What is the Seidel test? Test for corneal abrasion using a fluorescein strip, if it turns pale upon application to the corneal surface, positive test Signs of decompression illness? Onset of symptoms? Symptoms range from pain in the joints (where the bubbles form), to blockage of an artery leading to damage to the nervous system, paralysis or death. Usually present 10-60 minutes after surfacing. How long do signs/symptoms of pulmonary barotrauma of ascent (or arterial gas embolism) take to present? Within 5 min of ascent in 90+% of cases Ciguatera poisoning: What sign/symptom is pathognomonic? Hot/cold reversal (after ingestion of tropical, reef fish, barracuda, moray eel) Ciguatera is a foodborne illness caused by eating certain reef fish whose flesh is contaminated with toxins originally produced by dinoflagellates such as Gambierdiscus toxicus which live in tropical and subtropical waters Scombroid poisoning: Signs/symptoms? Symptoms are allergic in nature from histamine, and are commonly the result of the spoiling of dark-fleshed fish (which then releases histamine into the flesh) Bacteria have grown during improper storage of the dark meat of the fish and the bacteria produce scombroid toxin Typical signs/symptoms of rhabdomyolysis in athletes Increased muscle tone (secondary to muscle injury) Typically normothermic and normotensive (unlike heat stroke) What is the Athletic Female Triad? Amenorrhea Disordered eating (anorexia or bulimia) Osteoporosis Fifth disease: Signs/symptoms? Characterized by a “slapped-cheek” appearance in children and arthralgias in adults (aka erythema infectiosum) Cause: Parvovirus B19V associated with pure red-cell aplasia, particularly in patients with chronic immunosuppression or chronic hemolysis What sign(s) imply pneumothorax in an acute asthma attack? Patients who appear to be stable or improving and then experience sudden deterioration Need to rule out in all unstable patients with asthma. Samter's triad includes? (Cue: pulmonary) Asthma Aspirin sensitivity Nasal polyps What is "Sickling" in an athlete? Mechanism? Collapse, cramping, or struggling in an athlete with sickle-cell trait Mechanism: High tissue temperatures, Decreased O₂ in the blood Displaced O₂ from HbS by lactic acidosis Increased HbS by dehydration Treating Sickling in an athlete 15 minutes of soaking in a cold tub (high tissue temp) Receiving supplemental oxygen (dec O₂) Drinking fluids (dehydration) Distinguishing Sickling from Heat Illness (Cramping) Sickling: "slump to a stop" bc legs become too weak to hold up athlete Heat cramping: "hobble to a halt" bc FULLY CONTRACTED mm no longer function High Altitude Pulmonary Edema (HAPE) Signs and Symptoms? HA Tachypnea Dry Cough Decrease Exercise Performance Dizziness Fatigue Peripheral & Central Cyanosis Insomnia GI disturbance Late Signs: Bloody/pink sputum & Resp Distress Regarding the heart, name a few structural or arrhythmogenic causes of a syncopal event during exercise Prolonged QT interval Heart block Hypertrophic cardiomyopathy (and conditions like it) Wolff-Parkinson-White (as well as other pre-excitation syndromes) Best single prognostic indicator for sudden death in an athlete with hypertrophic cardiomyopathy (HOCM)? Decrease in BP with exercise Others: History of multiple sudden deaths in the family Nonsustained ventricular tachycardia Marked left ventricular hypertrophy (> 3cm) Resuscitation from sudden death Name some PE findings seen in athletes with hypertrophy cardiomyopathy (HOCM) Systolic ejection murmur which DECREASES with squatting (inc venous return) and fist clenching INCREASES with standing and Valsalva maneuver (decreases venous return) Name two drugs (or drug classes) that can increase the QT interval Stimulants (and common cold meds) Albuterol Albuterol has been associated with which electrolyte imbalance? Hypokalemia Which anti-hypertensive drug class is preferred in athletes with HTN? Exception? Angiotensin-receptor blockers and angiotensin-converting enzyme (ACE) inhibitors (meds ending in -pril) Exceptions: Athlete with h/o cholinergic urticaria and HTN--increased risk for exercise-induced anaphylaxis 2' to increase bradykinins Why is Diltiazem (and other nondihydropyridine calcium channel blockers) not used in ENDURANCE ATHLETES with HTN? Negative inotropic and chronotropic effects Why is Metoprolol (and other beta blockers) discouraged in athletes? Which sport forbids? May suppress cardiovascular performance required for aerobic exercise Athletes who participate in long-range riflery, beta blocks may confer an unfair advantage Why are diuretics banned by the International Olympic Committee? This class of drugs has the ability to hide the presence of androgenic steroids Conditions/factors that increase risk for Primary Exertional HA? Dehydration Hot weather High altitude Also Women > Men; 20-30 yo, throbbing bilaterally Most common cause of sudden cardiac arrest in the older (>35 yo) athlete (runner)? Coronary artery disease 1:50,000 marathon runners Most common cause of sudden cardiac arrest in the younger (<35 yo) athlete/runner? Congenital cardiac defects Tension Pneumothorax: Signs & Symptoms Subcutaneous emphysema Jugular venous distention Absent or decreased breath sounds on the affected side Pleuritic chest pain Tachycardia Progressive dyspnea Cyanosis Hyperresonance Deviation of the trachea away from the affected side Hypotension Indications for needle thoracentesis in athlete with Tension Pneumothorax Respiratory distress An appropriate mechanism of injury Typical physical findings (decrease breath sounds ipsilateral and tracheal deviation away from Hemodynamic instability (hypotension) A diagnosis of complex regional pain syndrome can be aided by obtaining a 3-phase bone scan. Of the following choices below, what diagnostic findings would be the most helpful? a) Focal increased activity on bone scan b) Diffuse increased activity with juxtaarticular accentuation uptake on the delayed images c) Normal bone scan in late stage of syndrome d) Phases 1 and 2 focal changes b) Diffuse increased activity with juxtaarticular accentuation uptake on the delayed images Update is typically diffuse; however, delayed images provide the most diffuse activity. Patients with complex regional pain syndrome do not have focal increased activity. What percentage of people with asthma have airways hyper-reactive to exercise AND are reported to have exercise-induced bronchoconstriction (EIB)? a) 50% to 90% and 50% b) 25% to 49% c) >90% d) 5%-20% a) 50% to 90% and 50% Hoagland’s criteria for diagnosing mononucleosis (four criteria): Pharyngitis Fever Positive serologic markers Lymphadenopathy Heterophile and viral capsid antigen antibody tests are more sensitive than a complete blood count. During the first week of illness, up to 25% of results from heterophile antibody tests will be negative. Viral capsid antigen IgM may be ordered if a more sensitive diagnostic test is required, and itssensitivity rate is 97% (95%-99%) and its specificity rate is 94% (89%-99%). Athletes participating in competitions who have documented asthma may benefit from which treatment to prevent bronchospasms induced by exercise (EIB)? a) beta-adrenergic agonist b) oral corticosteroids c) inhaled corticosteroids d) antihistamines e) nasal steroids a) beta-adrenergic agonist What are Chilblains? It is considered a mild form of a cold injury. Condition characterized by localized inflammatory lesions that result from repetitive or acute exposure to cold. Lesions are purple in color, edematous, and seen more often in young women than men. A central area of pallor and anesthesia of the skin surrounded by edema characterizes a first-degree frostbite. First, second and third degree cold injury (frostbite) characteristics: First-degree: Central area of pallor and anesthesia surrounded by edema Second-degree: Blisters with a clear milky fluid surrounded by edema and erythema Third-degree: Differs from second-degree frostbite because the injury is deeper and the blisters are hemorrhagic. Consuming alcohol predisposes a person to cold injury. Other risk factors include a prior cold injury, hand and arm exposure to vibration, and smoking. African-American women may be at increased risk of coldinjury. Major vs. minor criteria for Marfan syndrome include the following: Major: Scoliosis > 20 degrees (>60% of patients) Ectopia lentis (~50% of patients). Lens dislocation is usually superior and temporal and may present at birth or develop during childhood or adolescence Aortic root dilatation involving the sinuses of Valsalva (70%-80% of patients). Manifests at an early age and is more common in men than women Diastolic murmur over the aortic valve may be present Dural ectasia (confirmed via computed tomography or magnetic resonance imaging) Frequently occurs in the lumbosacral spine Minor: High-arched palate Erythema chronicum migrans is pathognomonic for Lyme disease Rash 6 cm in diameter on her abdomen that looks like an annular homogenous erythema with a central purpura

A 33-year-old woman who is a runner presents to you with questions about how to increase her running regimen for an upcoming marathon. She tells you that during the last 6 months she has only had 3 menstrual periods. You obtain a pregnancy test, and the results are negative. What is the most likely etiology of her menstrual dysfunction? a) Increased testosterone b) Increased luteinizing hormone (LH) c) Decreased gonadotropin-releasing hormone d) Increased prolactin c) Decreased gonadotropin-releasing hormone Menstrual dysfunction induced by exercise that coincides with a loss of menses typically occurs due to loss of the LH surge, which is caused by a disruption in the pulsatile secretion of gonadotropin-releasing hormone. The causative factors for this disruption are not yet known, but it has been linked to an energy deficit that disrupts normal brain function. Increased levels of testosterone and prolactin are not related to exercise-induced menstrual dysfunction. There will be a relative decrease in LH, not an increase in LH. Per the Advanced Trauma Life Support guidelines, what is the estimated minimum systolic blood pressure with a palpable radial pulse? a) 40 mm Hg b) 100 mm Hg c) 80 mm Hg d) 120 mm Hg c) 80 mm Hg The Advanced Trauma Life Support guidelines say that blood pressures (systolic) can be predicted based on palpable pulses. Femoral pulses of 60-70 mm Hg Carotid pulses 70-80 mm Hg Radial pulses above 80 mm Hg Which statement is correct about commotio cordis? a) Little league baseball requires batters children aged <12 years to use chest protectors. b) The apparent mechanism for death is ventricular fibrillation induced by an abrupt blunt precordial blow during a specific period in the cardiac cycle. c) A blow in the left area of the heart, baseballs thrown at 20 mph, and blunt impacts have more deadly outcomes in cases of commotio cordis. d) More than 25% of people with commotio cordis will survive if given cardiac support and rapid defibrillation and automated external defibrillator maneuvers are used. e) For ventricular fibrillation to occur and cause commotio cordis, the impact must occur within the QRS of the cardiac cycle. b) The apparent mechanism for death is ventricular fibrillation induced by an abrupt blunt precordial blow during a specific period in the cardiac cycle. Ventricular fibrillation is the mechanism of death in persons with commotio cordis. It is induced by a blunt precordial blow occurring in the up-slope of the T wave, causing sudden death in athletes. Although there have been discussions about chest protectors among little league baseball, no requirements currently exist. More deadly outcomes are associated with baseballs thrown at more than 40 mph as well as blows in the precordial area and the center of the chest. Less than 10% of persons with commotio cordis survive despite automated external defibrillator maneuvers and rapid defibrillation. Absolute indications to terminate an exercise test are: Patient wants to stop the test Moderate to severe angina ST elevation >1 mm without diagnostic Q waves Drop in systolic blood pressure of ≥10mm Hg from baseline during increase workload with other evidence of ischemia Poor perfusion Neurologic symptoms (eg, near syncope) Inability to monitor electrocardiography readings or systolic blood pressure Sustained ventricular tachycardia What HR change (during/following exercise) is predictive of increased mortality? A heart rate recovery pattern that is abnormal following exercise testing is important on a prognostic level because a heart rate change <12 beats/minute from peak to 2 minutes into recovery is predictive of all-cause mortality in 6 years. A 22-year old tennis player from Italy presents to you after passing out during a college tennis tournament. He does not report any chest pain. You order electrocardiography, which reveals an incomplete right bundle branch block and T-wave inversions in leads V1-V3. His family history is significant for the death of his grandfather of a heart problem at a young age. What should most concern you about sudden cardiac death in this patient? a) Coronary artery disease b) Hypertrophic cardiomyopathy c) Prolonged QT syndrome d) Arrhythmogenic right ventricular dysplasia d) Arrhythmogenic right ventricular dysplasia Most common cause of sudden death in young athletes in the US is HCM. However, in the Veneto region of Italy the most common cause is arrhythmogenic right ventricular dysplasia (cardiomyopathy) (ARVC), followed by premature CAD and HCM was rare and a distant third. Right ventricle becomes thin because it is replaced with adipose tissue. Results on electrocardiography may reveal premature ventricular contractions, right and left bundle branch block, and inverted T waves in the precordial leads. What is/are the issue(s) with Floroquinolones as related to Sports Medicine? 1) Associated with an increased risk of tendon injury/rupture 2) Can cause QT interval prolongation (greater than 460-480 ms) (prolonged QT syndrome) Give two examples of Sulfonylureas: Mechanism of Action (MOA): Issues in Athletes Glucotrol and Amaryl (DiaBeta is a 3rd) MOA: Inc Insulin production by the pancreas Issue: Long-acting, therefore dose adjustments are necessary for athletes Two examples of Thiazolidinediones and MOA Actos and Avandia Lower Insulin Resistance Second line agent Example of a Biguanides, MOA, issue(s) in athletes? Glucophage (Metformin) Dec glucose production in Liver Inc glucose uptake in Muscle Dec Insulin resistance Not assoc with Hypoglycemia Rare lactic acidosis with dehydration in athletes The anti-hypertensive medication least likely to affect training for an endurance athlete. a. Beta blocker b. Diuretic c. ACE Inhibitor d. Calcium channel blocker c. ACE Inhibitor What class(es) of Anti-hypertensive is/are banned by many sports organizations? Which anti-hypertensive are therefore preferred/become first line agents? Diuretics and Beta-blockers are banned Preferred: ACE Inhibitors, Ca Channel Blockers and Angiotensin II receptor blockers (ARBs) Ca channel blockers and ACE Inhib are usually preferred to ARBs Why are ACE Inhibitors not the first choice anti-hypertensive agent for treating Htn in athletes? MOA: Lower BP by causing vasodilation therefore reduce afterload Why is Amlodipine (Ca channel blocker) a good choice in athletes? MOA: Vasodilation, dec HR and contractility Amlodipine has LOW chronotropic effects Normal Sodium level on Chem 7 (basic metabolic panel? Hyponatremia? Normal Na⁺ = 136-144 mmol/L HypoNa⁺ = <135 A soccer player was struck in the eye and presents to the training asking about return to play. How many days do you have to hold from play and why?

4-7 days--this is the time frame for the most common risk of a re-bleed in a hyphema What is a "flail chest"? How is it recognized? Why does it occur? Paradoxical chest wall movement (moves inward with inspiration and outward with expiration) Fracture of at least 3 consecutive ribs in two locations (free floating chest wall segment) HIGH RATE OF INTERNAL INJURY

What is Tietze Syndrome? A rare, inflammatory disorder characterized by chest pain and swelling of the cartilage of one or more of the upper ribs (costochondral junction). Onset of pain may be gradual or sudden and may spread to affect the arms and/or shoulders. What is Paget-von Schroetter Syndrome? Which vessels are most commonly involved? Etiology? Presentation? Treatment? RTP? Effort Thrombosis/Spontaneous Thrombosis of the Axillary or Subclavian Veins (UE DVT) Typically follows strenous UE activity or Trauma BEWARE OF PE (in > 1/3 of patients) Presentation: Vasc Changes: Edema, cyanosis, distal venous engorgment and PAIN Treatment: Emergent Thrombolysis and anti-coagulation RTP ~ 3.5 mos What is Subclavian Steal Syndrome? Signs/Symptoms/Presentation? Subclavian A. stenosis/occlusion proximally leads to a REVERSAL of blood DOWN the Vertebral A. to the arm (at the expense of the vertebrobasilar circulation) Presentation: Vertebrobasilar Insufficiency: Presyncope, Syncope, CNS deficits Subclavian Insufficiency: Arm weakness, Paresthesias, Exertional Claudication Provocative Maneuver: Exercise of UE-->Reproduction of Sx, Loss of RADIAL PULSE What is Iliofemoral (Ext Iliac) Endofibrosis? Etiology? Presentation? Treatment? aka Cyclist's Arterial Disease as most commonly affects elite cyclists 20-30 yo External Iliac A stenosis secondary to mechanical (hip flexion) and stress stress (high blood flow due to exercise), compression from psoas hypertrophy or inguinal ligament Presentation: Unilat LE pain (15% Bilat), weakness during intense exercise, +/- thigh edema, paresthesias, progressive worsening Diagnosis: ABI post-exercise, Duplex US post-exercise, MRA, Angiography Treatment: Activity modification, PTBA (minimally invasive: percutaneous transluminal balloon angioplasty) or invasive surgery (resection, graft, endarterectomy) What is the etiology of Popliteal Artery Entrapment Syndrome (PAES)? Presentation, Diagnosis, Treatment. Congenital: Fibromuscular anomalies in popliteal fossa Functional: Physiological impingement of the Pop A due to exercise-induced increased blood flow and muscle hypertrophy (gastroc, soleus, plantaris, SM) Presentation: Calf claudication, exertional leg pain, paresthesias, exertional calf fatigue. Often asymptomatic at rest Usu unilateral (1/4 bilat) Male > Female Often < 30 yo Decreased pulses with active DF/PF and knee extension and may have a post-exercise bruit Diagnosis: Post-exertional ABI, Doppler segmental pressures, angiography, photoplethysmography Treatment: Functional: Conservative (Relative rest, compression stockings, stretches, elevation), if refractory: surgery. Congenital: Surgery to release band compressing artery Parameters/Measurements of Left Ventricular wall thickness in Athletic Heart vs. Hypertrophic Cardiomyopathy? Other means of differentiating? Athletic Heart: 13-15 mm (grey zone) Hypertrophic Cardiomyopathy: 18-20 mm Left Ventricular End Diastolic Diameter (LVEDD) Athletic > 55 mm; HCM < 45 mm History-Fam Hx of SCD or HCM A 19 yo basketball player has an episode of unexplained syncope during practice. He adamantly denies prior cardiac history and believes he was just dehydrated. Upon further questioning he admits that a cousin died suddenly at age 20 of cardiac causes. An EKG is obtained. Which abnormality would be suggestive of right ventricular dysplagia (ARVD)? a) Normal EKG b) T-wave inversion c) Prolonged QT interval d) Q waves e) Pre-excitation b) T-wave inversion Wolff Parkinson White: Diagnosis, Symptoms and Return to Play Symptoms - Palpitations, Syncope, Dizziness Diagnostics - EKG - delta wave c short PR interval and prolonged QRS Treatment - RF Ablation for high risk pathways RTP - 3 months after ablation

What is Brugada Syndrome? Sodium ion channel disease (autosomal dominant) Propensity for fatal ventricular arrhythmias EKG - Partial RBBB c coved ST segment elevation Risk - Most deaths occur at slow HR, often during sleep. Chronic intensive exercise increases vagal tone and therefore resting bradycardia. Exercise increases in core body temperature, a recognized trigger for SCD in Brugada Rec/Tx - Abstain from chronic or prolonged intensive exercise. Consider ICD (survivors of aborted SCD, Sustained VT and Syncope)

Common EKG Findings in Athlete's Heart? Sinus Bradycardia, early repolarization with ST elevation and peaked T-waves and voltage criteria for left ventricular hypertrophy

Swimmer presents with this lesion; what is it?

Molluscum Contagiosum A pox virus associated with swimming pools Highly contagious and appears to be spread by towels and kick boards (not the water) RTP - No new lesions x 72 hrs, anti-virals x 120 hours, cover dried lesions Wrestler presents with below rash on face; what is it?

Impetigo A common bacterial infection caused by Staph pyogenes or Staph aureus Highly contagious Rx: Mupirocin (Bactroban) bid x 10 days, followed by oral Abx (Cephalexin or E-mycin) if lesions/rash persists. RTP: After 72 hours of treatment and residual lesions (cannot be exudative or moist) covered Wrestler presents with the rash shown below. Diagnosis? Treatment? RTP?

Tinea Corporis or Tinea Gladiatorum (Ringworm) a superficial fungal infection. Invades skin in a centrifugal pattern Rx: A -cidal topical antifungal terbinafine (Lamisil) or naftifine (Naftin) or systemic therapy if disease is extensive. Hygeine is key to prevention RTP: Must be treated for at least 72 hrs and covered before allowing return to wrestling A rugby player presents to the medical tent with the below rash on his neck/face Diagnosis? Treatment(s)? RTP?

Herpes Rugbeiorum (Scrum Pox) - contagious HSV infection spread by direct contact, infection facilitated by abrasive effects of facial stubble (hence name scrum pox). Stinging/burning sensation may be present before developing the vesicular lesions Rx - Topical anti-viral (acyclovir, pencyclovir, etc) RTP - No new lesions x 72 hrs, anti-virals x 120 hours, cover dried lesions Treatments for H.pylori for PUD? Triple therapy: 10-14 days Amoxicillin (1g bid), Clarithromycin (500mg bid), PPI If fail, go to Quadruple therapy - Metronidazole, tetracycline, PPI, bismuth Splenic Laceration presentation, imaging and RTP? MOI - direct trauma to Left Upper Abd Presentation - Sharp pain in LUQ initially, followed by dull left side/flank pain, Abd distension, +Kehr's sign (referral to left shoulder secondary to free intraperitoneal blood irritating diaphragm Tachycardia, hypotension, diaphoresis, rapid respirations (suggesting internal bleeding) Imaging - X-ray - fading splenic outline, CT scan with contrast (greater sens/specif), Ultrasound (FAST) RTP - >3 mos for non-surg cases; post-splenctomy once scar healed and can tolerate activity (as early as 3 wks)

Testicular Torsion vs Epididimitis

Workup of exercise-induced hematuria should be considered after how many hours of symptoms? a) 24 b) 2 c) 12 d) 72 e) 96 d) 72 An athlete presenting with flank pain, hematuria, and hypovolemic shock following blunt trauma should prompt which of the following? a) Cystography b) IV hydration and CT scan c) IV hydration, surgical consultation, consideration for transfusion d) Observation, bed rest and serial UAs e) IV hydration, close monitoring with no immediate intervention c) IV hydration, surgical consultation, consideration for transfusion The hypovolemic shock indicates a more serious renal trauma (class IV or V-more significant laceration and therefore warrants a much more aggressive intervention) Cause(s) of Auricular Hematoma (cauliflower ear)? Treatment? Shearing of the perichondrium from the cartilage of the ear Treatment - Aspiration (acute and <2cm), I&D (acute and >2cm), if present >7 days referral. Splinting - Thermoplastic splint or compressive dressing RTP - Non-contact - Immediately Contact - removal of compressive dressing and protective gear Best Abx for Otitis Externa? Usually caused by streptococcus, staphylococcus, or pseudomonas Mild - Cipro HC (hydrocortisone) suspension Moderate - Ciprofloxacin po An athlete that is confronted with fever can have exercise performance impaired. Which of the following is NOT an effect that can be attributed to fever? a) Decreased coordination b) Decreased endurance c) Decreased flexibility d) Decreased strength c) Decreased flexibility For every degree above 37*C O₂ consumption increases by 13%. Fever promotes dehydration and is detrimental to exercise performance What's the risk of exercise when sick (fighting an infection and have a Fever)? Myocarditis Exercising in the acute phase of an illness may promote complications including myocarditis Infection/Fever evoke a cytokine-medicated host response resulting in negative nitrogen balance, muscle protein degradation and deteriorated muscle function Treatment options for URI keeping in mind NCAA and USADA restrictions? Decongestants (except ephedrine) are allowed Antihistamines are allowed (but can cause sedation) URI and RTP "The NECK CHECK" If symptoms at Neck or Above - exercise x 10 mins - if worse STOP, if not may RTP If symptoms BELOW the NECK or SYSTEMIC - rest until Sx resolve followed by gradual RTP What are the Centor Criteria? Would are they used for? Criteria to determine the likelihood of a bacterial infection in a sore throat One point for each History of Fever Anterior Cervical Adenopathy Tonsillar Exudates Absence of a Cough 0-1 No testing, no Abx 2-4 Rapid Strep testing, Abx 4 Consider empiric Abx w/o testing Mononucleosis is of concern in athletics secondary to the risk of splenic rupture. Which statement most accurately describes the criteria required for return to contact sports? a) The risk of splenic rupture with mononucleosis is minimal and return to contact sport is permitted when athlete is asymptomatic b) Contact sports should be permitted only when an imaging study e.g. ultrasound, shows that the spleen has returned to normal size c) Contact sports should be considered only after three weeks from symptom onset and the athlete is clinically asymptomatic d) Contact sports should be considered only after three weeks from symptom onset, the athlete is clinically asymptomatic and there is no evidence of splenomegaly on an imaging study c) Contact sports should be considered only after three weeks from symptom onset and the athlete is clinically asymptomatic Splenomegaly occurs in 50-100% of infected patients and peaks week 2-3 Imaging is UNRELIABLE to evaluate size in the absence of a baseline measurement Incidence of splenic rupture is 0.1-0.2% and almost ALL occur in the first 3 weeks of illness 21 yo female track athlete presents for consultation after screening labs showed a hematocrit of 32. The most common cause of low hematocrit in athletes is? a) Iron deficiency anemia b) Dilutional pseudoanemia c) Sickle Cell Trait d) laboratory error b) Dilutional pseudoanemia - Red cell mass is unchanged or even expanded in athletes - Plasma volume expansion > RBC expansion - Degree of expansion correlates with amount or intensity of exercise - Plasma expansion occurs within 3 hours following acute exercise; will normalize in 3-5 days if training stops - Will NOT affect MCV, Ferritin, RDW or haptoglobin 19 yo female nordic skier presents with fatigue and impaired ability to train. Lives at 4500' and trains at 7800' and reports NL menses. PE is WNL. Labs Hb=13.8, Hct=39, ferritin=19 Diagnosis? Iron deficiency Anemia (low Hct, low ferritin, low serum Fe, low MCV (<80 - microcytic anemia), HIGH TIBC) Ferritin NL>25µ/L Hct NL for Females=34.9 to 44.5 Hb NL for Females=12.1 to 15.1 g/dl Differentiating various types of anemia in athletes (via labs) Haptoglobin is a protein present in blood serum that binds to and removes free hemoglobin from the bloodstream. Thus it will be lower if there is an increase in hemoglobin in the bloodstream (from heel-strike hemolysis) in an attempt to clear it.

What is ECAST? Exertional collapse associated with SCT (Sickle Cell Trait) Mutation of ß-globin gene (chromosome 11q) GAG-->GTG α₂ß₂ - Normal hemoglobin α₂ßS - Sickle Trait (heterozygote) α₂S₂ - Sickle Cell Disease (homozygote) Pathophys - O₂ displaced from HbS with strenuous exercise, Lactic Acidosis, Increased tissue temperatures, Dehydration Sickling leads to Vascular Obstruction --> Ischemic Rhabdomyolysis ECAST risk factors Heat Altitude Early Season (deconditioned athletes) High intensity training Presentation: Muscle Pain and weakness but muscles look/feel normal (no cramping) Athlete slumps to ground but usu can communicate (differs from cardiac arrest) Tachypnea present (due to lactic acidosis) but can move air well (differs from acute asthma attack) Rectal temp <103F (differs from heat stroke) Most common injury(ies) sustained in school-aged children is/are? Contusions and Strains Adolescents - Overuse injuries more common (30-50%) than acute injury What is the most common overload injury in adolescents? Growth site injuries predominate with Osgood Schlatter disease most common Difference between Peds and Adults with regard to... Aerobic Capacity Anaerobic Capacity Metabolic costs of movement Recovery from Concussion Aerobic - Preadolescent capacity close to adult Anaerobic - Less developed that adults and will not mature until puberty Metabolic Costs - Higher in children (shorter stride length during running and greater inflexibility of antagonist muscle groups Gender differences are virtually nonexistent in prepubescent athletes Concussion - Incidence is lower in peds but recovery takes longer Also - Speed, power and mass are lower in children No difference noted in thermoregulatory responses (peds previously thought to have impaired thermoregulatory responses due to high ration of body surface to mass and diminished sweat capacity, but peds rely more on dry heat dissipation than on evaporative loss Differentiating cholinergic urticaria from exercise-induced anaphylaxis (EIA) Which does this woman have?

Cholinergic Urticaria Cholinergic Urticaria - Predominantly skin findings, NO VASCULAR COLLAPSE EIA - Systemic symptoms, Shock A 39 yo recreational soccer player presents with rhinorrhea, sneezing, itchy throat and eyes. He denies fevers, chills or sick contacts, and otherwise feel well. You suspect allergic rhinitis. You recommend: a) montelukast b) oral prednisone c) hydroxyzine d) fexofenadine d) fexofenadine Exercise and Rheumatoid Arthritis What have clinical research shown? Beneficial or Detrimental? Beneficial (RA and Juvenile RA) (however no proven benefit in JIA-juvenile idiopathic arthritis was noted with exercise) Exercise can reduce pain, morning stiffness and fatigue. Can improve functional ability and psychological well-being Studies have NOT demonstrated exacerbation of disease activity nor has it shown the ability to influence remission Several studies have suggested risk of long term articular damage from activities that repetitively load the joints. Thus, should discourage high-impact loading activities. What disease process is associated with these images?

Psoriatic Arthritis Pauciarticular, asymmetric distribution Assoc c Spondyloarthropathy, Enthesitis, Dactylitis (sausage fingers), nail abnormalities and Uveitis and Erosive "Pencil in Cup" changes on X-ray

Hallmark features of Reiter's Syndrome? Reiter's Syndrome aka Reactive Arthritis Arthritis following bacterial GI/GU infection Hallmark: Asymmetric, oligoarthritis of LE assoc c conjunctivitis, urethritis and other articular/non-articular findings M > F ages 20-40 What is Beck's Triad? What condition does it refer to? Cardiac Tamponade Hypotension Jugular venous distenstion Muffled heart sounds What ECG abnormality(ies) are Floroquinolones associated with? What other sports/ortho related condition are they associated with? ECG - prolonged QT syndrome (>460-480 msec) Other Condition - Assoc c tendon injury (especially in pt > 50 and when combined with corticosteroids) Drugs/agents ALWAYS prohibited (at ALL TIMES) by WADA Anabolic Agents Hormones Beta-2-agonists Hormone antagonists & modulators Diuretics and Masking Agents Enhancement of O₂ transfer (Epo) Chemical, physical and gene manipulators Drugs/agents prohibited by WADA during/in competition Stimulants Narcotics Cannabinoids Glucocorticosteroids WADA prohibited drugs/agents in particular sports Alcohol Beta-blockers Which drugs/agents require a TUE (therapeutic use exemption)? Beta-2-agonist Insulin Injected cortisone Must be submitted 21 days prior to competition