Chapter 27 Principles of Athletic Training

Diarrhea

Etiology: abnormal stool looseness or passage of a fluid, unformed stool. Can be caused by problems in diet, inflammation of intestinal lining, gastrointestinal infection, the ingestion of certain drugs, & psychogenic factors • Symptoms and signs: abdominal cramps, nausea, possibly vomiting, frequent elimination of stools (3-20/day); loss of appetite and light brown or gray, foul-smelling stool; weakness due to fluid dehydration • Management: treatment is cause-specific.

Peptic Ulcer

Etiology: acids secreted in stomach destroy mucous lining (stomach or small intestine); often occur in those people who experience extreme anxiety for a long period of time • Symptoms and signs: gnawing pain the epigastric region (appears 1-3 hours following a meal). Dyspepsia, heartburn, nausea, or vomiting. Pain usually lasts for minutes rather than hours. • Management: antacids can help neutralize gastric secretions. Hemorrhaging/perforation - surgery

Rib Contusions

Etiology: blow to ribcage may contuse intercostal muscles or produce a fracture. Breathing is very painful • Symptoms and signs: sharp pain during breathing, point tenderness and pain elicited when rib cage is compressed • Management: rule out fracture (x-ray). RICE and anti-inflammatory agents. Self-limiting injury

Appendicitis

Etiology: can be chronic or acute; caused by fecal obstruction, lymph swelling, or a carcinoid tumor; highest incidence in males 15-25 years; early the appendix is red and swollen, later it may rupture, causing peritonitis (bacterial infection is a complication of rupture of the inflamed appendix) • Symptoms and signs: mild to severe pain in the lower abdomen, nausea, vomiting, low grade fever; abdominal rigidity at McBurney's point; strain of psoas muscle/abscess in the sheath of the psoas can be mistaken for appy • Management: surgical removal is often necessary

Commotio Cordis

Etiology: cardiac arrest due to some blunt impact to the chest (must occur in a narrow window during the repolarization phase of the cardiac cycle, 15-30 msec prior to the peak of the T wave). Young athletes are at risk due to the pliability of their chest walls. • Symptoms and signs: ventricular fibrillation is the most common associated arrhythmia; immediate death occurs in about half of cases, while in others there is a brief period of consciousness before collapse • Management: resuscitation of the victims of commotion cordis is seldom successful (time is a critical factor); early CPR and especially early defibrillation with an AED is essential.

Constipation

Etiology: causes include lack of abdominal muscle tone, insufficient moisture in the feces, lack of a sufficient proportion of roughage and bulk in the diet to stimulate peristalsis, poor bowel habits, nervousness • Symptoms and signs: feeling of fullness, occasional cramping/pain in lower abdomen. Straining to defecate may cause rupture of blood vessels in rectum and bleeding from anus • Management: eat cereals, fruits, vegetables, and fats; determine cause of emotional stress; avoid laxatives

Indigestion (Dyspepsia)

Etiology: digestive upset; can be caused by emotional stress, esophageal and stomach spasms, and/or inflammation of the mucous lining of the esophagus and stomach • Symptoms and signs: increased secretion of hydrochloric acid (sour stomach), nausea, flatulence (gas) • Management: acutely - eliminate irritating foods, avoid anxieties that lead to gastric distress; chronic irritation may lead to gastritis (inflammation of stomach wall) or ulcerations of the gastrointestinal mucosa

Costochondral Seperation and Dislocation

Etiology: direct blow to anterolateral aspect of thorax or indirectly from a sudden twist or fall on a ball that compresses the rib cage. Displays many signs similar to rib fracture, except pain is localized in junction of rib cartilage and rib. • Symptoms and signs: sharp pain with sudden movements of trunk, difficulty breathing deeply. Point tenderness with swelling. May be a rib deformity and a feeling of crepitus as it moves in and out of place • Management: rest and immobilization (healing takes 1-2 months)

Traumatic Hydrocele of the Tunica Vaginalis

Etiology: excessive fluid accumulation caused by a severe blow to the testicular region; venous plexus on posterior aspect of testicle can become engorged, creating a varicocele; rupture of venous plexus results in rapid accumulation of blood in scrotum (hematocele) • Symptoms and signs: pain, swelling in the scrotum • Management: cold packs should be applied to scrotum, athlete referral to physician

Hyperventilation

Etiology: excessively rapid rate of ventilation usually due to anxiety-induced stress or asthma gradually develops a decreased amount of carbon dioxide in the blood (hypocapnia) • Symptoms and signs: difficulty in getting air and seems to be struggling to breath, panicked state, gasping and wheezing (appears that the athlete is not getting enough oxygen but the problem is that the levels of carbon dioxide are too low relative to the amount of oxygen) • Management: decrease the rate of carbon dioxide loss (slow rate of respiration, concentrate on breathing in through nose and exhaling through mouth, breathe into a paper bag). Typically the athlete will resume normal breathing within 1-2 minutes.

Liver Contusion

Etiology: hard blow to the right side of the rib cage can tear or seriously contuse the liver (esp. if it is enlarged) o Hepatitis: inflammation of the liver due to viral infection or alcohol consumption; can lead to cirrhosis • Symptoms and signs: hemorrhage and shock (surgery); referred pain just below right scapula, right shoulder, and substernal area and sometimes a referred pain to the anterior left side of the chest • Management: immediate referral to physician

Heart Contusion

Etiology: heart is compressed between the sternum and the spine by a strong outside force. Right ventricle is most often injured. Most severe consequence would be rupture of the aorta • Symptoms and signs: severe shock and heart pain, possibly arrhythmias that cause a decrease in cardiac output, which could be followed by death • Management: hospital ER, CPR may be necessary, treat athlete for shock

Sternum Fracture

Etiology: high-impact blow to the chest (more likely to occur in car accidents than athletics). May also cause contusion to the underlying cardiac muscle • Symptoms and signs: point tenderness at site of fracture that is exacerbated by deep inspiration or forceful expiration. Signs of shock or a weak, rapid pulse may indicate more severe internal injury • Management: x-rays, athlete should be closely monitored for signs of trauma to the heart

Food Poisoning (Gastroenteritis)

Etiology: infectious organisms (bacteria of the salmonella group, certain staphylococci, streptococci, or dysentery bacilli) that enter body either in food or drink. Contamination can occur due to temperature or an infected handler • Symptoms and signs: nausea, vomiting, cramps, diarrhea, anorexia. Staph infections last 3-6 hours; salmonella infections may last 24-48 hours • Management: rapid replacement of lost fluids and electrolytes (may need to be replaced intravenously). Bed rest, clear strained broth, bouillon, soft-cooked eggs, or bland cereals may be given.

Vaginitis

Etiology: inflammation caused by a variety of microorganisms; non-STI causes include bacterial infection, strong chemicals from douching, irritation from a tampon, and poor hygiene habits • Symptoms and signs: purulent, occasionally bloody, vaginal discharge. Strong odor with vaginal itching. Urination is frequent and painful. Vagina is red and painful to touch. • Management: STI cause - antibiotic/antifungal medication. Education about correct hygiene & cleanliness

Contusion of Ureters, Bladder and Urethra

Etiology: injury to bladder usually only occurs if it is distended by urine. Hematuria is often associated with contusion of the bladder during running ("runner's bladder"). Proteinuria: abnormal concentrations of protein in urine. Injury to urethra is more common in males (more exposed) • Symptoms and signs: pain/discomfort, abdominal rigidity, nausea, vomiting, signs of shock o Kidney injury: blood coming from urethra and passing of a great quantity of bloody urine o Bladder contusion: athlete is able to urinate; bladder rupture: athlete unable to urinate Bladder injury often causes referred pain to the lower trunk (upper thigh) • Prevention: empty bladder prior to activity; check for blood in urine after trauma

Injury to the spleen

Etiology: injury usually due to fall or direct blow to spleen (often with splenomegaly - mono); those athletes with mono should not participate in contact sports for 3 weeks • Symptoms and signs: severe blow to abdomen, signs of shock, abdominal rigidity, nausea, vomiting, Kehr's sign • Management: conservative, nonoperative treatment with a week of hospitalization. Full return at 4 weeks. If surgical repair is necessary, it will take 3 months to recover, spleen removal will take 6 months to recover

Muscle Injuries

Etiology: intercostal muscles are especially vulnerable to contusions and strains. Traumatic injuries occur most often from direct blows or sudden torsion of the athlete's trunk • Symptoms and signs: pain with active motion, pain during breathing, laughing, coughing, or sneezing • Management: pressure and application of cold for approximately one hour. After hemorrhaging has been controlled, immobilization should be used to make athlete more comfortable

Pancreatitis

Etiology: may be acute or chronic and often related to blockage of the pancreatic duct o Acute: necrosis, suppuration, gangrene and hemorrhage o Chronic: formation of scar tissue that causes malfunction of the pancreas; may occur from alcoholism • Symptoms and signs: acute - vomiting, belching, constipation, potentially shock, tenderness and rigidity o Chronic: jaundice, diarrhea, mild to moderate pain that radiates to the back • Management: acute - rehydration, pain reduction, treatment of shock, reduction of pancreatic secretions using medication, and prevention of secondary infection. Surgery is indicated if duct is blocked. Chronic - difficult; large doses of analgesics, administration of pancreatic enzymes, and a low-fat diet

Contusions of the Abdominal Wall

Etiology: most common in collision sports, catchers/goalies are susceptible • Symptoms and signs: severe blow may cause a hematoma that develops under the facial tissue surrounding the muscle; pressure that results from hemorrhage causes pain and tightness in the region of the injury • Management: cold pack and compression wrap; look for signs of internal injury

Rib Fractures

Etiology: occur most in collision sports (football, wrestling). Can be the result of violent muscle contractions. Direct injury caused by a direct blow, indirect injury caused by compression to ribcage. Ribs 5-9 most commonly fractured. Flail chest involves fracture of 3+ consecutive ribs on the same size. Direct fractures cause the most serious damage (rib displaced inwardly). Indirect fracture often causes rib to spring and fracture outward. Stress fracture to of the first rib may occur as a result of repeated arm movements (pitching, rowing), or repeated coughing or laughing. • Symptoms and signs: pain with breathing, point tenderness, possible crepitus during palpation • Management: x-ray, manage with support and rest (bracing may help but also predisposes to hypostatic pneumonia, which occurs when an individual does not take full inspirations because of pain)

Stitch in the Side

Etiology: possible causes include constipation, intestinal gas, overeating, diaphragmatic spasm (poor conditioning), lack of visceral support due to weak abdominal muscles, distended spleen, breathing technique • Symptoms and signs: cramp-like pain that develops on either left or right costal angle during hard physical activity • Management: relaxation of spasm (stretch arm on affected side or flex trunk forward while tightening abdominal muscles), identify cause and treat

Hernia

Etiology: protrusion of abdominal viscera through a portion of the abdominal wall o Inguinal: most common in males o Femoral: most common in females o Avoid irritation of hernia by falls/blows; development of strangulated hernia (gangrene & death) • Symptoms and signs: natural weakness aggravated by either a strain or a direct blow; pain and prolonged discomfort, superficial protrusion in groin area that is increased by coughing, reported feeling of weakness and pulling sensation in groin area • Management: surgery

Irritable Bowel Syndrome

Etiology: psychological factors often determine who the individual experiences and handles the condition • Symptoms and signs: abdominal pain that is relieved with defecation, alteration in stool frequency stool form, stool passage, passage of mucus and abdominal bloating and distention • Management: modify diet (dairy and gas-causing foods), antidiarrheal or antispasmodic medications, psychological counseling

Gastroesophageal Reflux

Etiology: reflux/backward flow of the acidic gastric contents into the esophagus (usually due to malfunction of lower esophageal sphincter). Repeatedly, may result in esophagitis (inflammation of lower esophagus) • Symptoms and signs: heartburn-like retrosternal pain that can progress to gripping chest pain; burning feeling with a sour liquid taste in the throat. Athlete may have difficulty swallowing. • Management: medication; surgery may be needed if medication is not successful.

Vomitting

Etiology: results from some type of irritation, which stimulates the vomiting center in the brain to cause a series of forceful contractions of the diaphragm and abdominal muscles, thus compressing the stomach and expelling • Management: antinausea medications; fluids to prevent dehydration

Spermatic Cord Torsion

Etiology: results from the testicle's revolving in the scrotum after a direct blow to the area or as a result of coughing or vomiting • Symptoms and signs: acute testicular pain, nausea, vomiting, and inflammation • Management: immediate medical attention (could result in atrophy of testicle)

Kidney Contusion

Etiology: susceptible to injury due to its normal distention by blood. Usually are injured due to an external force • Symptoms and signs: signs of shock, nausea, vomiting, rigidity of back muscles, and hematuria • Management: 24 hour hospital observation and gradual increase of fluid intake. If hemorrhage fails to stop, surgery may be necessary. Controllable contusions usually require 2 weeks of bed rest and close surveillance when activity is resumed.

Blow to Solar Plexus

Etiology: transitory paralysis of the diaphragm ("wind knocked out") • Symptoms and signs: stops respiration and leads to anoxia; when athlete is unable to inhale, hysteria may result • Management: loosen clothing around the abdomen, talk to athlete in a confident manner, bend athlete's knees, encourage athlete to relax by initiating short inspirations and long expirations

Hemorrhoids

Etiology: varicosities of the hemorrhoidal venous plexus of the anus (both internal and external anal veins). Chronic constipation or straining may stretch anal veins, resulting in a protrusion and bleeding or a thrombus • Symptoms and signs: painful nodular swellings near the sphincter of the anus; slight bleeding and itching; the majority are self-limiting and heal within 2-3 weeks • Management: management is palliative and serves to eliminate discomfort until healing occurs.

Scrotal Contusion

Etiology: very painful, nauseating, and disabling condition • Symptoms and signs: hemorrhage, fluid effusion, and muscle spasm (degree depends on intensity of impact) • Management: reduce testicular spasm by having athlete in a seated position, lift him a few inches, and drop him to the ground; after pain is diminished, apply cold pack (increasing pain - refer to physician)

Breast Injury

Etiology: violent up-and-down and lateral movements of the breasts can bruise or strain the breast. Constant uncontrolled movement over a period of time may stretch out the Cooper's ligament. o Runner's nipples - shirt causes abrasion (wear adhesive bandage). o Bicyclist's nipples: combination of cold and evaporation of sweat (wear a windbreaker) • Management: well-designed bra with little elasticity; protect breasts with plastic cup-type brassieres

Cystitis

Inflammation of the bladder (usually due to UTI). Kidney, prostate, and urethra may be involved. Acute cystitis causes frequent painful urination, chills, and fever. Treatment is antibiotics.

Urethritis

Inflammation of the urethra, often caused by gonorrhea or sometimes by other, nongonococcal organisms. Symptoms include pain on urination along with urethral discharge. Treated with antibiotics.

Abdominal Muscle Strains

MOI: sudden twisting of trunk or reaching overhead; severe pain and hematoma formation • Rectus abdominis is most commonly strained; ice and compression wrap

Gastrointestinal Bleeding

Reflected in bloody stools; causes include gastritis, iron-deficiency anemia, ingestion of aspirin, stress, bowel irritation, and colitis

Urinary Tract Infection

Usually caused by staphylococcus bacteria or Chlamydia. Causes frequent, burning, painful urination and treated with antibiotics. Prevention: increase fluid intake, practice sanitary bowel/bladder habits, wash genital area before intercourse, emptying bladder after intercourse, & immediately removing diaphragms after intercourse

Kidney Stones

Usually composed of crystalline mineral salts (calcium, phosphate, uric acid) that form in the urinary tract. Cause is unknown. Stones pass through urethra and are excreted (extremely painful process).

Contusion of Female Genetelaia

Very rare; usually if injured, external genitalia (vulva: labia, clitoris, vestibule) • Contusion could injure pubic symphysis (producing osteitis pubis)

Marfan's syndrome

abnormality of connective tissue that results in weakening of the structure of the aorta and cardiac valves, which can lead to a rupture of either a valve or the aorta itself. Mitral valve prolapses have been associated with both HCM and Marfan's

Lower right quadrant

appendix, ureter, bladder, colon, gonads

Upper left quadrant

heart, spleen, kidney, stomach, lung

Colitis

inflammation of the colon - caused by ulceration of the mucosal lining of the colon. o Signs include abdominal pain with colic, watery stools that contain pus, dehydration, intermittent fever and possible hemorrhage and perforation

Upper right quadrant

liver, pancreas, kidney, lung

Sternum

manubrium body xiphoid process (sternal notch, clavicular notch)

Pnemothorax

pleural cavity becomes filled with air that has entered through an opening in the chest (lung on that side collapses) - loss of one lung may produce pain, difficulty breathing, and anoxia

Hemothorax

presence of blood within pleural cavity, resulting from tearing or puncturing of the lung or pleural tissue. Produces pain, difficulty breathing, and cyanosis. A violent blow/compression without an accompanying rib fracture may cause a lung hemorrhage (pain, difficulty breathing, coughing up frothy blood, and signs of shock)

Traumatic Asphyxia

result of a violent blow or compression of the rib cage that causes a cessation of breathing, signs include purple discoloration of the upper trunk and head, conjunctivas of the eye display a bright red color; treatment is immediate mouth-to-mouth resuscitation and medical attention

Floating ribs

ribs 11-12

False Ribs

ribs 8-10

Tension Pneumothorax

the pleural sac on one side fills with air and displaces the lung and the heart toward the opposite side, which compresses the opposite lung. There will be shortness of breath and chest pain on the side of the injury. There may be absence of breath sounds, cyanosis, and distention of the neck veins. The trachea may deviate away from the side of injury. Total collapse of the opposite lung is possible

Hypertrophic cardiomyopathy

thickened cardiac muscle with no chamber enlargement and extensive myocardial scarring. This condition causes increased ventricular arrhythmia

True Ribs

upper 7 ribs

Lower Left quadrant

ureter, bladder, colon, gonads

Aortic Stenosis

usually associated with a heart murmur, can cause a fall in BP and cardiac collapse during exercise