All people participating in vigorous sports should have a complete examination at the beginning of the season; and re-evaluation is often necessary at seasonal intervals. Re-evaluation is always necessary with cases where the candidate has suffered a severe injury, illness, or had surgery.

Evaluation begins with questioning. Because of drilled routine, any doctor is well schooled in the taking of a proper case history. But with an athletic injury, both obvious and subtle questions often appear. How extensive was the preseason conditioning? How much time for warm up is allowed before each game or event? What precautions are taken for heat exhaustion, heat stroke, concussion, and so forth? Does the coach make substitution immediately upon the first sign of disability for proper evaluation? How adequate is the protective gear? How many others on the team have suffered this particular injury this season?

Who, what, when, where, how, and WHY? These are the questions which must be answered before any positive course of health care can be extended. A detailed history of past illness and injury is vital. In organized sports, an outline of the regimen of training should be a part of the history, as well as a record of performance. Most sports will require a detailed locomotor evaluation of the player. Special care must be made in evaluating the preadolescent competitor because of the wide range of height, weight, conditioning, and stages of maturation. A defect may bar a candidate from one sport but not another, or it may be only a deterrent until it is corrected or compensated. Many famous athletes have become great in spite of a severe handicap.


The Physician's Responsibilities

If a doctor only had to concern himself with injury prevention, care, and rehabilitation, his role would be much easier. But many other factors are inrvolved. For instance, consider motivation. The average coach has many pressures upon him, as do the players. These pressures may blind a coach to the fact that a player is participating with an injury, playing beyond the point of exhaustion, or playing with an injury where further trauma may lead to permanent injury. Players too, in their enthusiasm, may avoid reporting injury or even try to hide its effects.

The attending physician should mentally target that he is only responsible to the patient and his professional code of conduct. He is not responsible to the coach, trainer, ticket buyers, fans, school board, administrators, or the alumni association. Thus the question must be asked: Who has the authority to return an injured player to play or to practice: the physician, the trainer, or the coach? Obviously, no athlete should be allowed to risk permanent aggravation of an existing disability, regardless of the circumstance. In terms of pre-assessment before participation or competition, the physician should:

1. Determine the fitness of the individual by a thorough history and examination relative to a particular type of activity, and, when necessary, arrange for evaluation and treatment. During the interview, take note of any prior injuries or weakness from prior competition. Each complaint should be checked thoroughly as some athletes have a tendency to be stoic. New team members should be carefully checked for pre-existing disorders that may compromise an athletic career. In addition, the physician and coach may wish to determine minimum standards of strength and fitness before letting someone participate.

2. Conduct basic clinical tests. A routine full blood count and urinalysis are essential, a standard resting ECG is often important, and a chest x-ray film is desirable. Comprehensive tests should always be taken when clinical symptoms or signs appear. The physical examination should always include a spinal analysis, posture check, and neurologic and orthopedic evaluation.

3. Advise the candidate with an atypical condition of suitable sports or modifications. While all sports involve some risk, advise, or if necessary restrict, the candidate with overt or covert limitations from activities presenting great risk. Offer professional counsel which would contribute to optimal health and development.

4. Consider a psychologic assessment as to the athlete's goals, attitudes, desires, motivation, and reasons for participation. All physical, laboratory, and psychologic assessment tests must be made with the permission of parents or guardian in case of a minor.

The doctor must demand a degree of control equal to the responsibilities, and this is often difficult during the heat of competition. The physician's decisions will not always be treated with respect by the nonprofessional. Thus, it is imperative that the doctor do his best in establishing areas of cooperation and an atmosphere of mutual rapport.

A sport is a game, and a game should not unduly jeopardize a person's health or safety. However, the coach and the athlete justifiably expect both serious and minor disabilities to be treated with readiness, skill, and efficiency because any handicap has serious consequences. Both coach and athlete must feel that the doctor understands the problem and is as interested in returning the athlete to competition as they are. Honest, open communication is the cornerstone from which to build trust and confidence.


The Athlete

No rule exists that the athlete must confide in a doctor or accept his recommendations when there is a lack of confidence. The need for sympathetic understanding of the athlete and his particular problems and aspirations cannot be overemphasized. Creating an atmosphere of mutual confidence and trust is vital to establishing control. Likewise, the development of the athlete's confidence in the doctor will help to prevent “doctor shopping” by the athlete to get the opinion the athlete wants. Without confidence in the doctor, the athlete may not report possible masking or harmful do-it-yourself or over-the-counter remedies or devices.

All disabilities are important, and all must be dealt with individually: not by rote or preference for a favorite “star” or influenced by pressures where each prediction of potential disability may be publicized. Each athlete presents a variance as to strength and weakness, attitudes, motivations and goals, pain threshold, development, body type, the specific acute trauma, etc. In a squad of two dozen, there are 24 unique people. These factors must be analyzed, differentiated, and a therapeutic solution applied.


The Trainer

The ego of a physician is often deflated when he learns that the trainer is held in higher respect. If a team had to choose between a team physician or a trainer, the physician would usually lose. And this respect is usually well earned. The trainer's entire life has been devoted to the care of sports injuries. Loyalty also builds respect. Trainers have often been with the team for many seasons, while physicians have come and gone. Many trainers and coaches possess a remarkable memory which can recall in detail a similar injury occurring many years ago, its efficient treatment, the exact duration of the rehabilitation process, and the capabilities of the athelete on recovery --to the dismay of a young doctor's professional pride who must at least match the record.

While the trainer is commonly seen at the college and professional level, his aid is usually missing at the secondary and primary levels --and this lack makes the physician's role overly demanding and sometimes impossible. The reason for this is that a trainer must be an expert at applying bandages, splints, dressings, slings, specialized athletic taping, and other first-aid measures. He is an expert at evaluating, ordering, fitting, and maintaining equipment, and is often called upon to custom design a special piece from available material. The skilled trainer is an expert in physical conditioning, physical rehabilitation, and in a large variety of physiotherapeutic applications and their contraindications. He must be knowledgeable in the risks of various field conditions: what constitutes a safe infield, turf, or track. And he must be knowledgeable in what an athlete will eat, regardless of nutritional theory and professional advice.

The trainer is often called upon to be squad psychologist, sociologist, counselor, friend, and confident. He serves as father confessor to the troubled athlete and is able to handle a large variety of temperaments and demands under pressure from both squad and staff. The experienced trainer “knows his people” for he lives daily with their complaints, hopes, opinions, personality quirks, and the unchecked locker room shop talk which few doctors are allowed to hear. He knows the art of listening to feelings rather than words and thus gains an insight of capabilities others do not have. This insight is invaluable to both physician and coach who do not enjoy the closeness with the athlete which the trainer is allowed.

A good trainer is more than an assistant to the doctor, he often serves somewhat as a mentor to the new team physician. On the other hand, an unskilled trainer must be carefully judged and evaluated as to capability of delegated duties and willingness to perform. Is there a definite plan for handling a serious injury or health emergency both at games and at practice? Planning ahead is imperative. Duties and procedures must be cordially discussed and mutally agreed upon, not proclaimed. The doctor and trainer have different yet parallel roles, and each should respect the experience and limits of the other. Few young doctors can tape a sprained joint as skillfully as an experienced trainer. The handicap of little mutual confidence is an impossible situation.

Care must be taken that the unskilled trainer does not allow numerous supplements, potions or pills, capsules or contraptions left unattended and available to an athlete to pick up at will. The administration of oxygen before or after exertion has no physiologic basis in increasing stamina or aiding recovery from fatigue.

Hirata reminds us that “The doctor who runs out on the field at the slightest provocation on heavily attended game days, but leaves the trainer to sink or swim during weekday practice, may impress the crowd and himself but certainly not the trainer or the team. Far worse, he exhibits little respect for the trainer's integrity and in turn will receive very little.”


The Coach and Staff

As with the doctor-trainer relationship, the physician and coach have different yet parallel roles. The coach wants a winning team; the doctor wants a healthy team. Obviously, it is often impossible to “charm” an entire athletic staff or every athlete. Here lies the necessity of administrative power to cope with poor cooperation, else each disagreeable decision will be met with increasing subversion. While it is important to develop firm friendships with athlete, coach, and trainer, the doctor must take care that such cordial relationships do not cloud his professional principles.

Sometimes the physician is forced to be a scrutinizing evaluator of the coaching staff.

Has conditioning been developed progressively?

Are tactics with a known high rate of injury discouraged?

Are safety factors being ignored such as failure to use mouth protectors in practice as well as during games?

Are the causes for injury determined?

Does the coaching staff pressure the physician for shortcuts to optimum athletic fitness?

Does conditioning take into consideration individual differences of structure and function: inherited or acquired?

Are old wives' tales such as no water during practice being advertised on the field?

Are adequate precautions being taken to safeguard against heat exhaustion or heat stroke?

The questions appear endless.

Proper care implies doing needful and helpful things for the injured or sick individual to restore him or her to the best possible state of physical and mental health in the shortest time. These needful and helpful things include environmental, hygienic, therapeutic, and supportive measures to protect against contracting any additional pathologic condition, physical or emotional. Body, mind, and spirit must all receive attention.

In the larger athletic organizations, several members of a health-care team may be involved, where each person contributes something toward the patient's welfare. Each member of such a health team must understand and appreciate the other's role. Each must know where he fits in, what he is to do, to whom he is responsible, and how he is to do his part. Otherwise, function is impossible, and an injured player is in danger of being neglected.

All personnel and all players, regardless of social status or diagnosis, should be recognized as potential carriers of pathogenic organisms. It is thus essential to consider strict hygienic practices that prevent the transfer of these organisms from one person to another.

The majority of players seeking health care do so because of minor illness, injury, or concern over personal health. If these individuals are returned to competition from the dispensary or the attending doctor's office without adequate examination, treatment, and reassurance, they continue to worry about their health, lose confidence in the health care extended, and become less effective in their assignments. On the other hand, if they are needlessly referred to specialized care, time is lost unnecessarily and professional time and facilities are used needlessly.


The Athletic Dispensary

A dispensary is a treatment facility designed primarily to provide care of ambulatory athletes and to arrange for referral to another practitioner, hospital, or specialized clinic. Athletic dispensaries also perform various administrative, preventive, and sanitary activities related to sports and the personnel served. An athletic dispensary is often referred to as an “aid station”. Most dispensaries are fixed and usually located close to a stadium, arena, or field of play. Some, however, are mobile, and can move or be moved from place to place to provide health-care support at tactical locations.

      FUNCTION

A well-organized and efficiently operated facility is one of the most effective means of providing and extending health service to the club or team. Some of the more important activities carried on by an aid station involve

(1) sudden sicknesses,
(2) emergency treatment,
(3) continuing routine treatments or a series of treatments for players who do not need external care,
(4) physical examinations, diagnosis, and disposition of players receiving health care,
(5) sanitary inspections related to health of personnel and players served,
(6) administration of dispensary records, property, and supplies, and
(7) supervision of subordinate personnel.

      EMERGENCY CARE

Emergency treatment in a dispensary is the early care given to the injured, wounded, or sick by a trained professional prior to referral. Specific measures to be applied at the scene will be discussed later in the section concerning first aid. In the dispensary, the doctor in charge is usually the first professional to see the patient who has come or been brought to the dispensary for emergency treatment. He or she must be prepared to receive emergency situations and maintain proficiency in applying first-aid measures. Emergency equipment should be ready for use, in its proper location, and immediately available (not locked up). Trained personnel must be available who know how to operate all necessary emergency apparatus and how to use all items on an emergency basis. There is no time to look up a technique in a procedure manual or to review an instruction booklet. All emergency equipment should be inspected, maintained, and tested at regularly scheduled intervals.


Doping: A Dangerous Practice

While an exact definition of doping has not been universally accepted, doping is usually considered the act of using chemical substances with the deliberate goal of altering athletic performance, usually with the intent to gain an unfair advantage over a rival. To help control abuses in major competition, dope detection methods have been developed to identify such substances. Most substances taken to act during active competition can be detected by some type of chromatography.

The role of the physician is one of detection, disqualification, and deterrence if strict controls on banned drugs are to be maintained. Unfortunately, a clear definition of what is and is not allowable has not been achieved in all quarters. The four major types of drugs commonly used to modify performance are stimulants, sedatives, anabolic steroids, and anti-inflammatory agents and analgesics:

1. Stimulants are used to delay fatigue and enhance feelings of alertness, strength, and aggressiveness. The two major types of stimulants used are (a) the psychotonics such as the amphetamines, which act upon the central nervous system, and (b) the analeptics such as adrenaline and ephedrine, which influence the cardiac and respiratory regulating mechanisms. Caffeine is both a mild psychotonic and an analeptic. Among the side effects of the strong stimulants are psychologic dependence, hypertension, cardiac arrhythmias, hostile behavioral changes (eg, paranoid reactions), and cardiovascular collapse from impaired temperature regulation (ie, cutaneous vasoconstriction).

2. Sedatives are used to develop a “calmness” in a player whose performance depends greatly on precision and control such as in archery and rifle matches.

3. Anabolic steroids are troublesome drugs used to promote muscular development, especially during pre-season development programs, where great power is necessary (eg, weight lifting, shot put). The side effects of water retention, various forms of glandular suppression and exaggeration, and osteoporosis make them quite dangerous. Any drug that is sufficiently potent to alter metabolism in the healthy athlete is also likely to produce manifold undesirable effects.

4. Certain substances are used primarily to reduce pain. Anti-inflammatory agents (eg, salicylates, cortisone) and analgesics (eg, procaine) compromise the body's normal response to painful stimuli. When pain is eliminated, the benefit of muscle spasm to splint an injured part is lost, and further motion contributes to greater injury. The long-term effect is often traumatic arthritis.

For the sake of optimum health, both sexes should be allowed to participate in a wide variety of athletic events. Girls and women are now taking an increasing role in sports participation as various taboos and culturally imposed restrictions give way. While women have long been active in such sports as tennis and golf, they have recently increased their participation in such violent activities as wrestling, boxing, football, and demolition derbies.


Growth, Development, and Function

The capacity for physical activity during childhood is equal for both sexes. Strength, cardiovascular endurance, and motor skills exhibit few differences between the sexes up to the age of 12 years. After adolescence, however, males develop faster physically, which allows for greater power and potential, but the capacity to develop motor skills remains about equal.

The ratio of lean body mass to fat is one of the most obvious physical differences. Males present greater bone strength and density, greater muscle bulk and broadness in the shoulder area, and greater subcutaneous fat in the upper half of the body.

At maturity, females are generally shorter in height, have more flexibility in their joints, have more delicate ligaments and tendons, have more subcutaneous fat in the hips and lower body regions, have less erythrocyte and hemoglobin mass, exhibit a greater degree of pelvic tilt and obliquity, and the female elbow offers a greater carrying angle and tendency toward cubitus valgus. The female has smaller lungs, heart, liver, and kidneys than the male. Schroeder points out that female joints are more subject to injury in sports which require the expulsive effort, sudden stopping, sudden checking of speed and turns, and landing in jumps.


Special Sports Concerns

Contrary to common opinion, women have been shown to achieve much greater muscle strength without an appreciable change in muscle bulk. Weight-lifting, with proper technique, will not necessarily cause undue hypertrophy.

To ensure optimal endurance and performance, adequate iron is necessary in the diet to carry oxygen to the cells. Iron deficiency is the most common nutritional fault in American females. A female loses from 5 to 45 mg of iron per day during menstruation. Thus, most female athletes require supplementation and frequent monitoring of blood-iron content.

      PARTICIPATION DURING MENSTRUATION

With the exception of an athlete who is experiencing unusual discomfort or excessive flow, there is no physiological reason why training or competition should be avoided during menstruation. Statistics show that most Olympic sportswomen do not interrupt training during menstruation, although the type of training and the intensity of training may be modified. About one out of four sometimes interrupt training, and only one out of 20 do not train during menstruation.

Although the majority of females prefer tampon protection during some phase of menstrual bleeding, the recent controversy about “toxic shock syndrome” deserves caution and suggests frequent changes. Caution must also be given relative to diaphragms continually worn and to intrauterine devices which might complicate an abdominal blow.

The female athlete usually exhibits less colic, less premenstrual headaches and tension, and greater regularity than the nonathlete. In fact, physical exercise appears to be a distinct aid in the treatment of dysmenorrhea. Neither the menarche nor conditions for future pregnancy are disturbed by active participation in sports, and no detrimental long-range gynecologic effects from vigorous physical activity have been determined. However, according to Corwin, many female athletes report disruption or even cessation of their periods during intensive training. This has been shown to be related to lowering of the percentage of body fat which has a direct effect on hormonal levels and the menstrual cycle.

The influence of menstruation on athletic performance is a highly individualized effect. The female athlete who is distinctly disadvantaged by the physiologic function of menstruation can have her menstrual cycle medically adjusted so that competition will occur at the optimum time of her cycle, but this is not usually advisable. Eagles cautions against the numerous, and often serious, side effects from hormone therapy such as the potential for emboli formation following small foot fractures and the visual changes some females experience while on this type of medication. Headaches and fluid retention are other common complaints detected from cycle alteration.

      PREGNANCY

Except with a poor obstetric history, there is no evidence that a normal pregnancy will be threatened by exercise. Of all athletics, swimming appears to be the best physical activity for the expectant mother. On the other hand, there is evidence that physical fitness during pregnancy contibutes to ease of labor and postpartum light exercise assists the process of involution. Following delivery, intense competition is usually contraindicated for several months, especially if the mother is breast feeding.

Corwin reminds us that pregnant women should avoid increasing body temperature especially during the 1st and 2nd trimesters. Overtraining in environments of high humidity and heat (along with the practice of utilizing hot tubs, saunas, and jacuzzi baths) can be responsible for raising body temperature for longer than 10 min. This can cause irreversible neurologic damage to the fetus. The personnel of spas and health clubs involved with the pregnant women should be aware of this situation.

      THE BREASTS AND GENITAL ORGANS

A metal breast protector is necessary in all contact sports and in some noncontact sports such as volleyball to prevent contusions and pain. Breast injury may lead to a localized hematoma producing a region of fat necrosis characterized by a firm and painless lump developing several weeks or months after the accident. This is impossible to differentiate from breast cancer except by biopsy.

Haycock et al have proved that lack of an adequate supportive bra can cause discomfort as well as injury to the breast when walking and running. Their controlled-study data suggest that women without proper breast support experience trauma to the breasts and supporting ligaments, especially when the breasts are large or pendulous. Thus, the need for a properly engineered athletic bra is obvious. A sports bra should cover the breasts, prevent slapping or lateral shifting during activity, and offer enough support, without undue restriction or abrasiveness, that there are no signs of ache or tenderness after activity. Metal parts, seams, and allergenic effects may present problems.

The activity itself and the size of the breasts, along with the tone of the supporting muscles and ligaments, determine whether a special athletic bra, a regular bra, or no bra is adequate. In modern dance or swimming for instance, the no-bra situation may occur when the participants are small breasted because the stretch material in leotards and swim suits (plus water support) provide adequate support.

The most common female direct-trauma genital injuries are those involving vulval lacerations and hematomas (eg, vaulting, hurdles). Forceful douching occurs in inexperienced water skiers which can result in serious gynecologic problems. Prevention can be had by wearing rubber pants.

      DERMATOLOGIC PROBLEMS

Female skin is more delicate than that of the male. Many dermatologic problems can be prevented if conditioning and participation progresses slowly enough to allow the skin to accommodate to the acquired demands of excessive exposure to perspiration, dirt, and bumps.

During menstruation, large and bulky external sanitary napkins may irritate inner thighs during prolonged vigorous competition to the extent that a severe dermatitis develops.

Hair and fingernails also present special consideration. In many sports, hair must be either cut short or pulled out the way of vision through tight braiding pulled into buns or ponytails. This traction, however, may occasionally cause some degree of hair loss and balding. Traumatized fingernails may result in nail breaking and splitting which may lead to secondary infection.

      OVULATORY PATTERNS

Temperature patterns occur in the menstruating female reflecting the effects of ovulation. There is a fall in morning temperature just prior to menstruation that continues at this level until the midpoint between the two periods. In about 24-36 hrs before ovulation, the morning temperature rises and stays at a somewhat higher level until just before the next menses.

      TEMPERATURE RESPONSES IN SPORTSWOMEN

Because a woman has fewer functional sweat glands, body temperature in the female rises 2-3 degrees higher than that of the male before the cooling process of perspiration becomes significant. Thus, acute heat stress is a greater concern of female athletes. However, studies show that during prolonged activity in normal or hot weather women have less change in body temperature as compared to the male. While males sweat more, females cool quicker after muscular activity in hot weather. Women appear to adjust their perspiration rate more efficiently to the required loss of heat. This suggests that females present more efficiency in body temperature regulation and have a greater cardiovascular component of thermoregulation.