In every major sport at the professional, collegiate, and youth levels, a great deal of attention is paid to the cardiovascular screening and the management of both the medical and orthopedic history of athletes. There is a wealth of published studies documenting the standards of care for the screening and care of collegiate and professional athletes. Each of the professional sporting organizations as well as the National Collegiate Athletic Association (NCAA) have developed specific guidelines with regard to various medical issues such as cardiovascular screening, management of exertional heat illness, and diagnosis and management of mild traumatic brain injury (MTBI) for their athletes. While the expectations with regard to the timeliness and high-quality health care provided to college and professional athletes continue to evolve, what is being done to care for the umpires, officials, and referees?
The prevention, evaluation, diagnosis, and treatment of sports-related injuries in athletes has been examined extensively in the medical literature, but there is a paucity of information published regarding the medical care of umpires, officials, and referees. Despite several case reports of myocardial infarctions in collegiate football referees and the death of a Major League Baseball (MLB) umpire, there are few published studies in the medical literature addressing this population. The purpose of this article is to emphasize the importance of a thorough preparticipation examination for each official, umpire, and referee annually as is the standard of care for athletes and furthermore to provide a rationale for the types of screening that should be considered for this population based on their risk factors and injury risk.
Are sports officials athletes? Casual sports fans hardly notice sports officials unless they make a call that they do not agree with, but if you observe this distinctive population work, it becomes readily apparent that most sports officials are very athletic and their jobs can be just as physically and psychologically demanding as the players that share the field. There are several studies that demonstrate these demands. In a study published in the American Journal of Sports Medicine in 2004, Weston et al. (5) examined the demands of soccer refereeing. By imposing an appropriate high-intensity load on soccer referees over 16 months of training, the referees improved their fitness level by 46.5%, a level that is comparable with professional soccer players. In a study published in the Physician and Sportsmedicine in 2003, Turner et al. (4), from the Indiana University School of Medicine, screened the health of football officials working in the Southeastern Conference from 1997 to 2000. Initial screening of 102 football officials revealed that 10.1% had elevated systolic blood pressure, 13.9% had elevated diastolic blood pressure, and 3.8% had resting tachycardia. The average body mass index (BMI) was 28.6 kg·m−2, and 87.3% of the officials had a BMI that exceeded 25, meeting the criteria for overweight. Furthermore, one third had a BMI greater than 30, meeting the criteria for obesity. Total fasting cholesterol exceeded 200 mg·dL−1 in 44.2%, and low-density lipoprotein levels were above 120 mg·dL−1 in 62.3%. During the study, 70 officials (72%) underwent exercise treadmill testing, 51.4% were abnormal, requiring further work-up and treatment. Compared with age-adjusted national data, there were more overweight and obese officials compared with the general population. With the use of the Framingham study prediction model to estimate coronary heart disease (CHD) risk, analysis revealed that officials had a lower risk than the average national 10-year CHD risk but a higher risk compared with that of the low-risk population.
Considering the few studies in the medical literature and from our personal experience caring for umpires, sports medicine providers covering athletic events should consider several facts. While the physical and psychological demands vary for each official depending on their sport, they certainly can be sufficient enough to place any sports official at high risk for cardiovascular accidents. Additionally the lifestyle of full-time sports officials makes it difficult to control cardiac risk factors like obesity, hypercholesterolemia, and hypertension. From the study of Southeastern Conference football officials, it is apparent that sports officials have increased significant risk factors for the development of cardiovascular disease, which may warrant further evaluation for CHD as part of their preparticipation physical examination.
When sports medicine specialists perform cardiovascular screening for athletes, typically the emphasis is on screening for causes of sudden cardiac death, including hypertrophic cardiomyopathy, long QT syndrome, and anomalous coronary arteries (1). The American Heart Association (AHA) has reaffirmed recently its long-held position on preparticipation screening for cardiovascular abnormalities in competitive athletes (3). The AHA suggests that ECG screening for younger athletes is not warranted as a component of preparticipation evaluations unless specific observations in the history or physical examination exist that trigger a more extensive cardiovascular evaluation. Any positive signs or symptoms from the history and physical examination should be worked up aggressively utilizing ECG, echocardiography, and/or exercise treadmill testing. It is accepted generally that blanket screening for sudden cardiac death with ECG or echocardiogram is not cost effective. High school and youth sports officials typically are young and should be screened for cardiovascular disease according to the same guidelines as athletes in their age group. Collegiate and professional officials typically are an older population. Given the physical and psychological demands placed on them, their increased age, BMI, and risk factors for coronary artery disease (CAD), the cardiovascular screening of this group clearly should be more complete. According to the American College of Cardiology/AHA guidelines published in 2002 (2), most college and professional sports officials fall into a risk stratification category for which exercise treadmill testing would be recommended as part of their preemployment physical examination. Additionally the current American College of Sports Medicine guidelines are used to determine which individuals should receive a diagnostic exercise test before participation in vigorous exercise (above 60% of maximal oxygen consumption). The current guidelines recommend that all men over 40 years and women over 50 years of age, as well as younger individuals with two or more coronary risk factors, be classified at increased risk. It is unclear if this is the current practice, especially with regard to collegiate athletics.
Due in part to the attention placed on MTBI by the lay press over the past couple of years, there is currently a great deal of scrutiny with regard to the diagnosis, management, and return-to-play decisions for MTBI for athletes in all sports and at all levels of athletic participation. This should be also true for sports officials. Baseball and softball umpires are somewhat unique in this regard because their position as the home plate umpire places them at high risk for head trauma. Our experience is that 5% to 10% of MLB umpires sustain a concussion during any given season. Therefore, in MLB, the video replay of every head blow to an umpire is clipped and sent for review to the certified athletic trainer and sports medicine consultant. Every umpire who sustains a head blow or is involved in an incident, which could cause an MTBI, is interviewed by phone the day of injury and the following day for any signs or symptoms of MTBI. A qualified physician formally evaluates all positive responses, and return-to-play decisions are made with the assistance of neurocognitive and balance testing. The MLB sports medicine team began utilizing neurocognitive testing of umpires in 2001, but over a decade later, softball and baseball umpires at other levels may not be managed with this same scrutiny and level of attention to detail to ensure proper diagnosis and treatment of head injuries.
Due to the risk of MTBI in sports officials and the current standard of care regarding this injury, sports officials of other high-risk sports should not be only educated with regard to the signs and symptoms of MTBI but should undergo also baseline neurocognitive and balance testing and postinjury neurocognitive and balance testing in order to assist clinicians in making return-to-play decisions. Both neurocognitive and balance testing provide objective data useful to aid physicians in making return-to-play decisions.
On opening day, April 1, 1996, the Cincinnati Reds hosted the Montreal Expos. Seven pitches into the game, John McSherry, the 51-year old home plate umpire, staggered away from home plate and collapsed face down. He died immediately of a massive heart attack and officially was pronounced dead an hour later at a local hospital. This widely publicized tragedy illuminated a growing health care concern in collegiate and professional sport. Since that time, many significant changes have occurred resulting in a dramatic improvement in the health care provided to professional umpires. Currently, MLB umpires undergo an annual preparticipation physical examination that includes a complete medical and orthopedic examination, visual acuity and ocular examination, complete blood count (CBC), comprehensive metabolic panel, fasting lipid panel, and ECG. Baseline ECGs are utilized in this population to screen for undiagnosed CAD not as a means of screening for causes of sudden cardiac death as would be the case for younger athletes. All umpires without cardiac risk factors still undergo a modified Bruce protocol exercise treadmill test in order to asses cardiovascular fitness, and all umpires with CAD risk factors undergo a nuclear exercise treadmill test as a screen for cardiovascular disease and fitness determination every 1 to 3 years. CBCs and comprehensive metabolic panels are not routinely ordered for screening in younger athletes during preparticipation physical examinations unless there is a concern for a specific diagnosis. The annual physical examination also includes on-field functional testing and baseline neurocognitive and balance testing due to the high prevalence of MTBI. MLB employs a full-time certified athletic trainer who monitors and coordinates all medical and orthopedic care provided to the umpires. All medical and orthopedic care is provided by a board-certified internist/sports medicine specialist and a network of medical and orthopedic providers around the country.
National Basketball Association
The 64 (one female) full-time National Basketball Association (NBA) officials are required to complete an annual physical examination that is composed of a general orthopedic examination, baseline ECG, chest x-ray, CBC, basic metabolic panel, fasting lipid panel, urinalysis, and drug testing. The average age of NBA officials is 43 to 44 years old. For the purpose of cardiovascular screening and determining fitness, each official undergoes a modified Bruce stress test annually. NBA officials also are required to weigh in two additional times per year, although they do not have rigid BMI criteria, which must be met. The NBA uses the standards set by the United States Army as a guideline for their weigh-ins. The NBA has a full-time certified athletic trainer who monitors all medical and orthopedic issues throughout the season. He or she utilizes a national database of consulting physicians who provide the officials care for injuries and illness that occur during the season and the off season.
Umpires, referees, and sports officials deserve the same attention by the sports medicine community as the athletes with whom they share the field. Their employment puts them at risk for a constellation of medical, psychological, and orthopedic problems that should be understood and appreciated by those who provide care for them, as well as by all sports medicine specialists who cover sporting events. At the professional level, although the types of care are very different, the same level of care is provided to the officials that are provided to players. At the collegiate level, care provided to officials varies by conference and sport. Clearly more attention and research are needed for the care of this population of athletes. We propose that preparticipation screening and in-season medical and orthopedic evaluation should be just as rigorous for all officials as it is for athletes, especially in light of their increased cardiovascular risk and higher incidence of medical and orthopedic conditions.
The authors declare no conflict of interest and do not have any financial disclosures.
1. Maron BJ, Zipes DP, Ackerman MJ, et al.. 36th Bethesda Conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. J. Am. Coll. Cardiol. 2005; 45: 1313–5.
2. Gibbons RJ, Balady GJ, Bricker JT, et al.. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2002; 106: 1883–92.
3. Maron BJ, Thompson PD, Ackerman MJ, et al.. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115: 1643–455.
4. Turner JL, Walters R, Leski MJ, et al.. Preparticipation screening of athletic officials — SEC football referees at risk. Phys. Sportsmed. 2003; 31: 43–9.
5. Weston M, Helsesn W, MacMahon C, Kirkendall D. The impact of specific high-intensity training sessions on football referees’ fitness levels. Am. J. Sports Med. 2004; 32 (1 suppl): 54S–61S.