According to the U.S. Centers for Disease Control and Prevention's (CDC) most recent available data, during the 2005-2006 school year, an estimated 4.2 million students in the United States participated in the nine high school sports studied. Of these participants, there were approximately 1.4 million injuries, 80% of which were new injuries (25). The need for appropriate and efficient sideline management is crucial. Additionally, one of the most challenging areas of sideline sports medicine, especially without the benefit of imaging, is determining when an athlete can return to play safely, There is very little existing research on sideline management. Using the available research and medical experience, this article offers several approaches to treating injured athletes and allowing them back on the field without aggravating the presenting injury or placing them at greater risk for sustaining another injury.
BASICS OF INJURY ASSESSMENT
When evaluating any injured athlete, a diagnostic plan of "ABCDE" (airway, breathing, circulation, disability, evaluation/extremity) should be the starting point. After ruling out any immediate danger with the airway, breathing, and circulatory system, attention should be directed toward any significant brain or neck injury by examining and questioning the athlete appropriately. Neck and spine injuries will be addressed in more detail later in this article. If any problems with the airway, respiratory, circulatory, or central nervous systems are suspected, then appropriate stabilization and emergency transport should be implemented. Once any life-threatening injuries have been addressed, attention should be turned to the evaluation of extremities (10).
Neurovascular status is the initial and most important step in evaluating an injured extremity. This is performed by checking for distal sensation, motor function, and pulses in the affected extremity. If there is evidence of neurovascular compromise, immediate and appropriate steps should be followed. One on-the-field attempt to restore neurovascular status to the compromised extremity is reasonable and encouraged. Multiple attempts should not be performed unless emergency transport to the appropriate facility is unavailable for a substantial amount of time. Distal pulses always should be assessed before and after each manipulation. Keep in mind that there are certain injuries that are higher risk for neurovascular compromise, for example, femur fractures, open fractures, pelvic fractures, and major joint dislocations (specific neurovascular injuries with joint dislocations to be discussed later) (9,10). Other indications for on-field joint reductions include the preservation of skin, pain reduction, and ease of splinting for transportation. However, this only should be performed by an appropriately trained provider who understands anatomy, mechanisms of injury, and potential complications of reducing fractures or dislocations. Recall that fractures are associated more commonly with joint dislocations among individuals who are skeletally immature and older athletes (11). This is a crucial consideration before trying to reduce any on-the-field joint dislocations due to the increased risk of further displacing undiagnosed fracture or compromising an athlete's neurovascular status (9). In the patient who is skeletally immature, sports medicine professionals should err on the side of caution when evaluating on-the-field bone and joint injuries. Simply stated, if sideline providers have any doubts about an injury in an athlete who is skeletally immature, they should assume there is a fracture or fractures and avoid any attempt to reduce this injured joint before imaging is performed, unless there is evidence of neurovascular compromise. If neurovascular compromise is noted upon exam, one reduction should be performed before stabilization and transport, in an attempt to restore the athlete's neurovascular status (11).
Most bone and joint injuries are nonemergent and can be managed on the sideline without the need for urgent transport or imaging. After determining that an injury is nonemergent, the next important and difficult decision is to determine whether an athlete can safely return to play or should be withheld from play. For the most part, there are no set return-to-play guidelines and few or no articles about the sideline management of nonemergent bone or joint injuries. However, there are a few guidelines designed for determining the need for imaging in acute musculoskeletal injuries that may be implemented on the sideline, such as the Ottawa ankle, Ottawa knee, Pittsburgh knee, and Canadian C-spine rules (Table; Figs. 1 and 2). Even though these rules are not applied consistently, they have been well established as being highly sensitive in diagnosing fractures and reducing health care costs (18).
In addition to these imaging guidelines, there are other basic suggestions that may be helpful to determine whether athletes should return to play. Athletes should be held out of participation if 1) they have sustained injuries to joints that significantly affect their range of motion, 2) they have obvious crepitus, focal pain deformity, or step-off, indicating a long bone fracture, 3) they have significant joint instability, 4) they have inability to bear weight, 5) they do not wish to continue, or 6) they have the inability to perform the basic activity level needed for their specific sport and position (10). Injured athletes who do not meet any of these criteria may be cleared to play. For example, if a basketball player injures his or her ankle in the first half of a game and cannot immediately return to play secondary to pain, then a period of rest, such as halftime, icing, and/or taping can be used before removing that athlete permanently from the game. After this period of rest and treatment, another examination should be performed. Upon determining that there is no obvious fracture and the player wants to play, the player must pass a functional progression test. An example of a functional progression test is to have the player first run straight and lazy figure of eights, then have him or her increase speed and cutting ability. Essentially, a provider is trying to simulate a game environment. If the player can perform these functions with minimal discomfort and effort, then the player is eligible to return to the game. However, sports medicine providers may need to explain to the athlete, coaches, and/or parents that there are still inherent risks for returning to play after sustaining an injury, such as re-injury or a significant decline from previous performance (10).
Another sideline tool that may be helpful in assessing fractures is a tuning fork. Tuning forks have been used in the office setting for aiding the diagnosis of early tibial stress fractures with negative x-rays (15). A recent article in an emergency medicine journal suggests that the additional use of tuning fork testing of "Ottawa positive" patients could lead to a marked reduction in ankle radiographs. The list of the Ottawa ankle rules are listed in the Table. The tuning fork was somewhat sensitive in diagnosing ankle fractures, but not very specific. However, a negative tuning fork test would not completely rule out a fracture, but it could help in the assessment of certain suspected fractures (6). For example, a positive tuning fork test on an injured athlete who can pass a functional progression test would not be strong enough evidence to hold the athlete from returning to the field of play.
Other important factors to consider when assessing injuries at an event are to understand and be prepared for the sideline dynamics and logistics, such as having the appropriate equipment (e.g., medical bags, facemask removal equipment, medications), privacy issues, and medical support (e.g., emergency transport, athletic trainers). In addition, most sporting events are public events with many confounding influences, such as parents, fans, and coaches (24). Therefore, having the appropriate attitude and approach toward the athletes is important - always consider the importance of the game to the athlete, but not the importance of the athlete to the game. Don't be a fan or a coach - make medical decisions based purely upon the best interest of the athlete (16).
As many sideline providers have experienced, the evaluation of spinal injuries can be one of the most challenging bone and joint injuries, with potentially life-threatening and debilitating outcomes. Approximately 8.7% of all new cases of spinal cord injuries are related to sports activities, such as football, ice hockey, wrestling, diving, skiing, snowboarding, rugby, and cheerleading (3). Permanent spinal cord injuries are more likely to occur from cervical spinal injuries than from thoracic or lumbar injuries. Unstable fractures and dislocations are the most frequent causes of catastrophic cervical spine injuries in sports. Most of these injuries occur at the lower cervical spine level, mainly at C5-C6 level. The mechanism of injury typically results from an axial force to the top of the head with neck slightly flexed (4).
How does a sports medicine provider perform an on-the-field evaluation of an athlete with suspected spinal injury? Most importantly, for any unconscious athlete or witnessed mechanism of injury suggesting an axial load and/or concurrent concussion, a cervical spine injury should be considered, and c-spine immobilization is required until a serious cervical spine injury is excluded. In addition, the presence of significant cervical and upper thoracic spinal process pain, severe focal spinal muscle tenderness at the cervical level, and restricted neck motion upon physical examination may indicate structural injury to the vertebral body and increased risk for severe cervical spine injury. Transient quadriparesis and/or any neurological findings in bilateral extremities may be a strong indication that a serious cervical spine injury has occurred (5). Also, as previously mentioned, Canadian c-spine rules (CCR) may be helpful in determining the need for cervical spine x-rays in an alert (Glasgow Coma Scale score of 15) and stable athlete (Fig. 1). CCR has been determined to be highly sensitive in detecting cervical spinal injuries (26). However, the limitation of the CCR is the fact that the majority of sports-related mechanisms of injury could be considered dangerous mechanisms (force equal to or greater than falling from a height >3 ft), which would require imaging for most suspected spinal injuries in sports. Thus personal clinical judgment and experience still plays a vital role in assessing sideline spinal injuries, keeping in mind that if a serious spinal injury is ever suspected, appropriate stabilization and transportation for definitive care should be implemented.
Shoulder injuries are very common in sports. Without the benefit of imaging, it is important to understand the basic mechanism, evaluation, and treatment of common shoulder injuries. The shoulder is the most commonly traumatically dislocated major joint, and of these, the majority are anterior shoulder dislocations. The mechanism of injury typically is associated with forced abduction and external rotation of the arm. Often the shoulder will need to be exposed, by removing a shirt, jersey, and/or pads. One technique for determining a shoulder dislocation without removing football pads is to feel under the pads for a displaced humeral head (anteriorly or inferiorly). If there is no obvious deformity, have the athlete attempt to touch his or her opposite shoulder. If he or she can do so, it is unlikely there is a dislocation; if he or she cannot, shoulder dislocation is a strong possibility, because athletes with anterior shoulder dislocations cannot perform internal rotation (17). If the diagnosis of shoulder dislocation is still uncertain and the athlete continues to have significant pain or deformity, then the athlete should be placed in an arm sling and transported for imaging and definitive treatment. If a shoulder dislocation is strongly suspected, an appropriate reduction should be attempted in a timely manner (9). For all primary anterior shoulder dislocations, athletes should be withheld from competition for that game. Remember that neurovascular injuries are rare but possible with anterior shoulder dislocations, most commonly injuring the axillary nerve and less commonly injuring the musculocutaneous nerve and axillary artery (12,17). For athletes who have had recurrent dislocations or subluxations, most experts agree that return to competition is allowed when nearly full motion and strength have returned and the athlete can perform in sports-specific activities (13). However, these athletes should understand the increased risks of worsening instability and glenohumeral arthritis that may occur with recurrent dislocations (8).
Acromioclavicular (AC) joint dislocations also are common sports injuries and are difficult to differentiate from distal clavicle fractures. AC joint separations can occur from a direct blow to the shoulder or fall on an outstretched hand (FOOSH). There will be tenderness to palpation over the AC joint and may or may not show an obvious deformity. In addition, the athlete will have pain with resisted adduction. For the athlete to safely return to play, he or she must have full range of motion and strength (24). In the appropriate situations, padding can be used to protect the joint before the athlete returns to play (10).
Elbow injuries also are common and include posterior elbow dislocations and fractures, as well as a variety of soft tissue injuries. FOOSH, direct blow, hyperextension, and valgus stresses are common mechanisms for elbow injuries. Excluding an obvious elbow dislocation, crepitus, deformity, or step-off upon examination, many athletes with soft tissue elbow injuries can return to play during the same event. Therefore, it is important to understand the mechanism of injury and perform a thorough history and physical examination. Range of motion, tenderness, and strength are vital to the evaluation of elbow injuries on the sideline. Several questions need to be answered and addressed. Does the athlete have full range of motion and strength? Is the injury affecting his or her dominant or non-dominant side? Most importantly, does the athlete want to return, and can he or she perform the specific sport activity? All athletes with elbow dislocations and suspected fractures must be withheld from competition, placed in long arm posterior splints, and transported for appropriate imaging and treatment. For suspected elbow dislocations (90% of which are posterior or posterolateral displacement of the forearm relative to the humerus), onsite reduction would be prudent to reduce pain and ease transport and splinting. If bony crepitus is noted, indicating a possible fracture, then sideline reduction should be avoided unless there is evidence of neurovascular compromise (9,24). Brachial artery, transient median and ulnar injuries have been reported with posterior elbow dislocations (17).
Wrist and hand injuries can be assessed in a similar manner to elbow injuries - the previously listed questions will need to be answered. Many times, these injuries are overlooked or downplayed because the hand and wrist can heal well with minimal attention. To avoid suboptimal healing and long-term disability, it is important to take wrist and hand injuries seriously and take a systematic approach to each injury (14). When evaluating a wrist injury, attention should be placed on bony tenderness, especially snuffbox tenderness, crepitus, local swelling, and obvious deformity, as well as functional status, for example, can the running back grip and hold a football? If a wrist fracture is not suspected, the athlete wants to play, and he or she can perform his or her particular sport-specific function, then the athlete can return to play (20). Hand and finger injuries account for 9% of all sports injuries because they are the most active portion of the upper extremity and the least protected. Again, athletes with suspected fractures should be withheld from play until appropriate x-rays can be obtained. Interphalangeal joint (IP) dislocations, collateral ligament sprains of IP joints, and mallet fingers typically can be reduced on the sideline and protected by buddy taping if the athlete wants to return to play. In cases of Jersey fingers, ulnar collateral ligament sprains, and metacarpophalangeal dislocations, return is not advised (19,21).
When evaluating lower extremity injuries, the most important question is: can the athlete weight bear? An athlete unable to weight bear obviously increases the likelihood of a long bone fracture. However, the ability to fully or partially weight bear does not exclude all fractures, such as microfractures or fibular fractures.
Hip injuries are the least common of sports injuries, but they can be significant and debilitating. Sideline assessment of hip injuries is straightforward. Major fractures of pelvis, hip, or femur, as well as hip dislocations, typically are not subtle. These usually are apparent and need to be transported emergently to the appropriate care. Most other injuries including avulsion fractures, muscle sprains, and contusions should be assessed on the sideline - if the athlete can function appropriately, then the athlete can be cleared (1). The treatment of suspected quadriceps contusions also is important. Immediate icing and placement of the knee in a flexed position significantly can reduce hematoma formation and long-term disability (24).
Knee injuries commonly are observed in athletics. Understanding the mechanism of injury and obtaining a thorough history are vital in evaluating the severity of injury. Most major knee injuries, including knee dislocations, patellar dislocations, fractures, and major ligament tears, as with hip injuries, are not subtle. Return to play usually is out of the question. Remember to check for distal pulses and neurological function with any major knee injury (20%-40% of all knee dislocations have popliteal artery disruption and/or common peroneal nerve injury) (22). Knee dislocations are uncommon, but commonly are misdiagnosed secondary to the spontaneous relocation of the knee and the frequency of patellar dislocations. However, the consequences of misdiagnosing these injuries have long-term consequences, such as permanent nerve damage, chronic instability, and possible amputation (22).
For most other knee injuries, such as non-displaced mensical tears, grade 1 ligament injuries, and knee contusions, a systematic evaluation should be used. As previously mentioned, there also are Ottawa and Pittsburgh knee rules that can be helpful in answering return-to-play questions and the need for immediate radiographs (Fig. 2). In a review article, Pittsburgh knee rules were found to be equally sensitive and more specific than the Ottawa knee rules (23). For athletes to return to play, the injured athletes must have full range of motion of the knee, nonsignificant swelling, weight-bearing ability, and the ability to play their specific sport position. For example, a running back with a suspected grade 1 medial collateral knee sprain must be able to run full speed, plant, and cut with the injured side (7).
Ankle and foot injuries also are experienced frequently in sports - in some reports, lateral ankle sprains account for up to 45% of all injuries (27). The approach to these injuries is similar to other lower extremity injuries. The mechanism of injury, range of motion, bony tenderness, swelling, and weight-bearing ability are important in examining the foot and ankle of an injured athlete. Using the Ottawa ankle rules (Table) along with a tuning fork, as described previously, also can be helpful in evaluating for sideline ankle fractures. It is important to understand how to diagnose two commonly misdiagnosed injuries that require athletes to be withheld from play - syndesmotic ankle sprains and midfoot (lisfranc) sprains. Most athletes who have experienced a syndesmotic ankle sprain most likely will be unable to weight bear, have increased pain with ankle dorisflexion and exertional rotation, tenderness over the anterior syndesmosis ligament, and/or a positive Squeeze test. However, there may be minimal swelling of the ankle as compared with lateral ankle sprains and fractures (27). For lisfranc sprains, athletes will tend to have trouble performing single toe raises, weight-bearing, and/or cutting maneuvers. Pain typically is out of proportion to the exam findings. Once an ankle or foot fracture, lisfranc, or syndesmotic sprain has been effectively ruled out, an assessment of the injured athlete's ability to return to play can be performed as previously discussed with other joints. Simply stated, if the athlete can weight bear and pass a functional progression test, then the athlete can return to play. The use of taping, padding, and bracing may be helpful in allowing an athlete with soft-tissue ankle and foot sprains to return to play (27).
The sideline management of sports injuries is extremely complex and challenging for sports medicine providers. It requires prompt assessment of neurovascular and functional status by the sideline provider. Because of the complexity and variety of sideline injuries and lack of sideline imaging, more research is needed to develop useful guidelines and tools that could aid sports medicine professionals in assessing these injuries, such as the tuning fork, Ottawa ankle, and Pittsburgh knee rules. With the further development of useful and evidence-based sideline tools and guidelines, sports medicine providers would have greater ability to assess injured athletes and in turn, allow their safe and quick return to play.
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