memory, Cognitive function
– Ability to learn
– Orientation
 VERY useful if athlete receives TBI
– Presence of post-concussive symptoms
– More accurate for determining return to play
– Can demonstrate loss of baseline function
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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Anyone with traumatic brain injury and a recorded
Glasgow Coma Scale of 13 or less at any stage after the first 30 minutes OR who received a CT scan of the head as part of their initial assessment should be routinely followed up with, as a minimum, a written booklet about managing the effects of traumatic brain injury and a phone call in the first week after the injury
Approved Source: National Guideline Clearinghouse
Website: http://www.guideline.gov/summary/summary.aspx?doc_id=10281&nbr=
005397&string=concussion
Level of Evidence: B - A well-designed, nonrandomized clinical trial. A nonquantitative systematic review with appropriate search strategies and well-substantiated conclusions
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Lungs : look for symmetry of movement, listen for wheezes/rubs
 Abdomen : check for organomegaly, tenderness, rigidity
 Skin : check for rashes. growths
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 In a population of stable asthmatics short acting betaagonists, mast cell stabilizers, or anti-cholinergics will provide a significant protective effect against exerciseinduced broncho-constriction with few adverse effects
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Approved source: Cochrane Database
Website: http://www.cochrane.org/reviews/en/ab002307.html
Strength of Evidence: Twenty-four trials (518 participants) conducted in 13 countries between 1976 and 1998 were included. All drugs were effective at attenuating the exercise-induced bronchoconstriction response but to varying degrees even within the same individual. Compared to anti-cholinergic agents, mast cell stabilizers were somewhat more effective at attenuating bronchoconstriction
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

Male:
 Hernia (?)
 Testes both descended
 Single: should counsel about collision sports
Female:
 Pelvic not necessary part of basic exam
 Do w/ Hx of severe menstrual irregularities, primary or secondary amenorrhea
Both: Maturity & development (self rating?)
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

-Decreased ROM, function
- Hyper-flexibility

 Traditionally: UA dip for protein/glucose
– Non-pathologic proteinuria VERY common
– U-glucose NOT reliable & unproven in large studies for DM screening
 Same for CBC, Hct, Fe, Ferritin
 Cardiovascular screening (EKG, Echo) under investigation for cost-effectiveness
 Screen only those at risk or positive findings
– Vol 61, No 1 | January 2012 | The Journal of Family Practice
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

1
2
3
4
5
Does the problem put the athlete at greater risk for injury?
Is the athlete a risk to other players?
Can the athlete safely participate with treatment, rehabilitation, medicine, bracing or padding?
Can limited participation be allowed?
If clearance is denied, are there other activities that the athlete can safely participate in?
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

Contact/
Collision
Limited
Contact/
Collision
Strenuous Moderate Non-
Strenuous
Boxing
Field Hockey
Football
Ice Hockey
Lacrosse
Martial Arts
Rodeo
Soccer
Wrestling
Baseball
Basketball
Bicycling
Diving
Field Sports
Gymnastics
Horseback Riding
Skating
Skiing (all)
Softball
Squash/Handball
Volleyball
Aerobic Dance
Crew
Fencing
Discus, Javelin, Shot put
Running Track
Swimming
Tennis
Weight lifting
Badminton
Curling
Table tennis
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians
Archery
Golf
Riflery

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Individual assessment
 Generally accepted to limit activity during fever

URI’s and strenuous activity (re: cycling) can cause significant impact on the immune system
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 May Dispose to Sudden Death!
 Mild Hypertension: No restrictions
 Moderate to Severe: need assessment and possible treatment
 Benign functional murmurs: No restriction
 Mild Mitral valve prolapse: No restriction
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 PMHx of syncope
 Chest pain/tightness increased w/ activity
 FHx of sudden death
 Moderate to Severe regurgitation
REASSESS!
HIGH RISK!
 Oxford Journals Medicine European Heart Journal Volume 26, Issue 14 Pp. 1422-1445
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Most common cause of sudden death in athletes
 Usually find:
– Marked LVH (***Need to differentiate from normal
LVH in conditioned athletes)
– Significant L outflow obstruction & Arrhythmia's
Both increased by activity
– PMHx of syncope or FHx of sudden death in a young relative
 May participate in LOW intensity activities
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Most are ASYMPTOMATIC until Sudden
Cardiac Death (can be the 1 st symptom)
 Symptoms with activity:
– Chest pain
– Shortness of breath
– Lightedness
– Dizziness
– Loss of consciousness
 Children often do not show signs of HCM
– After puberty
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

By Dan O'Donnell
Story Created: Mar 7, 2011
Story Updated: Mar 8, 2011
MILWAUKEE - The shockwaves from high school basketball star Wes Leonard's sudden death last week have reverberated from Fennville, Mich. across the nation.
An autopsy revealed that Leonard suffered cardiac arrest brought on by dilated cardiomyopathy (DCM), a condition more commonly referred to as an "enlarged heart."
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 0.2% to 0.5% of the general population
– All types of HCM (Obstructive vs Nonobstructive)
 Appears in all racial groups
 Sarcomeres (contractile elements) in the heart replicate causing heart muscle cells to increase in size
– Results in the thickening of the heart muscle
 Typically an autosomal dominant trait
– 50% chance of passing trait
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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Claim 89% reduction in SCD by screening ALL athletes with ECG in the PPE
Actual numbers:
– 84 of 12,880 (0.65%) screened had any significant ECG abnormalities
– Study was done between 1979-2001
– 11 of that 84 (0.09% of the 12,880) had significant pathology
US athlete population alone is ~15 million

Peliccia et al, N Eng J Med 2008 V358(2) pp152-61
New findings higher familial incidence of HCM in
Veneto Italy population
– Pediatrics in Review November 2006; 27:418-424; doi:10.1542/pir.27-11-418
– European Heart Journal (2011) 32, 983–990 doi:10.1093/eurheartj/ehq428
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 SCD per year in healthy patients
– 1 / 133,000 Men
– 1 / 769,000 Women
 AMI w/in 1 hour of exercise 2-10%
– 2.1 – 10x higher than in sedentary patients
 SCD 6-164x greater than sedentary patients
 Recommend higher level of screening in high risk patients
 Circulation 2007: Exercise and Acute CV Events: Placing Risks Into Perspective
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Low risk:
 Men <45 Women <55
 Asymptomatic
 Meet no more than 1 risk factor
 Moderate risk:
 Older than preceding
 2 or more risk factors
 High risk:
 Signs / symptoms of CVS, Pulmonary, Metabolic disease or family history of SCD
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Considered + if singled-eyed or best vision in one eye >20/50
 NO effective eye protection for
– Martial arts, Boxing, Wrestling >>>>
Disallow!
 High risk:
– Football, Baseball, Racquetball
 Eye guards exist but protection is limited
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Functionally 1-eyed athletes and those who have had an eye injury or surgery must not participate in boxing or full-contact martial arts. (Eye protection is not practical in boxing or wrestling and is not allowed in full-contact martial arts.)
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Approved Source: National Guideline Clearinghouse
Website: http://www.guideline.gov/summary/summary.aspx?doc_id=4861&nbr=
3502&ss=6&xl=999
Strength of Evidence: Although the evidence for each recommendation is not specifically stated the evidence is drawn from reports from American National
Standards Institute. Occupational and educational personal eye and face protection devices. Washington (DC): American National Standards Institute; 2003 and American
Society for Testing and Materials. Annual book of ASTM standards: Vol 15.07. Sports equipment; safety and traction for footwear; amusement rides; consumer products. West
Conshohocken (PA): American Society for Testing and Materials; 2003.
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Incidence of renal trauma is 5-25%, but is mostly mild
– Other injuries more common that renal
 Solitary kidney:
– Pelvic, Iliac, Multicystic, Hydronephrotic,
Uteropelvic jct abn’s >>> No Collision Sports!
– Normal position:
 Counsel and sign consent
– Pediatrics Vol. 118 No. 3 September 1, 2006 pp. 1019 -1027
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Liver: determine primary cause (ex: mono)
–
OK to return once organ reduces size
 Spleen: Acute splenomegaly associated w/
HIGH risk rupture with Minimal provocation!
 Chronic splenomegaly: need to assess and treat individually
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Hernia: Only remove if symptomatic
 Gyn: No restriction w/ single ovary
– Do look for menstrual irregularities
– Female athletic triad
 (Amenorrhea, anorexia, osteoporosis)
 Testicular: Single may play all sports: CUP!
– Undescended testes more serious
 Increased risk of Ca
 Sickle Cell: (more later)
– Trait: No restrictions altitudes <4000 ft.
– Disease:
Very limited
 Even mild hypoxia can lead to sickling!
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Burners/Stingers: Can play once asymptomatic
– Recurrent: need atlanto-axial evaluation
 Transient Quadriplegia: NOT associated w/ increased risk of permanent quadriplegia
– However, MUST be evaluated
 Orthopedist or Neurosurgeon
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 TBI classified by
– #1 Amnesia
– #2 Symptoms w/ activity and at rest
 Both physical and mental function
– #3 Loss of Consciousness
– NUMBER of events (damage? cumulative !)
– Neuropsych testing (pre-participation, postinjury)
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Need to be aware of Post TBI Syndrome &
Second Impact Syndrome
– Pay close attention to subtle neuro signs and complaints of headache, poor concentration, dizzy
– Athlete must be symptom free w/ activity and at rest and back to baseline Neuropsych testing before being allowed to play
 Minor trauma can lead to rapid cerebral edema
– More common in younger / pre-adolescent athletes
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

October 29, 2010 Friday
"It was just a routine play. I don't think there was anything special," Orrick told the
Miami County Republic after the game. "I think he just hit the ground pretty hard with his head. He came on the sideline and told one of my assistants, 'my head is really hurting.' He sat down on the bench. He then stood up, but his legs went underneath him and collapsed there."
Nathan Stiles 17 y/o
Spring Hill HS, Kansas City
NBC Action News also reports that Stiles was taking part in his first game since returning from a concussion suffered in early October.
Stiles' father confirmed this to the Kansas City Star, noting that his son suffered a concussion during the homecoming game earlier in the month, but was cleared to play Thursday.
Al Spivak AOL News 10/30/2010 http://www.fanhouse.com/2010/10/30/nathan-stiles-kansas-high-school-football-player-diesafter-in
/
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Administer BEFORE starting any sports
– Mainly contact sports
 Studies demonstrate good correlation between reported symptoms and changes in neuropsych testing at 2 hrs
 However, correlation is lost at 48 hrs to 2 wks
 Most athletes returned to baseline in 2-4 weeks

More accurate at aiding in determining return to play than patients reports of symptoms

Other more advanced computer based systems for determining return to play
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Standardized Assessment of
Concussion
Brain Injury Association of
America
8201 Greensboro Drive
Suite 611
McLean, VA 22102
703-761-0750 / 800-444-6443
 Cost ?

 Originally developed by Prague Group 2005
 Symptom score sheet post-injury
 Mental function assessment in several areas
 Not a full neuro-psych test
 Does have some baseline to compare with post-injury
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 In use since 2005 mainly for sideline assessment
 For athletes 13 & older
– Child SCAT3 for 5-12
 Measures
– Symptoms
– Orientation
– Memory
– Balance / Gait
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Computerized system to aid in evaluating concussion management and safe return to play
 Battery of scientifically validated neuro-cognitive testing on large populations
– ?Does not require baseline testing for individual athlete
– However, does not allow for individual variation
 Becoming available for on the field management for high schools
– Already at the pro level & many colleges
 Best used pre- and post- concussion

 Updated Nov 2012
 British Journal Sports Medicine
 McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313McCrory P, et al. Br J
Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-
092313
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

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Day 1: light aerobic exercise (walking, swimming , or stationary cycling) keeping exercise heart rate less than
70% of maximum predicted heart rate. No resistance training
Day 2: sport-specific exercise, any activities that incorporate sport-specific skills. No head impact activities.
Day 3: non-contact training drills
Day 4: full contact practice, participate in normal practice activities
Day 5: return to competition
If any concussion symptoms return during any of the above activities, the athlete should return to the previous level, after resting for 24 hours.
Br J Sports Med 2013;47:250-258 doi:10.1136/bjsports-2013-
092313

Chronic Traumatic Encephalopathy
 Found most commonly in athletes with multiple head “injuries”
– Can be an accumulation of multiple small
“hits” & not all causing symptoms
 73% of pro-football players with CTE died in middle age (mean 45 y/o)
 64% of deaths have been from
– Suicide
– Abnormal erratic behavior
– Substance abuse
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Cognitive changes 69%
– Memory loss / Dementia
 Personality / Behavioral changes 65%
– Aggressive / Violent behavior
– Confusion
– Paranoia
 Movement abnormalities 41%
– Parkinsons (Dementia pugilistica)
– Gait / Speech problems
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 NONE!!!!!!!!
– Treat symptoms
 Prevention is currently the only available treatment option
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 DEFINITION OF ASTHMA: “Asthma is a chronic inflammatory disorder of the airways…associated with variable airflow limitation [bronchoconstriction] and increased airway responsiveness.”
(1997 NIH Guidelines)
Reference: National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of
Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute. National Institutes of Health; April 1997. National Institute of Health publication No. 97-4051.

 1 in 25 Americans have some form of persistent or recurrent Asthma
 3 in 10 know someone who has Asthma
 Nearly 50% of the population have experienced some form of Asthma
“Asthma in America - A Landmark Survey” Glaxo/Wellcome 1998

 Episodic
 Chronic or persistent
 Cough variant
 Allergic
 Cardiac

Viral “induced”
 Exercise induced

 Shortness of breath, coughing, and wheezing are SYMPTOMS of the spasm of the small bronchioles
 INFLAMMATION is the cause of the bronchospasm and mucus production
 For solely EIA, treating the symptoms alone is sufficient
 For persistent asthma, you MUST treat the inflammatory response!

 Avoid known triggers
– Outdoors during weather that is known to induce attacks
– Allergens (pets, pollens)
– Irritants
 Indoor air conditioning
 Exercise
 Relaxation techniques


Short acting “Rescue” medications
 Beta agonists
 MDI (metered dose inhaler)
 Diskus, Rotacaps
 Long acting bronchodilators
 Long acting beta agonists (salmeterol MDI)
 Time release po albuterol
 Theophylline

 Proventil, Ventolin, Maxair, Brethine,
Alupent, Tornulate, Xopenex
– Relatively short acting, quick onset
– OTC “Primatene”
VERY quick onset, VERY short acting

Emergency use “Rescue” inhaler
 Effective alone in EIA (short events)
 Do NOT treat inflammation in persistent asthma

 Serevent (salmeterol) MDI & Diskus
 Relative long onset, lasts for 12 hours
 Proventil Reptabs
– Less used due to side effects
 Theodur, Uniphyl
– Adjunct in COPD, nocturnal symptoms
 Effective in endurance events, sleep
 Useful with persistent symptoms
 Also, does NOT treat inflammation

 Corticosteroids *Now considered 1 0 therapy
– Inhaled & oral
 Leukotriene modifiers
– montelukast & zarfirlukast
 Mast cell stabilizers
– cromolyn
 Non-steroidal
– necromidal

 Inhaled steroids
– Flovent - 3 strengths, 1-2 puffs 2 x/day 4y/o
– Vanceril, Azmacort, 2-4 puffs 2-3 x/day 6y/o
– AeroBid, Pulmocort
 Intal (cromolyn) -
2 puffs 3-4 times/day
 Mostly used in very young children
 Leukotriene modifiers
Weak anti-inflammatory
– Accolate, Singular po

MOST
 Early epiphyseal closure - loss of growth
 Infections
 Slower wound healing




1 st described in 1910
Most common single genetic disorder found in
African Americans
– Found in 1/375 to 1/500 of persons of African descent
– 10% of African Americans have Sickle Cell Trait
– Also 1/1000 of Hispanic descent
– Also found in many others of Mediterranean, Arabic,
Indian, and South American descent
Various forms of the disease with varying severity
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians





“S” gene from both parents
– Homozygous HgB-SS
Most severe form of the disease
– Limits athletic participation
Discovered early in infancy due to onset of anemia & complication
– 1 st crisis can occur as young as 1 y/o
Survival into the 40’s with current diagnosis and treatment
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians



 Both the AAP – Committee on Sports Medicine and Fitness and National Athletic Trainers Assoc recommend FULL sports participation of athletes with Sickle Cell Trait
– Athletes with Sickle Cell Disease are recommended
NOT to participate in high exertion and collision / contact sports
ALL require individual assessment!!
Screening issues
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians





Be aware that athletes with “Trait” may not present with symptoms until as late as college or even professional level sports!
High profile cases
– Ereck Plancher, Univ Central Florida ’08
– Aaron O’Neil, Univ Missouri ‘05
– Devaughn Darling, Florida State ’01
Plancher had been diagnosed prior to participation but had NO symptoms prior to his death
Various sources list as many as 15 deaths attributed to Sickle Cell Trait complications
Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians

 Whatever applies to the pre-particpation exam in the general population also applies in the special needs population
 Common things are common!


Established early 1960’s by Eunice Kennedy
Shriver & developed by the Joseph P Kennedy
Foundation
 Mission: To provide sports training & competition for persons with mental retardation
 Winter & summer events every 4 years
 Local, state, regional, national, & international
 Local: 300-600 athletes
 International: 1500-6000 athletes
 1 st International Games were 1968 in Soldier Field,
Chicago

 At least 8 y/o & identified as having:
– Mentally challenged by an agency or professional(s)
–
Cognitive delays
–
Learning or vocational problems requiring special designed instruction
 No maximum age limits
 Training programs can begin at 6 y/o

 Swimming & diving
 Track & field
 Basketball
 Bowling
 Cycling
 Equestrian
 Soccer
 Golf
 Gymnastics
 Powerlifting
 Roller skating
 Softball
 Tennis
 Volleyball

 Alpine Skiing
 Cross-country skiing
 Figure skating
 Floor hockey
 Speed skating

 Any sport w/ direct 1on-1 competition
 Considered dangerous for mentally challenged athletes




Wrestling
Shooting
Fencing
Ski jumping
 Javelin
 Vault
 Triple jump
 Platform diving
 Trampoline
 Biathlon
 Boxing
 Rugby
 Football (US)






Levels of participation
–
Age, Sex, Ability
– “Developmental” sports for those w/ severe limitations
Coaches
–
Special-ed teachers, athletic instructors, parents
– Extensive knowledge of the physical & mental characteristics of each athlete
–
Low ratio athlete/coaches ~ 4:1
Volunteers
– Support services
Administration
– Physicians, nurses, PT’s & OT’s, trainers
– Work directly with SO executive director
“Adaptive Sports Program”

 Questionnaire: #1 tool
–
Done initially & yearly
–
Coaches must have an updated & reviewed questionnaire at ALL competitions
–
44 - 71% of problems that can affect ability to compete are identified by questionnaire
 Physical
– Initially & every 3 years
– Athletes develop new problems
 Htn, visual problems, concussions, surgery…
– Identifies approx: 29% problems

 Visual: 25%
– Refractive, cataracts, myopia, blindness
 Hearing: 8%
 Seizures: 19%
 Medical: 6% (similar to general population)
–
30% use medications
 Emotional & behavioral
–
Much higher than in general population


Atlanto-axial instability
– Most common & most controversial
 Spinal cord problems
– Injuries*
 Meningomyelocele
 Spinal bifida
 Hydrocephalus
 Cerebral palsy
 Wheelchair athletes
 Amputees (congenital & acquired)
 Visual & hearing impairment
 Seizures
 Type 1 Diabetes

 Up to 15% of Down syndrome
 All have abnormal collagen that leads to increased ligamentous laxity and decreased muscle tone
 Annular +/- Transverse ligament of C1
(Axis) stabilizes articulation of the odontoid process of C2 (Atlas) w/ C1
 Laxity may allow forward translation of C1 on C2 causing compression of the cervical spinal cord

 Reports of Down syndrome patients experiencing spontaneous subluxation & catastrophic spinal cord injury during surgery requiring intubation (anecdotal)
 Also with blows to the head and major falls
 2% experience symptoms related to AAI
–
Abnormal gait, neck pain, limited C-spine
ROM, spasticity, hyperreflexia, clonus, sensory deficits, upper motor neuron signs
 Asymptomatic AAI is of major concern
–
Highest risk between 5-10 yrs of age

 SO requires C-spine x-rays in neutral, hyper-extension and hyper-flexion
 Evaluation of the Atlantodens interval & spinal canal at C1-C2
 Intervals > 4.5 (5) mm are positive
– ~ 17% of athletes w/ AAI
 Neurosurgical evaluation required before allowing any participation
 Reassessment every 3-5 years
– Unsure if indicated if initial evaluation normal

 Participation allowed in most events except:
– Butterfly stroke
– Diving starts in swimming
– Pentathlon
– High jump
– Equestrian sports
– Artistic gymnastics
– Soccer
– Squat lifts
– Alpine skiing

 American Academy of Pediatrics & Comm. on Sports Medicine & Fitness concluded
“potential but unproven value”
 Current literature does NOT provide evidence for or against screening
–
Long term longitudinal studies are lacking
 Natural history of AAI is unknown
 85% of pts w/ AAI 5mm or > have no symptoms
 At this time screening is SO requirement

 Predisposed to injuries 2 0 to wheelchair use
 Loss of motor & sensory function below the level of the injury
 Lack of autonomic function
–
Thermoregulation
– Autonomic dysreflexia

 Seen 1 0 ly in lesions above T-8
 Loss of vasomotor responses
 Hypothalamus response limited by loss of impulse from below the injury
 Reduced venous return from the paralyzed muscles below the injury
 Impaired sweating below lesion reduces effective body area for evaporative cooling

Body core temps that go to either extreme in hot & cold environments
 Hypo but 1 0 ly extreme Hyperthermia
 Need to be aware of:
–
Clumsiness / Erratic wheelchair control
– Headache
–
Confusion or other mental status change
– Dizziness
–
Nausea / vomiting

 Acclimatization of athletes 2 weeks prior
 Daily posting of temp & heat stress index
–
Combination of solar & ambient heat and relative humidity
 Systematic schedule of fluid intake
–
Before, during, & after events
 Daily weights
 Availability of resuscitative and transportation services

 Occurs in injuries above T-6
 Loss of inhibition of the Sympathetic NS
– Sweating above lesion
– Hyperthermia
–
Acute hypertension
–
Cardiac dysrhythmias
 Multiple triggers
– Bowel & bladder distention
–
Pressure sores
–
Tight clothing
–
Acute fractures
– Environmental (temperature)

 Remove athlete from activity
 Remove sensory stimulus
–
Clothing
–
Bladder catheterization/bowel evacuation
–
Cooler/warmer environment
 Transport to hospital may be necessary
–
Uncontrolled hypertension or dysrhythmia
 Usually self-limited
 Watch for self-induced (“Boosting”)

 Spasticity, athetosis, ataxia
 Progressively decreasing muscle/tendon flexibility & strength

Contractures
 Impaired hand-eye coordination
 Mentally challenged
 Seizures
 Extreme risk for overuse injuries!
 50% in wheelchairs
 Modification of events to accommodate
– “Adaptive Sports Program”

 Indications for amputation:
–
Circulatory problems: Necrosis or infarction
–
Life threatening: cancer, infection
– Congenital deformity rendering limb insensate
 Upper limb more common in younger
 Length of limb preserved to protect epiphysis
 Appliances are smaller & require frequent adjustments to accommodate growth
 Prostheses are abused & need repair/adjustment
 Skin breakdown/ Phantom limb pain is less frequent in younger athletes

 Overgrowth of stump is common


Skin breakdown common in sports due to friction & pressure
Alteration center of gravity

Problems with balance (1 0 ly lower limb amputees)
 Hyperextension of knee & lumbar spine
 Early detection is key 2 0 decreased sensation in limb
 Athletes may compete using prostheses but no other assistive device

 Considered + if singled-eyed or best vision in one eye >20/50
 NO effective eye protection for
– Martial arts, Boxing, Wrestling
– Football, Baseball, Racquetball
– NOT allowable Special Olympics sports
 Eye guards exist but protection is limited

 Partial sight to total blindness
 Legal blindness: acuity < 20/200, visual field < 20 0
 No related physical disabilities except due to lack of experience with certain activities
 Modifications to equipment, rules & strategy may be required
– Tactile & audio clues
–
Tethers or guide wires
– Step & stroke counting
–
Guides

 Liver: determine primary cause (ex: mono)
–
OK to return once organ reduces size
 Spleen: Acute splenomegaly associated w/
HIGH risk rupture with Minimal provocation!
 Chronic splenomegaly: need to assess and treat individually

 May Dispose to Sudden Death!
 Mild Hypertension: No restrictions
 Moderate to Severe: need assessment and possible treatment
 Benign functional murmurs: No restriction
 Mild Mitral valve prolapse: No restriction

 Most common cause of sudden death in athletes
 Usually find:
– Marked LVH (***Need to differentiate from normal
LVH in conditioned athletes)
– Significant L outflow obstruction & Arrhythmia's
Both increased by activity
– PMHx of syncope or FHx of sudden death in a young relative
 May participate in LOW intensity activities

 Tend not to consider themselves disabled
– “Subculture” of society
 Variations:
–
Mild: threshold 27-40 dB
–
Profound: threshold > 90 dB
 Behavioral disorders 2 0 communication challenges
 No related physical disabilities except due to lack of experience with certain activities

 Common in athletes with developmental disabilities
 Familiarity with meds & side effects
– Attention span & cognitive impairment
 Decreased potential for seizures w/ exercise
– Metabolic acidosis due to lactate buildup & incomplete respiratory compensation
– Decreased pH

Stabilizes neuromembranes
 Good control must be obtained prior to participation in activities
 Be prepared as with ALL athletes

 Need to monitor glucose:
– 30 min before activity
– Immediately before activity
– Every 30-45 min during activity
 Ideal pre-exercise range is 120-180 mg/dl
– > 200 mg/dl: Postpone & take extra insulin to get glucose levels down 1 st
– Exercise with elevated glucose will cause levels to RISE further which can lead to increased diuresis, dehydration, and keto-acidosis

 Moderate exercise:
– AM activity reduce Reg by 25%
– PM activity reduce Reg by 25% as well as NPH or
Long Acting
 Strenuous or Long Term:
– AM activity reduce Reg by 50%
– PM activity reduce Reg by 50% as well as NPH or
Long Acting
 Insulin pumps or Lantus: as above
 Liberal hydration
– < 1hr: water alone OK
– > 1hr: think Na+ replacement
 (Sport drinks: remember they contain CHO!!)

 Autonomic dysfunction
– Avoid power lifting 2 0 bradycardia & syncope
– Increased hot & cold intolerance
 Hyperglycemia: treat & watch for KA
 Hypoglycemia
– Tremors, sweating, palpitations, pallor, hunger
– Long acting CHO’s, glucagon
 Late onset hypoglycemia: 6-28 hrs later
– Replace glycogen w/in 1 hr of activity
– Avoid activity near intermediate insulin peaks
– Use long-acting to avoid peaks
–
Watch for Neuro-glypenic Syndrome

 Some athletes non-verbal
– Cannot describe problems
 Some will hide problems
–
Not unlike other athletes
 Older athletes may demonstrate adolescent behavior & significant psychiatric problems
– Some have parents/caregivers in their 70’s
–
Some problems may be related to parental & caregiver “burn-out”

 Some problems out of scope of practice for
Family Physicians:
–
Dental disease
–
Complex Cardiac problems
–
Advanced Orthopedic problems
–
Ophthalmic problems
 Need to establish referral network of physicians comfortable & willing to care for
SO athletes

 Coaches need to be made aware of what medical problems athletes have and what medications they are on
–
Side effects
 SO PPE form needs to be revised to include major medical problems
– Currently form does not include this

 Podiatric problems: difficulty finding good athletic shoes that fit
– Pes planus
 Toenail fungus
 Tinea & groin abscesses
 Orthostatic hypotension

 Be aware of special needs but remember that
“Common problems are common!”
–
Take the usual precautions as outlined
 Participation is critical for these athletes
– Self esteem
–
Enhances physical development
 Requires a multidisciplinary approach
– Physicians, nurses, athletic trainers, coaches PTs
& OTs
 Most important: the Athlete

Some Pictures From MedFest 1:
Before We Start…

Jeffrey A. Zlotnick, MD, CAQ, FAAFP
Maddoc007@aol.com
New Jersey Academy of Family Physicians www.njafp.org
224 West State St., Trenton, NJ 08608
Phone: 609-394-1711 ~ Fax: 609-394-7712 or
Exec. Vice President: Ray J. Saputelli, MBA, CAE ray@njafp.org
Deputy Exec. Vice President: Theresa J Barrett, PhD, CMP, CAE theresa@njafp.org
Office Manager & Membership Services: Candida Taylor candida@njafp.org

Jeffrey A. Zlotnick, MD CAQ NJ Academy of Family Physicians