Most Common and Important Medical Conditions on the Sidelines and in the ATR
Rick Figler, MD
Cleveland Clinic Sports Medicine - Primary Care Sports Medicine Fellowship Director
Medical Director, Cleveland Clinic Concussion Center
Team Physician, Cleveland Cavaliers
Team Physician, John Carroll University
Team Physician, Solon High SchoolSports Medicine
Disclosures
• ROMTech
Sports Medicine
Overview• HEENT
- Nasal Injuries- Dental Injuries- Eye Injuries- Ear Injuries
• Abdominal Injuries• Genitourinary Injuries
• Medical Issues Affecting Participation- Cardiovascular- Diabetes- Shortness of Breath
• Infections - Skin Infections and Injuries- Bacterial and Fungal
• Viral- Atypical Infections- Inflammatory issues
Sports Medicine
HEENT• Nasal Injuries• Nasal Fracture• Septal Hematoma• Epistaxis• Dental Injuries• Jaw Fracture• Dental Injury• Ear Injuries• Tympanic Membrane Rupture• Otitis Externa• Auricular Hematoma “Cauliflower Ear”
• Eye Injuries• Lid Laceration• Corneal Abrasion• Hyphema• Orbit Fracture• Retrobulbar Hemorrhage• Retinal Detachment• Traumatic Optic Neuropathy
Sports Medicine
Abdomen and GU• Abdomen
- Solar Plexus Injury- Rectus Sheath
Hematoma- Liver Laceration- Splenic Laceration- Kidney Laceration- Bowel Injury- Pancreatic Laceration
• Genitourinary Issues- Testicular
Hematoma- Testicular Torsion
Sports Medicine
Medical Problems Affecting Sports Participation
• Cardiovascular- Syncope- Dizziness- Chest Pain- “Rapid” Heartbeat- Hypertrophic
Cardiomyopathy- Marfan’s Syndrome- Commotio Cordis
• Diabetes- Type 1 Diabetes- Type 2 Diabetes- Hypoglycemia- Severe Hypoglycemia- Hyperglycemia- Severe Hyperglycemia
• Shortness of Breath- Asthma- Exercise Induced
Bronchospasm- Vocal Cord Dysfunction
Sports Medicine
Skin Infections and Injuries• Bacterial and Fungal
Infections- Impetigo- Furunculosis- Tinea- Viral Infections- Herpes- Verrucae- Molluscum
• Atypical Infections- Mycobacteria Marinum
• Pityriasis• Inflammatory Injuries• Contact Dermatitis• Urticaria
Sports Medicine
Common Infections
• Viral • Bacterial
Sports Medicine
Bonus Content
• Mental Health Issues Affecting the Athlete
Sports Medicine
Consummate Team Physician• Recognition• Common medical issues• Patterns • Primary Care Sports Medicine Colleague• Emergent Concerns and appropriate
referral resources• Communication
Sports Medicine
Sports Medicine
Cardiac Issues
Sports Medicine
Sudden Cardiac Arrest / Death• Tragic event• Incidence fairly rare• Reasons for concern / possible referral to
cardiology- Exertional chest pain- Syncope or near syncope with exertion- Palpitations- Family history- Exercise intolerance Sports Medicine
From
What We Know
• Males have 3-5 times higher incidence• Black athletes 3.2 times higher than white• Division I basketball players
- Male basketball players more likely to die from SCD (1:8,978 AY) than auto accident (1:13,122 AY)
Sports Medicine
Prevention Strategies – SCA/SCD
• PPE- AHA Guidelines / History- Physical Exam
• ECG• Cardiology consultations
Sports Medicine
Our Best Tools….Emergency Action Plan
Sports Medicine
Save a Life
• Where is it?• Is it charged?• Do you know
how to use it?
Sports Medicine
Save a Life
• Identify athletes with anaphylaxis- Write scripts for Epi-pens- Make sure Epi-pens are where they are
supposed to be• Athletes with asthma
- Do not let them run out of meds- Active wheezing should not participate
Sports Medicine
Shortness of Breath
• Listen to athlete- Wheezing = hold from competition
• Pulse Ox• Hx of EIB? • Albuterol MDI / consider Epipen• If severe/refractory/pulse ox dropping…
send to the ERSports Medicine
COVID-19• 33,797,400 cases reported in US• 69.3% increase in 7 day average from
week prior• 35.8% increase in hospitalizations• 605,905 deaths in US• 26.3% increase in deaths• 48.6% of US population fully vaccinated
Sports Medicine
COVID-19 - Delta Variant• 61.7% of cases 83% of cases• 60% more transmissible
• On day of + test, over 1000Xs viral load than alpha
• Exposure to first + PCR 4 days (6 for alpha)• 99.5% of deaths since Jan in unvaccinated
- Viral infection and transmission in a large well-traced outbreak caused by the Delta SARS-CoV-2 variant Li et al
Sports Medicine
COVID-19• Fever or chills• Cough• Sore throat• Congestion or runny nose• Muscle or body aches• Headache • Fatigue• Nausea or vomiting• Diarrhea• Shortness of breath • New loss of taste or smell
Influenza• Fever* or feeling feverish/chills• Cough• Sore throat• Congestion or runny nose• Muscle or body aches• Headaches• Fatigue (tiredness)• Some people may have vomiting
and diarrhea, though this is more common in children than adults.
• MLS / MLB / NHL / NFL / NBA / WNBA- 789 professional athlete (58.3% sx / 41.7% non)- Abnormal screen in 30 athletes
• Echo – 15• ECG – 6• Troponin – 5• ECG and Echo – 3• TTE and troponin - 1• 5 (0.6%) ultimately w cMRI myocarditis(3) pericarditis (2)
- No adverse eventsSports Medicine
• 1597 athletes CV testing• 37 (2.3%) diagnosed with COVID-19 myocarditis• 9 had clinical myocarditis• 28 had sub clinical myocarditis• FU cMRI showed resolution• Symptom based screening caught 5 (0.31%)• No Adverse outcomes
Sports Medicine
COVID-19
• Know your team’s plan of action for COVID• Testing protocols• Masking policies• Sick individuals disposition• Quarantine• CDC / NCAA
Sports Medicine
Neck Check“Go or No Go”
“GO” - Above neck• Rhinorrhea / congestion• Pharyngitis• Slight headache• Otitis• Warm up
- Worsens – stop- No worsening – increase
activity
“No GO” – Below Neck• Fever (>100.5)• GI symptoms• Fatigue• Myalgias• Shortness of breath• Poor PO intake
https://www.cdc.gov/childrensmentalhealth/data.html
2003: 5.4%
2016: 16.5%
Mental Health in NCAAJ Athl Train. 2020 Nov 5
• ~1/5 adults with MH illness in their lifetime- 22.1% college students with anxiety- 18.1% college students with depression
• 3rd leading cause of hosp in young adults• Rates of depression highest in 18-25 yo
Sports Medicine
Sports Dermatology• Wrestling accounts for 73.6% of skin infections• 21% of collegiate wrestling illnesses/injuries • 8.5% of HS wrestling illnesses/injuries
Sports Medicine
Herpes Gladiatorum• Grouped vesicles, erythematous
base, +/- pain• 8-10 days after contact / exposure• First outbreak typically with
malaise, fever, ST• Valacyclovir or Famciclovir or
Acyclovir- 120 hrs college / 10d HS
Tinea• Erythematous scaly plaque• Central clearing with raised
irregular border• Head, neck, arms• Antifungal creams
- HS and college 72hrs skin / 14 days scalp
Skin and Soft Tissue Infection• Erythematous / induration /
fluctuant• CA-MRSA common in athletes• I&D / culture if fluctuant• “spider bites”• Sulfa / doxy / clinda / cephalexin
- Know local sensitivities!- College/HS 72 hrs (no drainage)
Sports Medicine
Impetigo
• Honey crusted erythematous plaques
• Strep pyogenes or Staph aureus
• Skin to skin contact• Topical mupirocin, oral
if larger area- College and HS 72hrs
Diabetes - Adjusting Insulin for Exercise
Blood Glucose TargetsPre-Exercise Monitoring
• Goal: 100-249, exercise w/o intervention• 71-99: give 15g of carbs, recheck in 15m• <70 or symptomatic: treat for hypoglycemia,
exercise should be postponed • >250: check for ketones
- Ketones present No exercise- Ketones absent Proceed with caution
Sports Medicine
Hypoglycemia
• Any blood glucose where the patient is symptomatic
• Blood glucose <70• Administer 15g of glucose and recheck
in 10-15m
Sports Medicine
What Does 15g of Glucose Look Like?• Glucose tablets (3-4)• Sugar (1 tablespoon or
5 sugar cubes)• Crackers (4-5 saltine
crackers) • Hard candy (5-6
pieces) • Raisins (2 Tbsp)
• Glucose gel (one tube)• Corn syrup, honey, or
syrup (1 Tbsp)• Non-fat milk (8 oz) • Orange juice (4 oz) • Soda (not diet) (4 oz)
HEENT
Eye Injuries – Equipment for Evaluation
• Telephone number of ED/Ophthalmologist• Penlight• Protective eye shield• Eye patches (sterile)• Steri strips• Sterile irrigating solution• Sterile cotton swabs• Fluorescein strips• Cobalt blue light• Antibiotic ophthalmic ointment• Anesthetic eye drops?• Direct Ophthalmoscope
Sports Medicine
HEENT
Sports Medicine
HEENT – Concerning….• Sudden loss of vision• Loss of field of vision• Pain with movement of eye• Photophobia• Diplopia• Persistent blurring• Proptosis of eye• Light flashes or floaters• Deep throbbing or stabbing
pain• Irregularly shaped pupil
• Embedded foreign body• Red/inflamed eye• Hyphema• Halos around lights• Laceration of lid margin• Subconj hemorrhage• Broken contact/glasses• Suspected globe perforation
Sports Medicine
Red Eye – NO pain, NO vision changes
Conjunctivitis
Subconjunctival Hemorrhage
Episcleritis
Sports Medicine
Red Eye – Pain or Vision ChangesCorneal Abrasion
Scleritis
Uveitis
Hyphema
HEENT - Traumatic• Ruptured Globe
• Full thickness disruption of sclera or cornea• Serious morbidity• Direct strike (ball)• Laceration (stick, glass)• Distortion of pupil• Pupil location displaced• Loss of red reflex• Rigid eye shield• No topical meds• Tetanus status• Penetrating objects secured and covered • Only 50% of children with globe rupture have good visual recovery
HEENT - Traumatic• Orbital Wall Fracture
• Blunt trauma to globe• Pain and tenderness• Lid edema / ecchymosis• Orbit hemorrhage and edema• Relative ptosis• Sunken globe• Subcutaneous emphysema• Subconjunctival emphysema• Nose blowing/sneeze causes eyelid swelling• Limited eye movement – upward gaze• Numbness along infra-orbital nerve (upper lip/cheek)
HEENT - Traumatic• Orbital Wall Fracture - Treatment
• Ice • Patch (hard)• Avoid increased pressure (nose blowing)• Nasal decongestants• Analgesics• Antibiotics• Refer for surg evaluation (ENT/Ophtho)• Typical 6 wks out
Sports Medicine
HEENT - Traumatic• Eyelid Lacerations
• Evaluate lid open and closed• Assess for other ocular damage• Update tetanus status• Refer lacerations if…
- Medial aspect of lid – lacrimal duct- Upper eyelid tissue loss- Through and through laceration- Across margin of lid
HEENT - Traumatic• Foreign Bodies
• Pain, photophobia, edema, tearing, redness, FB sensation
• Dirt, plastic, glass, contact, plastic• Look under eyelids• Irrigate if seen• Moistened Q tip, avoid needle• Close follow up
• Intra-ocular FB- Deformed anterior chamber or iris- Pupillary reflex abnormal- Shield and refer…
HEENT - Auricular Hematoma• Hematoma between perichondrium and
cartilage• Swelling / pain / deformity• Ice / Continuous compression 20 min• Prompt sterile aspiration (1-2 days ideal)• Pressure dressing for 7-14 days
- Dental rolls / “Button” / Gauze and collodian / Silicone splint molded to anterior and posterior ear / Magnets
• Prophylactic antibiotics • RTP 7-10 days• Risk permanent deformity
HEENT - Auricular Hematoma• Incision and drainage
- Anesthetize auricle with field block
- Clean with betadine- 11 blade curvilinear incision
where concave surface of anterior pinna would usually be
- Evacuate clot and fluid with pressure and irrigation
- Apply bolster dressing
Sports Medicine
Sports Medicine
HEENT – Nasal Fractures• Most common facial fracture (63%) –
nearly half from sports• Pain / epistaxis / deformity / crepitus• Rule out septal hematoma
- Prompt aspiration (ENT) within 48 hrs- If missed can lead to saddle nose
• Reduction attempt ok• CT if needed• Nasal decongestant• Mild risk for early RTP• Mask / protect 4 weeks
Sports Medicine
HEENT – Tooth Fx• Enamel only • “chipped tooth”• Typically not sensitive• RTP with mouthguard
• Enamel + Dentin• Sensitive Touch and Temp• RTP as pain permits• Dental referral 24h
• Enamel + Dentin + Pulp• “see red” / Sensitive• Crown fracture• Increased risk of infection• If pulp vital (focal bleeding)
IMMED dental ref or 24h
HEENT – Root Fx• Apical 1/3• Stable• RTP with mouthguard
• Middle 1/3• If pain tolerable / mouth
guard stabilizes….• RTP as pain permits• Dental referral 24h
• Cervical 1/3• If pain tolerable / mouth
guard stabilizes….• RTP as pain permits• Dental referral 24h
Sports Medicine
HEENT – Tooth Displacement• Concussion
- Mild injury- No displacement- May be sensitive to
touch- Soft diet / monitor- Delayed referral OK
• Subluxation- Mild displacement- Minimal mobility- May be sensitive to touch- Possible blood from
gingival sulcus- Soft diet / monitor- Delayed referral OK
HEENT – Tooth Displacement• Intrusion
- Appears shorter- LEAVE ALONE- Immediate dental
referral
• Extrusion- Partial avulsion or
dislodgment - May reposition- Bite on wet gauze
to splint tooth- Referral
HEENT – Tooth Displacement
• Avulsion- Locate tooth!- Handle crown, NOT roots- Cleanse gently with
water/saline- Replace in to socket- Clench on moist gauze- 90% salvage if <30 min- Poor outcomes if > 2 hrs- If can’t replant, transport in
special solution (preferred) OR cheek, saline, mild
- Refer for splinting
HEENT – Tongue Trauma• Direct pressure• Clean / irrigate• Pen VK for 5 days• Close large lacs >1-2
cm, gaping, split tongue• 5-0 or 6-0• No need to close <1 cm
Sports Medicine
Facial Fractures
• Look for symmetry / malocclusion• CT study of choice• Mandible fracture
- Tongue Blade Bite Test – sensitivity 88.5-100% / 95-100%NPV
- Refer to specialist- RTP non contact 4 wks, contact 2-3 mo
Sports Medicine
Mononucleosis• Initially HA, myalgias, malaise – first few days• Prominent fatigue, pharyngitis, tonsillar enlargement/exudate, fever, LUQ pain • 90% with elevated LFTs• Posterior palatine petechiae (1/3) distinguishing finding• +/- splenomegaly
- 40-60%- Pain referred to left shoulder (Kehr’s sign)- PE not good, 8% accuracy- No reliable US guidelines- Peak size 2-3.5 weeks
• Splenic rupture- 50% atraumatic- Risk <0.5%
Mono RTP
• Mean time to atraumatic rupture 15.4 days• Average time for traumatic rupture 23 days
- 74% - 21 days- 86% - 28 days- 90.5% - 31 days- 100% - 8 wks
Sports Medicine
NATA Data• 74,298 team seasons• 4.4 million injury exposures• 23,666 injuries• Investigated 6,921 injuries
- 2,069 head/neck/spine- 1,219 MTBI- 3,450 knee- 148 eye- 18 kidney- 17 testicle
Sports Medicine
Abdominal Trauma• Direct blow• Serial exams – monitor CLOSELY for rebound, guarding, increasing
pain with activity• Renal injury – flank pain, 98% hematuria, CT if concern
- RTP contusion 3 wks, removal, guided discussion on RTP• Liver injury – right shoulder/neck pain after blow to abdomen, LFTs
can be elevated but don’t always correlate with recovery, CT/US- RTP depends on severity – 3-6+ weeks
• GI tract injury – Duodenum most common, +/- right shoulder pain, midepigastric pain, TTP, CT/US- RTP depends on severity / injury
Sports Medicine
Abdominal Pain in The ATR• Adults
- Right lower quadrant pain- Abdominal rigidity- Periumbilical pain radiating to the right lower quadrant
• Children- Absent or decreased bowel sounds- Positive psoas sign (right sided Ober’s with leg straight)- Positive obturator sign (passive IR of right hip)- Positive Rovsing sign (Pain RLQ with palpation of LLQ)
• Appendicitis- Lifetime risk of 8.6% in males and 6.7% in females- Perforation rates among adults range from 17% to 32%
• RTP 2-6 weeks post surgery
Sports Medicine
Testicular Torsion• No preceding trauma• Severe, sudden pain• Most common in post pubertal boys• Urinalysis typically negative• Side-lying teste• Absent cremasteric reflex• Prehn’s sign
- Elevation of testicle should decrease pain- In testicular torsion, it INCREASES pain
• US shows poor/absent blood flowSports Medicine
Testicular Torsion• Attempt derotation
- Turn away from midline- Immediate relief suggests
torsion• If no relief, or return of pain,
IMMEDIATE referral to urology- Roughly a 12 hour window to fix
• Surgical exploration and derotation
Sports Medicine
Testicular Hematoma
• Direct blow to teste• Swelling, tense, tender• Monitor• Normal cremasteric reflex• US if concern, persistent pain – assess
hematoma, rule out fracture• Urology referral immediately
Sports Medicine
