On-the-Spot Treatment of Sports Injuries
An Expert Interview With Margot Putukian, MD
As part of Medscape's coverage of the 2012 Summer Olympics, we interviewed Margot Putukian, MD, Director of Athletic Medicine and Head Team Physician for Princeton University. Dr. Putukian is a former President of the American Medical Society for Sports Medicine (AMSSM) (2004-2005) and is currently President of the AMSSM Foundation. She also serves on the Ad Hoc Sports Science Safety Committee Task Force on Clinical Medicine for the American College of Sports Medicine. Dr. Putukian has been a leader in research on concussion, with involvement in the Team Physician Consensus Statements, the National Athletic Trainers' Association Position Statement, as well as the Zurich International Consensus Conference on Concussion. She has served on the US Lacrosse Sports Science & Safety Committee since 2004 and in 2009 was named Chair. She is also involved with the National Football League Head, Neck & Spine Committee, serving as Chair of the Return-to-Play Subcommittee. In this interview, Medscape asked Dr. Putukian about on-the-spot treatments for injuries during competitive events.
Medscape: What are common on-the-spot treatments for injuries to the lower extremities? And what are the criteria for allowing an athlete to return to competition after such injuries?
Dr. Putukian: Obviously it depends on what the exact injury is, but most acute lower extremity injuries are treated on the spot with ice, splinting, or immobilization, and, as long as there is no contraindication, nonsteroidal anti-inflammatory medications for pain. Additional diagnostic testing, such as an x-ray or other studies, may be helpful in determining the extent of injury, and the splinting or immobilization necessary, again, depends on the injury. For an acute ankle sprain, where the ligaments on the outer aspect of the ankle are torn, for example, it may be useful to provide some support (splinting and protection of the ankle as necessary), apply ice and compression, and elevate the ankle or leg. X-rays may be indicated to exclude fracture, and if there is no fracture, then the rehabilitation is to slowly restore range of motion, strength, and proprioception. It is often necessary to modify activities, such as having the athlete swim instead of run, or use other modes of exercise that do not interfere with the rehabilitative process. The criteria for return to play (RTP) after such injuries is restoration of full range of motion, full strength, and then assessment to make sure that functional activities (eg, running, jumping, cutting side to side) are back to an acceptable level where the athlete can participate without significant risk for additional injury. The RTP is typically gradual and slowly increases both the demands and the level of competition of the specific athlete.
Medscape: What about upper extremity injuries?
Dr. Putukian: This is the same as with lower extremity injuries. The only difference is that it's typically easier to immobilize and/or modify activities because weight bearing is not an issue.
Medscape: What protections are in place to prevent, diagnose, and treat cardiac arrest in intensive athletes?
Dr. Putukian: This depends on the age we are discussing. For youth athletes, we have the preparticipation physical examination, which should include and endorse the American Heart Association (AHA) 12-Element recommendations for preparticipation cardiovascular screening of competitive athletes. These recommendations address personal history, family history, and physical exam findings.[1] The PreParticipation Physical Evaluation (PPE) monograph,[2] currently endorsed by all major sports medicine organizations, also includes these 12 questions, so our college and youth participants have reasonable screening. Athletes who give even 1 positive response to these questions should have appropriate evaluations to exclude cardiac disease. Older athletes should have a physical examination that assesses cardiac risk factors and, in my opinion, should include the AHA 12 questions as well. An ECG and cholesterol screening might also be indicated.
Treating cardiac arrest should ideally include having available personnel certified in cardiopulmonary resuscitation and knowledgeable about the use of an automated external defibrillator (AED). Ideally, early access to defibrillation is defined as having the AED and personnel within 3-5 minutes.
Medscape: What is being used now to immediately stabilize patients who experience concussion?
Dr. Putukian: There is a spectrum of concussion, so this is difficult to answer. On the one extreme are athletes who present with symptoms that cannot exclude more serious brain injury or cervical spine injury; they should be spine-boarded and transported to an emergency center with facilities and personnel to handle cervical spine and brain injuries. On the other extreme are athletes with short-lived symptoms of concussion, with no evidence or concern for complications or more serious brain injury. These athletes improve within minutes, and the immediate concern is to make sure they do not return to activity until they are evaluated by a healthcare provider experienced in evaluating and managing concussion. Athletes should also be told to remain out of physical activity and minimize cognitive activity (eg, avoid texting, video games, computer use) until they are evaluated. Athletes should be given information on what to watch for (symptoms or signs of deterioration) and what to avoid, such as aspirin and alcohol, as well as when they should be seen for follow-up.
Medscape: What about patients who experience hyperthermia? Can they be treated immediately and in time to return to competition?
Dr. Putukian: Hyperthermia is a general term that includes a spectrum of heat-related illness that includes heat cramps, heat syncope, heat exhaustion, and exertional heat stroke, the most extreme and sometimes fatal form of heat-related illness. It is important to define the extent of thermal injury that is occurring because treatment can be different. A lot can be done to prevent heat-related illness, including hydrating, avoiding exercising in the heat and humidity (avoid the hottest part of the day), acclimatizing to the heat, and having an emergency action plan that incorporates guidelines for avoiding heat injury. When heat injuries do occur, it is important that they are assessed by reliable measures (rectal temperature), that the athlete is moved to a cool/shaded area, and that immediate cooling occurs, ideally with whole-body ice water immersion. If possible, the athlete should be provided with oral rehydration. RTP after heat-related illness depends on the extent of the thermal injury. For heat exhaustion, the recommendation is to wait at least 24-48 hours before returning and at least a week for exertional heat stroke. Each situation must be considered individually, as several factors should be considered in the RTP decision. The Korey Stringer Institute has a lot of good information related to avoiding hyperthermia, treating it, and RTP.
Medscape: How are electrolyte and dehydration deficiencies recognized and dealt with during events? Specifically, what happens to athletes who experience muscle cramping? Can they return to competition?
Dr. Putukian: Electrolyte imbalances and dehydration are recognized by healthcare providers during events in various fashions. Dehydration can be assessed by measuring blood pressure and pulse after an athlete is lying down for 2-3 minutes, then standing up for 2-3 minutes ("orthostatics"). Changes in blood pressure and pulse are then evaluated with this change in position. If there is a drop in blood pressure or an increase in heart rate when going from the lying to standing position, the athlete may be dehydrated.
Electrolyte abnormalities can be evaluated using various methods and are measured with a portable unit that takes a small amount of blood and provides a result. Electrolytes are most often measured during endurance road-running events. They are not typically measured in organized sports such as soccer, football, or other events that are not endurance-type activities.
Muscle cramping can occur if an athlete has electrolyte deficiencies or is dehydrated. Typically in organized sports, such as soccer and football, these can be treated by stretching, icing, replacing fluid and salt balance, and decreasing activity; often these athletes can return to activity. It may be more difficult for athletes participating in endurance sport events to return to activity immediately. It is important to make sure that they are not suffering from sickle cell crisis, where cramping occurs that typically is not associated with muscle contractions. Exertional sickling can be associated with rhabdomyolysis (muscle breakdown) and death and should be treated as an emergency. Screening for the presence of sickle cell trait can be useful, and knowing which athletes are at risk for heat-related illness is also important.
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