The Pre-Participation
Sports Examination
General & Special Needs Populations
Jeffrey A. Zlotnick, MD, CAQ, FAAFP, DABFP
Family & Sports Medicine
St. Luke’s University Health Network
Jim Thorpe, Bethlehem, PA
Assistant Clinical Professor Family and Primary Care Sports Medicine
UMDNJ – Robert Wood Johnson Medical School
UMDNJ – New Jersey Medical School
Philadelphia College of Osteopathic Medicine
Medical Consultant – “Healthy Athletes Initiative”
Special Olympics NJ
NJ Academy of Family Physicians
The Pre-Participation Exam
(PPE)
Primary goal is to evaluate 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
NJ Academy of Family Physicians
Primary Objectives

Detect conditions that may limit
participation
– Atlanto-axial instability in Down Syndrome
– Heart murmurs: Innocent vs. Hypertrophic Cardiomyopathy
(HCM)

Detect conditions that may lead to injury
– Lack of physical conditioning, weak muscles
– Poor exercise tolerance, heat intolerance
– High number of major joint problems: “Miserable Misalignment
Syndrome”

Meet legal and insurance requirements
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Secondary Objectives

Assess athlete’s general health
– May be the ONLY opportunity you have to see this patient and
discuss issues such as immunizations, substance abuse, and birth
control
Counsel 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
(e.g., swimmers with weak pectoral muscles)
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Timing
Best if performed at a MINIMUM of SIX
weeks before practice starts
 Gives time to identify & correct problems
noted on exam

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Frequency
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 most popular

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Methods
Private office by Primary Care Physician
 Multi-station exam with different providers
of various types (physicians, nurses, PAs)
 Each type of station has advantages and
disadvantages
 In-school physical

– Currently not required in NJ to get athletes to have a “Medical
Home.” However, there are exceptions.
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Private Office – Advantages




PCP knows the PMHx, the FHx, Immunizations
Less likely to overlook problems
Young athletes will be more willing to discuss
sensitive issues with a known person
Easier and less embarrassing to do GU exam (if
indicated)

Less chance for abnormalities to be overlooked
and not addressed
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Private Office – Disadvantages



Many athletes do not have a PCP
Limited time for appointments: time consuming
Varying levels of knowledge and interest in sport
specific problems
– Must be well versed in sports-specific demands

Greater cost: many cannot afford
– Higher income athletes will tend to go to different specialists for
each problem found

Tendency for poor communication between PCP
and school athletic staff
– Many un-indicated disallowed athletes
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Multi-Station – Advantages
Cost effective and easy to screen large
numbers of athletes
 Specialized personnel at each station

– Usually 5 to 6 stations

Good communication with school athletic
staff since the coach & athletic trainers are
usually part of the team
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Multi-Station – Disadvantages
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 levels of training of school
physicians

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Multi-Station – Requirements


Station
Sign-in, Ht/Wt, vital
signs, vision
History review,
physical (medical,
orthopedic, &
neurological)
assessment/clearance
Jeffrey A. Zlotnick, MD, CAQ


Personnel
Coach, trainer, nurse,
volunteer
Physician
NJ Academy of Family Physicians
Multi-Station – Options
Station





Personnel
Specific orthopedic exam
Flexibility
Body composition
Strength
Speed, agility, power,
endurance, balance
Jeffrey A. Zlotnick, MD, CAQ





Physician
Trainer or therapist
Physiologist
Trainer, coach, therapist,
physiologist
Trainer, coach,
physiologist
NJ Academy of Family Physicians
MEDICAL HISTORY IS KEY!
 Statistics
show that a good history will
identify 63% to 74% of medical
problems
 Anecdotal information from the athlete
agrees with the parents less than half of
the time
Reference: Medicine & Science in Sports & Exercise. 1999;31(12): 1727.
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Key Questions
The following questions need to be
asked or put on a questionnaire that
is reviewed
Ever been treated in a hospital
or had surgery?
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 passed to allow for healing
and rehabilitation after surgery?
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Taking any Rx or OTC Drugs?



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 STDs
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Taking any Rx or OTC Drugs?

Get information on use of OTC drugs
because athletes tend to abuse these:
– OTC asthma, decongestants, & diet pills can
cause increased heart rate and arrhythmias
– NSAIDs can cause increased bleeding
– 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
Allergies?

Drugs
– Know which drugs 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
Skin Problems or Rashes?
Mainly looking for herpes, scabies, lice, &
molluscum contagiosum
 Impetigo, herpes, and other conditions 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
History of Head Injury, LOC,
Seizure, “Burners or Stingers?”



History of seizure (epilepsy?)
Loss of consciousness (LOC) & headache Hx
important to determine ability to resist Traumatic
Brain Injury (TBI) & risk for Second Impact
Syndrome
Burners/stingers are brachial plexus injuries
– Usually resolve but are occasionally permanent

Cervical cord neuropraxia with transient
quadriplegia is rare
– Associated with cervical stenosis, congenital fusions,
cervical instability, disc problems
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
ANY History of Recurrent
Burners/Stingers or Transient
Quadriplegia?
NEED cervical spine films
BEFORE being allowed to
participate!
Concussion?

Concussion accounts for 6% to10% of all sport
related injuries
– Higher risk among high school athletes in contact sports (Langlois
2006)


1.6 to 3.8 million sports-related TBIs occur each
year
TBIs can be cumulative
–
–
–
–

Cognitive function (“Punch Drunk”)
Memory
Ability to learn
Reaction time
Increased risk of Second Impact Syndrome
– Primarily in younger (pre-adolescent) athletes
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Heat or Muscle Cramps?
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
Difficulty Breathing?
During or after activity?
 Seasonal allergies vs. asthma
 Also could be cardiac

– HCM
– Valvular disease
– Arrhythmias
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Special Equipment/Braces?
 Inspect
for fit & function
 Risk to other players?
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Problems with Eyes/Glasses?

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
Sprains, Strains, Fractures, or
Dislocations?
 Need
to determine need for
rehabilitation PRIOR to being
allowed to participate
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Other Questions
Medical problem or injury since last
evaluation (periodic exam)?
 Immunizations up to date?

– Td, Hep B, MMR, Meningitis
Women: Date of first and 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
Most Important Questions
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 or 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
Keep in Mind

90% of sudden death in athletes <30 y/o is
cardiovascular
Reference: Spotlight on sudden cardiac death. Cardiovascular Research. 2001:50(2):173-176.
Syncope or near-syncope may be a sign of
underlying hypertrophic cardiomyopathy
 Chest pain may be atherosclerotic
 Dyspnea on exertion may be caused by
asthma, valvular disease, or coronary artery
disease
 Palpitations may be arrhythmia, WPW

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Key Components of the
Physical Exam
Height & Weight

Compare to growth charts for age/sex
– Body fat: male 5% to 10%; female 12% to 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
Eyes
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
Cardiovascular System

BP: Use correct size cuff!
– >110/70 mmHg for <10 y/o or >120/80 mmHg*
for >10 y/o must be evaluated (*Latest JNC guidelines)


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
Neurological

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
Practice Recommendation

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
Other
Lungs: look for symmetry of movement,
listen for wheezes/rubs
 Abdomen: check for organomegaly,
tenderness, rigidity
 Skin: check for rashes and growths

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Practice Recommendation

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

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
Genitourinary
Male:
 Hernia?
 Testes both descended?
 Single: should counsel about collision sports
Female:
 Pelvic exam 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
Musculoskeletal
Need to assess major muscle groups and
joints via a screening exam
 Follow up closely on any abnormalities
noted

– Decreased ROM, function
– Hyper-flexibility
Laboratory Testing

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, Sickle trait
 Cardiovascular screening (EKG, Echo)
under investigation for cost-effectiveness
 Screen only those at risk or positive
findings


Reference: Exercise-induced Proteinuria? The Journal of Family Practice. 2012;61(1):23-26.
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Determining Clearance
MOST IMPORTANT PART!
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
Clearance is based on AAP
Committee on Sports
Medicine Recommendations
for Participation in Competitive
Sports

Based upon the amount of contact/collision
and intensity of exercise
Contact
Non-Contact
Contact/ Limited Strenuous Moderate NonStrenuous
Collision Contact/
Collision
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
Badminton
Crew
Curling
Fencing
Table tennis
Discus, Javelin, Shot
put
Running Track
Swimming
Tennis
Weight lifting
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Archery
Golf
Riflery
Some Specifics
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Acute Illness
Individual assessment
 Generally accepted to limit activity during
fever
 URIs and strenuous activity (e.g., cycling)
can cause significant impact on the immune
system

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Cardiovascular Abnormalities
May Dispose to Sudden Death!
 Mild hypertension: No restrictions
 Moderate to severe hypertension: 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
MVP with:
PMHx of syncope
 Chest pain/tightness increased w/ activity
 FHx of sudden death
 Moderate to severe regurgitation
 REASSESS!
 HIGH RISK!

Reference: Recommendations for competitive sports participation in athletes with cardiovascular disease. European Heart
Journal. 2005;26(14):1422-1445.
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Hypertrophic Cardiomyopathy
(HCM, IHSS)


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 & Arrhythmias,
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
Symptoms HCM
Most are ASYMPTOMATIC until Sudden
Cardiac Death (can be the 1st symptom)
 Symptoms with activity:

–
–
–
–
–

Chest pain
Shortness of breath
Lightheadedness
Dizziness
Loss of consciousness
Children often do not show signs of HCM
– After puberty
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Basketball Star's Sudden Death
Brings Awareness of Deadly Heart
Disease
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 caridomyopathy (DCM), a condition
more commonly referred to as an "enlarged heart."
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Incidence HCM

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
Cardiovascular Risks
ALL Causes

SCD per year in healthy patients
– 1/133,000 Men
– 1/769,000 Women

AMI w/in 1 hour of exercise 2% to 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

Reference: Exercise & acute CV events placing the risks into perspective: a scientific statement from the
AHA Council on Nutrition, Physical Activity, & Metabolism and the Council on Clinical Cardiology.
Circulation. 2007;115(17):2358-68.
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Who Should Be Screened?

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
Visual Impairment
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
Practice Recommendation

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.)

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
Kidney/Renal

Incidence of renal trauma is 5% to 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
Reference: Single kidney and sports participation: perception versus reality.
Pediatrics. 2006;118(3): 1019-1027.
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Hepato/Splenomegaly

Liver: determine primary cause (e.g., mono)
– OK to return once organ reduces size
Spleen: Acute splenomegaly associated
with HIGH risk of 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:
– 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
Neurological Problems

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
Traumatic Brain Injury
(Concussions)

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 is cumulative!)
– Neuropsych testing (pre-participation, postinjury)
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Traumatic Brain Injury
(Concussions)

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.
Reference: 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
Return to Play: NP testing based

Administer BEFORE starting any sports
– Mainly contact sports





Studies demonstrate good correlation between
reported symptoms and changes in neuropsych
testing at 2 hours
However, correlation is lost at 48 hours to 2 weeks
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
Neuropsych
Testing

Standardized Assessment of
Concussion
Brain Injury Association of
America
8201 Greensboro Drive
Suite 611
McLean, VA 22102
703-761-0750 / 800-444-6443

Cost?
SCAT: Sideline Concussion
Assessment Tool
Developed by Prague Group 2004
 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
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
SCAT2
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
ImPACT:
Univ of Pittsburgh


Computerized system to evaluate 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
– Does not allow for individual variation

Expensive!

Already in use at the professional level, some colleges
& high schools
– Becoming more available for on field management
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
CogState Sport
Also computer based system
 Requires a baseline

– Data submitted to secure online server
After injury, athlete can be re-tested from
any web-connected computer & able to
compare scores
 CogState also does analysis on pre- and
post- tests

– Reports by Email
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Return to Play
Based on Zurich protocols published in
Consensus Statement on Concussion in
Sport 3rd International Conference on
Concussion in Sport Held in Zurich,
November 2008
 Clinical Journal of Sport
Medicine. 2009;19(3):
185-200.

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Chronic Traumatic
Encephalopathy (CTE)

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
Symptoms CTE

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
Treatment CTE
NONE!
Treat symptoms
 Prevention is currently the only available
treatment option

Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
The Special Needs Population
Special Olympics NJ
NJ Academy of Family Physicians
Special Olympics (SO)




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
1st international games were 1968 in Soldier Field,
Chicago
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Eligibility

At least 8 y/o & identified as having:
– Mental retardation by an agency or professional
– Cognitive delays
– Learning or vocational problems requiring
special designed instruction
No maximum age limits
 Training programs can begin at 6 y/o

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Summer Sports







Swimming & diving
Track & field
Basketball
Bowling
Cycling
Equestrian
Soccer
Jeffrey A. Zlotnick, MD, CAQ







Golf
Gymnastics
Powerlifting
Roller skating
Softball
Tennis
Volleyball
NJ Academy of Family Physicians
Winter Sports





Alpine skiing
Cross-country skiing
Figure skating
Floor hockey
Speed skating
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Prohibited Sports


Any sport w/ direct 1on-1 competition
Considered dangerous
for mentally retarded
athletes









Wrestling
Shooting
Fencing
Ski jumping
Jeffrey A. Zlotnick, MD, CAQ




Javelin
Vault
Triple jump
Platform diving
Trampoline
Biathlon
Boxing
Rugby
Football (US)
NJ Academy of Family Physicians
Organization of Games

Levels of participation
– Age, Sex, Ability
– “Developmental” sports for those w/ severe limitations

Coaches
– Special education 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
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Pre-Participation Exam

Questionnaire: #1 tool
– Done initially & yearly
– Coaches must have an updated & reviewed
questionnaire at ALL competitions
– 44% to 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 approximately 29% problems
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Common 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 general population
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Complex Problems

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
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Atlanto-Axial Instability




Up to 15% of athletes have 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
Reference: Participation by Individuals with Down Syndrome Who Have Atlantoaxial Instability. Special
Olympics. www.specialolympics.org. Accessed 12/10/12.
http://sports.specialolympics.org/specialo.org/Special_/English/Coach/Coaching/Basics_o/Down_Syn.ht
m
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Atlanto-Axial Instability
Reports of athletes with Down syndrome
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, hyper-reflexia, clonus,
sensory deficits, upper motor neuron signs

Asymptomatic AAI is of major concern
– Highest risk between 5 to 10 years of age
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Atlanto-Axial Instability
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 to 5 years

– Unsure if indicated if initial evaluation normal
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Atlanto-Axial Instability

Participation allowed in most events except:
–
–
–
–
–
–
–
–
–
Butterfly stroke
Diving starts in swimming
Pentathlon
High jump
Equestrian sports
Artistic gymnastics
Soccer
Squat lifts
Alpine skiing
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Atlanto-Axial Instability
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 patients w/ AAI 5mm or > have no
symptoms
 At this time screening is SO requirement

Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Spinal Cord Injured Athletes
Predisposed to injuries 20 to wheelchair use
 Loss of motor & sensory function below the
level of the injury
 Lack of autonomic function

– Thermoregulation
– Autonomic dysreflexia
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Thermal Regulation
Seen 10ly 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

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Thermal Regulation
Body core temps that go to either
extreme in hot & cold environments
 Hypo but 10ly extreme Hyperthermia
 Need to be aware of:
–
–
–
–
–
Clumsiness/Erratic wheelchair control
Headache
Confusion or other mental status change
Dizziness
Nausea/vomiting
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Prevention
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

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Autonomic Dysreflexia


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)
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Treatment
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”)

Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Wheelchair Athletes


Usually other significant medical problems
10ly Overuse injuries to wrist & shoulders
– Rotator cuff impingement/tendonitis
– Biceps tendonitis

Fractures to the hands & wrists
– Epiphyseal plate weakest point
– Lower extremity fractures infrequent

Pressure sores
– Due to increase pressure & lower blood flow
– Insidious onset due to lack of sensation
– Tx: Custom seats, moisture absorption, padding
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Cerebral Palsy
Spasticity, athetosis, ataxia
 Progressively decreasing muscle/tendon
flexibility & strength >> Contractures
 Impaired hand-eye coordination
 Mental retardation
 Seizures
 Extreme risk for overuse injuries!
 50% in wheelchairs
 Modification of events to accommodate

– Get inventive (“Adaptive Sports Program”)
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Athletes w/ Amputations

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
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Problems






Overgrowth of stump is common
Skin breakdown common in sports due to
friction & pressure
Alteration center of gravity >> Problems with
balance (10ly lower limb amputees)
Hyperextension of knee & lumbar spine
Early detection is key 20 decreased sensation in
limb
Athletes may compete using prostheses but no
other assistive device
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Visual Impairment

Partial sight to total blindness
– Legal blindness: acuity < 20/200, visual field < 200
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
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Hearing Impairment

Tend not to consider themselves disabled
– “Subculture” of society

Variations:
– Mild: threshold 27-40 dB
– Profound: threshold > 90 dB
Behavioral disorders 20 communication
challenges
 No related physical disabilities except due
to lack of experience with certain activities

Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Seizures


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
Reference: Howard GM, Radloff, M, Sevier TL. Epilepsy and sports participation. Current Sports Medical Reports.
2004 Feb;3(1):15-9.
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Insulin Dependent Diabetes

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 1st
– Exercise with elevated glucose will cause levels
to RISE further which can lead to increased
diuresis, dehydration, and keto-acidosis
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians
Insulin Adjustments




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 Glargine: as above
Liberal hydration
– < 1hr: water alone OK
– > 1hr: think Na+ replacement

(Sport drinks: remember they contain CHO!!)
Complications

Autonomic dysfunction
– Avoid power lifting 20 bradycardia & syncope
– Increased hot & cold intolerance


Hyperglycemia: treat & watch for KA
Hypoglycemia
– Tremors, sweating, palpitations, pallor, hunger
– Long acting CHO’s, glucagons

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
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Special Concerns

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
 Part of “Healthy Athlete’s Initiative” SOI

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Special Concerns




Podiatric problems: difficulty finding good
athletic shoes that fit
– Pes planus
Toenail fungus
Tinea & groin abscesses
Orthostatic hypotension
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Special Concerns:
Communication Disorders


Elective mutism
– Children usually 3-5
– Have the ability to speak +/- use language, but refuse to
except under certain circumstances, or only to certain
individuals
Hearing impairment
– Seen at young age with delayed or abnormal speech &
language development
– Can be mild, moderate, severe & uni- or bilateral
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Autism

Pervasive developmental disorder with significant
impairment in
– Socialization
– Communication
– Sensory/motor development


7:10,000 births
Associated with
– Mental retardation
– Seizure disorders
– Psychiatric disorders
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Approach to the patient
Approach slowly
 Speak in a slow clear voice
 Try to maintain eye contact

– Be aware too much may cause the patient to
withdraw
Use hand gestures along with language
 Let the patient touch

– E.g., stethoscope, otoscope, splints, your hands

Watch the patient & caretaker for clues
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Healthy Athletes Initiative
MedFest
NJ Academy of Family Physicians
&
Special Olympics NJ
MedFest Program
SONJ and NJAFP
March 9, 2003: the first MedFest occurred
in Lawrenceville, NJ. This model has been
copied by a number of other organizations
 August 2005: an agreement was signed
between SOI and AAFP
 March 2012: Almost 1000 athletes have
been certified to participate that otherwise
would have never had the opportunity

Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Some Pictures From MedFest 1:
Before We Start…
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Registration
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Vitals
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
History Review
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Heart & Lung
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Orthopedic
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Ear, Nose & Throat
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Check out!
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Thank you!!
Jeffrey A. Zlotnick, MD, CAQ
NJ Academy of Family Physicians
Contact Information
Jeffrey A. Zlotnick, MD, CAQ, FAAFP, DABFP
New Jersey Academy of Family Physicians
224 West State Street
Trenton, NJ 08608
Phone: 609-394-1711 ~ Fax: 609-394-7712
MedFest Coordinator and NJAFP Office Manager:
Dr. Zlotnick – Maddoc007@aol.com
Candida Taylor – candida@njafp.org
NJAFP Executive Vice President:
Ray Saputelli, MBA, CAE – ray@njafp.org
Deputy Executive Vice President:
Theresa J. Barrett, MS, CAE – theresa@njafp.org
Jeffrey A. Zlotnick, MD CAQ
NJ Academy of Family Physicians