Injury and Health Risk Management in Sports: A Guide to Decision Making 3662607514, 9783662607510

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Werner Krutsch · Hermann O. Mayr Volker Musahl · Francesco Della Villa Philippe M. Tscholl · Henrique Jones Editors

Injury and Health Risk Management in Sports A Guide to Decision Making

ESMA European Sports Medicine Associates A section of ESSKA

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Injury and Health Risk Management in Sports

Werner Krutsch  •  Hermann O. Mayr Volker Musahl  •  Francesco Della Villa Philippe M. Tscholl  •  Henrique Jones Editors

Injury and Health Risk Management in Sports A Guide to Decision Making

Editors Werner Krutsch SportDocsFranken Nuremberg Germany Department of Trauma Surgery University Medical Centre Regensburg Regensburg Germany Volker Musahl UPMC Freddie Fu Sports Medicine Center University of Pittsburgh Pittsburgh, PA USA Philippe M. Tscholl Orthopaedic Surgery and Traumatology Geneva University Hospitals Geneva Switzerland

Hermann O. Mayr Department of Orthopedics and Trauma Surgery Medical Center, Albert-LudwigsUniversity of Freiburg Freiburg Germany Schoen Clinic Munich Harlaching— FIFA Medical Centre of Excellence Munich Germany Francesco Della Villa Education and Research Department Isokinetic Medical Group Bologna Italy Henrique Jones Hospital da Luz, Setubal Orthopedic and Sports Medicine Clinic Montijo Portugal

ISBN 978-3-662-60751-0    ISBN 978-3-662-60752-7 (eBook) https://doi.org/10.1007/978-3-662-60752-7 © ESSKA 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer-Verlag GmbH, DE part of Springer Nature. The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany

Preface

Sports medicine today comprises many different medical specialties and committed sports physicians aim at providing athletes with both general and specific medical services. A book describing the fundamental principles of sports medicine as well as therapeutic strategies that include specific approaches according to the respective sport discipline is essential for the comprehensive and lasting health care of professional and recreational athletes. Orthopedist, for instance, may benefit from having sound knowledge of internal medicine or sports neurology and cardiologists from in-depth knowledge of musculoskeletal injuries or sports dermatology. The main part of this book is thus focused on the exchange between different medical disciplines as a key factor for the treatment and ultimately the health of professional and recreational athletes. In this book, an international group of sports-medical experts of different specialties describe interesting approaches to a wide range of health care situations from their daily clinical practice. The key topics of this book are emergencies, surgical indications, primary prevention strategies, rehabilitation concepts after injury or illness, and the timing of return to competition, which are described by means of epidemiological statistics, athletes’ case reports, tables, and figures. Each chapter gives a structured overview of the respective topic and provides basic knowledge and background information, in-depth knowledge for practical routine in training and competition, typical pitfalls for sports physicians as well as authors’ recommendations for continuative literature on the topic. The editors trust that this handbook will be a valuable tool for decision-­ making in sports medicine. Nuremberg, Germany

Werner Krutsch

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Preface

As European Sports Medicine Associates (ESMA) Chairman, I am very proud to participate in this new ESMA project. The book Injury and Health Risk Management in Sports is really a handbook for decision making with the intention of helping sports and team doctors, sports surgeons, physiotherapists, coaches, fitness coaches, and athletes to understand the specifics of sports kinesiology, injury mechanisms, the rehabilitation process, and a satisfactory return to sports. This is also a book that intends to be the result of two main ESMA principles: education and divulgation in sports medicine. We want sports people to respect their sport, interpersonal communication, fair play, the prevention of sports-related injury, the recovery process, and, finally, to respect the right moment to return to competition. Sports have become more and more appealing to doctors and surgeons, and it is our mission to adopt and promote the best practices in sports medicine, not only to prevent injuries but also to help athletes return at their same performance level after an injury. I am sure that this book, with such competent people contributing, will help you all to understand our main messages. Montijo, Portugal

Henrique Jones

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Contents

Part I Different Aspects for Different Athletes: Principles and Special Considerations in Athletes 1 Junior Athletes ��������������������������������������������������������������������������������   3 Oliver Loose and Stephan Gerling 2 Adolescent Athletes��������������������������������������������������������������������������   7 Nathalie Farpour-Lambert 3 Sport in Female Athletes�����������������������������������������������������������������  17 Tiana Raoul, Clémence Coll, and Patricia Thoreux 4 Recreational Athletes ����������������������������������������������������������������������  25 Kaywan Izadpanah and Norbert P. Südkamp 5 Sports in Professional Athletes�������������������������������������������������������  31 Yunus Emre Ozdemir and Baris Kocaoglu 6 Elderly and Retired Athletes����������������������������������������������������������  37 Henrique Jones 7 Sports in Handicapped Athletes and Inclusion ����������������������������  43 Anja Hirschmüller 8 Sports in Daily Life��������������������������������������������������������������������������  51 Angelina Lukaszenko, Ferran Abat, and Jocelio Campos Moraes 9 Sports for Health������������������������������������������������������������������������������  55 Rogério Pereira, Renato Andrade, and João Espregueira-Mendes Part II General Aspects in Sports Medicine: Musculoskeletal Aspects in Sports—From Prevention to Return to Sports 10 General Aspects of Sports Medicine����������������������������������������������  63 Leonard Achenbach 11 Prevention Strategies in Traumatic and Overuse Injuries����������  67 Francesco Della Villa, Marco Gastaldo, and Matthew Buckthorpe

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12 Pre-seasonal Assessment and Performance Diagnostics: Orthopaedic and Functional Aspects ��������������������������������������������  75 Alli Gokeler and Daniel Büchel 13 Rehabilitation of Sports Injuries����������������������������������������������������  81 Helmut Hoffmann 14 Return to Play After Sport Injuries ����������������������������������������������  91 Alli Gokeler, Anne Benjaminse, and Bart Dingenen 15 Fatigue and Recovery����������������������������������������������������������������������  97 Henrique Jones Part III General Aspects in Sports Medicine: Specific Medical Care in Typical Sports Injuries 16 Polytrauma and the Unconscious Athlete�������������������������������������� 105 Daniel Mahr and Himanshu Bhayana 17 Head Injuries������������������������������������������������������������������������������������ 111 Johannes Weber 18 Spine and Trunk Injuries���������������������������������������������������������������� 117 Himanshu Bhayana and Daniel Mahr 19 Shoulder and Upper Arm Injuries ������������������������������������������������ 123 Felipe Eggers, Sebastian Siebenlist, and Andreas B. Imhoff 20 Elbow and Forearm Injuries���������������������������������������������������������� 129 Stephanie Geyer, Andreas B. Imhoff, and Sebastian Siebenlist 21 Wrist and Hand Injuries ���������������������������������������������������������������� 139 Katharina Angerpointner, Christoph Koch, and Sebastian Geis 22 Hip Injuries and Groin Pain ���������������������������������������������������������� 145 Radu Prejbeanu, Vlad Predescu, Horia Haragus, and Mihail Lazar Mioc 23 Thigh/Muscle Injuries �������������������������������������������������������������������� 153 Tomas Fernández-Jaén and Pedro Guillén García 24 Knee Injuries������������������������������������������������������������������������������������ 159 Henrique Jones 25 Ankle Injuries���������������������������������������������������������������������������������� 165 Henrique Jones 26 Foot Injuries ������������������������������������������������������������������������������������ 173 Markus Walther, Hubert Hörterer, and Marc Hilgers 27 Overuse Injuries of the Spine and Trunk�������������������������������������� 179 Christian Schneider 28 Overuse Injuries on the Upper Extremity ������������������������������������ 183 Lukas N. Muench, Andreas B. Imhoff, and Sebastian Siebenlist

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29 Overuse Injuries on the Lower Extremity������������������������������������ 189 Manuel Virgolino Part IV General Aspects in Sports Medicine: Principles of Treatment in Sports Injuries 30 Conservative Treatment Strategies������������������������������������������������ 197 Werner Krutsch and Florian Pfab 31 Indication for Surgical Treatment of Injuries of the Shoulder and Elbow�������������������������������������������������������������� 201 Maximilian Kerschbaum and Christian Pfeifer 32 Indication for Surgical Treatment of Injuries of the Wrist and Hand �������������������������������������������������������������������� 207 Christoph Koch, Katharina Angerpointner, and Sebastian Geis 33 Indication for Surgical Treatment of Injuries of the Hip, Groin, and Thigh���������������������������������������������������������� 213 Horia Haragus, Mihail Lazar Mioc, and Radu Prejbeanu 34 Indication for Surgical Treatment of Injuries of Knee and Shank �������������������������������������������������������������������������� 221 Henrique Jones 35 Indication for Surgical Treatment of Injuries of the Foot������������ 229 Markus Walther, Marc Hilgers, and Hubert Hörterer 36 Principles of Sports Equipment and Sportswear�������������������������� 235 Hartmut Semsch Part V General Aspects in Sports Medicine: Internistic Aspects and General Medical Problems of Athletes 37 The Pre-season Screening Examinations: Internist Aspects������������������������������������������������������������������������������ 245 Celeste Geertsema, Roger Palfreeman, and Stephen Targett 38 Prevention Strategies in Cardiovascular Diseases������������������������ 253 Paolo Emilio Adami and Antonio Pelliccia 39 Cardiovascular Screening in Athletes�������������������������������������������� 259 Barbara Barra, Claudia Favero, Andrea Ermolao, and Daniel Neunhäuserer 40 General Aspects of Return to Play After Specific Cardiovascular Diseases������������������������������������������������������������������ 267 Paolo Emilio Adami and Antonio Pelliccia 41 Strategies of Return-to-Play After Specific Cardiovascular Entities ������������������������������������������������������������������ 275 Marco Vecchiato, Barbara Mazzucato, Laura Padoan, Andrea Ermolao, and Daniel Neunhäuserer

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42 Sports and Infections ���������������������������������������������������������������������� 281 Helena Herrero 43 Dental Medicine ������������������������������������������������������������������������������ 287 Jean Luc Dartevelle, Lucile Goupy, and Alain Frey 44 Neurology������������������������������������������������������������������������������������������ 297 Claus Reinsberger 45 Ophthalmology�������������������������������������������������������������������������������� 303 Fabian Stelzle, Sabine Peschel, and Björn Scheef 46 Otorhinolaryngology and Facial Trauma�������������������������������������� 309 Volker Krutsch 47 Dermatology/Allergology���������������������������������������������������������������� 315 Florian Pfab 48 Gynecology and Obstetrics�������������������������������������������������������������� 323 René Bogesits Aufschneider 49 Urology���������������������������������������������������������������������������������������������� 329 Kai Braun and Robin Seiffert 50 Aesthetic Surgery and Sport ���������������������������������������������������������� 335 Lukas Prantl and Niklas Biermann 51 Psychological Aspects in Elite Athletes������������������������������������������ 341 Vincent Gouttebarge and Gino Kerkhoffs Part VI General Aspects in Sports Medicine: Emergency Management and On-Field-Treatment 52 Emergency Management: ABCD (Airway, Breathing, Circulation, Disability) ������������������������������������������������ 349 Rodolfo Ferrari 53 Emergency Management: Sports Injuries������������������������������������ 355 Michael R. Carmont, Patrick O’Halloran, and Matilda Lundblad 54 Emergency Management: Non-­traumatic Problems�������������������� 361 Rodolfo Ferrari 55 Pitchside Care���������������������������������������������������������������������������������� 367 Michael R. Carmont 56 Emergency Equipment on the Field���������������������������������������������� 373 Daniel Broman and Daniel Popp 57 Indication for Hospitalization and Clinic Care���������������������������� 377 Jan-Hendrik Naendrup, Thomas R. Pfeiffer, and Daniel Guenther

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Part VII General Aspects in Sports Medicine: Nutrition, Medication and Juristic Aspects 58 Anti-doping and Medication in Sports������������������������������������������ 385 Martial Saugy and Philippe M. Tscholl 59 Nutrition Aspects������������������������������������������������������������������������������ 393 Marco Freschi 60 Nutritional Supplements ���������������������������������������������������������������� 399 Marco Freschi and Luca Pollastri 61 Juristic Aspects�������������������������������������������������������������������������������� 405 Heiko Striegel, Raymond Best, and Andreas Nieß Part VIII General Aspects in Sports Medicine: Sports in Specific Environments 62 Sports in Hot and Cold Environments ������������������������������������������ 413 Robin Seiffert and Dominik Szymski 63 Sports in Altitude ���������������������������������������������������������������������������� 417 Sandra Leal, Pascal Zellner, and Philippe M. Tscholl 64 Scuba Diving������������������������������������������������������������������������������������ 421 Robin Seiffert and Dominik Szymski Part IX Aspects of Different Sports: Special Considerations in Team Sports and Ball Sports 65 Football �������������������������������������������������������������������������������������������� 427 Jonas Werner and Markus Waldén 66 Futsal������������������������������������������������������������������������������������������������ 433 Morgan Gauthier and Philippe M. Tscholl 67 Handball������������������������������������������������������������������������������������������� 439 Markus Wurm, Leonard Achenbach, and Lior Laver 68 Basketball������������������������������������������������������������������������������������������ 445 Kai Fehske, Tekin Kerem Ulku, and Baris Kocaoglu 69 Volleyball/Beach Volleyball ������������������������������������������������������������ 451 Nélson Puga and Diogo Dias 70 Field Hockey ������������������������������������������������������������������������������������ 457 Thomas Stoffels, Martin Häner, and Wolf Petersen 71 American Football��������������������������������������������������������������������������� 463 Robert Tisherman, Sean Meredith, Nicholas Vaudreuil, Ravi Vaswani, Joseph De Groot, Kevin Byrne, and Volker Musahl 72 Baseball �������������������������������������������������������������������������������������������� 471 Travis S. Roth, Chris H. Garrett, and Daryl C. Osbahr

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73 Rugby������������������������������������������������������������������������������������������������ 479 Michael R. Carmont, Francois Kelberine, and Catherine Lester 74 Ice Hockey���������������������������������������������������������������������������������������� 485 Gernot Felmet Part X Aspects of Different Sports: Special Considerations for Athletic Sports 75 Running Sports�������������������������������������������������������������������������������� 493 Gian Luigi Canata, Luca Pulici, Gaspare Pavei, and Katia Corona 76 Triathlon ������������������������������������������������������������������������������������������ 499 Casper Grim and Thilo Hotfiel 77 Jumping Sports�������������������������������������������������������������������������������� 503 Gian Luigi Canata, Luca Pulici, Gaspare Pavei, and Valentina Casale 78 Throwing Sports������������������������������������������������������������������������������ 509 Giacomo Zanon, Alberto Vascellari, and Alberto Combi Part XI Aspects of Different Sports: Special Considerations for Winter Sports 79 Alpine Skiing������������������������������������������������������������������������������������ 519 Amelie Stoehr and Hermann O. Mayr 80 Ski Touring �������������������������������������������������������������������������������������� 525 Lukas Ernstbrunner, Mohamed A. Imam, and Stefan Fröhlich 81 Cross-Country Skiing/Biathlon������������������������������������������������������ 531 Simon Euler 82 Snowboarding���������������������������������������������������������������������������������� 535 Tobias Baumgart and Christian Ehrnthaller 83 Ice Skating���������������������������������������������������������������������������������������� 543 Giacomo de Marco, Julien Billières, and Jacques Menetrey 84 Bobsleigh������������������������������������������������������������������������������������������ 551 Christian Schneider Part XII Aspects of Different Sports: Special Consideration for Martial Arts and Contact Sports 85 Judo �������������������������������������������������������������������������������������������������� 559 Ralph Akoto, Julian Mehl, Theresa Diermaier, Maxime Lambert, and Christophe Lambert 86 Wrestling������������������������������������������������������������������������������������������ 565 Szabolcs Molnár, Károly Mensch, and Krisztián Gáspár

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87 Boxing����������������������������������������������������������������������������������������������� 573 Holger Schmitt 88 Taekwondo/Karate�������������������������������������������������������������������������� 579 Markus Geßlein, Frank Düren, and Johannes Rüther 89 Fencing Sport����������������������������������������������������������������������������������� 585 Marcel Fischer Part XIII Special Considerations for Sports with Higher Speed and High Energy 90 Motorsports by Motorcycles ���������������������������������������������������������� 593 Gonçalo Moraes Sarmento and Ana Luísa Neto 91 Four-Wheeled Motorsports������������������������������������������������������������ 599 Robin Seiffert, Dominik Szymski, and Werner Krutsch 92 Cycling Injuries�������������������������������������������������������������������������������� 605 Nastassia Guanziroli, Julien Billières, and Jacques Menetrey 93 Equestrian Sport������������������������������������������������������������������������������ 615 Angelina Lukaszenko Part XIV Aspects of Different Sports: Special Considerations for Modern and Extreme Sports 94 Flying Sports������������������������������������������������������������������������������������ 621 Denis Bron and Ursula Heggli 95 Sport Climbing/Bouldering������������������������������������������������������������ 627 Andreas Schweizer 96 Canyoning ���������������������������������������������������������������������������������������� 635 Lukas Ernstbrunner, Mohamed A. Imam, and Stefan Fröhlich Part XV Aspects of Different Sports: Special Considerations for Swimming and Water Sports 97 Swimming Sports ���������������������������������������������������������������������������� 641 James W. Miller, Margo Mountjoy, Cees-Rein van den Hoogenband, Emilio Lopez-Vidriero, and Monica Solana-Trmunt 98 Water Jumping Sports�������������������������������������������������������������������� 651 Jean-Romain Delaloye, Frank Sander, Jozef Murar, Thomas Tischer, and Lukas Ernstbrunner

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99 Water Polo�������������������������������������������������������������������������������������� 659 Michael Badulescu 100 Sailing���������������������������������������������������������������������������������������������� 665 Dario Karamatic and Robin Seiffert Part XVI Aspects of Different Sports: Special Considerations for Other IOC Sports 101 Tennis���������������������������������������������������������������������������������������������� 671 Emilio Lopez-Vidriero, Rosa Lopez-Vidriero, Michael Najfeld, and Kai Fehske 102 Squash �������������������������������������������������������������������������������������������� 677 Bertrand Tapie, Charlotte Gil, and Patricia Thoreux 103 Badminton�������������������������������������������������������������������������������������� 683 Kai Fehske, Rosa Lopez-Vidriero, and Emilio Lopez-Vidriero 104 Table Tennis������������������������������������������������������������������������������������ 687 Clémence Goupil, Perrine Capron, and Patricia Thoreux 105 Golf�������������������������������������������������������������������������������������������������� 693 Lukas Clerc, Olivier Rouillon, and Didier Hannouche 106 Rowing�������������������������������������������������������������������������������������������� 699 Jürgen M. Steinacker, Johannes Kirsten, Kay Winkert, Mickel Washington, and Gunnar Treff 107 Archery and Shooting Sports�������������������������������������������������������� 705 Dominik Szymski and Robin Seiffert 108 Paralympic Sports�������������������������������������������������������������������������� 711 Anja Hirschmüller Part XVII Special Sports with Physical and Mental Dynamic and Coordination 109 Dancing Sports�������������������������������������������������������������������������������� 721 Björn Drews 110 Ballet������������������������������������������������������������������������������������������������ 725 Xavière Barreau, Charlotte Gil, and Patricia Thoreux 111 Gymnastics�������������������������������������������������������������������������������������� 733 Franziska Eckers, Lolita Fischer, and Philippe M. Tscholl 112 E-Sports/Computer Sports������������������������������������������������������������ 741 Robin Seiffert, Dominik Szymski, and Werner Krutsch 113 Chess������������������������������������������������������������������������������������������������ 745 Dominik Szymski and Robin Seiffert

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Contents

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114 Beach Sports ���������������������������������������������������������������������������������� 749 Leonard Achenbach 115 Gym and Fitness Studio���������������������������������������������������������������� 755 Felix Fischer Part XVIII Tips and Tricks in Player’s Care 116 Tips and Tricks for Athletes and Coaches������������������������������������ 763 Henrique Jones 117 Tips and Tricks for Medical Staff ������������������������������������������������ 767 Angelina Lukaszenko, Yunus Emre Ozdemir, Baris Kocaoglu, and Ferran Abat 118 Tips and Tricks for Fitness Coaches and Sport Scientists���������� 773 Andreas Schlumberger 119 Tips and Tricks for Sports Clubs and Sports Associations�������� 779 Antonio Maestro, Manuel Rodriguez-Alonso, and Iván Pipa 120 Tips and Tricks for Team Healthcare at Multisports Events ���� 787 Michael R. Carmont, Patrick O’Halloran, Lee Schofield, Doug A. Evans, and Ron Olson 121 Tips and Tricks for Stay & Play on Field ������������������������������������ 793 Werner Krutsch 122 Tips and Tricks for Healing Potential in Different Tissue���������� 799 Manuel Virgolino

About the Editors

Werner Krutsch, MD,  is Orthopedic Surgeon and Specialist in Knee Surgery and Sports Medicine. He is Associate Professor in the Department of Trauma Surgery at the University Medical Centre Regensburg and Deputy Director of the FIFA Medical Centre of Excellence Regensburg, Germany. Dr. Krutsch is a member of the Medical Committee and Co-Director of the Football Medicine Programme at the German Football Association DFB. He is the Medical Director of the Football Association Bayern and former FIFA DC Officer. Dr. Krutsch is additionally head of prevention at the second league football club SSV Jahn Regensburg and a member of committee in different orthopedic societies. Dr. Krutsch has had an active professional football career with clubs including VFB Stuttgart and 1. FC Nürnberg and won several national and international titles in football. He is currently the captain of the German national football team of medical doctors and a member of the Legends Team of retired player at the 1. FC Nürnberg. Research focus of Dr. Krutsch is football medicine and injury prevention in football with more than 70 publications as original paper or book chapters in the last 6 years. Hermann  O.  Mayr, MD, is Chief of the Department of Knee, Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Germany. He is also Research Associate in the Department of Orthopedic and Trauma Surgery of Freiburg University, Germany. From 2007 to 2012, he was Associate Professor. In 2012 he was appointed Extraordinary Professor at  Freiburg University. Hermann Mayr is Past Chair of the xix

About the Editors

xx

ESSKA Sports Committee, Founding Chairman and Past Chairman of ESMA (European Sports Medicine Associates, a Section of ESSKA), and Past President and Founding President of DKG (German Knee Society). He also served as President of AGA (Society for Arthroscopy and Joint Surgery) from 2009 to 2011. Hermann Mayr is one of the physicians of the German National Ski Team since 1990. He has been responsible for various inventions and is the holder of several patents. Volker  Musahl, MD,  is Professor of Orthopedic Surgery and Bioengineering at the University of Pittsburgh, Chief of Sports Medicine at the UPMC Freddie Fu Sports Medicine Center, Program Director of the Sports Medicine fellowship program, and associate head team physician for the University of Pittsburgh Football team. Prof. Musahl has received numerous honors and awards and has published over 250 peer-reviewed publications. He is Deputy Editor-in-Chief of Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA). His research interests include clinical outcomes research of knee and shoulder. He is currently co-principal investigator for two large-scale multicenter randomized controlled trials, the STaR trial and the STABILITY II trial. Francesco  Della  Villa, MD, is a Sport and Exercise Medicine physician as well as a clinician and researcher. He is in charge of clinical research and development, working in the Education and Research Department of the Isokinetic Medical Group, which is a FIFA Medical Centre of Excellence, located in Bologna, Italy. Dr. Della Villa is an active member of different international scientific societies. He had an international education with a focus on qualitative movement analysis and biomechanics. He has a particular interest in translating research into high level clinical practice, with a focus on rehabilitation and return to play after knee injuries, especially ACL injuries. His research interests vary from injury mechanism to functional outcomes following complex sports injuries. Husband, father, and lover of the nature, he is also a passionate saltwater fisherman.

About the Editors

xxi

Philippe  M.  Tscholl, MD, is Orthopedic Surgeon and Sports Medicine specialist, Senior Consultant at the Geneva University Hospitals for Knee Surgery and Sports Traumatology, Medical Director of the Swiss Olympic Medical Center, and member of the IOC medical center Re-FORM (Réseau Francophone Olympique pour la Recherche en Médecine du sport). He is a member of several international societies and expert groups around the knee and sports medicine, a member of the editorial board of the KSSTA journal, and the author of several scientific articles around the knee, especially the patellofemoral joint. He is in charge of the Swiss National Futsal team and the Under 18 Swiss National Ice Hockey team, team physician of several local American Football, Rugby, and Volleyball teams, and has participated at several European Youth Olympic Festivals and Under-18 IIHF World Championships as chief medical officer for Switzerland. He is former research assistant of the F-MARC, having investigated on the epidemiology of injuries and their mechanisms, age determination of the wrist on MRI, and the use of medication in professional athletes. Henrique Jones, MD,  is Orthopedic Surgeon and Sports Medicine Specialist, is the Clinical Director of the Orthopedic Surgery and Sports Medicine Clinic, Montijo, Lisbon, and practices surgery at Hospital de Luz, Setubal. He is currently Invited Professor of Lusofona University and Catholic University, Lisbon. H. Jones is also an Aerospatiale Medicine specialist and retired Colonel Doctor of the Portuguese Air Force and practiced in Portuguese Air Force Hospital, Lisbon, where he was Clinical Director and Head of Orthopedic Surgery Department (2003–2011). In sports medicine participation, he was the Team Doctor of Portuguese National Football Team in 3 European and 5 World Cup Competitions (1999–2014). He is a member of UEFA Medical Committee since 2010 and became VicePresident in 2017. Dr. H Jones is the Past President of Portuguese Arthroscopy and Sports Trauma Society (2016–2018) and ESMA Chairman (European Sports Medicine Associates, a Section of ESSKA) since 2018.

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List of Associate Editors Dominik  Szymski Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany Robin Seiffert  Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany

About the Editors

Part I Different Aspects for Different Athletes: Principles and Special Considerations in Athletes

1

Junior Athletes Oliver Loose and Stephan Gerling

1.1

Background

Youth sports culture has changed drastically over the past decades. It has become normal that children and adolescents participate in organized sports, specialize in a single sport at younger ages, and play all year round. More children are doing intensive training and have more rigorous competition schedules. Physical activity in children starts at the age of 2–3 years with gymnastics and balance bikes and continues with swimming and kicking until they enter into a club to specialize in their preferred sport at the age of 6–7  years. At the age of 10–11 professionalization, with its specific concomitants, and the selection for elite teams begins. By now, at the latest, a pre-participation screening (orthopedic and cardiovascular) should be performed to confirm eligibility for competitive sports. Playing multiple sports and delaying specialization, is more advantageous if the goal is to succeed athletically. Participating in multiple sports decreases the chance of injuries, stress, and burnout.

O. Loose (*) Department of Orthopedics, Olgahospital, Stuttgart, Germany S. Gerling University Children’s Hospital Regensburg (KUNO), Campus St. Hedwig, Regensburg, Germany e-mail: [email protected]

1.2

Physiological Aspects to Consider

Intensive training in young athletes may affect various components of their health, including cardiac, maturation, musculoskeletal. They also have special nutritional requirements—not only for their physical activity—but also for their growth in terms of calories, iron, calcium, and vitamin D. Especially in a pubertal growth spurt, it is important to ensure an adequate iodine intake for proper thyroid gland function as well.

1.3

Musculoskeletal Aspects to Consider

“Children are not little adults”—and in consequence there are some anatomical and physiological aspects to consider while working with young athletes (Table 1.1). The athlete’s body capacity to withstand stress and in consequence the sportive performance depends on the biomechanics of the growing skeleton. The musculoskeletal system in junior athletes not only consists of muscles, bones, tendons, ligaments, articulation cartilage, but also of apophysis and growth cartilage, which is unique in children. The growth area is divided into several regions: the epiphysis, the growth cartilage, and the metaphysis. The growth takes place in the cartilage area. There the composition of the cellular matrix is different and this leads

© ESSKA 2020 W. Krutsch et al. (eds.), Injury and Health Risk Management in Sports, https://doi.org/10.1007/978-3-662-60752-7_1

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O. Loose and S. Gerling

4 Table 1.1  Physiological differences in junior athletes compared to adult athletes

Airways (resistance) Breathing  Frequency  VO2 max Ability for endurance sports Circulation Regeneration Injury types  Overuse  Traumatic Basal metabolic rate Muscle mass Strength

1.4

 eneral Medical Aspects G to Consider

Children/ adolescents ↑↑/↑

Adults →

1.4.1 Cardiovascular Aspects

↑↑/↑ ↑/↑↑ ↑/↑↑

→ ↑↑↑ ↑↑↑

↑↑/↑ ↑↑/↑

→ →

↑↑ ↑ ↑ ↑/↑↑ ↑/↑↑

↑ ↑↑ → ↑↑↑ ↑↑↑

Sudden cardiac death (SCD) in children and adolescents is rare. The reported incidence of SCD for adolescent and young adults ranges from 0.5 to 20 per 100,000 person-years. Several studies have reported a higher risk (2–2.5 times greater) of SCD during athletic competition or exercise. Etiologies included congenital heart disease, hypertrophic cardiomyopathy, primary arrhythmia, mitral valve prolapse, myocarditis, and congenital coronary artery abnormalities (Fig. 1.1). Although SCD is often the initial presenting event, retrospective studies have shown that warning signs or symptoms were noted by 30–50% of affected individuals prior to SCD.  The most common symptoms were chest pain and actual or near syncope. Other symptoms included dizziness, palpitations, or dyspnoea. Pre-­participation screening has the potential to detect those athletes with higher risk of SCD. We recommend that junior athletes should undergo a standardized cardiovascular screening protocol with medical history taking, a physical examination, 12-lead resting electrocardiogram, and a transthoracic 2D-echocardiography before the start of competitive sport and should be repeated every second year to detect progressive diseases.

in c­ onsequence to a lower stability. In times of increased growth like in puberty, the mechanical stability of the growth areas decreases and is more susceptible for traumatic and overuse injuries. Locations of typical, age sport-specific injuries in junior athletes, are, for example, the proximal femur epiphysis (Epiphysiolysis capitis femoris), apophysis injuries (e.g., the proximal tibia apophysis: M.  Osgood–Schlatter), the apophysis of the vertebral body (M.  Scheuermann) or spondylolysis. Consequently, the training load has to be adapted to the development phases of the athletes. This consideration implicates a precise training regulation regarding intensity because of the heterogeneity of athletes especially in the pubertal phase (girls: 11–13 years, boys: 13–15 years). Another important aspect to prevent injuries in junior athletes regarding the musculoskeletal system is to perform regular orthopedic screenings to discover early static changes of the normal growth: the leg axis and rotations of the lower limb, hip mobility and spine axis, and finally yet importantly the foot anatomy. In addition, dynamic factors have to be determined regularly like the dynamic knee valgus in one-foot-standing, so that deficits can be detected early and can be approached with specific preventive training programs (mobilization, core stability, jumps and landings, agility) such as FIFA 11+.

1.4.2 Respiratory Aspects In majority of junior athletes, exercise tolerance is limited by cardiovascular and muscular factors. Yet some young athletes do experience respiratory problems with exercise. These problems can be related to underlying acute and chronic respiratory conditions (e.g., infectious disease, asthma, cystic fibrosis, chest wall deformities, neuromuscular disorders, and exercise-­ induced bronchoconstriction). Although respiratory symptoms can be suggestive of asthma, the diagnosis of asthma should be based on objective measurements. Pharmacologic management of respiratory problems can be difficult and in

1  Junior Athletes Fig. 1.1 Cardiovascular reasons for sudden cardiac death in athletes (modified Maron et al., 2007, Circulation 115:1643–1655). ARVC arrhythmogenic right ventricular cardiomyopathy, HCM hypertrophic cardiomyopathy, LVH left ventricular hypertrophy, MVP mitral valve prolapse

5 HCM 18%

indeterminate LVH-possible HCM coronary artery anomalies 36%

2% 3%

myocarditis ARVC

4%

MVP

4%

ion channelopathies

6% 8% 17%

treatment of athletes with asthma, anti-­doping regulations have to be considered (e.g., use of glucocorticosteroids, ß-adrenergic agonists). Exercise-inducible laryngeal obstruction has also been recognized as a relevant respiratory problem in children practicing sports.

1.4.3 Neurology Aspects If there is any history of pre-syncope or syncope in a junior athlete, a thorough medical checkup is mandatory. Cardiovascular diseases (e.g., primary arrhythmias, congenital heart defects, systemic hypertension, etc.), metabolic (e.g., hypoglycemia), and neurological reasons (e.g. epileptic seizures) have to be excluded. Even in pharmacological well-controlled epilepsy the decision to compete in water sports (e.g., openwater swimming, rowing, etc.) or disciplines with a potentially higher risk (e.g., climbing, motor sports) should be individualized. There is still an ongoing scientific debate about prophylaxis of concussion in youth sports (e.g., headings in football) to avoid possible irreversible damage of neurological structures. The sports associations are going to develop specific guidelines depending on sport disciplines and age.

1.4.4 Infectiological Aspects Prevention of sudden cardiac death due to myocarditis is a key issue in taking care of an athlete with

aortic rupture other cardiac diseases

an infectious disease. It is important to note that the clinical presentation of myocarditis with an asymptomatic course complicates both diagnosis and prevention. In myocarditis, the risk for sudden cardiac death does not correlate with the intensity of inflammation. In addition, exercise in patients suffering from myocarditis may worsen cardiomyopathy. The best method of prevention would be a detailed education of young athletes, their families and coaches explaining that suspending exercise during infections can reduce the risk for sudden cardiac death. Furthermore, junior athletes should be immunized by inactivated vaccines against tetanus, diphtheria, pertussis, hepatitis A, hepatitis B, Haemophilus influenzae type b, pneumococci, meningococci C, influenza and by live vaccines against measles, mumps, rubella, and varicella. An appropriate time for vaccination would be at the onset of resting periods. Side effects after inactivated vaccines can be expected within 2 days after vaccination, whereas after live attenuated vaccines they are more likely to occur after 10–14 days.

1.4.5 Psychological Aspects There is evidence of burnout and overtraining in children who are specializing in just one sport to early. The concerning statistic is that 70% of kids drop out of organized sports by the age of 13 years. Burnout in children can have very vague symptoms and signs. Often, these children feel depressed or they are irritable. To reduce the likelihood of burnout in youth sports, an emphasis should be placed

O. Loose and S. Gerling

6

on skill development over competition and winning. Diversifying and playing multiple sports is actually beneficial, mentally and physically. Multiple sports use different muscles and different bones. Furthermore, making sure that junior athletes take some time off from one particular sport is very important both physically and mentally.

1.5

Pitfalls in This Population

–– High risk of overuse injuries, especially in elite junior levels, caused by: Insufficient knowledge about specifics of the growing athlete (musculoskeletal) among coaches and health professionals. Specializing in one single sport to early (before puberty). Increased physical load without breaks. –– Risk of sudden cardiac death due to: Congenital cardiovascular disease. Infectious myocarditis.

1.6

Fact Box

–– During athletic competition or exercise there is a higher risk of sudden cardiac death. –– Pre-participation screening (orthopedic and cardiologic) is recommended to confirm eligibility for competitive sports.

–– “One sport kids” are prone to burnout, overtraining, and overuse injuries. –– Personalized training will reduce the risk of overuse injuries in the growing athlete. –– Physical and mental burnout is prevented through “prophylactic” breaks in training.

Recommended References 1. Drezner JA, Pelliccia A, Corrado D et  al (2017) International criteria for electrocardiographic interpretation in athletes: consensus statement. Br J Sports Med 51(9):704–731 2. DiFiori JP, Benjamin HJ, Brenner JS et  al (2014) Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med 48:287–288 3. Fritsch P, Oberhoffer R, Petropoulos A et  al (2017) Cardiovascular pre-participation screening in young athletes: recommendations of the Association of European Paediatric Cardiology. Cardiol Young 27(9):1655–1660 4. Gerling S, Loose O, Krutsch W et  al (2019) Echocardiographic diagnosis of congenital coronary artery abnormalities in a continuous series of adolescent football players. Eur J Prev Cardiol 26:988–994. https://doi.org/10.1177/2047487319825520 5. Loose O, Achenbach L, Krutsch W (2018) Injury incidence in semi-professional football claims for increased need of injury prevention in elite junior football. Knee Surg Sports Traumatol Arthrosc 27:978– 984. https://doi.org/10.1007/s00167-018-5119-8

2

Adolescent Athletes Nathalie Farpour-Lambert

2.1

Background

Adolescence is the developmental period occurring between childhood and adulthood during the second decade of life. It is a transitional period marked by substantial changes in physical maturation, cognitive abilities, and social interactions. Pubertal development is the hallmark of early adolescence characterized by rapid physical growth and the maturation of the reproductive system. Physical activity is associated with many benefits during adolescence, including improved aerobic fitness, muscle strength, motor skills, speed, coordination, balance, body composition and bone mineral density. Moreover, sport participation can reduce symptoms of depression, anxiety, and stress, and increase quality of life and wellbeing. It contributes also to improve the regulation of emotions, to develop inter-personal skills and quality peer relationships, and to enhance academic engagement and achievement. Despite its numerous known benefits, sports participation declines with age through adolescence, particularly for girls. This may be attributed to a number of factors including musculoskeletal injuries, competing demands between academic N. Farpour-Lambert (*) Department of Primary Care, University Hospitals of Geneva, Geneva, Switzerland Department of Women, Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland e-mail: [email protected]

and social commitments, limited access to affordable opportunities, alternative interests, conflicts with coaches or peers, issues around self-­ presentation arising alongside puberty onset, and conformity to traditional gender roles. This has implications for immediate and maintained physical activity across the lifespan. On the other hand, young athletes are being encouraged to train intensively during the critical phase of puberty resulting in increased risks of musculoskeletal injuries, diseases and drop-out from sport. The purpose of this chapter is to review a number of physiological and medical issues that surround health and performance of adolescent athletes.

2.2

Physiological Aspects to Consider

2.2.1 Growth and Maturation Puberty is designated by the development of secondary sex characteristics, the marked acceleration in linear growth, bone mineral acquisition and changes in body composition. Secondary sexual characteristics appear at a mean age of 10.5 years in girls and 11.5–12 years in boys. Five stages of puberty from childhood to full maturity (P1 to P5) have been described by J. Tanner. Girls are rated for breast development and pubic hair growth, while boys are rated for genital develop-

© ESSKA 2020 W. Krutsch et al. (eds.), Injury and Health Risk Management in Sports, https://doi.org/10.1007/978-3-662-60752-7_2

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8 Table 2.1 Pubertal development in girls and boys (Tanner stages) Pubic hair scale Stage 1: No hair (in female and Stage 2: Downy hair Stage 3: Scant terminal hair male) Stage 4: Terminal hair that fills the entire triangle overlying the pubic region Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh Stage 1: No glandular breast tissue Female breast palpable development Stage 2: Breast bud palpable under scale areola (first pubertal sign) Stage 3: Breast tissue palpable outside areola; no areolar development Stage 4: Areola elevated above contour of the breast, forming “double scoop” appearance Stage 5: Areolar mound recedes back into single breast contour with areolar hyperpigmentation, papillae development and nipple protrusion Male external Stage 1: Testicular volume 4.5 cm long)

ment and pubic hair growth (Table  2.1). Stages are typically assessed clinically, although selfassessments are also used. Breast and genital staging, as well as height velocity, should be relied on more than pubic hair staging to assess pubertal development because of the independent maturation of adrenal axis. In girls, puberty begins with the development of breast buds under the areola, also known as thelarche (Tanner stage 2), under the control of estrogens which are secreted by the ovaries. As puberty progresses, the glandular tissue of the breast increases in size and changes in contour. In females, thelarche is followed in 1–1.5 years by the onset of sexual hair (pubic and axillary), known as pubarche, secondary to androgen secretion by the adrenal cortex. The onset of menses, (menarche), arrives on average at the age of 12.5 years, regardless of ethnicity, following thelarche on average by 2.5 years.

N. Farpour-Lambert

In boys, the onset of puberty ranges from 9 to 14 years of age. The first secondary sexual characteristic visible is when testicular volume reaches greater than or equal to 4  mL, or a long axis ≥ 2.5 cm, and enters Tanner stage 2 (gonadarche). Testicular development can be evaluated with a Prader orchidometer, a set of models (ellipsoids) indicating specific testicular volumes. The growth and maturation of the penis usually correlate with pubic hair development under the control of androgen. Other major physical changes in boys include facial, body and axillary hair and lowering of the voice pitch. Spermarche, the counterpart of menarche in females, is the development of sperm in males and typically occurs during genital Tanner stage 4. The year of greatest height gain occurs at an earlier stage of puberty in girls (breast stage 2–3) than boys (testes stage 3–4). Peak height velocity (PHV) occurs at approximately 11  years of age (Tanner stage 2–3) and 13  years of age (Tanner stage 3), respectively, for girls and boys, and mean peak height gains for boys and girls average 9.5 and 8.3  cm per year, respectively. Linear height growth at puberty contributes approximately to one-fifth of the final height. Age at PHV is estimated from height measurements of individual children taken annually or semiannually across adolescence. Growth hormone plays a key role in the abrupt acceleration of linear growth that occurs during adolescence. Growth spurts in lower body dimensions occur, on average, before PHV, while spurts in body weight, lean tissue mass, bone mineral content and upper body dimensions occur after PHV in both genders. Many factors are known to influence growth and maturation: familial correlation, family stature, status at birth and early growth, household environment and nutrition. Acknowledging the normal variability, exercise training per se does not affect age at menarche in female athletes, and is not a factor affecting growth in height in adolescents. Skeletal age (SA) is an indicator of maturation of the handwrist skeleton viewed on a standard radiograph and can be performed in case of growth delay (height z-score below −2 or diminished height gain). Three methods for estimating SA can be

2  Adolescent Athletes

used: Greulich-Pyle; Tanner-­ Whitehouse, and Fels; most adult height prediction protocols are based on SA. In many cases of short stature, a familial component can be identified (short stature or late maturation in parents). Other causes of growth failure include undernutrition, glucocorticoid therapy, gastrointestinal diseases, metabolic diseases, genetic diseases, other chronic diseases, cancer, growth hormone deficiency, hypothyroidism, Cushing syndrome and sexual precocity. In girls and boys, peak bone mineral accrual is noted approximately 1  year later PHV, which may explain the increased incidence of fractures during puberty. The augmentation of bone mineral content and density during puberty is mainly due to bone growth in length and width. It can be assessed by dual-energy X-ray absorptiometry (DXA). Genetic factors account for 60–80% of bone development, however, extrinsic factors like weight-bearing physical activity, nutrition, substance abuse, diseases and injuries may influence it. Bone mineral accrual is clinically important as a 10% increase of peak bone mass at the end of growth may decrease by 25–50% the risk of osteoporosis fracture later in life. In both gender, but more so in boys, there is a substantial gain in lean body mass during puberty. From 5 to 17  years of age, the muscle mass of males increases from approximately 40 to 55% of the total body mass. Over the same age range, the muscle mass of females increases from approximately 40 to 45% of the total body mass. The advantage of having greater active muscle mass to recruit during exercise is potentially useful in providing an enhanced functional capacity and possibly metabolic rate in the exercise performance of adolescent males compared with females. The greatest change in body composition of the adolescent girls occurs in fat mass; from approximately 15% fat at 6 years of age to 25% at 17 years of age. In comparison, at 6 years of age, boys have approximately 10% of body fat which increases to around 15% by 17  years of age. Body composition changes during puberty are a complex and interactive result of genetic factors, sex hormones, growth hormone, leptin, energy intake and expenditure.

9

Selection or exclusion in many sports follows a maturity-related gradient largely during the interval of puberty and growth spurt. Early developing pubescent males are advantaged by having greater muscle mass than their later developing peers. This benefit may be most evident during physical exercises requiring strength, speed and power. Boys who are perceived as physically suited for a sport generally experience greater success; are identified at an earlier age; are given more important roles; receive more playing time, encouragement and resources; and more likely have access to elite coaches. In girls, the physical and functional characteristics associated with advanced maturation (greater stature, absolute strength) may afford an advantage in swimming and tennis. On the other hand, early pubescent females can be disadvantaged by having the additional fat gain, their functional capacity and motivation being reduced compared to later developing peers. A maturity-related gradient among female athletes is most apparent in artistic gymnastics, diving, figure skating and distance running, which favors later maturing. It is therefore recommended for prepubescent girls to develop perceived physical competence in a broad range of skills so that early or late puberty does not lead to cessation of all physical activity. The gain in fat mass which commonly occurs in female during puberty can be limited by regular physical activity, thus providing health benefits during the life course.

2.2.2 Strength Training and Conditioning Selectivity and talent development models consider the adolescent years as a “window of opportunity” for selection and sport-specific training, and imply enhanced trainability. A “trigger hypothesis” has been proposed for increased sensitivity of the muscular and cardiovascular systems to training associated with pubertal hormonal changes during adolescence, whereas the Long-Term Athlete Development model ­specifically indicated the interval of PHV as the reference for programming training proto-

N. Farpour-Lambert

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cols. There is some evidence that speed and flexibility peak gains appear before PHV in boys, while tests of strength and power attain peak gains after PHV, and peak velocity in maximal aerobic capacity (VO2 max) occurs at the time of PHV in both gender. Compared to adults, children have lower relative maximal strength and attain lower relative power outputs, mainly due to lower maximal voluntary muscle activation. Youth strength training can have potential benefits including improvement of motor unit recruitment and muscle strength, body composition, flexibility, coordination, aerobic capacity, serum lipid levels, sport performance, sport-related injury prevention and rehabilitation, and enhanced long-term health. It has been shown that preseason conditioning programs and pre-practice neuromuscular training can reduce injury rates in young athletes. With proper structure, technique, intensity, supervision and planning, regular participation in a resistance training program can be performed safely in the pediatric population. However, resistance training should be one component of a well-balanced and varied exercise program. Pre-pubertal children are metabolically comparable to well-trained adult endurance athletes and are thus less fatigable during high-intensity exercise than untrained adults. This may be explained by a higher percentage of slowtwitch type-I motor units in the accessible pool. A greater parasympathetic reactivation of the autonomic nervous system early in the recovery period after exercise has been also observed. Pre-­ pubertal children are therefore capable of working at greater fractions of their maximal capacity prior to or without exhaustion, concomitantly with lower carbohydrate and higher fat metabolism. This is in line with observed higher relative lactate and ventilatory thresholds, lower lactate production and faster recovery. The reduced anaerobic power of the young athlete compared with that of an adult athlete is therefore due to the intrinsic properties of the muscle. During puberty, the anaerobic capacity and anaerobic-to-aerobic power ratio increases with age leading some to the illusion of deteriorating aerobic fitness, whereas it is not. Endurance-based aerobic activities or

structured training (continuous or interval) should be incorporated in general training to preserve aerobic fitness during pubertal years. Normal adolescents can improve aerobic capacity by 10–25% with training. The primary concerns related to endurance training are overtraining (elevation in basal cortisol, increased resting heart rate, reduced physical and mental performance, gastrointestinal disturbances, chronic muscle soreness, elevation in skeletal damage markers, depressed immune function) and early specialization. In youths, the peak oxygen consumption (peak VO2, mL·kg−1·min−1) can be objectively measured prior and after training by a multistage treadmill/cycle ergometer test using validated pediatric protocols, or can be estimated using a 20-m multistage shuttle run field test. A decrease in youth’s aerobic fitness is usually a reflection of an increased sedentary lifestyle, or a limitation of physical activity due to a disease or injury. Aerobic training should be particularly encouraged in pubescent girls that commonly decrease their aerobic capacity during puberty.

2.3

Medical Aspects to Consider

2.3.1 Pre-participation Physical Examination The pre-participation physical evaluation (PPE) serves as a tool to encourage safe athletic participation. It aims to identify and averting causes of severe health conditions but also provides an excellent opportunity to provide information and guidance on issues ranging from nutrition, sleep, alcohol and drug use, injury prevention and physical condition. The convenient time for PPE is 4–6 weeks before preseason practice. This allows the athlete and the physician to make adjustment or to establish a treatment plan in case of injuries. Annual PPE is often considered the norm, or before starting a new school level. The multiple components of PPE are presented in Table  2.2. Laboratory and imaging studies should only be used as an extension of the history and physical examination when additional information is needed to evaluate a concern. Screening blood

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Table 2.2  Pre-participation physical evaluation in adolescents Components of the PPE Comments Sport’s history Discipline and level Regional/national/international Days and duration of sports training Days and duration of conditioning Other physical activities Number of competitions per month/year  Coaches Professional/volunteer  Athletes and parents expectations Medical history Past medical/surgical history Including prior injuries Growth and maturation Height and weight at birth, evolution of height, weight and pubertal development Medications Check WADA prohibited list Allergies Food, medications, pollens Immunization Tetanus, diphtheria, pertussis, poliomyelitis, Haemophilus influenzae, measles, mumps, rubella, pneumococcal, meningococcal, influenza, hepatitis A and B, varicella and human papillomavirus vaccines are recommended Substance use Tobacco, alcohol and drugs Supplement and ergogenic aid Sleep Sleep duration and quality, use of screens at night Nutrition Dairy products and other source of proteins (meat, poultry, fish, egg), fruits, vegetables and legumes, grains and nuts. Water, sugar sweetened beverages, sports/energy drinks Family history Parental height/weight; age at menarche/gonardache; cardiomyopathy, congenital heart disease, arrhythmia, atherosclerosis, sudden death, genetic conditions, endocrine diseases, eating disorders Social history Ethnicity, language, school level and performance, relationships with coaches/ peers/parents/siblings Review of systems Medical examination Height and body weight Barefoot with light clothes Body mass index, z-score/ BMI World Health Organization references percentile Waist circumference, waist/height ratio and skinfolds when indicated Skin Infections, eczema, dryness Eyes, oral cavity, ears, nose Frequent external ear and nose infections in water sports Cardiovascular system Resting blood pressure, heart rate, radial/femoral pulses, rhythm and murmurs Pulmonary system Respiratory rate, signs of distress, wheezing, stridor Digestive system Abdominal masses, tenderness, organomegaly Endocrine system Tanner stage, single or undescended testicle, testicular mass in males, hernia Musculoskeletal system Contour, limbs alignment, range of motion, stability and synergy of neck, back, shoulder/arm, elbow/forearm, wrist/hand, hip/thigh, knee, leg/ankle, foot Neurological system Visual acuity; comprehensive examination if prior history of head trauma BMI body mass index, WADA World Anti-Doping Agency

and urine tests are not recommended for asymptomatic athletes. Referral to a specialist should be considered whenever a serious health concern arises.

2.3.2 Musculoskeletal Injuries Injuries are common in adolescents participating in sports, particularly for those participating in a

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single sport on a nearly continuous yearly schedule, and are the main cause of sports cessation. Many injuries require medical treatment that can include surgical repair and lengthy rehabilitation, and can result in time lost from school and other activities, social isolation, loss of motivation, and delays in conditioning and technical development. Injuries may also require parents to be absent from work whilst attending appointments. In the longer term, musculoskeletal injuries have been associated with significantly increased risks of osteoarthritis and other chronic conditions, and concussion and its long-term sequelae are currently of primary concern. Injuries therefore represent an important burden for families and the health care system. The characteristics of the growing musculoskeletal system have been described in Chap. 1. Overuse injuries develop when repeated mechanical loading exceeds the remodeling capability of the structure under stress. They are the result of a complex interaction of multiple intrinsic and extrinsic factors, including growth-­ related factors that are unique to the pediatric population. Their prevalence ranges from 37 to 68% across various youth sports and half of the overuse injuries diagnosed in adolescents could be preventable. Intrinsic factors are individual biological characteristics and psychosocial traits (e.g. growth and maturation, anatomical factors, susceptibility of growth cartilage and bones to repetitive stress, muscle-tendon imbalance, previous conditioning, history of prior injury, menstrual dysfunction, psychological and developmental factors), whereas extrinsic factors are external forces related to the sport type, the biomechanics of the activity and the training environment (e.g. training workload, competition schedule, resting periods, sport technique, training environment and equipment, adult and peer influences). Many overuse injuries result from a complex interaction of multiple risk factors in specific settings, combined with an inciting event. Some risk factors are modifiable (e.g., muscle strength and neuromuscular function, training workload); whereas others are not (e.g. age, gender, anatomical factors). The injury risk seems to be greatest during the adolescent growth spurt and previous injury is the strongest predic-

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tor of future injuries, due to inadequate rehabilitation and/or a failure to identify and modify the factors that contributed to the first injury. The burnout is also a concern in competitive sport; young athletes with overuse injuries and/or presenting signs of burnout should benefit of a careful medical evaluation and treatment. Musculoskeletal injuries in adolescents commonly affect physis (growth plate), apophysis or articular cartilages. Approximately 15% of all fractures in children involve the physis. Acute physeal injuries are generally described using the Salter and Harris system (type I–V). Chronic physeal injuries can be seen in the distal radius (e.g. in gymnasts), the proximal humerus or the medial epicondyle (e.g. in racquet or throwing sports) and the proximal tibia (e.g. in runners) in a variety of sports, as a result of diminished metaphyseal perfusion due to repetitive loading and damage to the growing cells. The natural mineralization of chondrocytes is inhibited and cells continue to divide in the zone of proliferation. A widening of the physis can be observed radiographically or with magnetic resonance imaging (MRI). In severe cases, a partial or complete growth arrest resulting in altered long-bone growth can be observed. Apophyseal injuries occur at immature tendon-bone attachment sites. The patellar tendon-tibial tuberosity apophysis (Osgood–Schlatter disease), the inferior patellar pole apophysis (Sinding–Larsen–Johansson), the Achilles tendon-calcaneal apophysis (Sever’s disease), the ischial tuberosity apophysis, the antero-superior and antero-inferior iliac spines apophysis are common during the growth spurt, due to biomechanical factors related to long-bone growth and limb movement. The weakness of the growth cartilage relative to the tendon is a contributing factor in these injuries, as well as decreased flexibility that increase traction at the apophyseal insertion of the tendon. This may occur as a result of more rapid growth in the long bones than the muscle-tendon attachments. Sometimes, the whole physis can be avulsed (e.g. the tibial or ischial tuberosity). Osteochondritis dissecans is a focal articular cartilage lesion that typically occurs at the ankle, knee, or elbow. Its etiology remains unclear, but it may be due to a

2  Adolescent Athletes

lack of adequate blood supply to the cartilage. In some cases, repetitive loading may aggravate the existing abnormality of the articular cartilage. The first step of the treatment of overuse injuries is to protect the injured site by reducing tissue loading and mechanical stress. The training should be adapted but activities that do not stress the injured site generally can be continued. For example, weight-bearing activities (e.g. running, jumping) should be avoided for a patellar tendon-­tibial tuberosity apophysis or an Achilles tendon-­ calcaneal apophysis, but cycling or swimming or running in a pool with the use of a flotation can be recommended. For chronic physeal injuries, a sufficient period of rest is important, usually at least 6  weeks. In some cases, the healing process can take several months and radiographs can help guide the treatment. Bracing generally is not needed for physeal injuries unless pain is occurring during routine daily activities. Reducing or temporarily eliminating the mechanical stress at the injured site is usually sufficient to relieve the pain, but ice or other methods of cold application can be helpful. Acetaminophen may be used for pain relief if symptoms do not respond to rest and ice. There is no evidence that nonsteroidal anti-­ inflammatory drugs (NSAID) have any benefit in overuse injuries beyond their analgesic properties. Once pain is relieved, a comprehensive rehabilitation program, including proprioceptive retraining, can be initiated to restore tissue strength and flexibility. The next steps are general conditioning and then sport-specific activities. When the adolescent is able to perform sport-­ specific skills without pain, a full level of training can be resumed.

2.3.3 Pubertal Abnormalities and Menstrual Dysfunction Intensive physical training and participation in competitive sports during childhood and adolescence may impact athlete’s pubertal development. On the other hand, pubertal timing, early or late, may influence an athlete selection for a particular sport. Precocious puberty is defined as the onset of Tanner 2 secondary sexual characteristics before the age of 8 years in girls or the age of

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9  years in boys, if continued progression of pubertal development occurs in close follow-up. Delayed puberty should be considered if girls have not reached Tanner 2 stage (breast development) by age 13  years old, or if boys have not reached Tanner 2 stage (genital development) by the age of 14 years. Some boys can temporarily develop glandular breast tissue (pubertal gynecomastia) between genital tanner Stage 3 and 4, which may be psychologically disturbing but not physically harmful. Genetic factors, training load, nutritional status and psychological stress are the main determinants of pubertal timing in young athletes and a wide variation can be observed among adolescents. Pubertal delay may be caused by idiopathic conditions, nutritional deficiencies, hypothalamic pituitary gonadal axis variations, or neoplastic and genetic disorders. Those that practice aesthetic sports, especially gymnasts, are predisposed to a delay in pubertal development, but it has been shown that chronic negative energy balance associated with disordered eating or eating disorders, not training per se, plays a crucial role in the pathogenesis of functional hypothalamic hypogonadism in female athletes. Metabolic and psychologic stresses activate the hypothalamic-­ pituitary-­adrenal axis and suppress the hypothalamic-­ pituitary-ovarian axis. Girls who do not begin breast development by the age of 13 or have a delayed menarche need a comprehensive evaluation and a targeted treatment. Primary amenorrhea is defined as failure to start menses within 3 years of Tanner stage 2 or by the age of 14 years with the absence of growth or the development of secondary characteristics, or as absence of menses by the age of 16 years with normal development of sexual characteristics. Secondary amenorrhea is defined as the cessation of menstruation for at least 6  months or for at least 3 cycle intervals. Primary amenorrhea is a symptom with an extensive list of underlying causes, the majority of which are rare: hypothalamic and pituitary diseases (functional, isolated GnRH deficiency, constitutional delay of puberty, hyperprolactinemia), gonadal dysgenesis/primary ovarian insufficiency, polycystic ovary syndrome, outflow tract disorders, receptor abnormalities and enzyme deficiencies. The incidence of delayed menarche, however,

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needs to be assessed in relation to the age of menarche in the mothers of the young athletes rather than in relation to a less active control group. Laboratory and imaging studies may include: urine pregnancy test; serum prolactin, thyroid stimulating hormone (TSH), free thyroxine (T4), gonadotrophins (follicle stimulating hormone (FSH), luteinizing hormone (LH)) levels; and an abdominal ultrasound scan. The patient should be referred to an obstetrician-­ gynecologist for a comprehensive medical evaluation. Female adolescent athletes can also present a “female athlete triad,” which refers to the combination of low energy availability with or without disordered eating, menstrual dysfunction, and low bone mineral density. Low energy intake is a common cause of menstrual dysfunction in this population, up to 80% of athletes in aesthetic sports, athletics or weight-related sports being affected. Clinically, these conditions can manifest as disordered eating behaviors, menstrual irregularity or amenorrhea, and stress fractures (femoral neck, tarsal navicular, metatarsal, anterior tibial cortex). Consequences of these clinical conditions may be reversible so prevention, early diagnosis and intervention are critical. The goal of the treatment is restoration of regular menses as clinical marker of reestablishment of energy balance, and an increase of bone mineral density assessed by DXA. Adjusting energy expenditure and energy availability is the main intervention. A team approach involving the youth female athlete, obstetrician-gynecologist, dietician or nutritionist, coaches, parents and psychologist is recommended. Primary and secondary amenorrhea in youth female athletes can serve as a warning sign, as adolescence is an important time for bone accrual, growth, and development. Thus, screening systematically for low energy intake, weight loss or insufficient weight gain for age, establishing causes and consequences of menstrual disorders, and managing the condition with an interdisciplinary team is most effective. Screening for the female athlete syndrome should be an integral part of the PPE. The Female Athlete Triad Coalition’s Recommended Screening Questions can be used. In addition, parents and coaches should be educated and informed.

2.4

Pitfalls in This Population

–– Wide variation among individuals in the timing of the pubertal growth spurt; the selection or exclusion in many sports follows a maturity-­ related gradient. –– Insufficient knowledge about the growth and maturation, benefits and risks of competitive sports in adolescent athletes among adolescents, parents, coaches, and health care professionals. –– Increased risk of disordered eating, amenorrhea and osteoporosis in adolescent female athletes due to norms in aesthetic or weight-­ related sports; coaches and peers can reinforce a negative body image and disordered eating.

2.5

Fact Box

–– Regular physical activity promotes physical and psychological health in adolescents. –– The pubertal period is marked by substantial physical, psychological and social changes, and is considered as a critical window in competitive sports because it is associated with an increased risk of musculoskeletal injuries. –– The pre-participation evaluation may identify prior injury and underlying causes, and is an opportunity to provide information and ­guidance on lifestyle (e.g. nutrition, sleep) and health issues. –– A history of prior injury is a risk factor for overuse injuries and should be systematically recorded during examinations. –– Youth strength training can have potential benefits including sport performance, injury prevention, and rehabilitation. –– Adolescent female athletes should be screened for eating disorders and menstrual dysfunction, as potential predisposing factors to bone fragility and susceptibility to stress fracture. –– Education of adolescents, parents, and coaches regarding growth, maturation, benefits, and risks of competitive sports, and preventive measures is recommended. –– Communication between athletes, parents, coaches, and health care professionals is a key to prevent and manage injuries and diseases.

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–– Weekly and yearly participation time, and sportspecific repetitive movements should be limited, and resting periods should be preserved. –– An individual training and competition plan based on the sport and the athlete’s age, growth gain, readiness, prior injury history and current health status should be established.

Recommended References 1. Malina RM, Rogol AD, Cumming SP, Coelho e Silva MJ, Figueiredo AJ (2015) Biological maturation of youth athletes: assessment and implications. Br J Sports Med 49(13):852–859

15 2. DiFiori JP, Benjamin HJ, Brenner JS, Gregory A, Jayanthi N, Landry GL et al (2014) Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med 48(4):287–288 3. Popovic NB, Bukva B, Maffulli N, Caine D (2017) Chapter 44: the younger athlete. In: Brukner P, Clarsen B, Cook J, Cools A, Crossley K, Hutchinson M, McCrory P, Bahr R, Khan K (eds) Brukner & Khan’s clinical sports medicine: injuries, 1, 5th edn. McGraw-Hill, New York 4. Ackerman KE, Misra M (2018) Amenorrhoea in adolescent female athletes. Lancet Child Adolesc Health 2(9):677–688 5. Committee on Adolescent Health Care, American College of Obstetricians and Gynecologists (2017) ACOG Committee Opinion No. 702: female athlete triad. Obstet Gynecol 129:e160–e167

3

Sport in Female Athletes Tiana Raoul, Clémence Coll, and Patricia Thoreux

3.1

Background

Women have physiological, morphological, biomechanical and mental specificities that are very different from men. The “Female Athlete Triad”, first described in 1992, summarizes the consequences of eating disorders and menstrual cycle disorders, associated with osteoporosis in female athletes. This chapter focuses on the specificities of sportswomen: we will discuss the effect of hormones in this triad, but also other female specificities and pathologies, still poorly known.

T. Raoul · C. Coll Service de Médecine de l’Exercice et du Sport—APHP, Hôpital Jean Verdier, Bondy, France P. Thoreux (*) Service de Médecine de l’Exercice et du Sport—APHP, Hôpital Jean Verdier, Bondy, France Centre d’Investigations en Médecine du Sport (CIMS)—APHP, Hôpital Hôtel Dieu, Paris, France Département médical de l’INSEP (Institut National du Sport, de l’Expertise et de la Performance), Paris, France Institut de Biomécanique Humaine Georges Charpak—Arts et Métiers ParisTech—Université Paris 13, Villetaneuse, France e-mail: [email protected]

3.2

Physiological Influence of Hormonal Variations on Sports Performance

Ovarian secretions of steroids vary during the menstrual cycle. These secretions are useful for the proper functioning of energy metabolisms (carbohydrate, lipid and protein) involved in sports activity, and one can imagine that their variations could induce changes in physical abilities. For example, respiratory flow has been observed to increase with luteal phase progesterone. However, these hormonal variations, between the first and second phase of the cycle, are not sufficient to cause a change in muscle strength or an impact on energy metabolism or maximum oxygen consumption. There is no observed variation in either hemoglobin or hematocrit during the cycle. Therefore, there is no actual change in physical performance during the cycle (except for heavy menstruation that can lead to a decreased hemoglobin or even iron deficiency anemia).

3.2.1 Dysmenorrhea Dysmenorrhea is pain related to hypercontractility of the myometrium, due to a decrease in progesterone, and can be associated with increased psychological sensitivity to stress. It affects one sportswoman out of two, (same prevalence as in the general population), and there is no influence

© ESSKA 2020 W. Krutsch et al. (eds.), Injury and Health Risk Management in Sports, https://doi.org/10.1007/978-3-662-60752-7_3

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of the type of sport. Some studies have shown that athletes often noted a decrease in the intensity of dysmenorrhea symptoms during sports competitions: this can be related to the secretion of beta-endorphins, which acts as analgesics.

3.2.2 Premenstrual Syndrome (PMS) It occurs at the end of the cycle (5–8 days before the menstruations), and is defined by: –– Physical symptoms: ligamentous hyperlaxity, cramps, headache, weight gain, mastodynia, bloating –– And psychological symptoms: fatigue, mood disorder, increased sensitivity to stress. It can be responsible of social and professional discomfort in one woman out of three in the general population, and can have a significant impact on sports performance. A study by questionnaire conducted at INSEP in 2008 revealed that 83% of the 400 sportswomen interviewed had a premenstrual syndrome (PMS) (with bloating, weight gain, mastodynia, mental fatigue, irritability, and loss of energy). Sixty-four percent of them thought that PMS significantly reduced their physical performance.

3.2.3 Arrangement of Cycles and Hormonal Contraception This consists of lengthening the cycle to offset menstruation on request of the sportswoman. It is necessary to specify her motivations: –– Reduce dysmenorrhea –– Limit premenstrual syndrome –– To control the risk of iron deficiency anemia in case of excessively heavy menstruation. Oral hormonal contraception is the best fit to match all these goals. However, a particular attention must be paid to the type of contracep-

tive, in order to limit the undesirable effects potentially detrimental to physical performance: –– Avoid triphasic pills, which have a greater impact on body composition. –– Pay attention to the type of progesterone used, especially the level of norethisterone, which may cause hyperandrogenicity in some patients. We therefore prefer to use a monophasic estrogen-progestogen, or a third-generation progestin without androgenic effect.

3.2.4 Sports and Hormonal Disorders The “female athlete’s triade” (anorexia, amenorrhea, osteoporosis) is actually a continuum of symptoms, ranging from luteal insufficiency to amenorrhea, and anovulation. It is due to a reduced activity of the gonadotropic axis, caused by a poor energy reserve and an imbalance between inputs and energy expenditure (lack of inputs). The prevalence of hormonal disorders is higher among sportswomen than the general population: luteal insufficiency and anovulation are found in almost half of the female athletes (all sports combined), and amenorrhea is present in 7% of sportswomen, compared to 2–5% in the general population. Its prevalence does not increase with intensity or training volume, if the energy balance is preserved. The possible clinical expressions are, depending on the age of occurrence: –– Pubertal delay/primary cycle disorders The age of menarche is frequently delayed for high-performance girls (13.4 ± 1.4 years) compared to the general population (13  ±  1.3  years). The delay of menarche is more significant in slimming sports (13.7  ±  1.5  years) than in other sports (13.1 ± 1.4 years). A primary amenorrhea can also appear when there is a deficiency of nutritional

3  Sport in Female Athletes

contributions, which leads to a significant slowdown of the gonadotropic axis. –– Secondary cycle disorders/amenorrhea: they usually appear because of a weak energy reserve, with a lean mass threshold 3 months). The most affected sports are: –– “Aesthetic sports”: because of the search for thinness and aesthetics (gymnastics, figure skating, dance, synchronized swimming). –– Endurance sports: requiring lightness and strength, and in which body fat can decrease performance (athletics, running, cycling). –– Weight class sports (judo, karate, boxing, wrestling, weightlifting, rowing): in which weight control is necessary.

3.2.5 Consequences of Cycle Disorders –– Osteopenia, or even osteoporosis, which increases the risk of stress fractures. It is recommended to measure the bone mass density (BMD) score in all amenorrheas lasting over 6 months, stress fractures or eating disorders. –– Infertility due to the slowing of the gonadotropic axis (anovulation). –– Increased cardiovascular risk by reducing the protective effects of estrogen on endothelial function and no secretion.

3.2.6 Physical Activity and Menopause Physical activity is recommended after menopause as it decreases cardio-vascular morbidity and mortality (coronary and stroke), via:

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–– Improvement of lean mass/fat mass ratio and improvement of the lipid profile. –– Control of weight gain. –– Lower blood pressure. –– Improvement of insulin sensitivity. –– Decreased thrombotic risk. –– Reduced anxio-depressive symptoms and improved self-image.

3.2.7 Sport and Pregnancy 3.2.7.1 Is Physical Activity a Risk During Pregnancy? Doing sports is not a risk during a physiological pregnancy, in respect of medical contraindications. It does not increase the risk of peripartum complications, nor does it change the quality and quantity of milk or the growth of the child postpartum. On the contrary, the practice of a physical activity is recommended during pregnancy, as it contributes to maintaining and improving health status by: –– Limiting weight gain –– Reducing the risk of gestational diabetes –– Decreasing the venous symptoms of the gestational vascular pathology (fluid retention and increased risk of thromboembolism) Physical activity has shown a greater benefit when started in the year before pregnancy.

3.2.7.2 Sports Safety Tips The goal must remain the maintenance of a good physical condition, without an objective of performance or competition: –– Adapt the physical activity to the gestational state, and maintain awareness to hydration and adequate energy intake (especially from 13 SA). –– Progressive warm-up. –– No exercise in the supine position from the fourth month (avoid compression of the vena cava). –– Avoid altitude exercises (>1800  m), and formal contraindication to underwater diving.

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20 Table 3.1  Pregnancy contraindications to sports Absolute contraindications Pre-term work/amniotic fluid loss Cervico-isthmic stricture/strapping HTA pregnancy and pre-eclampsia Cardiovascular and/or severe pulmonary disease

Relative contraindications History of prematurity/ IUCD/repeated spontaneous miscarriage Malnutrition Membrane rupture Intrauterine growth retardation (IUGR) Placenta praevia >28 SA/ metrorrhagia Multiple pregnancy (≥3 fetuses) Twin pregnancy >28 SA Severe anemia (Hb