Chapter 14
Medical Care of Athletes
Mark Anthony Duca, MD
Introduction
The physicians role in the medical care of athletes has
become increasingly complex as the understanding of
physiology and its application to athletic performance
expands. With ever-developing technologies and ongo-
ing research to improve the care of the athlete, the re-
sponsibilities of the team physician have grown rapidly.
The care of an individual athlete often requires a
multidisciplinary approach. Expert opinions may be re-
quired from many medical specialties, and it is the role
of the team physician to serve as the gatekeeper and li-
aison between the athlete and the health care system.
Medical care of athletes now not only requires an
ability to assess and diagnose but a unique skill in coor-
dinating an overall game plan for their management.
The role of the team physician has evolved from one in
which preparticipation qualification and game-time in-
jury management were sole responsibilities to one in
which coordination of medical expertise with other
health-related professionals such as medical specialists,
athletic trainers, nutritionists, pharmacists, physical ther-
apists, and psychologists is essential. This dialog leads to
the safe participation of the athlete and maximizing of
their potential.
The medical management of the athlete not only re-
quires the ability to coordinate the preparticipation as-
sessment with management of on-the-field injuries, but
also the skill to outline a plan for rehabilitation and re-
turn to participation after an injury or illness.
The team physician must also be adept with proper
documentation when it comes to the care of athletes
and equally skilled at communicating treatment plans
with coaches, administrators, media, agents, and family
members. The team physician must also communicate
with others in a way that does not violate patient confi-
dentiality and is in strict compliance with Health Insur-
ance Portability and Accountability Act guidelines.
Athletic care from a medical standpoint, whether it
be for an elite, recreational, or nonprofessional athlete,
requires a detailed understanding of basic principles and
standards of care.
American Academy of Orthopaedic Surgeons
The Preparticipation Evaluation
The goal of the preparticipation evaluation, defined as
the assessment of an individual athletes qualification to
compete in a particular sport or activity, is multifaceted.
The preparticipation evaluation must be comprehensive,
yet at the same time sport-specific and focused, in an at-
tempt to identify any illness or conditions that predis-
pose the athlete to injury, assess appropriateness for
participation, and identify athletes at risk for specific,
sport-related injuries. For example, a detailed ocular and
visual acuity examination would be much more impor-
tant to the competitive archer than the Olympic swim-
mer; similar sports-specific factors should to be taken
into consideration when preparing for the evaluation.
The timing and frequency of the preparticipation
evaluation should be completed at least 4 to 6 weeks be-
fore competition. The optimal frequency of the exami-
nation has been debated in the literature. Annual exam-
inations with health maintenance and training
counseling have been advocated. Another approach has
been a baseline examination at any new level of compe-
tition followed by interval history review at the begin-
ning of each new season. The examination may need to
be done much more frequently, particularly with ath-
letes who participate in multiple sports throughout the
year.
The examination is divided into the history and
physical. Patient history is essential in identifying ath-
letes at risk for a particular injury. A standardized,
health-history questionnaire, completed by the athlete
and reviewed by a health-related professional, can be
very helpful (Figure 1). This tool can be modified for
specific sports and improve the efficiency of the evalua-
tion.
The physical examination is an assessment of overall
general health, with specific focus on organ systems per-
tinent to the athletes history or central to safe partici-
pation in their particular sport. Vital information includ-
ing height, weight, blood pressure, heart and respiratory
rates, and more recently, body mass index, should be re-
corded for every potential participant, and common
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Medical Care of Athletes Orthopaedic Knowledge Update 8

Figure 1 Sample preparticipation examination health questionnaire. (Reproduced with permission from Fields KB: Preparticipation evaluation of the school athlete, in Rich-
mond JC, Shahaday EJ, Fields KB (eds): Sports Medicine for Primary Care. Ann Arbor, MI, Blackwell Science, 1996, p 68.)

150 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update 8 Chapter 14 Medical Care of Athletes

Table 1 | Classification of Sports by Contact Table 2 | Medical Conditions Affecting Sports Participation
Contact Noncontact Conditions Requiring Clearance Before Sports Participation
Collision/Contact Limited Contact Strenuous Nonstrenuous
Atlantoaxial instability
Basketball Baseball Dancing Archery Hypertension
Field hockey Cycling Discus Bowling Dysrhythmia
Football Diving Javelin Golf Heart murmur/valvular heart disease
Ice hockey Fencing Shot put Rifle
Diabetes mellitus
Lacrosse Field Rowing
Martial arts High jump Running/Cross Heat illness history
Soccer Pole vault country Hepatomegaly, splenomegaly
Water polo Gymnastics Strength training History of repeated concussion
Wrestling Raquetball Swimming Asthma
Skating Tennis Absent/undescended testicle
Skiing Track One-eyed athletes or athletes with vision < 20/40 in one eye
Softball
Volleyball Bleeding diathesis
Congenital heart disease
Seizure disorder
Febrile illness
general health problems such as obesity and hyperten-
Eating disorders
sion should quickly be identified. Multiple studies have
One-kidney athletes
directly linked increased body mass indices with in-
creased morbidity and mortality rates. Recent, stricter Malignancy
blood pressure screening guidelines established for the Organ transplant recipient
general public will no doubt affect preparticipation ex- Obesity
aminations as well. Dermatologic disorder
The role of screening tests in the routine medical
evaluation of athletes remains unproven. Many studies,
looking at long-term benefits of screening modalities
such as electrocardiograms, echocardiograms, or even ment of a conditioning program. Whether it be sport-
urinalysis and chemistry screening profiles, have repeat- specific or for general overall fitness, concepts such as
edly failed to show any clear benefit. Thus, at this time specificity, prioritization, periodization, and work over-
these screening tests cannot be universally recom- load need to be addressed. Also, it needs to be under-
mended unless specifically indicated by the history or stood that conditioning and readiness is a combined
physical examination. product of overall general fitness, sport-specific fitness,
Clearance for participation and fitness assessment is and skills specific to the individual sport. Becoming fa-
dependent on the preparticipation physical examina- miliar with calculation of workloads for the purpose of
tion. The results of the examination then must be evalu- outlining a conditioning and fitness program using heart
ated in conjunction with the specific demands of the rates and metabolic measurements such as maximum
sport before a final determination on clearance for par- oxygen consumption (MVO2) can be useful as well.
ticipation can be made. Sport-specific requirements such Conditioning specificity refers to the unique condi-
as degree of exertion, degree of contact, agility, and en- tioning demands of an individual sport and the neces-
vironmental influences play a role in determining eligi- sary adjustments an athlete has to make to accommo-
bility (Tables 1 and 2). date those demands. Each sport has differences in
The team physician must be skilled and knowledge- muscle groups needed, aerobic capacity, flexibility, envi-
able about acting on any clearance recommendations. A ronmental and even psychological factors. Thus, the spe-
willingness to clearly communicate and document the cifics of a conditioning program are adjusted to meet
results of the preparticipation evaluation with the ath- these particular demands.
lete must be established. It is preferable that the exam- Prioritization refers to different levels of emphasis
ining physician coordinate any follow-up required to placed on certain components of a conditioning pro-
complete or change the clearance determination. gram based on the athletes preference with varying lev-
els of input from coaches, trainers, and ultimately, physi-
Conditioning and Preparation cians. Basketball players looking to improve their
Several basic principles of conditioning must be under- jumping ability may prioritize lower extremity strength-
stood to provide medical consultation in the develop- ening and agility training much in the same way a base-

American Academy of Orthopaedic Surgeons 151

Medical Care of Athletes
ball pitcher may emphasize upper extremity and arm
flexibility workouts.
Periodization refers to a planned variation in inten-
sity and duration of a specific workout over a pre-
defined duration of time. A distance runner training for
an upcoming marathon uses periodization as a condi-
tioning method by changing the length in miles and in-
tensity measured in speed at each training session be-
fore competition. The ultimate goal of periodization is
obtaining maximal performance based on the concept of
progressive overload, one at which conditioning is
started at moderate tolerable levels of exertion and pro-
gressively pushed to maximum exertion. Multiple stud-
ies have demonstrated this method of conditioning is su-
perior to training techniques in which intensity and
duration of training are kept constant over a given pe-
riod of time. Periodization cycles are defined by length
of time and are referred to as macrocycles, mesocycles,
or microcycles. Macrocycles generally refer to an entire
training year (season to season), mesocycles 3 to
6 months, and microcycles 3 to 6 weeks. Multiple vari-
ables can be adjusted during a periodization cycle in ad-
dition to intensity and duration of a conditioning work-
out. They can include variations in types of exercises,
number of repetitions of individual exercises, or length
of rest periods between exercises.
Conditioning can be further defined as a product of
aerobic capacity, strength, and flexibility. Aerobic capac-
ity cannot only be subjectively measured by perfor-
mance, but also objectively by measurement of the
MVO2 or VO2max, referred to as maximum oxygen up-
take. MVO2 represents the maximum oxygen-carrying
capacity of the oxygen transport system, which drives
adenosine triphosphate (ATP) synthesis during aerobic
metabolism. The oxygen transport system allows tissue
to extract oxygen from oxygenated blood and synthesize
ATP for energy for muscle activity. A very efficient sys-
tem allows for maximum performance. The MVO2 is de-
fined as the product of heart rate (HR), stroke volume
(SV), and the difference between arterial and mixed
venous oxygen concentrations (a VO2), or: MVO2 =
HR SV a VO2. ing HR to calculate the target exercise HR.
HR times SV is referred to as the cardiac output,
whereas SV is the difference in left ventricular volume
between end diastole and end systole. Routine measure-
ment of MVO2 is not practical because it requires the
use of a calorimeter, which may not be readily available.
Strength is an integral component to overall condi-
tioning and fitness and is defined as the ability of a par-
ticular muscle or muscle group to perform work. Al-
though specific strength training programs are beyond
the scope of this chapter, the concepts mentioned earlier
of specificity, periodization, and progressive work over-
load all apply here as well.
Flexibility training and development represents the
final component of a total conditioning program. Flexi-
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Orthopaedic Knowledge Update 8
bility is the ability of joints and particular muscle groups
to maximize their natural range of motion without com-
promising strength and endurance. Certainly flexibility
can vary from athlete to athlete. Thus, no set standard
can be developed for outlining a flexibility program. A
large body of evidence suggests that improved flexibility
decreases risk for injury although few data exist to im-
ply improved performance.
In contrast to flexibility, specific standards and
guidelines can be developed for both aerobic capacity
and strength training. For aerobic training, three meth-
ods are preferred to establish training guidelines. The
first, which is relatively easy to calculate, uses the maxi-
mum heart rate as a predictor of intensity. The sug-
gested intensity level is expressed as a percentage of the
maximal predicted HR. The target HR for conditioning
should be 60% to 90% of the maximum HR. A more
highly competitive athlete would aim for a larger per-
centage of the maximum rate, whereas the daily jogger
trying to stay in shape may use a lower percentage. For
example, a 40-year-old recreational jogger may use 75%
of his maximum HR to calculate his target HR. Calcula-
tion of the maximum predicted HR is done by subtract-
ing his age from 220. In this instance it would be 180
beats per minute (bpm); 180 is then multiplied by 0.75
for a product of 135, which now becomes a projected
target HR of 135 bpm. The second method requires a
few simple calculations. First, the maximal predicted HR
is established (example: age 40; 220 40 = 180 bpm HR
maximum). Next, the HR reserve is calculated by sub-
tracting the resting HR from the maximal predicted
HR. The HR reserve is then multiplied by an intensity
factor based on an individual athletes goals and level of
conditioning. A beginner should use an intensity factor
in the range of 50% to 65% of HR reserve. A moderate
conditioned or recreational athlete should use 65% to
75% of HR reserve. Finally, a highly conditioned athlete
trying to maximize aerobic capacity for competition
uses 75% to 85% of HR reserve. The product of the HR
reserve and intensity factor (example: HR reserve 140
0.70 for a recreational athlete) is then added to the rest-
A third method, which requires direct measurement
of MVO2 via calorimetry during maximal exercise stress
testing, is less practical but ultimately more accurate
than the second method. Similar to the HR method, the
oximetry method establishes the target as a percentage
of the MVO2 obtained during maximum exercise testing.
Similar intensity factors are used as guidelines for these
percentages. For example, an elite athlete should target
75% to 85% of the MVO2 as his conditioning intensity
whereas an intermediate or novice athlete would target
ranges from 65% to 75% and 55% to 65%, respectively.
A relationship can then be established between heart
rate and VO2 during exercise testing to determine a tar-
get HR for training.
American Academy of Orthopaedic Surgeons
Orthopaedic Knowledge Update 8
Much in the way HR or MVO2 are central to devel-
oping guidelines for aerobic training, the repetition
maximum (RM) can be used for developing strength-
training guidelines. The repetition maximum, or 1-RM,
is defined as the maximum amount of weight or resis-
tance that can be lifted for one repetition. An RM also
refers to a specific number of repetitions limited by a
particular weight or resistance. For example, a weight
that can be lifted 10 times until fatigue would be 10-
RM. A preferable utilization of the RM allows the pre-
scriber to establish an RM training zone based on the
target goal of strength training. A training zone is usu-
ally a range of three RMs (eg, 8 to 10 RM), which re-
duces the need to exercise to fatigue with each set.
The concept of specificity mentioned earlier can be
applied to strength training based on the goals and de-
mands of an individual athletes sport. Four common
variables may be adjusted within the training program
to achieve target goals. The RM, number of repetitions,
number of sets, and rest period between sets can all be
adjusted to optimize power, strength, and endurance.
Exercises focusing on improvements in power use lower
RMs (ie, higher weights or resistance), fewer numbers
of repetitions, higher numbers of sets, and longer recov-
ery times between sets. In contrast, training focusing on
muscular endurance uses higher RMs (ie, lower weights
or resistance), much higher number of repetitions, fewer
number of sets and less recovery time in between sets.
Strength training uses lower RMs than does power and
endurance training with repetition numbers, set num-
bers, and recovery times being similar to that of power
training.
Sideline Medicine
Sideline medicine is a phrase used to refer to the team
physicians approach to handling game-time injuries and
illnesses and developing a well-documented and orga-
nized plan for implementation at the site of competition
and practices. From a consensus statement released in
2001 regarding sideline preparedness for the team phy-
sician, the definition of sideline medicine is the identifi-
cation of and planning for medical services to promote
the safety of the athlete. Goals are to limit injury and
provide medical care at the site of competition. In addi-
tion, sideline medicine deals with three integrated as-
pects of athletic competition: preseason planning, game-
day operations, and postseason evaluation.
Preseason planning involves the use of the prepartic-
ipation evaluation to identify potential problems during
the season. The team physician must have access to any
prior relevant health information before determining el-
igibility for participation. Timely completion of the
preparticipation evaluation is advantageous because it
allows treatment or follow-up to be initiated before
American Academy of Orthopaedic Surgeons
Chapter 14 Medical Care of Athletes
competition, and involves review of the athletes pro-
posed competition schedule.
Medical care of the athlete involves coordination of
administrative duties such as establishment and docu-
mentation of an emergency response plan for the seri-
ously ill or injured competitor. Additionally, a policy to
assess playing condition and environmental factors at
the time of competition must be established, and a pro-
tocol involving administrators, competition officials,
coaches, and staff to make an educated decision regard-
ing safe competition conditions should be clearly delin-
eated. Finally, medical record keeping is essential in the
care of athletes and preseason planning should ensure
that this takes place.
Game-day preparations and operations involve the
assessment and management of game-day injuries and
illnesses and final determinations on clearance for par-
ticipation. A review of game-time playing conditions is
conducted according to the established preseason policy
and any concerns should be promptly brought to the at-
tention of coaches, officials, and relevant staff. A well-
prepared medical staff also needs to be familiar with
medical equipment and examination and treatment fa-
cilities available. When traveling, game-time review of
locations of examination areas, x-ray equipment, ambu-
lances, and local hospitals with the hometown medical
staff is essential to ensure a quick and efficient response
to any athletic injuries. The team physician also needs to
have a clear vantage point of the competition and easy
access to the athletes competing. Return to competition
decisions are a part of the game-day responsibilities.
Evaluation of concussions, soft-tissue injuries, and eye
trauma are a few examples where return to play deci-
sions are made by the team physician during competi-
tion. Game-day assessment also requires a postcompeti-
tion review of all injuries and illnesses that have
developed and an action plan to ensure necessary
follow-up. The postcompetition assessment should in-
volve the team physician, trainers, coaches, and relevant
administrators.
The postseason evaluation involves a comprehensive
summary of all athletic injuries and illnesses acquired
during competition. It provides a good opportunity to
collect data and identify trends during recent competi-
tion. It also is the time for the team physician to coordi-
nate appropriate follow-up during the off-season.
Dehydration and Heat Syndromes
Dehydration is a loss of all body water caused by de-
creased intake or increased losses by evaporation and
excretion. Prolonged dehydration can lead to tissue dys-
function and eventual hemodynamic collapse as the cir-
culating intravascular volume drops to a critical level
sufficient to lower cardiac output. As cardiac output de-
creases, so does blood supply to the skin, resulting in de-
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Table 3 | Participants at Risk for Dehydration/Heatstroke Table 4 | Total Body Water/Na+ Deficit Calculations
General Calculation of Total Body Water
Poorly acclimated or inexperienced competitors Deficit Calculation of Na+ Deficit
TBW = 0.6 (wt in kg) x ( 140 1)
[Na+]
Obese or poorly conditioned Meq Na+ deficit = 0.6 (wt in kg)
Elderly (140 [Na+]) + (140) x (vol def in
Prior history of dehydration/heatstroke L)
Medication Usage
Antihistamines TBW = total body water; [Na+] = measured serum sodium concentration (mEq/L)
Anticholinergics
Diuretics
Neuroleptics
Illness Table 5 | Clinical Estimates of Degree of Dehydration
Acute febrile illness
Recent vomiting or diarrhea % Dehydration (% wt) Clinical Signs/Symptoms
Uncontrolled systemic condition (for example, diabetes mellitus or
hypertension) 3% to 5% (Mild to Moderate) Orthostasis
Thirst
Decreased voiding
Dry mucous membranes
creased heat dissipation and a subsequent rise in core Reduced skin turgor
body temperature. At extremes of dehydration, sweating Dry axillary folds
mechanisms cease in an attempt to preserve intravascu- 8% to 10% (Moderate to Severe) All of the above plus:
lar volume. This in turn can lead to further increases in Supine hypotension
core body temperature, which left unchecked can be fa- Lethargy
tal. As little as a 1% drop in total body water has been Tachycardia
shown to affect performance. Tachypnea
Athletes are particularly at risk for dehydration and 12% to 15% (Severe) Hemodynamic collapse
heat illnesses based on the increased demands of com-
petition. It is not unusual for competitive athletes to
lose as much as 1 to 2 L of sweat per hour with vigor- creases in serum sodium levels can produce fatigue, leth-
ous, intense exercise. Athletic participants at risk for de- argy, weakness, confusion, and even hemodynamic col-
hydration and heatstroke are outlined in Table 3. lapse and death. Salt loading is not recommended
Aggressive volume replacement is essential during because of the plasma hypertonicity it may produce. Ta-
exercise. Rehydration also requires electrolyte replace- bles 4 through 7 serve as a brief guide for fluid and elec-
ment in addition to volume. Although electrolyte con- trolyte replacement.
centrations are highly variable, sodium is the cation ex- Thirst is a poor indicator of hydration status in hu-
creted in the highest concentration, with lower mans and should not be used alone as a guide for vol-
concentrations of potassium usually found. Both elec- ume replacement. Measurement of the weight of the
trolytes should be replaced, although the necessity is athlete while unclothed, both before and after competi-
lessened in low-intensity or short-duration exercise and tion, is an excellent way to monitor fluid losses. Hydra-
in those who consume a normal diet. At least 16 oz of tion before, during, and after exercise should be empha-
fluid supplemented with sodium and potassium should sized.
be ingested for every pound of weight lost with exercise.
Hypotonic salt, or isotonic, carbohydrate supplemented
beverages referred to as sports drinks are effective re-
Overuse Injuries
Overuse injuries refer to musculoskeletal maladies that
hydration solutions for palatability and rapid effective
develop as a result of environmental, biomechanical,
absorption. The presence of increased ingested sodium
and equipment factors. They involve one of the follow-
and glucose in the intestinal lumen promotes their
cotransport for absorption in the small intestine. This ac- ing anatomic structures: bursae, tendons, bones, joints,
tive transport creates an osmotic gradient that enhances and ligaments. Overuse injuries are often classified into
net water absorption by passive mechanisms. Plain wa- four stages based on degree of pain. Stage 1 is mild pain
ter ingestion can be effective for maintaining hydration, that develops only after activity. Stage 2 is moderate
but rehydration after exercise can be slowed by the pain that occurs during activity but does not restrict or
drop in serum osmolality it may create. If allowed to interfere with performance. Stage 3 is moderate to se-
progress, replacement of sweat losses with hypotonic vere pain that interferes with performance. Stage 4 is
fluid (water) leads to hyponatremia. Significant de- the most severe form of an overuse injury with signifi-

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Orthopaedic Knowledge Update 8
Table 6 | Approximate Deficits in Mild to Moderate
Dehydration (5%)
Type of Dehydration [Na+] meq/kg
Isotonic 4-5
[Na+] 134-145 meq/L
Hypertonic 0-2
[Na+] >145 meq/L
Hypotonic 5-6
[Na+] <134 meq/L
*Deficits are doubled for moderate-severe dehydration (10%)
cant pain even at rest. Table 8 outlines common overuse
injuries.
Medical Care of the Female Athlete
Providing optimal medical care for the female athlete
requires an understanding of unique gender-specific is-
sues. A comprehensive review of these topics is beyond
the scope of this chapter but topics such as exercise in
pregnancy, postmenopausal fitness, the female triad (al-
tered menstrual cycle, eating disorder, abnormal bone
metabolism), and athletic injuries seen disproportion-
ately in female competitors will be briefly reviewed.
Exercise during pregnancy is a vital part of the over-
all health of the mother and fetus. Recent studies have
shown a decreased morbidity and mortality rate among
expectant mothers who established a regular prepartum
exercise regimen. Normal physiologic changes during
pregnancy such as increased weight, increased intravas-
cular volume, increased total body water content, and
low back pain as a result of anatomic changes may
make exercise more challenging during pregnancy. How-
ever, the intensity and frequency of exercise can be rela-
tively maintained at prepregnancy levels until late in the
pregnancy. Several modifications should be made. Preg-
nant women who exercise should be keenly aware of
the propensity for thermal dysregulation and should
make extra effort to ensure adequate hydration and
provide an exercise environment that is optimal for ade-
quate heat exchange. Pregnant women should be aware
of increased caloric requirements, roughly 300 to 400
kcal/day, during pregnancy and adjust diet accordingly.
Furthermore, because of diminished maternal aerobic
capacity, the intensity of exercise may need to be modi-
fied. Exercise to exhaustion, even for elite athletes, is to
be discouraged during pregnancy and maternal per-
ceived exertion should be used as a guide for intensity
levels. Certain specific types of exercises during preg-
nancy should be avoided. Any type of exercise with a
chance of abdominal contact should be avoided. In gen-
eral, complex exercises associated with a propensity for
American Academy of Orthopaedic Surgeons
Chapter 14 Medical Care of Athletes
Table 7 | Guide to Fluid/Electrolyte Replacement
Isotonic Dehydration: Serum [Na+]134-145 meq/L
[K+] meq/kg Net loss of solute and electrolytes equal to water loss
Ex: Common; healthy athlete with inadequate hydration
4-5 Tx: Replace sum of maintenance losses (30-35 mL/kg body weight),
insensible losses (600-800 mL/day) and estimated water/electrolyte
0-2 losses over first 24 h; replace 1/2 of volume within first 8 h, rest over
next 16 h
5-6 Hypertonic Dehydration [Na+] >145 meq/L
Net loss of water greater than solute
Ex: Inadequate hydration with strenuous exercise
Tx: Repair TBW deficit over 48 h; rate of reduction of serum Na+ not to
exceed 10 meq per/24 h
Hypotonic Dehydration [Na+] < 134meq/L
Net loss of solute/electrolytes less than water
Ex: Unusual; seen in ultraendurance competitors who overhydrate
Tx: Do not replace more than one half total sodium deficit within first
24 h to avoid central pontine myelinolysis
3% NS used in rare situations with seizure
[Na+] of NS 154 meq/L [Na+] of NS 77 meq/L [Na+] of 3% NS 513
meq/L
Ex = example; Tx = treatment; TBW = total body water; NS = normal saline
falls should be avoided. Because of decreased venous
return and a subsequent drop in cardiac output, exercise
requiring prolonged, stationary standing after the first
trimester should be avoided. It is also important to re-
member that physiologic changes may not occur for 6 to
10 weeks postpartum and that prepregnancy exercise
practices should not be started immediately postpartum.
The benefits of regular exercise during pregnancy
are numerous and include maintenance of a healthy
weight and prevention of excess weight gain, more rapid
postpartum recovery, improved posture and fewer mus-
culoskeletal problems such as low back pain. Less pe-
ripheral edema, improved sleep quality, improved en-
ergy levels, and an improved overall sense of well-being
contribute to a positive experience during the preg-
nancy. However, every physician supervising an exercise
program during pregnancy should be aware of absolute
and relative contraindications to exercise. Absolute con-
traindications include preexisting uncontrolled hyper-
tension, diabetes mellitus, or valvular heart disease. Ob-
stetrical specific contraindications include preeclampsia
or pregnancy-induced hypertension, preterm labor with
the current or previous pregnancy, premature rupture of
membranes, second or third trimester bleeding, or in-
competent cervix. Relative contraindications to exercise
during pregnancy include history of multiple miscar-
riages, precipitous labor, breech fetal positioning, and
multiple gestations.
The benefits of exercise in the postmenopausal fe-
male are just as clear. A regular aerobic exercise program
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Medical Care of Athletes
Table 8 | Common Overuse Syndromes
Structures Involved
Bursae
Prepatellar bursitis
Greater trochanteric bursitis
Olecranon bursitis
Pes anserine bursitis
Tendon
Rotator cuff tendinitis
Biceps tendinitis
Patellar tendinitis
Achilles tendinitis
Anterior tibialis tendinitis
Medial/lateral epicondylitis
Bones
Stress fractures
Insufficiency fractures
Apophysitis
Ligaments
Plantar fasciitis
NSAIDs = nonsteroidal anti-inflammatory drugs; PT = physical therapy; ECSWT = extracorporeal shock wave therapy
of intermediate intensity most days of the week com-
bined with strength and flexibility exercises is essential to
the health of the postmenopausal athlete. Improvements
in bone density measurements, lipid profiles, body mass
indices, and sleep quality, all problematic in postmeno-
pausal females, are well established with regular condi-
tioning.
The female athlete triad consists of abnormal bone
metabolism, disordered eating, and abnormal menstrual
function. The exact incidence of the disorder is unknown
but several recent studies suggest that it may be as high
as 12% of all competitive female athletes. Prevalence
rates differ among individual components of the triad ex-
isting independently and also differ among individual
sports. A prevalence rate of nearly 50% for menstrual
dysfunction has been reported in some distance runners
compared with a general prevalence rate of 2% to 5%.
Menstrual dysfunction comprises an entire spectrum
of irregularity of menstruation. From delayed onset of
menarche, defined as onset of menses after age 16 years,
to complete amenorrhea, defined as the absence of 3 to
12 consecutive menstrual periods in the absence of
pregnancy, to oligomenorrhea (irregular, infrequent
menses), menstrual dysfunction is common in the fe-
male athlete. Females at risk tend to be younger, nullip-
arous, have lower body weights, and are involved with
more strenuous, high-intensity sports. A poor dietary
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Orthopaedic Knowledge Update 8
Symptoms Treatment
Anterior/inferior knee pain and swelling Protective padding, ice, NSAIDs, aspiration,
corticosteriod injection
Focal, lateral hip pain Rest, ice, PT, local injection
Elbow pain, swelling Protective padding, ice, NSAIDs, aspiration,
corticosteroid injection
Inferior knee pain Ice, NSAIDs, aspiration, corticosteroid injection
Nonlocalized shoulder pain PT, rest, NSAIDs, corticosteroid injection
Localized anterior shoulder pain Corticosteroid injection, rest, NSAIDs
Knee pain PT, rest, NSAIDs
Heel pain PT, rest, NSAIDs
Shin pain PT, rest, NSAIDs
Focal medial/lateral elbow pain Corticosteroid injection, PT, rest, NSAIDs
Localized pain Rest, correction of precipitating factors
Heel, instep pain PT, orthoses, splinting, ECSWT
history is often central to the development of menstrual
irregularities. Menstrual dysfunction is believed to be
caused by a lack of a pulsatile release of gonadotropin-
releasing hormone from the hypothalamus, which in
turn leads to diminished release of luteinizing and
follicle-stimulating hormone from the anterior pituitary
gland. The exact cause of diminished gonadotropin-
releasing hormone release is unclear but the role of cir-
culating -endorphins, cortisol, catecholamines, melato-
nin, and androgens are all currently under investigation.
Treatment options include optimizing diet and nutri-
tional status, exercise intensity modification, and hor-
mone therapy.
Eating disorders encompass everything from restric-
tion before competition to frank starvation or binging
and purging, referred to as anorexia nervosa and bu-
limia nervosa, respectively. Signs and symptoms include
a characteristically thin body habitus, thin hair and hir-
sute features, parotid gland hypertrophy, dental caries,
subconjunctival hemorrhages, scarring on the dorsum of
the hands, and rectal tears. Treatment depends on the
severity of the condition and often involves a multispe-
cialty approach including physicians, mental health spe-
cialists, and nutritionists. The exact prevalence of eating
disorders among female athletes is unknown.
Regular exercise in females leads to increased bone
density by increasing mechanical stress on bone. A low
American Academy of Orthopaedic Surgeons
Orthopaedic Knowledge Update 8
estrogen state seen with delayed or infrequent me-
narche, as is the case with the female triad, leads to poor
primary bone mass accumulation and the early develop-
ment of osteoporosis. If allowed to continue, the hy-
poestrogenic state promotes premature bone resorption,
further compounding the problem. Combined with poor
nutrition status, in particular a deficiency in calcium and
vitamin D, the rate of bone loss can be startling. Several
studies have recorded bone densities of female athletes
in their 20s that were comparable to those of females in
their 60s and 70s.
Although not exclusive to female athletes, several
common musculoskeletal athletic injuries are often seen
in females. Two ligamentous injuries more commonly
seen in females include ankle sprains (particularly ante-
rior talofibular) and anterior cruciate sprains and com-
plete tears. Women are particularly vulnerable to ante-
rior cruciate injuries but the exact cause is believed to
be multifactorial. Hormonally-mediated ligamentous hy-
perlaxity, decreased ligament size, and a narrowed inter-
condylar notch have all been proposed as possible etio-
logic factors. Ankle sprains seem to be more easily
explained because of the relatively reduced stability of
the talus from an inflexible heel cord and the propensity
of the female foot to favor a plantar-flexed position.
Lateral epicondylitis and rotator cuff tendinitis tend
to be more prevalent in females, who are believed to be
more susceptible to these injuries because of postural
differences produced by strength deficiencies and soft-
tissue laxity.
Overuse injuries of bone, particularly stress frac-
tures, are more commonly encountered in females who
comprise the classic triad. Healthy female athletes also
are at increased risk because of hormonal factors and
lower muscle to body mass ratios. Spondylolysis, a stress
fracture to the pars interarticularis of the lumbar spine,
is also seen more frequently in female athletes.
Mechanical low back pain is ubiquitous among fe-
males; the etiology is usually multifactorial. Two unique
sources of back pain among women are the aforemen-
tioned spondylolysis and pelvic instability produced by
sacroiliac joint dysfunction. Hormonal and mechanical
(particularly the effects of childbirth) factors lead to in-
creased laxity among the ligamentous, muscular, and
joint structures that comprise the pelvic ring. This in-
creased laxity leads to a propensity for subluxation, par-
ticularly anteriorly, that leads to pelvic ring asymmetry
and subsequent back pain.
Patellofemoral syndrome is another athletic injury
common in females. The athlete has anterior deep knee
pain with varying degrees of swelling and pain that of-
ten is noted to be worsened by walking down steps. The
increased propensity in females is believed to be the re-
sult of increased ligamentous laxity leading to abnormal
lateral patellar tracking. A lack of flexibility and weak-
ness of the hamstrings and vastus medialis obliquus also
American Academy of Orthopaedic Surgeons
Chapter 14 Medical Care of Athletes
contribute to abnormal patellar tracking. A wider pelvis
and increased Q angles have also been proposed as pos-
sible etiologic factors. A propensity for plantar flexion
leading to internal torsion of the tibia and femur accen-
tuates lateral patellar tracking and is also believed to be
a contributing factor. Treatment consists of biomechani-
cal modification and physical therapy modalities.
Annotated Bibliography
Preparticipation Examination
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This article presents new guidelines for hypertension man-
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A critical review of current recommendations for the
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This review article advocates the standardization of the
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Conditioning and Preparation
American Academy of Family Physicians, American
Academy of Orthopaedic Surgeons, American College
of Sports Medicine, American Orthopaedic Society for
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This article presents a governing body consensus state-
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Ebben WP, Blackard DO: Strength and conditioning
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A review of conditioning practices in the National Foot-
ball League reveals 69% of conditioning coaches follow a pe-
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Designing workouts to meet patients goals. Phys Sports
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Human power production capabilities and differences of
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Medical Care of Athletes
Sideline Medicine
Mellion M, Walsh WM, Shelton G: The Team Physicians
Handbook, ed 3. Philadelphia, PA, Hanley & Belfus,
2001, pp 126-135.
This book chapter presents an outline for game day man-
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Stricker PR: The sports medicine kit: Basics of the bag.
Pediatr Ann 2002;31:14-16.
A review of essential on-site materials for the team physi-
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Dehydration and Heat Syndromes
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Comp Biochem Physiol A Mol Integr Physiol 2001;128:
735-748.
This article reviews the necessity for carbohydrate, vol-
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Overuse Injuries
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Forty-two patients were assessed before and after extra-
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This article reviews the functional anatomy, pathophysiol-
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Orthopaedic Knowledge Update 8
Medical Care of the Female Athlete
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This article provides examples of very low bone mineral
densities in a sample of 52 female endurance runners.
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American Academy of Orthopaedic Surgeons