Figure Skating Medical SymposiumIthaca, NY December 6, 2010
Andrew Getzin, [email protected]
www.cayugamed.org/sportsmedicine
Program
• Andrew Getzin, MD, Medical Treatment of figure skaters
• Jake Veigel, MD, Injury Prevention
• Deb King, PhD, Figure Skating Stretching and Warm Up
• Discussion
Incidence of Injuries in Elite Junior Figure Skaters- Acute Injuries
Dubravcic-Simunjak, AJSM 2003
Ankle SprainLaceration,LegHead InjuryFracture, armFracture, legKnee ligament sprainKnee injuryShoulder dislocationFracture, wristFracture, finger
Incidence of Injuries in Elite Junior Figure Skaters- Overuse Injuries
Dubravcic-Simunjak, AJSM 2003
Stress FractureJumper's kneeShin splintsOsgood SchlatterGroin painHamstring SyndromeAchilles tendonitisAnkle ImpingementPlantar fasciitis
What is a Concussion?• Mild traumatic brain
injury• A disruption in
normal brain function due to a blow or jolt to the head
• CT or MRI is normal
• Invisible injury
Neurometabolic Cascade(Giza and Hovda 2001)
• Abrupt neuronal depolarization• Release of excitatory neurotransmitters• Changes in glucose metabolism• Altered cerebral blood flow• The brain goes into an ENERGY
CRISIS that usually last up to 7 – 10 days
Vulnerable Period
• There exists a window period when individual is at increased risk
• Should factor in return to play decision
Common Physical Symptoms• Headache• Nausea and vomiting• Clumsiness and poor balance• Dizziness and
lightheadedness• Blurred vision and light
sensitivity• Fatigue and lack of energy• Sleep disturbance• Symptoms often get worse
before they get better
Common Emotional Symptoms• Irritability• Anxiety• More extreme moods• Easily overwhelmed• Personality change• Lack of motivation
• Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’• Easily confused• Slowed processing• Easily distracted • Memory problems• Trouble reading• Poor mental stamina
Common Cognitive Symptoms
Predictions
• Outcome after concussion is difficult to predict
• Don’t be fooled by severity of injury at the time of injury
Physical Exam• Regular physical exam including HEENT,
neck, and neurological exam• 5 Word Recall- immediate and 5 minutes• Months of the year backwards• Digits backwards• Speech• Pronator drift: Rhomberg• Finger-to-nose• Gentle push with their eyes closed
Neuropsychological Testing• Computerized tests that measure
attention, memory, and processing speed (reaction time)
• Sensitive to effects of concussions• Tests can be repeated multiple times to
monitor recovery• Ideally, a baseline is done but there is
normative date for ImPACT
Who Should Have a CT Scan?
• GCS < 15• LOC• History of emesis• Severe headaches• Signs of basilar skull fracture• Severe mechanism
Kuppermann Lancet 2009
Principles of Concussion Treatment
• No cure for concussion, but treatment can help the person feel better and function better while symptomatic
• Early diagnosis and education is critical, and can improve outcome
• Rest early (7-10 days?) and then gradually increase activity
Treatment Strategy
• Education and reassurance• Medications for sleep, headache, etc.• Physical & Occupational Therapy
• Neck & back problems• Balance (fall prevention)• Vision and Cognition
• Neuropsychological Testing
Academic Accommodations
• Out of school if necessary• Communicate!• Limit study time• Possibly hold on testing
Stress Fractures
• Overuse from attempted skill over and over again
• Usually insidious onset
• Most common location is long bones of the feet
Pecina, Stress Fractures in Figure Skaters. AJSM 1990
Stress Fracture Treatment
• Unload the affected area
• Pain is a helpful guide• What can the skater
do while he/she heals?
Stress Fracture Prevention• Listen to your body for warning signs• Ensure good bone health
– Sufficient Vitamin D– Calcium– Energy balance
• Increase activity by <10%/week• Jump counts?• Biomechanics
Asthma in Figure Skating
• 1/3 – ½ of all figure skaters suffer from exercise induced bronchospasm
• Symptoms exacerbated by cold, dry air, and chemicals
• Skaters may present with chronic cough, decreased aerobic capacity or wheezing
McFadden E and Gilbert I. N Engl J Med 1994;330:1362-1367
Effect of the Interaction between the Intensity of Exercise and the Thermal Environment on the Pulmonary Mechanical Response
EIB Treatment- Non pharmacologic
• Increase physical fitness• Warm up for at least 10 minutes at sub-threshold level (60-70%
VO2max) before exercise begins (refractory period)• Cover mouth and nose with a scarf or mask (balaclava) during cold
weather• Exercise short bouts in warm, humidified environment• Avoid aeroallergens and pollutants• Cool down or gradually lower the intensity of exercise before
stopping• Wait at least 2 hours after a meal before exercising• Low salt diet?, Fish Oil Supplementation?
Tan and Spector, Exercise-Induced Asthma, Sports Med. 1998;25(1):1-6
EIB Treatment-pharmacologic• Inhaled beta 2
agonists• Inhaled
corticosteroids• Inhaled cromolyn• Inhaled nedocromil• Inhaled ipatropium• Oral leukotriene
agonist
Not All Shortness of Breath is Asthma
• Exercise Induced Brochospasm• Vocal Cord Dysfunction/Paradoxical Vocal Cord Motion• Asthma• Lack of Fitness• Bronchitis/URI• Anemia• Reflux• Panic Attack• Overtraining syndrome• Cardiac abnormalities