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DePutte, Toni Van, Ed.; And OthersTips on Training.American Alliance for Health, Physical Education,Recreation and Dance, Reston, VA. NationalAssociation for Girls and Women in Sport.ISBN-0-88314-231-783102p.AAHPERD Publications Sales, Box 704, Waldorf, MD20601 ($9.95).Guides - Non-Classroom Use (055)

MF01 Plus Postage. PC Not Available from EDRS.*Accident Prevention; Allied Health Personnel;Athletic Coaches; Athletic Equipment; *Athletics;Drug Use; Emergency Programs; First Aid; HigherEducation; *Injuries; Legal Responsibility; *MedicalServices; Nutrition; *Physical Education; PhysicalEnvironment; Safety; Secondary Education; WomensAthletics

ABSTRACTThe articles in this collection are addressed to

athletic coaches or ancillary health personnel practitioners whotreat athletes' injuries. Emphasis is upon proper immediate care,recognition and referral of serious injuries, and preventive measuresto reduce injuries. Papers include: (1) "Planning a High SchoolAthletic Training Program" (Stanley Nakahara); (2) "Basic AthleticInjury Care" (Katie Heffelfinger); (3) "Treatment of Injuries" (ToniVan DePutte and Holly Wilson); (4) "Rehabilitation" (Andi Seger); (5)"Athletic Conditioning" (Kathy Heck); (6) "Protective Equipment andDevices" (Holly Wilson); (7) "Legal Liability" (Richard T. Ball); (8)"Athletic Nutrition, Diet, and Weight Control" (Kathy Heck); (9)"Coping With the Heat and Humidity" (Holly Wilson); (10) "EmergencyPreparation" (Holly Wilson); (11) "Over-the-Counter Non-Rx Drugs"(Holly Wilson); (12) "Misconceptions of Athletic Injuries" (LindaArnold); (13) "The Female Athlete" (Christine Haycock); and (14) "TheGrowing Athlete" (Holly Wilson). A bibliography and recommendedreadings list are appended as well as position statements from theNational Association for Girls and Women in Sport Athletic TrainingCouncil. (JD)

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tz,

TIPS ON

2

Collaborated by theAthletic Training Council

Editorial Commiffee

A structure of theNational Association

for Girls andWomen in Sport

an association ofThe American Alliance forHealth, Physical Education,

Recreation and Dance

U.S. DEPARTMENT OF EDUCATIONNATIONAL INSTITUTE OF .-OUCATION

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

Li This Øocument has been reproduced asrectiied from the person or organization

ginating it.Minor changes have been made to improve

reproduction quality.

Points of view or opinions stated in this docu-

ment do not necessarily represent official NIE

position or policy.

"PERMISSION TO REPRODUCE THISMATERIAL IN MICROFICHE ONLYHAS BEEN GRANTED BY

W. L. Coofd

TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)."

Copyright © 1983

The American Alliance forHealth, Physical Education,

Recreation and Dance1900 Association DriveReston, Virginia 22091

ISBN 0-88314-231-7

3

Purposes of the American Alliance ForHealth, Physical Education,

Recreation and DanceThe American Alliance is an educational organization, structured for the purposes of

supporting, encouraging, and providing assistance to member groups and their personnelthroughout the nation as they seek to initiate, develop, and conduct programs in health,leisure, and movement-related activities for the enrichment of human life.

Alliance objectives include:1. Professional growth and developmentto support, encourage, and provide guidance in

the development and conduct of programs in health, leisure, and movement-related activitieswhich are based on the needs, interests, and inherent capacities of the individual in today'ssociety.

2. Communicationto facilitate public and professional understanding and appreciationof the importance and value of health, leisure, and movement-related activities as theycontribute toward human well-being.

3. Researchto encourage and facilitate research which will enrich the depth and scope ofhealth, leisure, and movement-related activities; and to disseminate the findings to theprofession and other interested and concerned publics.

4. Standards and guidelinesto further the continuous development and evaluation cfstandards within the profession for personnel and programs in health, leisure, andmovement-related activities.

5. Public affairsto coordinate and administer a planned program of professional, public,and governmental reiations that will improve education in areas of health, leisure, andmovement-related activities.

6. To conduct such other activities as shall be approved by the Board of Governors and theAlliance Assembly, provided that the Alliance shall not engage in any activity which would beinconsistent with the status of an educational and charitable organization as defined in Section501(c) (3) of the Internal Revenue Code of 1954 or any successor provision thereto, and none ofthe said purposes shall at any time be deemed or construed to be purposes other than thepublic benefit purposes and objectives consistent with such educational and charitablestatus. Bylaws, Article III

Athletic Training CouncilEditorial Committee

Toni Van DePutte, A.T. C. Chair of NAGWS Athletic TrainingCouncil. Athletic Trainer, YsletaHigh School, El Paso, Texas.

Earlene Durrant, A.T.C. NAGWS Athletic Training Council, Past Chair. Athletic Trainer,Brigham Young University, Provo, Utah.

Kathy Heck, A.T.C. NAGWS Athletic Training Council Executive Committee. AthleticTrainer, Michigan State University, East Lansing, Michigan.

Holly Wilson, A.T.C. NAGWS Athletic Training Council Executive Committee. SportsMedicine Consultant, Berkeley, California.

5

Table of ContentsIntroduction vii

\IPlanning a High School Athletic Training Program 1` 1

(Stanley Nakahara j

2 Basic Athletic Injury Care 5Katie Heffelfinger

3Treatment of injuriesToni Vcn DePutte and Holly Wilson

13

4 Rehabilitation 19Andi Seger

5 Athletic Conditioning 23Kathy Heck

6 Protective Equipment and DevicesHolly Wilson

27

Legal Liability 33Richard T. Ball7

0 Athletic Nutrition, Diet, and Weight Control 51

C) Kathy Heck

9 Coping with the Heat and Humidity 55Holly Wilson

'10Emergency PreparationHolly Wilson

59

/ 4 Over-the-Counter Non-Rx Drugs 75I Holly Wilson

12Misconceptions of Athletic injuries 81

Linda Arnold

'13The Female Athlete 85Christine Haycock

4 The Growing Athlete 89Holly Wilson1

Appendix ABibliography 93

Appendix BPosition Statements 97NAGWS Athletic Training Council

Appendix CRecommended Readings 99

6

Introduction

The services provided for athletic medicalcare are extremely varied in high schools andcolleges, ranging from a tray of ice cubesreserved for injury care to a fully equippedtraining room with a complete staff. Indeed,in these days of fiscal conservatism, a full-time athletic trainer, especially at the highschool level, is an unaffordable luxury.While some schools make an attempt to iden-tify some health-related staff member to dealwith athletic injuries, others rely solely oncoaches to recognize and treat injuries. All ofthese individuals are capable of acting in thiscapacity, but certainly not without propertraining, as is so often the case.

Contrary to common belief, a first aid kitand tape supply do not a trainer make. Manya coach will attest to the fact that nothing inthe training kit helps when an athlete suffersa concussion, sustains a fracture, or tears aligament. In these cases, the most valuabletools a trainer can utilize are standardequipmentthe hands and brain. In the ab-sence of a trainer, almost any staff membercan act responsibly enough to deal withthese circumstances if there is a basic knowl-edge of the injury and its care. The coach, astudent trainer, the school nurse, a localemergency medical technician, or therapistare such persons. In the case of athletic in-jury, it isn't so much what you are, as whatyou know.

It is the purpose of this manual to providetips on athletic training to ancillary person-nel so that they may ensure proper carethrough recognition and referral. Perhapsthe most important responsibility is to knowone's limitations. This also applies to train-ers, who serve to refer problems which gobeyond the scope of their expertise.

For the school nurse, EMT, coach, or otherperson assigned to athletic medical care,there are a few basic requirements. There is

vi i

no substitute for, nor excuse for not knowingcardiopulmonary resuscitation (CPR). CPRcourses are taught by the American RedCross, the American Heart Association, andmany colleges. The cost is minimal when thevalue of a life saved is considered. The sec-ond requirement should be standard firstaid, which is likewise taught locally by theAmerican Red Cross or through a college.These short courses are successfully taughtto individuals aged 13 and older, and theirlife-saving successes are well-documented.Everyone can learn, and indeed, shouldlearn CPR, especially when assuming re-sponsibility for the care of athletes.

Regardless of efforts to train ancillary per-sonnel for this role, the true answer to theproblem is the availability of a certified ath-letic trainer. Few people realize the educa-tional background of these professionalswho are required to meet rigorous standardsset by the National Athletic Trainers Associa-tion. Most athletic trainers acquire a B.S. de-gree in physical education, with emphasis inareas related to sports medicine such asanatomy, physiology, nutrition, kinesiol-ogy, exercise physiology, psychology,therapeutic exercise, evaluation, and ofcourse, first aid. They are required to serve800 hours (curriculum) to 1800 hours (ap-prentice) under the supervision of a certifiedathletic trainer in a practical setting. Beforethe national organization will certify candi-dates, they must prove competency in a vari-ety of areas, through a thorough written andpractical examination.

First and foremost, the athletic trainer isconcerned with minimizing the inherent riskof sports. Responsibilities, thus, include firstaid, evaluation, treatment and rehabilita-tion, pre-season screening, preventative tap-ing and wrapping, assistance to the coach indeveloping conditioning programs, and

7

education of coaches and athletes in areas ofcommon concern such as nutrition and diet-ing. Prevention of injuries has been widelyrecognized as a primary concern, often ac-counting for 40-60% of the trainers' ac-tivities.

It has been said that the trainer is alway,.;the first to arrive to school and the last toleave, and this is not surprising when oneconsiders his/her duties before, during, andafter practice. Multiply these responsibilitiestimes the numbers of teams practicing, andthe demands on a trainer's time can be un-derstood. Trainers are most energetic, oftenworking 60-80 hours per week to accomo-date the needs of athletes.

The major differences between an ancil-lary athletic care person and an athletictrainer are availability, scope of expertise,and prevention-orientation. It is most dif-ficult to prove that preventative measureswork; however, there are a few exampleswhich illustrate quite clearly the merit ofsuch efforts. A few years ago, some athletictrainers who studied the mechanism of foot-ball fatalities and neck fractures, discoveredthat spear-tackling was usually involved.Eventually this resulted in a rule change out-lawing the technique, followed by a sub-sequent drop in the casualty rate. Likewise,trainers have also prevented muscle strainsand joint sprains through enforcement ofstretching and strengthening exercises pre-scribed for susceptible individuals. Ensuringhealth in this manner surely enriches theathletic experience for participants, andhelps improve the quality of life througheducation about proper injury care and pre-vention.

The core of any injury prevention programis the pre-season physical examination,which should be required of all participants.While a routine physical exam may sufficefor a sedentary or moderately active person,it will not suffice as a means of determiningan athlete's participation fitness. In thesedays of increasing liability concerns, thepre-season physical exam has been recog-nized as a most important means of protect-ing both the individual and the institution.Though other health care persons may lendassistance, a medical doctor should directand perform the major components of thepre-participation medical exam. The follow-

vi i i

ing screening examinations should be mini-mal requirements of the physical: medicalhistory; height and weight; visual acuity;urinalysis; hemoglobin; sickle cell; menstrualhistory; orthopedic; blood pressure; pulse;general physical condition; flexibility;strength.

The medical history is an important sourceof information for the coach, trainer, andphysician. It should identify non-sport re-lated illnesses and injuries, as well as thosecommonly associated with athletics. Insur-ance information should be included on thisform to expedite proper hospital care in theevent of serious injury. The NAGWS Ath-letic Training Council has developed a medi-cal history questionnaire specifically forwomen athletes and this is available to you atno charge (see Chapter 10).

The extent to which a coach utilizes valu-able information gathered during the physi-cal exam can certainly affect injury rate. If thepredisposing factors to injury can be iden-tified, the deficiency can be corrected. Thusthe physical exam must include tests de-signed to identify deficiencies in joint stabil-ity, strength, and flexibility, factors whichare related to injury. Identification of thesefactors is an injury prediction system.Coupled with specific remedial exerci:es, itcan be an effective injury prevention system.

Because this type of detailed pre-participation screening is the exception tothe rule, the athletes and administrators willhave to be "sold" on its importance. Provid-ing a comprehensive athletic screening is likebuying injury protection insurance. Try it,and observe the results. Chances are thatyou can't afford not to maintain a screeningprogram. The price paid out in terms ofsidelined athletes just doesn't seem worth it.

Certainly there are some injuries that sim-ply cannot be prevented. When a 130-poundbaserunner collides with a 100-poundcatcher blocking home plate, anything canhappen. As the following chapters are read,note the emphasis on ensuring proper healthcare for the student athlete. The cornerstoneof good health care is prevention; the rest liesin one's ability to recognize injury, performathletic training skills within limitations, andrefer athletes to medical professionals whennecessary.

Planning a High SchoolAthletic Training Program

Stanley Nakahara, A,T.C.,

Finding an Appropriate Facility

An athletic training program can be a veryvaluable asset to the high school athletic pro-gram. The person who has been assigned theresponsibility of starting an athletic trainingprogram must secure the use of a room. Pref-erably, the room should be in the lockerroom in a location that is accessible to allathletes, both boys and girls. If accessibilityis a problem, it may be located outside thegym area. In securing this room, however,consideration should also be given to accessto water, drains, ventilation, and electricity)

The siie of the training room is dependenton the number of students it is to serve andwhether or not a certified athletic trainer is toutilize the facility. It should serve all studentsin the school, not only the boys and girlsparticipating in the interscholastic sportsprogram, but also those in the intramuraland recreational programs and the physicaleducation classes. Therefore, the size of theschool and the extent of the program willdetermine the space required.2

The minimum space needed for anadequately equipped training room is anarea 15 feet by 20 feet (300 square feet). This isthe minimum area required for one tapingtable, one treatment table, a sink with somecounter space, and basic training roomequipment such as a refrigerator or ice ma-chine and a whirlpoo1.3

A rough estimate of the area required canbe made by determining how many treat-ment and taping tables are needed toadequately serve the students, Approxi-mately 100 square feet of space is needed foreach table. This estimate includes the table orbench size, the working area around the ta-ble, and the associated counter and storagespace.4 About 20 athletes can be accommo-dated per table on any given day prior to a

1

practice or contest. By dividing the numberof students that the area is to serve duringthe peak load by 20, then multiplying thatnumber by 100, the approximate number ofsquare feet needed for the training room canbe determined.5 The floor of the trainingroom should be constructed of concrete andcovered with vinyl tile or one of the newsynthetic non-slip resin floor coatings thatcan be readily cleaned. The training roomcollects dirt and debris carried in from vari-ous activity areas, yet it must be kept cleanand sanitary. These synthetic resin materialsare suitable for all floors including those inwet areas. They are not slippery and can bereadily hosed off. The material should beapplied about 4 inches up the side of thewal1.6

The hydrotherapy equipment (the re-frigera tor, the ice machine, and thewhirlpool) should be installed in an area sep-arate from the other training room equip-ment. As a result of space limitations, theequipment may be placed in one corner ofthe room. A curb to separate this hydro-therapy area from the rest of the trainingroom is not necessary if the floor is slopedand if the drainage is adequate. The floor ofthe hydrotherapy area should have a slope ofapproximately 1% and there should be morethan one drain. This slope accommodatesdrainage which creates an area that is easierto clean and safe.7

'Klafs, C. E., and Arnheim, D. D. Modern Principles ofAthletic Training. St. Louis, MO: C. V. Mosby Com-pany, 1981.

2Ibid., 1981.Penman, K. A., et al. "Training Rooms Aren't Just

for Colleges." Athletic Purchasing and Facilities 6 (9):34-7.

'Ibid., 1981, pp. 34-7.5Ibid., 1981, pp. 34-7..6Ibid., 1981, pp. 34-7.Ibid., 1981,pp. 34-7.

Construction of this hydrotherapy area is amajor task because existing plumbing mayneed io be altered to provide an adequatenumber of water outlets and drains. In fact, itis necessary to anticipate the number ofwhirlpools that may ultimately oe requiredso that the rough plumbing can be installedwhen the room is being redone or con-structed.

If the room is being redone, outside win-dows should be eliminated if possible. If anew room is being constructed and windowsare required, they should be placed abovethe hydrotherapy area at least 7 feet from thefloor. In a room where there are separa teareas, indoor windows may be necessary forproper supervision of the entire room. Doorsshould be sufficiently wide to maneuver astretcher or gurney in and out of the trainingroom. A Dutch door is ideal to preventundue traffic in the training room. The wallsshould be covered with a glossy paint whichpermits easy cleaning. A light color such aslight green or white makes the room appearmore "antiseptic"; however, any color issuitable if it has good reflection characteris-tics. The walls around the hydrotherapy areashould be ceramic tile or a synthetic resinousmaterial similar to the floor surface. Acounter with cabinets and a sink should beinstalled along one wall in the main trainingroom area. The cabinets should lock and thesink should have hot and cold running wa-ter. A soap dispenser and a paper towelholder should be placed above the sink.Cupboards with lockable sliding doorsshould be securely attached to the wall abovethe counter. A bulletin board should be at-tached near the door. A few ankle wrap rol-lers should be installed just outside thedoor.8

The dectrical features of the training roomshould include florescent lighting which isvery energy-efficient. Such lighting illumi-nates between 50 to 60 foot candles. The elec-trical outlets should all be grounded and areset switch should be included in each of theoutlets in the hydrotherapy area. The outletsin the entire room should be approximately 4feet apart and 4 feet from the floor.9

The temperature desired for the most edi-ciency in the training room should be ap-proximately 76-78°. The warmer tempera-ture is required because athletes are usuallysparsely dressed while in the room."

Setting up a Training Room

Once the room has been secured and mod-ified, or built, the individual must equip it

with some basic equipment and supplies.The training room should have a desk, achair, and a file if a designated individual isassigned to supervise the area. (Hopefully,the individual is a certified athletic trainer.)An accessible telephone with an outside lineis an absolute necessity for emergency calls.The most important piece of athletic trainingequipment is a refrigerator or an ice machine.The refrigerator must be capable of makinglarge quantities of ice. In larger trainingrooms, a separate ice machine may be neces-sary to supply the demand.11

Treatment tables should be approximately30 inches high, 2 feet wide, and 6 to 7 feetlong. They should be covered by a foam padand a synthetic plastic cover of some type forease in cleaning. Taping tables are approxi-mately half the length of a treatment table.The two types of tables can be built fromeither wood or metal in various ways. Everytrainer usually has a preference for materialand a method of construction, but the budgetmay be an important factor to consider. Con-struction of such tables is an ideal project forstudents in the advanced wood and metalshop classes at the school.12

Two different size whirlpools should beconsidered for the hydrotherapy areasthefull body size and the smaller extremity size.If possible, at least one of each size should beinstalled to meet the various demands andalso to conserve energy. In some highschools there may be a corrective or adaptivephysical education room adjacent to thetraining room. Students in the corrective oradapted program might also use thewhirlpool(s) providing such a treatment isprescribed by the attending physician.

Lockable cupboards are necessary to storesupplies used in the training room. Suchsupplies include the basic items used in thefirst aid care and follow-up treatment of ath-letic injuries. Items such as tape, anklewraps, elastic bandages, gauze pads, gauzerolls, bandaids, moleskin, adhesive foam,aluminum finger splints, slings, tape adhe-rent, tape remover, external analgesics of var-ious strengths, first aid solutions, ointmentsand creams, paper cups, and plastic bagsmay be stored on the shelves in the cup-board. Special "instruments" such as athermometer, blood pressure cuff, stetho-scope, and possibly an ophthalmoscope/oto-

8Ibid., 1981, pp. 34-7.9Ibid., 1981, pp. 34-7."'Ibid., 1981, pp. 34-7.l'Ibid., 1981, pp. 34-7.

, 12Ibid., 1981, pp. 34-7.

2 10

scope, should be secured in a separate area ofthe cupboard. Dressing jars containinggauze pads, cotton-tipped applicators, cot-ton balls, and tongue depressors should bereadily available on the counter top butlocked up at the end of the day. The sameapplies to scissors, tape cutters, and hairclippers; otherwise, they have a tendency todisappear. Larger items such as blankets, pil-lows, and assorted materials used for protec-tive padding should be stored on separateshelving. Crutches and spine boards can behung on wall hooks and ice chests can bestacked in the hydrotherapy area."

Since these supplies often have to be pur-chased on bid in large quantities, a storagecloset or room should be secured. Bulksupplies such as cases of tape, large splints,and other large items can be stored in thiscloset or room. The storage space should beclean, cool, and dry. It should also be se-cured by a lock to ensure not only safety butthe availability of supplies when needed.

Finances and Budgeting

Besides acquiring a facility, an importantfacet of the athletic training program is howto finance the facility. Some school districtsspecify funds in the school's athletic budgetto supply and equip a training room. Manytimes, however, the training room budget isneglected to the point to which it is in-adequate. If this is the case, as the individualwho cares for the welfare of all the partici-pants, support may be gained from parents,coaches, players, and administrators. Dem-onstrate to them a very definite need to up-grade the athletic training program.

One of the popular ways of acquiringmoney is fund-raising. Hold jog-a-thons, car

113

washes, sell candy or school spirit items, andrun concession stands at home games. Ac-quire a drink machine to sell drinks to thestudents. The money from these fund-raisers and concessions can then be used toequip the training room. Another way to fi-nance the training room is to coordinate thespecial education budget for remedial and/oradapted physical education. Sometimesequipment can be bought which could beused in this special program as well as theathletic training program.

In determining a budget, be aware of thenumber of sport participants. One personshould order all the training supplies and beresponsible for distribution of the items. Thiswill help to eliminate waste and economizethe use of all supplies. Inventory will then beeasier and so will the ordering of supplies forthe following year.

When what is needed for ordering is de-termined, shop around at different suppliersto price the supplies. Specify exactly what isneeded and do not accept any substitutes.

In setting up a trainino: room, the initialcost is likely to be high because equipment aswell as supplies must be ordered. As theprogram continues, the non-reuseable itemsare the only items that must be reordered ona yearly basis, unless the facility expands.

The training facility needs to be main-tained yearly by student trainers. They canbe recruited from the physical educationclasses or the interscholastic teams. Once atraining facility is acquired, continuallysearch for new and better ways to help main-tain a high quality of professionalism andservice in the facility. This training room canbe an integral part of an outstanding in-terscholastic athletic program.

13Ibid, 1981, pp. 34-7.

Acute traumatic injuries in athletics pose aunique problem for the trainer, team physi-cian, coach, and the athlete. It is the respon-sibility of the medical support personnel andthe coach working together to resolve theseproblems, along with the total cooperation ofthe injured athlete, which is essential, to getthe individual safely back into the competi-five environment as soon as possible.

It is imperative that the coach, trainer, andteam physician have a methodical procedureto follow when evaluating athletic injuries toensure the safety and well-being of theathlete.

The first step in injury evaluation shouldbe to get a history of the incident. How didthe injury occur? Did it seem mild or severe?Did the athlete feel or hear a noise? All ofthese questions and more will give vital cluesto the nature of the injury.

The next step should be a physical exami-nation of the injured area. The examinershould observe, noting the general appear-ance at the site of the injury. He/she shouldlook for swelling, deformity, damage to theskin, and bruising. Next, palpitation of thearea should be done to feel any abnormalitiesor irregularities that may be present. Func-tional testing of the injured area can deter-mine the pain, loss of function, and instabil-ity on both active and passive ranges of mo-tion; however, such tests should only be car-ried out by a trainer, paramedic, or phys!-cian. As a coach, the range of motion of theinjured part can be checked by asking theathlete to move that part through its pain-free range. With musculoskeletal injuries, anx-ray examination may be ordered by the at-tending physician to provide additional in-sight into the extent of injury.

Immediate injury management consists offive primary procedures: (1) application of

ice; (2) compression; (3) elevation; (4) im-mobilization; (5) controlled rest.

The benefits derived from immediate ap-plication of ice to traumatic injuries such as asprain, strain, fracture, contusion, and dislo-cation cannot be overemphasized. Coldcauses vasoconstriction (a decrease in thesize of the blood vessel), decreases swellingin the surrounding tissues, reduces musclespasticity and also reduces the sensation ofpain. The initial ice treatment should be inthe form of an ice slush bath, shaved icepack, or cold whirlpool and should last 20-30minutes. Ice therapy should be continued forapproximately 15-20 minutes every hour forthe next 48-72 hours, depending on the se-verity of the injury, or until swelling andhemorrhaging have been completely con-trolled.

Compression is the second essential whentreating acute athletic injuries. Compressionin the form of an elastic bandage, foam or feltpadding, athletic tape, or a combination of allthree help to reduce the potential for swell-ing to the injured joint or soft tissue area.(See Figure 1.) It is of great importance thatthe compression be applied firmly but not sotight as to cut off blood circulation to theinjury site. During the initial ice application,compression should be applied by wrappingthe involved area with an elastic bandage.(See Figure 2.) The bandage should be wet tohelp conduct the coldness to the tissue.Compression should be maintained after theice therapy with a dry elastic bandage and/orathletic tape.

Elevation, the third part of the standardfirst aid procedure (I.C.E.) requires that theinjured joint or limb be raised slightly abovethe horizontal plane to aid in the control of orprevention of swelling. (See Figure 3.) How-ever, any suspected fracture should first betemporarily splinted . The involved part

5 12

a. Horseshoe.

b. Placement of horseshoe.

Figure 1. Horseshoe and compression wrap.

c. Compression wrap.

Figure 2. Ice pack on injury.

should be elevated whenever possible dur-ing the initial injury and recovery stages.

Severe injuries such as fractures, disloca-tions, and second or third degree sprains andstrains require temporary splinting or im-mobilization to prevent further tissue traumaand to control pain. Such injuries will un-doubtedly require more permanent im-mobilization in the form of a rigid splint,cast, or some type of tape strapping to en-

1

Figure 3. Elevation of injury.

courage and expedite the healing process.When needed, immobilization is prescribedby the team physician or trainer.

The final step to be considered in the man-agement of athletic injuries is controlled rest.This may be the most difficult aspect of in-jury management for the athlete as well asthe coach. It is the coach's responsibility togive total support to the team physician ortrainer during the duration of the recom-

mended rest period. Rest or inactivity in themind of the athlete is taboo. Therefore, thereasons for the rest must be thoroughly ex-plained to the athlete; his or her total cooper-ation and dedication is essential to achievethe desired results. Controlled rest will usu-ally include some type of daily therapy suchas therapeutic rehabilitation exercises alongwith modality treatments.

The appropriate initial management of theathletic injury may make the difference in theathlete being able to return to action in amatter of minutes or days as opposed to sev-eral weeks of inactivity due to poor man-agement procedures.

Types of Injuries

Sprains

A sprain is one of the most common dis-abling injuries seen in athletics. It is a firstdegree stretching, a second degree partialtearing, or a third degree complete tearing(rupture) of the ligamentous structures sur-rounding the joint. Sprains are usuallycaused by traumatic twisting of the joint re-sulting in over-stretching or tearing of one ormore ligaments. Ligaments are inelastic fib-rous bands that join one bone to another,thus forming a joint. These bands are de-signed to prevent abnormal range of motionof the joint while permitting normal func-tional motion. Most sprains are seen in theankle, knee, and shoulder joints.

In the first degree sprain, there is littlefunctional loss with only a few ligamentousfibers involved in the over-stretching pro-cess. The signs to look for will include: pointtenderness; a small amount of swelling; dis-coloration (in some cases). Treatment shouldinclude ice, compression, and elevation(I.C.E.), and maintenance of range of motionas well as strengthening exercises.

The second degree sprain is a more seriousligamentous injury resulting in a partial tear-ing of the ligament fibers. There will be localtenderness, moderate swelling, hemorrhag-ing, and some loss of function. The standardI.C.E. procedure is appropriate first aidtreatment. Usually the team physician willalso recommend immobilization and possi-bly surgery to repair the damage to the jointstructure.

The third degree sprain is a complete rup-ture of one or more of the stabilizing liga-ments. The symptoms are more extremethan those associated with the second de-gree. Surgery is usually required to restorejoint stability and function.

Strains

Strain refers to the injury chat involves themuscle tendon unit. The strain may rangefrom a minute separation of fibers caused byover-stretching or a forcefui contraction, to acomplete separation or rupture somewherealong the unit. A strain can be very painfuland debilitating depending on severity andlocation. The most common strains seen inathletics include those of the hamstrings,quadriceps, groin area, hw back, and biceps.

The first degree strain will produce no ap-parent disruption of the musculotendinousunit but there will be discomfort on function,low grade inflammation, and some musclespasticity. Immediate treatment should in-clude I.C.E. with slight stretching of the in-volved muscle but only to the point wherediscomiort is first felt. After ice therapy,apply a dry elastic bandage to maintain com-pression on the area. Care should be taken toprevent further damage to the area. Rehabili-tation involves gradual strengthening andstretching of the injured muscle. The athleteshould not return to activity until both rangeof motion and strength are normal and pain-free.

When the second degree strain occursthere is actual damage due to partial tearingof the muscle, tendon, or the attachmentwhich will cause definite loss of normal func-tion and pain. The athlete will demonstratepain upon contraction of the affected area;there will be point tenderness, swelling, thepossibility of hemorrhaging, muscle spastic-ity, and loss of strength. Treatment will in-clude immediate application of LC.E. plusstretching to the point of discomfort, andcontrolled rest. Ice therapy must be con-tinued until swelling is controlled, 48-72hours later. Ice treatment should be con-tinued or heat application begun. When painis absent, a slow cautious strengthening andstretching program should be begun. Protec-tion in the form of a compression wrap and athorough daily warmup stretching routinewill be necessary to prevent re-injury whenthe athlete returns to action.

The third degree strain is the most seriousbecause it involves a separation or rupture ofthe muscle through its belly, its musculoten-dinous junction or its tendinous attachment.The actual separation may be palpated; atother times only the bunching up of musclefibers can be felt. There will be pain at the siteof the injury, swelling, lack of integrity of themusculotendinous unit, spasticity of themuscle fibers, and hemorrhaging. Usually

7 14

surgery, immobilization, and rest are re-quired for the best recovery.

The best treatment for strains is preven-tion. Care must be taken to ensure that theathlete has knowledge of the importance ofwarm-up and stretching techniques, andadequate time to perform them.

Dislocations

Dislocations and subluxations (partial dis-locations) of the joint present a special prob-lem in terms of handicapping the athlete.They primarily result from forces that causethe joint articulation to go beyond its normalanatcmical range of motion. When subluxa-tion occurs, there is partial separation be-tween the two articulating bones causingdamage to the surTounding soft tissue andjoint capsule. A dislocation occurs when thetwo articulating bones are forced completelyapart, usually causing moderate to severedamage to the surrounding soft tissues andjoint capsule.

The majority of serious dislocations andsubluxations occur in the shoulder joint ofthe athlete. Finger, toe, and patellar(kneecap) dislocations are also common.

There are three major factors to be consid-ered when evaluating a possible dislocation:

visual deformity is almost always pres-ent or deformity can be felt when pal-pated unless the joint has spontane-ously reduced (gone back into place);after a severe blow or fall, if the joint hasbeen dislocated, the athlete is unable tomove that joint;there will be immediate pain and swel-ling.

Treatment for the dislocation and subluxa-tion should be immediate ice application andstabilization of the affected joint. It is impera-tive that medical attention be immediatelysecured to determine the extent of damage tothe joint capsule, muscles, tendons, and lig-aments. All dislocations and subluxationsshould be x-rayed to make sure there havebeen no bone fragments pulled away at thetendon and ligament attachments. Since thestabilizing structures of the joint have beenseriously traumatized, the joint should beimmobilized for a period of one to six weeks.If possible, during the first 48-72 hours, iceshould be applied to reduce pain, swelling,and muscle spasm. The immobilizationperiod should be followed by an extensiveprogram to regain normal range of motion ofthe involved and surrounding joints andstrength of the surrounding musculature.

15 8

Unfortunately even with complete rehabili-tation of the injury, once an athlete suffers adislocation, there is greater chance for recur-rence due to a weakness in the surroundingstabilizing structure.

Fractures

Although not seen as often in athletics assprains and strains are, the coach and trainershould be prepared to handle a fractureemergency. A fracture is defined as an inter-ruption in the continuity of a bone (a break inthe bone). The break may be partial or com-plete. There are two types of fractures: aclosed (simple) fracture; an open (com-pound) fracture, one in which one or bothends of the broken bone extends through theouter skin. Fractures should be suspected inany musculoskeletai injury and therefore, anx-ray is often warranted. An x-ray is theonly positive way to determine the possibil-ity of a fracture.

The signs and symptoms indicating a frac-ture are: specific pain (point tenderness) atthe area of the break; general tendernessaround the area; immediate swelling; visualor palpable deformity; discoloration. Thecoach, trainer, or team physician should alsobe aware of the history of the injurya directblow, hard fall, oi a twisting type of injurycaused by a great amount of force. In addi-tion, the athlete may have heard or felt thebone snap.

Immediate treatment should include theapplication of ice, temporary splinting, ele-vation, and treatment for shock followed byreferral to a physician for examination,x-ray, and casting. The healing process maytake six to eight weeks or more.

The optimal treatment of fracture dependsupon the prompt and definitive care givenimmediately at the time and site of the in-jury. Poor handling of a fracture may causeadditional involvement of surrounding mus-cles, nerves, blood vessels, or internal or-gans.

Another type of injury frequently seen inathletics is the stress fracture. This is a hair-line fracture of the 6one that does not gothrough the entire bone. This type of injurymay be deceptive because there is usually nohistory of injury. X-rays may be negative inthe early stages and yet the symptoms per-sist. Stress fractures are found mostly in themetatarsal area (forefoot) and the lower halfof the fibula due to the constant stress andpounding these areas absorb during athleticendeavors.

The signs of a stress fracture are persistentpoint tenderness and small amounts of swell-ing. The stress fracturc may not be seen inthe early x-ray and so if suspected, the areashould be x-rayed every week to witness theformation of callous build-up as the naturalhealing process takes over.

Once it has been determined that a stressfracture exists, care should be taken to padand protect the area and a period of rest maybe indicated by the team physician. Ice isinitially indicated to reduce inflammationand later heat may be applied to increasecirculation to the area.

Contusion

A contusion may be defined as a directblow to an area of the body causing bruisingof the skin and underlying muscle due tocapillary rupture and infiltrative bleeding.The result is a tender localized area of swell-ing and discoloration with possible musclespasm commonly referred to as a bruise. Ifthe blow is severe enough or repeated fre-quently to the same area, immature banecells from the underlying bone may be re-leased into the muscle fibers. Upon maturity,many months later, a bone has developedwithin the muscle, a condition known asmyositis ossificans.

The treatment of a contusion consists ofthe standard I.C.E. procedure in the initialstages (the first 48-72 hours), immobilizationin severe cases, and at all times, protection toprevent further injury or re-injury.

If the injury is minor and there is very littlebleeding or swelling that does not interferewith functional use of the part, little treat-ment may be required after the initial I.C.E.However, if there is extensive bleeding andinflammation, the I.C.E. procedure shouldbe prolonged until swelling is completelycontrolled; activity may have to be limitedduring this period. Local heat may beapplied to encourage healing and help dissi-pate the remaining waste products onceswelling is controlled.

Rehabilitation of the contusion injuryshould begin slowly and be within the limitsof pain. It should include active stretchingand range of motion and strengthening exer-cises. Some kind of pad should be made toprotect the area against further trauma.

Open Wounds

Open wounds can be easily and safelyhandled by the athlete, coach, or trainer if a

9

few general precautions are taken. The mostserious problem facing any skin lesion is thepossibility of infection. Even the most minoropen wounds are subject to infection if notproperly handled.

In general, all open wounds should becleaned with soap and water to rid them ofcontamination. Then an antiseptic and asterile dressing should be applied. Be surethe athlete has a current tetanus booster. It iseffective for ten years but one should be ad-ministered if the athlete has not had a boos-ter within five years of the date of the injury,that is, if tetanus is a distinct threat.

AbrasionsAbrasions are scraping injuries to the skin

that may range from simple to extensivedamage to the skin. Abrasions themselvesare easily handled if the basic first aid mea-sures to prevent infection are followed.

LacerationsA laceration is a separation of the skin usti-

ally caused by a sharp object; the edge of thecut is usually jagged. Small lacerations canbe treated by the coach or trainer. The bleed-ing is best stopped with direct pressure. Thewound must be thoroughly cleaned withsoap and water and an antiseptic and a sterilebandage applied. Most severe lacerationsshould be seen by a physician after initialfirst aid measures to control bleeding havebeen taken. The physician will then have theopportunity to clean the wound, applysteri-strips or sutures, if needed, and dressthe wound.

Puncture WoundsThe puncture wound is not common in

athletics but should be promptly and prop-erly handled when it does occur. It is usuallycaused by a sharp object penetrating just intothe skin or the underlying soft tissue. Thechance of infection is great with the puncturewound. In most cases, there is very littlebleeding which naturally cleanses thewound and the deep underlying portion ofthe wound may close over before it is exam-ined, trapping in the contaminating bacteriaand providing an ideal environment inwhich the anaerobic tetanus bacteria canmultiply.

Treatment of the puncture wound, ifminor, may only call for a complete cleaningof the wound with soap and water and ob-servation of the wound as healing takes placeto ensure that there is no infection develop-ing (which is an important part of the stan-dard care for any wound). The more serious

puncture wound should only be protectedfrom further contamination and seen im-mediately by a physician to determine theamount of damage to underlying tissues andto receive proper treatment. Do not clean thewound or remove any impaled object. If nec-e5sary, a tetanus booster will be given.

Blisters

Every athlete at one time or another willprobably suffer from a blister. Because theyar so common it is important that they arecorrectly treated to avoid any unnecessarydiscomfort or infection to the athlete. Poormanagement of a blister may cause an athleteto lose precious practice or game time.

Blisters are caused by friction from varioussources, the most common being poor-fit-ting shoes and socks rubbing the skin, im-properly applied athletic tape, and the wedg-ing effect caused by callus build-up. Thesewill cause the outer layers of the skin to sepa-rate from the underlying dermis where apocket of fluid or blood will collect. Blistersare mostly seen on the backs of the heels,balls of the feet, on the toes, and palms of thehands.

The best treatment of blisters is preven-tion. This can easily be done by making surethe shoes and socks fit properly, the socksare clean, powder is put in the shoes andsocks, callouses are kept shaved so they areflush with the skin, and a good tape adherentis used before applying athletic tape.

When blisters do occur, caution must betaken to prevent infection and to make theathlete as comfortable as possible. Anytimethe skin is open, the chance of infection in-creases markedly. The intact blister can beprotected from additional trauma with a feltdonut. However, if the blister is torn, trimcompletely around the edge of the raisedarea with sterile scissors to remove the torntissue. Make sure the trimmed edge issmooth. Clean the tender area with soap andwater and then apply the donut. Place asmall amount of petroleum jelly in the donuthole (antiseptic ointment or cream if the blis-ter is open) and cover the donut with a sterilegauze pad. Tape the two securely in place. Asmall amount of petroleum jelly can beapplied to the outer surface of the tape tolessen friction. Check the blister daily, espe-cially one that has been trimmed, for signs ofinfection, and change the donut. When thenew tissue under the raised skin is no longertender, cut off the covering with sterile scis-sors. Continue to protect the area with a

1710

donut, petroleum jelly, and sterile gauze padfor the next few days. Thereafter, just applythe petroleum jelly as a precaution.

Splinting and Immobilization

Some type of splinting or immobilizationshould be applied to any musculoskeletal in-jury before the athlete is transported fromthe injury site. If the area of injury is notproperly immobilized, further damage tounderlying tissues, nerves, and blood ves-sels could ensue and shock could occur as aresult of the trauma.

Splinting devices should always be acces-sible during athletic competition and practicesessions. The use of padded boards orairsplints is recommended. Always stabilizethe joints above and below the site of thefracture.

Fractures of the ankle or lower leg requireimmobilization of the foot up to and includ-ing the knee. Any fracture involving theknee requires immobilization of the entireextremity. With involvement of the upperleg and/or hip, the splint must also extendupward along the trunk. Fractures of thehand, wrist, and lower arm require splintingin a position of forearm flexion and a sling.Fractures of the elbow and upper arm requirestraight arm immobilization while disloca-tions of the elbow are splinted in flexion, theposition in which the injury was found.Shoulder injuries require that the shoulderjoint be relaxed. This can best be accom-plished by having the athlete hold the in-volved arm in a comfortable position whileusing an elastic bandage to secure it to thebody. A general rule when immobilizing andsplinting an injured limb is to splint the limbin the position in which it was found; hope-fully this will be more comfortable to theathlete.

Injuries to the neck and spine in athleticspose a problem that should only be handledby those trained and qualified in such mat-ters. When a neck or spine injury is suspected,the athlete should be immobilized and notmoved until the help of emergency medicaltechnicians, paramedics, or a physician isobtained.

The Unconscious Athlete

One of the most potentially serious situa-tions faced by a coach or trainer is that of theunconscious athlete. This condition can bebrought about by a blow to either the head orsolar plexus or by general shock.

Figure 4. Taking the carotid pulse.

The following steps are suggested in theevaluation of the unconscious athlete:

1. Know the history of the injury eitherfirsthand or by the accounts of thosewho witnessed the injury.

2. Assume there has been a neck or spineinjury. Do not move the individual un-less absolutely necessary and then onlyas a unit. Stabilize the head and neck atall times.

3. Quickly access the situation. Visuallyinspect the athlete and decide whichpart of the body was most affected bythe injury. Check to see if breathing isnormal and then check the carotidpulse. (See Figure 4.) If needed, beginartificial respiration or cardiopulmo-nary resuscitation. Otherwise progresswith a thorough physical examination,beginning with an examination of thehead. Determine first if there is bleed-ing or straw-colored fluid coming fromthe nose, ears, eyes, or mouth. Look forbumps, lacerations, or deformities thatmight indicate a skull fracture; next,move down the body and check for de-formity.

11

If at all possible, the unconscious athleteshould not be moved from the field untilconsciousness has been regained. The coachand trainer should avoid the use of ammoniacaps to arouse the athlete when there is ques-tion of a neck or spinal cord injury. Once theathlete is coherent, the individual should bequestioned as to pain, numbness, and tin-gling and tested for injury to the spinal cordand paralysis (sensation is felt; there ismovement of fingers and toes).

All athletes suffering an injury causing un-consciousness should be removed from playand seen by a physician for a completeexamination. The physician should besupplied with information about the circum-stances of the injury and the length of timethe athlete was unconKious.

Cardiopulmonary Resuscitafion (CPR)

Trainers and coaches should have a work-ing knowledge and be certified in the tech-niques of CPR. Classes are scheduledthroughout the year by the American RedCross or the American Heart Association.Hopefully, thiS knowledge will never be puttopractical use.

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The case of the athlete who has been in-jured so seriously that he/she is not breathingand the heart is not beating is a crisis thatcalls for immediate action. The purpose ofCPR is to (1) establish an airway; (2) re-

store breathing; (3) restore circulation. Thetechniques are not difficult to learn and eachcoach and trainer should be encouraged toacquire these skills.

1912

Treatment of Injuries 3Toni Van DePutte,

andHolly Wilson, A.T.C., Ph.D.

Since both cold and heat are used in thetreatment of athletic injuries, the question ofwhen to use what frequently arises. A briefsummary of the physiological effects of thesetwo physical agents may help to better un-derstand the appropriate use of each.

Cold in any form causes vasoconstrictionof the blood vessels in the area of application.The diameter of each vessel decreases in size,thus permitting less blood to flow throughthe area at a given time. Such a response maybe helpful in the immediate care of a newinjury to control swelling; however, in mostinstances, by the time the ice is applied theclotting mechanism has already sealed offthe damaged blood vessels. What swellingresults from the leaking of blood into the areahas already occurred, but bleeding is not theonly source of swelling. More important intreating the new injury is the fact that colddecreases the metabolic rate of the cells in thearea being treated. Consequently, the cellsdo not need as much oxygen. At a time whenthe availability of oxygen is limited bytrauma to its transport system, circulation,this response may actually prevent the deathof cells by oxygen starvation. Tissue damageassociated with an injury has two compo-nents: initial damage caused by the traumaticforce; secondary damage from the lack ofoxygen. Cut down the oxygen needs of thecells and tissue damage is not as great. Coldalso has an anaesthetic effect, reducing painbut not entirely eliminating the sensation.The body's early warning system is still func-tioning. This anaesthetic effect is importantin the immediate treatment of the injurywhen pain is intense and during the earlystages of rehabilitation when working onrange of motion. Finally, cold relieves mus-cle spasm. In many musculoskeletal injuriesthe body naturally attempts to splint the in-jury by tightening the muscles in the area.

The tight muscles must relax if rehabilitationis to progress. These effects, anaesthesia andreduction of muscle spasm, may last fromseveral minutes to several hours followingcold treatment. The cold actually interfereswith the transmission of nerve impulses andsuch interference lasts a varying amount oftime.

On the other hand, heat causes vasodila-lion, an increase in the diameter, of the bloodvessels. Consequently more blood flowsthrough the area at a given time. If heat isapplied to the affected part immediately fol-lowing an injury, swelling may increase as aresult of the vasodilation and recoverywould be delayed. However, vasodila tioncan be manipulated in treating the "olderinjury," one that is no longer swelling andhas already passed through the inflamma-tory stage (heat, redness, pain, swelling,etc.). Such an injury is 48-72 hours old andinto the repair and healing stage. The in-creased blood flow delivers the additionalnutrients and oxygen required for repair andalso carries away the metabolic byproductsas well as the debris remaining from the ini-tial trauma. Heat causes an increase in themetabolism of the cells in the area of applica-tion, thus increasing their need for oxygen. Ifheat is immediately applied to a new injury,many cells would die from oxygen starvationbecause their needs could not be met by theimpaired circulation. Heat also causes relaxa-tion but the response usually lasts only aslong as the treatment, i.e., once the treat-ment is terminated and the warm soothingsensation disappears, so does relaxation. Fi-nally, heat relieves pain but that relief is notas enduring with cold application.

A simple test can determine when it is safeto apply heat. This test uses signs associatedwith the inflammatory response. With in-flammation there is an increase in local tissue

13 20

temperature at the injury site and the in-volved tissue is red in comparison to thesurrounding tissue. As long as the involvedtissue feels warmer or appears redder thanthe surrounding tissue or the correspondingpart, heat should not be applied. The area isstill inflamed and additional swelling re-mains a distinct possibility. Continue withthe cold applications until there is no differ-ence in skin temperature or color.

Both cold and heat must be cautiouslyused in the treatment of injuries. Althoughfrostbite is rarely a problem in a controlledtherapeutic setting, there are certain precau-tions that must be taken when cold is appliedto the skin. Never apply cold to:

an area that has been previouslyfrostbitten;an individual suffering from Raynaud'sSyndrome (sensitivity to the cold inwhich peripheral circulation is restrictedby constriction of the blood vessels);an individual with a circulatory distur-bance.

During the treatment, the individual maycomplain of extremely intense cold followedby a burning sensation which is short-livedand followed by a tingling, aching, stingingsensation and finally numbness. Althoughthese are the same sensations experienced bythe individual going into frostbite, there isone big difference. In frostbite, the skin turnswhite because blood flow is directedelsewhere to maintain the body's core tem-perature. In a controlled therapeutic setting,the skin color should remain a bright redduring the cold application and for a shortperiod of time thereafter. If the area beingtreated does turn white, remove the sourceof cold immediately.

There are more precautions associatedwith a heat treatment than with cold becauseburning of the tissue is always a distinct pos-sibility. To limit the likelihood of burningsomeone, all heat applications should bewarm and soothing to the individual. Makesure the individual understands this; someindividuals may tolerate a little discomfortthinking if a little heat is good, more must bebetter. Always remember that tolerance toheat varies with each individual: usuallythose with darker complexions and darkerhair color tolerate heat better than those withlighter coloring. Whenever heat is applied,the following precautions must be kept. inmind. Never apply heat to:

a new injury (one less than 48-72 hoursold);

21 14

an area where metal is 2mbedded suchas surgical screws, pins, and platesmetal attracts heat and could causeinternal tissue burning;the eyes or genital area, both of whichare sensitive to heat;an area where there is a circulatory dis-turbance such as a purplish-red swollencontusion;an area where there is no sensation be-cause the individual cannot feel if theheat is burning the tissue.

Cold Therapy

Cold therapy (cryotherapy) can be appliedin a number of waysas an ice pack, iceslush, or ice massage. Each of these tech-niques will be discussed in detail; however,all these cryotherapy techniques are inex-pensive, economical, easy to apply, rela-tively safe, easy to set up at home, and withlittle inconvenience.

Ice Pack

An ice pack can be applied to almost anyarea of the body with little difficulty. Tomake an ice pack, chips or cubes of ice areplaced in a moist towel or a plastic bag. Thepack is then placed on the haumatized areathat has, hopefully, already been wrappedwith a wet elastic bandage for compression.Both the pack and the compression bandageare wet to help conduct the cold more quicklyto the part. Ice chips mold to the body partbetter than ice cubes but do not last as long.

The pack should remain in place for up to30 minutes. In review of cryotherapy litera-ture, there is some controversy concerningthe amount of time cold should be appliedimmediately after an injury. There has beensome confusion whether reflex dilation ofthe blood vessels actually takes place when acold application is left on the skin too long.This reflex dilation is thought to be asafeguard against frostbite. Obviously, dila-tion of the blood vessels should be avoided intreating the new injury. Research has shownthat such dilation occurs only in those areasof the body that are sensitive to the cold, i.e.,the fingers, toes, nose, breasts, andgenitalia. Consequently, it is safe to applycold as long as 30 minutes and it is recom-mended that cryotherapy be repeated everyhour and a half for the 30-minute timeperiod. However, cold need not be appliedto the new injury during the night as long asthe involved part is elevated and a compres-

sion bandage remains in place. Adequatesleep is also an essential part of the healingprocess.

Although ice packs are extremely useful,good contact between the involved tissueand the pack may be limited by anatomicalfeatures. Consequently, cold packs may notbe as effective a cooling agent as otherforms of cryotherapy.

Ice Slush

Cooling is uniform in this form ofcryotherapy because slush conforms to thebony anatomy. In faa, ice slush is ideal fortreating the distal aspects of either extremity.Unfortunately in treating new injuries withthis technique, the beneficial effects of com-pression and elevation on swelling must besacrificed. In exchange, the deepest coldpenetration of all cryotherapy is attained.

To set up an ice slush treatment, fill a largecontainer with water and ice until the tem-perature reaches equilibrium between55-65° F. Caution the athlete receiving thetreatment that it is initially extremely pain-ful, but the treatment time is not as long aswith an ice pack. Treatment is terminatedwhen the affected part is numb, usually from5-10 minutes.

This treatment is especially desired whenthe athlete is attempting to regain range ofmotion. The buoyancy of the water and theanaesthetic effect of the cold coupled withrelaxation of the protective muscle spasm,makes movement easier.

a. Frozen cup.

Figure 1. Ice cup for ice massage.

Ice Massage

As the name implies, ice massage is themovement of ice over the skin of the in-volved area. The ice is moved in a circular orback and forth pattern until the part is numb,approximately 5-7 minutes later. If themelted ice is wiped off the skin as it collects,numbness will occur sooner.

To obtain large pieces of ice that are easy tohandle; fill styrofoam cups with water andfreeze them. Leave the ice in the cup duringthe ice massage but peel down the edge. (SeeFigure 1.) The styrofoam serves as an in-sulator and protects the fingers from the ex-treme cold. Place a tongue depressor orspoon in each cup before freezing and use itas a handle during application.

Ice massage is not recommended for theimmedidate treatment of new injuries. Al-though cold penetrates deeper with thistechnique than with an ice pack, only a smallarea at a time can be treated. In addition,compression cannot be utilized in the controlof swelling. Ice massage is usually used as aprelude to range-of-motion exercises.

Superficial Heat Modalities*

Superficial heat modalities are heatingagents that penetrate no deeper than the skinand the underlying dermis at most. Al-though superficial heat modalities are

*A modality is any physical agent used therapeuti-cally in the treatment of an injury.

215

2

b. Peeling edge down forapplication.

a. Hot plate.

b. Electric frying pan.

Figure 2. Methods of warming a heat pack.

dangerous and should not be used withoutprescription by a physician, deep heat mod-alities such as ultrasound and diathermy arefar more dangerous with regard to the tissuetrauma either can create. Neither of thesedeep heat modalities should be used by any-one other than a trainer or physical therapistand not without a prescription.

Hydrocollator Pack (Heat Pack)

A hydrocollator pack is a canvas pouchfilled with silica gel that absorbs heat. It isheated in hot water prior to use so a pack caneasily be prepared at home on the stove, ahot plate, or other heating device. (See Fig-ure 2.) Follow the manufacturer's directionsfor heating and storage of the used pack.Packs are available in various sizes for use ondifferent body parts. Check at a local drugstore or medical supply company.

Treatment time is approximately 20 min-utes. Caution should be exercised when plac-ing a pack on the affected area. A pad of atleast six towels should be put between thepack and the exposed skin area. (See Figure

2j 16

c. Crock pot.

3.) In addition, because of the weight of thesilica gel, the athlete may not be able to toler-ate the weight of the pack on a recent tenderinjury.

Figure 3. Using foldedheat pack.

bath towels to insulate a

Whirlpool

A whirlpool promotes relaxation by meansof mechanical agitation of the water via theturbine. Relaxation is enhanced as the watertemperature approaches 110° F. The watertemperature should never be higher than115° F as this poses a danger in burning theathlete. Cold temperature whirlpools havealso been used in the treatment of new in-juries to the extremities. Here the physiolog-ical effects of the cold as well as the buoyancyof the water, both of which are useful whenthe athlete attempts to regain range of mo-tion, are used to the fullest potential. One -advantage of the whirlpool is that the watertemperature, hot or cold, changes veryslowly, so the temperature remains constantthrough the length of the treatment.

Treatment time varies according to thepart being treated. For an extremity, treat-ment time for a hot whirlpool ranges from20-30 minutes. With half ov full body immer-sion, treatment time should be no longerthan 15 minutes. Treatment time for coldwhirlpools is not as longthe colder thewater temperature, the shorter the treatmenttime. When the part is numb, treatmentshould be terminated.

Never leave an athlete unattended in a hotwhirlpool especially if one half or mole of thebody is immersed. The individual could faint

and, if left alone, the results could be tragic.Always turn the turbine on and off for theathlete receiving the whirlpool treatment.

Whirlpool treatment produces a beneficialeffect in the following conditions: musculo-skeletal inflammation; both acute (coldwhirlpool) and subacute (hot whirlpool);burns; open wounds; post cast immobiliza-tion; muscle spasm.

Combined Heat and ColdTreatment the Contrast Bath

A contrast bath is used to gain thephysiological benefits derived from bothheat and cold applications. However, as withany heat modality, a contrast bath should notbe used until swelling is controlled, 48-72hours after the injury occurred. The localapplication of heat followed immediately bycold produces an active contraction and re-laxation of the blood vessels which is helpfulin removing stubborn swelling. The heatcauses the blood vessels to dilate and thecold causes them to constrict creating a milk-ing action that forces fluid out qf the affectedarea.

There are several different time schedulesused in this form of therapy. Regardless, twolarge containers and a clock for the se t-up areneeded. (See Figure 4). One container

Figure 4. Set-up for a contrast bath.

17 21

should be filled approximately two-thirdsfull with hot water so that the temperaturelevels out between 105-110° F. The othercontainer should be filled with cold water,the final temperature ranging from 60-70° F.The treatment is begun by immersing thepart in hot water for ten minutes. From thatpoint on cold and hot immersions are alter-nated four times. The affected part should bekept in cold water for one minute and in hotwater for four minutes. The total treatmenttime is 30 minutes and should end with a hotwater immersion. This schedule is ideal iffollowed by a massage treatment. Some of

2518

4o?the swelling may then be manually forcedout of the area. With another time schedule,the treatment starts and stops with cold im-mersion. By ending with cold immersion,the blood vessels are constricted and there islittle change for additional swelling to occur.Total treatment time is 25 minutes with coldand hot immersions alternating every fiveminutes.

Contrast oaths have been employed withsuccess in the treatment of sprains and frac-tures (post-immobilization) -.4 the ankle,foot, hand, and wrist. Strains have also beeneffectively treated with contrast baths.

4

Rehabilitation 4Andi Seger, A.T.C.

To discuss the principles and concepts ofrehabilitation, the term rehabilitation mustbe simply and basically defined. Rehabilita-tion in the case of sports injury is a totalprogram of reconditioning, and in somecases, conditioning of the athlete following atraumatic or chronic injury. While this pro-gram is sometimes considered separatelyfrom a treatment program, the rehabilitationprocess begins immediately after the injuryoccurs, so this process is actually inclusive ofthe term "treatment program." There will betimes though, that a rehabilitation programmay have to be instituted at a later date as inthe case of an injury occurring during vaca-tion periods or an injury that should havebeen seen and treated, but was never givenproper care. As a general rule, the longer anathlete is out of activity, the longer the re-habilitation process. Excessive immobility orrest of an injured body part may actuallydelay the healing process. The rate at whichthe athlete begins to regain mobility and be-gins to exercise the body part will in largepart be based upon the physician's instruc-tions.

Anyone responsible for supervising a re-habilitation program should keep in mindthe primary objective of such a program, i.e.,to get the athlete back into full activity assoon and as safely as possible. An acceler-ated rehabilitation program to get the athleteback into full activity before fully recoveredcan only result in further injury, possiblepermanent disability, or a different type ofinjury to either the same or another bodypart.

A second objective and equally importantis to realize that an athlete who is out ofactivity for more than a few days will suffer adecrease in overall conditioning, and in par-ticular, cardiovascular fitness. Within thelimits of the physician's prescribed activity

level for the athlete during the rehabilitationprocess, the program must be structured sothat the athlete will be able to work on main-taining or increasing strength, flexibility,and cardiovascular endurance. If the pro-gram is not structured as above, the athletemay return to activity and competition at alower level of fitness and be unable to per-form at one hundred percent capacity. It mayalso result in another type of injury due tothis decrease in conditioning level.

When planning and supervising a rehabili-tation program, there are several areas thatmust be considered. The first of these is thepsychological effect of an injury to theathlete. In dealing with an athlete's psycho-logical state of mind, the most important factis to be realistic with the athlete. The exactnature of the injury and the approximatelength of time the athlete will be out of prac-tice and competition (if known) must be un-derstood by the athlete. He/she must also bemade aware of the type of rehabilitation pro-gram that will be gone through and mustunderstand why it is important that the pro-gram be followed exactly. The athlete alsoneeds to realize program goals and that thesuccess of the program will depend upon thequality and intensity of work at each stepalong the way. The harder the athlete worksand the more dedicated he/she is, the betterthe results. So that the athlete achieves thegoals set for him/her, the program supervisorcan do several things. Specific work timesshould be established so that the athleteknows that he/she is expected at designatedtimes. The supervising individual shouldalso ensure that the athlete is following theprogram as he/she should and that the exer-cises are being correctly done and that prog-ress is recorded. Finally, the individualsupervising the program should be able toprovide encouragement to the athlete, so

1 9 2t

that the athlete will continue to work hard.This individual does not have to be the coachor the staff trainer. A responsible student inthe form of a student trainer or managershould be able to do this, if knowledgeableabout the program and its purposes. It issometimes difficult to keep an athlete moti-vated, especially if the program will last aconsiderable amount of time, whether it beseveral weeks or several months. If theathlete feels that he/she is still an integral partof the team, it becomes much easier to keephim/her highly motivated. In cases in whichthe athlete has an injury that will not keephim/her out for the entire season, it is advisa-ble to have him/her attend at least part ofevery practice, even if unable to participatein most of the practice. As the athlete pro-gresses through the program, he/she shouldbegin to gradually work into practices,doing those activities which will not have achance of furthering the injury or causingsome other injury. The athlete must also beaware that when ready to return to competi-tion, he/she may be behind in skill level de-pending upon the amount of time lost. Anathlete that has been out several weeks mayassume that he/she will immediately go backinto a starting position. This will frequentlynot be the case, and the athlete should bemade aware of this. With an injury lastingtwo weeks or less, the athlete will usually beable to immediately regain position as longas the fitness level has been maintained.After recovering from a moderate to severeinjury, the athlete may be fearful about rein-juring the body part even though it is safe tofully participate. He/she may especially feelthis way when repeating the same type ofmovement that caused the injury in the firstplace. This is a problem that must be takencare of by instilling confidence in the athleteand by sometimes pushing the athlete. Inthis case it is most important that the coachand/or trainer be aware of the emotionalmakeup of the athlete should this problemarise.

A second area that must be consideredwhen organizing and supervising a rehabili-tation progra m is determining why theathlete was hurt. If the athlete may havebeen hurt because of a suspected strength orflexibility deficiency, then the recurrence of asimilar injury may be prevented. Several dif-ferent questions arise when looking at thecause of an injury: Was it unavoidable, hav-ing nothing to do with the level of condition-ing?; Was there a lack of general or specificflexibility?; Was it a recurrence of an old in-

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jury that was not completely rehabilita ted?;Was there a strength imbalance between theagonist and antagonist muscle groups?; Wasit the overall weakness of muscles and/ormuscle groups? If it can be determined thatone of the above problems existed and mightbe the cause of the injury, then the problemmust be corrected so that future problems, orpossibly more serious problems, areavoided.

A third area to consider is the sport itself.Different sports place varying levels of stresson muscles, tendons, ligaments, and joints,and the rehabilitation program must beplanned accordingly; the program must bespecific to the sport. For example, in a sportthat requires a great deal of leg muscle en-durance, the rehabilitation program mustnot only build sufficient streng and generalendurance of the leg muscle: , but shouldalso put extra emphasis on leg endurance. Insevere injuries, the athlete may also beforced to give up a certain sport in favor ofanother sport that might place less stress onthe injured area. With this type of injury, theathlete should be made to understand thatstaying in the current sport may be question-able.

When designing the actual rehabilitationprogram, several different areas must be in-cluded: range of motion; strength; endur-ance; speed; agility. The regaining of motionand flexibility is the first area of concern. As abasic rule, the athlete should have full rangeof motion of the injured body part beforerebuilding strength. The decision must bemade as to when to start on range of motion,and in some cases, especiallY in moderate tosevere injuries, the physician will make thisdecision. If the athlete has been in a sling,cast, or splint, motion will usually be begunas soon as the physician eliminates im-mobilization. A physician may also permitthe athlete to remove a sling or splint severaltimes a day to begin regaining of the range ofmotion. In less severe injuries, motion maybe begun following the acute phase of theinjury, which normally lasts from 24-72hours post-injury. The end of the acutephase is marked by stabilization of pain andswelling and sometimes by a noticeable re-duction of swelling. If motion is started andthe body part becomes increasingly painful,or becomes increasingly swollen, then theregaining of motidn must be curtailed untilthe part can be exercised without increasingthe inflammation in the area. It may take anadditional day or even several days beforethe athlete can again begin range-of-motion

exercises. As soon as the injured area cantolerate the exercise, range-of-motion exer-cises can be performed daily.

There are different techniques of regainingrange of motion, a few of which are some-what complex and require backgrounddepth in exercise therapy. The easiestmethod, and most commonly used, is tohave the athlete spend a couple of minutesevery hour simply attempting to move theinjured body part through the motions thebody part normally goes through. The re-gaining of full range of motion may takeanywhere from one day to several weeksdepending upon the extent of injury and thelength of any immobilization. The progressof the athlete should be checked daily, eitherthrough the use of a goniometer or by visualobservation.

When full range of motion has been re-gained, the athlete must begin work on re-building muscular strength and endurance.There are many different types of equipmentavailable on the market today that will ac-complish this. A key concept to remember isthat the program in which an athlete works,and the way in which the program isworked, is more important than the type ofequipment used. Regardless of how sophis-ticated the equipment is, if it is not properlyused and the athlete does not work to his/herpotential, increases in strength will be neg-ligible.

Several principles are involved whenworking on any type of strength program.As the athlete begins the program, he/sheshould be working daily strength-buildingsessions. Once the athlete reaches a plateauwhere he/she is no longer making steadystrength gains, he/she should then switch toworking three times per week. This plateaumay be reached within several weeks or sev-eral months depending upon the injury.When the athlete has regained at least origi-nal muscular strength and endurance, amaintenance program may be used. If theathlete performs a good quality workout atleast one day a week, the strength gains willbe maintained. If lack of muscular strength issuspected as the cause of the injury, theathlete should continue working three timesper week until appropriate strength has beenobtained. Because of the lack of strengthnorms for women, this will usually involveguesswork on the part of the individualsupervising the rehabilitation program. Ifthe women athletes have been involved in aweight-training program for pre-seasonconditioning then that should at leastprovide a baseline to work from in deciding

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whether the injured athlete is below the av-erage strength of the other women athletes.Whether it be the actual rehabilitation pro-gram or a maintenance program, the athleteshould be working to maximum level as longas he/she is relatively pain-free. Muscularpain when working hard is common with allbut a few types of exercise equipment, andthis is to be expected. If more than minorpain occurs at the actual injury site duringthe workout, the athlete should work just

-below this level to prevent irritation of theinjury.

There are three basic types of strength-building programs: isometric; isotonic; iso-kinetic. Regardless of the program, exercisesshould be based upon the type and locationof the injury. If the injury is to a specific jointarea, exercises should be given to strengthenall the muscles surrounding this area. Theexercises should also be specific to the way inwhich the muscles are used in the athlete'ssport.

An isometric strength program is based onbuilding strength against resistance withouta change in muscle length. It is frequentlyused as a strength-building technique whenthe injured body part is immobilized or islacking complete range of motion. If used inthis manner, it is usually recommended thatthe athlete do ten repetitions at six secondseach hour. The program may also be used tobuild strength after the athlete has regainedfull range of motion, but this is not employedas frequently. Most individuals involved instrength work agree that isometrics are spe-cific to joint angles when building strength.Therefore, the exercise should be worked atthree or four different angles throughout theentire range of motion with three to five rep-etitions of six seconds each at these angles.An isometric program has two advantages: itdoes not require equipment; the exercisescan be worked in any direction. Two maindisadvantages of the program are that im-provements are not easily monitored andmuscular endurance is not increased to anysignificant degree.

An isotonic strength-building program isbased on moving the body part through theentire range of motion against some form ofresistance. This resistance may be in the formof sandbags, dumbells, barbells, and weightmachines. Although there are a variety ofprograms in terms of sets and repetitions,the most commonly used for rebuildingmuscular strength is three to four sets of sixto ten repetitions. For rebuilding muscularendurance, the weight is lessened and two tothree sets of fifteen to twenty-five are most

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commonly used. The amount of weight usedin either case can be found simply by trialand error. The athlete should be able tobarely complete the last few repetitions ofeach exercise. Once the prescribed numberof sets and repetitions has been reached, theweight is increased. Full range of motionmust be stressed on each repetition and eachrepetition should be done slowly and cor-rectly, taking four to six seconds to complete.Isotonic exercise can be easily recorded andimprovement is readily seen. It also has theadvantage of eccentric lengthening as theweight is slowly lowered. This is termednegative work and research has begun toshow that negative work may be just as effec-tive or even more effective in buildingstrength as positive work or concentric con-tractions. The primary disadvantage is thatisotonic exercise does not work the muscle atmaximum potential throughout the fullrange of motion. It does not adjust to thediffering levels of strength potential found atdifferent angles throughout the range of mo-tion.

The program of isokinetics involves fixedspeed of movement throughout the fullrange of motion. With an ioskinetic devicethe speed of movement is set and the athleteexerts as much force as possible against thelever arm. Three sets of ten repetitions areused for building strength and two to threesets of twenty are done for endurance. Sincemany of the isokinetic units come withread-out dials, endurance work may also bedone until less than 50% of the first readingis reached. A primary advantage of ioskineticexercise is that the athlete can exercise at thespeed of contraction necessary for specificsports skills. In addition, it is not uncommonfor an injury to be the result of a deficiency ofmuscular strength in only one segment of therange of motion. Other advantages are thatimprovement is easily recorded and work onan isokinetic unit creates very little muscularsoreness. The main disadvantage is the ab-sence of the ability to perform negative workon this type of device.

Once range of motion, strength, and en-durance have been returned to their originallevels, agility will return as the athleteworks into practices. Specific drills that arenormally included in practice sessions willenable the athlete to regain the necessaryagility level.

Cardiovascular fitness, the last area toconsider, is extremely important. While it isbest if the injured athlete can begin workingon this immediately, the type of injury maydictate some possible contraindications. Forexample, even with an upper body injury,

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running and/or jogging may be contraindi-cated, especially during the earlier stages ofthe rehabilitation program because of theamount of jarring associated with it. Bicy-cling and swimming are two alternative pro-grams of cardiovascular fitness that may beused. Some type of cardiovascular programshould be started as soon as there is nochance of creating irritation or inflammationof the injured body part.

In deciding when and if an athlete is readyfor full practice and competition, severalguidelines are used. In the case of a moderateor severe injury that has been seen by aphysician, the physician should make thedecision. With an injury not seen by a physi-cian, the coach or trainer will usually makethe decision. Even with an excellent rehabili-tation program, there is always the questionof whether the injured body part will with-stand the rigors of full competition. With asevere injury this is sometimes a questionthat even the physician will not ha- 2 to an-swer. The athlete may be cleared to partici-pate but may find that the body part cannotwithstand the stress placed upon it. To avoidthis problem, the coach or trainer should iso-late the sports skills and have the athletedemonstrate that he/she can perform them athis/her pre-injury level before being permit-ted to participate in practices as well as com-petition. As the athlete progresses throughthe rehabilitation program there will be agradual increase in his/her ability to performthe necessary skills involved in his/her spe-cific sport.

Along with the athlete being able to per-form the skills involved in the game thereshould be an objective analysis of theathlete's range of motion, strength, and en-durance. The basic criteria for return to com-petition is achievement of 90-100% strengthand full range of motion. In the case of anextremity, strength and range of motionshould be measured by comparing the in-jured with the uninjured body part. Endur-ance of the body part should also be tested bybilateral comparison, with the criteria beingequality of strength at 20-25 repetitions. Theendurance test is vitally important becausethe athlete's maximum strength may beequal; if the muscular endurance is notequal, the body part, particularly when deal-ing with the knee, may be reinjured.

If the above criteria have been met and theathlete is in good cardiovascular shape,he/she should be able to safely return tocompetition. It must be remembered that atthis point, the athlete should be put on aprogram to ensure the maintenance of theacquired muscular strength and endurance.

Athletic ConditioningKathy Heck, A.T.C.

A well-conditioned athlete has several ad-vantages over a less-fit competitor. Athleticfitness ensures greater resistance to injury,improved skill execution, and an increasedtolerance for work. Programs designed tobuild and to maintain athletic fitness -3nsistof three major components:

flexibilityrange of motion of thejoints;strengththe ability of muscles to exertforce against resistance;endurancethe ability to persist.

In developing such programs the compe-titive year is divided into four seasons:

pre-seasonthe four to eight weeksprior to the beginning of a competitiveseason;in-seasonthe competitive season it-self;post-seasona 10-14-day "R & R" orrest period following the end of thecompetitive season;off-seasonthe period of time betweenpost-season and the beginning of thepre-season period.

Conditioning activities vary according to thetime of the competitive year. If the athleteengages in several sports throughout theyear, there is overlap among the condition-ing seasons. However, the basic principlesstill apply.

In the off-season period athletes should beinstructed to build a conditioning base. Thisincludes long, slow distance running of 30minutes or more, stretching, and weight-training three to five times weekly. The off-season is also the time for basic skill work orfor major sport technique changes to bemade. While the athlete is away from thepressures of the competitive season, suchchanges can all be accomplished much moreeffectively.

23

With a good strength and endurance basedeveloped in the off-season, the pre-seasonconditioning period emphasizes work spe-cific to the athlete's particular sport and/orposition. Endurance work is directed at thetype of staying power needed in the sportitself, e.g., base-running drills for softball,fast break drills for basketball, speedwork forsprinters in track, etc. Weight-training iscontinued to build and to maintain strength,and flexibility work is also increased.

In-season training is directed toward themaintenance of athletic conditioning, strat-egy, and sports skills. To build fitness,workouts must be conducted a minimum offour to five times weekly. To maintain fit-ness, two to three workouts per week arerequired. The post-season break is not al-ways possible for multi-sport athletes. But itdoes provide a much-needed vacation fromthe conditioning routine.

Flexibility

The body is a series of levers (the bones)moved by the shortening and the lengthen-ing of the muscles. If the muscles are not aselastic or as flexible as they should be, effi-ciency and skill execution is hindered.Sedentary living and the increases in bodyfat that tend to accompany that lifestyle,serve to decrease flexibility. Flexibility is bestdeveloped and maintained through dailystatic stretching exercises. The calves, quad-riceps, hamstrings, low back, groin, trunk,shoulders, and neck are the areas of particu-lar importance. It is important to stretch priorto exercise to give the body an adequatewarm-up. This is vital to the prevention ofmuscle strains and ligament sprains. Musclesoreness following activity can also begreatly reduced by stretching after an exer-

cise session. Flexibility training should bedone on a daily and year-round basis.

The technique used in static or slow-tension stretching is to stretch the appropri-ate body part to the point of tightness, holdthat position for 15-30 seconds, relax, andrepeat 3-4 times. Bouncing (ballistic) stretch-ing is a dangerous technique and shouldnever be used. Receptors in the muscles arestimulated by fast, jerky movements, andthe resulting effect is contraction rather thanrelaxation and lengthening of the muscle tis-sue. Bouncing may result in over-stretching,soreness, and injury.

Flexibility Tests

Can the athlete:touch the palms to the floor while keep-ing the legs straight?;complete a shoulder grip exercise inboth directions?;touch the nose to the knee while doing ahurdle stretch?;touch the knee to the floor while doing aquadriceps hurdle stretch?;complete a wall push-up with the bodyat a 450 angle and the heels on the floor?;touch the knees to the floor while doinga groin sit?

If so, the athlete is relatively flexible andneeds only to maintain his/her present levelof flexibility. If not, stretching should bedone 2-3 times daily. A good source of flexi-bility routines is the book Stretching by BobAnderson.

Endurance

Endurance is the ability to persist, and it isdependent upon one's cardiovascular (C-V)fitness. A simple gauge to determine im-provement in one's cardiovascular fitness isa decrease in the resting heart rate. As C-Vfitness improves, the heart rate decreasesand the amount of blood pumped with eachbeat (stroke volume) increases. Therefore,the heart is beating less often, but each con-traction is more powerful and more efficient.A change in the resting heart rate shouldappear 6-8 weeks after beginning a regularexercise program. The average heart rate is72 beats per minute, but this is a highly indi-vidual matter. Many athletes involved inendurance-type sports have resting heartrates in the low 50s or high 40s.

The resting heart rate can be determinedby taking one's pulse at either the radial ar-tery in the wrist or the carotid artery in the

2431

throat. The body must be at rest for approxi-mately five minutes prior to taking the rest-ing rate. Count the heartbeats for 15 secondsand multiply by four. The heart rate can alsobe used to monitor the intensity of an exer-cise session by using the following formula:

220 (base number)20 (age)200

x .80 (80% of maximum capacity)160 (maximum exercise heart rate)

Subtract the subject's age (for example, 20years of age) from the base number of 220.Then, multiply that number by 80%, since ayoung, healthy individual should be exercis-ing at approximately 80% of his or hermaximum capacity. The resulting number isthe maximum heart rate that should beachieved during an exercise session. To buildor maintain C-V endurance one must exer-cise:

strenuously enough to elevate the heartrate to 120-160 beats per minute;for a minimum of 20 minutes;at least 3-5 times weekly.

The pulse rate must exceed 120 beats perminute for the exercise to be of any C-V bene-fit, but it should not exceed the maximumexercise heart rate of 160 beats per minute.The individual should exercise to the point offatigue, check the pulse rate, and as soon as itdrops to 120 beats per minute, resume exer-cise. Scientifically, one's C-V fitness is basedupon the maximum amount of oxygen thatcan be utilized by the body. The techniquesused to determine maximum oxygen con-sumption, V02, are costly and time-consum-ing. Therefore, Dr. Kenneth Cooper, M.D.,the author of Aerobics*, developed the 12-minute run test to estimate maximum V02capacities of athletes. Quite simply theathlete runs as far as he or she can on a trackfor 12 minutes. Dr. Cooper's book offerscharts to determine fitness levels accordingto 12-minute run tests results. This test ismost beneficial when used as a pre-, in-, andpost-season gauge of the athlete's fitness. Itis accurate and easy to administer.

Running for conditioning should prefera-bly be done on grass or on a soft track. Softsurfaces reduce the jarring effect that run-ning has upon the body. Good shoes arevital. They must fit properly and have goodarch support, a firm counter, and a wedgeheel. Use good running form: knee action

*Cower's latest book in the Aerobics series is TheAerobics Way.

high; arm swing relaxed; body erect; headup; eyes forward; rocking up on the toesfrom the heel. Never run down hills; run upand walk down. Keep in mind that swim-ming and cycling may be substituted forrunning. According to Fox and Mathews intheir book Interval Training the activities canbe compared in the following manner:

Activity Time Distance

Running 8:00 minutes 1 mileSwimming 8:00 minutes 1/4 mileCycling 8:00 minutes 2.5 miles

Long, slow distance work should be done inthe off-season. As competition nears, timesand distances should be altered to make theendurance training more specific to the indi-vidual's sport.

Strength

Strength ca,n be built or developed in avariety of ways. The most common tech-niques are calisthenics, where the body'sown weight is used as a form of resistancesuch as in push-ups or sit-ups, and isotonics,where weights are lifted. Weight-lifting isthe fastest and most efficient means of de-veloping muscular strength. Some generalprinciples of weight-training include:

lifting should be done on alternate days;the lifting activities should buildstrength needed for the athlete'ssport(s);good form is necessarythe individualshould train, not strain;

a proper and complete warm-up is nec-essary;provide specific sets, repetitions, andworkload progressions for the athlete;chart progress via record-keeping;safety must be emphasized at all times.

Many techniques are used to determinethe loads and repetitions for weight-training. The most common is the DeLormetechnique. The athlete determines themaximum weight he or she can lift 10 times.Then, the individual completes three sets of10 repetitions at 50%, 75%, and 100% of the10-count maximum weight. In all cases theoverload principle must be observed; with-out placing an overload on the body it willnot respond with increasing strength. TheDeLorme technique ensures that the amountof overload will be within the individual'sability range and will train, not strain, themuscles.

Strength training is crucial in the preven-tion and the rehabilitation of athletic injuries.It is important and safe for both male andfemale athletes and can lead to safe, im-proved performances by all.

The basic principles of conditioning aresummarized in the following timetable.

Conditioned athletes have an inherent ad-vantage over their less-fit competitors. Im-proved, safer performances are desired by allathletes. Athletic conditioning is hard work,but its benefits are many.

Strength Flexibility Endurance

Off-season 3x weekly Daily 3-5X weeklyBuild Maintain Build Base

Pre-season 3x weekly 2X daily 3-4x weeklyBuild Build Specific to sport

In-season 2x weekly Daily 2-3x weeklyMaintain Maintain Maintain

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Protective Equipmentand Devices*Holly Wilson, A,T.C., Ph.D.

Protective equipment is necessary to con-trol those hazards of the sport that cannototherwise be eliminated. All too often in-juries occur because standard protectiveequipment is of poor quality, improperly fit-ted, or in disrepair. To avoid many prob-lems, purchase equipment only from an au-thorized dealer. Before a decision is made,discuss specific needs with representativesfrom various manufacturers. The coach, ath-letic director, team physician, and trainershould evaluate each piece of equipment be-fore the order is made. In general, the size,strength, and skill level of each athleteshould be considered when ordering and as-signing equipment.

Before each season, review with theathletes the importance of protective equip-ment. Emphasize why it must be worn aswell as properly fitted and in good repair.Show the group how to properly use aridcare for each piece and how to make a quickinspection for defects. Check with the manu-facturer or sales representative for recom-mendations concerning cleaning and main-tenance of equipment. Many detergentsbreak down plastic, so conscientious clean-ing with the wrong substance may actuallyreduce the protective quality of the equip-ment.

During the meeting is also a good time toreview the team rules, a few of which shouldconcern equipment, e.g.:

1. Protective equipment must be worn atall times during practices and games.

2. Protective equipment must not be mod-ified without the prior consent of thecoach, trainer, or team physician.

3. Protective equipment must be properlyused and not abused.

4. Any defects in personal equipMentmust be immediately reported beforeactivity is started.

Since protective equipment varies fromsport to sport, it is not possible to includeguidelines here for the fitting and care ofeach piece. When available, follow the man-ufacturer's recommendations for fitting andcare. There are however, a few pieces ofequipment used in almost all sports that arerarely considered equipment, much less pro-tective equipment. Both athletic shoes andeyeglasses should be thought of as protectiveequipment. A mouthguard, which is fre-quently used in many sports, is also dis-cussed here.

Athletic Shoes

Although the choice of shoes is usually thedecision of the athlete, that choice should bebased on sound reasoning rather than due tothe whim of the athlete. The coach shouldprovide the athlete with some importantpointers about selecting athletic shoes. Dur-ing activity the stresses placed on the feet,which in most cases are still growing, de-mand more than the minimal supportprovided by less expensive shoes. Injuriesmay be minimized by the correct shoes. Infootball, susceptibility to ankle and knee in-juries is markedly decreased when soccershoes are worn instead of the conventionalfootball cleats. In basketball, high-top shoesprovide additional support for the unstableankle. Shoes for racket sports and basketballshould be reinforced along the forefoot. Thisreinforcement not only prolongs the life ofthe shoe but also provides more support andprotection for the foot. In running shoes,particularly those designed for training, sta-

*The copyright for this article has been retained by theauthor. Similar material will appear in the book,Coaches' Guide to Athletic Training, which has been ac-cepted for publication by Human Kinetics Publishers.

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heelcounter

heel wedge rch supportor "cookie"

Figure 1. Running Flat

bility and support are sacrificed as morecushion is added to the midsole. Items toconsider when choosing any shoe for ath-letics include the support and snugness of-fered by the heel counter which should befirm, the fit and firmness of the arch support,and the thickness and flexibility of the sole,especially the forefoot. (See Figure 1.) If theshoes are going to be used on a hard surface,the soles should be somewhat flexible. On anirregular surface, the soles should be stiffer,perhaps with a steel shank. Waffle or ripplesole shoes are designed for straight forwardmovement, not lateral changes of direction,since the likelihood of an ankle sprain in-creases with such movement. The heelsshould be level, not tilted inward or out-ward, when the shoes are placed flat on thetable.

Fiffing Athlefic Shoes

Regardless of the type of shoes worn, theyshould fit properly and provide good sup-port for the feet. Shoes should be fit in theafternoon when the feet are swollen to en-sure accurate sizing. In addition, the samenumber and type of socks worn during prac-

34 280 A

tices and games should be worn when tryingon the shoes. Shoes should be fit to thelength of the arch rather than the length ofthe athlete's foot. Fit can be checked easilyand quickly. The ball of the big toe should bedirectly over the widest part of the shoewhen the athlete is standing. (See Figure 2.)If it falls in front, the shoe is too short. Anabnormal crease in the shoe along the innerarch confirms this finding. The break of theshoe, where it bends on push-off, should beat the widest part of the shoe. Check bothfeet for one may be substantially larger thanthe other. Fit the shoes to the longer foot. Ifthe shoe is not comfortable, it does not fit. Inreality, the shoe will break the athlete in; theevidence is blisters, corns, and calluses.

Care of Athletic Shoes

It is more than likely that the shoes maybecome saturated with water sometime dur-ing the season. If so, fill each with crumblednewspaper and allow the leather, canvas, ornylon to dry out slowly. Slow drying delaysdeterioration of the shoe. If warranted, applya coat of saddle soap to the shoes when thor-oughly dry.

Figure 2. Correct shoe fit.

a. Padded.

b. Unpadded.

Figure 3. Commercially-available heel cups.

Shoes should never be washed in thewashing machine or dried in a dryer. Eitherone causes premature deterioration ofmaterialsfabric as well as bonding be-tween layers.

Heel Protection

Some running shoes have a plastic heelcup incorporated into the shoe as the counterto absorb and spread the repetitive poundingon the heel when running. Unfortunately, abruised heel may occur in sport activitiesother than running and attempts to protectthe tender area are often for naught unless aheel cup is used. A vinyl foam doughnut cutto conform with the shape of the heel rarelyprovides adequate protection. Plastic heelcups, padded or unpadded, may be pur-chased at many sporting goods stores. (SeeFigure 3.) If the protection afforded by theunpadded heel cup, or even the paddedheel cup, is inadequa te use 1/4-318" vinylfoam to line the inside surface, and cut backon activity!

Corrective Lenses

Athletes who need prescription lenses tocorrect an eyesight problem should not relyon street-worn frames and lenses for eyeprotection in sports. Wire-rim frames andglass lenses are particularly dangerous. Suchframes and lenses are not designed to with-stand the stress and may actually cause aninjury to the eye. Prescription lenses shouldbe ground of industrial plastic and set ineither an industrial or sports frame, or, sometype of goggle with a Lexan-injected moldedlens may be worn over prescription glasses.Contact lenses, either hard or soft, do notprovide any protection for the eye. Softlenses are recommended over the hard type,however, only because they stay in placebetter. If an athlete must wear contact lensesfor proper vision, the individual should wearsome kind of protective eyewear. Most of theeye protectors worn in racket sports that donot have lenses interfere with peripheral vis-ion. Such protective devices are adequateonly in badminton and tennis where the sizeof the missile is too large to enter the orbit ofthe eye. Only in badminton may street-wornglasses provide adequate protection againstdamage from an aerial missile.

Mouthguards

Although mouthguards are not as com-mon to sports as athletic shoes or eyeglasses,

29 35

they are common to most contact/collisionsports and play an important role in prevent-ing lacerations of the mouth, fractures of thejaw/teeth, and concussions. The mouth-guard imparts the force of a blow to all teethrather than localizing it at the point of im-pact. Consequently, the mouthguard shouldalways be worn whether the athlete is justparticipating in a drill, scrimmaging, orcompeting in a game. Many athletes dislikemouthguards (and refuse to wear one) be-cause they feel that mouthguards are uncom-fortable and interfere with breathing as wellas with speech. In most cases, these prob-!ems are minimal and are far outweighed bythe protection the mouthguard provides. Ifthe mouthguard is particularly troublesome,check the fit. It may have been improperlyfitted.

Two types of mouthguards are generallyused in athletics. The mouth-formed iscommercially available in junior and seniorsizes while the custom-fit is molded by adentist or an oral surgeon. The mouth-fittedmouthguard is momentarily heated in boil-ing water and then the athlete molds thesemi-pliable plastic form to the bite. Cautionthe athlete not to bite too hard for the teethcould go through the plastic form. Whenproperly fitted, this mouthguard is tightenough to stay in place by itself. Breathingand speaking may be affected but only min-imally. Custom-fit mouthguards are morecomfortable and interfere less with breathingand speech than the commercial ones but aremore expensive. Consult a local dentist or anoral surgeon for details concerning cost.Since an impression of the bite is made, themouthguard fits exactly and stays in place. Acustom-fit mouthguard is recommended foran athlete with braces, a bridge, a plate, mis-sing teeth, or an odd-shaped dentition.

Regardless of the type of mouthguardworn, it should be trimmed only to alleviateabnormal rubbing. The tips should be noshorter than the last molar. Too much trim-ming reduces the effectiveness of themouthguard as a protective device. Moreimportant, the trimmed mouthguard maybecome a hazard for it could be swallowedand obstruct the airway.

Care of Mouthguards

Like any other piece of equipment, amouthguard should be well-cared for so thatit lasts several years:

Store the mouthguard in a liquid solu-tion. Consult a local dentist if a solution

36 30

is not recommended by the manufac-turer of the mouthguard, or daily rinsethe mouthguard with a disinfectantwash to keep it odor-free and clean.Keep the mouthguard in its carryingcase when travelling to and from prac-tices and games.Avoid chewing on the mouthguard.

At the first sign of wear, mold a new mouth-guard for the athlete. On trips always carry afew spare mouthguards so that a new onecim be molded if necessary. Above all, en-force the team rule that the mouthguardmust be worn whenever the athlete is on theplaying field.

Improvising

Protective equipment can adequatelyserve its intended purpose only when it isgood quality equipment, properly fitted, andin good repair. Even when these require-ments are met injuries do occur which, insome instances, necessitate a modification instandard equipment. Such modificationsmay require only the addition of more pad-ding for protection of the tender area or theycould be more complex requiring the im-provisation of a protective pad.

Sometimes protective equipment is notcommercially-available in the proper size soa facsimile must be custom-made. This prac-tice is especially true as more girls andwomen are competing in athletic programs.Existing equipment often does not fit theirsmaller stature or anatomical configuration.

Materials for Construction of Pads

Different materials are used for padding asensitive areaadhesive felt and foam,foam rubber, vinyl foam, and plain felt. Thechoice of material is dependent on the sever-ity of the injury, its location, and the tender-ness of the area to be padded. Because foamspreads the force as well as absorbs it, it canbe advantageously used to protect areas sub-jected to repeated impact such as the heel orball of the foot. However, the various typesof foam have different force-absorptioncapacities. Vinyl foam provides the mostprotection in comparison to adhesive foamand foam rubber. It is the material of choicewhen padding bruises (contusions). The aircells in adhesive foam and foam rubber col-lapse under force permitting the two sur-faces to come into contact. Thus the force ofthe blow is transmitted directly to the under-lying tissue requiring protection. Vinyl

4.

foam, on the other hand, has such absorp-tion capacity that the two sides rarely comenear one another. Unfortunately vinyl foamis expensive and it is not available except inlarge sheets. Smaller pieces of vinyl foammight be available at a local medical supplycompany, orthopedic brace shop, or from alocal orthopedic surgeon or podiatrist. Themost useful sizes of padding material for in-jury protection or prevention are 1/2", 3/4",1/4", and 1/8" thicknesses.

To reuse a vinyl foam or foam rubber pad,trim the tape from around the edges of thepad. If the athlete attempts to pull the tapeoff, the pad usually rips. Continue to reusethe pad until it has lost its cushioning effectdue to the tape build-up. Use the old pad as apattern to make a new one.

Sheets of plastic air bubbles, commonlyused as packing material can be used to padsome flat areas such as the thigh or forearm.Unlike vinyl foam or foam rubber, the sheetsof bubbles cannot be reused. At the end of anactivity period a majority of the air cells havecollapsed which reduces the pad's protectivequality. Large rolls of the packing materialare available from various manufacturers butit may be possible to acquire a smaller quan-tity from a local store that regularly shipsfragile merchandise.

Felt, like foam, sprLads the force, but itdoes not absorb it. It does, however, providesupport, so felt is used in the construction ofarch pads. It is also used for doughnut orhorseshoe pads to protect blisters, corns, orplantar warts because the natural sliding ac-tion of the foot in the shoe tears up a foampad. Another advantage of felt is that it canbe split into different thicknesses. Divide acorner of the felt sheet at the desired thick-ness and carefully but firmly pull the twolayers apart. Felt pads, especially those madefrom wool felt, are quite durable and can bereused for several days. (Trim the tape fromaround the edges as for a foam pad.) Woolfelt withstands "packing" from weight-bearing pressure better than cotton felt, but itis difficult to find in small quantities. Or-thopedic surgeons and podiatrists fre-quently use felt in treating musculoskeletalinjuries and may be willing to split an orderor donate any scraps. Prepackaged assort-ments of felt may be purchased at manysporting goods stores that handle athletictraining supplies. The felt squares come in avariety of thicknesses ranging from 1/8-3/8" .

Small squares of moleskin, adhesive foam,and adhesive felt (wool blend) are availableat most local drug stores. Adhesive felt isavailable in a variety of thicknesses. Precut

31

pads, including doughnuts, are alsocommercially-available in latex rubber or feltat most drug stores. Although the pads havean adhesive backing, adhesive tape can alsobe used to secure the pad in place. Unfortu-nately, precut pads are more expensive thanhomemade renderings and such pads canonly be used once. In fact, it may be neces-sary to replace the pad before activity as wellas after. Finally, a slight modification may benecessary in the precut pad before it can beused. Do not use medicated pads for anytype of skin lesion unless instructed to do soby a physician. Not only do such pads tendto overmedicate but if improperly used, evenhealthy tissue can be damaged.

Construction of PadsFrequently a pad must be constructed be-

cause commercial pads do not meet specificneeds. In the long run, this practice may bemore economical. When constructing pro-tective pads, the following tips may be help-ful:

1. The depth of the involved tissue deter-mines the thickness of the padding ma-terial, e.g., if the area is swollen or cov-ered with a thick callus, a thicker pad isneeded. To esfimate the proper thick-ness, apply gentle pressure with thefinger to either side of the involved softtissue.

2. Moisten the area to be padded with wa-ter. Outline it in indelible pencil andthen press the padding against thearea. The pattern transfers to the pad-ding and serves as a guide for cutting.

3. Taper the edges of the pad to preventthem from rolling up or the pad fromshifting as a result of shearing forces.

4. Proper placement of the pad is of ut-most importance. If improperly placed,the resulting discomfort is often greaterthan that associated with the originalcondition. To ensure proper position-ing apply manual pressure to the padbefore taping it securely in place. Theathlete should not experience any dis-comfort.

Certain materials have traditionally beenused to construct the different types of pads.Moleskin cut in an oval shape is used toreduce friction between the ball of the footand the shoe which decreases the chance of ablister developing. Such a pad is especiallyuseful when the area is callused. (A smallpiece of gauze may be placed between thepad and the skin.) Adhesive felt or foam isused for the construction of doughnut pads;

37

a. Doughnut.

Figure 4. Converting a doughnut pad to a horseshoe.

however, the doughnut has given way to thehorseshoe in the protection of common footailments such as blisters, plantar warts, andcorns. (See Figure 4.) With the natural tend-ency of the foot to slide forward in the shoe,the front edge of the doughnut "catches"thus increasing the stress at that point. Whenthe pad is converted into a horseshoe, theback and sides of the lesion are still pro-tected, but there is no front edge to "catch."Also there is no doughnut hole, a com-mon site of discomfort as tender tissue isdisplaced downward into the hole.Commercially-made doughnut pads can beeasily modified prior to application. Simplycut out a small wedge and then bevel theends of the horseshoe. Bevelling allows thefoot to freely slide forward with minimal re-striction so that irritation is reduced.

Pads for bruises (contusions) are cut in theshape of a doughnut out of thick vinyl foam ifavailable. (If not, fold a sheet of air bubblesinto several thicknesses, put it over the ten-der area and secure it in place.) Several layersof material may be glued together to achievethe desired thickness; however, a specialglue for use on rubber material must be used.The size of the cut-out piece should corre-spond to the size of the tender area. This istrue when cutting any doughnut or horse-shoe and some speciality pads.

b. Horseshoe.

For sensitive bruises (contusions) that areprone to repeated blows, a more durable padis required. Hard-press board thigh pads,which were predominantly used in footballprior to the introduction of vinyl-dippedpads, may sometimes be modified to provideadequate protection. Pad the underside witha doughnut, approximately 3/5" thick, andglue the two together. Put the pad in placeand cover it with an elastic bandage. Start thebandage just below the bottom of the padand angle it up one side of the part and downthe opposite side. Continue this "her-ringbone" pattern until the pad is covered. Ifavailable, secure the bandage with elastictape. Start the tape at the bottom of the pad,applying it in a circular fashion around theaffected part. Overlap each layer by one-halfthe width of the tape and make sure theentire bandage is covered. If necessary, toprevent the pad from slipping, apply a turnor two of tape around the part directly on theskin. If elastic tape is not available, apply afew strips of athletic tape around the part,two just below the top of the elastic bandageand two just above the bottom. These stripsshould not be too tight as the underlyingmuscles must 'have room to relax and con-tract or they may cramp.

3832

Legal Liability*Richard T. Ball, Afforney-at-Law

I. Litigation: Will It Destroy Athletics?

One of the most valuable environments inAmerican society for the growth and de-velopment of young people is found in com-petitive athletics. There are opportunities insports for valuable learning experienceswhich are not elsewhere available during theformative years and which provide excellentpreparation for the rigors of life. Most impor-tant to those of us who engage in the teach-ing and coaching of school-age youngsters isthe potential development of intangiblecharacteristics such as working with others,accepting authority, developing self-discipline, and learning the important rela-tionship between determination, hard work,and success.

A great and probably unfillable voidwould be felt should the competitive envi-ronment be destroyed. Indeed, any diminu-tion of athletic programs reduces the numberof youngsters who will reap rewards whichmight not otherwise be available to them.

Athletics Threatened with Destruction

The most common obstacle to solving aproblem is denial that it exists. When a largesegment of a society chooses to ignore ordeny the existence of a threatening menace,the size of the obstacle increases, not in alinear fashion, but geometrically. By the timeenough people awaken to the need for ac-tion, the damage can be irreparable and theresult fatal.

For several years, a small but vocal numberof concerned people have cried a warning toAmerican society: "This precious environ-ment, so important to our young, is beingthreatened with total destruction. Litigationarising out of athletic injuries is acceleratingout of control and, if the tide is not turned

quickly, the institution will crumble andfall."

For the most part, their warnings have fal-len upon deaf ears. Society at large simplyhas not comprehended the relationship be-tween "a few lawsuits" and the total demiseof athletics. More frightening, most of thosewho live and work in and have deep love forthat institution have chosen to deny that anysuch problem exists or that tragedy couldresult.

The time for awakening to reality haspassed. Those who regard competitiveathletics to be important must begin to takeaction immediately. In the belief that muchof the tendency toward denial results from alack of awareness of facts, this article will bedesigned to convey to the reader in-depthinformation concerning the nature of theprobNn, the reasons it exists, and what canbe done to solve it. In the process of doing so,special attention will be given to exploringcertain myths which have intensified theproblem.

It is important to know how and why ath-letic injuries occur, what can and cannot bedone to prevent them, what roles equipmentand coaching do and do not play in theircause and prevention, and how all those re-lated in any way to the American athleticenvironment can join together in a commoncause to guarantee the continued healthyexistence of competitive athletics.

An important aspect of this educationalexercise is to correctly identify the problemand then work to keep that problem dearlyin focus throughout the discussion. The dif-ficulty encountered by most people is suc-cessfully separating facts from myths.

*Reprinted with permission of Cramer Products, Inc.and the author.

33 39

Rate of Severe Injury

The problem is not the occurrence of catas-trophic injury or death in football or anyother athletic endeavor. Despite the physicalviolence of the game, the rate of severe injuryin football is extremely low. Statisticalstudies show that within the same age groupa young athlete is exposed to far less riskthan in common environments, particularlyvehicular transportation and even in thehome. Naturally, severe injury rates in othersports are even lower than football. While itis possible that careful attention to condition-ing programs and teaching techniques mayreduce the injury and death levels evenfurther, no degree of care or concentrationwill absolutely eliminate severe injury fromthe athletic scene.

The problem is not with athletic equip-ment and, more specifically, the footballhelmet. The gravest crisis to the future ofathletics resulting from litigation has arisenwithin the football helmet industry. All foot-ball helmets currently on the market aredoing an excellent job of performing theirassigned task. The National Athletic Injury/Illness Reporting Survey reveals that over a3-year-period there is not significant differ-ence in the levels of severe head injuryamong the various helmets on the markettoday. It is a fact that head and neck injury infootball are not related to the equipmentbeing worn by the injured person. The sameis true of similarly serious injuries in wres-tling, gymnastics, baseball, and other sportswhere serious injuries and deaths have oc-curred.

Economic Impact of Severe Injury

The problem which must be dealt with isthe economic impact caused by litigationwhich is founded in emotion and poorjudgment rather than rationality and fact.Protracted litigation brought by youngathletes who have suffered debilitating in-jury in athletics and which involves years ofpreparation, the testimony of numerousmedical, scientific, statistical, and athleticexperts from all over the country, and re-quires several weeks of trial, is creating aburden which manufacturers and schoolswill soon be incapable of bearingparticularly in this age of intense concernabout tax reform and the repeated tendencyto cut back athletic programs first when at-tention is given to economizing in education.Unless a rapid change is made, the cost ofmaintaining athletic programs will become

too severe and the institution will indeeddisappear.

Many people are prone to attack the judi-cial system and its traditional procedures asthe culprit. Such an approach is misguided.It is important to America that a forum existsin which an aggrieved party may present acase for recovery against one responsible forthe loss and be justly and fairly recom-pensed. The problem arises from misuse ofthat process. It is magnified by those whocome forward in the court of law and renderprofessional opinions concerning the causeand mechanism of injury and the manner inwhich that cause might be eliminated with-out having developed adequate support forthose theories.

The potential in football and other sportsfor violent impact of human bodies againstone another or against fixed objects is great.Any high energy impact can result in severeinjury. Many times severe injury creates anextreme economic need.

Repeatedly, in litigation involving ath-letics, physicians, engineers, and evencoaches have come forward with theoriesconcerning injury cause and mechanism forwhich they have no support. Any testingperformed has been minimal and the in-terpretation placed upon the results of thosetests questionable. However, they are toooften accepted as fact.

Jurors are laypeople, often uneducated inmedical or scientific matters and frequentlywithout the ability to truly understand thetestimony of these experts. Because of thetremendous emotion generated by the sightof a young athlete who has been rendered aquadriplegic or suffered the destruction ofmind and body through injury to the brain,the plaintiffs and their attorneys are able tomake a strong argument that the opinions ofthese well-meaning experts who fault theathletic equipment for the tragedy should beaccepted and a substantial reward given tothe injured person.

The existence of injuries and lawsuits doesnot establish that athletic equipment ispoorly designed or manufactured. To theknowledge of this writer, claims againstmanufacturers universally involve a chargethat the equipment was improperly de-signed. They do not arise from instanceswhere the equipment failed as a result ofsome manufacturing defect. It must be un-derstood that there are limitations to the de-gree of protection to be enjoyed from a pieceof athletic equipment. A gymnasdcs mat isnot and cannot be designed to absolutelyprotect a gymnast who dismounts from a

3440

high position and lands incorrectly. Footballhelmets are not and cannot be designed toprotect the neck, and they are even incapableof preventing most of the severe injurieswhich can occur to the brain in the footballenvironmen t.

Cost of Lawsuits

Many people find it difficult to understandhow litigation against schools and helmetmanufacturers can possibly threaten ath-letics. Very few cases have been tried andeven the number which have been filed andwhich have been settled, or are still pending,is extremely low when compared with suitsfor example, against the automobile indus-try.

Bear in mind that the protection soughtagainst the potential for lawsuits arising outof injury which the injured claim otherscaused is the purchase of insurance. Insur-ance carriers charge premiums which arebased upon their prediction of the financialrisk to which they are exposed. Even thoughthere are probably only 50-60 lawsuits cur-rently pending against all helmet manufac-turers, many of these involve neck fractureand quadriplegia from severe injury to thebrain. One verdict alone in Dade County,Florida, was in the amount of $5.3 million.Another more recently rendered in Philadel-phia was in the amount of $600,000. Whilewriting a policy of insurance and charging apremium, the carrier must have in mindthose potential losses.

More significantly, even the cost of win-ning these lawsuits is enormous. The casesof catastrophic injury which have been triedagainst football helmet manufacturers revealthat the expense of preparing a case and tak-ing it to trial will usually exceed $100,000 andmay very well be 2-3 times greater. Whenmultiplied times the 50-60 lawsuits which arepending and an undetermined numberwhich might be brought in the future, it canbe seen that the insurance industry faces atremendous potential expense from this rela-tively low rate of suit experience.

As a consequence of these expense risks,the premiums charged to the manufacturersof athletic equipment have escalated to as-tronomical levels within recent years. Someare now paying premiums 50-100 timesgreater than they were four years ago. Thereare football helmet manufacturers who cur-rently pay in excess of $1 million, and forsome this involves coverage requiring a sub-stantial out-of-pocket expense on each claimby the manufacturer itself before the insur-

35

ance coverage even becomes effective.Where the risk of loss appears to the insur-ance company to be too great, coverage issimply refused, and the manufacturer mustthen bear the cost of defense and payment ofclaims out of its normal operating budget.

Whether the cost involved is for insurancepremiums or self-insurance, the effect is atremendous increase in the cost of doingbusiness. The only available means for deal-ing with this problem is to increase the priceof the product. This effect is transmitted im-mediately to the schools. Obviously, there isno way that schools will be able to bear un-limited increases in the cost of football hel-mets, baseball batting helmets, wrestlingmats, gymnastics mats, and other equip-ment.

Schools and Litigation

The schools themselves are far from beingfree of problems created by litigation. Inmany suits involving catastrophic injury inthe athletic environment, the coach and theschool are named as defendants. This againbrings into play the problem of insurancecoverage and its cost. The school is thencaught in the position of having to pay bothfor the manufacturer's insurance coverage(through the increased price of equipment),and the cost of its own insurance. Obviously,the public is not going to tolerate unlimitedbudgets for this purpose.

The solution to the problem is education ofthose who are directly or potentially in-volved in the litigation process. The tide oflitigation will not be stopped by force. Thegeneral public can do nothing to prohibitinsurance companies from charging higherpremiums. If that risk becomes too great andthe company decides not to write the insur-ance, this again is beyond the control of thepublic.

Certainly, manufacturers cannot be prohib-ited from charging prices for their productswhich are necessary to cover the cost ofdoing business as it is increased by the risk oflitigation. It is doubtful that the federal gov-ernment will be willing to underwrite thecost of either the claims or the manufacturingof athletic equipment.

There is a limit to the ability of our econ-omy to tolerate the rising costs and con-sequently the answer must be in stemmingthe tide of the lawsuits themselves. Onlywhen people within the athletic environ-ment, including parents of athletes, medicalpeople who treat athletic injuries, engineerswho design athletic equipment, and the pub-

41

lic at large understand the full scope of thisproblem and become willing to do some-thing about it, will a solution be found.

In the following paragraphs, attention willbe directed to the particular facets of theproblem and the efforts which can be madeby coaches and other school personnel toeffect a solution.

Checklist for Coaches

A brief checklist is provided below forcoaches to employ during their sport season.This may eliminate some potential problems.

1. Meet with parents and athletes as agroup before practice begins or asearly in the season as possible, andexplain all the risks involved in thegame. Stress that everything possiblehas been done to reduce those risks.Advise that equipment cannot totallyeliminate them. Despite all efforts andthe efforts of all coaches across thecountry, a few participants will beseriously injured every year.

2. Stress the values of the game whichjustify the risks and the far greaterrisks which are present in other com-mon activities.

3. Make sure the parents understand theprogram, and keep the door open forquestions and comments.

4. Make sure the equipment is safe,sound, and in good condition. Allhelmets should meet NOCSAE sped-fications.

5. Distribute to each player a writtencopy of the rules related to the use ofthe head in blocking or tackling. Stressthese rules daily, especially in tacklingsituations.

6. Be alert for and, if necessary, eliminatefrom the program, players who are notadequately prepared physically, men-tally, and emotionally for the violenceof the game.

7. Give special attention to the develop-ment of neck strength, particularly inplayers using heavy helmets.

8. Make every effort to have present atevery practice a person properly qual-ified to deal with severe injury whohas no other responsibility. Thiswould preferably be a certified athletictrainer. In any event, know how todiscern and properly deal with severeor potentially severe injury, especiallyto the head and neck at all practicesessions.

36

9. Have a physician qualified in sportsmedicine present at every game.

10. If severe injury occurs, don't panic.Remind parents, press, and all con-cerned that no one is to blame. Makeno speculative statements about howthe injury occurred. Store any equip-ment involved and any films or pho-tographs of the incident. Notify themanufacturer of the equipment in-volved immediately. Have the schoolseek the counsel and advice of alawyer knowledgeable in the athleticinjury field.

II. Catastrophic injury: Why Must It Be?

Rising costs imposed by the need to de-fend suits in which athletes seek huge sumsof money for injuries will eventually forceschools out of athletics if change is not ef-fected. Attention was called to the urgencyfor discouraging use of the judicial system asa response to fatal or totally disabling injury.

No athletic injury gives rise to such dra-matic public concern as injury to the brainand spinal cord. An understanding of themechanisms by which these trauma occurwill not only aid in reducing the risk of thosewhich are avoidable, but enhance under-standing and acceptance of the fact that someannual incidence is inevitable.

Not isolated to Football

The risk of head and neck injury is notspecific to football. In baseball, death or dis-ability from brain trauma, usually inflictedby thrown balls, is a yearly occurrence, andsevere neck injury, usually from collisions onthe basepaths, is a realistic threat. The poten-tial for severe head and neck injury is presentin wrestling, gymnastics, swimming, anddivingany sport involving rapid bodymovement.

A notion prevails that the greatest risk ofinjury to the brain comes from impact of itssurface with the bony interior of the skull.Ayub Ommaya, M.D., acting chief ofneurosurgery at the National Institute ofHealth, has spent several years attempting todispel this misconception.

While he does not minimize the impor-tance of trauma to the surface of the brain,Dr. Ommaya points out that most of the in-juries produced in this fashion have little, ifany, long-range effect. Of grave concern arethose injuries which result from rapid rota-tional movement of the brain, particularly

42

when combined with movement of the skullin a different direction or at a different rate.

Causes of Concussion

The original Latin term from which thoword concussion was derived was literallytranslated as "shaking about of the brain."Because it is a sizable mass, precariouslyperched atop the much smaller spinal cord,under certain circumstances the brain pos-sesses the characteristics of a ball on a whip.The fact that it literally floats in cerebrospinalfluid, a liquid with properties and behaviormuch like water, enhances this response.Such an effect only occurs if the mass israpidly set in motion.

Obviously, a blow to the head may initiatethis process. A sudden blow to the body mayalso cause rapid acceleration of the head withresultant "whipping" of the brain. Thisphysical experience is most often observed inrear-end automobile accidents, with their in-famous whiplash injuries. This injury is noless possible in sports, particularly football,where there may be violent and often unex-pected blows to the body which suddenly setthe head in motion or change the direction ofits motion. The helmet is in no way involved.

Concussion may vary in severity frombrief, transient loss of neurologic function(being "stunned" or having one's "bellrung") to more serious incidents of pro-longed unconsciousness and amnesia. Whathas not been understood, and what Dr.Ommaya's research has verified, is thatthese variances are determined by the depthin the brain at which the shaking phenome-non (concussion) is experienced. If the phys-ical movement is mild, the effect will be feltonly on the surface, and the neurologic con-sequence will be slight. As the violence of theshaking increases, the effects are experi-enced more deeply, posing the greatest risk.The tearing of sensitive tissues in the brainwith resultant bleeding and development ofpermanent scar tissue leaves the victim in alifelong compromised condition.

The important thing to understand is thatno blow to the head, much less impact to theskull, is needed to cause concussion. O.J.Simpson once commented that he had expe-rienced two concussions during his footballcareer, both of which occurred when hejumped to catch a pass, had his legs under-cut, and landed solidly on his buttocks. Weall relate to the experience in boxing of ahighly effective knockout punch being deliv-ered to the point of the chin. These are justtwo examples of concussion which occur

when the head is suddenly and violentlyjerked. No blow to the skull is required.

Subdural Hematoma

The vast majority of the brain injurieswhich have plagued football and stimulatedlawsuits are not concussions. The mostcommon occurrence is the subduralhematoma. In this injury the initial severetrauma is not to the brain at all, but to bloodvessels which lead out of the brain. It is,however, initiated by the same type of sud-den rotational acceleration which leads toconcussion.

The veins in the brain pass out of the topand sides of the brain through the dura, afibrous sheath which is loosely attached tothe skull, and which houses the cerebro-spinal fluid.

Although the space between the surface ofthe brain and the dura is not large, undersudden, violent movement, the brain stif-fens and literally bounces within the skullcavity. If this occurs, the veins are stretchedand a shearing stress is applied.

Under virtually all human experiences, theveins tolerate this stress without serious re-sult. On rare occasion, however, the shearstress will be too great and the veins tear. Theresult is bleeding into the space which isdesigned to contain only cerebro-spinalfluid. Because this gathering of blood(hematoma) is in the area below (sub) thedura, it is denoted as subdural hematoma.

The brain is capable of accommodating aslow, mild development of such blood, oftenwithout any observable side effects and usu-ally without severe problems. This is knownas a chronic subdural hematoma. If, however,the bleeding is more profound the effects willbe felt within 48 hours. This is a potentiallyfatal occurrence and is called an acute sub-dural hematoma

Because of the similarity in body move-ment which sets the two injuries in motion,there will virtually always be some degree ofconcussion when the veins are torn. Con-sequently, the player is compromised tosome degree immediately. Very often, how-ever, this is a very mild concussion, which isfollowed by a lucid interval, during whichthe player may perform without readily dis-cernible problems for a period of minutes orperhaps hours. Once the intracranial pres-sure caused by the bleeding becomes too in-tense, the player will begin to evidence seri-ous neurologic symptoms and very quicklybecome comatose. This is a life-threateningcircumstance and usually must be surgically

3 7 43

treated within 30-60 minutes if the patient isto survive.

The subdural hematoma is not to be con-fused, either in description or mechanism,with the epidural hernatoma which also ap-pears annually in fatality and injury statis-tics, primarily involving baseball players.The latter injury, which develops morerapidly and is fatal a greater percentage of thetime, involves a gathering of blood above thedura in the very minute potential space be-tween that fiber and the skull. In this in-stance, the damaged vessels are arteries,which bleed more rapidly than veins. Be-cause there is no opportunity for rotationalmovement, such trauma results only frominbending or fracture of the skull.

If there were truth to the allegations of afew physicians and engineers that footballand baseball helmets are woefully in-adequate, allowing direct blows to the skullsof players, there would indeed be anepidemic of epidural hematomas. On thecontrary, the rate of such injuries is ex-tremely minute. As previously indicated,statistical studies reflect that -all helmets onthe market are doing an excellent job of pre-venting all brain injuries, and especiallythese deadly epidural traumas which arereally the only severe risk which a helmet caneliminate.

Fracture/Dislocation of the Neck

One of the saddest misconceptions everdeveloped advocates a relationship betweenfootball helmets, gymnastics mats, or otherpadded protection, and fracture/dislocationof the neck with resulting quadriplegia. Dr.Ommaya reports that he is unaware of asingle instance of neck fracture from a blowto the head where the victim's head andbody are stationary at the moment of theblow. It seems that movement of the body isessential to fracture/dislocation of the neck.Albert Burstein, Ph.D., director of theBiomechanics Department at the New YorkHospital for Special Surgery, gives a mostlogical explanation for this observation.

Dr. Burstein explains that when bonesbreak or joints are disrupted, the force caus-ing the injury can be a direct blow. Moreoften, kinetic energy developed within thebody will cause the force. This is virtuallyalways true of neck injury.

Kinetic energy (measured in foot pounds)is defined in engineering as the ability to dowork, and is created when a body (mass) isset in motion (velocity). The greater theweight of the body and the faster it moves,

the more kinetic energy it possesses. Whenthis energy comes to a stop, the result is thecreation of force.

According to Dr. Burstein, these bio-mechanical principles explain the neckfractures and dislocations in athletics. A footpound of kinetic energy is described as onepound of body weight dropped from aheight of one foot. Obviously, a 150-poundgymnast dismounting from a high bar sixfeet off the ground develops a tremendousamount of energy before hitting the matbelow (900 foot pounds!). Similarly, a 150-pound football player running at top speeddevelops a great deal of energy, especially ifdiving to make a tackle. In either case, tre-mendous force is developed when the bodystops.

Because it is a jointed skeletal structure,the entire human body does not stop im-mediately upon impact. For example, whena gymnast dismounts incorrectly and landshead first, the head will stop, but the bodywill keep moving. We are speaking of timefactors in milliseconds, but if the neck is thepoint where the force will be applied whenthe energy of the trunk of the body comes toa stop, the gymnast is in grave trouble. Thedirect application of only 8-10 foot pounds ofenergy will fracture the neck. Here the en-ergy transmitted may be hundreds of footpounds.

Design of the Body to Absorb Energy

Fortunately, the body as a whole, and theneck in particular, does an excellent job ofabsorbing energy and reducing the forcetransmitted to the bones and ligaments. Thejoints of the skeletal system are designed tobend substantially in one direction in orderto bring these soft structures into play. Con-sequently, if the gymnast can quickly tuck soas to land shoulder first in a rolling fashion,the neck will not be severely injured. If thefootball player's head is erect and as it stopsthe neck is hyperextended the direction inwhich the joints in the neck are designed tobendthe muscles and other soft tissue willabsorb the energy and the bones and jointswill not be damaged.

It is only when the neck is positioned sothat the vertebrae are in a straight columnand the joints cannot bend in response to thetransmission of energy that severe damageoccurs. This happens if the head is noddedforward only slightly and is grossly exagger-ated if the chin is brought down onto thechest. In a flexed position, the joints of the

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neck will buckle under excessive load. Thedamage may be to the bones and/or liga-ments. If the result is too much movement ofthe vertebrae, the spinal cord is traumatizedand paralysis occurs.

The important fact to understand aboutthis process is that the risk to the neck is theforce created by energy of the body. Accord-ing to Dr. Ommaya, energy contained insome outside mass which impacts the top ofthe head would have to cause damage to thebrain and skull before breaking the neck.Such damage is not present in the case ofneck fracture/dislocation and quadriplegiasuffered in athletics. Dr. Burstein points outthat if the energy which causes the injurypassed from the" head into the neck, thedamage to vertebrae would be in the first andsecond vertebrae rather than at the lowerlevels which have been involved.

Furthermore, logic dictates that theamounts of energy contained in the bodyunder circumstances such as those involvedin football, wrestling, gymnastics, andswimming and diving is the cause of neckfracture.

Understanding these mechanisms of brainand neck injury makes obvious the impossi-bility of absolutely eliminating them.

Susceptibility

Obviously, anyone who puts his or herbody into a position where massive amountsof energy are transmitted directly into astraight, stiff neck or suffers a horrendousuppercut blow which sets the head into arapid rotating movement, may''well suffer atragic result. Some people, because of aunique physical weakness, will be more sus-ceptible to injury.

The intent here is to educate, not encour-age a negative, fatalistic attitude. Attentionmust always be given to the great benefits ofthe athletic experience. Life is not, and neverwill be without its risks. There is not morejustification for concentrating unnecessaryattention on this negative aspect of the ath-letic experience than on any other phase ofliving.

There is, however, reason to bear in mindthat involvement of the head in contact is thecommon denominator in both types of catas-trophic injuries. By constantly remindingand teaching players not to use any part ofthe face or head as a primary point of contact,football coaches will take great strides to-ward eliminating the preventable injuriesfrom the game.

This is not to say that players should notkeep their heads erect and move into a blockor tackle with their eyes always on the target.As pointed out above, the neck is best able tohandle stress if it is extended and upon im-pact bends to the back. However, it is im-perative that the primary application of forcenot be to the face or neck. At the instantcontact is made, the head must be slipped tothe side so that force is applied to the shoul-der.

It is also imperative that the neck muscula-ture of players be as well prepared as possi-ble to bear the stress imposed. A strong,well-developed neck will not prevent neckfracture if too much force is applied to thebones, but will aid the player in keeping thehead properly positioned at all times.

Symptoms

Equally important is for the coach to bealert to those situations where the catas-trophic injury may have occurred. Usuallythe neck fracture/dislocation causes im-mediate paralysis, but this is not always true.The player may suffer an injury to a jointwhich causes pain, but no apparent disabil-ity. If properly handled, the athlete will re-cover without serious problems. If, how-ever, he/she is sent back into contact, theresult could be tragic.

The player with a subdural hematomawould demonstrate minimal evidence of in-jury at first. However, these minimal signsact as a warning to be on the alert for moresevere problems and to take every precau-tion for the player's well-being. Any playerwho has experienced a violent, suddenmovement of the head followed by any con-cussion symptoms must be watched verycarefully for 24-48 hours and should be ex-amined by a neurosurgeon. This observationmay include waking the athlete several timesduring the night to check responses. Diag-nostic tools are now available by which thepresence of a developing subdural hemato-ma may be discovered before the problembecomes critical.

The need for the presence of a certifiedathletic trainer at all practice sessions and fora physician qualified in sports medicine at allgames is poignantly accentuated. It is hopedthat with the foregoing general explanationof the biomechanical factors involved in suchinjuries the coach will be better able to avoidthose occurrences which increase the risk ofsuch tragedies and to deal with them if theyoccur.

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Ill. Capabilities and Limitations ofProtective Equipment

Design Considerations

The designer of equipment must considersuch factors as the economic position of thebuyer, usefulness, comfort, durability, andthe users' acceptability of the product. A de-signer must also carefully consider trade-offs .Every product has certain advantages anddisadvantages. By designing to eliminateone danger, the manufacturer may createanother; by selecting material suitable forone purpose, the manufacturer may create aproblem by using the product for other pur-poses.

Baseball helmet manufacturers havestruggled with these problems for years. Ini-tially there was great resistance to wearingsuch a device at all. Even today, players re-fuse to wear a helmet which they don't con-sider light, comfortable, attractive, and con-venient. In light of these problems, it is dif-ficult to design a helmet which adequatelyprotects against a ball which may be pitchedat speeds above 100 mph.

A different kind of dilemma is confrontedby the manufacturers of mats for wrestlingand gymnastics. The manufacturer is re-quired to strike the delicate balance betweena mat which protects against injuries and yetallows freedom of movement. If the mat istoo thick and soft, movement will be hin-dered.

Manufacturers of eyeguards for handball,racquetball, and squash have faced litigationin which it was claimed that injury occurredto the eye despite the wearing of theeyeguard. The only way to guarantee that nocontact will be made with the eyes is to to-tally cover them. The use of glass would poserisks, and there is no plastic available whichdoes not seriously impair vision. Narrow eyeopenings are safer, yet they impair vision. Byover-designing, the manufacturer may elim-inate use of the protection altogether.

Football as a DilemmaFootball manufacturers are confronted

with the most complex dilemma of all in con-sidering the factors and trade-offs involvedin equipment design. The same type ofheadgear will be worn by people rangingfrom high school freshmen to adult profes-sionals, will be kept on players' heads for 2-3hours per day, 5-6 days per week, over aperiod of 3-4 months, and will be used inblistering heat and freezing cold, humid anddry air, rain and snow, in mud and dust, on

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grass, hard-packed dirt, and carpet-coveredconcrete. Helmets used daily in practicemust also present an attractive appearanceon game day. The equipment must be strongenough to resist the impacts, yet lightenough to be safely worn, give coverage to asmuch of the head as possible, and not restrictthe vision, hearing, or movement of theplayer.

Over the years, manufacturers havelearned that the trade-offs involved in vary-ing helmet styles can be extreme. The strapsuspension system is an excellent protectionconcept because it aids the head in effectivelymoving away from a blow to the helmet.However, to function effectively, the sus-pension is required to fit tightly and can't bemodified to accommodate unusual skullshapes. In an effort to solve these problemsof comfort and fit, padded systems were de-veloped. These helmets were hotter,heavier, and did not move the head awayfrom the blow. The protection given was ex-cellent, as long as there was still compressi-bility in the padding; once it became entirelycompressed, the padding was as hard as theshell. In an effort to accommodate this prob-lem, helmets with a combination of air, wa-ter, and padding were developed. Theseprovide both fit and protection, but are out ofnecessity, extremely heavy and frequently inneed of the repair or replacement of parts.

The most interesting irony about the vari-eties of helmets which have been developedand the trade-off factors involved is thatstatistically it has been proven that the pro-tection given by all helmets on the markettoday is the same . . . regardless of the pro-tective system. Since all helmets give thesame high level of protection, a coach or ath-letic director must decide which is the mostpractical and functional and what trade-offsare involved.

If players wear an exceptionally heavyhelmet, they must develop the neck musclesto avoid fatigue which might result in theplayer putting his/her head into positionswhich create a risk to the brain or neck. If ateam is to use a helmet with padding whichcompletely encircles the head and has nospace for the flow of air, players must re-move the helmets frequently so that the headcan cool and the body heat can be reduced. Itcan readily be seen that there is no simpleanswer to the problem of design or selectionof the "best" football helmet.

Helmet FailureWhile there is occasionally a clear and ob-

vious failure of a particular product, those

4 6

situations usually involve comparativelyminor injuries. There is not a single lawsuitknown to the author alleging massive braininjury or neck and spinal cord injury inwhich the helmet involved is said to havefailed. The serious cases all involve claimsthat the design of the product is inadequate togive the required protection, or that the de-sign contributes to the injury. It is the con-tention of the plaintiffs in these cases thatevery unit of that particular model of equip-ment has exactly the same defect. The attackswhich have been made onprotective athleticequipment have virtually always come frompeople who are outside of both manufactur-ing and athletics.

It is also important to bear in mind thatthese attacks upon athletic equipment arealways theoretical; they are based upon labo-ratory experiment, rather than the actual ex-perience in the athletic environment. Mostoften the person attacking a football helmetdoes so by way of comparing it to a differenthelmet, which in laboratory experiment pro-duces results which are allegedly better.

Essential to the opinions of these so-calledexperts is a great deal of speculation regard-ing the levels of tolerance of human beings toinjury. It is not known precisely at what levelof force concussion or other damage occursto the brain, nor can it be determined pre-cisely how much energy was involved in ablow which caused a particular injury. To saythat a certain amount of increased protectionwould have prevented the injury requirespure speculation.

Claims against Manufacturers

The oldest and broadest claim againstmanufacturers in cases of catastrophic injuryrelates to the energy absorption capabilitiesof the equipment involved. As pointed out inthe second section of this series, once thebody is in motion, it possesses kinetic energywhich must be expended. As the energycomes to a stop, it creates force, the mag-nitude of which is governed by the time anddistance over which the body stops moving.The attackers say that protective equipmentcan and should be designed to effectivelyreduce the force and thus eliminate injuries.

Manufacturers have attempted to discoverthe ideal material for use in helmets to bringthe energy of a blow to a stop before itreaches the skull and brain. One self-appointed expert has proposed that the idealpadding for all helmets is a material consist-ing of polystyrene beads. This is best de-scribed as an extremely dense styrofoam and

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is used in vehicular crash helmets. It wasused in the Cougar and Bell Toptex footballhelmets, and proved so unacceptable thatthey are no longer on the market. In fact, inone study the rate of low-level concussionwith this type of helmet was dramaticallyincreased.

The author believes that head injury ishead injury, and head protection is head pro-tection, inasmuch as the brain does not knowthe source or nature of the energy inputwhich might cause it injury. Consequently,all helmets should be tested in essentially thesame fashion. The test circumstance advo-cated by this individual is derived from astandard for vehicular crash helmets.

This would mean that all helmets would bevirtually identical, regardless of the purposefor which they're used. The presence of afirm crushable liner is virtually essential tomeeting this standard and it is almost impos-sible to design a functional, practical helmetfor football which would pass such a test,much less for baseball, hockey, skiing,bicycling, and other such activities.

A second concept advocates the erriploy-ment of a soft outer shell for all football hel-mets. This is primarily advanced as a meansfor protecting other players from blows ad-ministered by the helmet, but some theorizethat increased protection will be enjoyed bythe wearer. Those who advocate such a mod-ification have engaged in no testing to de-termine the effects to the neck and brain ofthe wearer of the helmet from such a changein the surface of the shell.

The most damaging attack upon protectiveequipment, particularly football helmets,gymnastic mats, and wrestling mats, relatesto catastrophic injury of the neck resulting inspinal cord damage and paralysis. Hereagain, the analysis has been made that theequipment contains inadequate energy ab-sorption capabilities and if properly mod-ified the injury could be avoided. Because itis always impossible to determine theamount of energy and resultant force whichwas involved in the injuring impact, suchexperts are forced to compare the equipmentinvolved with some alternative equipment,compare the energy absorption performanceof the two pieces of equipment, and thenspeculate that with the inaeased energy ab-sorption the injury would not have occurred.

Another self-appointed expert has pro-pounded the theory that the posterior rim ofmost football helmets can impose a forceupon the neck in a manner similar to a guil-lotine and thus cause dislocation/fracture ofthe neck. The claim here is not that the mask

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is used as a handle to jerk the head of theplayer around, but rather that because itprotrudes too far, a mechanical disadvantageis created upon the neck as a result of theadditional leverage. The author alleges thatwhen the helmeted head is rapidly extendedto the rear, the posterior rim of the helmetstrikes the neck with excessive force. Onceagain, this opinion was obtained and ex-pressed without a shred of concrete medicalor scientific evidence existing in its support.

Equipment Manufacturers' Responses

The industry's response to these attackshas been diverse. In all instances, manufac-turers remind both the attackers and the ath-letic public that they must look at the fullspectrum of considerations. Of extreme im-portance is the design and marketing of ahelmet which players can and will use, andwhich will serve all of the purposes for whichit is intended. Design engineers in the hel-met industry carefully evaluate the trade-offs, determining every problem whichmight be created in an effort to solve someother problem. Finally, it is essential that allpeople concerned recognize the limitationsupon the ability of equipment to protectagainst injury and the inadequacy of ourknowledge about the actual tolerance levelsof athletes to injuries.

As explained in the second section, concus-sion and subdural hematoma injury arecaused by rapid rotational acceleration of thebrain. So long as the head is free to movesuddenly backward and forward, these rota-tional phenomena can occur. Only bystabilizing the head on the shoulders couldsuch a risk be eliminated. Obviously, a hel-met of that type would be totally non-functional for the game of football. To at-tempt eliminating rotational movement withpadding would require a helmet 6-8 inchesthick.

With respect to football helmets, it is im-portant to bear in mind the potential ultimatecapabilities of the equipment to give protec-tion. The only purpose a helmet can serve isprotection of the scalp and skull. Skull frac-tures and the epidural hematomas whichwould occur with inbending of the skull arenon-existent in football. Many experts claimthat the plastic of the shell deflects undercertain high energy loads in football, causingthe shell to come in violent contact with theskull. If this were true, skull fractures andepidural hematomas would be epidemic innumber.

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The suggestion that energy absorptionmaterial would help prevent neck and spinalcord injuries demonstrates a total lack of un-derstanding of the biomechanics involved.As previously explained, fracture of the neckis caused by force transmitted when the en-ergy of the body comes to a stop. The prob-lem which exists is that the athlete is movingin a head first fashion and suddenly the headslows down or stops while the body keepsmoving for a few milliseconds. The forcegenerated when the body comes to a rest isthen imposed upon the neck, which cannottolerate that force. To solve this problemwith padding would require that the head beslowed or stopped more gradually and inconcert with the body.

How much distance would have to be in-volved for this to be accomplished? It isknown that in cases of neck fracture sufferedby trampolinists, they came down on top oftheir head in the middle of the trampoline.The webbing of the trampoline deflects asmuch as two feet before it is stretched to itsmaximum capacity and stops moving. Atthat point, the head comes to a rest but thebody is still moving with sufficient energy tobreak the neck. If, two feet of stopping dis-tance is insufficient, how can one conceive ofdeveloping a padding for a football helmet orgymnastic and wrestling mats which wouldsolve the problem? The answer is obvious.Football helmets are not, never were, and neverwill be designed to protect the neck from fracture.

The suggestion that the configuration ofthe helmet shell and/or facemask causes frac-ture of the neck likewise demonstrates igno-rance of biomechanical principles as well asmedical facts. In the first place, there is noreported case in which the claim is made thatthe victim's neck was broken by the rear rimof the helmet acting as a guillotine and inwhich that victim had any bruising on theneck. Since far less force is required to bruisethe skin than to fracture the bones of thecervical spine, this defies logic.

Secondly, it is impossible to bring theposterior rim of the helmet into contact withthe cervical spine without releasing the chinstrap and moving the helmet out of its nor-mal position on the head of the wearer. Any-one involved in football realizes that whenthe chin strap is released, the helmet comesoff.

Finally, radiographic motion picture evi-dence has recently been produced involvinghyperextension movements by volunteerswearing football helmets, which positivelyestablishes that when the head is extendedbackward, the rear rim of the helmet pro-

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ceeds down and away from the cervical spineand does not move in toward the cervicalspine. If it eventually comes in contact withthe back of the wearer, it does so at a point nohigher than the seventh cervical vertebra. Allof the cases of neck fracture/dislocation infootball involve injury between the third andsixth cervical vertebra.

The suggestion was made to the footballhelmet industry that to avoid this risk, theposterior rim of the helmet be cut one inchhigher. The one manufacturer who compliedwith this design suggestion is involved in amulti-million dollar law suit brought by ayoung man who suffered quadraplegia in afootball game wearing that helmet; the alle-gation is that the rear rim of that helmetcaused the neck fracture. Also, elevating theback rim exposes the extremely vulnerableoccipital area to blows which can be fatal. Noavailable foam padding can adequately pro-tect against such blows.

Facemask Involvement in Injury

Testing recently completed by design en-gineers reveals that the size and shape of thefacemask have no bearing upon the amountof force experienced by the neck when thefacemask is impacted. In all likelihood this isbecause when the fa cema sk is lifted orpushed backward, the effect upon the headis always experienced only at the foreheadand the chin strap. Until the chin strap be-gins to pull on the chin, the head does notrespond to an upward movement of thefacemask.

In all instances then, the force applied tothe neck will come from the chin. Thesuggested change of moving the facemaskcloser to the face and making it releasable orcollapsible would totally negate the protec-tive capabilities of the mask. Players wouldbe better off if the mask were completelyremoved so they did not receive a false senseof protection. It would be questionable wisdomto take such drastic action in response to a purelyspeculative theory that the facemask plays a role incatastrophic neck injury.

A soft outer shell, which would reduceinjuries to those struck by a helmet, wouldmean extreme risk to the wearer. Testingwithin the helmet industry reveals that theforces to the brain and neck are dramaticallyincreased when a soft covering is placed overthe hard plastic shell. One of the great pro-tective features of helmets is that most blowsrapidly glance off the surface. This would nolonger be true with a soft shell. Even if thesurface were made extremely slick by the

-"

addition of some chemical coating, the dish-,ing effect which would occur in the softsurface upon impact would still increase theamount of time of the blow; this has a directbearing upon the force transmitted to boththe brain and the neck. A far more effectivemeans for protecting players from the helmets ofother players is to eliminate the use of the helmetas a weapon.

While a perfect, totally protective helmethas not and cannot be devised, all reasonablyconducted surveys of the protective perfor-mance of helmets on the football field revealan excellent result. By increased awarenessof the trade-off factors involved in varioushelmets, coaches can be certain of enjoyingthe maximum possible advantage from thehead gear of their players.

It is also imperative that coaches, players,their parents, and the general public realizethe inherent limitations upon the helmet togive protection, the fact that players andcoaches can do as much as anyone to elimi-nate head and neck injury by avoiding theuse of the head as a primary point of contact,and tha t unless there is a failure of the helmetshell with resulting damage to the scalp andskull, the helmet is not to be faulted in casesof injury to the neck and brain.

IV. Factors in Protecting Athletes:Equipment, Training, Medical Care

There are several steps to protection of theathlete, including equipment management,conditioning and training athletes, and ap-propriate medical care.

Examination of Existing Equipment

Old, worn-out, inadequate protectiveequipment must be replaced immediately.Unless a decision has been made to replacethe entire inventory of equipment, the firststep in selection involves careful examina-tion of the equipment by a person of appro-priate skill, background, and experience.This is usually someone involved in equip-ment manufacturing, sale, or recondition-ing. Until the school has a full-time, carefullytrained person whose, sole concern is equip-ment management, there is no more reliablecritic available than a representative of thesporting goods industry.

The recommendations of such a personmust be carefully considered. Nothing ismore alarming to a trial lawyer than to learnof recommendations for the replacement ofpoor equipment being ignored for economicreasons.

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Selection of new equipment must also in-volve the advice of a trusted representativeof the sporting goods industry. Any pur-chase should be negotiated only with an au-thorized dealer or representative of themanufacturer. The savings enjoyed in thepurchase of equipment from "bootleggers"is heavily outweighed by problems whicharise in exercising warranty rights, and ob-taining parts for repair and maintenance orassistance in solving problems with theequipment. Acquisition of equipmentthrough a "bootlegger" for economic rea-sons is also a fact which can and will beplayed upon by a plaintiff's lawyer in litiga-tion which involves the school.

It is a mistake to select equipment withoutconsideration of the size, strength, intelli-gence, maturity, and capability of the athletewho will use it. It is similarly incorrect toemploy a protective device for one purposewhen the intended purpose of the manufac-turer was entirely different. For example,football helmets employing a suspensionsystem which combines foam padding,water cells, and inflatable air chambers, wereoriginally designed to accommodate prob-lems of fit. A misconception developedamong coaches, trainers, and athletes is thatthis helmet was developed to solve problemsof concussion and was particularly suitablefor a player who had suffered a head injury.These helmets are no better able to preventconcussion than any other, and to acquirethem for ,'-at purpose is a mistake.

There is a marked difference in the weightof various helmets, and to safely employ theheavier models an athlete must haveadequate neck strength. Many helmets bytheir design completely encompass the headwith padding, allowing no room for move-ment of air. Heat elimination can only takeplace through evaporation and air move-ment. Any helmet which inhibits these pro-cesses must be employed with extreme cau-tion in a hot, humid climate.

Of equal importance in the management ofprotective equipment is the process of main-tenance, repair, and replacement on a regu-lar basis. From the very start of the season itis critical to have an adequate supply of re-placement parts. It is important that repairstake place immediately.

BecSuse of constant use, equipment mustbe carefully inspected on a weekly basis. Thisagain shows the need for a full-time personwhose sole responsibility is the managementof equipment. While athletes must be taughtto make their own inspections on a dailybasis, follow-up by someone more skilled

44

and experienced is essential. There must alsobe an annual inspection, preferably at theclose of the season, by a skilled consultantwho can designate the equipment whichneeds reconditioning or replacement.

Very often athletes will take protectiveequipment home and make some modifica-tion which they think will improve its ap-pearance or comfort. The result can be disas-trous. If athletes understand the danger towhich they expose themselves in using a de-vice which is broken or worn-out, thoy willlend better assistance to the inspection.

Individual Suitability to Athletics

In training and conditioning athletes, at-tention must be given to the whole person,taking into consideration mental and emo-tional factors as well as physical characteris-tics. Not every individual is suited for com-petitive athletics. The best preventive mea-sure with respect to some injuries is a "weed-ing out" process very early in the season. Anopportunity to compete should be affordedevery youngster willing to meet the condi-tions of participation. However, participa-tion may indeed be harmful to some.

For example, a youngster with outstand-ing physical skill may have attributes of ag-gression or self-destruction which makehis/her participation in contact sports an un-reasonable risk. Other athletes possess suchextreme fear of injury or failure that theirjudgment is impaired, thus increasing therisk of injury. Coaches must evaluate eachathlete from the standpoint of the potentialfor individual growth from participation insports.

Stressing emotional control and an intel-lectual, rational approach to athletics is asvital to prevention of injury as any aspect ofphysical development. All too often thecatastrophically injured athlete is an unusu-ally aggressive youngster who failed or re-fused to heed repeated warnings concerningthe risks involved in certain activities ortechniques. The philosophy of trying to hurtan opponent will often result in severe injuryto the attacker rather than the intended vic-tim.

Heat and Humidity

It is imperative that coaches be continuallyaware of the effects of the environment. Heatand humidity pose grave risks. Every foot-ball season is marred by the tragedy ofdeaths from heat stroke. The number ofother injuries which are the result of exces-

50

sive body heat is probably ridiculously high.The U.S. Armed Forces have discovered

that excessive body heat results in a lus ofboth physical coordina tion and ra tionaljudgment. The combination of the two leadsto carelessness and clumsiness, the result ofwhich can be a rash of various injuries to thehead and orthopedic structure. This problemcan be magnified by certain types of equip-ment, particularly helmets, unless appropri-ate precautions are taken.

The basic common solution to excessivebody heat is an adequate moisture level inthe body and cooling of the body surface.Any rapid loss in body weight (even two orthree pounds) is normally a result of loss ofbody fluids. In hot, humid weather, the bodyneeds all of that fluid to properly cool itself.Under such circumstances, practice sessionswithout frequent water breaks are extremelydangerous, and athletes must be not onlyallowed, but encouraged to remove theirhelmets frequently so that the head can cool.

Cold, Playing Surfaces,Fatigue, and Coaching

Cold weather likewise poses risks. Thewarmup process is of greater concern undersuch circumstances. In many regions theclimate may dramatically change during thecourse of the season, and a coach must makeappropriate adjustment in both practice andgame situations.

Playing surfaces are known to pose vary-ing risks to certain types of injury. For exam-ple, there is an indication that friction be-tween the sole of the athlete's shoe and thesurface of synthetic turfs is a major cause ofinjury to the knee. Dr. James Arnold, theteam orthopedist for the University of Ar-kansas, reports that an epidemic problem ofknee injury was solved in the Arkansas foot-ball program by simply wetting down theplaying surface prior to practice.

Fatigue is another factor which can lead toserious harm. This again will be a cause ofpoor judgment and loss of coordination, buttoo often the athlete will not recognize his/her own limitatiohs, or the fact that he/shehas exceeded those boundaries.

Finally, special attention must be given toplayer techniques as a means of preventinginjury. Particularly in football, the tech-niques used by players are responsible forcatastrophic injury to a far greater degreethan any other controllable factor. Use of ti-ehead as a primary point of contact in eitherblocking or tackling is an invitation to disas-ter. Players must be constantly reminded of

this fact and, if necessary, eliminated fromthe team rather than allowed to continue useof this dangerous technique.

In every sport, players should be taughtthe mechanisms of potential injury, themethods of avoiding and preventing suchinjuries, and constantly encouraged to em-ploy a healthy attitude toward their athleticendeavor.

Injury Specialists

The employment of at least one certifiedathletic trainer in every institution oi athleticorganization is as necessary as the employ-ment of a coach for every sport. Preferably,the athletic trainer should be on duty evenduring P.E. activity, but is particularly im-portant during practice periods and games.The athletic trainer should have no respon-sibilities other than the health, safety, care,and treatment of the athletes. A regular pro-gram should be employed for the trainer toeducate the coaches concerning problemsand considerations of their particular sport,or involving a particular athlete.

Every team should likewise have alicensed medical practitioner with whom afixed arrangement is made to render servicesas a team physician. This needs to be anindividual capable of treating the wholebody, rather than simply a specialized prob-lem, and to whom the trainer and coachescan turn at any time for advice and carewhich is beyond the skill and expertise of thetrainer. It is especially important that theteam physician be present during games,since the rate and severity of injury are signif-icantly greater there than during practice.

In addition to the team physician, whoshould probably be a general practitioner orone who specializes in family practice orsports medicine, the team should have ac-cess to specialists who might be called uponto handle more serious problems. At aminimum, these should include an or-thopedic surgeon and a neurosurgeon, butthere is wisdom in including an internist, ageneral surgeon and perhaps even a car-diovascular specialist. This may soundluxurious, but it involves no expenditureuntil an injury occurs. The point is to estab-lish a relationship with particular physicianswhich is known to the athletic and medicalpersonnel at the school, and to the physicianand his/her staff. If a severe injury occurs, theschool will know whom to call and the physi-cian's office will know that it is a prioritymatter when the call is received. Many times

the decision whether to contact a specialistwill be made by the team physician, but his/her job is made easier if the school has under-taken the responsibility to establish satisfac-tory relationships with particular specialists.

Hospitals

The school should be aware of the facilitiesavailable at various hospitals, and particu-larly of those hospitals best equipped tohandle serious emergency situations. Forexample, a "teaching hospital" which offersprograms in orthopedic surgery andneurosurgery is preferable because at alltimes there is a specialist in the hospital. Theschool must assure that the injured athlete istaken to the correct facility and must notifythe hospital of the athlete's impending arri-val.

Teams which engage in contests againstopponents in other towns must take addi-tional special precautions to guarantee theavailability of proper treatment in the eventof injuries to their athletes. If the teamphysician cannot make such trips, the schoolmust make arrangements for the attendanceof a local physician at the game. The schoolmust also have information concerning pref-erable hospital facilities and the names ofspecialists in advance of the contest so that-there will be no time delay if an emergencyshould arise.

At all practices, as well as games, theequipment necessary for the handling of aserious emergency must be on the field.There must also be a telephone on the field tomake an immediate call for help if it isneeded. Every reasonable effort to reducethe delay in obtaining treatment for an in-jured athlete should be undertaken. Ad-vance arrangements should be made for thefastest possible ambulance service to beavailaole at both practices and games. Again,an important factor is the establishment of arelationship with the ambulance company sothat they know to give the call a prioritywhen it is received.

As pointed out by Russell Lane, M.D.,team physician at Amherst College and amember of the NCAA Standing Committeeon Competitive Safeguards and the MedicalAspects of Sports, "Our goals must be tohave good athletic trainers, good medicalback-up, good communications network,good available transportation, and a goodhospital facility singled out as the ultimatedestination. In short: a good plan for action."

Health and Safety

When an injury occurs, it must be givenimmediate attention and top priority. Far toooften, the concern of a coach is to get theathlete back into action, or off the field so thatplay can continue, rather than determiningthe condition and needs of the victim. It ishere, more than any other time, that theteam needs the presence of someone whosesole concern is the care and treatment of in-juries.

One of the gravest risks is the failure toconsider and properly guard against thoseeffects which are not immediately obvious.Such problems arise most commonly withrespect to injuries to the neck, the cervicalspine, the internal organs, the cardiovascu-lar system, and as a result of excessive bodyheat. Injury to the head is often accompaniedby an injury to the cervical spine, and viceversa.

A complete loss of sensation and/or motorfunction of a major portion of the body usu-ally signifies trauma to the spinal cord,which should be carefully investigated. Al-though function and sensation return withina few minutes, there is a possibility of furthermovement of the vertebral column and per-manent injury to the spinal cord.

Blows to the trunk may cause injury to theinternal organs which requires immediatetreatmen t. Athletes die of cardiac arrestwhich might have been avoided had coachesbeen more aware of, and paid more attentionto the signs and symptoms leading to thecardiac failure. There is also an annual inci-dence of death from heat stroke which iscompletely avoidable.

Extreme caution should always be exer-cised in returning an athlete to action follow-ing an injury or illness. While there are obvi-ously minor aches and pains which neitherrequire nor justify medical examination, it isimperative that in every circumstance thecoach consider the long-range well-being ofthe athlete rather than immediate concernsabout expediting practice or winning a game.

Participation

In deciding whether an athlete should beallowed to participate, one of the mostdangrirous practices is to allow the athlete tomake the decision. A variety of factors maylead athletes to insist upon continued par-ticipation when they are seriously injured.An excellent example is the recent experi-ence of the Dallas Cowboys in a playoff gameduring which Roger Staubach suffered a

4652

serious concussion. After a lengthy medicalexamination, he reportedly returned to thefield and informed coach Landry that hewanted to play, despite the fact that he wasstill suffering from substantial amnesia re-sulting from the concussion.

The preferable approach is to place allproblems relating to the conditioning, train-ing, and treatment of athletes in the hands ofa trainer and physician. Realizing, however,that in many instances the school has notprovided the athletic departmelit with anymedical assistance whatsoever, the forego-ing information is designed to alert coachesto problem areas in which they should morethoroughly educate themselves, and also tocaution them to take the most conservativeapproach in the interest of protectingathletes against injury, and also protectingthe school against litigation.

V. A Capable Coach is the BestDefense against the Threat o Litigation

Competitive athletics has great potentialfor enhancing growth and development.This is best achieved by making sports as safeas possible. Theoretically, if this remains ut-most in the minds of schools and coaches,they will need no further protection fromlitiga tion.

Unfortunately, litigation trends havecreated an added dimension for concern. Forexample, doctors must do more than giveadequate, competent treatment; they mustalso employ special measures as precautionsagainst malpractice suits. Similarly, thecoach and school must go beyond protectionof the athlete; they must also safeguardagainst litigation.

Two types of lawsuits pose a threat toschool athletics. Indirectly, product liabilitycases against manufacturers and dealers ofsporting goods have an impact upon schoolprograms. Increases in insurance premiumsare passed on to the schools through priceincreases. Football helmet manufacturers,for example, must charge between $3 and$15 per helmet just to cover liability insur-ance costs. Those figures could easily doubleor triple in the next 2-5 years. Of even greaterconcern are suits alleging negligence, thethreat of which has directly increased.

Prudence of Coaches

To avoid liability for an injury, the schooland coach must do no more than be "reason-

ably prudent," in short, to be averagea"C-student." However, some "expert wit-ness" may come forth in behalf of the injuredparty with an idealistic concept of what isreasonably prudent.

As unrealistic and impractical as these"20-20 hindsight" views may be, jurors areoften persuaded to accept them. The resultscan be devastating. Last summer, a schooldistrict in California suffered a verdict of $1.2million because a group of jurors were con-vinced that a tackling drill in which a playerwas injured was unreasonably dangerous.

Several areas of concern require attentionto adequately protect the school. Some ofthese areas correlate closely with injury pre-vention. In general, coaches must attendcarefully to equipment matters, teaching,training, and conditioning of athletes, and tomedical care. They must also engage in effec-tive public relations and wise handling ofserious injury situations.

Standards and Helmets

In 1974, the National Operating Commit-tee for Standards in Athletic Equipment(NOCSAE) published a standard for footballhelmets. The NCAA adopted a rule requir-ing that by September 1, 1978, all helmets inuse by member schools had to meet thatstandard. The National Federation of StateHigh School Associations extended its dead-line for compliance to September 1, 1980.

In the view of the author, every schoolmust immediately make all possible efforts toconvert its football helmets to those whichmeet NOCSAE requirements. If a player suf-fers a brain injury in a non-certified helmet,sttong argument will be made that the schoolwas negligent in failing to meet a standardwhich it knew was designed to improve headprotection. Absolute protection against in-jury is not possible, but no coach or schoolshould provide its athletes with any less thanthe best equipment available.

Although no comparable standard hasbeen developed for other types of protectiveequipment, it is foolishness to use equip-ment which does not meet the approval ofrecognized athletic organizations, or is sig-nificantly different in kind and quality fromthat recommended by respected leaders andexperts in the particular sport.

Repair and maintenance of equipmentmust be consistent with the specifications ofthe manufacturer. Follow all instructionsand use only those replacement parts in-tended for the equipment. Integration ofparts from different manufacturers, perma-

47 53

nent removal of parts or other substantialmodification of the helmet, may not only benegligent, but also creates a new and differ-ent product for which the manufacturer mayno longer be legally responsible.

Younger Players and Protection

Employ regular procedures for replace-ment of equipment. The practice of handingused equipment down to younger or lesscapable players must be undertaken with ex-treme caution. If protective capabilities havebeen reduced in the least, the equipment isno longer acceptable fcr any player.

No item of protective equipment is de-signed for indefinite use, and the fact that anitem does not appear damaged is not always adependable indicator. Prudence requires re-placement every 3 to 4 years regardless ofappearance. Once a decision is made to dis-card equipment, destroy it or completelytransform it so no one can subsequently useit for protective purposes.

In the teaching of athletes, the first step isto instill an awareness of the risks of partici-pation. Players need and have a right toknow the mechanics of catastrophic injury,the limited capabilities of equipment, andthe fact that some injury is inevitable. Withthis information, they will assume more re-sponsibility for their own behavior, and beless likely to cast blame on others if an injuryoccurs.

Rules for Player Protection

Repeatedly emphasize the rules of thesport, particularly those designed for playerprotection. Give special attention to thoserules designed to prevent severe injury (suchas prohibitions against use of the head infootball, or intentionally ramming into anopponent in baseball) by distributing writtencopies to every player. Teach athletes thatviolation of these rules most often results ininjury to the violator and also requires themto relate back to the coach the substance ofthe rule and its purpose.

Take care to protect even against such un-likely occurrences as seizures, cramps, sys-tem arrest, or other physiologic dysfunctionresulting from exertion when no adult ispresent to render aid. Lack of adequatesupervision is probably the most commonhistoric attack against school personnel; pro-tect against all unsupervised activity.

Injury-prevention Clinics

Coaches must engage in a constant pro-gram of continuing education to keep them-selves apprised of the latest information intraining and conditioning. This requires notonly academic study, but attendance atsports medicine and coadling clinics.

One very important source of informationis the National Athletic Injury/Illness Report-ing System (NAIRS). By enrolling in thisprogram, a school receives regular reportsregarding athletic injury and illness and theirrelationship to equipment, environment,and activity. With this information, schoolsand coaches can determine whether somecontrollable factor is crea ting a risk toathletes. To ignore the availability of suchinformation would lead to serious problemsif preventable injury or illness occurs. Theuse of such a program is one more indicationthat the school and coach are using everyavailable means to protect athletes.

Training Personnel

In the area of medical a ttention, notenough emphasis can be given to the needfor a certified athletic trainer. Today, thereare not enough such people in the country tofill a job in every school. But until schoolsannounce their willingness to hire trainers,there will be little incentive for interestedpeople to pursue such a career. In the mean-time, there are fir more people available toengage in competent athletic training thanthere are positions available simply becauseschools have refused to recognize the need.

The argument that employment of atrainer is not economically possible will meetwith harsh and unpleasant results in a law-suit filed because an athlete was harmed bythe absence of anyone qualified to deal with aserious injury. By expecting coaches to act astrainers, schools are exposing themselves toliability not only for the improper handlingof an injury situation, but by failing to dem-onstrate total concern for the well-being ofathletes. Every school must have on its staff aperson whose sole concern is the health andsafety of the athletes.

For schools where there is no trainer avail-able, institute special measures for dealingwith emergencies. The best alternative is aparamedic unit. The school must be certainthat immediately upon the occurrence of in-jury a telephone is available and that allmembers of the athletic staff know where tocall for help.

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Likewise, it is the school's responsibility tobe certain that the emergency aid agency isaware of the school's needs and of how togain the fastest access to the injured athlete.Go to that agency before the school year witha map which shows the route to the schooland the location of various facilities. It alsowould be wise to go through practice exer-tises with all members of the athletic staffand every potential ambulance driver. Theschool must make the decision where to takean injured athlete and give appropriate in-structions rather than leaving that decisionto an ambulance driver.

Returning Injured Athletes to Practice

In no instance should a coach make a med-ical decision to allow an athlete to return toactivity after an injury or illness withoutmedical advice. Obviously, occasions arisewhen even a layperson can determine thatcontinued participation does not pose ahazard. But the absolute rule must be,"When in doubt, keep the athlete out."

Receipt of a consent or release form from aparent which allows return to activity is notadequate pri ction for the coach andschool. Even when the physician has givenclearance, the coach must be satisfied thatthe player is capable of tolerating every riskand stress which is to be expected from theactivity.

Use of Effective Public Relations

One of the surest ways of generating alawsuit arising out of an injury is for coachesto refuse to communicate effectively with theathletes and their parents, and to allowanimosity to develop toward the program. Itis not enough to engage in a public relationseffort after the injury occurs; then, it may betoo late. From the first day of practice, par-ents and athletes must know that the coach'sdoor is always open, that they may expresstheir discomforts, ask questions, or makesuggestions.

Refusal to communica te may be inter-preted as having something to hide; iftragedy strikes a family, they are much morelikely to attack that kind of coaching situa-tion.

It is an important safeguard against litiga-tion that the athletic program maintain ahighly visible profile in the community withrepeated reminders of the valuable role itplays. If the program is respected and appre-ciated, thoughts of filing suit against it will beless likely to develop.

Careful attention must be given to the re-moval of every unnecessary or unreasonablerisk from athletic programs. Many drills andtechniques which were once accepted havebeen found to be dangerous.

Just as important to protection against liti-gation is elimination of anything whichsuggests that it is, or appears to be, unrea-sonably dangerous. One of the most com-mon problems is vocabulary. Althoughphrases such as "suicide," "crucifixion,""hamburger," "meatgrinder," "gauntlet,"and "punishment drill" have been used overthe years, the response of parents of an in-jured athlete who was involved in such anexercise is something quite different. Use ofsuch descriptive terms is certainly not essen-tial to successful coaching.

At the start of every season, coachesshould meet with the parents of athletes as agroup to explain all that is being done toprotect their children, from selection of thebest equipment, to the use of extensive con-ditioning exercises to prepare all the athletesfor participation.

Financial Burden

The strongest motivating factor for litiga-tion is economic need. Families who sufferthe tragedy of a catastrophic athletic injuryare saddled with a horrendous financialburden. Inability to meet those demandscauses parents to turn in desperation tolawyers and courtrooms. By providing afund from which to care for the injured child,the school will reduce the risk of suit.

Schools must diligently search for themost extensive medical policy and then en-courage parents to add a supplemental pol-icy for their children who are involved inathletics. The author advocates that a special-ized program which will provide both medi-cal care and maintenance for life is an essen-tial step to solving the litigation problem.

Should a tragic accident occur, the firstand most important rule is, "Don't panic."The best example of creating litigation prob-lems by overreacting emotionally to atragedy is the "anguished doctor syn-drome;" the physician who expresses grieffor the death or poor result of a patient byexclaiming, "If only I had tried . . ." Mostoften, this is not an admission of error, but anexpression of frustration with the outcome.However, it may come back to haunt thedoctor in the courtroom.

Similarly, if a coach reacts to a case ofquadriplegia by lamenting, "If only we hadspent more time on tackling techniques," or,

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"I wondered if she was ready to try thatdismount technique," the words may some-day be used against the coach and school inlitigation.

The most dangerous practice following asevere injury is to speculate to anyone aboutwhy or how the tragedy occurred. Factswhich were observed should be carefully re-corded. Any possible evidence which mightshed light on the situation must be carefullyand permanently preserved. This includesthe equipment involved, films or photo-graphs of the occurrence, statements of wit-nesses, and the identity of all persons pres-ent who might be witnesses.

An immediate report and full cooperationmust be given to the dealer and manufac-turer of any equipment being used, and thatequipment must be carefully stored away. Itis especially important not to even remotelysuggest fault or wrongdoing on the part ofanyone else. Accusation of anyone may leadto litigation against everyone involved.

Full cooperation should be given to therepresentatives of the manufacturer, onceassured that they will not ultimately attemptto blame the school or coach for the injury.

It is wise to obtain the advice and counselof a lawyer, but this must be someone withparticular expertise in athletic injury litiga-tion.

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Finally, the public relations effort referredto above must be renewed with fervor. Main-taining a good rapport with the athlete andfamily is crucial, but community relations arealso important. The media can play a criticalrole in determining whether a suit will befiled. Reminders about the mechanisms ofinjury, the inability to absolutely preventthem, and the extensive safety measuresemployed in the school's program are essen-tial.

Effective, widespread education and pub-lic relations is one of the solutions to thelitigation problem. If coaches, athletes, andparents know how injuries occur, know thatsome cannot be prevented, but are con-vinced that the school and coach have doneeverything in their power to provide a safeexperience,, athletes will expend greater ef-forts to protect themselves, and parents willbe less likely to employ a lawyer to solve theireconomic problems if an injury occurs. Atevery turn, coaches and schools must dem-onstrate that their supreme concern is for thehealth and safety of athletes.

In short, coaches must give as much atten-tion to eliminating the risk of litigation asthey give to producing a winning program.

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8Athletic Nutrition, Diet, andWeight Control

Kathy Heck A T C

Coaches, athletic trainers, and teachers areimportant information sources for athletesseeking nutritional advice. In providing suchinformation two goals should be kept inmind: to assist the athlete in obtainingmaximum performance through proper dietand weight control; to aid the individual inthe development of good eating habits forlater life.

Diet

There is no perfect athletic diet. In fact, thediet eaten by athletes should be just the sameas for any normal individualexcept for anincreased caloric intake to provide sufficientenergy for physical activity. The recom-mended "balanced diet" developed by theNational Academy of Science's Food andNutrition Board consists of:

Dairy Products2-4 servings daily

Fruits and Vegetables4 or more servings daily

Bread and Cereals4 or more servings daily

Meat, Fish, or Poultry2 or more servings daily

Protein

In addition to the basic four food groups,nutritionists have further identified six es-sential nutrients: proteins; fats; carbohy-drates; vitamins; minerals; water. Actuallyeating the recommended servings of each ofthe basic food groups ensurf s the individualof getting all the essential nutrients exceptwater.

Protein sources include meat, fish, dairyproducts, eggs, soybeans, etc. These foodsare primarily utilized in the growth arid "re-pair of tissue and are only a secondary source

51

of energy. Therefore, exercise does notgreatly increase an athlete's daily protein re-quirement. A protein intake of one gram pertwo pounds of body weight per day is suffi-cient even when attempting to gain weightor strength during weight-training pro-grams. To assure maximum utilization ofprotein, intake may be distributed through-out the day rather than ingesting the day'ssupply at a single meal.

Diets consisting of only protein foods maypose a hazard to the athlete. Excessive levelsof protein intake may be toxic since the fixedacids of urea and ammonium are byproductsof protein metabolism. As waste products,these acids circulate in the body until filteredby the kidneys and excreted via the urine.Thus, an elevated level of waste products incirculation may contribute to early fatigue inthe athlete. The high protein diet also re-quires that the individual's fluid intake beincreased to assist the kidneys in filtering thefixed acids from the blood. Protein foods areslow to digest taking four to six hours towork their way through the stomach andupper bowel. For these reasons proteins arenot the ideal element for pre-game meals inathletics. It is far more advantageous to re-place the traditional steak and eggs with ahigh carbohydrate content meal.

Carbohydrates

Carbohydrates, the sugars and starches,compose the cereals and grains, e.g., waf-fles, spaghetti, breads, potatoes, etc. Thesefoods provide the quickest and most efficientsource of energy for athletic events. Car-bohydrates are easily broken down to glu-cose and used for energy or converted toglycogen and stored in the liver and muscles.Glycogen storage is important to the athletesince it determines how long he or she can

57

function prior to exhaustion. The averagestorage equals 1500-2000 calories. The deple-tion of stored glycogen is best illustrated bythe phenomena of "hitting the wall" experi-enced by trained marathon runners. This issaid to occur at the 20th mile of a marathonrace, or after approximately two hours oftime. After glycogen stores are depleted, thebody must rely on energy stored in the formof fat.

By loading up on carbohydrates prior tocompetition, performance is not improved,but individuals may be able to maintainmaximum exertion longer. This is of particu-lar importance to athletes involved in endur-ance sports such as distance running,swimming, and cross-country skiing, soccer,field hockey, lacrosse, etc. The techniques of"carbohydrate loading" have been de-veloped to assure maximum precompetitionglycogen storage. The athlete begins sevendays prior to competition and completes aworkout similar to the length of the competi-tive event to deplete glycogen storage levels.For the next three days a high protein, lowcarbohydrate, diet is eaten and normalworkouts are completed. Then, during thelast three days prim to competition theathlete switches to a high carbohydrate, lowprotein diet, and the workouts are tapered.In this fashion, the athlete attempts to "load"glycogen prior to competition.

Obviously, the "carbohydrate loading"has disadvantages:

Many athletes are unable to handle thetoxic effects of high protein intake.The cycle takes a full week and cannot bedone effectively more than several timesper year.With an increase in glycogen storage, theathlete will also experience an accom-panying increase in water storage (2.7grams of water per gram of glycogen).This resulting increase in body weightmay be detrimental to many athletes.The actual effects of the "carbohydrateloading" technique are questionable.Research on its effects is not conclusive,and proving that the positive effects arenot merely psychological may be dif-ficult.

For these reasons "carbohydrate loading"is not suggested for all athletes, particularlynot for team sport athletes playing severalgames each week. But as a practical applica-tion, it is recommended that athletes insports requiring a high level of endurance eathigh carbohydrate content food in the lasttwo to three meals prior to competition. This

will ensure adequate levels of glycogen stor-age without encountering the undesirableside-effects of complete "carbohydrate load-ing."

Fats

When the body does consume all availableglycogen stores, it switches to a more con-centrated type of energy in the form of fat.As an energy source, fat provides twice asmuch energy per gram as do carbohydrates,but is a much more difficult substance tometabolize. It is thought that females are ca-pable of metabolizing fat more easily thanmales, and this opens the possibility thatfemale runners may have an advantage overmales in ultra-distance races of 50 miles ormore. Fats are necessary to the diet assources of the fat-soluble vitamins A, D, E,and K and to provide satiety value and tasteto foods. Dietary sources include oils, butter,animal fat, whole milk, fried foods, etc. Be-cause high-fat content foods may be difficultto digest and slow the gastric emptying pro-cess, they should not be a major componentof precompetition meals.

Vitamins

Vitamins are often a source of controversyin athletic nutrition. But despite the belief ofmany, there is no data to support the ideathat performance is enhanced by vitaminsupplementation. A well-balanced dietprovides all of the necessary vitamins forathletes and non-athletes alike. Supple-ments to vitamins are recommended only ifthe daily diet is not of the proper composi-tion. In that case a daily multiple vitaminsupplement may be advised. Excessive in-take of the fat-soluble vitamins (A, D, E, K)may be harmful since they are stored in thebody and can build up to toxic levels. Exces-sive amounts of water-soluble vitamins (Cand the B complex) are filtered through thekidneys and excreted via the urine on a con-tinuous basis. Vitamin C, though whentaken excessively, can be destroyed withinthe body and result in "rebound deficiency."

Minerals

Minerals of particular importance are iron,and the electrolytes involved in muscularcontraction and relaxation, salt and potas-sium. Since anemia can be considered astress injury attributed to heavy workouts,iron supplementation may be important tocertain athletes. This may be particularly true

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for female athletes who lose iron on amonthly basis via menstruation. The electro-lyte minerals are lost through perspirationand need to be adequately replaced to ensuremaximum athletic performance. This can beachieved by salting food to taste and by regu-lar dietary intake. When the athlete is under-going extremely heavy workouts, electrolytesupplementation may be necessary, eitherby salt/potassium tablets or by commercialelectrolyte preparations. Caution must beused in administering salt tablets to athletes.They should be taken ody:

with meals to avoid stomach upset;with a minimum of 8 ounces of water orother fluid to ensure proper water/saltconcentration in the body;three to four hours prior to activity toallow salt to be present in the body dur-ing exercise.;at a rate of no more than one tablet persix pounds loss of body fluids; this is bestdetermined by weighing prior to and fol-lowing practice sessions.

Water

Water is an often-overlooked nutrient, butone that is of extreme importance in ath-letics. The normal individual requires aminimum of eight glasses (2000 ml) of fluidsdaily. This requirement is greatly increasedfor athletes because of fluids lost throughperspiration, and dehydration can become aserious problem for athletes. Initially, it con-tributes to early fatigue and diminished per-formance, but dehydration can progress tomuscle cramps, heat exhaustion, and even tothe potentially fatal syndrome of heat stroke.Since adequate fluid intake is so important,unlimited access to water during workouts isessential. This is of particular importance inwarmer climates and in sports where heavyprotective equipment is worn. It has beenfound that the thirst mechanism is in-adequate in assuring the body of proper fluidreplacement. Therefore, it is useful to keep adaily weight chart to monitor fluid losses.The athlete should force fluids when theday's weight is not equal to the previousday's recorded weight. This can seriouslyaffect performance, and the loss of onepound of body weight equals one pint offluids.

Pre-game Meals

As previously mentioned, pre-game mealsshould consist of high-carbohydrate foods

such as pancakes, waffles, spaghetti, maca-roni, potatoes, breads, etc. The meal shouldbe eaten three to four hours prior to game-time to assure the athlete of the smallest pos-sible stomach volume. Fluids can com-fortably be taken up to within 20-30 minutesbefore the start of activity. The pre-gamemeal should consist of foods familiar to theathlete and the meal should be nonirritatingand pleasant-tasting. Milk has often beenconsidered a poor pre-game beverage, but itmay be very soothing to the athlete with anervous stomach. Foods and beverages con-taining high concentrations of sugar shouldbe avoided prior to and during competition.This includes candy bars, honey, and dex-trose pills. High concentrations of sugardraw fluids to the gastrointestinal tract andslow gastric emptying. A solution as dilute as2.5% glucose will decrease the rate of gastricemptying by 10% AdQquate blood sugarlevels are important, but quantities ingestedat a rate of greater than 50 grams (3 roundedtablespoons) per hour can impair perfor-mance. Rapidly consuming large amounts ofsugar results in insulin being released tostabilize the blood sugar level. This results ina rapid decrease in the blood sugar level, andthe body suffers a "roller coaster" effectwhich can lead to early fatigue and weak-ness.

Liquid meals may be useful for athletes,either as a dietary supplement for attemptingto gain weight or as a pre-game meal. Theymay eliminate the dry mouth, abdominalcramps, and nausea experienced by athleteswith pre-contest digestive distress. A liquidmeal costs far less per serving than the tradi-tional steak, and it can be a convenient wayto feed athletes when playing away fromhome. There is no proof that liquid mealsenhance athletic performance, but they dohave advantages that make them useful incertain situations.

Weight Control

Since 20-30% of the American populationis overweight, it is safe to assume thatathletes are not immune from weight controldifficulties. For athletes, excessive fat is deadweight that results in less speed, diminishedendurance, and lower resistance to injury.

Height-weight charts are not always anaccurate means of determining an athlete'sideal weight, especially the individual with alot of muscle bulk. A better estimate is thebody fat percentage which can be estimatedby underwater weighing or skinfold cali-pers. It has been found that body fat percent-

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age is inversely proportional to maximumoxygen uptake. In other words the athleteswith lower body fat percentages seem to bethose who can utilize oxygen most effi-ciently. The following chart indicates accept-able body fat percentages:

Sex Athletes Desirable ObeseMale 7-12% 12-15% 20%+Female 12-15% 15-25% 27%+

The key to weight control is that caloricexpenditure must match or exceed caloricintake. To achieve this goal, the overweightathlete must undergo a permanent change ineating habits. One pound of weight gain re-sults from the intake of 3,500 unusedcalories. An estimate of daily caloric re-quirements is as follows:

Males FemalesTo Maintain 2400 1900To Lose 1500 1200Light Activ-ity

2900 2400

Moderate Ac-tivity

3700 3000

Heavy Activ-ity

4300 3600

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When attempting to lose weight, anathlete's intake should never drop below1200 calories per day for females and 1500calories for males. And weight loss should begradualno more than 2-3 pounds perweek. Athletes should be especially encour-aged to avoid fasting diets. Such rapidweight loss consists of only 35% fat and 65%lean body tissue. Therefore, this sort of dietis particularly dangerous for athletes andgrowing adolescents. Sensible eating is im-portant to any weight control program. Ob-viously, if fad diets worked, the constantflow of new ones would not exist. Most aredangerous, ineffective, and boring. It shouldbe a matter of year-round concern; "starvingdown" in pre-season is unwise and un-healthy.

,..; iaryThere are no wonder foods or, winning

dietary formulas for the athlete. The- basicsof nutrition are as important as the basicskills of the sport itself. Only through properdiet and weight control can the athleteachieve his or her full potential and developgood eating habits for the future.

6 0

Coping with the Heatand HumidityHolly Wilson, A.T.C., Ph.D.

With the beginning of either the fall orspring sports season, the coach should beconcerned with environmental conditions ofheat and humidity, particularly in the mid-west and southern regions of the UnitedStates. While a hot environment poses athreat to the active athlete it is not as danger-ous as one in which the humidity level is alsohigh. In a hot, humid environment the activeathlete may be unable to maintain the coretemperature of the body within its narrowcritical range of 96-108°F.

The athlete is not only generating bodyheat through activity but also absorbs beatfrom the environment when the atmospherictemperature is greater an that of the skin'ssurface. The major temperature regulatorymechanism of the body is sweating; how-ever, as the humidity level increases, indicat-ing that the atmosphere is approaching sat-uration, cooling through sweating becomesineffective. Sweat must evaporate for cool-ing to take place. In a hot, humid environ-ment when evaporation of sweat is hin-dered, the athlete continues to sweat andthis is wheri the individual may get intotrouble.

Weight loss during activity is primarilyfluid loss, not the metabolism of fat. Forexample, if the athlete runs at a rate of 5 mph,7.5 cal/kg of body weight/hour would be ex-pended. Therefore, an athlete weighing 60kg (132 pounds) would expend only 450calories if the individual ran for one hourwithout stopping at a rate of 5 mph. Onepound equals 3500 calories. For every twopounds of body weight the athlete loses dur-ing activity, one quart of water has been lost.This fluid comes from the body fluids so thecirculatory blood volume decreases as theathlete continues to sweat. Heat stress is anembarrassment of the circulatory system.

If the athlete loses only 1% of the bodyweight (1.3 pounds in a 132-pound athlete)due to water loss, there is some physiologicalimpairmentreflex time decreases as doesstrength. Under such a condition, the athletemay be more susceptible to injury becausethe individual is unable to react as quickly orexert as much force. Of course, the athlete'ssusceptability to injury would increase asfluid continues to be lost. At a 3% loss ofbody weight (approximately 4 pounds in a132-pound athlete) pulse rate increases asdoes rectal temperature. The reflex responsecontinues to decrease and the athlete be-comes less mentally alert. The athlete be-comes susceptible to heat exhaustion as a 6%loss of body weight is approached; however,a gray area is entered with a weight loss of3-6%. Some athletes will show signs of heatexhaustion while in this gray area due toindividual differences. The signs and symp-toms of heat exhaustion are:

pale, clammy skin;increase in respiratory rate;muscular weakness;decrease in blood pressure;normal or subnormal body temperature;nausea and vomiting.

The increased respiratory rate and vomitingcompound the problem even more becauseboth result in additional fluid loss. Theathlete displaying symptoms of heat exhaus-tion should be removed from activity, takento a cooler area, wet clothing removed if pos-sible, and fluids administered. The athletemay be a candidate for heat stroke, if fluidbalance is not restored. It is important toforce fluids for thirst is not a good indicator ofthe athlete's fluid needs.

The atnlete is susceptible to heat strokewhen more than 6% of the body weight islost (approximately 8 pounds, in a 132-

5561

pound athlete). The signs and symptoms ofheat stroke are lethargy, lightheadedness,dizziness, confusion, vomiting, diarrhea,muscle cramps, unconsciousness, and anelevated body temperature. In addition, theathlete has hot dry skin because the sweatingmechanism has turned off. The individualhas lost all the fluid the body can sparethrough sweating in an attempt to regulatebody temperature. (The critical temperatureat which brain damage occurs is108°F.) Everyattempt must be made to reduce the athlete'stemperature as quickly as possible, or deathmay occur. The athlete may be placed on achair under a cold shower, submerged in acold whirlpool, sponged off with lukewarmwater (not alcohol) or cooled with an electricfan. Call a physician and ambulance im-mediately because, in most cases, the athleteis unable to take fluids orally so they must beadministered intravenously.

Watch the tall lean participant closely in ahot humid environment. This individualproduces more heat per body area than theoverweight individual who is carrying excessmetabolically inactive tissue, fat. However,the latter individual does expend additionalenergy lugging around the excess weight.

To prevent heat stress, acclimatize athletesto the environmental conditions in whichthey are going to be active. Acclimatizationvaries according to the time of year, the geo-graphical location, and the sports activity.Athletes must be conditioned to the temper-ature, the humidity, and even the-clothingwhich they are going to wear during partici-pation. The physical condition of eachathlete at the beginning of the season is amajor contributing factor in susceptibility toheat stress. The conditioned athlete con-serves body salts (electrolytes) by producinga less-concentrated sweat and sweating lessprofusely. Each athlete should engage in anindividualized off-season conditioning pro-gram so he/she can return to school in good,if not excellent, physical condition.

The athlete should begin the conditioningprogram approximately eight weeks prior tothe season. The program should focus on thedevelopment of cardiorespiratory fitness,both aerobic and anaerobic. The amount ofparticipation in each will be determined bythe sport in which the athlete is going tocompete. Suggested activities for developingcardiorespiratory fitness are running,swimming, and bicycling. In addition, theathlete should not ignore the development ofstrength through weight-training. Car-diorespiratory fitness activities should be

scheduled three days a week and weight-training two days a week.

The athlete should be active at approxi-mately the same time that practice will bescheduled in the fall or spring. Only in thisway will the individual become acclimatizedto the heat and humidity. The athlete shouldwear clothing similar to the school's athleticuniform in both fiber content and body areacovered.

In the fall or spring, early season practicesmust be progressive to achieve acclimatiza-tion. Alternate work and rest periods, but donot drag out practices. Make them short andhard. Provide plenty of water and allow theathlete to take water breaks when desired,and not according to the coaches' schedules.Do not give salt tablets or a saline solutionprior to or during activity. The high concen-tration of salt in the gastrointestinal tract, as aresult of ingesting salt tablets or a hypertonicsaline solution (greater than 0.9%), requiresdilution before absorption can occur. Con-sequently, fluid is withdrawn from the bodyfluids to dilute the salt. A hypotonic solution(0.1%) may be used after practice to replacethe fluid lost during activity; however, salt-ing of food regularly will usually replace thesalt lost in the sweat. The same holds true forpotassium supplementation especially iffresh fruits or vegetables are regularly eaten.Items high in potassium but low in caloriesinclude oranges, grapefruits, apricots,watermelons, cantaloupes, tomatoes, ar-tichokes, and brussels sprouts. Avocadoes,bananas, dates, and raisins are good sourcesof potassium but they are also high incalcries. Replacement of fluid is the criticalthing!

Instead of purchasing a commercial salinesolution, which tends to be expensive, youmay make your own with 6 quarts of water, 1teaspoon of salt, and a flavoring. This is a0.1% saline solution that can be absorbedwithout further dilution in the gastrointesti-nal tract. Do not use a flavoring that requiresthe addition of sugar for sweetening. Sugarincreases the emptying time of the stomachand may cause intestinal cramping anddiarrhea.

Make use of a weight chart to ensure thatthe athletes are not losing too much fluid andapproaching chronic dehydra tion. (SeeTable 1.) Weigh each athlete before practiceand then immediately after, before the indi-vidual has ingested any water (other thanthat during practice). Repeat this procedureevery day. Each athlete should weigh in (be-fore practice) at approximately the same

56 62

Table 1. Weight chart.*

Nameof

Player

Date

Time ofPractice

Rel. HumidityWet Bulb Temp.

10 z

al

00

to ]A

t1

00

3.

5Ea

cs

..,I ,

1

tata975

0Vro

14

0!

00

Itix

64

*Reprinted with the permission of Cramer Products, Inc.

weight every day. An athlete with a waterloss problem, should be watched closely.The individual should prehydrate by drink-ing 1-3 quarts of fluid prior to each practice,spreading the intake out over several hours.

If an athlete is unable to regain fluid bal-ance between practices the individual ismore susceptible to heat stress and may be-come chronically dehydrated. The signs ofchronic dehydration are loss of appetite,nausea, and diarrhea as well as the loss ofweight. Prehydration is a necessity with thisathlete; otherwise dehydration will affectvital body processes. For example, if theathlete does not have enough fluid the kid-neys cannot adequately remove the wasteproducts of exertion. In effect, the blood be-comes too thick to pass through the kidneytubules for cleansing. Consequently, theathlete may develop a subclinical uremia. Foradequate kidney clearance the athlete shouldexcrete 1000 to 1500 cc of urine per day. Evenwith prehydration, if the athlete does notregain body weight, the individual should bewithheld from practice and examined. Theremay be a reason other than fluid loss forcontinued weight loss. Usually it is an im-proper diet.

The intensity of each practice should bedetermined by the environmental. condi-tions, not the coach. Immediately beforepractice, check the temperature and humid-ity by calling the local radio or weather sta-tion. The following chart should be a guideas to the intensity of practice.

Temperature Humidity Activity

80-90°F Under 706/o O.K.F Over 70 °) Caution, rest

(particularlyduring earlyseason).

90-100' F Under 70% Caution, rest.F90-10 Over 70%0° Shorten

practice orchange time.

Over 1000 Shortenpractice orchange time.

As a rule of thumb, anytime the tempera-ture and humidity levels add up to 150 ormore, curtail the practice, change the prac-tice time, or schedule a "chalk talk." By tak-ing a few simple precautions heat stress canbe guarded against and hopefully manyproblems eliminated.

65

58

1Mlic

Emergency Preparation* 1 0Holly Wilson, A.T.C., Ph.D.

To borrow a well-known phrase, be pre-pared, before an emergency occurs. A pre-determined emergency plan should be estab-lished and frequently reviewed so thateveryone involved knows and understandswhat to do when and if an emergency doesoccur.

Field Set-up

The activity area should be set up prior toevery practice and game to deal with the careof common injuries. Accept the fact that in-juries are part of the game, but those injuriesthat do occur may not seem as disruptive ofpsyche, practice, or the game plan, if pre-pared. Chance of injury can frequently beminimized by making a daily inspection ofthe playing surface and surrounding area.Check fields for holes and debris such asglass, metal, and empty cans. In the gym,loose boards, wet spots on the floor, nearbywindows, and wall fixtures that project out-ward are just a few of the many hazards thatmay need to be contended with. Equipmentstored around the edges of the court is usu-ally forgotten about but could also be a po-tential hazard.

Water, ice packs, towels, a blanket,splints, an arm sling or a tria -flar bandage,and a first aid kit should be the sidelinesfor immediate use every time the team takesthe field or court for a practice or gamewhether it be at home or away. Water may bestored in a cooler or in plastic squirt bottles ifa hose or drinking fountain is not nearby. Ahigh impact plastic cooler is superior to thestyrofoam type. Although more expensive,the additional cost is soon justified by itslongevity. Plastic coolers are available in 2-,3-, and 5-gallon sizes. Squirt bottles are notas hygienic as paper cups but ease and econ-omy often "justify" their use. They are easier

to carry and store if housed in a wire orwooden rack. Unfortunately, the plastic-coated cardboard carrier in which manymanufacturers pack a set of six bottlesquickly deteriorates. A student in a wood-shop class can make a rack without muchdifficulty. Throughout the activity period,the water supply should be frequentlychecked. Water should be available to theathletes according to individual need, notthe coach's schedule. Provide ice, water,paper cups, and towels for the visiting teamif at all possible.

Any of the splints commercially-available(board, plastic air, cardboard, or ladder), issuitable for sideline use. (See Figure 1.)Some splints come arranged in sets pack-aged in handy carrying kits. Keep in mind,however, a suspected fracture should onlybe splinted by someone knowledgeable inproper splinting techniques as well as theuse of the particular splint. A simple non-angulated fracture could become a moreserious injury and possibly an open fracture(one with an external wound) when handledroughly or improperly.

It is highly recommended that all coachescomplete a course in advanced first aid andemergency care offered by a local chapter ofthe American Red Cross.

Arst Aid Athletic Training Kit

The first aid athletic training kit need notbe an expensive medical bag, athletic train-ing kit, or compartmentalized paramediccase. A simple tool box or fishing tackle box isa satisfactory substitute. In the latter in-stance, however, one or more of the plastic

*The copyright for this article has been retained by theauthor. Similar material will appear in a book, Coaches'

Guide to Athletic Injuries, which has been accepted forpublication by Human Kinetics Publishers.

59 66

a. Ladder

c. Plastic without zipper.

Figure 1. Commercially-available splints.

60 6 7

b. Plastic with zipper.

d. Cardboard.

trays may need to be removed (simply cutthrough the rivets with a metal saw). Ideallythe case should be tall enough so that bottlesand spray cans can be stored upright. Do notbuy a prestocked athletic training kit formany of the items are seldom used.

The kit should be checked after each prac-tice and game and, if necessary, restocked.Only the person delegated to care for injuriesshould use the items in the ki;.. Only withsuch a restriction do the contents remain inorder and readily available in adequateamounts. A well-equipped first aid athletictraining kit should contain the followingitems:

Elastic Bandage (cotton)*at least one3-inch, one 4-inch, and one 6-inch ban-dage should be packed; if there is room,pack another 4-inch bandage.Tape*carry 2-3 rolls of 11/2-inch ath-letic tape. It can easily be split to thedesired width. Add more if needed andif space is available.Tape Adherentit is more economicalto paint the involved area with liquidthan to use an aerosol spray. The liquidmust be stored in an airtight containerso that the ingredients do not evaporate.Apply a lubricant such as petroleumjelly around the rim of the jar and the lidfor ease in removal. A regular paintbrush may be used for application of theadherent. After using the brush, clean itwith tape remover. Recently, a pumpspray applicator for tape adherent wasintroduced on the market as an eco-nomical alternative to the aerosol spray.Similar containers may be found at alocal hardware store. It may be neces-sary to clean the nozzle frequently toprevent the adherent from plugging up.Tape Removerinstead of the liquid, abox of single, individually packagedgauze pads saturated with tape removercan be purchased. In the long run, theseunit dose packages may be more eco-nomical and are certainly less messy andeasier to use. Make sure the athletethoroughly washes the skin with soapand water after using any tape remover.Underwrappack one roll unless a lotof taping is done. (If so, critically exam-ine whether all the taping needs to bedone.)Tape Cutterif possible always use atape cutter to cut off a strapping. Cut-ting through many thicknesses of tapequickly makes bandage scissors dull.Bvndage Scissors*stainless steel scis-sors are more expensive than chrome

61

and there is little justification for theadded expense. The standard size scis-sors used in the training room are 71/4inches; however, 51/2-inch ones are use-ful when cutting bandages off smallbody parts. Sdssors might be availableat a very nominal cost from governmentsurplus.Nail ClippersTweezers*--splinter forceps availablefrom a medical supply dealer are moreuseful than the tweezers found in mostdrug stores. Once again, chrome is fine.Penlight Flashlight*Antiseptic Cleansing Agent*althoughit is a poor antiseptic, 3% hydrogenperoxide is recommended because itsfoaming action may loosen embeddeddebris. Store it in a light resistant amberbottle so that the hydrogen peroxidedoes not break down into its componentparts.Mild Soap*do not use an antibacterialor deodorant soap for cleansingwounds. Instead, use a mild soap suchas Ivory or Camay.Antiseptic SolutionIsopropyl alcoholor one of the nonstaining, nonstingingiodine derivatives (povidone-iodine)such as Betadine is recommended.**The latter is more expensive.Frequently, either one of these two an-tiseptics is used to disinfect a "tool"such as a pair of splinter forceps prior touse.Antiseptic Cream*carry a mild, singleingredient cream. An ointment has agreasy base that seals off the wound andmay make it more prone to infection.Skin Lubricantpetroleum jelly isperhaps the most common and availablelubricant used in the training room.Sterile Gauze Pads*--3 x 3-inch padsare the most useful size; however 4 x4-inch pads may be needed to coverlarger wounds. Cut smaller sizes fromthe larger pads, but keep each pad in theprotective wrapper while cutting. If tap-ing only a few ankles, use 3 x 3-inch

*Recommended for preparation of a first aid kit only."Most of the microorganisms that enter a wound are

washed away with a thorough soap and water cleansingand those culprits that do remain are easily handled bythe body's natural defenses. Surface wounds are usu-ally better off without any one of the many antisepticsfound on the drug store shelves. (Deep wounds shouldbe left for the physician.) If an antiseptic must be used,apply it to the edges of the wound and surroundingarea, not the open skin, especially if using Isopropylalcohol!

68

pads to protect the heel and lace areas.Otherwise, it is more economical to usenonsterile gauze sponges or "bubbles,"3 x 3-inch squares cut from sheets of airbubble packing material.Bandaids*if economically feasible,carry all three strip sizes, 1 x 3-inchstrips, 3/4 x 3-inch strips, and extralarge. If the budget is limited, omit the3/4-inch (the one-inch strip can be cutdown to the desired width). Purchasebandaids in boxes of 100 or an industrialpack to save money.Butterfly Closures or Steri Stripsbutterfly closures are useful to tem-porarily close lacerations. Althoughcommercially-available, a butterfly caneasily be made from a small strip of ath-letic tape. (See Figure 2.) Steri Strips areoften used by physicians to close a lacer-ation instead of stitching the wound.They are expensive and available only inboxes of 100 packets, each packet con-taining several strips depending on thewidth. The qs-inch or 1/4-inch width ismost frequently used. Perhaps a localphysician would donate a packet or twoas well as give instructions on theproper use and application of such clo-sures.Gauze Bandages*conforming, self-adhering bandages are easier to usethan plain gauze bandages but are moreexpensive. Carry a few 2-inch rolls.

Analgesic Balma water-solubleanalgesic is recommended instead of anoil base one. Regardless, the balmshould be mild, especially if used foranalgesic packs.Tongue Depressorsbesides beingused as ointment spreaders, the juniorsize depressors double as temporaryfinger splints. (For injuries to the first orsecond segment, bend the depressor soit is curved; otherwise, for injuries to thethird segment, leave the depressorstraight. Regardless, pad the splint be-fore applying it to the injured finger.)Cotton-tipped Applicators (Sterile)*store the cotton-tipped applicators andtongue depressors in a closed containerto retain theif cleanliness. Some tooth-brush holders work well.Hand Mirrora protective case may bemade from felt.Eyewash (Sterile)--avoid using a prod-uct containing boric acid. Boric acid ispotentially dangerous because, in somecases, it has been found to be a systemicpoison.Contact Lens Wetting Solution(Sterile)different solutions are re-quired for hard and soft lenses.Contact Lens Storage Casemany op-ticians specializing in contact lens carehave extra plastic cases in which lenses

*Recommended for preparation of a first aid kit only.

4"

Figure 2. Pattern for making a butterfly closure.

62 69

are shipped. If necessary, use these fortemporary storage of lenses.Towel Squares, Disposable Baby Diap-ers, or Combinefor making analgesicpacks.Adhesive Felt and FoamVs- and 1/4-inch thicknesses are the most useful formaking donuts and other specialitypads.MoleskinVinyl FoamV4- and 3/8-inch thick-nesses are used for padding bruises(contusions) and tender areas.Triangular Bandage or Sling*Safety PinstRubber BandstNeedle and ThreadtTamponsbe alert to the early warningsigns of Toxic Shock Syndromea highfever (usually 102° F or higher), vomitingor diarrhea, and a rash that looks likesunburn. Avoid brands that incorporatea deodorant into the tampon.Aspirinpurchase a small quantity of agood house brand. However, there maybe restrictions from dispensing medica-tion by the regulations of the schoolboard.Change for a Telephone Call*List of Emergency Phone Numbers*First Aid Manual*First Aid Policies and Procedures*

It may be necessary to pack two kits. Oneshould contain the materials required forstrapping and padding while the other issolely for first aid care. A zippered vinyl gymbag is suitable for the strapping and paddingsupplies.

If possible, supplies should be bought lo-cally at the drug store, medical supply com-pany, or a sporting goods store. It may benecessary to purchase supplies from severalplaces for a preference may develop for cer-tain brand items. Frequently, local busines-ipeople are more than willing to donatesupplies to help a team out. For example, alocal pharmacist may donate new emptyprescription bottles and capsules to use ascontainers in the first aid athletic training kit.(Be sure that every item in the kit is well-labeled: name of the product; directions foruse; precautions; expiration date.) In addi-tion, manufacturers of over-the-counterproducts often send pharmacists unit dose ortrial size samples of new products. Some ofthe products may be suitable for the care ofathletic injuries. A local camera shop maydonate empty plastic film canisters or plastic

slide boxes. Both are useful containers for thefirst aid athletic training kit.

A few money-saving tips are listed below.Undoubtedly some additional ideas mayarise as a result of a limited budget.

1. Ice may be available for first aid usefrom a nearby concession stand orcafeteria. Buy a bag of ice if necessaryrather than using commercially-madechemical cold packs. The chemicalcold packs are expensive and they donot get as cold or last as long as icepacks. If they leak, the chemical maycause irritation to the skin, especially ifa wound is present. Aerosol coldsprays are dangerous (frostbite) andabsolutely unnecessary! Plastic bagsand ice will suffice for all needs. Alocal grocery store may donate a roll ofplastic bags used in the fruit and veg-etable section. If bags must be pur-chased, the heavy duty plastic bagswith the ziplock closure may be moreexpensive but they outlast flimsierbags. The zip closure makes it easy topour out water as ice melts.

2. Cups for ice massage may be reused.Put a tongue depressor or spoon in thewater before freezing and use it as ahandle during application. If avail-able, small metal juice cans are idealcontainers for freezing.

3. Warm wet towels or hot water bottlescan be used as a superficial heat mod-ality in place of a heat pack. A 15-20-minute hot shower with the showerhead aimed at the injured part mayalso be therapeutic; but only if swel-ling is controlled.

4. A hose and a large plastic containercan be used to simulate a whirlpool.When treating a new injury, do notdirect the flow of the cold wateragainst the tender tissue. The force ofthe water can aggravate the sensitivearea and result in an increase in swel-ling.

5. Plain aerosol shaving cream may beused in place of mild soap for cleans-ing wounds. Although slightly moreexpensive, the shaving cream is easierto use.

6. Old socks may be used as ice packs.Fill the sock with ice and tape the end

*Recommended for preparation of a first aid kit only.tThese loose items may be carried in a plastic con-

tainer such as a soap box along with nail clippers,splinter forceps, and mirror.

63 70

shut. Store the sock dry in the freezeror cooler. Just before use, moisten thesock with water and then place it onthe injury.

7. Gauze sponges rather than sterilegauze pads or cottonballs can be usedfor cleanups such as removing tapeadherent and tape residue. Thesponges are not sterile so they shouldnot be used to clean wounds.

8. An applicator for liquid tape adherentcan be made from a tongue depressorand a piece of felt. Staple the felt to theend of the depressor.

9- A convenient container for carryinggauze pads in the first aid kit can bemade from the bottom half of a largerectangular plastic medication bottle.Ask a local pharmacist to save emptybottles and then cut off the upper halfwith a warm sharp knife. Tape the cutedge.

10. Heavy duty plastic bags with a ziplockcan be used in the first aid kit to keepitems together, clean, and waterproof.

11. Used elastic bandages may be avail-able from a local hospital. Check withthe emergency room or orthopedicdepartment because used bandagesare frequently discarded.

12. Plastic coreE, from tape rolls can betrimmed into a protective covering foran injury to the fingernail or toenail.Pad the inner surface with adhesivefoam or a sterile gauze pad.

13. A plastic bottle rack makes an idealtray for serving water to a team. If theslots are labeled with each player'sname then the same paper cup may berepeatedly used by the player so ctyscan be conserved. Replace the cupseveryday for each practice and game.

Emergency Plan

Even if the proper emergency equipmentand supplies are readily accessible on thesidelines, prompt action is impossible with-out a predetermined plan for handlingemergencies. The plan should be developedlong before the beginning of the season andit should be evaluated frequently andchanged as necessary. After all, differentsports practice at different sites, so somemodification in the plan is required with thechange of seasons. Personnel from the localambulance service, the team physician, thetrainer, the school principal, and the coach-

ing staff should all have input in the de-velopment of the plan.

Responbibilities must be delegated accord-ing to each individual's capabilities. To exe-cute the plan quickly and efficiently, eachperson must know the task assigned to themand understand just what is involved tocarry out the task. Pinpoint critical locationsbeforehand. For example, where is thenearest entrance to the field that is accessibleto an-ambulance? If it is a locked gate, will itbe unlocked during practices and games, orwill the key be readily accessible? Where isthe nearest phone? If only a pay phone isnearby, the appropriate change must bereadily available. Tape the coins to the insideof the first aid kit along with a list of all theemergency phone numbers. Include on thelist the numbers for the local ambulance orrescue squad, hospital emergency room, firedepartment, police department, team physi-cian, school health center, school principal,etc. Also include the names and numbers ofthose medical specialists who have workedwith the team. When working with minors,carry an emergency care card on eachathlete. Emergency care cards should in-clude the following information:

the name and phone number, home andbusiness, of parents or guardian;the name and phone number of the fam-ily physician;information on allergies and medicalproblems such as asthma, epilepsy,diabetes, etc.;faith, religion;a record of injuries incurred by theathlete and the corresponding treat-ments.

Telephone calls should be made only bythe designated individual. If in a school set-ting, there may be a set protocol to follow.For example, the school district may have acontract with one of the local ambulancecompanies for athletic events. Check withthe school principal or school board to besure that the emergency plan complies withany established protocol.

In an emergency, while the designated in-dividuals give first aid, call the ambulance orrescue squad, the parents or guardian, andthe family and/or team physician. When talk-ing with the ambulance service, give yourname and role, the type of injury (head,neck, spine, extremity, internal), and theexact location of the injured athlete. Also in-form the service of the number of the phone fromwhich the call is being made. Do not hang up firstfor the service nzay not have all the required in-

64 71

formation. Remain at the phone to provideany additional information or clarify anyfacts if the service calls back. If the directionsto the location are complicated and an extraperson is available, ask the individual tomeet the ambulance at the point where driv-ing is no longer possible, or directions be-come confusing. The individual can then di-rect the ambulance or rescue squad to theinjured athlete. If possible, prior to the sea-son, review with the ambulance service per-sonnel the location of the various playingfields and courts and the best access to each.

With little planning and effort, the athleticenvironment can be made safer. Such pre-cautions are well worth the time and effort ifonly one injury can be prevented. It is notenough to have a predetermined plan; itmust be understood, practiced by all, evalu-ated frequently, and modified as necessary.Furthermore, all coaches should be knowl-edgeable not only about the skills of thesport, but first aid and CPR techniques aswell.

Legal Liability

It is well worth the time to become familiarwith the laws of the state regarding the careof an injury victim whether employedfulltime, paid coach, or unpaid volunteer.ff.Many states have a Good Samaritan Lawthat protects the individual who stops toprovide aid to a stricken individual. To beprotected under this law, however, caremust be provided that would be equivalentto that given by others with similar back-grounds in a similar situation. A coach orphysical education teacher has a responsibil-ity to students or athletes to provide a higherstandard of care than a member of the gen-eral public. Both the coach and the physicaleducation teacher should have received spe-cialized training in first aid.

First aid techniques are recognized by thecourt as being the accepted standard of careto be used in an emergency. There is a bigdifference between first aid and treatment.As a first aider, recognize and understandthis difference. The best safeguard is to knowpersonal limitations and provide care accord-ingly. Let common sense be the guide.

Neither a waiver nor the fact that a coachmight not be paid for services protects him/her from possible liability in the event of aninjury. The couri does not recognize waiverforms for minors because parents cannotsign away the rights of a minor, even whenthe individual is their offspring. Moreover,whether paid or not, the coach is responsible

for the group and must perform competentlyat his/her level of training.

To be protected as a coach, against a law-suit, and more importantly, to protect thewelfare of athletes, take these precautions:

Develop a sense of safety awareness andincorporate it in the philosophy of sportjust as if it were part of the strategy ofthe game.Maintain equipment and facilitiesthrough periodic inspection and repair.Both should be thoroughly checked be-fore activity. Facilities should beplanned and their use scheduled toavoid over-crowding.Require annual medical examinationsfor all athletes. Such exams should bescheduled before the beginning of theseason, early enough to allow for possi-ble remediation of any problems uncov-ered during the testing. However, thetime period should not be so long thatan athlete could be injured before prac-tice starts. The medical staff performingthe examinations should have the finalsay concerning each athlete's clearanceto participate. Recommendations forrehabilitation of specified individualsmust be carried out before permission isgranted to practice. (Agency-sponsoredprograms such as Little League Baseballor Pop Warner Football should also re-quire a signed physical examinationform from the family physician eachyear.)Keep up to date on the techniques andstrategief, of particular sport(s). Be re-sponsiNe and teach athletes how toavoid injuries and how to perform in thesport. This involves teaching propertechniques as well as appropriate useand care of protective equipment, pre-cautions for weather extremes, and therisks of competing when ill, injured, ornot fully recovered from an injury.Proper preparation as a coach includestraining in first aid techniques (at least acourse in Standard First Aid and Car-diopulmonary Resuscitation.) A coursein Advanced First Aid and EmergencyCare is highly recommended. All threecourses are frequently offered by the

Waking this one step further, look into the state lawsconcerning the operation of physical therapy mod-alities. If employed at a school where various treatmentmodalities are made available to coaches (and athletes),be prepared for a surprise! In many states only physicaltherapists working under the supervision of a physiciancan legally operate such modalities.

65 72

American Red Cross. If possible, com-plete courses in child growth and de-velopment, anatomy, and physiology.Schedule competition based on size,weight, and skill level of the participantsrather than age or grade level. Individu-als should not be forced into competi-tion until physically and mentally pre-pared. Equipment fitting should takeinto account size, strength, and skill ofthe participant. Officials should becompetent so that the intensity of thegame can be controlled.Arrange with a local physician or groupof physicians to provide medical cover-age for all games and practices. If thephysician designated as the team physi-cian cannot be in attendance at allgames, arrangements must be madewith another physician to cover theevent(s). (If permitted by league rules, acertified athletic trainer could cover thegame(s) in place of a physician.) Forpractices, it may be possible to securethe services of an emergency medicaltechnician or paramedic.Work closely with the physician andother coaches and allied health person-nel before the season begins to developfirst aid policies and procedures for thecare and disposition of an injuredathlete. Make sure that all coaches re-ceive a copy of the policies and proce-dures and that a copy is included in eachfirst aid athletic training kit. Reviewthem periodically during the season.Allow sufficient time for conditioningprior to the beginning of the competitiveseason. Time must also be permitted forthe teaching, learning, and practicing ofnew skills. During each practice,schedule sufficient time for warm-up,cool-down, and water breaks.

Regardless of the precautions taken, in-juries do occur. In some instances, it may bedifficult to determine whether the injury isserious enough to take the athlete out of ac-tivity. While it is easy to distinguish betweena mild and severe injury, the difference be-tween a mild and moderate one may be moreperplexing. When in doubt, lean towardconservatism. Treat the injury as the more

66

serious one. Think in terms of a long-rangegoal, the well-being of the athlete. The star-ter going at half speed with an injury may no:be as good as the second or third stringergoing at full speed. Educate athletes aboutthe risks of participating when ill or injured.No athlete who has been withheld from ac-tivity as a result of an injury or illness shouldbe permitted to return to practice andlorcompetition without medical clearance. Ifsuch clearance is not obtained before allow-ing the athlete to participate, the coach islegally liable if the athlete is reinjured or sus-tains another injury as a result of the disabledcondition.

Report all injuries. Information gatheredfrom these reports is invaluable in identify-ing causes. It also implements the develop-ment of more effective safety precautions. Tobe useful, injury reports should be filled outcompletely and should include the followinginformation:

time, date, place, activity;name and address of injured individual;description of injury;mechanism of injury (how it occurred);complaint (the part injured, symptoms);first aid rendered;medical diagnosis and disposition;nature and date of medical clearance forreturn to practice;restrictions;date of medical clearance for unlimitedreturn;name, address, and phone number ofwitnesses (2);name and signature of individual mak-ing report.

The last four items of information cannot berecorded until after the athlete is examinedby a physician and released for activity. Keepthe completed reports on file for ready refer-ence if the need arises.

Everyone involved in athletics shouldhave personal liability insurance. In addi-tion, if working directly with the athletes,everyone should have a thorough under-standing of the insurance coverage providedby the school or league. It might also be wiseto check the insurance policy on the car usedto transport athletes. Coverage of this maynot be included in personal insurance.

73

NAGWS Sports MedicineMedical History Questionnaire

terscholasticllntercollegiate Athletics

This form will be kept confidential and will be used as supplementary information by theexamining physician.

Date of Physical

Name Age Height Weightlast first

Birthdate Social Security or I D #

School Address Phone

Parent or Guardian

Home Address City State Phone

I am a candidate for the Teamsport

Medical History (circle and/or check appropriate answer):

1. Have you ever been trtmted for any of the following:

Yes No infectious mononucleosisYes No virus pneumoniaYes No asthmaYes No rheumatic feverYes No scarlet feverYes No heart murmurYes No epileptic seizureYes No hepatitisYes No diabetesYes No sickle cell anemiaYes No illness requiring rest over one week

during the past year

2. If answer is "yes" to any of the above, please provide dates and treatment received forthe illness.

3. During the past five (5) years have you received any of the following injuries:Yes No knocked outYes No concussionYes No severe headachesYes No whiplashYes No pinched nerveYes No fracture of head or neckYes No sprained neckYes No strained neck (muscle involvement only)

4. If answer is "yes" to any of the above, please provide dates and details.

67 74

5. Yes No Do you have vision in both eyes?If no, please give details

6. Yes No Are you missing a paired organ, e.g., kidneys?If yes, please give details

7. Yes No Do you wear glasses? Regular Safety frames

8. Yes No Do you wear contact lenses? Hard Soft

9. Do you wear any of the following?Yes No permanent bridgeYes No permanent crown or jacketYes No removable partialYes No full plateYes No braces

10. Indicate if you have had any of the following during the past five (5) years:Yes No fractureYes No shoulder or throwing arm injuryYes No elbow injuryYes No wrist injuryYes No back injuryYes No knee injuryYes No Osgood-Schlatter's diseaseYes No ankle injuryYes No shin splintsYes No menstrual difficultiesYes No surgery

11. If the answer is "yes" to any of the above, please provide dates and details

12. Yes No Do you have a pin, screw, or plate in your body as a result of a bone orjoint surgery? If so, explain

13. Yes No Do you take any prescribed medications or drugs? If so, explain

14. Do you have allergies to any of the following:Yes No PenicillinYes No Sulfa drugsYes No TetracyclineYes No CodeineYes No AspirinYes No DarvonYes No bee stingsYes No Tincture of BenzoinYes No other

68

15. Yes No Do you carrry insurance that covers you as an athlete?Company

Address

Policy #

All of the above questions have been answered completely and truthfully to the best of my

knowledge.

Athlete's Signature

Parent's/Guardian's Signature

Date.

7669

Check-in Sheet

Date Name

Sport ID #

I. Yes No Have you incurred any injury or illness since your last physical that kept youfrom participating in any sports or recreational activities this summer?

If yes, please explain the circumstances below:

Date of injury

Type of injury

Body part affected

How did injury occur7

Was a physician consulted? Yes No

Additional information

Date of illness

Type of illness

Was a physician consulted? Yes No

Additional information

2. Yes No Do you have any existing problem(s) that you would like to see a physician

about?

If yes, what is the problem(s)

77

70

Emergency Information Cardttt

Please Print

Name Birthdate Age

Parent's (Guardian) Name Home Telephone

Address Grade

Phone No. of Parent during Day: Father Mother

In an Emergency, if Parents Cannot Be Contacted:

Notify at(Name) (Telephone Number)

Family Doctor Doctor's Phone

Preferred Hospital Known AllergiesThe team physician, trainer, and coach may apply first aid treatment until the family doctorcan be contacted. Yes NoWe give our consent for coaches, trainers, and team physician to use their own judgment insecuring medical aid and ambulance service in case the parents cannot be reached.Yes__ No

Date Parent's Signature

tReprinted with the permission of Cramer Products,Inc.

7178

Injury Report

Name Date of Injurylast first

Address Time of Injury

Phone Location

ID # Sport

Cbssification: PE IM ATH REC

Body Part Affected: (check)HeadNeckShoulderBackChestHip

Nature of Injury: (check)Severe CutBruiseStrainSprainDescribe How Injury Occurred:

Arm ThighElbow KneeWrist Lower LegHand AnkleFinger FootOther

Disposition:ReleasedStudent HealthFamily PhysicianHospital

Name of individual making report

Signature

Witnesses:

(1)Name(1)Address(1)Phone

Date

FractureDislocationReinjuryOtherSigns and Symptoms:

First Aid Rendered:

Supplies (Checked Out (Number):Elastic BandagesCrutches

Other

Returned Date

(2)

(2)

(2)

7972

Diagnosis:

Disposition:

Physician's Report

Recommendations:

Restrictions:

No practice until (date) Prescription:Expected return to competition (date)Return appointment (date)

Signa ture Da te

8073

Parent Notification Cardttt

DateDear Parent:

has received ainjury of the Although there is noevidence of serious injury at this time, it would be best to follow the instructions given on theattached sheet. Please call me at or contact your family physician if youhave any questions.

Coach/Trainer

tttReprinted with the permission of Cramer Products,Inc.

8174

Over-the-Counter 1Non-Rx Drugs

Holly Wilson, A.T.C., Ph.D.

In athletics performance is often affectedby the individual's well-being. For example,at one time or another during the season, anathlete may be afflicted with a cold. The nasalcongestion that usually accompanies it mayprofoundly affect the athlete's ability to sus-tain activity because oxygen exchange is re-stricted. Anxiety, travel, or new food experi-ences may alter gastroirostinal functionsuch that the athletes dtvelop a case ofdiarrhea or constipation. When attemptingto deal with such problems, it is helpful if thecoach has a basic understanding of the pros_and cons of self-medication as well as theeffectiveness of the various classes of medi-cation available over the counter to the con-sumer.

Over the past few years self-medicationhas been advocated by the medical profes-sion but only if the consumer is informed.For only the informed consumer can makewise decisions concerning health care. Theconsumer must realize that over-the-counterdrugs are potentially harmful. In fact, anydrug, whethet it be available over thecounter or only by prescription is a potentialpoison if improperly used. Many problemscan be avoided if the medication is takenaccording to instructionsthe recom-mended dosage at the proper time intervals.However, even by taking such precautionsthe unexpected may occur. Adverse drugreactions are not uncommon even whenover-the-counter drugs are administered.Children, the elderly, and individuals underphysical, mental, and emotional stress aremore sensitive to drugs. For example,athletes absorb, distribute, and break downdrugs faster as a result of their high metabolicrate during activity.

Important factors to keep in mind whenbeing self-medicated are:

use the simplest formulation available;check the list of ingredients before pur-chasing the product;read the instructions thoroughly beforetaking the medication;follow all instructions;consult a physician if the condition lin-gers on.

Presented in the next few pages is a con-cise summary of recommendations concern-ing the use of these classes of over-the-counter drugsinternal analgesic, anti-infectives, and cold remedies. For additionalinformation, the reader is urged to consultone of the many books now available onover-the-counter medication, e.g., TheMedicine Show published by ConsumersUnion.

Internal Analgesics

Internal analgesics are pain relievers andaspirin is perhaps the best known represen-tative of this widely-used class of over-the-counter drugs. Aspirin is a valuable drug forits many and varied therapeutic effects. Be-sides relieving pain, the drug also reducesfever and acts as an anti-inflammatory agent.

Although the drug is available in a numberof different formulations, e.g., plain, buf-fered, time-released, effervescent, etc., allaspirin is the same. Other than brand name,the only difference between standard five-grain tablets is price. Therefore, purchase agood quality house brand of aspirin ratherthan a nationally-advertised brand. How-ever, check tablet compactness by looking atthe bottom of the bottle before purchasingthe brand. If the tablets are crumbling theyare not compact enough and will dissolve inthe mouth. On the other hand, tablets may

" 82

be too compact and pass through the gas-trointestinal tract without dissolving.

The most common side effect associatedwith regular intake of aspirin is gastrointes-tinal upset. Taking aspirin with a full 8-ounceglass of fluid and/or meals may alleviate theproblem. If not, a buffered aspirin may re-duce the discomfort enough so that dilutingthe aspirin with fluid is effective. As a iastresort enteric-coated aspirin, which is moreexpensive, may be tried. The protective coat-ing prevents the drug from dissolving until itreaches the small intestine where it is ab-sorbed with little, if any, discomfort.

The most effective dose for pain relief is650 mg or two five-grain aspirin tablets. Tak-ing more tablets does not increase the onsetor duration of pain relief.

A high dose of aspirin (8-16 tablets perday) is often prescribed following a mus-culoskeletal injury to control the inflamma-tory process and thus promote healing. Re-gardless of whether or not the condition ispainful, the individual should take the aspi-rin as scheduled. A constant level of theanalgesic must be present in the blood to cutdown on the inflammation. Ringing in theears or vertigo are two early signs of aspirinoverdose. These symptoms are reversible bysimply decreasing the intake of aspirin andcontinuing to take it on schedule.

When aspirin is prescribed on a regularbasis, all medication, both prescription andover-the-counter, must be reported to thephysician. Aspirin interacts with a widevariety of drugs including some as commonas Vitamin C.

If the tablets begin to smell like vinegarthey are decomposing and should be dis-posed. The effectiveness of the drug is onlyslightly changed but gastrointestinal irrita-tion increases markedly.

Individuals who are allergic to aspirinmay take one of the non-aspirin substitutesfor pain relief or reduction of fever. Unfortu-nately none of the substitutes is an anti-inflammatory agent. Therefore the use ofsuch substitutes in sports medicine is espe-cially limited when the athlete is taking theanalgesic for its anti-inflammatory effect.

Acetaminophen is the most common andmost effective aspirin substitute. It does notirritate the storhach so it should be used inplace of aspirin for pain relief and/or feverreduction. Phenacetin has been withdrawnfrom the market because its use has beenassociated with the development of kidneyproblems.

Anti-infectivesAnti-infectives are those drugs used to

control the spread of infection in local tissue.Included in this class of medications are an-tiseptics, antifungals, and antibiotics.Whenever the skin is abraded (open) it canno longer serve as a protective barrier againstforeign matter such as dirt, bacteria, fungi,etc. Even a drug may be considered foreignmatter and the application of any drug to theopen skin may delay healing and/or cause amedication dermatitis.

Read the instructions before applying anydrug to the skin, particularly if the skin isabraded. Follow the instructions carefullyand discontinue using the drug if any one ofthe following symptoms develop: itching;burning; blistering or redness of the skin;rash; oozing crusting dermatitis.

Antiseptics

Antiseptics are drugs applied to living tis-sue to kill or prevent the growth of microor-ganisms. However, in most instances, thebody's own natural defense mechanisms cancontrol and destroy the invading organisms.

The correct method of applying antisepticsis around the edge of the wound. Rarelyshould the drug be applied directly to theabraded skin. Only surface wounds shouldbe treated at home. Treatment of deepwounds should be limited to basic first aidtechniques to control bleeding and preventfurther contamination and trauma. Evalua-tion of the extent of damage is easier for thephysician when the wound remains un-cleaned and untreated.

Antiseptics are classified by their majoractive ingredient. Only those commonlyused in home treatment of surface wounds,will be discussed.

Two oxidizing agents are among the mostuseful antiseptics for home treatment. Threepercent hydrogen peroxide is a poor antisep-tic but it is useful for cleaning out contami-nated surface wounds. It foams when itcomes in contact with abraded skin; how-ever, it should be applied only after a thor-ough cleansing of the wound. The presenceof organic matter such as blocd, cinders,grass, or dirt decreases its effectiveness.Hydrogen peroxide should be stored in alight-resistant amber bottle for it is very un-stable and sensitive to light. It easily breaksdown into its component parts. In fact, if theantiseptic does not foam when it comes incontact with abraded skin, it has dissociated.The other oxidizing agent recommended for

76 83

home treatment is povidone-iodine. It is lessirritating and less toxic than the iodine fromwhich it is derived. It also does not stain likeiodine. Unfortunately povidone-iodine isslightly less effective than iodine and is moreexpensive.

Perhaps the most common antisepticsfound in first aid kits are two mercureal com-poundsmercurochrome and merthiolate.Merthiolate is the stronger of the two. Unfor-tunately with the popularity of these twodrugs neither one is as effective as iodine.Furthermore, the effectiveness of these twodrugs is lessened by the presence of serumand tissue proteins which collect at the site oftissue damage.

Surface acti' agents, such as benzal-konium chloride, are frequently used as an-tiseptics because they do not irritate the skin.However, the antiseptics in this group maybe deactivated during application by cotton,soap residue, or cellulose.

Boric acid is found in many over- the-counter products ranging from antiseptics tomouthwashes and eyewashes. It is a poor-ntiseptic, but more importantly, it is poten-tially dangerous. In some instances, it hasbeen found to be a systemic poison.

The antiseptic that is most effective incombating microorganisms and recom-mended by pharmacists is Isopropyl alcohol.(Povidone-iodine is the antiseptic recom-mended for home- or self-treatment.) Whencorrectly used it is the least irritating andmost effective of all antiseptics. ObviouslyIsopropyl alcohol should not be placed di-rectly on abraded skin but only around theedges of the wound to control the growth ofmicroorganisn lb.

Antifungals

Antifungals control the growth and spreadof fungal infections. Unfortunately many ofthe agents used as antifungals may actuallyaggravate an existing condition. For exam-ple, as previously mentioned, Boric acid may_cause systemic toxicity in some individualsand the agent is frequently found in someproducts for athl 2te's foot, a common fungalcondition. In some cases, the antifungalagent may only be strong enough to eradi-cate mild cases. Undecylenic acid, an ingre-dient in many over-the-counter products forathlete's foot, will control a mild case but notclear it up. Tolnaftate is the most effectiveantifungal agent for self-medication, yet theconsumer must pay the price for such effec-tiveness. Products containing tolnaftate are

more expensive than those containing otherantifungal agents.

Unfortunately to irradicate a case ofathlete's foot completely, the agent must beapplied for up to six months, even thoughevidence of the disease is not visible. Newgrowths from the spores that remain in thearea must be controlled.

Antibiotics

Antibiotics are topically applied to inhibitthe growth and reproduction of bacteria.Most are highly specific meaning they areeffective at controlling only certain bacteria.Such agents should be used sparingly for astrain of bacteria can easily become resistantwith overuse of the ointment. In addition,allergic reactions are not common.

The antibiotics commonly found in over-the-counter ointments are neomycin, baci-tracin, and polymyxin B sulfate. Lae threemay be found in combination or separately.Most often the body defenses can effectivelycontrol the growth of any bacteria remainingin or around the wound following a thor-ough cleansing. However, if signs of infec-tion (heat, redness, swelling, pain, and pointtenderness) develop, the individual shouldbe immediately referred to a physician.

Cold Remedies

The common cold is a self-limiting diseasewhich lasts for one to twd weeks and iscaused by a virus. Since there are a multitudeof viruses that could be responsible foi theupper respiratory tract infection characteris-tic of a cold, medical science has yet to isolatea cure. At this time, the best the consumercan hope for is symptomatic relief.

In attempting to alleviate symptoms, theconsumer has two choices in self-treatment:to use a variety of single ingredient products;to use one combination product, frequentlyreferred to as a shotgun remedy. Therationale behind shotgun remedies is if amedication is to be effective at relieving themultitude of symptoms associated with thecommon cold, it must contain a little bit ofeverything. In reality, however, there are afew drawbacks to such thinking. First, all thevarious ingredients found in a shotgun rem-edy may not be needed if the individual isnot suffering from all the symptoms the rem-edy is designed to relieve. Secondly, theremay not be enough of any one ingredient tobe therapeutically effective. Thirdly, there isa greater chance of an adverse reaction oc-curring as the medication becomes more

7 7 8 4

complex. In most instances, it is far wiser,therapeutically and economically, foi the in-dividual to purchase single-ingredient medi-cations and only take those necessary to re-lieve the symptoms being displayed.

Antihistamines and Decongestants

Nasal congestions is perhaps the chiefcomplaint of one who suffers from a cold. Inseeking relief, the consumer must make adecision whether to use an antihistamine or adecongestant. With a little basic backgroundinformation, the choice may not be so dif-ficult to make.

The effects of antihistamines are essen-tially the same. An antihistamine, as thename applies, blocks the release of his-tamine. Histamine, as well as several otherchemical mediators, are released by cells fol-lowing invasion of the body by a virus. It isthese chemical mediators that are responsi-ble for the dilation of capillaries in the mucusmembrane lining the respiratory tract andthe resulting congestion. Therefore, an an-tihistamine is not totally effective at relievinga stuffy nose for its target is only one of themany chemical mediators. The commonside-effects associated with the use of an an-tihistamine are drowsiness, dry mouth, andblurred vision. Obviously in athletics the useof such medication should be restricted forthe athlete should be mentally and physi-cally alert when in play. Furthermore, theuse of antihistamines by an athlete who isactive in a hot, humid environment maypredispose that individual to one of the heatstress syndromes. Constriction of the super-ficial blood vessels interferes with effectivecooling of the body.

The congested athlete can find relief fromthe use of decongestants but these products,too, are not without problems. The drug maybe administered, either topically, as a nasalspray, or orally. If used oo frequently a nasalsprar may actually cause nasal congestion.The drug shrinks the mucus membrane soeffectively that it interferes with the lining'sprotective function. Consequen tly moremucus is secreted so the lining can onceagain trap foreign material on its sticky sur-face. This rebound effect occurs each timethe spray is used so the consumer is justperpetrating the conditior. . A nasal sprayshould be used as directed ior no more than2-3 times a day for 3-4 days. Use of a long-duration spray decreases the possibility ofrebound congestion.

Oral administration of a decongestantposes less of a problem. The major side-ef-

78

fects are nervousness and restlessness aswell as excessive dryness of the nose, mouth,and throat. Relief is not as great with oraiadministration because the drug is carried inthe blood stream to all the various mucusmembranes in the body. The action is moregeneralized than with a nasal spray.

Cough Remedies

A cough is a protective reflex, therefore itshould not be eliminated completely, eventhough the cough may not be productive andis merely self-perpetuating. A coughmedicine or antitussive only contrOls the fre-quency and severity of a cough but does notalleviate it.

There are three types of cough medicineavailable to the consumer: central actingagents; expectorants; demulcents. Commoncentral acting agents are dextromethorphanand codeine, the latter being a prescriptiondrug. Both are effective in reducing the fre-quency and intensity of a cough, but dex-tromethorphan is recommended for self-treatment. It has none of the side-effects as-sociated with the use of the narcotic codeine.Expectorants such as ammonium chloride orterpin hydrate increase fluid production andhelp mobilize secretions. Demulcents coatthe irritated tissue and stimulate saliva pro-duction. Wild cherry, honey, and licorice arecommon demulcents that are frequentlyfound in cough drops. Such preparations,however, are no more effective than plainhard candy in soothing irritated tissue.

Prior to purchasing a cough medicine, payparticular attention to the percent of alcoholin the product. Although alcohol is a depres-sant of the central nervous system, it alsodries up the mucus membrane and wouldthus cause additional irritation.

In self-treatment the consumer should at-tempt to mobilize secretions and sooth theirritated tissue by sucking on plain hardcandy, drinking hot beverages, and inhalingsteam. In the latter instance, if a vaporizer isnot readily available, an effective substitutecan easily be made. Bring a pan of water to aboil and then turn off the heating source.Place a towel over the individual's head toform a tent and thus confine vapors. Instructthe individuai to breathe deeply.

Sore Throat Remedies

Among the common complaints of thecold sufferer is a sore throat; however, thiscondition may be of bacterial origin ratherthan viral. It is important to identify the

85

cause particularly if the sore throat lingers onfor more than 2 days and/or is accompaniedby a fever. Sore throats caused by eitherstreptococcus or staphylococcus bacteria arefar more dangerous because complicationsinvolving the heart or kidneys could arise asa result of improper or delayed treatment.Fortunately, bacterial infections are not ascommon as viral infections and in most in-stances, antibiotics are effective in treatingthem. (Antibiotics are not effective againstviral infections). If a 10-day course of antibio-tics is prescribed by a physician the entireamount must be taken to control the diseaseprocess. Do not stop taking the medicationjust because symptoms improve or disap-pear.

Other than aspirin there are few over-the-counter products that are helpful in re-

lieving the symptoms of a sore throat. To beeffective the aspirin must be taken orally andabsorbed into the blood stream. If used in agargle, the inflamed tissue could be easilyirritated by one of the acid particles in thewater. Antiseptic gargles and mouthwashesmay contain alcohol which is an irritant aspreviously explained. Throat lozengers, es-pecially those with an antibacterial agent oran anaesthetic agent are frequently associ-ated with sensitivity reactions.

In treating a sore throat the consumershould avoid all over-the-counter prepa-rations other than aspirin and gargle withwarm salt water. The mixture is made byadding 1/2 teaspoon of salt to 8 ounces or onecup of warm water. If the condition persistsfor more than two days or is accompanied bya fever, medical attention should be sought.

8679

Miconceptions of 1 2Athletic Injuries

Education of athletic trainers, coaches,and athletes is necessary to eliminate themisconceptions involving athletic injuries.These misconceptions have arisen from cer-tain "traditions" among athletes and coacheswho have previously been misinformed as tothe proper way to evaluate and treat injuries.No longer should athletes be subjected to the"walk it off" attitude of coaches. The level ofcompetitiveness has advanced tremen-dously, and the rate of injuries has also in-creased. Without a proper evaluation or aknowledge of significant warning symp-toms, a very serious symptom may be over-looked which could be detrimental to theathlete's future.

It should be noted that if a physician's careis needed, it is vital for the athlete to be seenby someone with a background and/or inter-est in sports medicine. For possible bone andmuscle injuries, an orthopedic physicianshould be seen; for possible nerve damage aneurologist should be seen, and so forth.Many general practitioners, or family doc-tors, may very well have an inadequatebackground in specific medical problems,such as orthopedic problems, which com-promise the majority of athletic injuries.

Prevention of injury is important in all as-pects of athletics. There are many injurieswhich cannot be prevented. However, theincidence of muscle strains can be reducedwith proper stretching exercises. Athletesare told to "warm-up" before participation.This might be interpreted as a means forwarming up the skin with the use of ananalgrsic balm. These products are skin irrit-ants and produce a warm sensation on thesurface of the skin. Once the skin is warm,the athlete thinks he/she is "warmed up"and ready to play. He/she has unintention-ally been misled and therefore does not un-derstand the meaning or purpose of "warm-

Linda Arnold, A.T.C.

ing up" with proper stretching techniqueswhich could prevent a muscle strain.

Without the care of a certified athletictrainer to provide evaluation of injurieswhen they occur, the athletes may be put indanger. The coach should have a good back-ground in recognizing serious symptomsand must know proper first aid procedures.

For the majority of athletic injuries, thebasic treatment consists of ice, compression,and elevation. Placing heat on a new injuryor placing the injured area in a hot whirlpoolwill only cause serious complications. Heatcauses an increase in blood flow which, inturn, causes unnecessr_ry swelling in dam-aged tissues. Heat may very well be usedlater for rehabilitative purposes, but can onlycomplicate the treatment if used when theinjury initially occurs.

There are several misconceptions in rec-ognizing symptoms of injuries. It is assumedby many that if an injured area can bemoved, it is not fractured. "Broken" and"fractured" are both terms used to describe acrack or break in a bone. The seriousness of afracture may ranbe from a small crack (hair-line fracture) in the bone to a complete break.Most fractured areas can be moved; theathlete may not desire to move it, but move-ment may be possible. Therefore, othersymptoms of a fracture are much more im.:portant to consider in this injury evaluation.

Swelling is another important symptom. Ifswelling does occur, it is assumed that therehas been significant tissue damage. How-ever, swelling cannot be an all-inclusiveevaluative tool. An athlete may sustain amajor ligament or tendon tear and developlittle swelling, or, the athlete may merelyrupture a superficial blood vessel which re-sults in rapid swelling but is actually an in-significant injury. The amount of swellingcannot be used to measure the seriousness of

81

87

an injury. Proper evaluation of the injury isnecessary to determine its seriousness.

As with swelling, pain also cannot be aconclusive determining factor in injury eval-uations. Athletes differ in levels of pain to-lerance as much as they differ in levels ofskill. An athlete with a major injury mayexperience minimal pain. On the other hand,an athlete with a low pain tolerance mayexperience tremendous pain with a minorinjury. Also, it is often difficult for an athletewho has never been injured to distinguishthe difference between pain and injury. Paincan often be a warning signal, but does notalways signify damage to a body part.

There is another thing to consider withregard to pain after an injury. During aninjury which results in a complete rupture ofa ligament, the pain may be intense duringthe injury and then subside somewhat fol-lowing the severance of the ligament. If thepain subsides and if there happens to be littleswelling following the injury, the athletemay delay seeing a physician and jeopardizehis/her chance for an adequate recovery.

It is often felt that the athlete has the rightto play with an injury if he/she so consents.However, proper evaluation proceduresmust take place so that all possible complica-tions can be considered before allowing theathlete to make this decision. Most schoolsaccept the responsibility of seeking a physi-cian's care for athletic injuries. Should therebe any chance of further injury by participa-ting with an injury, it would be very inadvis-able to leave the decision up to the athlete ifthe attending physician prescribed no par-ticipation. So, in fact, the final decision restswith the athlete with respect to not playing,but should be the physician's decision withregard to playing with an injury.

The appearance of braces and protectivetaping is much more prevalent now in wom-en's athletics. It should be strongly advisedthat neither taping nor braces be used with-out a specific reason. The theory of "if ithurts, tape it up" has got to be eliminatedfrom athletics. Taping should only be used torestrict a specific movement or to support aninjured area. If tape is not properly used, theathlete can suffer from its use, rather thanbenefit from it. Improperly used tapingtechniques could result in swelling, re-stricted circulation, pressure on nerves, tapecuts, blisters, etc. Therefore, it becomes nec-essary for coaches to receive instructions ontaping techniques to educate them on thiscommon practice.

Although taping is fairly common, the useof braces has become almost as popular. In

no way should a brace be placed on anathlete without a physician's consent. Bracesare often placed on athletes for psychologicalsupport. However, the use of psychological"tricks" should be avoided if at all possible.Good, sound rthabilitation programs canoften restore arrinjured athlete back to a nearnormal condition which may not require theuse of a brace.

Recently, a concern in women's athleticshas been the use of protective equipment tofurther avoid injuries to the "frail" femaleathlete. It is often necessary to use protectiveequipment for specific needs of certainathletes. However, to use all the protectiveequipment available would result in anathlete being dressed in eye goggles, amouthguard, a neck collar, a sports bra, hippads, knee pads, elbow pads, knee braces,ankle braces, etc. Common sense must beused to find the best method to prevent in-jury in each specific sport. Protective equip-ment may, in fact, be a means of prevention,but one should not go overboard in this area.

A commonly mistreated injury amongathletes is that of a "jammed" finger. Thetraditional treatment has been to im-mediately pull the finger. This treatmentshould be strongly avoided. A "jammed"finger usually consists of sprained ligamentcsurrounding a joint in the finger. This sprainmay involve a simple stretching or a com-plete rupture of the ligaments. If the liga-ments are partially torn, they may be com-pletely ruptured by pulling on the finger. Aninjured finger may be the result of a fracturein the joint area. It is not possible to eliminatethe possibility of a fracture without first exa-mining an x-ray of the injury. Therefore, itshould be assumed that a fracture may bepresent. Another possibility involving frac-tures of this area is the fact that a piece ofbone may be chipped off. Manipulation ofthe finger may allow this fragment of bone tolodge in the joint. Surgery would then berequired to dislodge the bone fragment,causing this somewhat minor injury to de-velop into a major problem.

The American Medical Association hasdeveloped a Bill of Rights for athletes. Underthis Bill, athletes have the right to goodhealth supervision. With regard to thepreviously-mentioned misconceptions, thisright has been violated in many ways.Adequate care of athletes, provided byeducating coaches or securing the services ofa certified athletic trainer, is the most accu-rate way to eliminate these traditional ill-advised practices. Athletes have sufferedlong enough from the results of these mis-

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conceptions. Every effort should be made byathletic organizations to provide the bestpossible care for their athletes.

"Get the Gum our

Perhaps the most dangerous misconcep-tion among athletes is the concept that chew-ing gum will not hinder their performance.There has always been concern for the besttechniques for preventing injuries. How-ever, the very act of chewing gum while par-ticipating in athletics may cause a very po-tential life and death situation. It is very frus-trating to see a coach or even an athletictrainer pass out gum to a team before a game.These same people are often the ones whoare most concerned about preventing alltypes of injuries, but do not make the effortto prevent a possible death.

Comments such as "I've chewed gum allmy life while playing and I've never gottenchoked" do not prevent this type of death.Those athletes who have died from this con-dition probably felt the same way. This acci-dent does not happen often but it only takesone time, and a few minutes at that, to kill anathlete. Coaches who allow gum chewingmay have never realized the possible seriousconsequences which could follow. Educa-tion of athletes and coaches is essential toeliminating this traditional practice.

Those who feel the risk is slim and con-tinue to allow gum chewing should at leastmake the effort to learn the proper tech-niques of clearing an obstructed airway.

The problem with chewing gum developsif the athlete gets hit unexpectedly from therear, or if he/she gets knocked unconscious.A review of the anatomy of the throat showsthe location of the airway, or trachea. Thetrachea (A) lies under the skin on the front ofthe neck. The passage for food, theesophagus (B) lies behind the trachea. Whenswallowing occurs the epiglottis (C) coversthe opening of the trachea and prevents foodfrom entering the airway.

An unexpected blow from the rear canvery easily cause the head to be thrown back,straighten the airway, and permit the gum tolodge in the airway (D). To dislodge the gumfrom this area, proper techniques in adminis-tering the Heimlich Maneuver would be nec-essary.

The American Red Cross currently teachesthree maneuvers for the removal of airwayobstructions: back blow; abdominal thrust(Heimlich Maneuver); probing the mouth. Ittakes a very short time to learn, but the re-sults of its use may mean the difference be-tween life or death. It should be emphasizedthat a person receive proper training in thistechnique to fully understand the procedure.It must also be noted that this procedureshould never be practiced on another persondue to possible internal injuries.

Figure 1. Anatomy of the throat.

83 89

Jewelry Hazards

Uncommon among men athletes, but verycommon among wonien athletes, is thewearing of jewelry during participation. Ifjewelry is attractive when not playing, whywould it not be attractive while playing? In-dividual team sport participants can mostlikely wear jewelry and have few problems.It is very common to see tennis players andgolfers wearing several pieces of jewelry.However, for those athletes in contact sports(or any sport for that matter), this practiceshould be avoided. Injuries to the athlete andthe opponent could very likely occur.

Rings can cause serious prpblems whenthe athlete sustains a finger injury. If swellingis immediate, the ring most likely wouldhave to be cut from the finger. Rings can alsocause injuries by scraping or hitting an op-ponent. Should a ring get caught on somepiece of equipment, the results could be adislocated or amputated finger.

84

Necklaces are a cause of many serious eyeinjuries. This most often happens to an op-ponent as a long necklace hits the individualin the eye. Should the necklace get caught onequipment, an opponent's clothing, or onthe athlete's hand, etc., an unnecessary in-jury could occur.

One of the most popular trends in jewelrynow is the use of beads in braided hair styles.Although these are felt to be attractive bymany, they are definite hazards in athletics.Like necklaces the longer sets of beads areflying objects in an opponent's face andshould not be permitted in contact sports.

By not permitting the wearing of jewelry, acoach may prevent some very unnecessaryinjuries. Athletes have to contend with thethreat of many injuries which cannot be pre-vented. Therefore every effort should bemade to eliminate those which can be pre-vented.

The Female AthleteChristine Haycock, M.D., F.A.C.S.

During the past decade there has beenmuch controversy as to just how importantthe anatomical and physiological differencesare between male and female athV.f es. Ingeneral the average female is shorter andlighter than the average male. There are ex-ceptions to this of course, but the bone struc-ture of the female is definitely lighter thanthe male and there is less lean muscle mass.

A major difference between men andwomen is thf! amount of body fat. A typicalyoung woman's body has about 25% bodyweight of fat while a young man would haveabout 15%. While athletes of both sexes -areprobably thinner than the average sedentarysubject, nevertheless this difference persists.A female long-distance runner may dropdown to as low as 7% body fat, while mencan often drop as low as 5%.

Another difference is that men have theirmajor reproductive organs externally carriedin the scrotum, whereas women have theadvantage of having their reproductive or-gans carefully protected within the bonypelvis. In this sense women are better pro-tected for contact sports than men.

Women's breasts are more developed thanmales, since these organs are basically in-tended for the reproductive purposes ofnursing infants. However, many womenathletes may have very small breasts and thiscan be an advantage, for example, in a long-distance runner. The vulnerability of thebreast to injury has been grossly overratedand, in general, injuries to the breasts areminor and of no serious consequence.

Women have a wider pelvis than men andtherefore their center of gravity is lower thanthat of men. This can be an advantage or itcan be a disadvantage. The female athleteplaying tennis might be more stable in theready position than a male, but on the otherhand she would have more difficulty lifting

85

her body off the ground for any type of jump-ing activity. Jüs development of the hipsbecomes more obvious as the female be-comes older, hence it accounts for one of thereasons why the best women gymnasts areusually in their early teens.

In the past the wider female pelvis and theresulting greater angulatiln of the femur onthe pelvis had been attributed as the cause ofincreased injuries to women's knees. Morerecently, however, it has been shown thatthese injuries are more likely related to poorconditioning than anatomical development.With an increase in conditioning programsfor women, less knee injuries are being re-corded.

Women do tend to be more bowleggedthan men and this can cause stress to theoutside of the knees and ankles. A womanwho is bowlegged should buy shoes thatcant to the inside to increase pronation, andthus avoid knee injuries. On the other hand,should a woman be knocked-kneed sheshould find shoes that reduce the pronationwith a wedge built into the sole to alleviatethe stress to the inside of the knees, ankles,and feet.

Much has been made of the fact thatwomen have more laxity in their joints thanmen. However, there are also many menwho have "loose" joints which does not poseas a great problem providing that a goodconditioning program is carried out tostrengthen the joints. It is an advantage forthe gymnast and the dancer, and with a goodconditioning program does not lead to anymore sprained ankles or other difficultiesthan the average male athlete may en-counter.

Back problems in women are more promi-nent due to the fact that their spines have agreater curvature (lordosis). There is also acongenital condition called spondylolisthe-

91

sis in which there is a slippage of the lowervertebrae of the spine which, if not recog-nized early in the teen years, can lead tomany problems later in the female athlete,particularly for the gymnast. Hence, with agood conditioning program and theavoidance of such sports as gymnastics thisindividual can perform normally in sportsnot requiring marked flexion of the back.Because women do tend to have more backproblems, and also tend to be a little pot-bel-lied, it is extremely important that exercisesthat strengthen the abdominal musculatureas well as the back muscles be carried out,and that attention be paid to posture.Women must learn to tuck in their tummiesand straighten their backs to avoid problems.lems.

Because there is less muscular develop-ment in women, due to less male hormones(testosterone), women do not have the upperextremity and shoulder strength that mostmen do. This accounts for their difficulty indoing pull-ups. Pitching motions in softball,particular in the fast pitch variety, can causemore problems in women than men for thisreason, and can result in overuse problemssuch as tendonitis. More recently the liftingof weights and the use of various types ofgymnastic apparatus to increase the upperbody strength in women have proved to bemost valuable in the prevention of difficul-ties in the shoulders and arms and has in-creased performances in women athletes.

It has been suggested that women shouldbe encouraged to enter a sport that was mostsuitable for their own body type. A tallskinny woman will do well in track and fieldand fast-moving sports, whereas theheavier, squattier type of female wouldprobably do better in softball, disc, and jave-lin throwing, and other sports in which herlow center of gravity can be to an advantage.

It might be wise for the coach or trainer totake a careful look at his/her female athletesto determine their body types and to antici-pate problems that might arise from markedlordosis, wide heavy hips, or the lack ofupper body development and place theminto training programs to correct any de-ficiencies and also pay close attention to thetype of shoes, for example, that are worn bythese women.

Other differences in women are less obvi-ous since they are hormonal in nature andhave to do with the fact that a womanmenstruates. Women athletes who haveheavy menstrual cycles may tend to be a littleanemic so it is important that these womenuse supplemental iron during their

86

menstrual period to avoid an iron deficiencyanemia that could interfere with oxygen up-take in endurance sports. A simple blood testcan determine this and a quick resolution ofthe problem can be made.

There has been much discussion recentlyover the amenorrhea seen in women athletesand conc iderable discussion has ensued as towhether or not this is a problem that shouldconcern the athlete or not. So far the evi-dence has not shown any really deleteriouseffects if the athlete who lessens strenuoustraining resumes her period in a short time. Ifthe female athlete does not resume normalperiods following cessation of heavy train-ing, then it is advisable that she see agynecologist and ensure a good hormonalbalance so that no future problems will oc-cur. There certainly is no decrease in fertilityin women athletes who have undergonerigorous training. Positive evidence indi-cates that girls who exercise have less prob-lems with dysmenorrhea.

Some recent studies have suggested thatwomen on birth control pills may lack certainnutrient substances in their bodies and re-search is continuing along these lines; how-ever, it is generally felt that the athlete whoeats a well-balanced diet with perhaps amineral and vitamin supplement, particu-larly during her menstrual period, is in nogreat danger of this.

A woman who is large-breasted will prob-ably need a good supportive bra to limit themotion of the breasts relative to the rest ofher body since large pendulous breasts candefinitely throw an athlete off stride, orprove to be a detriment to good competitiveeffort. There are many bras now on the mar-ket made of a high cotton and low polyestermixture which will provide support andcomfort to obviate the problem.

Another condition that women are moreprone to is thyroid disorders. Should therebe any problems associated with persistentweight gain or rapid weight loss, change inhair body distribution, excessive sweating,etc., it would be wise to have some bloodtests done to determine if there is any hyper-or hypothyroidism present which needs tobe corrected.

Women tend to bruise more easily thanmen because they have greater capillaryfragility. A woman athlete who tends tobruise more readily than he- teammE.es canbe placed on supplemental Vitamin C to re-duce as much as possible the tendency torupture her capillaries with minor blows. Ex-cept for the fact that bruises are nasty look-ing, they really pose no serious problems.

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Pregnancy poses no great restrictions onathletic endeavors in the first trimester if thewomen are having an uneventful preg-nancy. However, beyond the first trimester,it is considered inadvisable for her to en-dulge in contact sports. Any other restric-tions necessary would have to be determinedby her physician and the progress of thepregnancy.

87

Research has indicated 'hat the injuriesseen in female athletes are really no differentthan those seen in the male except for thosefew directly related to anatomical differ-ences. Therefore, with good conditioningprograms and proper nutrition, the womanathlete should have no more difficulties en-dulging in sports than her male counterpart.

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The Growing AthleteHolly Wilson, A,T,C.

The growing athlete is prone to differentsorts of sport injuries than the mature athletebecause the individual's musculoskeletalsystem is immature. During childhood andadolescence, the skeleton is in a constantprocess of ossification in which cartilage isconverted to rigid bone. At the end of eachlong bone are growth centers where lon-gitudinal growth takes place. It is this ossifi-cation process that accounts for such growth.The greatest activity in these growth centers,and hence the most rapid gains in height andlimb length, is seen during childhood be-tween the ages of 51/2 and 7 and duringadolescence between the ages of 9 and 12 infemales and 13 and 15 in males. It is not untilapproximately the mid-teens in females andthe late teens to the early twenties in malesthat the last of these growth centers close andskeletal maturity is attained. Until maturityoccurs, these growth centers are the weakestpart of the musculoskeletal system.

A typical long bone has several growthcenters. (See Figure 1.) The end of the boneincluding its smooth articular cartilage liningis the epiphysis. It is a secondary ossificationcenter. Separating the epiphysis from theshaft of the long bone is the growth plate orphysis. The physis is the primary ossificationcenter for the bone. It is made up of cartilageand it is the area where growth in lengthoccurs. Where a muscle attaches to a bonyprominence, each prominence has a separategrowth center called an apophysis. The shaftof the bone is called the diaphysis and thetough membrane covering the entire longbone except the smooth articular cartilageends is the periosteum. The periosteum pro-tects the underlying bone and houses theblood vessels that bring nourishment.

There are four types of injuries seen in thegrowing athlete that may not be seen in themature athlete. Three of these injuries in-

Diaphysis

Physis (Growth Plate)

Epiphysis

Figure 1. Growth centers of an immature longbone.

volve the various growth centers: theepiphysis; the physis; the apophysis. Con-sequently, they are only seen in the growingathlete.

The epiphysis may be traumatized by acompression force such as landing from a fallor a jump. With impact between the boneends, small pieces may partially or com-pletely separate from the epiphysis. As a re-sult of complete separation, the chips of bonewith cartilage float freely within the jointspace and are called "joint mice." If these

89 9 4

chips become symptomatic (cause pain,swelling, etc.) and interfere with the func-tion of the joint, they may need to be surgi-cally removed. Those that remain partiallyattached may eventually reattach and poselittle, if any, problem. The ankle and theknee are common sites for "joint mice."

The physis or growth plate is susceptibleto damage from a direct blow or a twistingmotion. Either force may shear through thegrowth plate and dislocate the epiphysisfrom the underlying shaft of the bone, thediaphysis. The injury is called an epiphysealseparation and may result in growth compli-cations; however, the incidence of such prob-lemS is low. There are several factors thatcontribute to the development of a complica-tion: the age of the athlete; the specificgrowth plate involved; the type of separation(one of four grades); the immediate medicalattention given. Grade one or two epiph-yseal separations rarely result in loss of limblength, angular deformity, or joint malfunc-tion.

A muscle tendon may be torn loose (av-ulsed) from its attachment at an apophysis asa result of pivoting, running, jumping, ortwisting. At an apophysis, the muscle ten-don attaches to cartilage which is not asstrong as an attachment directly into theperiosteum and underlying bone. Further-more, during the adolescent growth spurt,flexibility is outgrown approximately everysix months. The bones elongate so rapidlythat the muscles and ligaments cannot keepup. Consequently, the individual is inflexi-ble and prone to muscle injury. The damage,however, may be an avulsion of anapophysis rather than to the muscle, mus-culotendinous junction, or tendon as seen inthe mature athlete. Common sites for suchavulsions are the hamstrings from the ischialtuberosity, the iliopsoas from the lessertrochanter of the femur, the rectus femorisfrom the anterior inferior iliac spine, and theabdominals from the iliac crest. The inci-dence of such injuries can be decreased byworking on a daily statis stretching programand thoroughly warming up prior to eachactivity session.

The fourth type of injury is the stress frac-ture which one sees more frequently in the6-21 age group than in the mature athlete. Asthe name implies, stress fractures are theresult of repetitive stress causing an eventualbreakdown of bony structure and hence, anincomplete fracture. If the athlete continuesthe repetitive activity, the stress fracture maybecome a complete fracture. Another frac-ture that may also be seen in this age group is

a pathological fracture. Such a fracture oc-curs where there is a defect in the growingbone. The force causing the injury is usuallyinsignificant but the weakened structure isunable to withstand the stress.

In the growing athlete, the musculo-skeletal system appears to be vulnerable. Yetthere are certain anatomical and physiologi-cal characteristics of the youthful system thatprovide some compensation for and protec-tion against trauma. The bones of the grow-ing athlete are porous, that is, they bendwith the force, absorbing and dissipating theimpact rather than resisting it like the strongrigid bones of the mature athlete. Such abone can bend to a 45° angle or more beforebreaking. If the bone does break, the break isusually incomplete, a greenstick fracture. If itdoes not break, the bone will straighten outbut not completely. Medical care should besought, for this injury is also considered to bea type of fracture called a bend fracture. Theperiosteum, the membrane covering thebone, is thicker and stronger in growingathletes. It has greater potential for repairand replacement of damaged cells because ithas more bone-forming cells. In addition, ithas a better blood supply to accomodatehealing as well as growth. Consequently,healing is more rapid, but the time requiredfor mending increases with each year of age.Nonunion of fractures is almost unheard ofin this age group. Fractures in growingathletes are more stable than in the matureathlete. The tough periosteum resists tearingand the break is often incomplete so there isless play, if any, in the broken bone ends. Asa result, involvement of the adjacent bloodvessels and nerves is not as common. Fi-nally, fractures in growing athletes have atendency to remodel. The body attempts tocorrect any discrepency in bony configura-tion resulting from a fracture. Remodelling,like the healing rate, is inversely related toage. Furthermore, the closer the injury site isto the physis or growth plate, the more likelyit is that remodelling will occur.

Musculoskeletal injuries in growingathletes should be treated conservativelyuntil the possibility of growth center in-volvement is ruled out. Dislocations and iso-lated ligament tears are uncommon in thisage group because ligaments are strongerthan the growth centers. With an injury tothe physis or growth plate, pain and/or de-formity will be immediately localized aboveor below the joint, not at the joint space. Thegrowing athlete may have difficulty pin-pointing the pain, for it is often referred toother parts of the body. Be sure to check all

90 95

the areas identified by the athlete as beingpainful.

Treat all suspected epiphyseal separationsas if they were fractures. Apply compressionwith a wet elastic bandage and splint theinvolved joint as well as the adjacent joints.Place an ice pack over the area and elevatethe part. Keep the ice pack in place for nomore than 20-30 minutes. (Ice may be appliedagain and repeated in P/z-2 hour intervals.)Make arrangements for the athlete to be seenby a physician.

Although the musculoskeletal system ofthe growing athlete is immature, the inci-dence of serious injury to the system, includ-

ing injuries to the growth centers, is nothigh. The growing athlete, F, lrticularly theyounger one, does not usuP 'f have the sizeand strength to generate e; 'ough force tocause serious injury. This is important, forduring periods of rapid growth when themuscles and ligaments are outgrown, themuscles do not have the strength to protectthe musculoskeletal system from trauma.Furthermore, it must be realized that thereare risks involved in mosl of the activities inwhich children engage. In fact, the activitywould not be considered fun unless someelement of daredevilry was a part of the activ-ity.

9691

Abraham, William M. "Exercise-induced MuscleSoreness." The Physician and Sportsruedicine. Oc-tober, 1979, pp. 57-66.

Adolph, E. F. "Heat Injories during DistanceRunning.' Medicine and Science in Sports. July,1975, p. 1.

Allman, F. "Prevention of Sport Injuries." Ath-letic Journal. March, 1976.

Alwine, Daryle. "What YoU Should Know aboutOsgood-Schlatter's Disease." 'Athletic Journal56:72-3.

Anthony, Susan. "Taping Techniques." 1) TheAnkleAthletic journal 57:72-3; 2) The AchillesTendonAthletic Journal 57:14-5; The Lon-gitudinal ArchAthletic Journal 57:68-9.

Barnes, Lan. "CryotherapyPutting Injury onIce." The Physician and Sportsmedicine. June,1979, pp. 130-6.

Bentivegna, Angelo. "Diet, FitneSs and AthleticPerformance." The Physician and Sportsmedicine.October, 1979, pp. 98-105.

Bergfield, John. "First, Second and Third DegreeSprains.". The American Journal of SportsMedicine. May/June, 1979.

Blonstein, S. L. "Concussion." The Journal ofSport Medicine and Physical Fitness 17: 79$1.

Bodner, Leslie. "Historical Poll of Women inSports." The American Journal of Sports Medicine.January-February, 1980, pp. 54-5.

Bonnette, Allen R. "Using the Swimming Pool toRehabilitate Injuries." Athletic Journal 59.

Boyd, Harold, and McLeod, Jr., Andin. "TennisElbow." Journal of Bone and Joint Surgery. Sep-tember, 1973, pp. H83-7.

Brooks, Christine. "Developing the Female Dis-tance Runner." Athletic Journal. January, 1978,

, ,PD 8 10 80, , and 81.Brown, Harvey C. "Common Injuries of the

Athlete's Hand." Canadian Medical AssociationJournal. September 17, 1977, pp. 621-5.

Brubaker, Clifford E. "Injuries to Runners." Jour-nal of Sportsmedicine. July/August, 1974, pp.1189-98.

Cahill, B. R. "Osgood-Schlatter Disease in Com-petitive Sports." Journal of the American MedicalAssociation. January 9, 1978, p. 143.

Cahill, Bernard R. "Little League Shoulder."

AppendixBibliography

Journal of Sports Medicine. May-June, 1974, pp.1515-53.

Cahill, Bernard, and Griffith, Edward. "Effect ofPreseason Conditioning on the Incidence andSeverity of High School Football Knee In-juries.' The American Journal of Sports Medicine.July-August, 1979, pp. 180-4.

Clancy, W. G.; Micheli, L. J.;Jackson, D. W.; andStanich, W. "Low Back Pain in Yciung andMiddle-aged Athletes." The American Journal ofSports Medicine. July, 1979.

Clancy, William G., and Neidhart, David. "Achil-les Tendonitis in Runners." The American Jour-nal of Sports Medicine 4.

Cleary, Pat. "The Caloric Costs of Rope Skip-ping." The Physician and Sportsmedicine. Febru-ary, 1980, pp: 23-32.

Cooper, David. "Hamstring Strains." Physicianand Sportsmedicine 6 (Part 2).

Cooper, Donald. "Traumatic Bursitis." Physicianand Sportsmedicine 6 (Part I).

Cooper, Donald. "Treatment of Hip Pointers."Physician and Sportsmedicine 6 (Part I).

Cooper, Donald, and Fair, Jeff. "Contact Der-mitis." The Physician and Sportsmedicine. De-cember, 1978, pp. 123-7.

Cooper, Donald L., and Fair, Jeff. "PreventingChest and Upper Adbominal Pain Associatedwith Exercise." The Physician andSportsrnedicine. July, 1977, pp. 93-4.

Coutts, Kenneth D.. "Leg PoWer and CanadianFemale Volleyball Players." Research Quarterly.October, 1976, pp. 332-5.

Cox, Jay. "Injury Nomenclature." The AmericanJournal of Sports Medicine. May-June, 1979, pp.211-3.

Cox, Jay S. "Women in Sports: the NavalAcademy Experience." The American Journal ofSports Medicine. November/December, 1979.

Crava, Sakari, and Saarela, Jussi. "Exertion In-juries to Young Athletes, a Follow-up Researchon Orthopedic Problems of Young Track andField Athletes." The American Journal of SportsMedicine. July-August, 1979, pp. 180-4.

Crobitt, R. W., et al. "Female Athletics." Journalof the American Medical Association. June 3, 1974,pp. 1266-7.

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Dale, Edwin, "Reproductive Physiology of theFemale Distance Runner." The Physician andSportsmedicine 7: 81,-95.

Darden, Ellington. "Nutrition for Athletes."Sports Medicine Newsletter. 1980.

Davies, George C. "The Ankle Wrap: Variation,for the Traditional." Athletic Training 12(4):194-7.

Day, M. J. "Hypersensitive Response to Ice Mas-sage.". Physical Therapy 54(6): 592.

Dehaven, Kenneth, et al. "Chondramalacia Patel-lae in Athletes." American Journal of SportsMedicine 7(1): 5-11.

Dosti, Rose. "Diet and Athletic Training Capac-ity." Swimming World & Junior Swimmer 19(6):

Drissoff, William B. "Runner's. Injuries." ThePhysician and Sportsmedicine. becember, 1979,pp. 53-64.

Engerbreton, David L. "The Diabetic in PhysicalEducation, Recreation and Athletics." Journal ofPhysical Education and Recreation. .April, 1977,pp. 18-21.

Fairbanks, ,Leland. "Return to Sport Participa-tion." The Physician and Sportsmedicine. August,1979.

Feigel, William P. "The Runner's Knee." Runner'sWorld. May, 1980, pp. 37-40.

Ferris, Elizabeth. "The Myths SurroundingWomen's Pdrticipation in Sport and Exercise."Journal of Sports Medicine 19 (3): 309-11.

Fimrite, Ron. "Stress, Strain and Pain." Sportsllhistrated. August, 1978, pp. 30-3.

Fowler, Peter. "Shoulder Problems inOverhead-overuse Sports." American Journal ofSports Medicine. March/April, 1979, pp. 141-2.

Francis, R.; Bunch, T.; and Chandler, B. "LittleLeague Elbow: a Decade Later." The Physicianand Sportsmedicine. April, 1978.

Fultz, Jack. "Coping with Injuries." The Runner16.

Garrick, J. G., and ReClua, R. K. "Injury Patternsin Children and Adolescent Skiers." The Allied-can Journal of Sports Medicine. July/August, 1979.

Gelabert, Raoul. "Preventing Dancers' Injuries."Tlw Physician and Sportsmedicine. April, 1980,pp. 69-74.

Getchell, Bud. "The Caloric Costs of Rope Skip-'ping and Running." The Physician andSportsmedicine. 8 (2): 55-60.

Glover, Elbert. "Aspirin: Is It the Next WonderDrug for Everyone." Runner's World. April,1980, pp. 67-70.

Grimes, Donald W., and Bennion, David. "Func-tional Foot-reconditioning Exercises." Ameri-can Journal of Sports Medicine 6(4): 194-7.

Harris, D. V. "Lazy Bones: Shake a Leg-orBreak It." Wonwn's Sports 5(2): 55.

Harris, Dorothy V. "The Anemic Athlete."Women Sporis. December, 1977..

Harris, Dorothy V. "The Monthly Mystery."Women Sports. September, 1977.

Harris, Dorothy V. "The Pregnant Athlete."Women Sports. June, 1977.

Harris, Dorothy V. "Survival of the Sweatiest."Women Sports. November, 1977, p. 48.

Haycock, Christine. "Susceptibility of, WomenAthletes to Injury: Myths vs. Reality."Journal ofthe American Medical Association, July, 1976, pp.163-5.

Hoffman, Terrence; Stouffer, Robert; andJackson, Andrew. "Differences in Strength be-tween the Sexes." The American Journal of SportsMedicine 7: 264-7.

Jackson, D. W., et al. "Quadricep Contusions inYoung Athletes Relations of Severity of Injuryto Treatment and Prognosis." Journal of Boneand Joint Surgery. January:1973, pp. 95-105.

Jackson, Douglas W. "Injury Prediction in theYoung Athlete: a Preliminary Report." TheAmerican Journal of Sports Medicine. January/February, 1978, pp. 6-11.

Jackson; Jarret; Bailey; Kausek; Swanson; andPowel. "Injury Prediction in the Young Athlete:a Preliminary Report." The American Journal ofSports Medicinc 6(1): 6-14.

James, Stanley; Bates, Barry; and Osternig, Louis."Injuries to Runners." The American Journal ofSports Medicine. March-April, 1978, pp. 40-50.

Jastremski, Chester. "Swimmer's Ear." Swim-ming World & Junior Swimmer 19(9): 98-9.

Jenks, G. "Prevention of Heat Injuries during Dis-tance Running. A Position Statement from theAmerican College of Sports Medicine." Journalof Sportsmedicine 3(4): 194-6.

Knight, Kenneth. "Cyrostretch for MuscleSpasm." The Physician and Sportsmedicine. Ap-ril, 1980, pp. 112-8.

Knight, Kenneth. "The Effects of Hypothermia onInflammation and Swelling." Athletic Trainthg11(1): 7-10.

Knight, Kenneth. "Total Injury Rehabilitation."The Physician and Sportsmedicine. August, 1979.

Krauth, B. "Injuries and the InflamMation Pro-cess." Athletic Journal 55: 94-5.

Krissoff,- William B. "Runner's Injuries." ThePhysician and Sportsmedicine. December, 1979,pp. 54-64.

Kuland, Daniel. "Tennis Injuries: Prevention andTreatment, a Review." The American Journal ofSports Medicine. July-August, 1979, ppt 249-53.

Landwer, G. E. "Heat." Runner's World 15(5):72-4.

Lestwauik,, Joseph J., et al. "Injuries in In-terscholastic Wrestling." The Physician andSportsmedicine. March, 1980, p. 111.

Lezberg, Sandra F. "Screening for Scoliosis."Physical Therapy 54 (4): 371-2.

Mack, William. "Playing Hurt-the Doctor's Di-lemma." Sports Illustrated. June 11, 1979, pp.30-6.

McCluskey, George M. "A Treatment for AnkleSprains." American Journal of Sports Medicine4(4).

Mickelsen, Olaf. "Nutrition and Athletics." Foodana Nutrition News 41(7): 2-5.

Millar, Anthony. "An Early Stretching Routinefor Calf Muscle Strain." Medicine and Science inSports. June; 1976, p. 39.

Mirken, G. "Carbohydrate Loading: a DangerousPractice." Journal of the American Medical Associa-,tion. March 26, 1973, pp. 1511-2.

9498

Mirkin, Kent. "Groin Pain." The Runner. April,1980, p. 12.

Mirtin, Gabe. "Remedies for Shin Splints: WhatYou Can Do to Prevent and Cure Them." TheRunner (12): 20.

Nelson, Ralph. "What Should Athletes Eat? Un-mixing Folly and Facts." Thr Physician andSportsmedkine. Niwember, 1975, pp. 67-72.

Nicholas, James. "Injuries to Knee Ligaments."Journal of the American Medical Association212 (13):, 2236-9.

Nischl, Robert. "Keeping Fit:" World Tennis. Jan-uary, 1979, p. 14.

Olsen, Perry. "How Running Can Hurt YourBack." The Runner. April, 1980, p. 61.

Opie, L. H. "Sudden Death and Sport." Lancet.February, 1975, pp. 233-6.

Ostrom, Russell C. "Knee Rehabilitation Follow-ing Surgical Procedure." Physical Therapy. De-cember, 1977, pp. 1376-9.

Pearl, Bill; Kurland, Hai- Vey; Lewis, Mitch; andWong, Donald. "Injuries: the Agony of Body-building." Muscle Digest 4(1): 17-23.

Pedegana, Larry R. "Waterskiing Injuries." ThePhysician and Sportsmedicine. June, 1979; pp.108-14.

Pettrone, Frank A. "Acromioclavicular Disloca-tion." The American Journal of Sports Medicine.July-August, 1978, pp. 160-3.

Plowman, S. "Physiological Characteristics ofFemale Athletes." Research Quarterly of theAAHPER. December, 1974, pp. 349-62.

Priest, James; Braden, Vic; and Gerberich, Su San."The Elbow and Tennis Part I." The Physicianand Sportsmedicine. April, 1980, pp. 78-86.

Priest, James, and Nagil, Donald, "Tennis Shoul-der." American Journal of Sports Medicine.january-February, 1976, pp. 28=42.

Priest, James D., et al. "A Study of Players withPain." Physician and Sportsniedicine. May-, 1980,pp. 77-85.

.Prueske, Eleanor. "The Athletes Foot (PersonalHealth)." ,Current Health 5 (6): 14-5.

Riley, Dan; "Prevention and.Rehabilitation of In-juries." Scholastic Coach. March, 1980, 44-6,96-7.

Shepard, Roy J. "Exercise for the Asthmatic Pa-tient." Journal of Sports Medicine and Physical Fit-ness 18 (3).

Shon, D. H. "Treatment of the Most CommonAthletic Injuries." Athletic Journal 55:60.

Sinton, Dr. William A. "The- Ankle: Soft TissueInjuries." The Journal of Sports Medicine 1 (3).

Sissel, Bill. "A Fun Way to Develop the Ankle."Athletic Journal. February, 1980, pp. 40 and 88.

Smith, J. L., and Bozymowski, M. "Attitude to-wards Warm-up." Research Quarterly 36 (1).

Snedeker, Jeff; Recine, Victor; and MacCarter,Carl. "Cryotherapy and the Athletic Injury."Athletic Journal 55: 16+.

Speroff, Leon. "Exercise and Menstrual Func-tion." The Physician and Sportsmedicine. May,1980, pp. 42-,52.

Stanitski; McMaster; and Scranton. "On the Na-ture of Stress Fracture." The American Journal ofSports Medicine 6 (6): 391-6.

Starkey, Jerry A. "Treatment of Ankle Sprains bySimultaneous Use of Intermittent Compressionand Ice Packs." The,American Journal of Sports,Medicine. July-August, 1976, (4), pp. 142-4.

Subotnick, Steven. "Nine Mistakes Runner'sMake." 15 (4).

Tambereli, Al. "Prevention and Care of Knee In-jury." The Athletic Journal. February, 1978, p.40.

Torg, J. S., et al. "The National Football Head andNeck Injury Register." JAMA. April 6,1979, pp.1477-9.

Vincent, L. M. "The War with Water." DanceMagazine 53 (7): 96-7.

Walter, Norman E, "Stress Fractures. in YoungAthletes." American Journal of Sports Medicine 5(4).

Weems, Fred. "What the Coach Should Knowabout the Pitching Arm." Scholastic Coach. Ap-ril, 1980, pp. 44-7 and 84.

Weiss, D. "Help Prevent Arm Injuries withStretching Exercises." Athletic Journal 57: 50-4.

Wells, Robert L. "Improve Flexibility to PreventInjuries." Athletic Journat 60 (2):- 54-5 and 78.

Whiteside, P. A. "Men's and Women's Injuries inComparable Sports." Physician andSportsmedicine 8 (3): 131-8.

Williams, Melvin. "Drugs and Athletic Perfor-mance." 1974, pp. 3-19.

Wilmore, J. H. "Inferiority of Female Athletes:Myth or Reality." Journal of Sports Medicine 3 (1):1-6.

Wynn, Terry. "The Sock Wrap." The AthleticJournal. February, 1978, p. 61.

9995

AppendixPosition Statements

NAGWS Athletic Training Council

Mouthguards in Athletics

The NAGWS Athletic Training Couneilstrongly endorses the use of mouthguards inathletics. Adopting regulations requiringrnouthguards to be worn has resulted indramatic decreases in mouth, tooth, andhead injuries in men's football and ice hoc-key. Not only do mouthguards provide pro-tection for the teeth, gums, and lips, buttheyalso can be instrumental in absorbing theconcussive forces of a blow to the head, neck,or face. The protection a mouthguardprovides .may be significant enough to pre-vent and/or to reduce the severity of headinjuries in athletics.

Prosthetics and Protective Equiprnent

Integrating students with handioppingconditions and development of new prosthe-tic and protective devices, has raised concernamong coaches, trainers, and physi 'al edu-ca tors in regarding The legality of s ch de-vices in competitive athletics. If wcaring aprosthetic or a protective device enables anindividual with a handicapping condition ora previously-injured a thlete to competesafely, he or she cannot be denied competit-ive opportunities because such devices arerequired.

An athlete must first receive medical ap-proval to participate in his or her chosensport; devices worn must be in accordancewith state or local athletic governing bodyrules and Jules of the sport itself. Theprosthetic or protective device must pose nohazard to the athlete, his or her teammates,or opponents. Protective devices such asknee braces containing metal parts (includ-ing Lenox-Hill knee braces), metal or ortho-plast splints, plaster, fiberglass, or silicone(RTV-11) casts, felt, and foam rubber protec-

ti.i7e padding are all used to protect injuredbody parts. Such devices should not be al-lowed if they are dangerous to the athlete,his or her teammates, and opponents. Nor isit acceptable for wearers ,of prosthetic or pro-tective devices to gain an athletic advantagevia the device itself. All such devices must bewell-padded so as to avoid presenting anonyielding or dangerous, hard er- than-the-hurnan-body-itself, surface to the indi-vidual's teammates or opponents. Mostitems, when covered with approximatelyone-half inch of close-cell slow recoveryfoam rubber, pose no hazard to other partic-ipants.

Lacrosse Injuries

Those familiar with the sport of lacrosseremember a day when the men's and wom-en's style of play were entirely different.Traditionally, the men play a hard-hitting,contact game. For them protective gear isboth needed and required. In the past, worn-en'sjacrosse had been a game"of skill, speed,and finesse. Yet now, with women becomingincreasingly competitive, the style of play ischanging. Injuries, particularly to the head,face, and upper body, have increased asbody and stick contact has become more fre-quent. The option of requiring protectiveequipment in the women's game is beingmore frequently discussed.

We, the members of NAGWS AthleticTraining Council, feel that the injury situa-tion in women's lacrosse must be closelymonitored in future years. We endorse thefollowing:

1. Upgrade the quality of coaching andofficiating by more frequent and morecomprehensive clinics and instruc-tional sessions offered by NAGWS/USWLA. Included should be informa-

tion concerning proper conditioning,correct skill execution, safe playingareas 2inc1 equipment, rule, interpreta-tions, etc.

2. Provide for stricter rule enforcement ofexisting rules, including the use of yel-low (warning) and red (suspension)cards for dangerous checking, barricad-ing, and face-cheCking. Offendingplayers and their teams must be re-sponsible for their dangerous actions.

3. Consider rule changes to reduce poten-tially injurious situations from develop-ing, i.e., stricter and more explicitwording of rules concerning stick-checking, face-checking, and barricad-ing, etc.

4. Carefully monitor injury statistics viaNAIRS and surveys of individual in-stitution injury records throughNATA-certified trainers.

5. An effort should be made on the part ofplayers, coaches, trainers, fans, andathletic administrators to maintain thebeauty and integrity of women's la-crosse.

6. Mouthguards should be worn to reduceor prevent the incidence of injury teteeth, gums, mouth, etc.

Suggested Preparation for EmergencySituations during Practice and

CompetitionEquipment that should be readily accessible

in a nearby training room or storage room forall practices and games in field hockey, vol-leyball, basketball, gymnastics, softball,swimming and diving, and track and field islisted below:

stretcher;spine board*(short) with neck tractionunit (if unit is unavailable, substitute 4five-pound sandbags);blanket;crutches;cervical collar;arm sling (a large muslin triangularbandage with two safety pins may besubstituted).

Equipment that should be readily availableon the field or court for all practices andgames in any sport is listed below:

splintsbaard, plastic air, cardboard,or ladder;ice with small plastic bags;towels;elastic wraps-3", 4" 6";waterdrinking fountain, cooler, hose,plastic squirt bottles;

first aid kit.Items suggested for the first aid kit:

variety of tape;tape adherent;tape remover;underwrap;tape cutter;bandage sassors;nail clippers;tweezers;pen light;cleansing agent;alcohol or substitute;Hydrogen Peroxide;first aid cream;petroleum jelly (Vaseline);sterile gauze pads-3" x.3", 4" >.< 4" ;band aids 1-3, 3/4" x, 3", extra large;gauze rolls-2";analgesicmild;gauze spongeS-3" x 3";tongue depressors;cotton-tipped applicators;ammonia capsules;hand mirror;ophthalmolic solution sterile;contact lense wetting solutionsterile;combine;felt;foam-1/4", 3/s";elastic wraps-4";safety pins;rubberbands;needle and thread;tampons;aspirin.**

In addition, the trainer or coach covering asport should:

1. Know where the nearest phone is lo-cated.

2. Have $.20 taped to the first aid kit foruse in a pay phone.

3. Carry a first aid emergency care man-ual.

4. Know procedure for securing ambu-lance service.

5. Post all emergency phone numbers, in-cluding the team physician's on the in-side of the first aid kit and adjacent tothe phone in the training room and/oroffice.

6. Carry the telephone numbers of eachathlete's parents or guardian if workingwith minors.

*Only to be used by trained medical or paramedical.personnel.

**Ability to dispense medication, including aspirin,may be prohibited by school regulations.

98 101

11,

Appendix CRecommended Readings

Albohm, Marge. Health Care for the Female Athlete.Florida: The Athletic Institute, 1982.

American Alliance for Health, Physical Educa-tion, Recreation and Dance. Youth SportsGuidefor. Coaches and Parents. WashingtDC: The American Alliance for Health, PhysicalEducation, Recreation and Dance, 1977.

American Red Cross. Advanced First Aid andEmergetwit Care. Garden City, NY: Doubledayand Company, Inc., 1979.

Alderson, Bob. Stretchhtg. Palmer Lake, CO:Stretching Inc., 1975.

Consumers Union. The Medicine Show. r' Iew York:Pantheon Books,1976.

Cooper, Kenneth. The Aerobics .Way. New York:Bantam Books, 1977.

Fox,, Edward, and Mathews, Donald. IntervalTraining. Philadelphia, PA: W. B. SaundersCompany, 1974.

Galton, Lawrence. Your Child in Sports. NewYork: Franklin Watts, 1980.

Haycock, Christine, ed. Sports Medicine for the Ath-letic Female. Oradell, NJ: Meclical Economics,.1978.

99

Henderson, John. Emergency Medical Guide. NewYork: McGraw-Hill Book Company, 1978.

Jackson, Douglas, and Pescar, Susan. The YoungAthlete's Health Handbook. New York: EverestHouse Publishers, 1981.

Kapit, Wynn, and Elson, Lawrence. The AnatomyColoring Book. New York: A Canfield Press/Barnes and Noble Book, 1977.

Klafs, Carl, and Arnheim, Daniel. Modern Princi-ples of Athletic Training. St. Louis, MO: C. V.Mosby Company, 1981.

Klafs, Carl, and Lyon, M. Joan.-The Female Athlete.St. Louis, MO: C. V. Mosby Company, 1978.

Marshall, John, with Barbash, Heather. The SportsDoctor's Fitness Book for Women. New York: DellPublishing Company, 1981.

The Physician and Sportsmedicine, Suite 200, 4530West 77th St., Minneapolis, MN 55435.

Smith, Nathan. Food for Sport. Palo Alto, CA: BullPublishing Company, 1976.

Southmayd, William, and Hoffman, Marshall.Sportshealth. New York: Quick Fox, 1981.

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