Epidemiology and Prevention of Injuries

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Chapter 678 Epidemiology and Prevention of Injuries

Gregory L. Landry

The Centers for Disease Control and Prevention recommend moderate to vigorous physical activity on a regular basis for all adolescents. Physical activity has favorable effects on hypertension, obesity, and serum lipid levels in youths. In adults, physical activity is associated with lower rates of cardiovascular disease, type 2 diabetes mellitus, osteoporosis, and colon and breast cancer.

Pediatricians should promote physical activity to their patients, especially those with lower rates of physical activity and sports participation, including children with special health care needs and those from lower socioeconomic groups. Coincident with promoting sports participation and physical activity, physicians have the responsibility of providing medical clearance for participation in physical activity and sports and for diagnosis and rehabilitation of injuries.

Approximately 30 million children and adolescents participate in organized sports in the USA. Approximately 3 million injuries occur annually if injury is defined as time lost from the sport. Deaths in sports are rare, with the majority of nontraumatic deaths caused by cardiac diseases (Chapter 430). Overall, injury rates and injury severity in sports increase with age and pubertal development, related to the greater speed, strength, and intensity of competition.

Recognizing mechanisms of injury and enforcing rules that reduce the likelihood of that mechanism of injury, including penalizing dangerous play, have reduced catastrophic injury rates. Injury rates have also been reduced by removing environmental hazards, such as trampolines in gymnastics and stationary (vs breakaway) bases in softball, and by modifying heat injury rates in soccer tournaments by adding water breaks and reducing the playing time. Wearing equipment such as mouth guards can reduce dental injuries. A common reason for reinjury is lack of rehabilitation of old injuries; appropriate rehabilitation reduces injury rates. Preseason training for high school athletes, with an emphasis on speed, agility, jump training, and flexibility, is associated with lower injury rates in soccer and fewer serious knee injuries in female athletes. Traditional stretching maneuvers or massage might not reduce the risk of injury or muscle soreness, but ankle taping is helpful particularly to prevent reinjury of the ankle. One setting for implementing some of these prevention strategies and for detecting unrehabilitated injuries and medical problems that could affect participation in sports is the preparticipation sports examination (PSE).

Preparticipation Sports Examination

The PSE is performed with a directed history and a directed physical examination, including a screening musculoskeletal examination. It identifies possible problems in 1-8% of athletes and excludes <1% from participation. The PSE is not a substitute for the recommended comprehensive annual evaluation, which looks at behaviors that are potentially harmful to teens, such as sexual activity, drug use, and violence, and assesses for depression and suicidal ideation. The purposes of the PSE include detecting medical conditions that delay or disqualify athletic participation owing to a risk of injury or death, detecting previously undiagnosed medical conditions, detecting medical conditions that need further evaluation or rehabilitation before participation, providing guidance for sports participation for patients with health conditions, and meeting legal and insurance obligations. If possible, the PSE should be combined with the comprehensive annual health visit with emphasis on preventive health care (Chapters 5 and 14).

State requirements for how often a youth needs a PSE differ, ranging from annually to entry to a new school level (middle school, high school, college). At a minimum, a focused, annual interim evaluation should be done on an otherwise healthy young athlete. The PSE is optimally performed 3-6 wk before the start of practice.

History and Physical Examination

The essential components of the PSE are the history and focused medical and musculoskeletal screening examinations. Identified problems require more investigation (Tables 678-1 and 678-2). In the absence of symptoms, no screening laboratory tests are required.

Table 678-1 PREPARTICIPATION SPORTS EXAMINATION

COMPONENT OF THE PHYSICAL EXAMINATION CONDITION TO BE DETECTED
Vital signs Hypertension, cardiac disease, brady- or tachycardia
Height and weight Obesity, eating disorders
Vision and pupil size Legal blindness, absent eye, anisocoria, amblyopia
Lymph node Infectious diseases, malignancy
Cardiac (performed standing and supine) Heart murmur, prior surgery, dysrhythmia
Pulmonary Recurrent and exercise-induced bronchospasm, chronic lung disease
Abdomen Organomegaly, abdominal mass
Skin Contagious diseases (impetigo, herpes, staphylococcal, streptococcal)
Genitourinary Varicocele, undescended testes, tumor, hernia
Musculoskeletal Acute and chronic injuries, physical anomalies (scoliosis)

Table 678-2 MEDICAL CONDITIONS AND SPORTS PARTICIPATION

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CONDITION MAY PARTICIPATE EXPLANATION
Atlantoaxial instability (instability of the joint between cervical vertebrae 1 and 2) Qualified yes Athlete (particularly if he or she has Down syndrome or juvenile rheumatoid arthritis with cervical involvement) needs evaluation to assess the risk of spinal cord injury during sports participation, especially when using a trampoline
Bleeding disorder Qualified yes Athlete needs evaluation
Diabetes mellitus Yes All sports can be played with proper attention and appropriate adjustments to diet (particularly carbohydrate intake), blood glucose concentrations, hydration, and insulin therapy
Blood glucose concentrations should be monitored before exercise, every 30 min during continuous exercise, 15 min after completion of exercise, and at bedtime
Eating disorders Qualified yes Athlete with an eating disorder needs medical and psychiatric assessment before participation
Fever No Elevated core temperature can indicate a pathologic medical condition (infection or disease) that is often manifest by increased resting metabolism and heart rate. Accordingly, during the athlete’s usual exercise regimen, fever can result in greater heat storage, decreased heat tolerance, increased risk of heat illness, increased cardiopulmonary effort, reduced maximal exercise capacity, and increased risk of hypotension because of altered vascular tone and dehydration. On rare occasions, fever accompanies myocarditis or other conditions that can make usual exercise dangerous
Heat illness, history of Qualified yes Because of the likelihood of recurrence, the athlete needs individual assessment to determine the presence of predisposing conditions and behavior and to develop a prevention strategy that includes sufficient acclimatization (to the environment and to exercise intensity and duration), conditioning, hydration, and salt intake, as well as other effective measures to improve heat tolerance and to reduce heat injury risk (e.g., protective equipment and uniform configurations)
HIV infection Yes Because of the apparent minimal risk to others, all sports may be played as athlete’s state of health allows (especially if viral load is undetectable or very low)
For all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood
Certain sports (such as wrestling and boxing) can create a situation that favors viral transmission (likely bleeding plus skin breaks); if viral load is detectable, then athletes should be advised to avoid such high-contact sports
Malignant neoplasm Qualified yes Athlete needs individual assessment
Musculoskeletal disorders Qualified yes Athlete needs individual assessment
Myopathies Qualified yes Athlete needs individual assessment
Obesity Yes Because of the increased risk of heat illness and cardiovascular strain, obese athletes particularly need careful acclimatization (to the environment and to exercise intensity and duration), sufficient hydration, and potential activity and recovery modifications during competition and training.
Organ transplant recipient (and those taking immunosuppressive medications) Qualified yes Athlete needs individual assessment for contact, collision, and limited-contact sports
In addition to potential risk of infections, some medications (e.g., prednisone) increase tendency for bruising
Skin infections, including herpes simplex, molluscum contagiosum, verrucae (warts), staphylococcal and streptococcal infections (furuncles [boils], carbuncles, impetigo, methicillin-resistant Staphylococcus aureus [cellulitis and/or abscesses]), scabies, and tinea Qualified yes During contagious periods, participation in gymnastics or cheerleading with mats, martial arts, wrestling, or other collision, contact, or limited-contact sports is not allowed
Spleen, enlarged Qualified yes If the spleen is acutely enlarged, then participation should be avoided because of risk of rupture
If the spleen is chronically enlarged, then individual assessment is needed before collision, contact, or limited-contact sports are played
CARDIOVASCULAR
Carditis (inflammation of the heart) No Carditis can result in sudden death with exertion
Hypertension (high blood pressure) Qualified yes Those with hypertension >5 mm Hg above the 99th percentile for age, sex, and height should avoid heavy weightlifting and power lifting, bodybuilding, and high-static component sports
Those with sustained hypertension (>95th percentile for age, sex, and height) need evaluation
The National High Blood Pressure Education Program Working Group report defined prehypertension and stage 1 and stage 2 hypertension in children and adolescents <18 yr of age
Congenital heart disease (structural heart defects present at birth) Qualified yes Consultation with a cardiologist is recommended
Those who have mild forms may participate fully in most cases; those who have moderate or severe forms or who have undergone surgery need evaluation
The 36th Bethesda Conference defined mild, moderate, and severe disease for common cardiac lesions
Heart murmur Qualified yes If the murmur is innocent (does not indicate heart disease), full participation is permitted; otherwise, athlete needs evaluation (see structural heart disease, especially hypertrophic cardiomyopathy and mitral valve prolapse)
Dysrhythmia (Irregular Heart Rhythm)
Long-QT syndrome Qualified yes

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