Pandemic and Post-Pandemic Injury Prevention in Sports - Presentation for the MIAA Wellness Summit Wednesday, March 10, 2021 Andrew Chen, MD and ...
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Pandemic and Post-Pandemic
Injury Prevention in Sports
Presentation for the MIAA Wellness Summit
Wednesday, March 10, 2021
Andrew Chen, MD and Kate Fischer, ATC
University Orthopedics
Speakers
Andrew Chen, MD, CAQSM Kate Fischer, ATC, LAT
● University Orthopedics Mansfield ● University Orthopedics East Providence
● Clinical Assistant Professor at Brown University and East Greenwich Locations
Warren Alpert Medical School ● Head Athletic Trainer at South Kingstown
● Team Physician for Bishop Feehan High school
High School
● Assistant Team Physician for Brown University
● B.S. in Athletic Training/Sports Medicine
● Assistant Team Physician for the Providence
Bruins from Quinnipiac University
● Family Medicine Residency - The Institute for
Family Health / The Mount Sinai Hospital (NYC)
● Sports Medicine Residency - Case Western
Reserve University / University Hospitals
(Cleveland)
Disclaimer We have no conflicts of interest to disclose. We are not promoting any service or product. The content included is not intended to be a substitute for professional medical evaluation, diagnosis, or treatment in specific cases. This presentation is not meant to establish a complete standard of care or offer legal advice.
Objectives Discuss COVID-19 infection prevention in the context of sports Discuss injury prevention in the context of the pandemic Discuss always-important topics regarding sports injury Key word: Fitness
COVID-19 Pandemic As of 3/1/2021, in the US there have been... >28.6 million diagnosed cases and >513,000 deaths. Information and guidance are constantly being updated.
COVID-19 Pandemic As of 3/1/2021, in MA there have been... >583,000 diagnosed cases and >16,000 deaths. Information and guidance are constantly being updated.
COVID-19 Pandemic The current state of the pandemic in MA as of 3/1/2021: https://beta.healthdata.gov/Community/COVID-19-State-Profile-Report-Massachusetts/j75q-tgps
COVID-19 Pandemic The current state of the pandemic in MA as of 3/1/2021: https://beta.healthdata.gov/Community/COVID-19-State-Profile-Report-Massachusetts/j75q-tgps
COVID-19 Pandemic The current state of the pandemic in MA as of 3/1/2021: https://www.mass.gov/info-details/covid-19-response- reporting#covid-19-interactive-data-dashboard-
COVID-19 Pandemic The state of the pandemic is improving, BUT… - There are new variants of the virus - There are confirmed cases of the variants in MA - Not everyone is vaccinated yet Therefore, we must stay vigilant to keep ourselves, teammates, coaches, friends, and family safe! https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/scientific-brief- emerging-variants.html
COVID-19 and Sports The CDC offers guidance to supplement - NOT replace - local rules and regulations regarding reducing the risk of COVID spread in the context of youth sports. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/youth-sports.html MIAA has sport specific guidance here: http://miaa.net/contentm/easy_pages/view.php?sid=38&page_id=317
COVID-19 and Sports General principles to reduce the spread of infection: First, recognize symptoms. Note that they vary by case. They may appear 2-14 days after exposure to the virus. ● Fever (>100.4° F) or chills ● Cough ● Shortness of breath or difficulty breathing ● Fatigue ● Muscle or body aches ● Headache ● New loss of taste or smell ● Sore throat ● Congestion or runny nose ● Nausea or vomiting ● Diarrhea
COVID-19 and Sports
General principles continued:
Stay home when appropriate
- If you tested positive, have symptoms, or had “close contact” with someone who tested positive or
have symptoms
- “Close contact” → 15 cumulative min within 24 hrs
Physical distancing
- Stay >6 ft apart
- Avoid greeting others with physical contact, e.g. handshakesCOVID-19 and Sports General principles continued: WEAR MASKS!!! - Consistent and correct use of masks by athletes, staff, and spectators - Sometimes cannot be worn for high-intensity activity - Must be worn when not engaged in activity, e.g. when taking a break, socializing, or on sideline
COVID-19 and Sports
General principles continued:
Hand hygiene and respiratory etiquette
- Wash hands often with soap and water for
>20 sec
- When no soap and water, use hand sanitizer
that is >60% alcohol
- Cover nose and mouth with tissue when
coughing and sneezing, then immediately
wash hands
- Avoid touching your face with your hands
- NO spittingCOVID-19 and Sports General principles continued: Ensure there are adequate supplies of - Soap - Water - Hand sanitizer containing at least 60% alcohol - Paper towels - Tissues - Disinfectant wipes - Masks (as feasible) - No-touch trash cans
COVID-19 and Sports General principles continued: Cleaning and disinfection - Frequently touched areas on the court or field of play at least daily, ideally between uses - Frequently shared objects or equipment between uses Avoid sharing (caring is NOT sharing!) - No sharing of items that are hard to clean, sanitize, or disinfect - No sharing of water bottles, towels, clothing, helmets, etc. - Minimize sharing equipment, e.g. balls, bats, protective gear
COVID-19 and Sports General principles continued: Ventilation - If playing inside, make sure ventilation systems are working appropriately - Increase circulation of outside air by opening doors and windows - Use portable ventilation such as fans to move air out of enclosed spaces Communal spaces - Avoid use of communal spaces - If they must be used, decrease number of people allowed in them to allow for physical distancing - Stagger practice times or use spaces in shifts - Allow time to clean the space between uses
COVID-19 and Sports
MIAA recommendation highlights:
- Temperature screening for athletes and coaches prior to practices/games
- Record of attendance (part of contact tracing)
- Limit to no more than 25 players on an indoor playing surface for
practices/games
- Locker rooms limited to 10 players or under for changing, toilet use only with
masks and social distancing enforced
- No bench use during practice. Can be used during games if players are 6ft apart
as are their equipment
- No non-essential personnel on the field (e.g. managers, photographers)
- NO tube style “gaiters”
- Sport-specific recommendations/modifications can be found on miaa.net
http://miaa.net/contentm/easy_pages/view.php?sid=38&page_id=317COVID-19 and Sports The CDC and NFL published a scientific paper regarding COVID-19 lessons from the 2020 season applicable beyond football:
COVID-19 and Sports: What We Learned from the NFL Found evidence of virus transmission in less than 15 min of cumulative interaction (
Return to Sports after COVID Infection Limited data, recommendations based on expert opinion After isolation and before return to sport, AAP recommends visit with PCP for pre-participation exam - Focus will be on cardiac and respiratory symptoms If normal, no further work-up Gradual return to activity 10 days after positive test and 24 hours symptom free off medications If any new symptoms or concerning findings on exam, PCP will consider getting an EKG and referring to a cardiologist
COVID-19 and Sports Final Thoughts The NFL found no evidence of on field transmission from team to team - Also, strict mask-wearing and good ventilation decreases infection risk off the field Infection more often occurs outside the field of play Follow the CDC and MIAA COVID-19 guidelines Athletes diagnosed with COVID-19 should isolate, rest, and avoid exercise for ten days from symptom onset Athletes diagnosed with COVID-19 should check in with their doctor for clearance to return to sports Return to activity should be slow and graded Get vaccinated when the shot is available to you (coaches, staff, parents)
Injury Prevention During COVID-19 ● Fall II Season Changes- Environmental Considerations ● The 4-Sport Athlete ● COVID Lifestyle Changes - The Sedentary Athlete
Season Changes: Environmental Considerations
Heat illness is less of a concern but cold
weather injury should be on your radar
● Hypothermia
● Frostbite
● Chilblain
● Immersion FootCold Injury Prevention
Heat illness is less of a concern but cold weather injury should be on your radar
● Dress in layers
○ Base layer: sweat wicking to keep you dry (avoid cotton)
○ Mid layer: warmest/insulating (polyester, fleece, wool)
○ Outer layer: allows moisture to escape while keeping wind and rain/snow out
○ Extremities!!!
■ Head: ear coverings for football
■ Hands: gloves while playing, mittens on sideline
■ Feet: merino wool (wicking + insulating)
● Warm-up properly: slowly & continuously
● Take regular indoor breaks to re-warm
● Keep track of time outside/adhere to local guidelines
● Maintain a well-balanced diet & stay hydrated
● Identify any players with known risk factors (young, old, diabetic, female, and
black populations)The 4-Sport Athlete
The term “overuse injury” is a broad term used to describe an injury caused by repeated micro-trauma,
rather than a specific or single injury event.
● Shorter seasons → less time for sport-specific overuse and stress related injuries
● More variety in movement patterns
○ Redirect stress to different muscle groups
○ Produces more well rounded athletes
● Athletes can try a new sport (Soccer → Football/Volleyball)
○ Contributing to a lifelong love for athletics
● Not necessarily decreasing overall load
● Caution with participation in extra club and travel teams
○ Doubling up on practices and games while decreasing rest and recovery
● Take care to ensure appropriate rest and recoveryRest VS Recovery
Rest Recover
(n): a state of motionlessness or inactivity (v): to get back: regain
(v): To cease from action or motion : refrain (v): to bring back to normal position or
from labor or exertion condition
● Stretching
● Getting enough quality sleep
● Meditation ● Walking
● Downtime with family and friends ● Light cross training
● Unstructured play (tag, manhunt, ball games etc.)
● Injury prevention & rehabilitation routines
● Hydration & Nutrition
● Massage
● Intentional psychological/stress managementA word on SLEEP
70% of high schoolers are not
getting 8-10 hours of sleep
each night
Quality Sleep:
● Consistency: go to bed and wake up at the same time (weekends only doesn’t count)
● Quiet, dark, cool room to sleep in
● Remove electronic devices from the room before and during sleep
● Avoid large meals and caffeine before bed
● Increased physical activity during the daytimeCOVID-19 Lifestyle Changes: The Sedentary Athlete A sedentary athlete as a person who participates in regular exercise but spends the rest of the day sitting at a desk, watching television, or relaxing without movement. We are not moving our bodies as much as we used to. This has been especially evident during the COVID-19 pandemic. We are built to stand upright and move often...BUT exercise is often engineered out of our lives in exchange for convenience. We must counteract this to stay healthy and stay in the game.
Sedentary Athlete Injury Prevention
Commit to incorporating more movement into your day
● Try to get up at least every 30 minutes for a few minutes of movement
○ Stretching
○ Walk or bike to school/bus stop
○ Take dance, stairs, or stretch breaks if learning from home
○ Stand to learn
○ Take the dog for a walk
○ Play outside with friends (unstructured)
○ Help with chores!
○ Have a fitbit or smart watch? Program it to remind you to move every 30 minutes.
What this does not mean is to add another sport or add in more high impact, high
intensity exercise. It's important to have a good balance of activity levels including low,
medium, and high intensity movement.
Act quickly if you do experience pain or injury symptoms! See a healthcare professional
(AT, PT, MD, etc.)Common Problems
● Hip Flexor Tightness + Glute Inhibition/Weakness
○ “Overuse injury” or muscle imbalance
○ Hip flexors become shortened and glutes are lengthened with excessive
sitting
○ Reciprocal inhibition: Tight hip flexors → inactive glutes
○ Sit for shorter periods of time, move more frequently
○ Hip flexor stretching and adductor stretching (especially PNF)
○ Glute activation and strengtheningCommon Problems
● Shin splints/Medial Tibial Stress Syndrome
○ Stress injury
○ Decreased hip strength/stability
○ Overpronation with walking/running
○ Poor running form
○ Evaluation by ATC, PT, or MD
○ Rest from impact/aggravating activity
○ +/- boot, +/- shoe inserts
○ Running form evaluation
○ Gradual ramp up periodAlways Important Topics in Sports Injury
Head Injuries and ConcussionsEmergency Action Plan
Every school and each team needs to have an organized and efficient way to
assess, stabilize, and transport a seriously injured athlete
Chain of command
- Medical Team Lead (Head ATC or Team Physician)
Delineate roles
- Someone to assess injured athlete, someone to grab AED, someone to call
911, someone to control crowd, etc.
- Can be coaches, assistant coaches, players, volunteers
- Do this in the beginning of the season so everyone knows their roles!Emergency Action Plan - Preparation Know primary referral hospital Have appropriate equipment organized and ready - Backboard w/ padding and blocks - Facemask removal tools - Airway equipment - CPR equipment (including AED) Practice scenarios prior to season (ATC or physician to organize)
Emergency Action Plan - Pre-Game Checklist AD, AT, and physician (for both teams if present) should meet prior to game Administrator in charge ideally responsible for crowd control, comforting parents, etc.) “Time out” protocol - Review EAP and procedures - Review roles and identify location of each person present (EMT, AT, MD) - Go over hand signals, voice commands, communication, etc. - Review supplies (AED!), make sure mask removal tools work - Where is the ambulance? If not on field, review how to get it on the field - Again, which hospital will be used (neurological injuries)?
Emergency Action Plan - The Unconscious Athlete If athlete is unconscious when first assessed, error on side of caution Treat as spine injury Do not remove helmet or pads (facemask can be removed with appropriate equipment to access airway) Immobilize and transport
Concussions Type of traumatic brain injury (TBI) Can be caused by - a direct bump or blow to the head - a hit to the body making the head and brain move suddenly May or may not involve loss of consciousness Not a structural injury, rather functional injury - Chemical changes in the brain as a response to injury - CT scans and MRIs are normal
Concussion in Sports Rates highest in: Boys Girls - American football - Basketball - Baseball - Field hockey - Basketball - Ice hockey - Lacrosse - Lacrosse - Soccer - Soccer - Softball - Wrestling - Volleyball Pierpoint LA, Collins C. Epidemiology of Sport-Related Concussion. Clin Sports Med. 2021 Jan;40(1):1-18. doi: 10.1016/j.csm.2020.08.013. PMID: 33187601.
Concussion Signs and Symptoms
Concussion Diagnosis Usually diagnosed by ATC or team physician If neither are available, the athlete should be removed from game upon suspicion of a concussion
Importance of Concussion Recognition Recognizing and appropriately responding to a concussion early can prevent further injury or death Second impact syndrome - Rare rapid brain swelling from second concussion prior to resolution of first Zackery Lystedt Law now implemented in all 50 states - Concussion education for athletes, parents, coaches - Removal of athlete from play on suspicion of concussion - Athlete must wait >24hrs and obtain permission from a healthcare provider
MASSACHUSETTS (c) If a student participating in an extracurricular athletic activity becomes unconscious during a practice or competition, the student shall not return to the practice or competition during which the student became unconscious or participate in any extracurricular athletic activity until the student provides written authorization for such participation, from a licensed physician, licensed neuropsychologist, certified athletic trainer or other appropriately trained or licensed health care professional as determined by the department of public health, to the school’s athletic director. If a student suffers a concussion as diagnosed by a medical professional, or is suspected to have suffered a concussion while participating in an extracurricular athletic activity, the student shall not return to the practice or competition during which the student suffered, or is suspected to have suffered, a concussion and shall not participate in any extracurricular athletic activity until the student provides written authorization for such participation, from a licensed physician, licensed neuropsychologist, certified athletic trainer or other appropriately trained or licensed health care professional as determined by the department of public health, to the school’s athletic director. (d) A coach, trainer or volunteer for an extracurricular athletic activity shall not encourage or permit a student participating in the activity to engage in any unreasonably dangerous athletic technique that unnecessarily endangers the health of a student, including using a helmet or any other sports equipment as a weapon.
Concussions during Practice or Game
In other words…
“If in doubt, hold them out.”911 if... Transport to ED if - One pupil larger than the other - Drowsiness or inability to wake up - A headache that gets worse and does not go away - Slurred speech, weakness, numbness, or decreased coordination - Repeated vomiting or nausea, convulsions or seizures (shaking or twitching) - Unusual behavior, increased confusion, restlessness, or agitation - Loss of consciousness (passed out/knocked out)
Other Concussion Facts
Helmets and mouthguards do not prevent concussions
Symptoms can present up to a day after the incident
Athletes who had a prior concussion are more likely to get another one in their
lifetime
High school athletes often do not report symptoms
- 2017 study found only 21% reported a concussive event to an authority
figureWhy High School Athletes Don’t Report Symptoms Top responses (participants could select more than one): - Didn’t think it was serious - 33.7% - Didn’t want to lose playing time - 26.7% - Didn’t want to let team down - 19.9% - Didn’t know it was a concussion - 17.3% - Didn’t want to have to go to doctor - 14.9% Higher percentages of non-reporting with AT not present Very important for coaches and parents to recognize symptoms!
Concussion Recovery REST - Physical and mental rest to avoid worsening of symptoms Avoid bright lights and loud noises - NO SCREENS Avoid activities that increase risk of another head injury OK to walk around and listen to relaxing music if they do not worsen symptoms OK to do CHORES, e.g. washing dishes, folding clothes. Better than doing nothing! Get full nights of sleep - After the first couple days, avoid napping during the day See your trainer or doctor to help with guidance for school and activity
Return to Sport after Concussion
6-Step Return-to-Play Progression
- Once athlete is symptom-free
- Ideally with the guidance of an ATC
1. Back to regular activity (e.g. school)
2. Light aerobic activity (e.g. 5-10 minutes on a stationary bike, light jog)
3. Moderate aerobic activity (moderate intensity biking, jogging, lifting for
shorter than usual period of time)
4. Heavy, non-contact activity (sprinting, normal lifting routine, sport-specific
non-contact drills
5. Practice and full contact in a controlled environment
6. CompetitionConcussion Prevention
Create a safe sports culture
Limit contact in practice when appropriate
Teaching/learning good technique
Eliminating dangerous drills from practice and dangerous plays from the game
- For example, in 2015 the Ivy League advanced the kickoff line to the 40-yd
line
- This increased the number of touchbacks and decreased the number of
concussionsConcussions Portions of this talk were borrowed from the CDC website, which is an excellent resource for concussion information https://www.cdc.gov/headsup/index.html
Resources
CDC COVID-19 Information:
https://www.cdc.gov/coronavirus/2019-ncov/index.html
Massachusetts State COVID-19 Information:
https://www.mass.gov/info-details/covid-19-updates-and-information
MIAA COVID-19 Task Force:
http://miaa.net/contentm/easy_pages/view.php?sid=38&page_id=317
CDC Concussion Information:
https://www.cdc.gov/headsup/index.htmlQuestions?
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