KIN 188 – Prevention and Care of Athletic Injuries

General Medical Conditions

Introduction Cardiovascular disorders Neurological conditions Respiratory tract conditions Gastrointestinal conditions Endocrine conditions Infectious diseases Dermatological conditions Special population conditions

Cardiovascular Conditions Blood and lymph disorders

Syncope

Shock

Blood pressure disorders

Sudden cardiac death

Non-cardiac causes of sudden death

Blood and Lymph Disorders Anemia

Iron-deficiency anemia Sickle cell anemia

Hemophilia

Reye’s syndrome

Lymphangitis

Anemia Defined as reduction in either red blood cell volume or

hemoglobin (Hgb) concentration

Iron-deficiency anemia Iron-deficiency characterized by deficient Hgb synthesis Most common in adolescent girls and women of childbearing age

from menstrual blood loss and increased iron demand during pregnancy

Treat with dietary iron supplements and vitamin C for iron absorption Sickle-cell anemia

Most common in African-Americans Results from abnormalities in Hgb structure that produce a

characteristic sickle-shaped red blood cell that cannot transport oxygen

Sickle cells clump together and often block vessels causing organ failure

No known treatment, hydration and modified exercise considerations (environment, duration, etc.)

Blood and Lymph Disorders Hemophilia

Bleeding disorder associated with deficiency of body’s blood-clotting system

Presents with large/deep bruises, prolonged bleeding from minor wounds

Reye’s syndrome Disruption of urea cycle in body resulting in ammonia in blood,

hypoglycemia, severe brain edema and critically high intercranial pressure

Almost always follows URI of viral nature (varicella and flu most common, but also can be from common cold)

Rare condition which may result in coma or death if not recognized and treated appropriately

Lymphangitis Inflammation of lymphatic channel secondary to infection distal to channel Most common presentation is swollen lymph nodes (groin – LE, axilla – UE)

Syncope Sudden, transient loss of consciousness (“fainting”) occurring

in healthy individuals

Most frequent cause is neural mediated syncope (NMS) from sudden drop in blood pressure reducing circulation to brain leading to loss of consciousness

Other causes may be related to heat illness, dehydration, emotional stress, cardiac arrhythmias and changes in blood volume or distribution

Initial management includes lying the individual down safely and assessing vital signs – recovery usually occurs within minutes, activate EMS if not and recurrent episodes should be evaluated by MD

Shock Occurs if heart unable to exert adequate

pressure to circulate enough oxygenated blood to organs

May be from damaged heart that fails to pump properly, low blood volume from blood loss or dehydration or because blood vessels dilate causing blood to pool in large vessels away from vital areas

Shock Most prevalent symptoms are

associated with vital signs Rapid, weak pulse Rapid, shallow respirations Decreased blood pressure

Skin turns cool/pale/clammy – lips and nail beds may become cyanotic

Represents a medical emergency and is potentially life-threatening

Blood Pressure Disorders Hypertension

Defined as sustained blood pressure greater than 140/90 mm Hg

Risk factors include age, diabetes, heredity, high blood lipids (atherosclerosis), obesity, race (African-American), gender (men), smoking

Treat with lifestyle and diet modifications and medications of other efforts unsuccessful

Hypotension Characterized by fall of 20 mm Hg or more from

individual’s normal baseline pressure Can be caused by shock, orthostasis (change in body

position), overtreatment of hypertension (meds) Of no concern in conditioned individual - CV efficiency

Sudden Cardiac Death Hypertrophic cardiomyopathy

Abnormal thickening of left ventricular wall prior to age 20 Leading cause of sudden death in young, active individuals Produces impaired ventricular filling, blood flow obstruction

and/or arrhythmias Mitral valve prolapse

Regurgitation of blood from left ventricle to left atrium during ventricular contraction

Results in murmur – often present with chest pain, dyspnea and palpitations during exertion

Myocarditis Infection causing inflammation of muscular walls of heart Sudden death occurs when inflammatory changes in heart

muscle lead to death of adjacent muscle cells causing life-threatening arrhythmias

Sudden Cardiac Death Acquired valvular heart disease

Defect/insufficiency in heart valve (stenosis or regurgitation)

If mild, participation OK – if severe, not recommended Coronary artery disease (atherosclerosis)

Most common cause of sudden death in individuals over 30 Impairs blood flow to heart muscle resulting in myocardial

infarction (heart attack) Marfan’s syndrome

Genetic condition characterized by arm span exceeding height, hypermobile joints, eye defects and aortic defects

Sudden death usually from aortic rupture (short life span) Arrhythmias

Several rare conditions resulting in arrhythmias and/or ventricular fibrillation can cause sudden death

Non-Cardiac Causes of Sudden Death

Commotio cordis Cardiac arrest from low-impact blunt force trauma to

the chest in the absence of structural cardiovascular disease

Substance abuse Certain drugs can cause cardiac changes that

predispose individual to sudden death (amphetamines, cocaine)

Erythropoietin is hormone that stimulates red blood cell production – ergogenic aid used to aid performance for endurance athletes – causes increased blood volume/viscosity causing decreased circulation and MI

Non-Cardiac Causes of Sudden Death

Head injuries Sudden death from catastrophic brain injuries

(epidural/subdural hematoma, second-impact syndrome)

Present with altered vitals, dilated pupil, posturing

Heat illness Secondary to heat stroke, especially if not recognized

and treated quickly

Sickle cell trait Secondary to clumping of sickle cells Increased risk during exertion in hot/humid

environments and at increased altitudes

Neurological Conditions Headaches

Migraine headaches Post-traumatic headaches Treatment

Seizure disorders/epilepsy Types of seizures Management

Meningitis

Encephalitis

Headaches Migraine headaches

Defined as idiopathic, episodic HA disorder with attacks lasting 4-72 hours

Recurrent, moderate to severe, acute onset Thought to be associated with vascular

responses Often preceded by aura (flash of light, odor,

taste, feeling dizzy, etc.) Usually unilateral, nausea/vomiting,

photophobia, phonophobia, desire to lay in dark/quiet area

Headaches Post-traumatic headaches

Most common neurological symptom following head trauma

Occurs within 2 weeks of trauma and can last up to 8 weeks

Greater risk if Loss of consciousness and/or amnesia present with head trauma

Return to play considerations (second impact syndrome, tumors)

Headache management Most treated with medications (OTC vs. Rx)

Seizure Disorders Definitions

Seizure Abnormal discharge of electrical activity from the

brain Seizure disorder

Recurrent episodes of sudden, excessive discharges of electrical activity in the brain whether from known or unknown causes

Epilepsy Describes recurrent, idiopathic episodes of sudden,

excessive discharges of electrical activity in the brain

Types of Seizures Partial

Localized onset and presentation, no loss of consciousness Sensory/motor deficits, emotional experiences,

visual/olfactory/auditory hallucinations, deja vu Complex partial

Large area affected, consciousness impaired Purposeful actions in “trance-like” state, no memory

Generalized Grand mal (convulsive) – tonic/clonic, often have aura, may

lose bodily function (50-90 seconds, up to 5 minutes) Petit mal (non-convulsive) – blank stare (3-15 seconds)

Special epileptic syndromes Febrile seizures in infants/children (102˚F) Reflex epilepsy (flickering lights, specific sounds, etc.)

Seizure Management Note time of onset and resolution

Protect individual from injury Remove eyeglasses, nearby objects, etc. and protect head Do not restrain person or stop seizure Do not place anything in mouth

Loss of control of bodily function may occur – spectators/observers

Ensure adequate airway and wait until individual fully awakens – activate EMS if seizure is continuous or if another occurs in rapid succession

Respiratory Tract Conditions Upper respiratory

tract infections Common cold Sinusitis Pharyngitis Laryngitis Tonsillitis Allergic rhinitis

General respiratory conditions Bronchitis Asthma Exercise-induced

bronchospasm Influenza Pneumonia

Upper Respiratory Tract Conditions

Common cold Primarily accounted for by rhinoviruses, usually

1-6/year Sx vary dramatically, treat symptoms with OTC

Sinusitis Inflammation of perinasal sinuses from infection,

allergens or environment Most common sx are sinus pain and pressure, nasal

discharge (often colored if bacterial origin) Treat per onset, nasal sprays use OK if limited

Pharyngitis (sore throat) Often associated with other infections Treat per onset, gargles, lozenges/sprays

Upper Respiratory Tract Conditions Laryngitis

Inflammation of vocal chords from infection, environmental exposure and/or vocal overuse

Hoarse voice or loss of voice Treatment per onset but involves vocal rest to avoid

irritation Tonsillitis

Infection of tonsils (lymph nodes) at back of throat, often can see pus and/or redness over tonsils

Treat with antibiotics if bacterial, treat symptoms if viral, tonsillectomy considered if chronic

Allergic rhinitis (hay fever) Inflammation of nasal mucosa from exposure to allergens

(pollen, mold, dust, pets, etc.) Managed with limited exposure to allergen and

antihistamine medications

General Respiratory Conditions Bronchitis

Inflammation of mucosal lining of bronchii May be viral or bacterial, typically have

coughing, wheezing and/or large amount of purulent mucous, treat per onset

Asthma Bronchospasm leading to inadequate airflow

during respiration (esp. expiration) Most common symptom is dyspnea

(difficulty breathing), wheezing and anxiety often occur

Typically treat with bronchodilator inhalers

General Respiratory Conditions Exercise-induced bronchospasm (asthma)

Diagnosis via forced expiratory volume measure with peak flow meter (10% decrease post-exercise normal, >10% identified as EIB)

Symptoms are tightness in chest, dyspnea, burning sensation with breathing, cough within 8-10 minutes of exercise, treat per asthma

Influenza Specific viral bronchitis typically occurring in epidemics,

immunizations available “Flu-like” symptoms typically start after 1-2 days and last

up to 5 days Pneumonia

Infection of lungs, treated per onset (viral vs. bacterial) Symptoms vary per onset, but typically include high fever,

pleurisy (chest pain), phlegm producing cough

Gastrointestinal Conditions Upper GI

disorders Gastroesophageal

reflux Dyspepsia Gastric ulcer Gastritis Gastroenteritis

Lower GI disorders Irritable bowel

syndrome Crohn’s disease Ulcerative colitis Constipation Diarrhea Hemorrhoids

Upper GI Conditions Upper GI conditions at level of stomach

or above Gastroesophageal reflux

Regurgitation of gastric juices (acids) into esophagus (“heartburn”)

Treat with antacids and diet modification Dyspepsia (indigestion)

Upper GI pain without known cause Often feels overfull after eating, may have

nausea and vomiting, can mimic heartburn Treat with antacids and diet/activity

modification

Upper GI Conditions Gastric (peptic) ulcer

Caused by excessive gastric juice production, consumption of excessive alcohol/spicy foods/orange juice/coffee, use of tobacco products

Common symptom is pain in stomach region within 1-3 hours of irritation

Gastritis Inflammation of stomach lining and erosion of gastric mucosa

from anxiety, NSAID overuse, excessive caffeine/alcohol May present with GI bleeding, vomiting (hematemesis)

Gastroenteritis Acute inflammation of mucosal membrane of stomach or small

intestine from viral/bacterial infection, food poisoning, anxiety, etc.

Presents with indigestion, nausea/vomiting, gas, diarrhea Usually self-limiting in 2-3 days, anti-motility meds, hydration

issue

Lower GI Conditions Irritable bowel syndrome

Altered bowel functions (constipation, diarrhea or alternations of each) combined with abdominal pain with no known cause

Most common treatment is diet modification Crohn’s disease (regional enteritis)

Chronic, patchy and segmented inflammation of intestine through all layers of intestinal wall resulting in thickening/toughening of wall and narrowing of intestinal pathway

Ulcerative colitis Chronic inflammation of only mucosal lining of large

intestine Often presents with bloody stools/diarrhea

Lower GI Conditions Constipation

Infrequent or incomplete bowel movements Can occur with insufficient dietary fiber, improper

bowel habits, medication side effects Diarrhea

Abnormally loose, watery stools – multiple possible origins

Treat with anti-diarrhea meds (limited use), hydration concerns

Hemorrhoids (piles) Dilations of veins around rectum/anus Present with pain, itching and small amounts of

rectal bleeding Treat symptoms, typically resolve in 2-3 weeks

Endocrine Conditions Thyroid disorders

Hyperthyroidism Hypothyroidism

Pancreatitis Acute vs. chronic

Diabetes mellitus Types of diabetes Complications of diabetes Nutrition and exercise recommendations

Thyroid Disorders Thyroid gland produces hormones that

regulate rate of body’s use of fats and carbs, regulate body temperature, influence heart rate, regulate production of protein and regulate amount of calcium in blood

Rate of hormone release from thyroid gland controlled by pituitary gland and hypothalamus

Hyperthyroidism Caused by overproduction of thyroxine

hormone – accelerated metabolism More common in women ages 30-50 Symptoms include goiter (enlarged

thyroid), tachycardia, loss of sleep, heat intolerance, ophthalmopathy (bulging eyes)

Treated with meds that affect thyroid function, partial removal of thyroid or use of radioactive iodine which shrinks the thyroid

Hypothyroidism Caused by insufficient or loss of function

of thyroid – lower metabolism Most common in women over 40 Symptoms include unexplained weight

gain, hypertension, goiter, heavier than normal menses, increased sensitivity to cold

Treat with hormone replacement therapy to normalize levels of hormones

Pancreatitis Pancreas produces digestive juices and enzymes as

well as insulin and glucagon for regulation of blood sugar

Acute pancreatitis Primarily caused (90%) by gall stones which blocks ducts

and also by alcohol abuse Typically self-limiting and treated symptomatically

Chronic pancreatitis Permanent damage (slow, progressive limiting) to

pancreatic function primarily from alcohol abuse (high mortality rate)

Ultimately ceases insulin production causing diabetes Treated with pain management, diet modification or

surgery

Diabetes Mellitus Types of diabetes

Type I Juvenile onset/insulin dependent, onset before age 30,

lean body type, insulin injections required to control blood glucose, common in Whites, minor family history link

Type II (most common Adult onset/non-insulin dependent, onset after age 30,

obese body type, insulin injections needed in 20-30% of patients, diet alone often able to control blood glucose, common in Blacks, Native Americans and Hispanics, typically have family history

Gestational diabetes Development of type I diabetes usually during later half

of pregnancy Typically resolves once baby is delivered

Diabetes Mellitus Complications of diabetes

Circulatory complications Associated with early development and rapid

progression of atherosclerosis >80% of diabetics die from CV disease (heart

attacks) Also associated with impaired kidney function and

retinal degeneration (loss of vision) Nerve complications

Nerve deterioration results in loss of sensation Most prominent in hands/feet Unable to feel injuries – may lead to amputation

Diabetes Mellitus Complications of diabetes

Insulin shock Hypoglycemia results from exercise and

unbalanced efforts of diet and insulin Aggressive/belligerent behavior,

pale/cool/clammy skin, decreased performance, treat with sugar (conscious vs. unconscious considerations)

Diabetic coma In absence of insulin, hyperglycemia develops Development of diabetic ketoacidosis from

inability to metabolize carbohydrates Fruity breath, dry/red/warm skin, confusion

progressing to coma, treat with insulin

Diabetes Mellitus Nutritional and exercise recommendations

Type I diabetes nutrition Must correlate insulin injections with meals and

consider results of exercise (lower blood sugar) Ingestion of high carbohydrate foods for pre-activity

meals, snacks during activity and after activity meals Type II diabetes nutrition

Must also be aware of carbohydrate ingestion to balance blood sugar and avoid hyper-/hypoglycemia

Exercise recommendations Exercise essential to managing diabetes and also helps

minimize risk of cardiovascular disease and peripheral vascular disease complications

Infectious Diseases Common childhood diseases

Bacterial Diptheria, tetanus, whooping cough, Hib

Viral Polio, chicken pox, measles, mumps, German measles

Atypical presentations due to immunizations

Infectious mononucleosis

Viral meningitis

Sexually transmitted diseases

Bacterial Childhood Diseases Diptheria

Life-threatening infection of upper respiratory region Presents with thick, patchy, gray/blue/white membrane over

mucous membranes of throat/palates/nose Tetanus (lockjaw)

Enters through open wounds, puncture most common, often treat with booster shots

Presents with involuntary muscle spasms, first in jaw/neck Whooping cough (pertussis)

Extremely contagious respiratory infection – must recognize and treat early with antibiotics for effective treatment

If allowed to progress, presents with violent coughing episodes followed by exhalations with high pitched whoop

Hib (haemophilus influenzae type b) One of leading causes of bacterial disease in kids <5 and also

leading cause of meningitis in that group Treat aggressively with antibiotics x 2+ weeks

Viral Childhood Diseases Polio (poliomyelitis)

Inflammation of gray matter of spinal cord Results in spinal and muscle paralysis

Chicken pox (varicella) Very contagious but mild disease in children, can be

severe in adults Characteristic rash starts on trunk/scalp and

progresses to extremities Mumps (parotitis)

Most common in children 5-9 years old Most common symptom is swollen salivary (parotid)

glands with associated lack of desire to swallow (eat/drink)

Viral Childhood Diseases Measles (rubeola)

Short incubation period (7-18 days), high fever (103-105˚F), Koplik’s spots in mouth (blue/gray specks with red halo), rash starts on head/neck and progresses to body, longer resolution (3-5 days)

German measles (rubella) Mild disease in children and adults, severe

risk if to unborn child during pregnancy Long incubation period (14-23 days, low-

grade fever, rash starting on face and spreads to body, quick resolution (2-3 days)

Infectious Mononucleosis Caused by Epstein-Barr virus Commonly called “kissing disease” due

to transmission through saliva Symptoms include headache, malaise,

fatigue, severe sort throat Splenic enlargement occurs to fight

virus – risk of rupture (especially in contact sports) – usually screen with ultrasound before clearing for return to play

Viral Meningitis

Inflammation of lining of central nervous system – rare, but severe disease

Can be exposed from water bottles, water coolers, drink dispensing machines that aren’t kept clean

Severe symptoms and can be fatal

Sexually Transmitted Diseases Affect >12 million Americans annually

Greatest risk in 15-19 year olds Chlamydia is most common bacterial STD in US,

preventable with safe sex practices, treated with antibiotics

Gonorrhea is second most common STD In men, have yellow/green discharge and pain with

urination – in women, often no symptoms until progresses to PID

Herpes simplex II typically results in genital ulcers, once exposed = always present but usually dormant

Genital warts from human papilloma virus present with cauliflower like appearance on genetalia

Dermatological Conditions Bacterial conditions

Abcess, acne, paronychia, folliculitis, furuncles/carbuncles, cellulitis, impetigo

Fungal conditions (tinea) Pedis, cruris, corporis, capitis, versicolor, candidiasis

Viral conditions Herpes, warts

Other conditions Eczema, psoriasis, hyperhidrosis, contact dermatitis,

urticaria, bites and stings

Bacterial Dermatological Conditions Abcess

Circumscribed collection of pus in a localized infection, may be a cavity formed by liquefaction necrosis of solid tissue

Acne Blockage of sebaceous glands resulting in bacterial infection Presents as blackheads or whiteheads, most common to

face/neck/back regions Paronychia

Occurs at lateral borders of nails (“ingrown nails”) usually secondary to hangnail or trimming too close

Area becomes red/swollen/painful, typically treated with soaks and occasionally surgically removed

Folliculitis Inflammation of a hair follicle (“ingrown hair”) usually presenting

with pustule at site More common with short/coarse hair and subsequent to friction

from clothing, equipment and/or shaving

Bacterial Dermatological Conditions

Furuncles (boil)/carbuncles Furuncles is singular and carbuncles is cluster of

furuncles Complication of folliculitis that goes deeper than follicle

and develops into pustule of walled-off purlument material

Cellulitits Painful infection of dermis and subcutaneous tissues Often appears as tender, reddened and “tight” area of

skin over infected region Impetigo

Highly contagious via direct contact Presents with sores that rupture and form honey-colored

crust that then turns red Most common to face/neck region

Fungal Dermatological Conditions All tinea infections are “ringworm”

Preventable with personal hygiene and facility cleansing considerations

Tinea pedis (“athlete’s foot”) Most common, typically transferred in locker

rooms/showers, very itchy Tinea cruris (“jock itch”)

More common in men than women Tinea capitis

On scalp – starts small and enlarges – may see bald spots in areas of infection

Fungal Dermatological Conditions Tinea corporis

On body – presents with circular patches of scaly skin with raised borders – common on trunk and axillas in wrestlers

Tinea versicolor Most commonly identified after sun exposure –

infected area lighter in color Not contagious

Candidiasis Yeast fungal infection of skin or vagina from friction in

hot/moist/humid area All fungal infections treated with antifungal

medications and changing/avoidance of warm, most environments

Viral Dermatological Conditions Herpes

Gladiatorum Caused by herpes type I virus Presents with clusters of vesicles, itchy – treat

outbreaks with antiviral meds, limit participation when infection is active

Zoster (shingles) Presents as red rash with blisters, most common on

torso Can treat successfully with antivirals early

Warts (verrucae) Caused by human papilloma virus (HPV) Most common on hands (small, round, elevated) and

feet (plantar warts – dark dots) Burn, freeze or remove with scalpel

Other Dermatological Conditions Eczema

Inflammation of the skin characterized by redness, scaling and exudate, typically itches increasing risk of other infections

Psoriasis Characterized by rapid buildup of rough, dry, dead

skin cells forming thick scales Most common on elbows, knees, scalp and gluteal

cleft Hyperhidrosis

Excessive perspiration especially to palms and axillary regions

Can be especially problematic in activities that require holding objects (balls, racquets, oars, etc.)

Other Dermatological Conditions Contact dermatitis

Allergic – direct contact with substance (tape, soaps, etc.) causing local inflammatory reaction

Irritant – results when skin is damaged or ulcerated (friction burns from turf or equipment)

Urticaria (hives) Elevated, red, itchy wheal secondary to hypersensitivity to

foods, drugs, infections, heat, cold, chemicals Bites and stings

Typically relatively benign unless anaphylaxis occurs Symptoms include respiratory distress, rapid/weak pulse,

hypotension, numbness, seizures, unconsciousness, etc. – can be life-threatening

Treat with administration of epinephrine via Epi-Pen device which typically isn’t definitive care, but buys time for that to occur

Special Population Conditions Female athletes

Menstrual disorders Eating disorders Osteoporosis

Athletes with disabilities Wheelchair athletes Amputees Cerebral palsy Visual impairment

Senior athlete considerations

Female Athlete Conditions Menstrual disorders

Dysmenorrhea Menstrual cramps from overproduction of prostaglandins that

cause uterine muscle to contract, most problematic during first few days of menstrual cycle

Often treated with OTC meds to relieve pain and cramping Exercise-induced amenorrhea

Primary amenorrhea is absence of menstruation by age 16 Secondary amenorrhea is absence of menstruation for 3+

cycles after menarche Often associated with weight loss, low body fat and excessive

exercise, especially in women endurance athletes Reduced bone density and increased risk of stress fracture

Female Athlete Conditions Eating disorders

Bulemia nervosa Characterized by binge/purge behavior, typically have normal

body weight for age/height Use vomiting, laxatives, diuretics to purge

Anorexia nervosa Characterized by distorted body image, excessive exercise,

controlled eating habits and body weight 15% below normal for age/height

Osteoporosis Decreased bone mass/strength and associated increased risk

of bony injury Component of “Female Triad” with amenorrhea (inadequate

estrogen for bone health) and disordered eating habits (improper nutrition and mineral levels

Most common in activities with “appearance” characteristics associated with achievement (gymnastics, swimming/diving, figure skating, etc.)

Athletes With Disabilities Wheelchair athletes

Upper extremity strains/sprains, blisters and neurological injuries common due to propulsion efforts

Higher risk of heat illness due to decreased ability to sweat and regulate body temperature

Amputees Most common problem is irritation at junction of limb and

prosthetic device, especially in LE due to weight-bearing Cerebral palsy

Muscle strains are common due to increased load on muscle/tendon units due to constant spasticity and decreased joint range of motion

Visual impairment Increased risk from collision with obstacles and decreased

ability to respond to surface changes

Senior Athlete Considerations Growing concern with aging and more

active population Decreased bone mass, decreased tissue

elasticity, muscle fiber atrophy, cartilage degeneration all associated with aging Adhesive capsulitis in shoulder, Achilles

tendon rupture, plantar fascia tears, etc. are common

Physical activity generally delays onset of these changes