Newswise — The start of a new school year in the Keystone State typically means a new Pennsylvania Interscholastic Athletic Association (PIAA) fall sports season is here. With plenty of energy after a summer of training, student-athletes and coaches are eager to hit the fields and courts for official practices, while fans start to make plans for Friday Night Lights.
The fall months are an exciting time for those who enjoy sports whether you’re a football, soccer, tennis, golf, volleyball, or cross country student-athlete, parent, or fan. There’s so much to look forward to.
Of course, there are always concerns too. Concussions happen. Bones break. ACLs tear. And on a very rare occasion an athlete has an issue with their heart.
To help ease some of these concerns, Pennsylvania state law – strongly supported by Pennsylvania physicians – requires all high school coaches pass tests related to concussion management and sudden cardiac arrest. And leading up to each season – fall, winter, and spring – coaches across Pennsylvania prepare themselves for the worst through mandatory online education on these subjects.
Ethan Blum is a rising lacrosse star at Carlisle High School. During his 9th Grade season last spring, Blum played in nearly every junior varsity game and was one of its top scorers. He even earned some varsity time on Carlisle’s PIAA District III Championship squad.
But, he did miss two games during his first year of high school sports as an early season hit to his head resulted in a concussion.
For Blum, who excels in the classroom, it was difficult taking time off just as his high school career was starting. But, following protocol directed by state law, he did. And it didn’t take long for him to return to action when his brain was ready.
For Blum, his journey to recovery started when a coach recognized the signs that he may have experienced a concussion. Immediately he was sent to an athletic trainer, and not long after that a physician.
“I had to completely shut down my brain to recover,” Blum said. “That meant no lacrosse, no school, no tv, and no video games.”
William C. Welch, MD, president of the Pennsylvania Neurosurgical Society, says Blum’s story is classic when it comes to how concussions happen in sports, and he’s glad the state law that was followed helped in the recovery process.
“There’s a greater awareness of concussions today than there were years ago,” says Dr. Welch, a practicing neurosurgeon at the University of Pennsylvania. “State law has raised the awareness level, and when someone has their ‘bell rung’ there seems to be more caution.”
Dr. Welch says that a concussion is a traumatic brain injury that can be caused by a blow to the head or body or possibly even a fall. Essentially what happens is that the impact jars the brain inside the skull.
“Most people associate a big hit with a concussion, but it doesn’t have to be,” says Bruce MacLeod, MD, president of the Pennsylvania Medical Society (PAMED), which lobbied in favor of the new law. “Soccer players ‘heading’ the ball have been known to develop concussions. All it really takes is the brain shaking around inside a person’s head.”
Symptoms can vary, and may not be the same from patient to patient. But in general, there are some common signs that coaches are trained to investigate during a practice or game. These include problems thinking or remembering, headaches or dizziness, nausea or vomiting, and an athlete feeling tired. Outside a practice or game, the student-athlete may see changes in their sleep patterns or have a change in their emotions. Parent-coach communications is important in the latter symptoms.
The state law has several parts. The most important section of the law is likely the mandatory online training course that each coach must complete every year. The course, titled “Concussion in Sports – What You Need To Know” and provided by the National Federation of State High School Associations, walks a coach through the science behind concussions and trains them to recognize the symptoms. Coaches are taught “when in doubt, sit them out.”
But the state law goes beyond just education. The law also provides guidance on the steps that must be taken for a student-athlete to return to competition. In a nutshell, the coach is not permitted to return a player to participation until the athlete is evaluated and cleared for return in writing by an appropriate medical professional. Specifically, the medical professional must be a licensed physician, certified health care professional, or psychologist trained in the evaluation and management of concussions.
Coaches who do not comply face harsh penalties. A first violation requires suspension for the rest of the season. Second violation adds a suspension for the next season, while a third violation is a permanent suspension from coaching.
In Blum’s case, before returning to his sport, he was required to pass progressive sport-specific challenges such as running to see how his brain would react. He passed the challenges, and after about 10 days out of play was cleared to participate again.
Sudden Cardiac Arrest
Ask any Pennsylvania basketball fan about athletes that have collapsed due to sudden cardiac arrest (SCA) and they’ll instantly mention Hank Gathers, a Dobbins Technical High School star from Philadelphia who died on the basketball court while playing for Loyola-Marymount University in 1990.
Gathers was a promising basketball star. After leading Dobbins Tech to the Public City League Championship, he continued his playing days at the University of Southern California before transferring to LMU. During his senior season at LMU, he was a candidate for player of the year and was projected to be an NBA lottery pick.
Gathers had hypertrophic cardiomyopathy, a disorder in which the heart muscle becomes abnormally thick and the leading cause of sudden cardiac arrest in young athletes.
Gathers may be the most commonly remembered athlete with SCA, but he isn’t the only student-athlete that has collapsed with SCA.
While stating it is not certain sudden cardiac death is more common in athletes, a 2012 study published in Circulation, the Journal of the American Heart Association, says on average one competitive athlete will experience sudden cardiac arrest every three days in the United States. The study also says that it “is clear that vigorous exertion transiently increases the risk of sudden cardiac death in individuals with cardiovascular disease.”
“It’s a tragedy when an athlete, especially young athletes, suffer sudden cardiac arrest,” says Matthew Martinez, MD, FACC, of the Pennsylvania Chapter of the American College of Cardiology who practices sports cardiology with the Lehigh Valley Network in Allentown. “Pennsylvania has taken appropriate steps through state laws that attempt to build awareness of the issue and protection for athletes through high school coaches, but there is more work to do.”
In May 2012, Pennsylvania Gov. Tom Corbett signed House Bill 1610, which became the Sudden Cardiac Arrest Prevention Act or Act 59. The bill had overwhelming support in both chambers of the Pennsylvania legislature.
Like the concussion law, the Sudden Cardiac Arrest Prevention Act requires coaches, parents and athletes to receive education on SCA on a yearly basis. It also establishes protocol for removal from play as well as return to play after being cleared by a licensed physician or certified nurse practitioner. And, penalties exist to address coaches who do not follow these protocols.
“There’s a lot of pressure on coaches to win and many athletes and their families have dreams of athletic scholarships to college,” said PAMED’s Dr. MacLeod. “It’s tempting to play an athlete because of that pressure. The way this law is designed, it takes that pressure off the coaches back while building greater awareness of sudden cardiac arrest.”
In terms of education, Pennsylvania coaches may receive their training through an online course called CardiacWise. During this course, coaches learn about the causes of sudden cardiac arrests in athletes as well as the signs and symptoms.
Dr. Martinez points out that sudden cardiac arrest doesn’t always happen because of disease like what happened to Gathers. In sports like baseball, a misplaced pitch that hits a batter in the chest can also cause a lethal disruption of the heart’s rhythm. When this happens, it is called Commotio Cordis.
“The heart is essentially a timing mechanism,” says Dr. Martinez. “Each heart beat has different phases, and there is a very small window in the timing in which the heart’s rhythm is vulnerable if struck. While rare, situations have arisen in sports like baseball, softball, lacrosse, and martial arts.”
Dr. Martinez suggests that during practices and competitions – whether youth, high school, or adult – that an automated external defibrillator (AED) be available on the sideline and that all coaches and trainers understand when and how to use it.
State laws don’t cover everything say pediatricians, particularly ACL injuries
Physicians are quick to point out that within the sports world, there are many types of injuries that can occur, and state laws aren’t able to cover them all. Trainers, coaches, players, and parents need to pay close attention on the field to other potential health risks.
One such area of growing concern in recent years is anterior cruciate ligament (ACL) injuries.
According to an April 2014 study published in Pediatrics, the official journal of the American Academy of Pediatrics, the number of ACL injuries reported in athletes under the age of 18 has been increasing during the past two decades. One reason for this increase is because of intensive sports training at an earlier age.
“Because of hyper specialization, more children are becoming focused on a single sport at an earlier age,” says Josh Williamson, MD, FAAP, a pediatrician and sports medicine physician of the Pennsylvania Chapter of the American Academy of Pediatrics. “That’s not good for the overall development of the child.”
Dr. Williamson says that parents sometimes believe their child will have a better shot at getting a full-ride to college on an athletic scholarship and thus believe they must specialize at a very early age. But, he adds, that concept doesn’t hold true and they may be doing more harm than good.
“It’s best to diversify your child’s sports,” says Dr. Williamson. “They need overall development, and early specialization actually may lead to injuries and burnout.”
Reports from the American Medical Society for Sports Medicine support Dr. Williamson’s point. In a UCLA sports specialization study, 88 percent of NCAA Division I athletes at the school played two or three sports as children. The majority of those athletes did not specialize until after age 12.
Other studies point out that those who specialize too young may increase their risk to injuries.
With ACL injuries becoming more common, athletes playing certain sports may be at greater risk.
Pediatrics, quoting data from the National High School Sports-related Injury Surveillance Study, says the sports with the highest rate of ACL injuries for high school athletes are girls soccer, boys football, girls basketball, girls gymnastics, and boys lacrosse.
“The top two high school sports for ACL injuries – girls soccer and boys football – are fall sports in Pennsylvania,” says Dr. Williamson, who practices in Pottstown, Pa. “Research shows that neuromuscular training may help prevent some ACL injuries, so coaches and athletes should incorporate that type of training into their pre-season and season drills.”
Ophthalmologists share concerns about eye injuries
It’s important, says David Silbert, MD, board member of the Pennsylvania Academy of Ophthalmology and a pediatric ophthalmologist practicing in Lancaster, Pa., that rules about protective eyewear be enforced by referees and coaches. He adds that even in certain sports without such rules, parents should think about eye protection for their child.
“There are literally thousands of sports-related eye injuries in Pennsylvania every year,” he says. “Across the nation, some reports suggest more than 100,000 sports-related eye injuries occur on a yearly basis.”
Some of these injuries will lead to permanent loss of vision in an eye, Dr. Silbert adds.
Sports with flying projectiles often pose the greatest risk for an eye injury. While spring sports like baseball and softball tend to be eye-injury leaders, fall sports in Pennsylvania like girls field hockey and girls tennis also come with risk.
The smaller the ball, the greater the risk of direct eye injury as the ball more easily conforms to the shape of the bones around the eye. Softer balls such as tennis balls, racquet balls and squash balls can be particularly dangerous as their softness allows them to conform better to the orbit and transfer greater energy to the eye. Sports with sticks are a risk to the eyes, but even sports like soccer or basketball risk significant eye injury from direct contact with an opposing player’s finger, elbow, or foot. Impacts to the face and eye can cause direct vision loss but can also cause fractures of the bones around the eye, leading to intractable double vision which can’t always be fully remedied.
“Many sports have rules for eyewear, and that has made a difference,” says Dr. Silbert. “Probably the best rule to follow is to wear eye protection even if there’s no rule being enforced by officials. Athletes should protect their eyes from all types of injuries ranging from getting hit it the eye with a ball or stick to getting a piece of turf stuck in the eye.”
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This news release is brought to you by the Pennsylvania Health News Service Project, consisting of 18 Pennsylvania-based medical and specialty associations and societies. Members of PHNS include Pennsylvania Allergy & Asthma Association, Pennsylvania Academy of Dermatology & Dermatologic Surgery, Pennsylvania Academy of Ophthalmology, Pennsylvania Academy of Otolaryngology, Pennsylvania American Congress of Obstetricians and Gynecologists, Pennsylvania Chapter of the American College of Cardiology, Pennsylvania Chapter of the American College of Emergency Physicians, Pennsylvania Chapter of the American College of Physicians, Pennsylvania Chapter of the American Academy of Pediatrics, Pennsylvania Medical Society Alliance, Pennsylvania Medical Society, Pennsylvania Neurosurgical Society, Pennsylvania Psychiatric Society, Pennsylvania Society of Anesthesiologists, Pennsylvania Society of Gastroenterology, Pennsylvania Society of Oncology & Hematology, Robert H. Ivy Society of Plastic Surgeons, and Urological Association of Pennsylvania. Inquiries about PHNS can be directed to Chuck Moran via the Pennsylvania Medical Society at (717) 558-7820, firstname.lastname@example.org, or via Twitter @ChuckMoran7.