Sports MedicineSports Medicine Sports MedicineSports Medicine

David W. Hang, M.D.David W. Hang, M.D.

Assistant Clinical Professor of Orthopedic Assistant Clinical Professor of Orthopedic SurgerySurgery

University of California at Los AngelesUniversity of California at Los Angeles

DirectorDirectorShin Kong Orthopedic Sports Medicine InstituteShin Kong Orthopedic Sports Medicine Institute

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Sports MedicineSports Medicine

Sports Medicine ProgramSports Medicine Program

2/3 of injury occurs during practice (high school)2/3 of injury occurs during practice (high school)

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Team PhysicianTeam Physician

Orthopedist or family practice physicianOrthopedist or family practice physician

Basic medical knowledge and emergency evaluationBasic medical knowledge and emergency evaluation

Supportive and cooperation with the team (AT, PT, coach)Supportive and cooperation with the team (AT, PT, coach)

Prescribe pre-injury conditioning and post-injury carePrescribe pre-injury conditioning and post-injury care

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Athletic TrainerAthletic Trainer

Front-line, on site directorFront-line, on site director

Provide optimal sports healthcareProvide optimal sports healthcare

Direct supervision of physicianDirect supervision of physician

Liaison between different partiesLiaison between different parties

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Athletic TrainerAthletic TrainerFacility and materialsFacility and materialsInjury prevention (conditioning)Injury prevention (conditioning)Assessment of injuryAssessment of injuryAppropriate first-aidAppropriate first-aidDetermination of return to sportDetermination of return to sportAppropriate medical profession referralsAppropriate medical profession referralsEffective rehabilitation programEffective rehabilitation programEducational and counseling programEducational and counseling programOrganize physical examinationOrganize physical examinationRole model for future medical professionalRole model for future medical professional

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Playing SurfacesPlaying SurfacesLittle research other than grass and synthetic turfLittle research other than grass and synthetic turf

Inconclusive resultsInconclusive results

Astro turf > grass > Tartan turf ??Astro turf > grass > Tartan turf ??

More serious sprains and torn ligament on grass ?More serious sprains and torn ligament on grass ?

Synthetic surfaceSynthetic surface– Prepatellar bursitisPrepatellar bursitis– Olecranon bursitisOlecranon bursitis– Heat StrokeHeat Stroke

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Screening examination

Legal and insurance requirementLegal and insurance requirement

Determine overall health of the individualDetermine overall health of the individual

Assess physical maturityAssess physical maturity

Detect conditions that predispose to injury Detect conditions that predispose to injury

Identify and treat injuries before participationIdentify and treat injuries before participation

Baseline for return to participationBaseline for return to participation

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DocumentationDocumentation

States specific formStates specific form

Parental / guardian consentParental / guardian consent– ExaminationExamination– ParticipationParticipation– TreatmentTreatment

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ExaminationExamination

Individual / office basedIndividual / office based

Group / station basedGroup / station based

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Office Based ExaminationOffice Based Examination

Privacy, comprehensive, better medical recordsPrivacy, comprehensive, better medical records

High cost, time consuming, increased demandHigh cost, time consuming, increased demand

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Station Based ExaminationStation Based Examination

Reduce cost, time efficient, team staff involvementReduce cost, time efficient, team staff involvement

Impersonal, great deal of coordinationImpersonal, great deal of coordination

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Components of Screening ExaminationComponents of Screening Examination

Detailed medical historyDetailed medical historyPMH, PSH, Allergy, Rx, Immunization, FHPMH, PSH, Allergy, Rx, Immunization, FH

CV – murmurs, syncopy, CP, SOBCV – murmurs, syncopy, CP, SOB Neurological injuries – concussionNeurological injuries – concussion Heat / cold injuryHeat / cold injury MenstruationMenstruation

Physical ExaminationPhysical ExaminationGeneral General DentalDentalGenitalGenitalMaturation (Tanner stages)Maturation (Tanner stages)

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RecommendationRecommendation

Clearance without restrictionClearance without restriction

Clearance with restriction Clearance with restriction (15%)(15%)

Disqualification Disqualification (1%)(1%)

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Disqualifying ConditionsDisqualifying Conditions

**Always consider alternative activities !!!Always consider alternative activities !!!

Atlantoaxial Instability Atlantoaxial Instability Musculoskeletal MusculoskeletalCardiovascular GynecologicCardiovascular GynecologicVisual Impairment Visual Impairment Hepato- / Splenomegaly Hepato- / SplenomegalyNeurologic Neurologic Kidney Abnormalities Kidney AbnormalitiesInguinal HerniaInguinal Hernia Sickle Cell Trait Sickle Cell TraitDermatologicDermatologic Testicular TesticularPulmonaryPulmonary Acute Illness Acute Illness HIV HIV

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AA InstabilityAA Instability

No contact / collision sportsNo contact / collision sports

No repetitive flexion / extensionNo repetitive flexion / extension

C-spine radiograph in Down’s (10 - 20%)C-spine radiograph in Down’s (10 - 20%)

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CardiovascularCardiovascularHTN (higher than 95 percentile)HTN (higher than 95 percentile)

10 – 12 years 10 – 12 years : : 125/80125/8013 – 15 years 13 – 15 years : : 135/85135/8515 years / older 15 years / older : : 140/90140/90

Restriction Restriction 1) Diastolic > 115 mm Hg1) Diastolic > 115 mm Hg 2) End-organ involvement2) End-organ involvement

Controlled HTNControlled HTN 1) No End-organ : Moderate intensity activities1) No End-organ : Moderate intensity activities 2) LVH / 2) LVH / renal function : Low intensity (golf / bowling) renal function : Low intensity (golf / bowling)

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Cardiac MurmursCardiac Murmurs

Mitral Prolapsed (No participation)Mitral Prolapsed (No participation)

Syncopy Syncopy

Family history of sudden deathFamily history of sudden death

Chest pain or arrhythmias Chest pain or arrhythmias (worse with activities)(worse with activities)

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Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy

Most common cause of sudden death in young athletesMost common cause of sudden death in young athletes

DisqualificationDisqualification1)1) LVHLVH2)2) LV outflow obstructionLV outflow obstruction3)3) ArrhythmiaArrhythmia4)4) SyncopySyncopy5)5) Sudden death in relativeSudden death in relative

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Vision ImpairmentVision Impairment

Best corrected vision : 20/50 (one eye)Best corrected vision : 20/50 (one eye)

Restricted SportsRestricted Sports

Boxing, wrestling, full contact karateBoxing, wrestling, full contact karate

Protective eyewear useProtective eyewear use

Football, racquetball, baseballFootball, racquetball, baseball

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Renal / Liver / SpleenRenal / Liver / Spleen

No contact or collision sports No contact or collision sports

1) Renal (abnormal solitary kidney)1) Renal (abnormal solitary kidney)

2) Hepatomegaly (surpassed bony protection)2) Hepatomegaly (surpassed bony protection)

3) Splenomegaly3) Splenomegaly

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ConcussionsConcussions

ConfusionConfusion AmnesiaAmnesia LOCLOC

Grade I (Mild)Grade I (Mild) + + - - - -

Grade II (Moderate) +Grade II (Moderate) + + + - -

Grade III (Severe)Grade III (Severe) + + + + + +

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ConcussionsConcussions

First ConcussionFirst Concussion Second ConcussionSecond Concussion Third ConcussionThird Concussion

Grade I (Mild)Grade I (Mild) Return to playReturn to play

(Asymp. for 20 (Asymp. for 20 min.)min.)

Stop contest / practiceStop contest / practice

Return to playReturn to play

(Asymp. > 1 wk)(Asymp. > 1 wk)

Terminate seasonTerminate season

Return to playReturn to play

(Asymp. > 3 mos)(Asymp. > 3 mos)

Grade II Grade II (Moderate)(Moderate)

Stop contest / practiceStop contest / practice

Return to playReturn to play

(Asymp. > 1 wk)(Asymp. > 1 wk)

Terminate seasonTerminate season

Return to playReturn to play

(Asymp. > 1 mon)(Asymp. > 1 mon)

Terminate seasonTerminate season

Return next seasonReturn next season

(Asymp.)(Asymp.)

Grade III (Severe)Grade III (Severe) Stop contest / practiceStop contest / practice

Return to play 1 monReturn to play 1 mon

(Asymp. > 2 wk)(Asymp. > 2 wk)

Terminate seasonTerminate season Terminate seasonTerminate season

(MRI)(MRI)

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Neurologic InjuryNeurologic Injury

Neuropraxia (Burner)Neuropraxia (Burner)

AsymtomaticAsymtomatic Participation ParticipationRecurrent Further evaluationRecurrent Further evaluation

SeizureSeizure

ControlledControlled Participation Participation

Poorly controlledPoorly controlled 1 month after last seizure (on Rx) 1 month after last seizure (on Rx)

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Objectives of Fitness AssessmentObjectives of Fitness Assessment

Minimize injuryMinimize injury

Improve athletic performanceImprove athletic performance

Identify weakness that hinders performanceIdentify weakness that hinders performance

Assess achievement of personal goalAssess achievement of personal goal

MotivationalMotivational

Wellness counselingWellness counseling

Evaluate preseason conditioningEvaluate preseason conditioning

Sports specific profile (risk factors identification)Sports specific profile (risk factors identification)

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EvaluationEvaluationResting heart rate and BPResting heart rate and BP

Body mass index (BMI)Body mass index (BMI)

Skin fold measurementSkin fold measurement

AbilitiesAbilities– Muscle strengthMuscle strength– Muscle enduranceMuscle endurance– PowerPower– FlexibilityFlexibility– SpeedSpeed– Aerobic enduranceAerobic endurance– Anaerobic enduranceAnaerobic endurance– AgilityAgility– BalanceBalance– Reaction timeReaction time

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NutritionNutrition

Micronutrient (vitamins)Micronutrient (vitamins)

Macronutrients (fat, carbohydrate, protein)Macronutrients (fat, carbohydrate, protein)

DietDiet– Carbohydrate Carbohydrate (4 calories / gm) (4 calories / gm) : 60 - 70% (starch): 60 - 70% (starch)– Fat Fat (9 calories / gm)(9 calories / gm) : : 15 - 20%15 - 20%– Protein Protein (4 calories / gm)(4 calories / gm) : : 10 - 15%10 - 15%

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Carbohydrate LoadingCarbohydrate Loading

Glycogen storage for endurance activityGlycogen storage for endurance activity

– 100 gm of carbohydrate within 15 - 30 minutes after exercises100 gm of carbohydrate within 15 - 30 minutes after exercises– Additional 100 gm of carbohydrate every 2 to 4 hoursAdditional 100 gm of carbohydrate every 2 to 4 hours

(Need 20 hours to replace depleted store)(Need 20 hours to replace depleted store)

Complex carbohydrateComplex carbohydrate– More glycogen storageMore glycogen storage– Less insulin responseLess insulin response– Contains basic nutrientsContains basic nutrients

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ProteinProteinEssential amino acids (8 Essential amino acids (8 – not produced by body– not produced by body))

1.2 - 2 gram / kg / day 1.2 - 2 gram / kg / day (4 cal / gm)(4 cal / gm)

Complete protein (contain essential AA Complete protein (contain essential AA – meat, milk– meat, milk))

Incomplete protein (seeds, nuts, peas, grains, beans)Incomplete protein (seeds, nuts, peas, grains, beans)

Branch-chain AA (Leu, IsoLeu, Val)Branch-chain AA (Leu, IsoLeu, Val)– Source fSource foror muscle repair and muscle energy muscle repair and muscle energy– Availability: Availability: 50% within 1 hr and 100% at 2 hrs50% within 1 hr and 100% at 2 hrs– Aids glycogen productionAids glycogen production

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FatFat

Most concentrated source of energy Most concentrated source of energy (9 cal / gm)(9 cal / gm)

Saturated (Saturated (animal) animal) or unsaturatedor unsaturated (vegetable) (vegetable)

Muscle energy at rest or latent endurance eventsMuscle energy at rest or latent endurance events

Available after 20 - 30 minutes Available after 20 - 30 minutes of exerciseof exercise

Consumes more oxygen Consumes more oxygen (use more oxygen)(use more oxygen)

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WaterWater

60% of body weight60% of body weight

Cooling effectCooling effect

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Fluid consumptionFluid consumption

2 1/2 cups 2 hrs & 1 1/2 cup 15 minutes before2 1/2 cups 2 hrs & 1 1/2 cup 15 minutes before

5 - 8 oz every 15-20 minutes (during)5 - 8 oz every 15-20 minutes (during)

Sodium and 6-8% glucoseSodium and 6-8% glucose

No ETOH or caffeineNo ETOH or caffeine

2 cups of water for each k2 cups of water for each kgg of body weight lost of body weight lost

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Training dietTraining diet

Avoid feeling hungry or weakAvoid feeling hungry or weak

Empty stomach and upper bowels at competitionEmpty stomach and upper bowels at competition

Sufficient waterSufficient water

Minimize slow digesting foodMinimize slow digesting food

Carbohydrate 2 to 4 hrs before competitionCarbohydrate 2 to 4 hrs before competition

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Body FatBody Fat

Anthropometry (skin folds*)Anthropometry (skin folds*)

Men Men 16 to 18% 16 to 18%

Women Women 22 to 26% 22 to 26%

(* (* subscap., triceps, axilla, chest, biceps, subscap., triceps, axilla, chest, biceps,

iliac crest, abdomen, thigh)iliac crest, abdomen, thigh)

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Exercise Program Exercise Program (Weight Loss)(Weight Loss)

3 3 times a weektimes a week60 to 70% of maximum heart rate for 30 minutes60 to 70% of maximum heart rate for 30 minutesMaximum weight loss Maximum weight loss (60 minutes of continuous aerobic activity)(60 minutes of continuous aerobic activity)

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Master AthletesMaster Athletes

Endurance : maintained with conditioningEndurance : maintained with conditioning

Strength : Sports specific strengthStrength : Sports specific strength

Power : loss quicknessPower : loss quickness

Flexibiity : loss with ageFlexibiity : loss with age

Speed : loss with age (upper > lower)Speed : loss with age (upper > lower)

Coordination : nerve degeneration (other elements ?)Coordination : nerve degeneration (other elements ?)

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Master AthletesMaster AthletesInjuiresInjuires

– Chronic “wear-and-tear” with acute tearChronic “wear-and-tear” with acute tear– Previous injury / surgery Previous injury / surgery

IllnessIllness– Adaptation to chronic health conditionsAdaptation to chronic health conditions

(DM, CA, OA, CAD)(DM, CA, OA, CAD)

Rehabilitation and maintenanceRehabilitation and maintenance

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