Medical Concerns for the Adolescent Athlete

Hayley Queller, MD

St. Charles Orthopedics

Non-operative Sports Medicine

Sports Medicine Program Director

DISCLOSURES:

• NONE!

Outline

• Exercises Induced Asthma

• Diabetes

• Exertional Rhabdomyolysis• Special population

• Athlete’s Diarrhea

• Infectious Mononucleosis

• Epidemiology

• Pathophysiology

• Diagnostic Testing

• Risk in sport

• Treatment

• Return to Play

Asthma: Epidemiology

• ~235 million people worldwide were affected by asthma; 7% US population• 250,000 people die worldwide per year from the disease

• 4210 Americans die per year from the disease

• Low and middle income countries make up more than 80% of the mortality

• More common in developed than developing countries

• Twice as common in boys as girls

• Children who are born in low-income families have higher risk of asthma

Asthma: Pathophysiology

Bronchoconstriction: Muscles around the

airways constrict and tighten making the airways

narrower.

Inflammation: Swelling in the airways narrows

the diameter of the airway. Mucous is produced

clogging the airways.

Asthma: Symptomatology

Coughing, especially at night

Wheezing or breaths that sound high pitched when exhaling

Chest pain or tightness, frequent “side-aches”

Shortness breath

Excessive fatigue not consistent with conditioning

• Symptoms worsen with

• Allergens/Irritants

• Bronchoconstriction

• Increased respiratory rate

• Strong emotions

• Laughing

• Crying

• Stress

• Cold air

• Causes airway edema

Asthma: Risk in Sport

• When to be concerned about an athlete• Blue lips

• Difficulty walking, talking or drinking liquids

• Quick-relief medications are not working, are unavailable, or have been taken too recently to give again

• Nostrils flaring

• Neck, throat or chest retractions

• Change in athlete’s level of consciousness or signs of confusion

• Condition rapidly getting worse

Asthma: Treatment

• Use rescue or quick-relief medications: BETA-AGONISTS• Albuteral: relax the muscles around the airways

• 2-4 puffs 15-20 minutes before activities

• 15 minutes to start working; works for up to 4 hours

• Gradual warm up and cool down periods

• Protect airways from cold air• Mask or scarf to warm the air before entering the airways

• Maintenance therapy • Inhaled corticosteroids: help with swelling in the airways

Asthma: Return to Play

1- Encourage the athlete to use an inhaler before playing--prevention.

2 - Using an inhaler once during the same session for symptoms is okay. Symptoms must be fully resolved before playing again.

3 – If an inhaler is needed another time during the session due to symptoms, the athlete should be off the field for the rest of the day. It may be a sign that the athlete’s asthma may not be well controlled.

Asthma Action Plan

• Can use a peak flow meter on the field to get an objective measure of lung function.

• A peak flow meter measures how much air the athlete can blow out at once, which indicates how open the airways are.

PLAY!

Treat, then play once

in the green zone

Treat, then call 911

if no better

What YOU need

• Asthma action plan for each asthmatic

• Peak flow meter

• Extra albuterol inhaler with a spacer

Diabetes: Epidemiology

• Generally Type 1 Diabetics in the young athletic population

• Heterogeneous disorder characterized by destruction of pancreatic beta cells, culminating in absolute insulin deficiency

• Autoimmune-mediated destruction of pancreatic beta cells

• Girls = Boys

• >>European origin

• Incidence of type 1 diabetes reaches a peak at puberty

Diabetes: Pathophysiology

Diabetes: Symptomatology

• Urinary frequency

• Thirst

• Hunger/polyphagia

• Weight loss

• Visual disturbances

• Fatigue

• Ketosis

Diabetes: Diagnostic Testing

• Fasting Blood Sugar• >126mg/dL

• Random Blood Sugar with glucosuria• >200mg/dL

• HgA1c• >6.5%

• ideally <7.5% in a well controlled adolescent

Diabetes: Risk in Sport

• Hypoglycemia • Blood glucose < 70 mg/dL

• tachycardia, sweating, palpitations, hunger, nervousness, headache, trembling, and dizziness

• Usually the result of overinsulinization

• rate at which subcutaneously injected insulin is absorbed increases with exercise

• exogenously administered insulin levels do not decrease during exercise

• impaired release of glucose-counterregulatory hormones (ie, glucagon and catecholamines) caused by either a previous bout of exercise or hypoglycemic episode

Treatment of Hypoglycemia

Diabetes: Treatment

• Basal and bolus insulin doses to regulate blood glucose levels• Decrease both prior to exercise• Pump users– lower basal rate

• Pre exercise blood glucose should be 110-250 mg/dl• Check 2-3 times before exercise at 30 min intervals• Decrease the insulin bolus dose up to 50% at the pre exercise meal

• During exercise >1 hour blood glucose should be checked every 30 min• ≥250 mg/dl—no activity allowed

• not enough insulin in the system body will burn fat and enter ketosis

• Fast acting carbohydrate intake if <100 mg/dL (10-15g fast acting glucose)

• Post exercise• Shortly after exercise, snack or meal• If they tend to experience late onset hypoglycemia, measure blood glucose 2-4 hours post

exercise and again before going to bed• Check once during the night if they experience nighttime hypoglycemia• If nighttime hypoglycemia reoccurs decrease the evening meal insulin bolus by 50%

What YOU need

• Glucometer

• Glucagon kit

• Fast acting glucose (frosting works!)

• Urine ketone strips

• Sharps container

Exertional Rhabdomyolysis: Epidemiology and Presentation

• Rhabdomyolysis is associated with hyper- and hypothermia, sickle cell trait (and other ischemic conditions), exertion, crush syndromes, infection, autoimmune and metabolic disorders, and certain drugs

• Presentation• Myalgias

• Muscle swelling

• Muscle weakness

• Darkened (brown or tea colored) urine

Exertional Rhabdomyolysis: Pathophysiology

• Breakdown and necrosis of striated skeletal muscle after engaging in physical activity

• Due to an increase in intracellular free ionized calcium to a level much higher than normal in the cytoplasm and mitochondria

• This increase in intracellular calcium leads to the activation of proteases and production of reactive oxygen species, eventually culminating into the death of the skeletal muscle cells

• Necrosis of skeletal muscle cells releases intracellular contents causing pain, swelling, and potential end organ damage in the athlete

Exertional Rhabdomyolysis: Diagnostic Testing

• Elevated Serum Creatine Kinase (CK)• Greater than 5000

• Myoglobinuria• Urine dipstick positive

Exertional Rhabdomyolysis: Risk in Sport

• Deconditioned athlete participating in high intensity, high repetition physical activity

• Exercise in hot, humid conditions

• Sickle cell trait, particularly at higher altitudes

• Metabolic myopathies

• Disorders of glycogenesis, glycolysis or lipid metabolism

Increased Risk with Medications/Drugs

• Amphetamines

• Methadone

• SSRI’s

• Anti-psychotics

• Statins

• Antihistamines

• Alcohol

• LSD

• Heroin

• Cocaine

Special Population

• Althetes with sickle cell trait are at a 37 times higher risk of exertional-related death when compared with their non–sickle cell trait counterparts

• The depletion of ATP that occurs with exertional rhabdo and the sickling nature of red blood cells may deplete skeletal muscle of oxygen or may represent an autoimmune phenomenon

Sickle Cell Trait: Precautions

• Implement a pre-season conditioning program

• Modify exercises as needed during season

• Implement aggressive hydration protocols

• Educate athletes on beverages that can cause diuretic effect

• Avoid strenuous activity in hot and humid conditions

• Avoid strenuous activity in altitudes over 2500ft

• Modify activity after illness or sleep deprivation

Exertional Rhabdomyolysis: Treatment

• Mild cases• oral hydration and rest

• Severe Cases (CK> 5 times the upper limit of normal)• Hospital admission is indicated for intravenous hydration with normal saline

(1-2 L/h) maintaining a urine output of 200 mL/h

• Daily tracking of CK levels, kidney function, and electrolyte values

• Continuous hemodialysis may be needed

• Avoidance of medications that increase risk of rhabdo/dehydration

• NSAIDs

• Diuretics

Exertional Rhabdomyolysis: Return to Play

• Once discharged from hospital, care must be taken to gradually recondition athletes for activity

• Slow progression and build up over time

• Weekly check-ups recommended

• CK and other labs should be normal

• Very aggressive hydration to avoid recurrance

What YOU need

• A list of athlete’s with sickle cell trait

• ASK your athletes what color their urine is after a hard training session

• Spot check

Athlete’s Diarrhea: Epidemiology

• Occurs in 30% of athlete’s and gym goers

• More common amongst distance/endurance athletes

• Women > Men

• Higher risk when using NSAIDs and ASA

Athlete’s Diarrhea: Pathophysiology

• During physical activities there is a redistribution of cardiac output from the GI system to the skeletal muscle• Decrease in GI blood flow by about 20%

• Mild transient gut ischemia

• During activity there is increase in release: • VIP (vasoactive intestinal peptide)

• increases gut motility, increases water secretion, increases electrolyte secretion (changes gut permeability)

• Motilin

• Increases gut motility

Athlete’s Diarrhea: Diagnostic Testing

• Diagnosis of exclusion– rule out other causes of diarrhea• No fever

• No blood

• No vomiting

• No associated muscle aches/pains

• Never occurs after 48 hours of exertion

Athlete’s Diarrhea: Risk in Sport

• Increased risk of dehydration

• Impairs athletic performance

• Inhibits appropriate recovery

• Small risk of ischemic bowel

Bill Rodgers

• former American record holder in the marathon

• best known for his victories in both the Boston and the NYC Marathons in the late 1970-80s

• Fastest marathon time 2:09:27

• “More marathons are won or lost in the porta-toilets than at the dinner table.”

Athlete’s Diarrhea: Treatment

• Decrease fiber, fat, protein, and fructose intake before activity

• Adequate preparticipation hydration with low osmolar beverages (glucose rather than fructose and sucrose)

• Some evidence for dietary nitrates• Helps increase splanchnic perfusion

• “Train the gut”

Athlete’s Diarrhea: Return to Play

• Avoid high-fiber foods in the day or even days before competition

• Avoid aspirin and NSAIDs such as ibuprofen

• Avoid high-fructose foods. Fructose + glucose combination may not cause problems and may be better tolerated.

• Avoid dehydration

• Ingest carbohydrates with sufficient water– low osmolality

• Practice nutrition strategies

Infectious Mononucleosis: Epidemiology

• No racial or sexual difference

• The peak incidence occurs 2 years earlier in females

• Most clinical symptoms are a consequence of T cell proliferation and organ infiltration

• Incubation period : 30 – 50 days

• Oral secretions are major cause of transmission• “Kissing Disease”

• Blood products/Transplanted organs• EBV less commonly than CMV

Infectious Mononucleosis: Symptomatology

• Lymphadenopathy (90%)

• Fever

• Sore throat

• Exudative tonsillopharyngitis• 1/3 patients

• Splenomegaly (50%)• High risk of rupture**• TTP Left costal margin

• Hepatomegaly (60%)

• Tonsillar hypertrophy• Occasional airway obstruction

• Cough or rhinitis

• Rash (15%)• Maculopapular• Increased risk when given abx

• Abdominal pain

• Eyelid edema

• Fatigue/Malaise

• Nausea

• Myalgias

• Headache

Infectious Mononucleosis: Diagnostic Testing

“Hoagland’s Criteria”• Classic Triad

• Fever• Rarely>104 degrees F

• Pharyngitis• Exudative

• Lymphadenopathy• Posterior cervical

• Laboratory• 50% Lymphocytes

• 10% Atypical Lymphocytes

• Confirmation• Titers

• Monospot (heterophile ab)

• high false-negative rate in the first week of the illness

• Associated testing• Elevated LFTs

• Thrombocytopenia

Infectious Mononucleosis: Risk in Sport

• Thrombocytopenia increases risk of bleeding in contact sport

• Upper airway obstruction with tonsillar hypertrophy

• ** Splenic Rupture**• 0.1-0.2% risk

• May be traumatic or atraumatic

• Usually in the 2nd-3rd week of illness

• mild-to-severe abdominal pain below the left costal margin, sometimes with radiation to the left shoulder and supraclavicular area

• SHOCK

Infectious Mononucleosis: Treatment

• Supportive/symptomatic care

• Concommitant Strep• Treat with abx other than amoxicillin (RASH)

• Use of steroids• Marked inflammation of the tonsils: impending airway obstruction

• Massive splenomegaly

• Myocarditis

• Hemolytic anemia

• Hemophagocytic syndrome

• Seizure and meningitis

Infectious Mononucleosis: Return to Play

• Presence of “complications” will dictate return to play• Labs should be back to normal and fitness levels assessed

• Patients should not participate in contact sports or heavy lifting (valsalva precautions) for at least 2-3 weeks or until clinically resolved and no SPLEEN ENLARGEMENT

• Contact activity is controversial as splenic rupture is high in first 4 weeks but can occur up to 7 weeks.• EDUCATE

• Splenic ultrasound may be misleading!

• Serial studies may be needed as ? What is “normal “ study

Thank you!