Athletic Health Care

Development Manual
Practice Guidelines
Policies and Procedures

John Gabriel, MA, ATC. LAT

Certified Athletic Trainer and
Licensed Athletic Trainer
2014
Previous Editions 1990, 1998, 2009, 2012
 Introduction

This manual was developed based on a publication of the American College Health Association, which
published its college nurse-directed health services manual in 1971. That manual was a cooperative
effort of the ACHA and the American Association of Community and Junior Colleges (AACJC). The
manual meet a need for a prototype model for college health services; as few colleges had a well
structured health care delivery system in place for their students. This manual was intended to assist
the certified athletic trainer working in educational institutions to structure and implement a sports
health care program for competitive athletes at their respective institutions.

Historically the National Athletic Trainer's Association has been comprised primarily of collegiate
athletic trainers, along with members working with professional sports teams. Over the last thirty years
the profession of athletic training has lead to the clinical athletic trainer gaining a more significant role
in the association. Currently, the number of clinical athletic trainers has surpassed the college athletic
trainers within the profession. With this change in primary practice environment has come a need for
expanding the roles and responsibilities of the athletic trainer. Licensure has compounded the need for
athletic trainers to get out of the "locker room" and into the model of a licensed health care provider.
Demands for increased recordkeeping and higher professional standards in general have lead to an
evolution in the profession of athletic trainers.

This manual is a logical step in that evolution. For many years the athletic trainer has been a health
quasi care provider often ignored by the mainstream of the health care community. Athletic trainers
operated at the edge of the athletic community, a second-class citizen; even within their own athletic
organisms. Although road blocks to professional recognition still exist, the current generation of
athletic trainers is creating dramatic changes in athletic health care providerhip in the United States
and even the world.

The traditional model of the athletic trainers as extensions of a team physician has been challenged by
the landscape of medical care in the United States today. As older physicians in many communities
have retired, the role of the team physician has been left unfilled by a new generation of medical
providers who are more comfortable in larger medical group practices and managed care
organizations. In addition, many older and well established health care institutions; such as hospitals,
have been absorbing medical practices within their organizations. More and more the athletic trainer
has been left to be the primary provider of athletic health care. To ignore these realities has been to
deny the participants the level of care they require and demand. There have been many changes in
student health care services, not to mention for the sports active population. Athletic trainers need to
be recognized as the focal point for athletic health care for student-athletes. This manual will outline
various aspects of athletic health care and the role of the certified athletic trainer in providing direction
to the care of the student-athlete.
 TABLE OF CONTENTS

Introduction

Basic Guide for Program Development

General Information Administrative Relationships
The Student Athletic Health care Program-Services and Activities
Overview of Services Immediate Care Services Hospitalization
Provisions for Urgent Care Health Records
Drug Screening and Testing Medications
Mental Health
Dental Health
Health and Wellness Educational Strategies
Environmental Health and Safety
Research
Communications
Community Resources
Quality Assurance
Athletic Trainer Certification Team Physician Certification
Health Personnel
Role of the Director\Head Athletic Trainer Role of the Staff Athletic Trainer
Role of the Physician
Role of Support Staff
Athletic Health care Facilities
Fiscal Management
Appendix
 Basic Guide for Program Development
General Information

The development of a well coordinated, effective athletic health care program requires an
understanding of the institution's mission and it's relationship to the student-athlete. Ideally,
there should be a comprehensive health service available to students, offering immediate care,
health counseling, referrals, and wellness education. When this is not possible the institution
should provide services that include access to local health care resources; including health
assessments and community referrals. A mechanism should exist for the education of the
student population as to what services are available and the complexities about obtaining
appropriate medical care. Good health, including social and mental adjustment as well as
physical well-being, is essential to learning and efficiency. This is especially true for the student-
athlete, who must meet the rigors of both an academic and a athletic life.

Every college is a community, and every community needs a plan for protecting its members
from injury and disease. As rates of communicable disease and injuries increase in the general
population, they also increase among the student population. Every campus should provide
education to all it's students and staff on immunization, self-care, and illness/injury prevention.
The need is especially critical for student-athletes who engage in strenuous physical activity
that makes them susceptible to various illnesses and injury. In addition, student-athletes
engage in long and extended travel and have contact with larger numbers of other individuals
at other institutions; which increases the risk of cross contaminations. This is compounded by
the physical nature of sports that allow for a greater opportunity for physical harm and injury.

There are differences between private and public, and commuter and residential colleges that
influence the types of general health care services provided to students. Athletic programs in
particular have had to use a variety of different approaches to providing health care to it's
athletic population. Colleges by their nature attract students with a variety of skills and medical
conditions. smaller institutions historically have attracted athletes based on enrollment needs
and have student-athletes with a range of skill level. studies have demonstrated that the lower
the skill level of the athlete the higher the probability of injury. In addition to boarder ranges of
skill, smaller institutions often do not have the resources to provide the best facilities,
equipment or coaching; further compounding the problem.

It is very difficult for student-athletes to access health care if they are residential students far
from home. Independent students are frequently not covered by insurance plans. Even
students under the coverage of a parent's or guardian's insurance may be in a managed care
arrangement and may not be familiar with how to access local health care that would be
eligible for benefits under their insurance plan. Many physician practices provide college
students medical care only though prepaid medical plans. This often leaves the uninsured or
underinsured with the expensive option of seeking care through hospital emergency rooms - or
not seeking care at all.
In 1991 the American Nurses Association proposed the community-based, nurse directed
health center for colleges as a cost effective solution to health care needs of students. The
National Athletic Trainer's Association has been a long-time promoter of the use of athletic
trainers to serve the needs of athletes. Arguments for athletic trainers often outline the cost
effectiveness of having a certified athletic trainer providing students athletic health care.
 Administrative Relationships

Responsibility for a comprehensive athletic health care program should be coordinated through
the college's athletic department or wellness resource center. Preferably the student health
center; if one exists, should be part of the coordination effort. The main areas of responsibility
include injury/illness assessment, urgent care, treatment of minor illnesses, coordination of
medical resources, health and fitness counseling, health education, and appropriate medical
referrals. The athletic health care program should operate independently, in an accessible
location where confidentiality can be maintained. There should be a certified athletic trainer as
the person appointed as director or administrative officer of the athletic health care program.
In many settings, the athletic director is assigned as the administrative position supervising
athletic health care; even though this individual is not knowledgeable about health delivery
systems. The athletic trainer becomes the defacto director. In athletic health care the certified
athletic trainer is the most appropriate for this position. It is advisable that a physician be
enlisted as a consultant. A large number of program have orthopedists acting in this capacity.
However, a family practice physician can provide a broader range of medical care, especially for
illnesses and diseases that might affect the athlete. If possible a part-time physician; through a
college health center, should be available.

The program director should be knowledgeable about trends in higher education and be aware
of the abundant educational opportunities a college can provide student-athletes. This should
include an understanding of health education as a mechanism for helping student-athletes to
develop healthier lifestyles, and avoid chemical and alcohol abuse.

Whenever possible, the director should have a full-time appointment. When professional
qualifications and responsibilities warrant, the director should have faculty or administrative
rank. All certified athletic trainers must pursue continuing education and resources should be
made available for these functions.

The director should have authority to make professional appointments and to establish athletic
health service functions and activities consistent with current standards of practice. Although
the lines of responsibility will vary with each institution, the director must be responsible to a
campus administrator concerned with the welfare of students and student life. Typically the
director of athletics is the immediate supervisor for athletic trainers. The director, athletic
director or head athletic trainer, should also have access to the highest decision-making and
budgetary planning levels of the institution. This is crucial to the operation of the athletic health
care program and permits visibility for health issues that are of concern to the college
community.

The director should have access to appropriate legal counsel and advice, particularly regarding
statutes and regulations concerning informed consent, confidentiality of communications and
records, reportable conditions, liability, drug regulations and risk management.
The director should prepare regular reports about the activities and services provided by the
athletic health care program. These reports should be circulated to all areas of the institution
concerned with the welfare of students and risk management. Means of communications
should be established with the coaching staff to promote the goals of athletic health care and
to provide another avenue for students and staff to learn about available services.
Communications with the coaching staff and student-athletes is essential to the success of the
program.
 Overview of Services

Every college, regardless of its size, resources, composition, student body, or special
occupational problems, should have a program in which the health needs of the general
student population are being achieved ACHA, 1991). The athletic department should provide
health care for the special needs of its athletic population. The basic goals of an athletic health
care program should be:

A. Promote and maintain those conditions that will permit a safe and healthy competitive
environment. The athletic program should encourage each student-athlete to realize
optimum physical, emotional, intellectual, social and spiritual wellness through their
participation in organized athletics. The athletic health care program should promote this
philosophy through preventative measures to protect athletes from illness/injury.

B. Improve those factors in the college community and its physical environment that may
compromise the well-being of the student-Athlete.

C. Provide ambulatory care, emergency services, and/or referrals.

D. Provide rehabilitative services and/or referrals.

E. Assist with the coordination of health counseling and mental Health services for student-
athletes.

F. Liaisons should be established with an supporting resources, contributing to a team

approach that not only includes orthopedic care, but psychological support.

G. Assist in the coordination of institutional resources to form an environmental health and

safety program for all athletic facilities and environs.

H. Be involved with an ongoing illness and injury prevention program through working with
coaching staff and wellness personnel.

Immediate Care services

Services should be developed to de immediate assistance for any student-athlete, staff member
or visitor who has a known or suspected health problem. These services should be of high
quality under all circumstances. Ensuring the availability of immediate care services does not
require that the athletic department establish an extensive clinic with a wide range of
diagnostic and therapeutic t resources.

However, there should be a certified athletic trainer with appropriate assessment skills and a
school nurse available to provide general health care to student-athletes. Collaboration with a
physician is advisable. Circumstances will dictate whether the institution has a formal
arrangement with a physician on a part-time or full-time basis, or as a consultant. All
ambulatory services should be consistent with guidelines for the provision of immediate care
of illnesses and injuries suffered by athletes.

These guidelines must conform to the current standards of practice for sports medicine
care and athletic training,

These guidelines must also conform to any practice act regulating the practice of athletic
training in the jurisdiction in which the athletic program is located, and must be within
the competence of available personnel,

Guidelines for Implementation

1. Provide adequate facilities in an area accessible to staff and athletes, including

visitors to the institution,

2. Provide at least one full time certified athletic trainer to provide coverage during
scheduled athletic practices and events.

3. Provide regular, scheduled hours for athletic health care, and those hour's
communicated to coaches and athletes, In addition, the availability of general
health care services should be communicated to student--athletes as well. A
pamphlet outlining athletic health care services, availability, location, and office
hours should be distributed to everyone involved with the athletic program. If
available, a pamphlet outlining general health care services should also be
distributed at the same time.

4. Maintain a daily record of visits by student-athletes to the athletic health care

service, categorizing services rendered. Periodic reports should be sent to the
appropriate administrators regarding athletic health care service activities.

5. Clearly outline referral procedures, including a plan for the physical transfer of an
injured or seriously ill student-athlete to the nearest health care facility. The
transfer plans should be constructed with the consultation of campus officials
familiar with the legal and insurance ramifications.

6. Provide a listing of local diagnostic and therapeutic resources that are available
and accessible to student-athletes. Financial considerations must also be
considered for students with limited funds available for health care. A clear
understanding of managed care plans; along with their rules and restrictions, and
how they affect the health care the student-athlete with such insurance coverage
is essential in order to make appropriate referrals.
7. Maintain confidentiality at all times (except where legal exceptions apply)
concerning the details of health records, including all complaints, examinations,
and diagnoses. Confidentiality of medical records should be clearly stated and
explained to all student-athletes at the beginning of each sports season, The
discussion should include an explanation of legal exceptions to confidentiality.

8. Records should be maintained in regards to risk management activities,

equipment inspections, facilities inspections, and staff in-services.

9. Current certifications in first aid and basic life support for all staff charged with
the supervision of student-athletes and facilities must be maintained in the staff
members personnel record.
Provisions for Hospitalization

Most colleges and universities do not provide inpatient services, nor is such care usually
appropriate in this setting. Consequently, athletic care services at colleges and university
without infirmaries or hospitals must make arrangements for hospitalization of student-
athletes the same as the college’s student health service. Rest areas should be available in
college health services (see ACHA guidelines, 1991) for temporary care of the ill and injured.
Acute injuries and illnesses can be transferred to a local hospital, but unfortunately, after
discharge health care may be required. The student-athletes will have to rely on family, friends
or team mates for assistance.

Payment for hospital care is a serious problem for most students; athlete or non-participant
alike. Many college athletic departments provide a excess accident policy for injuries that are
the result of direct participation, these policies usually do not cover medical illnesses. Colleges
may offer a student the opportunity to purchase short-term medical and dental insurance at
rates lower than those generally available. Students without insurance coverage should be
encouraged to buy personal health care insurance coverage. The coverage must provide for
sports related injuries from intercollegiate athletics. In some colleges and some states, this is
mandated.

Guidelines for Implementation

1. Establish a list of all general hospitals within the service area of the institution, and
make this information available to the staff and student-athletes.

2. Become familiar with the free care policies in the area hospital s so that students can be
helped to understand that application process.

3. Review the students health insurance policy to make sure that it will meet a large
proportion of the predictable needs at the lowest possible cost The college should
obtain the advice of an expert in designing supplementary insurance programs for
student athletes. Whenever possible, students should be involved in decisions
regarding any secondary insurance program.

4. Have appropriate athletic health care facilities and general health care facilities for the
college community available and accessible to the ill and injured.

5. Have a clear policy regarding the transportation of acutely ill or injured student-athletes,
staff and visitors.

6. Have an emergency notification system in effect, including information and releases on

minor student-athletes, The system must include emergency parental/guardian
notification and insurance information for hospital staff who receive on a admission.
This information must also be carried by coaches on trips away from the campus.
Provisions for Urgent Care

A basic responsibilities of every institution to have a plan to manage situations that require
immediate medical care. The plan should include the department of athletics which by the
nature of athletic competition in an environment of high risk, The plan should include prompt
assessment , administration of first aid, and transportation of victims to sources of definitive
care. The plan should be in effect whenever the athletic department has planned activities
underway and not just when the school is in session. This would include at such times as
significant numbers people are on campus for sporting events, camps and clinks. Major
objectives for such a plan are to:

A. Make first aid care available by providing a system for the recognition and care of sports
injuries at the site of practice and competition.

B. Develop a standard set of procedures to be followed by all college and/or paramedical

personnel in urgent care situations.

C. Establish a system to promptly and accurately transmit information to a central location,

either the athletic health care facilities or the athletic department main office.

D. Develop a plan for prompt and effective transfer of the sick or injured to the athletic health
care facility; if appropriate, or the nearest medical care facility.

E. Identify faculty, staff, and students who have first aid or other health care training or
experience.

F. Develop a staff of student assistant athletic trainers who can render care in lieu of the
certified trainer being present or who can assist the certified trainer provide care. (NATA
Guidelines preclude the use of students unless they are directly supervised by a certified
athletic trainer)

Guidelines for Implementation

A. There should be agreement on each campus about who will be responsible for ensuring
policies and procedures are in place for handling sports related urgent care, including major
disasters. This is often done through a campus health and safety committee.

B. A significant number of people on the athletic department should be certified in basic CPR
and first aid, in addition to the athletic trainer and training staff. The training should be
available on a regular basis, along with recertification sessions.

Overview of Services
Every college, regardless of its size, resources, composition, student body, or special
occupational problems, should have a program in which the health needs of the general
student population is being achieved (ACHA, 1991). The athletic department should provide
health care for the special needs of it's athletic population.
The basic goals of an athletic health care program should be:
A. Promote and maintain those conditions that will permit a safe and healthy competitive
environment. The athletic program should encourage each student-athlete to realize
optimum physical, emotional, intellectual, social and spiritual wellness through their
participation in organized athletics. The athletic health care program should promote this
philosophy through preventative measures to protect athletes from illness/injury.

B. Improve those factors in the college community and its physical environment that may
compromise the well-being of the student-athlete.

C. Provide ambulatory care, emergency services, and/or referrals.

D. Provide rehabilitative services- and/or referrals.

E. Assist with the coordination of health counseling and mental health services for student-
athletes. Liaisons should be established with all supporting resources, contributing to a
team approach that not only includes orthopedic care, but psychological support.

F. Assist in the coordination of institutional resources to form an environmental health and

safety program for all athletic facilities and environs.

G. Be involved with an on-going illness and injury prevention program through working with
coaching staff and wellness personnel.
Immediate Care Services

Services should be developed to provide immediate assistance for any student-athlete, staff
member or visitor who has a known or suspected health problem. These services should be of
high quality under all circumstances.

Ensuring the availability of -immediate care services does not require that the athletic
department establish an extensive clinic with a wide range of diagnostic and therapeutic
resources. However, there should be a certified and licensed athletic trainer with appropriate
assessment skills and a school registered nurse available to provide general health care to
student-athletes. Collaboration with a physician is advisable. Circumstances will dictate
whether the institution has a formal arrangement with a physician on a part time or full-time
basis, or as a consultant.

All ambulatory services should be consistent with guidelines for the provision or immediate
care of illnesses and injuries suffered by athletes. These guidelines must conform to the current
standards of practice for sports medicine care and athletic training. These guidelines must also
con-form to any practice act regulating the practice of athletic training in the jurisdiction in
which the athletic program is located, and must be within the competence of available
personnel.

Guidelines for Implementation

A. Provide adequate facilities in an area accessible to staff and student-athletes, including

visitors to the institution.

B. Provide at least one full time certified athletic trainer to provide coverage during scheduled
athletic practices and events.

C. Provide regular, scheduled hours for athletic health care, and those hours communicated to
coaches and athletes. In addition, the availability of general health care services should be
communicated to student-athletes as well. A pamphlet outlining athletic health care
services, availability, location, and office hour's should be distributed to everyone involved
with the athletic program. If available, a pamphlet outlining general health care services
should also be distributed at the same time.

D. Maintain a daily record of visits by student-athletes to the athletic health care service,
categorizing services rendered. Periodic reports should be sent to the appropriate
administrators regarding athletic health care service activities.

E. Clearly outline referral procedures, including a plan for the physical transfer of an injured or
seriously ill student-athlete to the nearest health care facility. The transfer plans should be
 constructed with the consultation of campus officials familiar with the legal and insurance
ramifications.

F. Provide a listing of local diagnostic and therapeutic resources that are available and
accessible to student-athletes. Financial considerations must also be considered for
students with limited funds available for health care. A clear understanding of managed
care plans; along with their rules and restrictions , and how they affect the health care of
the student-athlete with such insurance coverage is essential in order to make appropriate
referrals.

G. Maintain confidentiality at all times (except where legal exceptions apply) concerning the
details of health records, including all complaints, examinations, and diagnoses.
Confidentiality of medical records should be clearly stated and explained to all student-
athletes at the beginning of each sports season. The discussion should include an
explanation of legal exceptions to confidentiality. All policies and procedures must comply
with federal HIPAA and state medical records regulations.

H. Records should be maintained n regards to risk management activities, equipment

inspections, facilities inspections, and staff in-services.

I. Current certifications in first aid and basic life support for all staff charged with the
supervision of student-athletes and facilities must be maintained in the staff member’s
personnel record.

Hospitalization
Most colleges and universities do not provide inpatient services, nor is such care usually
appropriate in this setting. Consequently, athletic health care services at colleges and university
without infirmaries or hospitals must make arrangements for hospitalization of student-
athletes the same as the college health service . Rest areas should be available in college health
services (see ACHA guidelines, 1991) for temporary care of the ill and injured. Acute injuries and
illnesses can be transferred to a local hospital, but unfortunately, after discharge health care
may be required. The student-athletes will have to rely on family, friends or team mates for
assistance.

Payment far hospital care is a serious problem for most students; athlete or non-participant
alike. Many college athletic departments provide an excess or secondary accident policy for
injuries that are the result of direct participation, these policies usually do not cover medical
illnesses.

Colleges may offer a student the opportunity to purchase short-term medical and accident
insurance at rates lower than those generally available. Students without insurance cover-age
should be encouraged to buy personal health care insurance coverage. The coverage must
provide for sports related injuries from intercollegiate athletics. In some colleges and some
states, this is mandated.

Guidelines for Implementation

A. Establish a list of all general hospitals within the service area of the institution, and make
this information available to the staff and student-athletes.

B. Become familiar with the free care policies in the area hospitals so that students can be
helped to understand that application process.

C. Review the students health insurance policy to make sure that it will meet a large
proportion of the predictable needs at the lowest possible cost. The college should obtain
the advice of an expert in designing supplementary insurance programs for student-
athletes. Whenever possible, students should be involved in decisions regarding any
secondary insurance program.

D. Have appropriate athletic health care facilities and general health care facilities for the
college community available and accessible to the ill and injured.

E. Have a clear policy regarding the transportation of acutely ill or injured student-athletes,
staff and visitors.

F. Have an emergency notification system in effect, including information and releases on

minor student-athletes. The system must include emergency parental/guardian notification
 and insurance information for hospital staff to receive on an admission. This information
must also be carried by coaches on travel away from the campus.

Provisions for Urgent Care

A basic responsibility of every institution is to have a plan to manage situations that require
immediate medical care. The plan should include the department of athletics, which by the
nature of athletic competition operates 'in an environment of high risk. The plan should include
prompt assessment, administration of first aid; and transportation of victims to sources of
definitive care. The plan should be in effect whenever the athletic department has planned
activities underway and not just when the school is in session. This would include at such times
as significant numbers of people are on campus for sporting events, camps and clinics.

Major objectives for such a plan are to:

A. Make first aid care available by providing a system for the recognition and care of sports
injuries at the site of practice and competition.

B. Develop a standard set of procedures to be followed by all college and/or paramedical

personnel in urgent care situations.

C. Establish a system to promptly and accurately transmit information to a central location,

either the athletic health care facilities or the athletic department main office.

D. Develop a plan for prompt and effective transfer of the sick or injured to the athletic health
care facility; if appropriate, or the nearest medical care facility.

E. Identify faculty, staff, and students who have first aid and other health care training or
experience.

Guidelines for Implementation

A. There should be agreement on each campus about who will be responsible for ensuring
policies and procedures are in place for handling sports related urgent care, 'including major
disasters. This is often done through a campus health and safety committee.

B. A significant number of people on the athletic department should be certified in basic CPR
and first aid, in addition to the athletic trainer and training staff. The training should be
available on a regular basis, along with recertification sessions.

C. The athletic health care staff and athletic; department should have a yearly review of
procedures and the response process. After any significant episode, they should review the
adequacy of the
performance of the response and the action of each member of the athletic health care
team. It is wise to hold urgent care drills on a regular basis to "test" the response system.

D. Contact local emergency system personnel and determine what services are available and
reach an agreement about how these what services will interface. These individual can also
assist in developing disaster plans.
E. Contact hospitals in the area adjacent to the college and sports venues to determine set-
vices provided. Have this list available along with pertinent telephone numbers for quick
reference.

F. All athletic department telephones should be marked with a campus urgent response
number. Additional numbers for the athletic trainer, health service and athletic office
should also be available. Directions on what types of information that should be given to
the emergency services personnel over the telephone should appear along with the
telephone numbers on a placard next to all telephone, even pay telephones. Some
institutions may require all calls to go to the school operator who will contact the
emergency response team and EMS personnel if necessary.

G. Orientate staff and student-athletes at the beginning of each team’s season about the
urgent care response procedures and what services are available.

H. Post notices in prominent locations within the athletic department and it's facilities, giving
the urgent care telephone numbers and instructions concerning the information that should
be given when reporting an accident or ether emergency. This should at the least include
the name of the caller, the specific location of the causality, the type of situation, and the
number of persons involved.

Health Records
It is important to establish a health record system from which information can be retrieved
quickly. The health information obtained from student- athletes will vary according to the
needs of the specific program and the school's secondary insurance carrier. Some reasons for
initiating health records are to:

A. Screen for admission into the athletic program to ensure students meet minimal physical
requirement.

B. Establish an ongoing individual health record for each student- athlete.

C. Review health information in order to identify student-athletes with special medical

conditions and medication requirements.

D. Gather statistics about participants in the program, comply with immunization

requirements.

E. Collect and collate insurance information on student-athletes.

Guidelines for Implementation

A permanent health record, including a health history, should be established for all participants
in the athletic program. This should include all non-athletes that may be seen by the staff in
athletic health care, Complete and continuing health records are important to ensure continuity
and quality of care, as well as for medical and legal reasons.

The record should include an appropriate notation of every visit to the athletic care health
service for evaluation and treatment of sports injuries, or other form of personal health care.

Health histories serve to identify students for whom special considerations must be given due
to existing medical conditions, and those needing additional evaluation, continuing treatment,
or other medical consultations.

Ask for health information that serves the needs of the athletic department and specific
program needs as indicated. The information may also show what future health care needs may
be required by the student-athlete.

Information gained must be kept confidential and used only in the direct interest of the
student-athlete. This is especially true of medical conditions that would affect the student-
athletes ability to participate in the program. Patient information is not revealed to any other
college or institutional personnel without the written informed consent of the student-athlete,
except in cases of extreme urgency where there is an obvious "need to know", as defined in the
athletic department and college policies.
Detailed health information should not be requested if the college has no qualified practitioner
to review and interpret the information. Nothing is gained by accumulating files or data that
will not be used. " Completed health forms, filled out elsewhere, should be returned directly to
the athletic health care service.

The health record should contain a continual record of all visits or transactions within the
athletic health care service. It should include

 the athletic health history forms

 the pre-participation physical examination
 all visits to the certified athletic trainer, team physicians and surgeons and other health
professionals
 all diagnostic tests and procedures, whether provided by the college health services or at
another resource
 all consultations, whether performed in the athletic health care facilities, student health
center or at another resource.
 all significant athletic department administrative actions (hardship requests, dismissals,
etc.)
 all telephone consultations, including advice and referrals given

Confidentiality of medical records is essential

A. All health records should be kept in a secure location with access limited to professional and
necessary athletic department officials and members of the athletic health care staff

B. All health records should be kept in locked files when not in use or under the direct custody
of athletic health care personnel Information from the athletic health care record should be
transmitted to third parties, including academic and administrative personnel, only with
written informed consent of the student-athlete,

C. Students need to be made aware of the risks of transmitting their health record to third
parties when the information is to be used for screening for employment, government
clearances, etc.

D. Establish a written policy conforming to statutes concerning the release of health

information, both to persons within and outside the college. In general, clinical information
should not be released to anyone without specific written authorization from the student-
athlete.

E. Conduct in-service educational program for staff to teach how to handle confidential
information and situations involving emergencies.
F. Student-athletes should be reunited to share medical information concerning unusual
medical conditions that combined with strenuous physical activity can create dangerous
outcomes. This includes exercise induced asthma, diabetes, allergies or other disorders.
Student awareness of the services provided by the athletic health care program and as an
educational resource.

By taking advantage of the "teachable moment", individual contacts in the athletic health care
facilities can influence health behavior. Every visit by a student-athlete becomes an opportunity
to teach.

Speakers brought in by the athletic department can provide information over a variety of
relevant topics, such as anabolic steriod abuse and smokeless tobacco use. This method usually
requires that the institution has funding available for special educational programming. Letter
grants to public service agencies and organizations can be utilized to contact speakers bureau
or public service funding that is available for special needs programming.

There are many instructional videotapes and computer programs available about wellness,
sports-related health topics, injury prevention and physical conditioning. These can be made
available for use in the athletic health care facility or for loan.
Environmental Health and Safety

Every college campus is required by law to provide a safe and healthful environment for
students, staff and visitors. The certified athletic trainer must take a active role, along with the
athletic director, in developing plans for effective control of environmental factors that may
affect the health and safety of the student-athletes in the program. The athletic trainer should
be aware of the broad range of factors to be considered; the development of policies and
procedures; liaisons with the public health department, Fire Marshall’s office and other
agencies. The athletic trainer should be involved with the campus health and safety committee.
In addition, the athletic trainer should be familiar with the wide range of state and federal
health, safety, and environmental laws.

Athletic trainers should not be responsible for areas beyond the scope of their expertise.

Guidelines for Implementation

A health and safety committee should be developed by the college administration. The certified
athletic trainer and director of athletics should be a member. An administrator who is a
proponent of health and safety should chair the committee and campus security should be
represented. The athletic health care program and athletic department should develop a
procedure for recording all injuries and accidents. Summary reports should be submitted to
administration. Reports of injuries and accidents should be used to identify areas or activities
with special hazards such as weight rooms, swimming pools, walkways and stairwells. These
reports can also be used to evaluate the promptness and efficiency of first aid services.

The athletic department should develop a standing committee of the coaching staff, athletic
trainer and director that communicates and coordinates with the campus health and safety
committee concerning health and safety concerns specific to the athletic program and playing
environs. The athletic department committee should recommend policies and procedures and
work with other staff members and the student-athlete in complying with protective
regulations.

The athletic department committee can contact manufacturers of athletic equipment regarding
accident prevention. Often consultants will be available at no cost. These agencies and
companies may have educational materials available for your staff at no cost.

If the college does not have a process already in place to monitor new health requirements, the
athletic trainer should keep informed on new regulations and health trends. Subscriptions to
journals and trade periodicals, some available at no cost, will provide information on current
conditions in athletic liability and health care for athletes. Because many areas of employee
health education are mandated by law, OSHA standards regarding health and safety; and
particularly those related to health care providers (ie: Hepatitis and HIV) must be readily
available as a reference source.
OSHA standards regarding the handling of blood-bourne pathogens, Hepatitis B vaccine must
be offered to all high-risk workers.

The athletic department should be aware of the laws governing the health and safety of the
college environment. There are consultants available in each of these areas who can provide
guidance to your college administration.
Occupational Health

The following outline is appropriate for a small athletic department.

For a more comprehensive college athletic program charged with overseeing their own
occupational health and safety needs should refer to Appendix A, "Comprehensive
Occupational Health Services for Intercollegiate Athletics".

Some athletic programs operate as a independent entity, many times supported by a

foundation structure. The staff and facilities are responsible to a board of control and the
director of athletics. A facilities manager or director will be responsible for health and safety
programming. Occupational health is concerned with health and safety issues -in the
workplace. It includes job safety and working conditions for faculty, staff, and student
employees. It is concerned with buildings, grounds, machinery, weight rooms, swimming pools,
chemicals, safety equipment, asbestos removal, infection control, and a myriad of related
issues. A small college athletic department would not have the necessary staff or qualified
personnel to oversee and direct this program The athletic trainer will be the usual staff member
to manage a health and safety program for the athletic department and be involved with other
health and safety issues on campus.

Most occupational health regulations are dictated by local, state, and federal laws. These
include the Occupational Safety and Health Act, worker's compensation laws, the Drug Free
Workplace Act, and environmental protection laws.

Guidelines for Implementation

A. A health and safety committee dealing with concerns that affect the operations of the
athletic and recreation departments should consider the following issues:

B. Identify experts in the community. For example, occupational therapists can do on-site visits
and recommend alterations in work stations in order to prevent overuse and misuse
injuries.

C. Identify experts on campus such as the supervisor of buildings and grounds, the chief
custodian, and department heads. They should be knowledgeable about the chemicals,
pesticides, instructional supplies, and equipment used in their respected areas of the
athletic program and should be represented on the committee. They should help develop
policies and procedures regarding proper handling and disposal of hazardous materials.
Campus staff should be familiar with the use of protective equipment, ventilation systems,
and the laws relating to their areas of responsibility.

D. Athletic department employees must be educated about the safety factors associated with
the use of hazardous materials and equipment. The athletic health care provider should be
 knowledgeable concerning medical problems that can arise from use and mishandling of
hazardous materials.

E. The athletic director is responsible for personnel, buildings and grounds and is charged with
the compliance of all related laws and statutes dealing with health and safety. OSHA
regulations detail ways to identify safety issues and correct hazardous situations.
Environmental protection laws dictate the control and use of hazardous materials. Worker's
compensation laws determine the procedures for handling on-the- job injuries. All of these
laws have associated regulations that cannot be changed by a college committee.

F. Occupational health issues that directly concern the athletic health care staff may include
the following:

1. Report hazardous conditions and staff injuries to the appropriate personnel, usually the
director of athletics.

2. Have employees complete a physical examination as part of employment procedure.

3. Screen high-risk student-athletes and workers for medical conditions that could lead to
illness and/or injury. This is important in situations where workers; especially student
workers are not required to have an employment examination.

4. Ensure that students comply with immunization requirements.

5. Make Hepatitis B vaccine available to all staff and students working in athletic health
care, include maintenance staff, coaches and equipment personnel.

6. Assist with first aid and CPR courses for staff and students.

7. Administer first aid to sick and injured employees and have a system in place to assist
with referral and emergency transportation.

8. Make appropriate referrals to the employee assistance program.

Research

Certified athletic trainers in the collection of injury records and statistics are in the process of
constant research. This research is utilized primarily to identify areas for injury prevention
efforts. The organized accumulation of data, gathered in the daily operation of the athletic
health care service, can be useful in identifying various aspects of the athletic health care
delivery system other than injury statistics.

A small college athletic department might consider having students involved with on-going
research projects as part of an internship study program. The overall focus of the research
should be documenting improvements in services.

Research need not be done in isolation. Collaborative efforts with other college departments,
other colleges, state and district athletic training associations, and the National Athletic Trainers
Association maybe valuable.

The NATA has a research foundation that provides grants to certified athletic trainers for
research projects. Workshops on conducting research and publishing results are held
periodically. Possible sources of funding for research projects may be; the college academic
affairs office, state and federal governments, foundations, voluntary health agencies, college
development funds, or interested individuals. A good source of information is a college grant
writer.
Communications

Clear communication is essential for the effective management of an athletic health care
service program. It is important to keep the administration of your college informed about your
accomplishments, about the health needs of student-athletes, and about the financial impact of
new state and federal regulations.

It is essential to communicate the availability of your services to student-athletes and to

coaches and staff who may advise student-athletes. The athletic health care service staff must
communicate with each other, the athletic director and coaching staff about goals, policies,
procedures, problems, and plans.

Guidelines for Implementation

A. Develop a format for collecting athletic health care data and give regular reports - including
an annual report - appropriate people, such as:

1. staff members
2. athletic director
3. administrator in charge of area that includes athletics chief executive administrator(s)
4. director of student health
5. program medical director

B. Plan to meet on a regular basis with your immediate supervisor.

C. This allows you to discuss changing needs, successes, and finances, and gives the
administrator a clear picture of the important function of the athletic health care service
program.

D. Schedule regular athletic health care staff meetings, with a planned agenda, to encourage
full staff participation. Ensure that staff members have a clear understanding of their job
expectations and scheduling process.

E. Keep the coaching staff informed about current athletic health care issues and upcoming
programs. Be open to their concerns about health issues they observe with their athletic
teams and about the campus in general.

F. Participate on college committees in order to enhance communication. This gives the head
athletic trainer an opportunity to meet with other members of the campus community.

G. Maintain regular contact with the campus safety officer regarding possible hazardous
conditions, accidents, and safety issues.
H. Inform student-athletes about the services available in athletic health care and conduct
periodic surveys to determine student needs and their satisfaction with the services
provided.

I. Some effective ways to publicize a athletic health care service program include:

1. Prepare a videotape or slides to show to athletic teams and at health fairs.

2. Develop an attractive brochure describing athletic health care services
3. Volunteer to appear on campus radio and television programs.
4. Write articles or be interviewed for the student newspaper.
5. Ensure that your service is included in the college catalogue and student handbook.
Community Resources

Community resources are invaluable to a athletic trainer centered athletic health services
program. The athletic health care service should work towards a coordinated sports health and
safety plan by identifying community agencies offering services that can not be provided on
campus.

Some agencies that do not render direct services may provide speakers and other programs for
health education.

If is helpful for athletic health care staff to participate in the activities of the student health
center, health agencies, health councils, and health planning organizations. Time spent in these
activities will result in a positive contribution to the agencies and to the overall campus health
programs.

Guidelines for Implementation

Contact the health department, local hospitals, voluntary health agencies, clinics, and dental
and medical societies to learn about ways you can work together to enrich the athletic health
care program.

Useful agencies in many communities include:

* American Heart Association
* American Red Cross
* American Diabetes Association
* Epilepsy Foundation
* Division of Rehabilitative Services
* National AIDS Hotline
* Local Family Planning and Health Clinics

Contact local hospitals and public health departments that can help you identify additional
organizations and support groups in your area.

Contact local fire, police, or private ambulance services to determine what is available and to
reach an agreement about how these services will work together. These organizations can also
assist the college athletic department with disaster planning.

Establish liaisons with local educational institutions to explore opportunities for collaboration.
Continued Quality Improvement

All health care services, regardless of size, should implement an organized, professional peer-
based quality improvement program. All health practitioners and service activities should be
included in the process. The continued quality improvement program (CQI) will wary according
to the college and it's administration, the size of the athletic department, and the scope of
practice.

Guidelines for Implementation

A. The athletic health care program should establish a process for periodically assessing client
satisfaction.

B. Client health records should be used to compare case management to established

procedures.

C. Concerns or problems detected from surveys should be evaluated, and corrective action
taken. dates and actions taken to correct problems should be documented.

D. Reports of improvement of the service should be shared with the college administration.

E. Colleagues from other athletic health care departments and sports care clinics may be
called upon to assist with the peer review process.
Health Personnel

A. The personnel who staff the athletic health care service must be selected with care. The
head athletic trainer\director should have a significant role in the selection of the staff,
including the consulting physicians. Whenever possible, students should be on the search
committee for the head athletic trainer. Appropriate and qualified staff should be able to
ensure professional services consistent with health needs of the student-athlete.

B. Ensure medical consultation to the athletic health care staff to establish appropriate
standardized procedures.

C. Ensure that all procedures comply with applicable laws and statutes governing health
professionals within the jurisdiction.

D. Coordinate the use of existing community resources with a well- organized sports care
program, which avoids duplication of services while fulfilling identified athletic health care
needs.

E. Participate in planning educational opportunities for students that relate to all dimensions
of wellness.

F. Create an inviting atmosphere in which student-athletes feel secure discussing health

issues.

G. Communicate athletic health care policies clearly - especially those regarding confidentiality
- to student-athletes, administrators, faculty, and staff.

H. Serve as role models for health promotion activities, while encouraging a wellness
environment within the department of intercollegiate athletics.
Role of the Director\Head Athletic Trainer

The director\head athletic trainer assumes the responsibility for the overall management of
athletic health care. The director\head athletic trainer has an opportunity to use his or her skills
and knowledge, in a variety of ways, to create a program that is unique to the institution.

This includes not only direct student health care but also teaching, counseling, and serving as a
campus consultant on sports health care related matters.

Qualifications

Athletic health care services in community colleges and many small private colleges may not
have a full time athletic trainer, or rely on clinical athletic trainers for their services. In addition,
many certified athletic trainers at smaller institution have multi-responsibilities; such as faculty
teaching assignments. It is recommended that a director be a graduate of an accredited
curriculum program in athletic training and have a master's degree with experience in
counseling, administration, or health education. A bachelor's degree with similar experience is a
minimum. The director must be licensed to practice in the jurisdiction in which the college is
located. She or he should hold professional membership and participate in the National Athletic
Trainers Association and the College Athletic Trainers Society, its district affiliate, state
association, and other appropriate professional organizations.

Professional certification in emergency care and cardiac life support in accordance with current
NATABOC guidelines.

Responsibilities Institutional\Departmental

A. Determine how athletic health care service goals can relate to the goals and objectives of
the institution.

B. Become acquainted with the administrative officers who are responsible for policy
determination and educational administration.

C. Obtain an organizational chart of the campus. Determine who to contact for assistance with
personnel, finances, program development, and general support. Learn the accepted
channels of communications.

D. Seek opportunities to participate in the college government and institutional planning.

Express willingness to serve on committees, especially those involving student services,
athletics, health, staff development and safety.

E. Develop a proposal to the college administration that a physician be appointed to consult

with the director\head athletic trainer regarding all aspects of the health program.
 Clarification of the physician's role, liability of the college, and expected results should be
included.

Athletic Health Care

A. Develop an organizational chart with a job description, including essential functions, for
each athletic health care service employee. Clearly specify the responsibilities and define
the essential and recommended qualifications for each position.

B. Evaluate each employee according to college procedures.

C. Develop policy and procedure manuals for the athletic health care service program. Update
these manuals annually or when revisions are made. Ensure the manuals are reviewed and
initialed annually
by athletic training staff and the medical director\team physicians.

D. Ensure institutional liability insurance for the athletic health care staff. Encourage each
professional to consider additional individual personal liability insurance. Contact a legal
counsel for a coverage review.

E. Develop a quality assurance (CQI) plan, with effective ways to use the talents of all
personnel.

F. Develop a referral list of health professionals, clinics, and resources in the area, including
specialty services and university clinics.
G. Learn about the student-athlete population in the institution - age range, socioeconomic
status, ethnic diversity, access to health care, and need for health insurance. This
information will
support the decision for types of services initiated within the athletic health care program
and the cost.

H. Develop a plan for implementing services with a fiscally-sound budget, in concert with the
institution's and the athletics departments financial situation.

I. Promote continuing education among the athletic health services staff and coaching staff
and include funds for staff development in the budgeting process.

J. Submit monthly reports to your athletics director\immediate supervisor and any other
administrators directly and indirectly involved. Prepare a detailed annual report that
includes a thorough analysis of all activities, including goals, for the next year. Distribute this
report to administrators, the student government, and members of the athletic
departments advisory board.
Faculty/Staff

Become acquainted with faculty and staff, both professionally and personally. Participate as
actively as possible in varied campus activities.

Inform faculty and staff of procedures regarding confidentiality, "absence excuses," and medical
withdrawals from athletics and physical education. Clearly state that information given out only
with the student's knowledge and written consent.

Community

Maintain a liaison with community health and social agencies.

These contacts are important for building community support for the athletic health care
program and can be invaluable resources.

Become acquainted with other institutions of higher education and secondary schools in your
area. Meet with their athletic health care providers to learn how your programs can assist one
another.
 Sports Health Care
Patient Care Guidelines
Policies &
Procedures

John Gabriel, MA, ATC. LAT

Certified Athletic Trainer and
Licensed Athletic Trainer
2014
Previous Editions 1990, 1998, 2009, 2012
 FOREWORD

The Licensed Athletic Trainer's General Operating Guidelines\Procedure Manual has been
adopted as a guideline for the licensed athletic trainer to perform those tasks and functions
that within the prevention, management and rehabilitation of injuries of student-athletes in
intercollegiate/interscholastic at (college/school). The basis for the licensed athletic trainer to
accomplish these procedures and guidelines emanates from the state of (state), regulations
governing the practice of athletic training and the competencies for professional practice
established by the NATA. A copy of the code is available in the offices of the licensed athletic
trainers. Copies can be obtained from:

Address and Contact Information of the state in which the program is housed

DEFINITIONS:

Licensed Athletic Trainer, (L.A.T) Licensed (A.T.C.)

An allied health professional who has successfully completed the college/university

undergraduate degree, fulfilled the requirements for certification as established by the Board of
Certification of the National Athletic Trainers Association Board of Certification, Inc., and passed
the national certification examination administered by the Board of Certification.

The six domains of athletic training competency from which specific tasks are measured in the
examination are:

Prevention
Recognition and Evaluation
Management, Treatment and Disposition
Rehabilitation
Organization and Administration
Education and Counseling
 GOALS AND FUNCTIONS OF THE SPORTS HEALTH CAREPROGRAM

I. GENERAL

The Sports Health Care service program was established in (year) for the services of a licensed
and licensed athletic trainer. The goals of the program are to provide emergency sports care
and entry-level health care services to the (college/schools) student-athletes.

II. FUNCTION

The primary function of the licensed\licensed athletic trainer is to provide sports care to
student-athletes engaged in the college's intercollegiate athletic program. The licensed athletic
trainer is licensed by the State of (state program is housed) and all applicable laws a regulations
pertaining to the practice of athletic training will be strictly observed. Guidelines for practice
are established and published by the National Athletic Trainers Association. Copies of these
guidelines are on file in Athletic Department and are accessible on request. Additional copies
are on file in the training rooms in (locations of facilities used for sports health care). The
overall goal of the program is to provide the student-athlete engaged in organized sports
activities at the college; quality care in the prevention and management of sports injuries. To be
accomplished by the use of prudent conditioning practices and appropriate health care when
necessary. The licensed\licensed athletic trainer will provide Sports Health Care Services to the
student-athletes at the college. Physician referrals for rehabilitation services will be conducted
through the licensed\licensed athletic trainer, with the treatments being provided by the
licensed/licensed athletic trainer at the (college/school) training rooms. It is upon the referral of
the attending physician and/or evaluation by the licensed\licensed athletic trainer (operating
under written guidelines of the attending\team physicians) that a student athlete can be
treated. The licensed\Licensed athletic trainer then plans and administers a treatment program
which utilizes appropriate physical measures. This includes planning with the athletic
department staff appropriate preventative and reconditioning programs, including follow-up
care with written after care instructions as necessary.

The overall medical director of the SPORTS HEALTH CARE program at the college and team
physicians is comprised of the physicians from (location or name of medical group provides
medical oversight if any). As a member of the (college/school) health services team the
licensed\licensed athletic trainer contributes to the total evaluation and care of the student-
athlete's medical condition. The primary objective of the athletic trainer is to help develop the
safest, healthiest competitive environment for each athletic participant. The difference
between good and excelling health care, lies in the time and attention which can be given to
each student-athlete.

Total sports health care lies in preventative as well as rehabilitation care of conditions related
to sports. In prevention, it is to give the student-athlete, their parents, and the coach the
awareness of factors that contribute to injuries and methods that help minimize the risk of
injuries occurring. In rehabilitation the goal is to help the student-athlete and coach cope with
or master the physical disability and return the student-athlete or sportsmen to their chosen
activity.

Due to special training and background, the Sports Health Care team is prepared to provide
educational services to the student-athlete and personnel at the college. This provides for a
healthier competitive environment for the student-athlete and protection for the staff. Sports
Health Care Services are easily accessible to the student-athlete at the (college/schools)
training rooms from (days and hours of operation). Treatments are provided during these hours
during pre-practice preparation time and prior to competitions.

The service is accessible during regular college sessions. There is adequate space for initial
assessment and care of most athletic injuries and for related clerical work. Because of the
diverse locations of the practice facilities on campus, Sports Health Care Services provides
supervisory control over coverage. Direct coverage by the professional licensed/licensed
athletic trainer is based on type of activity and number of participates. Priority for coverage
going to collision sports first. Because athletic injuries are primarily mild to moderate in nature
requiring only short-term care patient census and turnover rapidly changes. Equipment and
staff requirements are thus budgeted accordingly.

III. HOURS OF OPERATION

SPORTS HEALTH CARE maintains the following schedule:

Monday thru Friday:

Rehabilitation: (add times) Scheduled as required
Pre-practice preparation: (add times) Arranged as needed.

Medical Coverage and Additional Treatment Time as Available.

The licensed/licensed athletic trainer is available for consultation by
Calling Sports Health Care at (contact numbers)

Sports Health Care Services maintains all student-athlete health records and physical forms for
emergency reference and for insurance purposes. [All claims for insurance on the institutions
student-athletic policy are administered through SPORTS HEALTH CARE Services.]

The extent and depth of Sports Health Care rendered, as determined by the team
physicians, medical advisors, and/or attending physician.

1. Evaluations; posture, musculo-skeletal evaluations, strength testing, range of motion,

and functional evaluations.
2. Exercises for the maintenance of, or increase in strength, range of motion, coordination,
and endurance.
3. Ambulation training with assistive devices, such as crutches, braces, and prosthetic
devices.
 4. Hydrotherapy, such as whirlpool baths and contrast baths.
5. Cryotherapy such as ice packs, ice massage and immersions.
6. Massage and manual therapies.
7. Preventative strappings and special protective devices.
8. Preventative conditioning and reconditioning programs.
9. Counseling on nutritional aspects and weight control.
10. Treatment protocols and standing orders are maintained in the licensed athletic
trainer’s office and the office of the Director of Athletics.

IV. RESPONSIBILITIES

Sports Health Care Services are responsible for the quality of the sports care given the student-
athlete and the instruction of the family and the student-athlete for home health care. The
licensed/licensed athletic trainer will prepare and maintain permanent records of the
evaluation findings and progress at regular intervals. Students enrolled at the college, the
original is retained in Sports Health Care Services for seven years. Confidentiality of records are
regulated pursuant to the State of Indiana law governing medical records with access restricted
to licensed health care providers with notations in the students records and the School Nurse
and Director of Athletics through a signed release form required of all student-athletes
participating in athletics.

V. METHODS OF REFERRAL

As part of the care of the individual student-athlete the licensed/licensed athletic

trainer may become aware of conditions that warrant Sports Health Care therapy.
Early referral of a student-athlete or sportsman will enhance the prognosis. All
prescriptions for treatment must be initiated by a licensed physician or the
licensed/licensed athletic trainer as the team physician’s designee. The
licensed/licensed athletic trainer is Obligated as a member of the health care team to refer
students to the team physician or designated medical specialist when appropriate.

Referral forms and injury reports will be made out in writing on the appropriate
forms from Sports Health Care Services. Referral and injury report forms may
be found in the student health services. All injury forms will be filled out by the
licensed/ licensed athletic trainer or team physician. Injuries and insurance
referrals are handled through Sports Health Care Services.

VI. COMMUNICATIONS

Sports Health Care Services can be reached by calling (direct contact number), or on campus
extensions (numbers of on campus telephone extensions).
 Sports Health Care Manual - Organization

Forward
Table of Contents

SECTION I Introduction

Goals and Functions of AHC

SECTION II Administrative Policies and Procedures

Appointment Scheduling in SIC – Policy and Procedure

Assumption of Risk – Policy and Procedure
Attendance for Medical Appointments and Therapy – Policy
Automatic Defibrillator Use - Policy
Dispensation of Non-Prescription Medications – Policy and Procedure
Policy on OTC Medications
Medications – Identified Medical Conditions
Emergency Plan – Policy and Procedure
Campus Wide
Road Trip Emergencies
Athletic Facilities
Lightening Safety
Evaluation of Injuries – Injury Management
Injury Evaluations Policy and Guideline
Injury Management and Injury Reporting Criteria
Injury Reports and Patient Care Documentation
Team Injury Reports and Coach’s Reports
Equipment Checkout – Policy and Procedures
Flu Plan
Medical Recordkeeping and Retention of Records
No Call – No Show for Medical Appointments
Physical Rehabilitation Referrals
Physician Protocols
Records Retention
Return to Play Guidelines
Treatment Logs – Policy and Procedures

SECTION III General Care Guidelines

Abdominal Injuries
Anaphylaxis
Cervical Spine
Facial Injury
Head Injury
Head Injury Management - Field
Concussion Testing Protocols – Policy Regarding Use
Headaches -Management
Hemorrhage Control and Management
Hypertension Management
Immediate Threats to Life
Medical Emergencies
Non-Life Threatening Conditions:
Contusions
Dislocations
Fractures
Heat Illness
Illness – General
Sprains
Strains
Wound Care
General care guidelines
Lacerations and closure using adhesive strips
Pain Management
Seizures
Shock
Suture Removal

General Care Policies:

Eating Disorders
Impaired Organ
Infection Control
Exposure to Communicable Disease
Hand Washing
MRSA
Universal Precautions
Insurance
Latex Allergies
Medical Disqualification
Needle Stick Injury
Substance Abuse – Anabolic Steroids
Substance Abuse – Alcohol and Recreational Drugs

SECTION IV Therapeutic Interventions

THERAPEUTIC MODALITIES

Cryotherapy
 Cold Packs, Ice massage and immersion
Sequential cold compression units
Thermotherapy
Moist heat pack use
Laser therapy
Hydrotherapy (Whirlpool)
Ultrasound
Electrical Muscle Stimulation
Trans-electrical Nerve Stimulation (TENS\MENS)

Phonophoresis
Therapeutic Massage

THERAPEUTIC EXERCISE & REHABILITATION GUIDELINES

Lower Extremity Programs:

Foot and Ankle:

Ankle Rehabilitation
Foot Care Guidelines
Post Operative Ankle Ligament Repair Rehabilitation
Plantar Fasciitis
Turf Toe Injury Care

Lower Extremity:
Anterior Compartment Syndrome
Lateral Compartment Conditions
Posterior Compartment Conditions
Shin Splints
Tibial Stress Syndrome

Knee:
Non-Surgical Management of the ACL Deficient Knee
ACL Patella Tendon Autograft Reconstruction Rehabilitation
ACL Hamstring Tendon Autograft Reconstruction Protocol
ACL Allograft Reconstruction Protocol
Meniscal Repair Rehabilitation
Arthroscopic partial medial or lateral meniscectomy
PCL Reconstruction Protocol
Patellofemoral Pain Syndrome (PFS)

Upper Leg and Thigh:

Adductor Injuries
 Hamstring Injuries
IT Band Syndrome
Quadriceps Injuries

Upper Extremity Programs:

Shoulder:
Arthroscopic Subacromial Decompression Rehabilitation
Arthroscopic Anterior Stabilization (with or without Bankart Repair)
Open Anterior Stabilization (with or without Bankart)
Posterior and Posterior Inferior Capsular Shift Protocol
Arthroscopic Debridement of Type I and III SLAP Lesions Protocol

Arthroscopic Labral Repair Protocol-Type II, IV, and Complex Tears

Acromioclavicular Joint Separation

Elbow:
Tennis Elbow
Ulnar Collateral Ligament Reconstruction Using Autogenous Graft

Hand and Wrist:

Hand and Digit Therapy Guidelines
Thumb and Wrist Therapy Guidelines

Thoraic and Back Rehabilitation:

Lower Abdominal Muscular and Soft Tissue Injuries

Chest Soft Tissue and Muscular Injuries
Lower Back Soft Tissue Therapy
McKenzie Treatment
Williams Series Protocols
Middle and Upper Back Treatments

Cervical and Facial Injury Therapy

Neck Care Program

Facial Muscular Injury Therapy

Additional Guidelines:

Return to Sport after Knee Injury / Surgery Guidelines

Running Injury Prevention & Return to Running Program Guidelines
 Running Injury Prevention Tips & Strength Training Program for Runners
Muscle Flexibility and Stretching

SECTION V ASSESSMENT AND TESTING

Knee and Lower Extremity

T-Test for Lower Extremity
Criteria for Return after Knee Surgery
Illinois Agility Test
SEMO Test
Ankle Stability and Balance
Lunge Test (Ankle Joint Function)
Hop Test (Agility)
BESS (Balance)
Shoulder Assessments
Elbow\Forearm and Wrist Function & Strength
Hand Functional Assessment
Back Injury Evaluations
Back pain decision tree
Back pain scales
Head and Neck Injuries
BESS
SCAT2
Glascow and Maddox Scales

SECTION VI SUPPORTING MATERIALS & REFERENCES

GUIDELINES, POLICIES & PROCEDURES
SECTION II - Administrative Policies and Procedures
 SECTION TABLE OF CONTENTS
Administrative Policies and Procedures

Appointment Scheduling in SIC – Policy and Procedure

Assumption of Risk – Policy and Procedure
Attendance for Medical Appointments and Therapy – Policy
Automatic Defibrillator Use - Policy
Dispensation of Non-Prescription Medications – Policy and Procedure
Policy on OTC Medications
Medications – Identified Medical Conditions
Emergency Plan – Policy and Procedure
Campus Wide
Road Trip Emergencies
Athletic Facilities
Lightening Safety
Evaluation of Injuries – Injury Management
Injury Evaluations Policy and Guideline
Injury Management and Injury Reporting Criteria
Injury Reports and Patient Care Documentation
Team Injury Reports and Coach’s Reports
Equipment Checkout – Policy and Procedures
Flu Plan
Medical Recordkeeping and Retention of Records
No Call – No Show for Medical Appointments
Physical Rehabilitation Referrals
Physician Protocols
Records Retention
Return to Play Guidelines
Treatment Logs – Policy and Procedures
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Automated External Defibrillator

Purpose:

To ensure appropriate patient care when the AED is used. To maintain and update AED
knowledge and proficiency among Licensed Athletic Trainers, coaches, and students assistants.

Policy:

1) Licensed Athletic Trainers are required to attend an American Heart Association Health Care
Provider or American Red Cross CPR/AED Professional Rescuer course, for their initial AED
training prior to their employment, thereafter a current American Heart Association Health
Care Provider or American Red Cross CPR/AED Professional Rescuer Basic Provider card will be
adequate.

2) American Heart Association Health Care Provider or American Red Cross CPR/AED
Professional Rescuer training will be reimbursed by the athletic department to meet the license
requirements of the licensed athletic trainers.

3) If a card is lost, stolen or mutilated, there will be a cost to issue a duplicate card.

4) Training attendance records will be maintained by each individual athletic trainer

References:

Public Access Defibrillation Guidelines, Federal Register: May 23, 2001 (Volume 66, Number
100); Notices Page 28495-28511

Untrained Volunteers Perform High Quality CPR When using an Automatic External Defibrillator
with a CPR Voice Prompting Algorithm, Circulation 2007; 116:II 437.
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Assumption of Risk

Purpose:

To define the assumption of risk as it applies to the student-athlete at (COLLEGE/SCHOOL).

Policy:

The athlete will read and sign the following form prior to any athletic practice or participation at
(COLLEGE/SCHOOL).

Procedure:

The assumption of risk form will be included in the student athlete’s medical packet. The form
will also be available in its single form in the athletic office.

Attachment:

Form
 UNIVERSITY INTERCOLLEGIATE ATHLETICS
Name: ______________________________________Sport: _______________Date:________________
ASSUMPTION OF RISK
BY ITS NATURE, PARTICIPATION IN INTERCOLLEGIATE ATHELTICS INCLUDES A RISK OF INJURY WHICH
MAY RANGE IN SEVERITY FROM MINOR TO LONG TERM CATASTROPHIC, INCLUDING PERMANENT
PARALYSIS FROM THE NECK DOWN TO DEATH. Although serious injuries are not common in supervised
intercollegiate athletic activities, it is possible only to minimize, not eliminate the risk. Participants can
and have the responsibility to help reduce the chance of injury. STUDENT-ATHLETES MUST OBEY ALL
SAFETY RULES, REPORT ALL ATHLETIC INJURIES TO THE LICENSED ATHLETIC TRAINERS, FOLLOW A
PROPER CONDITIONING PROGRAM, AND INSPECT ALL EQUIPMENT DAILY.
By signing this form, you acknowledge that you have read and understand this warning.

Athlete Signature: ___________________________________________ Date: __________________

Parent/Guardian: ____________________________________________ Date: __________________
MEDICAL CONSENT
MEDICAL CONSENT
I hereby grant permission to the University team physicians and Licensed Athletic Training staff to
provide medical care to myself in the event that I become injured while participating in intercollegiate
athletics. I understand that any treatment, medical, or surgical care that is provided to me will be done
only if it is considered medically necessary for my health and well being.

Athlete Signature: __________________________________________ Date:__________________

Parent/Guardian: ___________________________________________ Date:__________________
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize and request (COLLEGE/SCHOOL) licensed athletic trainers and / or their consulting
physician (s) to furnish any and all requested information to their physicians, or athletic trainers, which
directly pertains to my participation in athletics at (COLLEGE/SCHOOL). Said authorization shall include,
but is not limited to: information concerning my physical condition, illnesses, injuries, treatment,
hospitalizations, examination, X-rays, or other forms of diagnostic testing. I hereby fully discharge all
parties to whom this authorization extends from any and all penalties of breach of student-athlete
confidentiality.

Athlete Signature: ____________________________________________ Date:__________________

Parent/Guardian: _____________________________________________ Date:__________________
MEDICAL REFERRAL PROCEDURE EXPLANATION
REFERRAL PROCEDURE EXPLANATION
Any appointment made with specialists (orthopedist, podiatrist, etc.) will require a referral from the
university sports medicine staff and maybe from your insurance carrier or primary care physician. It is
your responsibility to acquire this referral. Participation in athletics at (COLLEGE/SCHOOL) is limited to
athletes covered by their own medical insurance. (COLLEGE/SCHOOL) athletics only offers catastrophic
and secondary accident insurance coverage to student-athletes.

Athlete Signature: _____________________________________________ Date:__________________

Parent/Guardian: _____________________________________________ Date:__________________
(05/2010)
Sports Health Care

Section: Administrative Policies and Procedures

Subject: Competition and Practice Coverage

Purpose:

The Sports Health Care Department will attempt to follow the following guidelines for providing
medical coverage to practices and competitions. Due to the size to the athletic training staff the
following guidelines are subject to change due to availability of a Certified Athletic Trainer (ATC)
and discussion with the Director of Athletics, head coach of the sport and head athletic trainer.

Policy:

1. The following competitions are required to have a certified athletic trainer providing
medical coverage, exhibition games may be an exception, and this will be determined by
the Director of Athletics, head coach and the athletic training staff:

 All home volleyball games (post-season play if available)

 All football/lacrosse contests (post-season play if available)
 All wrestling contests (post-season play if available)
 All hockey home matches (post-season play if available)
 All soccer matches (post-season play if available)
 All basketball games, men & women (post-season play if available)
 All regular season softball games (exception: Spring trips and tournament play)
 All regular season baseball games (exception: Spring trips and tournament play)
 All home track meets

When requested and possible an ATC will travel with those teams who do not have coverage on
away competitions.

When possible, due to the number of available ATCs, the following competitions will have
multiple ATCs:
 All home tournaments: soccer, wrestling, volleyball, M/W basketball, softball, and
baseball.
 Due to overlapping seasons the sport/team which is finishing its season will have first
priority to those just starting their season.
2. The following practices will have an ATC as medical coverage directly on-site:

 M/W Soccer
 Football/lacrosse
 Wrestling
 Ice Hockey
 Softball
 Volleyball
 M/W Basketball
 Baseball

The following practices will have medical coverage directly on-site or the ATC will be in the
athletic training room:

 M/W Cross Country/Track

 M/W Golf
 M/W Swimming/Diving
 Water Polo
 M/W Tennis

3. During competitions an (COLLEGE/SCHOOL) department personnel may need to travel

with a student-athlete to the hospital/ER should the student-athlete need to be
transported. This will be determined before the competition or immediately following
injury/incident. The person who goes with the student-athlete can be a “student
manager” or “volunteer coach” (as long as this coach has been recognized as part of the
department for the season), and an “assistant coach”, “head coach”, other department
personnel if willing and available (faculty-athletic rep., equipment manager, SID...), ATC
or parents/ guardian. This person is acting as the contact person at the hospital and
needs to have the ATC’s cell phone number.

An ATC will travel to the hospital/ER if available, however due to (COLLEGE/SCHOOL) guidelines
there must be an ATC present at the following competitions at all times:

 M/W Soccer
 Football/lacrosse
 Home Volleyball
 Wrestling
 M/W Basketball
 Ice Hockey
 Softball
 Baseball
Due to these guidelines, if there is only one (1) ATC at the competition another person will need
to be selected to travel with the student-athlete. Parents are preferred if willing and available,
otherwise it will be assigned department personnel.

The medical coverage of competitions and practices will be determined by NCAA requirements,
NCCAA requirements, (COLLEGE/SCHOOL) requirements and the risk of the sport, high risk sport
first, moderate risk second, low risk last. This will be determined by consulting theNCAA
guidelines and the injury ratio data in the NCAA Sports Medicine Handbook. Sports with an
increased risk of catastrophic injury potential will have priority.

References:

NCAA Sportsmedicine handbook

Internally generated document
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Dispensation of Non-Prescription Medication

Purpose:

To regulate and document the dispensing of OTC medication to (COLLEGE/SCHOOL) student-

athletes from the Sports Health Care.

Policy:

A small supply of some nonprescription over-the-counter medications is maintained in each

training room for student athletes until the athlete can obtain their own supply of OTC
medication. The licensed athletic trainer may carry a limited supply in the first aid/training kits.

The staff athletic trainers are the only personnel allowed to dispense a unit does amount (2-4
tablets) OTC medication. The ATC (Licensed Athletic Trainer) will check the athlete’s medical
history for any contraindication conditions prior to dispensing OTC medication. The ATC will
dispense the OTC medication depending on the signs and symptoms of the athlete and in
accordance to indications/contraindications of the medication.

The ATC will record the distribution in the Med Log (see attached) immediately following
dispensing the OTC medication. A Med Log form will be filled out for each athlete at the
beginning of their first year and be maintained until exit from the university or athletics.

Guidelines for Implementation:

The following is a guideline for staff to follow when dispensing over-the-counter medication.
A. Obtain history of injury or illness prior to dispensation.
B. Understand the action/type of the medication being dispensed.
C. Follow medication directions for dispensing medication.
D. Inquire:
1. Has the individual ever taken this medication before?
2. Is the individual allergic to any medication?

E. Aspirin should not be given to a young individual with flu-like symptoms or

chicken pox because of the possibility of Reye's syndrome.
 F. No more than a 1-day dose may be dispensed, at any one time. A physician
evaluation will be recommended if the athlete’s condition warrants medical
care.

G. A label must be attached to the zip-lock plastic pill pouch with the following
minimum information.
 Name of product (medication)
 Medication strength and number of pills

MEDICATIONS AVAILABLE IN TRAINING ROOMS

Acetaminophen, USP 500mg

Sting-Kill: Insect Bite Swab, 0.5cc (Benzocaine, Isopropanol, Menthol).
Naproxen Sodium (Aleve) 220 mg. caplets.
Loperamine
Gavisicon

IDENTIFIED MEDICAL CONDITIONS

Procedure

Obtain medical history as part of school physical and have athlete complete history form for
varsity sports participation (see appendix). Note medical condition requiring specific
medication.

As per standing orders, the athletic trainer has permission to carry an emergency dose of
medication for the prescribed athlete. As per standing order, in case of an emergency, the
athletic trainer may assist the athlete with the administration of prescribed medication. If, in
the judgment of the athletic trainer, there are significant signs/symptoms present, medical
assistance should be sought.

Conditions:

1. Diabetic Emergency
a. Recognition:
 Dizziness
 Drowsiness
 Confusion
 Rapid Breathing
 Rapid Pulse
 Feeling/looking ill
b. Management:
Conscious Victim:
 Check vital signs
 Give fluid or food containing sugar
  If no improvement in 5 minutes, call EMS
 Refer: EMR
Unconscious Victim:
 Check vital signs
 Manage patient as indicated.
 Call EMS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)

Over the Counter

Maximum
Generic Name Brand Name Single Dose Daily Dose Duration
Ibuprofen Advil, Unpin, 2 X200 mg 1200 mg Short
Motrin IB every 4–6 hr
Ketoprofen Actron, Orudis KT 1 X12.5 mg 75 mg Short
every 4–6 hr
Naproxen Sodium Aleve 1X 220 mg 660 mg Intermediate
every 8–12 hr

Prescription
Generic Name Brand Name Single Dose Daily Dose Duration
Bromfenac Duract 25 mg 150 mg Short
Diclofenac Potassium Cataflam 50 mg 200 mg Short
Diclofenac Sodium Voltaren 25, 50, 75 mg 200 mg Short
XR 100 mg
Etodolac Lodine 200, 300, 400, 500 mg 1200 mg Intermediate
XL 400, 600 mg
Fenoprofen Calcium Nalfon 200, 300, 600 mg 3200 mg Short
Flurbiprofen Ansaid 50, 100 mg 300 mg Short
Ibuprofen Motrin, Rufen 300, 400, 600, 800 mg 3200 mg Short
Indomethacin Indocin 25, 50 mg 200 mg Short/Intermediate
SR 75 mg
Ketoprofen Orudis, Oruvail 50, 75 mg 300 mg Short
SR 100, 150, 200 mg
Ketorolac Toradol 10 mg 40 mg Short
Meclofenamate Meclomen 50, 100 mg 400 mg Short
Mefenamic Acid Ponstel 250 mg 1000 mg Short
Nabumetone Relafen 500, 750 mg 2000 mg Long
Naproxen Sodium Anaprox 275, 550 mg 1375 mg Intermediate
Naproxen Naprosyn 250, 375, 500 mg 1500 mg Intermediate
Naproxen EC-Naprosyn, Naprelan 375, 500 mg 1500 mg Intermediate
Oxaprozin Daypro 600 mg 1800 mg Very long
Piroxicam Feldene 10, 20 mg 20 mg Very long
Sulindac Clinoril 150, 200 mg 400 mg Intermediate
Tolmetin Sodium Tolectin 200, 400, 600 mg 2000 mg Short

References:

NCAA Sportsmedicine handbook

Internally generated document
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Emergency Action Plan

Purpose:

To define the Emergency Action Plan as it applies to (college/school) athletics.

Policy:

To adhere to the following Emergency Action Plan:

Emergency Action Plan

SERIOUS INJURY IS ANY CONDITION WHEREBY THE ATHLETE'S LIFE MAY BE IN DANGER OR
RISKS PERMENANT IMPAIRMENT. THESE INJURIES INCLUDE BUT ARE NOT LIMITED TO:
CERVICAL SPINE INJURIES, HEAD INJURIES, LOSS OF LIMB, SERIOUS BLEEDING, SHOCK, SERIOUS
FRACTURES, HEAT STRESS, DIFFICULTY BREATHING, UNCONSCIOUSNESS, AND
CARDIOVASCULAR ARREST.

These emergency procedures are applicable at the following locations at (college/school):

Baseball Field, Softball Field, Soccer Fields, Tennis Courts, and Gymnasium

Emergency Personnel:

NATA Licensed and Licensed Athletic Trainer(s) are on site for practice and competition. EMS
personnel are available by calling 911. The athletic training staff is licensed by the American Red
Cross in CPR and AED for the Professional Rescuer. The (college/school) Athletic Training Staff
must be made aware of any athletic related emergency or injury that has occurred to any
student-athlete.

Emergency Communication: Utilize cellular phones only when on site with licensed athletic
trainer during practices and events. Due to HIPAA, please do not use any two-way radio to
communicate emergency and/or injury information. When using campus phones you must dial
9 to get an outside line, then number. Local EMS is 911. Or dial on campus (COLLEGE/SCHOOL)
Safety and Security using a campus phone. Campus security can directly contact local EMS.
Emergency Equipment: Supplies (AED, Crutches, Splint Bag, Kits, and OSHA Materials) located
on field and gymnasium with the athletic trainer. Additional emergency equipment is accessible
from the athletic training facilities in the sports centers.

Coaches: Communicate kit and practice schedule needs. The kits must be stocked and have the
appropriate secondary insurance information and the athletes primary insurance information.

The ATs are responsible for the stocking of the kit.

EMERGENCY PLAN RELATED INFORMATION

Weather Events:

In the case of inclement weather, the attending athletic trainer will recommend to the head
coach that practice or competition be terminated (the ultimate decision will be with the
attending athletic trainer). Decisions will be based on NCAA recommendations concerning
threatening weather. All personnel will immediately seek shelter at designated areas, (soccer
practice, baseball-dugout or locker room, softball-dugout or locker room, cross country-nearest
safe shelter to the area they are running at, tennis courts. Of note, once a game or
competition has begun, the umpire or official holds the responsibility of game termination. The
athletic director has the authority to override the official’s decision in the case of inclement
weather. Also, all issued weather warnings will be heeded by all of (COLLEGE/SCHOOL)’s
athletic teams. The staff athletic trainers are to go to each venue and warn them of any
impending thunderstorm or tornado warnings. Refer to the Lightning Safety Policy.

Location of all phones:

Phones for emergency actions are available for the following sports at the following locations in
the event that an onsite cellular phone is not accessible:
1. If a cellular phone is available it can be used at any location on campus to enact the EMS
by dialing 911.
2. Soccer Field: access to a phone is located within the Gymnasium in either the
administrative assistant’s office or the athletic training room.
3. Soccer practice field: access to a phone at the practice field is located across the street
in Gymnasium in either the administrative assistant’s office or the athletic training
room.
4. Gymnasium: phone access in the athletic training room.
5. Softball Complex: At this time there is no phone access at the site. The nearest location
is to send someone to call at the Gymnasium or Student Center Building to use the
phone, upstairs by the main entrance.
6. Baseball Field: Phone access is located in the Gymnasium in either the administrative
assistant’s office or the athletic training room.
7. Tennis Complex: Phone access is located in the Gymnasium in either the office or the
athletic training room.
Reference:
NCAA Sportsmedicine handbook
Internally generated document
Sports Health Care

Section: Administrative Policies and Procedures

Subject: Road Trip Emergency Medical Procedure

Purpose:

To establish a plan of action to handle injuries and severe illnesses that occurs to student-
athletes and athletic staff on trips off-campus.

Policy:

Whenever traveling with a university athletic team and an athlete requires hospitalization or a
physician's attention, you should always adhere to the following procedure.

 If at all possible, wait until you reach (town or city of school) before seeking medical
attention. However, the athlete’s health and well being is most important. If you are in
doubt, quickly seek the closest medical attention. Always err on the side of good judgment.

 If you are near the opponent's hometown, always seek help from the opponent's athletic
trainer and team physician, if possible.

 Always introduce yourself to the opponent’s athletic trainer and/or team physician before
the athletic contest begins. If an emergency arises, they will already be familiar with you.

 Always offer your services to an injured opponent, even if you are at his home facility. In
certain situations you may be the most knowledgeable in the area of sports medicine if the
opponent does not have an athletic trainer or physician present. Never force yourself or
your services on an injured opponent; leave the decision to them and their coach.

 Always carry insurance and medical history information on your athletes in the team’s field
first aid kit.

 Whenever (COLLEGE/SCHOOL) athletes need medical attention out of town, first file all bills
to his/her insurance, then any subsequent bills should be charged to the athlete at his/her
home address. Copies should be sent to the athletic insurance administrator at the
university’s athletic department address.
 If travelling without a certified athletic trainer; contact the team’s athletic trainer as soon as
possible if the injury is serious. The team’s athletic trainer may then contact the athlete's
parents and/or spouse.
 Attending athletic trainers may stay with the injured athlete at the hospital if necessary.
This should not be done unless there are other university athletic trainers to cover potential
injuries of the remaining team members. There is always the possibility of a more serious
injury to another team member.

 If the team’s athletic trainer cannot be reached by telephone, then the student-athletes
coach should contact another member of the athletic training staff as soon as possible.

 Only medical treatment that is absolutely necessary should be administered by non-

university medical personnel; if possible, all secondary medical treatment should be
handled by the university medical staff.

References:

NCAA Sportsmedicine handbook

Internally generated document
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Lightening Safety

Purpose:

The following policy is implemented to insure the safety of students, staff, and the public during
times of Lightning. It applies to all out-of-doors district activities including but not limited to
athletics, field trips, band practices/events, etc.

Policy:

The (college/school) employs the Thunderbolt lightning prediction and warning system as an
aid in predicting severe weather situations. Because of this, it is important that all college
athletic personnel understand the Thunderbolt warning system and take appropriate
precautions when the system indicates impending severe weather.

System Failure Procedure:

If there is lightning, but the Thunderbolt system does not activate - use the "30-30 Rule":

a. Thirty (30) second flash-to-bang - count the number of seconds from the time you see
the lightning (flash) until you hear the thunder (bang). If this number is 30 or less, all
personnel must evacuate the field and seek safe shelter.
b. Once you have evacuated the field, there should be a 30 minute wait from the last
lightning flash or thunderclap until resuming play.

Contest officials may use their discretion:

a. Even if the Thor Guard does not activate and there are more than 30 seconds from
flash-to-bang, once play has begun, the contest official has the authority to suspend
play based upon his/her determination of the safety of the participants.
b. In such situations, school officials should met with the game officials to determine the
length of the suspension and resumption of the contest.

Safe Shelter:
a. A safe location is a frequently inhabited building such as the school or out building.
b. A secondary choice is a fully enclosed vehicle with a metal roof such as a bus or car.
c. If no safe structure or vehicle is available, find a thick grove of small trees surrounded by
larger trees or a dry ditch. Assume a crouch position on the balls of your feet,
minimizing contact with the ground.
d. Do not take refuge under bleachers or near fences, light poles, or individual trees.

Sample Announcement for Severe Weather:

"Ladies and Gentlemen: We are requesting your assistance in seeking safe shelter due to
current weather conditions. Players are to meet with their coaches inside the building. We are
asking the fans not to remain on, under or near the bleachers, light poles, or fences. You are
encouraged to move inside the building or to your cars. When it is safe to continue, an
announcement will be made. The teams will warm up and play will then continue. Thank you
for your cooperation."

Reference: National Athletic Trainer’s Association Position Statement: Lightning Safety for
Athletics and Recreation (JNATA, 2000;35(4):471-477.
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Injury Management – Evaluation Guidelines

Purpose:

To establish a set of guidelines for the licensed athletic trainer to follow in the assessment of an
injury or illness to a student-athlete.

Policy:

The following guidelines are designed to be a roadmap of actions that the licensed athletic
trainer can follow when assessing an injury. Additional assessment techniques can be employed
based on the skill and training of the individual licensed athletic trainer:

I. PRIMARY ASSESSMENT
Responsiveness
Mental Status
Airways
Breathing Checks
Respiratory Arrest
Obstructed Airway (Heimlich)
Circulatory Checks/Pulses
External Cardiac Compression (ARC/AHA Basic Life Support)
Detection and Management of Life-Threatening Emergencies
Activation of E.M.S. System

II. SECONDARY SURVEY - Immediate Care of Injury/Medical Condition

Systems Check
Vital Signs
Stop, Look and Listen

III. STABILIZATION AND MANAGEMENT OR ATHLETE

First Aid Procedures
Monitor Status and Vitals
Treatment for Shock
Extrication/Transportation

IV. RECORDKEEPING
 Injury Report – see appendix for evaluation forms for athletes and non-athletes.
Insurance Information
Vital Medical Information (Medic-alert, etc.)
V. REPORTING GUIDELINES
Report on Current Status
Transport or Referral

References:

NCAA Sportsmedicine handbook

Internally generated document

See injury evaluation form

 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Injury Management – Injury Reporting Criteria

Purpose:

To establish a set of guidelines for the licensed athletic trainer to follow when determining if a
formal assessment of an injury or illness to a student-athlete will be required.

Policy:

The following guidelines are designed to be a roadmap of actions that the licensed athletic
trainer can follow when determining if a formal written assessing an injury is required.
Additional decision making paradigms may be employed based on the skill and training of the
individual licensed athletic trainer.

Criteria for Formal Injury Record:

1. Injury that causes a loss of participation time.

2. Injury or condition requiring a referral to a health care facility or provider.
3. Injury that may require an insurance claim to be filed on the student’s behalf.
4. Any medical emergency requiring a call to the local EMS system.
5. Conditions requiring rehabilitation or a patient care plan to be created.

References:

NCAA Sportsmedicine handbook

Internally generated document
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Injury Reports and Patient Care Plan - Documentation

Purpose:

To establish guidelines for documentation of information of (COLLEGE/SCHOOL) student-

athletes in the Athletic Training Rooms on campus.

Policy:

All athletes will fill out and sign all required athletic department documentation and forms.
This includes the following forms:

 Health History
 Physical Examination
 Acknowledgement of Financial Responsibility
 Release of information
 Assumption of Risk
 A copy of their Insurance Card
 Drug Testing Consent
 Sickle Cell Information and Waiver of Test
 Emergency Card

The above listed forms must be completed correctly and be on file with Sports Health Care
before the student-athlete is allowed to participate in their sport. An exit form must be signed
upon end of eligibility, leaving the university or their sport.

Upon an injury or sports related illness the licensed athletic trainer will:

1. Write the initial SOAP note within 24 hours of the injury. *

2. Fill out a secondary insurance claim form if injury warrants referral for medical/surgical
Intervention (see Policy on Referral for outside medical care)
3. Design and document treatment plan on the Patient Care Plan.
4. Record the patient’s progress on the Patient Care Plan progress notes.

*SOAP notes shall include the following information as defined by the BOCAT (Board of
Certification of Athletic Training) standards of practice:
a. Athlete’s name and any other identifying information.
 b. Referral source.
c. Date, initial assessment results and database.
d. Treatment plan and estimated length.
e. Treatment methods, results and revisions.
f. Date of discontinuation and summary.
g. Licensed athletic trainer’s signature.

SOAP notes shall be written for any athlete who has an injury severe enough to keep them from
practicing/playing for one day even if no treatment is warranted or if the athlete needs to be
sent to a physician/ER. This includes, but is not limited to: musculoskeletal injuries, neurological
injuries, head injuries, heat illness, internal injuries, eye injuries, dermatology conditions, and
dental injuries. (see Policy on Injury Reporting Criteria)

All confidential documentation will be kept in a secure location (see Policy on Confidentiality).

Reference: National Athletic Trainer’s Association Documentation Recommendations

 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Team Injury Reports and Coach’s Reports

Purpose:

To establish guidelines for dissemination of information on injuries to student-athletes to

coaches and athletic officials for statistical reference , risk management and injury management
care.

Policy:

When appropriate and in compliance with FERPA and HIPAA guidelines, the sports health staff,
team physicians and consultants will provide “need to know” information to coaches and
athletic officials concerning the physical and medical condition of student-athletes and their
ability to continue activity. This will include:

 Injured reported to sports health.

 Medical reports from providers providing care to student-athletes for conditions that would
affect their ability to participate in intercollegiate sports; including off-season physical
activity.
 Medical eligibility
 Medical disqualification (see policy on Medical Disqualification)
 College insurance and drug testing qualifications.

References:

NCAA Sportsmedicine handbook

Internally generated document
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Return To Play/Activity Guidelines

Purpose:

To establish guidelines for the safe return to sports activity for student-athletes. Provide a plan
of action for safe return under medical supervision.

Policy\Guideline:

Exclusion of an athlete because his or her physical condition increases the risk of personal harm
will be based on "reasonable medical judgments given the state of medical knowledge."

Relevant factors included in the decision to return an individual to sports activity will consider
the nature, duration, probability, and severity of harm from athletic participation as well as
whether the risk of injury can be effectively reduced by medication, protective equipment, or
other reasonable accommodations to enable participation.

The (COLLEGE/SCHOOL) team physicians\consultants can exclude an athlete if a medical

condition prevents the athlete from playing well enough to compete successfully in a sport or if
it poses a significant risk to other participants. (see medical disqualification policy)

Guidelines to test and assess the athletes ability to return to play include physiological and
fitness testing for musculo-tendinous conditions and neurological assessments for head and
neck injuries. Following the recommendations of the American College of Sports Medicine
return to play criteria the following guidelines will be addresses in decision-making paradigm in
determining return to play:

It is essential for Return-To-Play that the team physician confirm the following criteria:
• The status of anatomical and functional healing
• The status of recovery from acute illness and associated squealae
• The status of chronic injury or illness
• That the athlete poses no undue risk to the safety of other participants
• Restoration of sport-specific skills
• Psychosocial readiness
• Ability to perform safely with equipment modification, bracing, and orthose’s

It is essential that the rehabilitation professionals working with that student athlete to:
 Coordinate the development of a rehabilitation plan that is designed to:
 o Restore function of the injured part.
o Restore and promote musculoskeletal and cardiovascular function, as well as overall
well-being of the injured or ill athlete.
o Provide sport-specific assessment and training to serve as a basis for sport-specific
conditioning. (see The Team Physician and Conditioning of Athletes for Sports: A
Consensus Statement _2001)
o Provide for continued equipment modification, bracing, and orthose’s.
o Continue communication with the player, family, rehabilitation providers, athletic
trainers and coaches concerning the athlete’s progress.
o Include documentation

The following guidelines will assist the sports health care team determine if it’s safe for the
student – athlete to return to sports after a musculo-skeletal injury:

• The injury has healed.

• Pain and swelling are resolved.
• The injured joint has a full range of motion.
• There is full or close to full (90-percent) strength.
• Patients feel they can “trust” the injured leg. They don’t experience a sense of instability.
• The student-athlete understands the risk of re-injury associated with returning to sports.
• Precautions have been taken to reduce the risk of re-injury.

References:

NCAA Sportsmedicine handbook

Internally generated document
Also see specific criteria for individual injuries in policy manual.
 Figure 1
FIGURE 1. Three-step decision-based RTP model. The decision-based RTP model for an injury or illness is specific to the individual practitioner
making the RTP decision. The large black circles represent the states of nature elements (the circumstances under which a decision is made).

The RTP square represents the final decision that actually results in an action being taken. The texts on the far right are individual factors or
components identified from the literature that contribute information to the states of nature. These factors are grouped into Medical Factors,
Sport Risk Modifiers, and Decision Modifiers and are on the left because they represent the general concepts the clinician should focus on when
making a decision (the details are provided on the right).

In Step 1, the health status of the athlete is assessed through the evaluation of Medical Factors. For example, symptoms, signs, and testing
provide information on how much healing of the injury or illness has occurred. In

Step 2, the clinician evaluates the risk associated with participation. For example, the health status is usually heavily weighted when the known
reinjury and long-term sequelae risks are high (e.g., if an athlete participates with only partial healing). However, there are Sport Risk Modifiers
that also affect the risk associated with participation. For example, it may be possible to protect the injury with padding or to minimize risk by
changing the position of the player. Although the RTP decision is fundamentally based on the risk associated with participation, decision making
in all fields is based on a risk-benefit balance. There may be benefits to an athlete that affect what is considered an acceptable risk. For
example, play-off competitions may result in significant financial and nonfinancial gains.

Accounting for these Decision Modifiers (Step 3) is the final step in the process that leads to the actual RTP decision. Decision Modification is set
aside from the other steps because Participation Risk does not contribute information about Decision Modification, and Decision Modification
cannot be used to determine RTP except in the context of Participation Risk. Finally, the process is recursive, and decisions to not clear an
athlete for participation are revisited as the healing process continues; the decisions that allowed an athlete to play are revisited if symptoms or
signs recur or if the status of any of the Sport Risk Modifiers or Decision Modifiers is changed.
 Sports Health Care

Subject: Equipment Check-out

Section: Administrative Policies and Procedures

Purpose:

To contain athletic training equipment costs.

Policy:

1. All equipment that is used by the student-athlete must be checked out prior to use.
Examples are: cryocuffs, crutches, slings, braces, ace wraps, etc.

2. Equipment shall be in good condition upon return to the ATC (Certified Athletic Trainer).

3. The ATC will sign out the equipment and date the Equipment Checkout form upon
checkout.

4. The ATC will sign in the equipment and date the Equipment Checkout form upon return and
check the condition the equipment was returned.

5. Al equipment must be returned in person by the student athlete to the athletic training
staff, not to other personnel, in order for the equipment to be considered “returned”.

6. If the equipment is lost, the student-athlete will be charged for the replacement of the
item.

7. Final transcripts will be held on student-athletes who fail to return training room equipment

See equipment checkout card.

 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Flu Plan – (COLLEGE/SCHOOL)

Purpose:

To establish guidelines for dissemination of information on H1N1 Flu to (COLLEGE/SCHOOL)

student-athletes on campus. And provide a plan of action

Policy\Guideline:

H1N1 Influenza (Swine Flu) is a strain of influenza that can be spread up to two days
before symptoms occur and people are most infectious when they have a fever. Viral
shedding is highest 2 days after onset of symptoms and children shed more of the virus.

Measures for everyone to take to help reduce the spread of the influenza virus include:
1. Frequent hand washing with soap and water or alcohol gel if soap and water
are not available;
2. Frequent cleaning of commonly touched surfaces such as desks, counters,
door knobs, and telephones;
3. Covering coughs and sneezes with a disposable tissue or sleeve;
4. Avoiding touching your eyes, nose or mouth;
5. Avoiding public gatherings when you are ill;
6. Staying home if you are ill to help prevent passing the infection to others.
CDC recommends that people with influenza-like illness remain at home until
at least 24 hours after they are free of fever, or signs of a fever without the use
of fever-reducing medications such as Tylenol or ibuprofen.

Symptoms to be alert for include:

1. Fever (greater than 100 degrees)
2. Coughing
3. Sore throat
4. Gastrointestinal symptoms of nausea and diarrhea
5. Body aches
Groups that are considered high risk of complications from the flu:
1. Children under the age of 18 who are receiving long-term aspirin therapy and
who might be at risk for Reye’s syndrome
2. Pregnant women
3. Those suffering from: asthma, chronic pulmonary, cardiovascular, hepatic,
hematological, neurologic, neuromuscular or metabolic disorders.

When appropriate, special considerations may be made for those who are considered
High Risk individuals, by contacting the Human Resource Department or Office for
Campus Life.

Student Procedures to follow in the event that you experience the

Flu-like symptoms:

1. Do not attend classes and limit interactions with other people except to seek
medical care.
2. Call the Office for Campus Life to report that you will not be attending classes as
a result of having the flu. Campus Life will contact your instructors.
3. Do not return to classes until 24 hours after you are free of fever without the use
of fever reducing medications.
4. If possible, residential students with flu-like illness who live relatively close to the
campus should return to their home to keep from making others sick.
5. For those students who cannot leave campus, and do not have a private room,
temporary, alternate housing will be provided for ill students until 24 hours after
they are free of fever.
6. Campus Life personnel and/or Resident Life personnel will maintain contact with
the ill students including delivering their meals to them.
7. Students with flu-like illness should promptly seek medical attention if they have
a medical condition that puts them at increased risk of severe illness from flu, are
concerned about their illness, or develop severe symptoms such as increased
fever, shortness of breath, chest pain or pressure, or rapid breathing.
This information is based on information from the CDC.

For more information visit www.flu.gov or call 1-800-CDC-INFO (1-800-232-4636).

Additional information to consider if there is increased severity of H1N1.
SECTION III General Care Guidelines
 SECTION TABLE OF CONTENTS

General Care Guidelines

Abdominal Injuries
Anaphylaxis
Cervical Spine
Facial Injury
Head Injury
Head Injury Management - Field
Concussion Testing Protocols – Policy Regarding Use
Headaches -Management
Hemorrhage Control and Management
Hypertension Management
Immediate Threats to Life
Medical Emergencies
Non-Life Threatening Conditions:
Contusions
Dislocations
Fractures
Heat Illness
Illness – General
Sprains
Strains
Wound Care
General care guidelines
Lacerations and closure using adhesive strips
Pain Management
Seizures
Shock
Suture Removal

General Care Policies:

Eating Disorders
Impaired Organ
Infection Control
Exposure to Communicable Disease
Hand Washing
MRSA
Universal Precautions
Insurance
Latex Allergies
Medical Disqualification
Needle Stick Injury
Substance Abuse – Anabolic Steroids
Substance Abuse – Alcohol and Recreational Drugs
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Abdominal Injury

Purpose:

Recognize and manage possible abdomen al injures to student-athletes.

Objectives of Care

Pre-hospital care focuses on rapidly evaluating life-threatening problems, initiating resuscitative

measures, and initiating prompt transport to a definitive care site. The injured patient is at risk
for progressive deterioration from continued bleeding and requires rapid transport to a trauma
center or the closest appropriate facility, with appropriate stabilization procedures performed
en route.

Guideline:

External hemorrhage rarely associated with blunt abdominal trauma. If external bleeding is
present, control it with direct pressure. Note any signs of adequate systemic perfusion.
Consider intraperitoneal hemorrhage whenever evidence of hemorrhagic shock is found in the
absence of external hemorrhage.

Recognition:

 Vomiting, blood or "coffee grounds" in vomitus

 Pain accentuated with coughing, sneezing or movement
 Constipation or diarrhea, bloody or tarry black stool
 Rebound tenderness
 Psoa’s sign
 Abdominal distention, tenderness or
 Look for signs of impending shock:
 Rigidity
 Restlessness
 Clammy skin
 Hypotension
 Rapid pulse
 Rapid breathing
 Kehr's sign
 Pain shift to right lower abdominal quadrant, suggests possible
appendicitis
Quadrant Evaluation Guide – Specific Organs Found in Each Quadrant
 Table 1: Abdominal Anatomy and Location
Abdominal quadrant Anatomy
Left upper Spleen, pancreas, stomach, kidney, colon
Right upper Liver, gallbladder, pancreas, duodenum, kidney, colon
Appendix, ascending colon, small intestine, ovary,
Right lower
fallopian tube
Left lower Small intestine, descending colon, ovary, fallopian tube
Three central areas of the abdomen: epigastric (above the umbilical area), periumbilical
(around the umbilical area), suprapubic (above the pubic area)

Table 2: Solid and Hollow Organ Comparison

Solid organs Liver, spleen, pancreas, kidneys, adrenals, ovaries
Stomach, intestines, gallbladder, urinary bladder,
Hollow organs ovaries

Table 3: Abdominal Quadrant Pain & Possible Condition

Ascending colon, appendix, ovary, fallopian tube. Ectopic
Right lower quadrant
pregnancy, appendicitis
Pancreas, spleen, kidney. Gastritis, pancreatitis, splenic
Left upper quadrant
involvement
Sigmoid and descending colon, ovary, fallopian tube.
Left lower quadrant
Diverticulitis, ectopic pregnancy, ovarian torsion
Appendicitis, gastroenteritis, myocardial infarction,
Midline or periumbilical
pancreatitis
Flank pain Abdominal aortic aneurysm, renal colic
Pain originates in front and radiates Pancreatitis, appendicitis, posterior duodenal ulcer,
posteriorly ruptured abdominal aortic aneurysm
Suprapubic or lower abdominal
Ectopic pregnancy, ruptured ovarian cyst, others
discomfort

I. Management

Treatment should be guided by the patient's chief complaint, provider discretion and local
protocols. In all cases, the patient's airway, breathing and circulation should be supported.
Consider administering oxygen, especially in acute abdominal cases.
   
Because abdominal pain can cause varying levels of distress, the patient may experience
extremes in comfort and positioning. Providers will need to ensure the patient's safety if he is
unable to remain still while on an ambulance stretcher. This is especially important during
transport or when the stretcher is being moved.
  Place patient in a position of comfort
 Be alert for vomiting
 Give nothing by mouth (NPO)
 Handle patient gently
 Keep an accurate, detailed record of the secondary survey
 Immediate or delay referral, as indicated.

Acquire expeditious and complete spinal immobilization on patients with multisystem injuries
and on patients with a mechanism of injury that has potential for spinal cord trauma in the rural
setting, the pneumatic anti-shock garment may have a role for treating shock resulting from a
severe pelvic fracture.

II. REFERRAL - Signs/symptoms for immediate referral

Transport the patient to an appropriate receiving facility. In the event he refuses transport, inform him
of the possible consequences ranging from complications to the risk of death. Discussions like these
should be carefully documented in accordance with local protocol.

 Severe pain
 Presence of what appears to be radiating or referred pain
 Tenderness, rigidity, spasm of muscles
 Blood in urine or stool
 Sign of shock
 Rebound tenderness
 Prolonged discomfort, sensation of weakness or pulling groin
 Superficial protrusion or palpable mass
 Increasing nausea
 Vomiting
 Any perineal laceration (women).
 Any doubt regarding the nature and severity of condition.

References:

Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA. Practice management guidelines for
nonoperative management of penetrating abdominal trauma. Chicago (IL): Eastern Association for the Surgery of
Trauma (EAST); 2007. 49 p. (AHRQ Website)

John Udeani, MD, FAAEM  Assistant Professor, Department of Emergency Medicine, Charles Drew University of
Medicine and Science, University of California, Los Angeles, David Geffen School of Medicine. (Website:
Medscape)article: Blunt Abdominal Trauma Treatment and Management, Medscape.com article; October 25, 2011.
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Anaphylaxis

Purpose:

Provide guidelines for staff and the licensed athletic trainers at (COLLEGE/SCHOOL) on how to
manage an anaphylactic emergency with a student athlete, staff or visitor.
 To provide, as far as practicable, a safe and supportive environment in which student-
athletes at risk of anaphylaxis can participate equally in all aspects of the athletic program.
 To raise awareness about anaphylaxis and the college’s anaphylaxis management
policy/guidelines in the campus community.
 To engage with the parents/guardians and medical providers of each student-athlete at risk
of anaphylaxis in assessing risks, developing risk minimization strategies for the student.
 To ensure that staff have knowledge about allergies, anaphylaxis and the college’s
guidelines and procedures in responding to an anaphylactic reaction.

Guideline:

I. RECOGNITION:

Anaphylaxis is a severe, rapidly progressive allergic reaction that is potentially life threatening.
The most common allergens in college students are peanuts, eggs, tree nuts (e.g. cashews),
cow’s milk, fish and shellfish, wheat, soy, sesame and certain insect stings (particularly bee
stings).

The key to prevention of anaphylaxis in athletic and educational environments is knowledge of

the student-athlete who has been diagnosed as at risk, awareness of allergens, and prevention
of exposure to those allergens. A partnership between the student-athlete, parents/guardians
and medical providers is important in helping the student-athlete avoid exposure.

Adrenaline given through an adrenaline auto injector (such as an EpiPen® or Anapen®) into the
muscle of the outer mid thigh is the most effective first aid treatment for anaphylaxis.

Typical signs and symptoms are:

 Dyspnea (labored or difficulty breathing)

 Chest tightness
 Wheezes
 Feeling of lump in throat
 Hoarseness or strider (harsh, high-pitched sound)
 Swelling of eyelids, tongue, lips
 Nausea, vomiting, cramps, diarrhea
 Pruritus (severe itching)
 Urticaria (eruption of pale evanescent wheals; hives)
II. MANAGEMENT

Individual Anaphylaxis Health Care Plans

The sports health care department will ensure that an Individual Anaphylaxis Health Care Plan
is developed in consultation with the student-athlete, their parents/guardians, and medical
providers for any student-athlete who has been diagnosed by a medical practitioner as being at
risk of anaphylaxis.

The Individual Anaphylaxis Health Care Plan will be in place as soon as practicable after the
student-athlete is enrolled and where possible before their first day of college classes or any
sports activities.

Activities should include:

 Patient Education
 Medical ID Tag
 Personal emergency kit
 Lie patient flat, legs elevated
 Maintain open airway
 If patient has identified allergy, with emergency kit - help administer appropriate
medication

The student’s Individual Anaphylaxis Health Care Plan will be reviewed, in consultation with the
student-athlete:

 Annually, and as applicable,

 If the student’s condition changes,
 Immediately after the student has an anaphylactic reaction.
 Refer to appropriate medical provider if management issues occur if needed

It is the responsibility of the student-athlete and their family to:

• Provide an ASCIA Action Plan completed by the student’s medical practitioner with a
current photo,
• Inform the school if their athlete’s medical condition changes, and if relevant provide an
updated ASCIA Action Plan.

Communication

The sports health care department will be responsible for providing information to all staff and
student-athletes about anaphylaxis and development of the college’s anaphylaxis management
strategies.
Staff training and emergency response

Faculty and other college staff, who have contact with the student-athlete at risk of
anaphylaxis, are encouraged to undertake training in anaphylaxis management including how
to respond in an emergency.

At other times while the student-athlete is under the care or supervision of the college
including sporting events, work study duty, camps and special event days, the sports health
care department must ensure that there is a sufficient number of staff present who have up to
date training and know how to recognize, prevent and treat anaphylaxis. Training will be
provided to these staff as soon as practicable after the student-athlete enrolls.

Wherever possible, training will take place before the student’s first day at the college. Where
this is not possible, an interim plan will be developed in consultation with the student and their
parents/guardians.

The college’s first aid procedures and student’s ASCIA Action Plan will be followed when
responding to an anaphylactic reaction.

III. REFERRAL

Immediate

See Appendix for Additional Guidelines

Risk Minimization – Anaphylaxis Management Plan

The key to prevention of anaphylaxis is the identification of allergens and prevention of

exposure to them. The school can employ a range of practical prevention strategies to minimize
 exposure to known allergens. The table below provides examples of risk minimization
strategies.

Setting Considerations
Classroom  Display a copy of the students ASCIA Action Plan in the classroom.
 Liaise with parents/guardians about food related activities ahead of time.
 Use non-food treats where possible. If food treats are used in class, it is recommended that
parents/guardians provide a box of safe treats for the student at risk of anaphylaxis. Treat
boxes should be clearly labeled. Treats for the other students in the class should be
consistent with the school’s allergen minimization strategies (see Step 4 of ‘allergy
awareness’ in schools).
 Never give food from outside sources to a student who is at risk of anaphylaxis.
 Be aware of the possibility of hidden allergens in cooking, food technology, science and art
classes (e.g. egg or milk cartons).
 Have regular discussions with students about the importance of washing hands, eating
their own food and not sharing food.
 Casual/relief teachers should be provided with a copy of the student’s ASCIA Action Plan.
Cafeteria/Food  If schools use an external/contracted food service provider, the provider should be able to
Service demonstrate satisfactory training in the area of anaphylaxis and its implications on food
handling.
 With permission from parents/guardians, canteen staff (including volunteers), should be
briefed about students at risk of anaphylaxis, preventative strategies in place and the
information in their ASCIA Action Plans. With permission from parents/guardians, some
schools have the students name, photo and the foods they are allergic to, displayed in the
canteen as a reminder to staff.
 Liaise with parents/guardians about food for the student.
 Food banning is not recommended (see Step 4 of ‘allergy awareness’ in schools), however
some school communities may choose not to stock peanut and tree nut products (including
nut spreads) as one of the school’s risk minimization strategies.
 Products labeled ‘may contain traces of peanuts/tree nuts’ should not be served to the
student known to be allergic to peanuts/tree nuts.
 Be aware of the potential for cross contamination when storing, preparing, handling or
displaying food.
 Ensure tables and surfaces are wiped clean regularly.
Playing Fields and  The student with anaphylactic responses to insects should wear shoes at all times.
Campus Grounds  Keep outdoor bins covered.
 The student should keep open drinks (e.g. drinks in cans) covered while outdoors.
 Staff trained to provide an emergency response to anaphylaxis should be readily available
during non class times (e.g. recess and lunch).
 The adrenaline auto injector should be easily accessible from the yard.
 It is advised that schools develop a communication strategy for the yard in the event of an
anaphylactic emergency. Staff on duty need to be able to communicate that there is an
anaphylactic emergency without leaving the child experiencing the reaction unattended.
Refer to Case Studies provided for examples of how schools could manage this.

On-site events  For special occasions, class teachers should consult parents/guardians in advance to either
(e.g. sporting develop an alternative food menu or request the parents/guardians to send a meal for the
events, in school student.
activities, class  Parents/guardians of other students should be informed in advance about foods that may
parties) cause allergic reactions in students at risk of anaphylaxis as well as being informed of the
 school’s allergen minimization strategies (see Step 4 of ‘allergy awareness’ in schools).
 Party balloons should not be used if a student is allergic to latex.
 Latex swimming caps should not be used by a student who is allergic to latex.
 Staff must know where the adrenaline auto injector is located and how to access if it
required.
 Staff should avoid using food in activities or games, including rewards.
 For sporting events, it may be appropriate to take the student’s adrenaline auto injector to
the oval. If the weather is warm, the auto injector should be stored in a container to
protect it from the heat.
Off-site school  The student’s adrenaline auto injector, ASCIA Action Plan and means of contacting
settings – field emergency assistance must be taken on all field trips/excursions.
trips, excursions  One or more staff members who have been trained in the recognition of anaphylaxis and
the administration of the adrenaline auto injector should accompany the student on field
trips or excursions. All staff present during the field trip or excursion need to be aware if
there is a student at risk of anaphylaxis.
 Staff should develop an emergency procedure that sets out clear roles and responsibilities
in the event of an anaphylactic reaction.
 The school should consult parents/guardians in advance to discuss issues that may arise, to
develop an alternative food menu or request the parent/guardian to send a meal (if
required).
 Parents/guardians may wish to accompany their child on field trips and/or excursions. This
should be discussed with parents/guardians as another strategy for supporting the student.
 Consider the potential exposure to allergens when consuming food on buses.

Off-site school  When planning school camps, a risk management plan for the student at risk of anaphylaxis
settings – camps should be developed in consultation with parents/guardians and camp managers.
and remote  Campsites/accommodation providers and airlines should be advised in advance of any
settings student with food allergies.
 Staff should liaise with parents/guardians to develop alternative menus or allow students
to bring their own meals.
 Camp providers should avoid stocking peanut or tree nut products, including nut spreads.
Products that ‘may contain’ traces of peanuts/tree nuts may be served, but not to the
student who is known to be allergic to peanuts/tree nuts.
 Use of other substances containing allergens (e.g. soaps, lotions or sunscreens containing
nut oils) should be avoided.
 The student’s adrenaline auto injector and ASCIA Action Plan and a mobile phone must be
taken on camp.
 A team of staff who has been trained in the recognition of anaphylaxis and the
administration of the adrenaline auto injector should accompany the student on camp.
However, all staff present need to be aware if there is a student at risk of anaphylaxis.
 Staff should develop an emergency procedure that sets out clear roles and responsibilities
in the event of an anaphylactic reaction.
 Be aware of what local emergency services are in the area and how to access them. Liaise
with them before the camp.
 The adrenaline auto injector should remain close to the student at risk of anaphylaxis and
staff must be aware of its location at all times. It may be carried in the school first aid kit,
although schools can consider allowing students, particularly adolescents, to carry it on
Off-site school their person. Remember, staff still has a duty of care towards the student even if they carry
settings – camps their own adrenaline auto injector.
and remote  The student with allergies to insect venoms should always wear closed shoes when
settings (cont.) outdoors.
 Cooking and art and craft games should not involve the use of known allergens.
  Consider the potential exposure to allergens when consuming food on buses/airlines and in
cabins.

References:

National Institute for Health and Clinical Excellence Level 1A, City Tower, Piccadilly Plaza,
Manchester M1 4BT

S Shahzad Mustafa, MD  Physician in Allergy, Immunology, and Rheumatology, Rochester

General Medical Group; Clinical Assistant Professor of Medicine, University of Rochester School
of Medicine and Dentistry (Website: Medscape)

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Cervical Spine Injury

Purpose:

To provide the licensed athletic training and athletic staff a guide to the management of a
cervical injury to reduce the probability of further injury and disability.

Cervical Spine Trauma Commonly Seen in Athletes

Diagnosis and
Condition Mechanism Pathology Symptoms Treatment Return to Sport
Transient • Axial loading • Spinal cord • Motor and/or • MRI • Once symptoms
Quadriplegia • Hyperextension contusion and sensory, affecting • Steroids resolve, if there
(TQ) edema two to four limbs is no congenital
spinal stenosis
on MRI
Stingers • Traction or • Brachial plexus • Episode of upper • Observation • When symptoms
Burners compression of • Neuropraxia extremity unilateral • For recurrent resolve
brachial plexus numbness, weakness, episodes, EMGs
or burning pain and MRI of
brachial plexus
Cervical • Multiple episodes • Herniated disc, • Radiculopathy in • MRI • 1-level fusion, if
herniated of axial loads “hard” or soft upper extremity • Indications for asymptomatic
disc or twisting • Myelopathy surgery: • 2-3 levels of
injury to neck Myelopathy fusion, relative
Persistent pain contraindication
unresponsive to • More than
nonoperative 3 levels of
treatment fusion, absolute
contraindication
Cervical • Cervical loading • Ligament sprain • Neck pain • Cervical collar • Asymptomatic
strain/sprain or eccentric • Muscle strain • Radiculopathy • Flexion/extension and full-strength
muscle contraction • Tenderness and radiographs neck function
spasm once spasm restored
has resolved.
• If instability
returns, may
require fusion
Spear • Multiple episodes • Cervical stenosis • Neck pain • Therapy to restore • Controversial
tackler’s of cervical trauma • Loss of cervical • Catastrophic full ROM • May need to
spine with axial load lordosis cervical fractures avoid contact
• Cervical sports
spondylosis
Cervical • Multiple episodes • Narrowing of • Upper extremity • MRI demonstrating • If symptomatic
stenosis of trauma cervical canal by weakness spinal cord or asymptomatic
• Congenital hypertrophy of • Paresthesias contour with TQ,
ligaments and • Lower extremity deformation or contact sports
facet joints myelopathy obliteration of should be
• Disc encroachment local CSF space avoided

Guideline:

I. RECOGNITION
  Injuries may range from minor neck pain to paralysis. Utmost caution is necessary
when evaluating an athlete with neck pain.
 Decrease range of motion (torticollis)
 Shooting pain into posterior scalp, behind ear, around neck, or down shoulder
(brachial plexus trauma included)
 Radiating pain
 Loss of sensation
 Muscle spasm
 Insecure feeling of neck

Combined Evaluation of Head and Neck Injuries

1. Note exact time of injury. Management decisions are based on duration of symptoms.
2. Assess loss of consciousness. Management of unresponsive athletes should follow the ABCs of trauma care (i.e.,
check airway, breathing, and circulation).
3. Assess peripheral strength and sensation without moving the athlete’s head or neck.
4. Palpate the neck for asymmetric spasm or tenderness at the spine.
5. Assess isometric neck strength without moving the athlete’s head or neck.
6. Assess active range of motion at the neck.
7. Perform axial compression and Spurling test. If negative, athlete may be moved.
8. Assess recent memory and postural instability.
9. Inquire about symptoms such as headache, nausea, dizziness, or blurred vision.
NOTE: Steps 1 through 7 present a progressively greater risk to the spinal cord; therefore, if any part of the examination is
abnormal, instability is presumed and testing is stopped. If an abnormality is found at any point of the examination, the neck
should be immobilized and the patient prepared for transport to an emergency department.
EVALUATING NEUROLOGIC STATUS
Orientation vs. Recent Memory
Orientation questions concerning time and place, which are components of the Mini-Mental Status
Examination, are less sensitive in detecting concussion than questions that assess recent memory. A
series of questions can be used to assess recent memory in athletes with possible concussion:
1. At which field are we playing?
2. What team are we playing?
3. Which quarter (period, half) is it?
4. How far into the quarter (period, half) is it?
5. Which team scored last?
6. What team did we play last week?
7. Did we win?
Postural Instability
Measures of postural instability can be sensitive to the balance impairment associated with concussion. A
sophisticated force-plate system has been used in research settings to reliably detect concussion in athletes.

Symptoms of Concussion
Altered taste or smell Amnesia or memory Fatigue Headache Impaired coordination
difficulty Anxiety Attention deficit Blurred Intolerance to light or smells Lethargy Loss of
vision Delayed verbal or motor response consciousness Nausea, vomiting Postural
Depression Dizziness, vertigo Emotional instability Sleep disturbance Tinnitus Vacant
labiality or irritability stare
Adapted with permission from Practice parameter: the management of concussion in sports (summary statement).
Report of the Quality Standards Subcommittee, American Academy of Neurology. Neurology 1997;48:582.

II. MANAGEMENT
 Immobilize spine, if indicated
 Check for associated head injury
 Maintain airway, assist breathing if necessary
 Check pulse, begin CPR if indicated
 Monitor vitals and maintain neurologic watch
 Immediate or delay referral, as indicated

American Academy of Neurology Guidelines for Management of Concussion

Grade Description Management
1 Transient confusion Remove from contest and examine every five minutes. Allow return to play if all
No LOC Symptoms lasting symptoms clear in less than 15 minutes. After second grade 1 concussion, eliminate
 less than 15 minutes from play for one week.

2 Transient confusion Remove from contest and disallow further play that day. Examine on-site
No LOC Symptoms lasting frequently and reexamine the following day. Allow return to play if asymptomatic
more than 15 minutes for one week. Order imaging if symptoms last more than one week. After second
grade 2 concussion, eliminate from play until asymptomatic for two weeks.

3 Any LOC Transport to hospital if LOC is prolonged or if there is persistent confusion or

abnormalities on neurologic examination; send patient home if findings are normal
at initial evaluation. Disallow play until asymptomatic for one to two weeks
(depending on length of LOC). Order brain imaging if symptoms last more than one
week. After second grade 3 concussion, eliminate from play until asymptomatic for
one month.
LOC = loss of consciousness.

III. REFERRAL - Signs/symptoms for immediate referral

 Pain and tenderness over spinous process
 Deformity
 Numbness or paraesthesia
 Loss of sensation
 Diaphragmatic breathing
 Hypotension without other signs of shock
 Unconscious state

References:

North American Spine Society. NASS Headquarters: 7075 Veterans Blvd., Burr Ridge, IL 60527
Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care (2011 Guidelines)

Prehospital care of the Spine-Injured Athlete, Inter-Association Task Force for Appropriate Care
of the Spine-Injured Athlete, national Athletic Trainers Association (March, 2001)

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Chest injuries

Purpose:

Provide guidelines for the on-the-field management of a possible chest injury.

Guideline:

I. RECOGNITION

 Bruises (contusions) over chest; laceration(s) of chest wall

 Point tenderness to palpation
 Pain on breathing (inspiration/expiration) or coughing
 Respiratory distress
 Deviation of trachea
 Unequal expansion or paradoxical movement of the chest wall
 Decreased or absent breath sounds on one side
 Muffled heart sounds
 Distended neck veins (possible cardiac tapenade)
 Cyanosis (bluish skin color)
 Coughing up blood (bright red or frothy?)
 Shock
Chest wall injuries, summary
Condition Symptoms & signs Investigations Treatment
1st rib stress Shoulder and neck pain Bone scan Broad arm sling
fracture Neck root tenderness CT Soft neck collar
MRI Rest
Other rib stress fracture Posterior pain X-ray Rest
Tenderness Analgesia
Chest spring pain
Slipping rib syndrome Acute pain Nerve block Rest
Activity related Analgesia
Hooking test Technique modification
Steroid injection
Surgery
Sternal stress fracture Pain X-ray Rest
Local tenderness
Costochondritis Localized pain and Reassurance
tenderness Analgesia
Steroid injection
Condition Symptoms & signs Investigations Treatment
Tietze’s syndrome Localized pain and Reassurance
tenderness Analgesia
Inflammation Steroid injection

II. MANAGEMENT
  Maintain open airway
 Assist with breathing, if indicated
 Control external bleeding, if indicated (see Hemorrhage SOP)
 Cover sucking chest wounds, if indicated.
 Eviscerations - do not reduce, cover with moist/sterile dressing
 Immediate or delay referral, as indicated.

III. REFERRAL - Signs/Symptoms for immediate referral:

 Difficult or labored breathing

 Shortness of breath - inability to catch breath
 Severe pain in chest
 Diminished chest movement ("protective splinting by patient")
 Shifting or moving trachea
 Vomiting or coughing up blood
 Suspected "rib Fx”, costochondral separation
 Signs of shock
 Any doubt regarding nature and severity of the condition

References:

Demehri S, Rybicki FJ, Dill KE, Desjardins B, Fan CM, Flamm SD, Francois CJ, Gerhard-Herman
MD, Kalva SP, Kim HS, Mansour MA, Mohler ER, Oliva IB, Schenker MP, Weiss C, Expert Panel
on Vascular Imaging. ACR Appropriateness Criteria® blunt chest trauma - suspected aortic
injury. [online publication]. Reston (VA): American College of Radiology (ACR); 2011. 5 p (AHRQ
Website)

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Facial Injuries (Eye, Ear, Nose, Teeth, Jaw)

Purpose:

Identify a set of guidelines to manage facial injuries.

Guideline:

I. RECOGNITION

 General signs/symptoms: ecchymosis (discoloration), swelling (edema), protrusions,

impaled object, tenderness, instability, bleeding (hemorrhage).
 Eye: reduced visual acuity, eye movement irregular (tracking poorly), unequal or
sluggish pupil reaction, sensitivity to light (pain/photophobia)
 Maxillofacial (Jaw)/Teeth: loss of tooth, malocclusion, deformity, paraesthesia along
jawline.

II. MANAGEMENT

 Rule out head and neck injury

 Immobilize cervical spine, if indicated
 Maintain airway
 Control bleeding (see Hemorrhage SOP)
 Carefully rinse and replace avulsed skin and teeth
 Save amputated parts in moist, sterile dressing
 Clean and dress wound, if indicated
 Apply ice and compression, if indicated
 Immediate or delay referral, as indicated

III. REFERRAL - Signs/symptoms for immediate referral

Jaw: Obvious deformity

Crepitation
Severe swelling
Malocclusion
Loss of symmetry
Loss of jaw movement

Nose: Epistaxis
Foreign Body
Severe Swelling
Deformity, crepitation
Rhinorrhea
Ear: Hemorrhage
 Foreign body
Otorrhea
Swelling, hematoma formation
Infection or inflammation
Blanching of skin
Sudden hearing impairment: tinnitus, vertigo, sudden fullness in ear.
Teeth: Bleeding around tooth
Chipped, cracked, broken or dislodged
Malocclusion
Sensitivity to air and temperature
Eye: Foreign body
Suspected abrasion, laceration
Loss of vision
Double vision
Irregularly shaped pupil
ocular pain
Hemorrhage into anterior chamber
Restricted eye movement

References:

Treating and Preventing Facial Injury, American Association of Oral and Maxillofacial Surgeons
(AAOMS) (American Association of Oral and Maxillofacial Surgeons 9700 West Bryn Mawr
Avenue, Rosemont, Illinois 60018-5701) 2012

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Head Injury

Purpose:

To define the head injury guidelines as it applies to the (COLLEGE/SCHOOL) student-athlete.

Policy:

No head injury should be considered trivial. Concussions and the potential complications such
as second impact syndrome are potentially life-threatening situations. (NCAA Sports Medicine
Handbook 2001-2112). (COLLEGE/SCHOOL)’s ATC’s (Licensed Athletic Trainers) will follow the
Colorado Guidelines for assessing concussions. (COLLEGE/SCHOOL) ATC’s will assume any
unconscious athlete has a cervical spine injury and will then follow the protocol for cervical
spine injuries. With the exception of emergency transport, the ATC will set up any further
physician or neurologist appointments for determination of return to play status.

RECOGNITION

A. Mild Concussion:

 No loss of consciousness, stunned, dazed

 Momentary confusion
 No memory loss
 Mild transient tinnitus
 Mild transient dizziness
 Usually no unsteadiness

B. Moderate Concussion

 Transitory loss of consciousness « 5 Minutes)

 Slight mental confusion
 Mild retrograde amnesia
 Moderate tinnitus
 Moderate dizziness
 Varied unsteadiness

C. Severe Concussion

 Prolonged loss of consciousness (>5 Minutes)

 Severe confusion
 Prolonged retrograde amnesia
 Severe tinnitus
 Severe dizziness
 Marked unsteadiness
 D. Signs of Increasing Intracranial Pressure

 Deteriorating state of consciousness

 Slurred speech pattern
 Loss of sensation
 Hemiplegia or quadriplegia
 Headache
 Vomiting
 Unequal pupils
 Increase in blood pressure with slowing pulse
 Abnormal respirations or apnea

II. MANAGEMENT

A. Mild Concussion

 Athlete should recover quickly

 Monitor for post-concussion symptoms
 Remove from activity until symptoms have subsided

B. Moderate Concussion

 Monitor Airway
 Check vital signs
 Evaluate for cervical injury
 Remove from activity, return only per physician order
 Refer for evaluation

C. Severe Concussion

 Maintain airway
 Check vital signs
 Treat for cervical injury
 Remove from activity, return only per physician order
 Refer

D. Signs of Increasing Intracranial Pressure

 Maintain airway
 Remove from activity, return only per physicians order
 Refer
 Activate EMS and Transfer to EMR if indicated.
III. REFERRAL

A. Mild Concussion
Monitor athlete for 24-48 hours - refer if signs/symptoms change.

B. Moderate Concussion
Refer to physician for evaluation.

C. Severe Concussion
Immediate medical attention required.

D. Signs of Increasing Intracranial Pressure

Immediate medical attention, activate EMS or transfer to
EMR as soon as possible

References:

NCAA Sportsmedicine handbook

National Athletic Trainer’s Association Position Statement: Management of Sports-Related
Concussion. (2004)
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Heat Illness

Purpose:

Provide guidelines to prevent and manage possible heat illness conditions.

Guidelines:

I. RECOGNITION

 Headache, weakness, dizziness

 Confused, delirious or in a coma
 Temperature very high (over 105 degrees F)
 Skin hot, red, dry
 Pulse rapid; thready in classic heat stroke; bounding in exercise-induced heat stroke.
 Blood pressure usually normal early; hypotension in exercise-induced' heat stroke
 Tachypnea (rapid breathing)

II. MANAGEMENT

 Cool patient as rapidly as possible

 Move to cool, well ventilated location
 Remove as much clothing as possible
 Monitor vital signs closely
 Refer

III. REFERRAL

 Immediate
 Transport to hospital as soon as possible; continue cooling en route

Practice Guidelines:

Per heat index, practice intensity and duration will be adjusted according to heat index
indicators. Heat indicators will be measured using a sling psychrometer.
References:
National Athletic Trainer’s Association Position Statement: Exertional Heat Illnesses
National Athletic Trainer’s Association Position Statement: Fluid Replacement for Athletes
Inter-Association Task Force on Exertional Heat Illnesses: Concensus Statement
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Hemorrhage
Purpose:

To reduce the loss of blood and the possibility of shock and the onset of infection.

Guideline:

I. RECOGNITION

1. Closed Wound:
 Swelling
 Discoloration
 Deformity
 Signs of Blunt Trauma
2. Open Wounds:
 Abrasions
 Cuts
 Punctures
 Avulsions

II. Interventions and Practices Considered (Field Triage Decision Scheme):

1. Step one: assessment of the following physiologic criteria:

 Glasgow coma scale
 Systolic blood pressure
 Respiratory rate

2. Step two: assessment of the following anatomic criteria:

 Penetrating injuries proximal to elbow and knee: head, neck, torso, extremities
 Flail chest
 Multiple proximal long-bone fractures
 Crushed, de-gloved, or mangled extremity
 Amputation proximal to wrist or ankle
 Pelvic fractures
 Open or depressed skull fracture
 Paralysis

3. Step three: assessment of the following mechanism-of-injury criteria:


Falls (height)

High-risk collision with other player or object (apparatus)

Struck with external object at high velocity (pitched or hit ball)
4. Step four: assessment of special patient or system considerations:

 Anticoagulation and bleeding disorders

 Burns
 Time-sensitive extremity injury
 Pregnancy >20 weeks
 Emergency Medical Services (EMS) provider judgment
 5. The following criteria were considered but removed from the revised decision
scheme:

 Step One: Physiologic Criteria

 Revised Trauma Score <11
 Step Three: Mechanism of Injury
 Sudden and severe impacts
 Extrication off the court or playing field time >20 minutes
 Step Four: special considerations
 Cardiac disease
 Respiratory disease
 Insulin-dependent diabetes mellitus
 Morbid obesity
 Immuno-suppressed patients

II. MANAGEMENT

1. Closed Wound:

 P.R.I.C.E.R.
 Protect area from further trauma with splint, wrap, pad, or crutches.
Rest affected part to reduce bleeding
 Ice compact for pain and swelling control
Compression for swelling control
 Elevation (if not fracture suspected).
Rehabilitation begins with good initial care.

2. Open Wounds:

 Apply steady, direct pressure over wound

 Elevate part, if possible, and if condition allows (splint fractures)
Apply ice, if indicated
 If bleeding persists, apply compression and Refer
 Monitor vital signs
Treat for shock

III. REFERRAL

1. Closed wounds:

Contusions, per standing orders, as soon as possible, as indicated by severity and

any possible Internal Injuries (Kehr's sign, blood in urine, etc.)

2. Open Wounds:

 Minor: if indicated.
  Moderate: Refer as quickly as possible
Severe: Immediate

Program Policy:

CDC universal precautions/OSHA Blood borne Pathogen Standards for handling human blood
should be followed. (See NCAA guidelines)

Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP,
Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW, National Expert Panel on Field Triage,
Centers for Disease Control and Prevention. Guidelines for field triage of injured patients.
Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep 2009 Jan
23;58(RR-1):1-35.
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Hypothermia
Purpose:

Provide guidance in the management of hypothermia.

Guideline:

A. Assessment of Patient
1. Mild Hypothermia: A patient who is cold and has the following signs is
considered to have mild hypothermia:

a. Alert
b. Vital signs not depressed
c. Vigorous shivering

2. Moderate or Severe Hypothermia – consistent with a temperature below 90 oF

(32o C). A patient who is cold and has any of the following signs or symptoms is
considered to have moderate to severe hypothermia:

a. Depressed vital signs, such as a slow pulse and/or slow respiration.

b. Altered level of consciousness, including slurred speech, staggering gait,
decreased mental skills, or the lack of response to verbal or painful
stimuli.
c. No shivering in spite of being very cold. (Note: This sign is potentially
unreliable and may be altered by alcohol intoxication.)

B. Basic Treatment for Hypothermia

1. Prevent further heat loss:

a. Insulate from the ground;

b. Protect from the wind, eliminate evaporative heat loss by removing wet
clothing (once the patient has adequate shelter);
c. Insulate the patient, including the head and neck;
d. Cover the patient with a vapor barrier (such as a blue tarp, a large piece
of plastic, large garbage bags etc.); and
e. Move the patient to a warm environment.

2. Activate the emergency medical services system to provide transport to a

medical facility.

3. Do not give alcohol or permit patient to use tobacco.

4. Oxygen should be administered, if available. Oxygen should be heated to a

maximum of 108°F (42°C) and humidified if possible. Heating oxygen without
 humidification is not an effective warming technique.

5. Splinting should be performed, when indicated, in an anatomically neutral

position if possible with caution to prevent additional injuries to frostbitten
tissues.

C. Treatment for Mild Hypothermia

1. Treat the patient as outlined in Management Section.

2. If there is no way to get to a medical facility, or if it will take more than 30

minutes for the patient to arrive at a medical facility, rewarm the patient with
one or more of the following methods:
a. Vigorous shivering is a very important method for increasing heat
production. Shivering should be fueled by calorie replacement with fluid
containing sugars (sugar content is more important than hot drinks);
b. Do not allow the patient to drink liquids unless the patient is capable of
swallowing and protecting the airway.
c. Apply heat to areas of high surface heat transfer including the
underarms, sides of the chest wall, the neck and groin;
 d. Place the patient in a sleeping bag and provide close skin-to-skin contact
with a warm body. The patient should not be placed in a sleeping bag
with another individual who is hypothermic. This method may not speed
core warming in a vigorously shivering patient but will slowly warm a
nonshivering patient;
e. Consider a warm shower or a warm bath for the patient, if he or she is
alert and mobile; and
f. Mild exercise, such as walking or stepping up and down on an object, will
produce heat and may be helpful. This should only be conducted after
the patient is dry, has had calorie replacement, and has been stable for at
least 30 minutes.

D. Treatment for Moderate to Severe Hypothermia with Signs of Life (Pulse or

Respirations):

1. Treat patients who are hypothermic very gently (do not rub or manipulate
extremities, or attempt to remove wet clothes without cutting them off).
2. Obtain a core temperature as trained and authorized.

3. Treat the patient as outlined in sections B and C above with the following
exceptions:

a. Do not allow the patient to sit or stand until rewarmed (do not put in
shower or bath).
b. Do not give the patient oral fluids or food.
c. Do not attempt to increase heat production through exercise, including
walking.

4. Reassess the patient's physical status periodically.

5. Transfer to a medical facility as soon as possible.

E. Treatment for Severe Hypothermia with No Life Signs:

1. Treat the patient as outlined in Section B. Handle very carefully.

2. Check for respiration and signs of circulation for 60 seconds. If the patient is not
breathing and has no signs of circulation, give 3 minutes of ventilation. Recheck
for respiration and signs of circulation for a further 60 seconds. If the patient still
is not breathing and has no signs of circulation and there are no
contraindications, continue ventilations. Start chest compressions only if the
patient will not receive definitive care within 3 hours.

3. Use mouth-to-mask breathing or bag-valve-mask (BVM) with oxygen when

giving ventilations. Care must be taken not to hyperventilate the patient as
 hypocarbia can reduce the threshold for ventricular fibrillation in the cold heart.
 When using a BVM, ventilate the hypothermic patient at 6 breaths per
minute (half the normal rate).
 When using mouth-to-mask ventilations to the hypothermic patient, give
12 breaths per minute.

4. If the rescuers are authorized to use an automated external defibrillator and the
device states that shocks are indicated, one set of three stacked shocks should
be delivered. If the core temperature of the patient cannot be determined or is
above 86 °F (30o C), treat the patient as if normothermic. If the patient's core
temperature is below 86 °F (30o C), discontinue use of the AED after the initial
three shocks until the patient’s core temperature has reached 86 °F (30 oC).

5. If CPR has been provided in conjunction with rewarming techniques for more
than 30 minutes without the return of spontaneous pulse or respiration, contact
the base physician for recommendations. If contact with a physician is not
possible,

References

CDC: "Winter Weather: Hypothermia."

Red Cross: "Frostbite and Hypothermia."
Healthwise: "Hypothermia."
National Institute on Aging: "Age Page -- Hypothermia: A Cold Weather Hazard."
Merck Manual: "Hypothermia."
Journal of the American Medical Association: "Guidelines for Cardiopulmonary Resuscitation."
Journal of the American Medical Association: "Emergency Cardiac Care."

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Hypertension

Purpose:
To provide guidance to licensed athletic trainers and staff on dealing with student5s who have
been medically identified to have hypertension.

Policy:

Students who have been identified as having high blood pressure or hypertension will have the
diagnosis added to the student’s permanent medical record. A management plan will be
developed to monitor the student’s blood pressure and record the readings for reference.
Students that have blood pressure readings above the attending physician’s safe parameters
will be reported to the attending physician and a course of further action developed. Students
with conditions that cannot be adequately managed will be recommended for medical
disqualification.

Procedure:

When the attending physician report and recommendation for monitoring is received the
athlete will be scheduled for daily blood pressure checks in the athletic training room. The B/P
readings will be kept as part of an evaluation and care a plan using the current injury evaluation
form. The form will be kept in the athletic training room in a secure location. Significant
changes in B/P will be reported ASA to the attending physicians with the date and time of the
call recorded on the patient care plan.

FACTORS TO CONSIDER WHEN MANAGING ATHLETES WITH HYPERTENSION

Incidence of hypertension is low in athletes but advances with age.

In evaluating athletes it’s important to rule out the intake of substances that affect blood
pressure.
Evaluations must include echocardiogram and exercise stress testing.
Sports activity is permitted depending on the presence of well controlled blood pressure values
and low CV risks.
Pharmacological interventions need to be well monitored by the athlete’s medical provider.
Participation decreases CV risks it can increase the chance of cardiovascular incidents.

Taddei, Stefano, University of Pisa, Italy “Hypertension in Special Populations: Athletes”,

presented at ESC Congress 2010 Stockholm; cardiology congress; cardiovascular disease,
European Society of Cardiology.
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Immediate Threat to Life

Purpose:
To provide guidance to licensed athletic trainers and staff on dealing with immediate life
threatening conditions.

Policy:

The licensed athletic trainer, per N.A.T.A. requirements, must maintain a current CPR
certification card from either the American Red Cross (ARC), the American Heart Association
(AHA) at the Professional Rescuer level. All coaches per NCAA guidelines must have a current
certification in CPR.

Guidelines:

IMMEDIATE THREATS TO LIFE

Examples:

Airway Obstructions
Respiratory Arrest
Cardiac Arrest
Hemorrhage
Shock

In conditions where there is exposure to blood, body fluids or mucous membranes, universal
precautions based on the Centers for Disease Control (CDC) recommendations or the
Occupational Safety and Health Administration Bloodbourne Pathogen Standards, as the case
may be, should be followed.

In addition the guidelines from the NCAA and NJCAA dealing with blood and body fluids, and all
rules pertaining to sporting events and specific rules dealing with blood and fluids should be
adhered to as well.

I. RECOGNITION/MANAGEMENT

The licensed athletic trainer or staff shall assess a patient for the presence of a life-threatening
condition by conducting a primary survey. Basic life threatening conditions include:

Airway obstruction
Respiratory arrest
Cardiac arrest
Anaphylactic shock
Severe bleeding/shock
If the primary survey identifies a life-threatening condition, the licensed athletic trainer or
his/her designee, per standing orders, shall provide care to the level of their training (preferably
basic life support) and activate the E.M.S. system. Basic Life Support includes management of
an obstructed airway, rescue breathing and Cardiopulmonary Resuscitation (CPR).

Basic Life Support efforts should continue until one of the following occurs:

1. Victim recovers, regains breathing and functional pulse.

2. Resuscitation efforts have been transferred to another qualified person.
3. A physician or physician directed person (e.g. paramedic) or team assumes
responsibility.
4. Victim is transferred to trained personnel involved with emergency medical
service (EMS).
5. Rescuer is exhausted and unable to continue BCLS.

II. REFERRAL

Activate EMS System

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Medical Emergencies

Purpose:

Provide athletic trainers and staff with guidelines to follow in dealing with medical
emergencies.

Guideline:

On Main Campus

 Report all medical emergencies occurring on campus to the Office for Campus Life after
calling 911 or 9-911.
 Always determine and report if the person is conscious or unconscious.
 In a life or death situation, Call 911 or 9-911, if the phone system being used requires dialing
a “9” for an outside line
 The Office for Campus Life will dispatch officers to the scene.
 All Campus Life staff is trained in first aid and CPR.
 The Office for Campus Life will call the EMS squad whenever necessary.
 The Office for Campus Life staff, or other licensed university personnel, will provide first aid
until the EMS squad arrives.
 The EMS squad crew will take over treatments of injured or sick person and transport them
to a local hospital, whenever necessary.
 Students, visitors, and employees needing treatment beyond first aid will be sent to a local
medical establishment or hospital for treatment.

Off Campus Sites

 Call 911 or 9-911, if the phone system being used requires dialing a “9” for an outside line,
and request an EMS unit
 Report accident or illness to the Office for Campus Life immediately after situation is under
control. Accident forms must be filled out by the supervisor or instructor and filed with the
Campus Life Director or Human Resource Coordinator.

Emergency Phone Numbers

Call 911 or 9-911, if the phone system being used requires dialing a “9” for an outside line

Non-emergency Phone Numbers

Campus Life Office
(XXX-XXXX)
Office Hours

Monday-Friday
 8:00 A.M.-4:30 P.M.
Local Police Officer On-Call
(XXX-XXX-XXXX)
(COLLEGE/SCHOOL) Security
(XXX-XXX-XXXX)

Specific Guidelines for Care (see individual policies)

 Abdominal Pain
 Adverse Drug Reactions
 Anaphylaxis
 Asthma and Allergies
 Back injury
 Back Pain
 Bites and Stings
 Broken Bones
 Burns
 Choking (Heimlich Maneuver)
 Colds and Flu
 Cuts and Abrasions
 Diabetic Emergencies
 Drowning
 Earaches and Ear Infections
 Electrical Injury-Shock
 Eye Emergencies and Wounds
 Fainting
 Fever
 Food Poisoning
 Foreign Bodies in Nose or Ears
 Head Injury
 Headache
 Heart Attack
 Heat-Related Illnesses
 Hypothermia-Frostbite
 Neck pain
 Nosebleeds
 Poisoning
 Puncture Wounds
 Rashes
 Seizures
 Shock
 Snake Bites
 Sore Throat
 Sprains and Strains
 Stroke
 Suicide
 Sunburn and Sun Safety
 Teeth (Dental Emergencies)
 Vomiting and Diarrhea

References

What to Do in a Medical Emergency, American College of Emergency Physicians

2121 K Street, NW, Suite 325, Washington, DC 20037 www.EmergencyCareForYou.org
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Contusions
Purpose:

To provide general guidelines in the management of contusions on various parts of body to

reduce complications from edema and hematoma in soft tissue.

Guidelines:

I. RECOGNITION

A. Mild (1 degree)
1. Little or no spasm
2. Mild disability
3. Mild localized tenderness
4. Little or no swelling
5. Mild pain with normal motion
6. No abnormal motion
7. Injury to skin and underlying tissues from a direct blow resulting in minor
tissue damage

B. Moderate (2 degrees)
1. Some loss of function
2. Pain on normal motion
3. Moderate swelling
4. Muscular spasm
5. Localized tenderness
6. Limitation of motion; decreased flexibility
7. Palpable lump (hematoma)
8. Injury to skin and underlying tissues from a direct blow resulting in tissue
damage with considerable hemorrhage and spasm.

C. Severe (3 degrees)
1. Massive hemorrhage; definite enlargement and swelling
2. Point tenderness
3. Inability to move part
4. Muscle spasm and tightness in form of a lump
5. Severe pain
6. Injury to skin and underlying tissues from a direct blow resulting in severe
tissue blood vessel damage.

II. MANAGEMENT

1. Initial
P - Protect or stabilize original injury from additional trauma (Soft splint)
R - Rest
 I - Ice Application Mild contusions do not need medical attention. Ice should be
applied to the injury within the first 24 to 48 hours.
C - Compression Elastic compression wrap (either wet wrap or dry wraps) A
compression bandage may help reduce swelling during the first 2 to 3 days.
E - Elevation of limb, if applicable
R – Rehabilitation

2. Use of adjunct therapy to reduce edema and hematoma:

 Use of micro current therapy for edema reduction applied across the site of
trauma.
 After 24 to 48 hours, application of heat (e.g., hot packs, hot showers,
heating pads, and hot whirlpool bath) may help speed reabsorption of the
blood by increasing circulation to the injured area.
 Non-narcotic medication such as acetaminophen (analgesics) may be
administered for pain. Aspirin and non-steroidal anti-inflammatory drugs are
usually avoided since they can contribute to continued bleeding.
 Therapeutic ultrasound is often used to promote tissue repair by increasing
the number of new tissue cells and encouraging protein synthesis involved in
healing. Although enhanced cell proliferation has been shown, this can lead
to increased scar tissue and some studies have shown no benefit to outcomes

3. Stabilize:
 Rigid splint
 Crutches Elevation and protected movement, use of crutches for severe
lower extremity injury.
 Sling and/or sling and swathe
 Refer as indicated
4. On-Going:
 Treat per Rehabilitation SOP and/or physician's orders.
 Biocompress – cold sleeves, elevated 45 minutes x 3 times daily
 HVGS on positive with dispersal in small of back and active electrode below
site of trauma.
5. Approximate recovery times:
 Mild Contusion - 1 to 3 days
 Moderate Contusion - 7 to 10 days
 Severe Contusion - 4 to 6 weeks
 Refer, PRN

III. REFERRAL - Signs/Symptoms for evaluation

1. FOOT/ANKLE/LOWER LEG
 Gross deformity
 Suspected fracture or dislocation
  Significant or unexplained swelling
 Significant pain, persistent pain - especially in compartments (anterior)
 Decreased circulation, motor function or sensations in leg or foot
 Joint instability
 Crepitation
 Suspected mal-alignment or structural abnormalities
 Any doubt regarding severity or nature of the injury
 Refer as indicated

2. KNEE
 Gross deformity
 Significant or unexplained swelling
 Loss of mot ion, weakness
 Joint instability
 Significant pain
 Abnormal sensations, i.e., clicking, popping, grating
 Crepitation
 Locked knee
 Any doubt regarding severity or nature of the injury
 Refer as indicated

3. HIP/THIGH
 Gross deformity
 Significant loss of motion
 Severe disability
 Noticeable and/or palpable mass, depression
 Suspected fracture
 Injury that does not respond to treatment within 2 to 3 weeks
 Significant or unexplained swelling
 Crepitation
 Any doubt regarding severity or nature of the injury
 Refer as indicated

4. SHOULDER
 Suspected fracture, separation or dislocation
 Gross deformity
 Significant loss of motion, weakness
 Significant or continued (persistent) pain
 Joint instability
 Abnormal sensations in distal extremity
 Significant or absent distal pulse
 Crepitation
 Any doubt regarding severity or nature of the injury
  Refer as indicated

5. ELBOW/FOREARM
 Gross deformity
 Significant or unexplained swelling
 Significant or persistent pain
 Significant loss of motion, weakness
 Joint instability
 Suspected fracture and/or dislocation
 Abnormal sensations at or distal to elbow
 Crepitation
 Any doubt regarding severity or nature of the injury
 Refer as indicated

6. WRIST/HAND
 Gross deformity
 Suspected fracture and/or dislocation
 Significant or unexplained swelling
 Significant or persistent pain
 Joint instability
 Loss of motion, weakness
 Crepitation
 Any doubt regarding severity or nature of the injury
 Refer as indicated

References

Earl, Brett J., et al. "Contusions." eMedicine. Eds. Joseph P. Garry, et al. 8 Dec. 2005. Medscape.
9 Dec. 2008 <http://emedicine.com/sports/topic28.htm>

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Dislocations – Shoulder

Purpose:
Guidelines for the management of shoulder dislocations from sports injuries.

Guidelines:

I. RECOGNTION
 Deformity, sometimes fixed or locked in position
 Loss of function or inability to use joint
 Pain
 Loss of sensation or parasthesia in distal part
 Diminished or absent distal pulse

Determine if shoulder dislocation is present :

 Evaluate neurovascular status (before and after)
 Visually inspect and palpate for deformity
 Check Range of Motion
If dislocated/subluxed prepare for reduction
 Instruct athlete what is about to happen
 Use technique most familiar with

II. MANAGEMENT
 Ice
 Immobilize/splint in position
 Reduction not advised unless trained and understanding specific orders of
team/consulting physicians:
Techniques: attempt only once:
 External Rotation- Place athlete on their back with the affected arm abducted to about 90
degrees, using one hand to maintain the adducted position and other hand to guide the arm
through slow external rotation with constant axial rotation
 Spaso- Place athlete on their back with the affected arm forward flexed 90 degrees and
gentle longitudinal traction and external rotation are applied

AFTER REDUCTION:
 Immobilize with sling
 Recheck neurovascular status
 Refer athlete to Emergency Department if NOT reduced
 Refer to team physician if reduced

III. REFERRAL
 Immediate

References

John P. Cunha, DO, FACOEP and David A Halperin, MD, Adjunct Instructor, Department of
Emergency Medicine, Indiana University Medical School; Consulting Staff, Department of
Emergency Medicine, Memorial Hospital of South Bend. Shoulder Dislocation; Website:
http://www.emedicinehealth.com

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Dislocations -Patella

Purpose:

Guidelines for the management of shoulder dislocations from sports injuries.

Guidelines:

I. RECOGNTION
 Deformity, sometimes fixed or locked in position
 Loss of function or inability to use joint
 Pain
 Loss of sensation or parasthesia in distal part
 Diminished or absent distal pulse
 Rapid, acute swelling.
 Extreme pain initially until relocation occurs.
 Continued pain along medial (inside) ligaments.
 Discoloration medially at site of ligament injury.
 Sense of instability and apprehension that problem will recur.

II. PRESENTATION:
 Patella displaced laterally
 Knee flexed

III. REDUCTION:
 Simply extending the knee is often all that is necessary
 Next apply medially directed pressure onto patella.
 
IV. AFTERCARE:
 Check Neurovascular status
 Immobilize in extension for referral to ED or team physician

References

New England Musculoskeletal Institute, Medical Arts & Research Building

UConn Health Center, 263 Farmington Avenue, Farmington, CT
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Dislocations - Digits

Purpose:

To provide a set of guidelines for the management of a possible fracture with a student-athlete.

Guidelines:

I. PRESENTATION:

 Dorsal PIP and DIP dislocations– A dorsal dislocation presents with middle phalanx
dorsal in relation to proximal phalanx. A volar dislocation has a lateral displacement
in addition to volar.

II. REDUCTION:

 Dorsal DIP/PIP – traction, mild hyperextension & direct pressure on base of the
more distal phalanx then bring into flexion. The first step in reduction is to recreate
the injury by hyper-extending the PIP or DIP. This should be followed by light axial
traction applied to the finger with pressure applied to the base of the dislocated
digit until the joint is relocated.
 Volar PIP – Hold MP joint in flexion to relax lateral bands, provide traction and then
flexion and bring them into extension. Often difficult to reduce.
 MP – NO TRACTION—NO HYPEREXTENSION hold wrist in flexed position, apply
steady pressure in a distal and volar direction. Difficult to reduce.

III. AFTERCARE:

 Dorsal DIP/PIP : Neutral splinting for dorsal PIP dislocations can also be used and is
reported to avoid post-splinting flexion contractures. Post-reduction x-rays should
be obtained to confirm congruency of the joint and to ensure that there are no
associated fractures.
 Check Neurovascular status
 Splint/Tape and refer to ED if not able to reduce
 Splint/Tape and refer to team physician if reduced

 Volar DIP and PIP dislocations: These are more likely to be unstable, but the goals of
reduction are the same as for dorsal dislocations. The finger should be flexed with
mild axial traction applied to the digit. The physician should then apply pressure to
the base of the digit until reduction is complete. Post-reduction x-rays should be
obtained to confirm congruence of the joint and to ensure that there are no
 associated fractures. The finger should be placed in an extension splint immobilizing
the smallest number of joints possible. If concentric reduction is not possible
because of soft tissue entrapment, consultation with a hand surgeon is warranted.

 MCP dislocation: With simple dislocations, the finger is usually held in extension,
and there is some contact between the joint surfaces. The wrist should be flexed to
relax the flexor tendons, and the affected digit should then be hyper-extended. The
physician should then apply a volar-directed pressure to the dorsum of the affected
digit. It is paramount that excessive traction not be applied, as a simple dislocation
can be converted into a complex MCP dislocation with significant soft tissue
entrapment. If this occurs, the joint will often become irreducible and require
operative treatment.

Simple dislocations can be buddy taped, while fracture dislocations require immobilization in a
splint. Post-reduction x-rays should be obtained to confirm congruence of the joint and to
ensure that there are no associated fractures. Following reduction, the provider should ensure
adequate perfusion to the finger by assessing capillary refill. Post-reduction, patients should
begin protected range of motion as pain permits. In treating finger dislocations, instituting early
motion and providing stability must be balanced.

References:

The BMJ Evidence Centre, Joint Dislocation, Key articles:

Brady WJ, Knuth CJ, Pirrallo RG. Bilateral inferior glenohumeral dislocation: luxatio erecta, an
unusual presentation of a rare disorder. J Emerg Med. 1995;13:37-42.

Steinbach LS, Dalinka MK, Daffner RH, et al. ACR appropriateness criteria: acute shoulder pain.
2010. <http://www.acr.org (last accessed 27 November 2011)>.

Kosnik J, Shamsa F, Raphael E, et al. Anesthetic methods for reduction of acute shoulder
dislocations: a prospective randomized study comparing intraarticular lidocaine with
intravenous analgesia and sedation. Am J Emerg Med. 1999;17:566-570.

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Fractures

Purpose:

To provide a set of guidelines for the management of a possible fracture with a student-athlete.

Guidelines:

I. RECOGNITION
 Pain
 Localized point tenderness
 Crepitation
 Loss of function, unnatural mobility
 Guarding
 Ecchymosis
 Causes of Fractures:

High impact sports injuries

Traumatic, forceful and unnatural movements
Overuse - prolonged long-distance walking or running
Falls
Accidents
Osteoporosis
Tumors growing near the bone

III. TYPES OF FRACTURES:

Simple The bone is broken in one place

Closed The skin over the broken bone has not been pierced
Comminuted The broken bone has three or more bone fragments
Open or Compound The skin over the fracture has been pierced and the broken bone is
exposed
Undisplaced The broken bone pieces are aligned
Displaced The broken bone pieces are not aligned
Transverse fracture The fracture is at a right angle to the long axis of the bone
Greenstick fracture The fracture is on one side of the bone, causing a bend on the other side
of the bone

III. MANAGEMENT
 Ice
 Immobilize/splint in position
  Crutches or sling
 Refer for X-Rays (Family Clinic or EMR)
 Refer for evaluation

Treatment for Fractures

The type of treatment will depend on the kind of fracture and the specific bones involved.
Casting After the broken bones have been manipulated back into their proper positions,
a plaster or fiberglass cast is applied to keep the bones from moving .
External Pins or wires are set into the bone through the skin above and below the
fixation fracture. These are connected to a ring or a bar outside the skin that holds the
pins in place. (External fixation frame; i.e. Hoffman’s, etc.)
Internal In a surgical procedure, metal rods, wires, or screws are inserted in the bone
fixation fragments to keep them together.

IV. REFERRAL
Immediate

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Sudden Illness

Purpose:

To provide guidance to athletic staff on managing illnesses in student athletes.

Guidelines:

I. RECOGNITION
Collect medical history from the student-athlete

II. ASSESS PHYSICAL STATUS

SIGNALS FOR SUDDEN ILLNESS

Feeling lightheaded, dizzy, confused or weak.
Changes in skin color (pale, ashen, flushed)
Sweating , Diarrhea, Seizures
Nausea, Vomiting
Change in consciousness
Paralysis or inability to move
Slurred speech
Difficulty seeing
Severe Headache
Trouble Breathing
Persistent pressure or pain
Constipation, Diarrhea
Respiratory sounds, Congestion.

III. MANAGEMENT/REFERRAL
As indicated by signs/symptoms and judgment of the licensed athletic trainer.

CARE FOR SUDDEN ILLNESS

Help victim rest comfortably
Keep the victim from getting chilled
Reassure the victim
Watch for changes in consciousness and breathing
Do not give anything to eat or drink unless victim is fully conscious.
 CARE FOR SUDDEN ILLNESS (Cont.) If the victim….
Vomits: Place victim on his or her side
Faints: Position on back and elevate legs 8-10 inches if possible
Diabetic: Give conscious victim some type of sugar. (pref. Liquid)
Severe Allergic Reaction: Assist with medication (Epi-pen)
Fainting: When someone loses consciousness and reawakens.
Fainting itself is not harmful, and the victim will usually
recover.

1. Delay Referral – Offer sound advice

Foods to eat – dietary
Fluids – clear
Rest
Over-the-counter medications per standing orders
Cough medicines
Antacids
Laxatives

2. Immediate Referral
Assist athlete in making appointment for physician examination
Temperature > 1010 F
Length of illness > 2-3 days
Fluid loss – diarrhea, vomiting
Respiratory difficulty
Lymphaginitis
Tonsilitis
Moderate dermatitis
Conjunctivitis
Unexplained signs/symptoms

IV. CARE FOR SUDDEN ILLNESS

 Help victim rest comfortably

 Keep the victim from getting chilled
 Reassure the victim
 Watch for changes in consciousness and breathing
 Do not give anything to eat or drink unless victim is fully conscious.
 If the victim….
 Vomits: place victim on his or her side
 Faints: position on back and elevate legs 8-10 inches if possible
 Diabetic: give conscious victim some type of sugar. (pref. Liquid)
 Severe Allergic Reaction: Assist with medication (Epi-pen)
 Fainting: when someone loses consciousness and reawakens
  Fainting itself is not harmful, and the victim will usually recover.

V. UNCONSCIOUS CARE:

Lower to the ground or other flat surface.

Position on back and elevate legs 8-10 in.
Loosen tight clothing
Check ABC’s
Do not give them anything to eat or drink
If vomits position on side
call 9-1-1

VI. SEIZURES CARE:

SEIZURES: MAY BE CAUSED BY:

Extreme heat
Diabetic condition
Injury to the brain
Acute or chronic condition
Epilepsy
A person may experience aura before the seizure occurs.
GENERAL INFORMATION ON SEIZURES:
Most only last a few minutes
Most are not life threatening
Call 9-1-1 if:
Seizure lasts more than 5 minutes
Seizure reoccurs

CARE:
Do not hold or restrain the person
Do not place anything between the victim’s teeth
Remove all objects that can cause injury
Cushion victim’s head

VII. DIABETES

 Inability to convert sugar from food into energy.

 Can lead to other medical conditions such as blindness, nerve disease, kidney disease,
heart disease, or stroke.

TYPE I: INSULIN-DEPENDENT
Usually occurs in childhood
Occurs when the body produces little or no insulin
Most type I diabetics inject insulin into their bodies daily
Warning Signals:
 Frequent urination
 Increased hunger and thirst
 Unexpected weight loss
  Irritability
 Weakness and fatigue

TYPE II: NON-INSULIN-DEPENDENT (A.K.A.) ADULT-ONSET

Most common type
Usually occurs in adults
Can occur in overweight children
Body makes insulin but not what is needed
Exact cause unknown.

WARNING SIGNALS
Any signals of type I
Frequent infections
Blurred vision
Numbness in extremities
Slow to heal cuts/bruises
Itching
SIGNALS AND CARE OF DIABETIC EMERGENCY
Signals:
 Changes in level of consciousness
 Rapid breathing or pulse
 Feeling or looking ill
Care:
 Conscious victims can take food (sugar water)
 Call 9-1-1
 If unable to swallow, do not give them anything
 
VIII. STROKE (CVA)

Caused when the blood flow to a part of the brain is cut off or when there is bleeding
into the brain.

SIGNALS AND CARE FOR A STROKE

Signals:
F: Face
A: Arms
S: Speech
T: Time
Also may have:
Blurred vision
Experience sudden, severe headache; dizziness; or confusion
CARE:
Call 9-1-1
Record time the signals started
Make sure airway is open

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Sprains

Purpose:

Provide guideline in the management of sprains.

Guidelines:

I. RECOGNITION

A. Mild (1 degree)
 Mild disability
 Mild localized tenderness at site of ligament damage
 Little or no pain on normal motion
 Will be able to walk or have function of joint
 Mild pain on stretch of involved ligament
 No abnormal motion
 Little or no swelling
 Ligament stretch with no loss of strength or stability of joint

B. Moderate (2 degree)
 Some loss of function
 May have function of joint but with much difficulty
 Pain abnormal motion
 Tenderness at site of tear
 Moderate pain on stretch of involved ligament
 May have abnormal motion in one or more ranges of motion
 Moderate swelling
 Joint tightness due to swelling
 Partial ligament tear with loss of strength and joint stability; and end point
felt.

C. Severe (3 degrees)
 Complete loss of function
 Abnormal motion of joint possible
 Severe pain on normal motion and severe to no pain on stretch of ligament
 Severe swelling with possible immediate discoloration
 Tenderness to the point of nausea at site of tear
 Joint tightness due to swelling and spasm
 Complete ligament tear with loss of strength and joint instability; no end
point felt
II. MANAGEMENT
1. Initial
P - Protect
R - Rest
I - Ice application*
C - Compression either wet wrap or dry*
E - Elevation of limb, if applicable
STABLIZE: Protect or stabilize original injury from additional trauma
 Soft splint
 Ankle - Open basket-weave strapping with 1 ½ inch adhesive tape.
 Rigid splinting or AFO (ankle-foot orthosis)
 Crutches
 Upper extremity- Sling and/or sling and swathe.
2. Advanced Management Protocols for Foot and Ankle sprains:
a. TENS unit: 100 width and 40 pulse rate – continuous.
b. Pads bilateral to ankle mortise, red over site of acute pain.
c. Horse show felt pad on side of tendon/ligament damage (inversion/eversion)
d. Elastic wrap (3” of 4” depending on patient’s foot size) from toes to above
the calf.
e. Walking boot for early ambulation, assist with crutches for hyper-acute pain
for 12-24 hours, wean patient off crutches ASAP. Relief from pain using TENS
should occur within 10-15 minutes.
f. Preferred treatments is use of a sequential compression unit with HVGS (100
pps on + x 45 minutes three times per day)
2. On-Going
Treat per Rehabilitation SOP and/or physician's orders
Approximate recovery times:
 Mild Sprain - 2-3 days to a week
 Moderate Sprain - 10 days to 3 weeks
 Severe Sprain - 3-4 weeks to 3 months

Refer, PRN

III. REFERRAL - Signs/Symptoms

1. FOOT/ANKLE/LOWER LEG
 Gross deformity
 Suspected fracture or dislocation
 Significant or unexplained swelling
 Significant pain, persistent pain - especially in compartments (anterior)
 Decreased circulation, motor function or sensations in leg or foot
 Joint instability
 Crepitation
  Suspected mal-alignment or structural abnormalities
 Any doubt regarding severity or nature of the injury
 Refer as indicated
2. KNEE
 Gross deformity
 Significant or unexplained swelling
 Loss of motion, weakness
 Joint instability
 Significant pain
 Abnormal sensations; i.e., clicking, popping, grating
 Crepitation
 Locked knee
 Any doubt regarding severity or nature of the injury
 Refer as indicated

3. HIP/THIGH
 Gross deformity
 Significant loss of motion
 Severe disability
 Noticeable and/or palpable mass, depression
 Suspected fracture
 Injury that does not respond to treatment within 2 to 3 weeks
 Significant or unexplained swelling
 Crepitation
 Any doubt regarding severity or nature of the injury
 Refer as indicated

4. SHOULDER
 Suspected fracture, separation or dislocation
 Gross deformity
 Significant loss of motion, weakness
 Significant or continued (persistent) pain
 Joint instability
 Abnormal sensations in distal extremity
 Significant or absent distal pulse
 Crepitation
 Any doubt regarding severity or nature of the injury
 Refer as indicated

5. ELBOW//FOREARM
 Gross deformity
 Significant or unexplained swelling
  Significant or persistent pain
 Significant loss of motion, weakness.
 Joint instability
 Suspected fracture and/or dislocation
 Abnormal sensations at or distal to elbow
 Crepitation
 Any doubt regarding severity or nature of the injury
 Refer as indicated
6. WRIST/HAND
 Gross deformity
 Suspected fracture and/or dislocation
 Significant or unexplained swelling
 Significant or persistent pain
 Refer as indicated
 Joint instability
 Loss of motion, weakness
 Crepitation
 Any doubt regarding severity or nature of the injury

REHABILIATION (see specific EBM guidelines.)

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Strains

Purpose:

Provide guidelines to staff for managing musculo-tendinous injuries in athletes.

Guidelines:

I. RECOGNITION
A. Mild (1 degree)
 No applicable disruption
 Low grade inflammation and swelling
 Some discomfort on active motion
 No loss of strength or motion
 Local tenderness
 Over-stretch of muscle and/or tendon resulting in micro-trauma to fibers

B. Moderate (2 degrees)
 Actual damage to fibers with decreased strength
 Moderate swelling and inflammation
 Loss of normal function
 Pain on normal motion (disability pain)
 Increased tenderness - may have palpable defect
 Marked decrease in flexibility
 Over-stretch of muscle and/or tendon resulting in partial tear of fibers

C. Severe (3 degrees)
 Rupture of fibers or avulsion at attachment
 Complete loss of function - no strength
 Muscle enlargement, swelling, irregularity - defect
 Pain to severe pain
 Tremendous limitation of motion
 Over-stretch of muscle and/or tendon resulting in complete tear of
structures

II. MANAGEMENT
1. Initial
P - Protect - Protect or stabilize original injury from additional trauma
R - Rest
I - Ice if applicable
C - Compression either wet wrap or dry
E - Elevation of limb, if applicable
  Soft splint
 Open basket-weave strapping with 1 1/2 inch adhesive tape.
 Rigid splinting or AFO (ankle-foot orthosis)
 Crutches
 Sling and/or sling and swathe
Refer as indicated
2. On-Going
Treat per Rehabilitation SOP and/or physician's orders
Approximate recovery times:
 Mild Strain - 10 days to 2 weeks .
 Moderate Strain - 3-4 weeks/to 6-8 weeks
 Severe Strain - may require long term bracing or surgical intervention.
Refer, PRN

III. REFERRAL - Signs/Symptoms for evaluation

1. FOOT/ANKLE/LOWER LEG
 Gross deformity
 Suspected fracture or dislocation
 Significant or unexplained swelling
 Significant pain, persistent pain - especially in compartments (anterior)
 Decreased circulation, motor function or sensations in leg or foot
 Joint instability
 Crepitation
 Suspected mal-alignment or structural abnormalities
 Any doubt regarding severity or nature of the injury
 Refer as indicated
2. KNEE
 Gross deformity
 Significant or unexplained swelling
 Loss of motion, weakness
 Joint instability
 Significant pain
 Abnormal sensations, i.e., clicking, popping, grating
 Crepitation
 Locked knee
 Any doubt regarding severity or nature of the injury
Refer as indicated

3. HIP/THIGH
 Gross deformity
 Significant loss of motion
 Severe disability
 Noticeable and/or palpable mass, depression
  Suspected fracture
 Injury that does not respond to treatment within 2 to 3 weeks
 Significant or unexplained swelling
 Crepitation
 Any doubt regarding severity or nature of the injury
Refer as indicated
4. SHOULDER
 Suspected fracture, separation or dislocation
 Gross deformity
 Significant loss of motion, weakness
 Significant or continued (persistent) pain
 Joint instability
 Abnormal sensations in distal extremity
 Significant or absent distal pulse
 Crepitation
 Any doubt regarding severity or nature of the injury
Refer as indicated
5. ELBOW/ /FOREARM
 Gross deformity
 Significant or unexplained swelling
 Significant or persistent pain
 Significant loss of motion, weakness
 Joint instability
 Suspected fracture and/or dislocation
 Abnormal sensations at or distal to elbow
 Crepitation
 Any doubt regarding severity or nature of the injury
Refer as indicated
6. WRIST/HAND
 Gross deformity
 Suspected fracture and/or dislocation
 Significant or unexplained swelling
 Significant or persistent pain
 Joint instability
 Loss of motion, weakness
 Crepitation
 Any doubt regarding severity or nature of the injury - Refer as indicated
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Wounds

Purpose:

Provide guidelines for managing open wounds occurring in sports activities.

Guidelines:

I. RECOGNITION/MANAGEMENT/REFERRAL
Abrasions; Superficial, little bleeding, oozing, weeping
 Clean, scrub with Hibaclean or soap. (Saline solution recommended)
(Betadine/Nitrodine/Hydrogen/Peroxide[3%])
 Remove debris
 Apply antiseptic cream and sterile dressing
 Check daily, change dressing as needed
 Refer as necessary
 Securely cover or occlude wound for activity
Laceration: Jagged edges; may bleed freely; contusion and tearing; often leaves scar
 Control bleeding .
 Clean with Hibacleans or soap (Betadine/Nitrodine/Hydrogen/Peroxide)
 Apply steri-strips (any available skin closures) and/or refer for sutures, if
necessary (within twelve hours of incident)
 Determine last tetanus
 Inspect daily, change dressing as needed
 Refer, as necessary
 Securely cover or occlude wound for activity
Incision: Smooth edges, freely bleeding
 Control bleeding
 Clean with Hibacleans or soap (Betadine/Nitrodine/Hydrogen/Peroxide)
 Apply steri-strips (any available skin closures) and/or refer for sutures, if
necessary (within twelve hours of incident)
 Determine last tetanus
 Inspect daily, change dressing as needed
 Refer, as necessary
 Securely cover or occlude wound for activity
Puncture: Any size opening, usually minimal bleeding
 Clean with Hibacleans or soap (Betadine/Nitrodine/Hydrogen/Peroxide)
 Apply steri-strips (any available skin closures) and/or refer for sutures, if
necessary (within twelve hours of incident)
 Determine last tetanus
 Inspect daily, change dressing as needed
 Refer, as necessary
 Securely cover or occlude wound for activity
 Avulsion: Completely loose, hanging as a flap; may bleed freely
 Control bleeding
 Clean
 Save avulsed tissue (moist, sterile dressing)
 Refer, activity status per physician orders
 Securely cover or occlude wound for activity

II. Criteria for wound Cleansing

1. To remove visible debris after a wound has initially occurred and to aid assessment
2. To remove excess slough and exudate in order to aid patient comfort
3. To remove remaining dressing material (Miller & Gilchrist, 1998)

Guideline Statement
Wound cleansing (where necessary) should be carried out by irrigation with sterile
normal saline warmed to body temperature.

III. Other Solutions Used for Wound Cleansing:

The following solutions should not be routinely used in the cleansing of wounds. They
should only be used where the risk of infection outweighs the reported detrimental
effects of the solution and should only be used further to Consultant, Microbiological
or Pharmacological advice:

• Povidone Iodine – only licensed as a skin antiseptic and not for use on open wounds
• Chlorhexidine – 0.5% shown to inhibit epithelialization and granulation of tissue
(Neider & Scoph, 1986). If used on traumatic wounds with a high risk of infection, then
0.05% in aqueous form should be used.
• Potassium Permanganate: No research traced relating to benefits, toxicity or allergies.
BNF states that it may be irritant to mucous membranes. Sometimes used under
instructions of dermatologist, vascular surgeon or General Practitioner for weeping
eczema.
• Hydrogen Peroxide: Not recommended for wound cleaning except in exceptional
circumstances. There have been unsubstantiated reports of air emboli resulting from its
use in cavity wounds. (Sleigh & Winter, 1985)

Guideline Statement
Systemic antibiotics should be used to treat clinical wound infections
Antiseptics are toxic to human tissue and may delay wound healing

IV. Criteria for Choosing a Dressing

 It should be recognized that a wound will require treating differently at various stages of
its healing. No dressing is suitable for all wounds. Following careful selection of the
appropriate management plan for the patient, the wound assessment tool should be
used to monitor the progress of the wound through to its healing stage.

Guideline statement

Criteria for Choosing a Dressing In Order of Importance (Miller & Collier, 1997)
1. Choose a dressing that maintains a moist environment at the wound/dressing
interface. (The only possible exceptions are peripheral necrosis secondary to
arterial disease.
2. Choose a dressing that is able to control (remove) exudates. A moist wound
environment is good; a wet environment is not beneficial
3. Choose a dressing that does not stick to the wound and cause trauma on
removal
4. Choose a dressing that protects the wound from the outside environment
5. Choose a dressing that will aid debridement if there is necrotic or slouchy tissue
in the wound (caution with ischemic lesions)
6. Choose a dressing that will keep the wound close to normal body temperature
7. Choose a dressing that is acceptable to the patient
8. Choose a dressing that is cost-effective
9. Diabetes – choose a dressing that will allow frequent inspection.

V. Dressings Supplies

Methods for wound management should be re-assessed at each dressing change.

However, the following list is issued as guidance to minimize wastage of prescribed
dressings as the wound changes.

Wound Type / Suggested Duration of Supply *

Black/Necrotic 7 days
Slouchy 7 - 10 days
Low or no exudates >10 days
Medium to high exudates 2 - 4 weeks
Granulating 2 - 4 weeks
Epithelialising 2 - 4 weeks
* The amount supplied depends on the frequency of dressing changes.

Manufacturers’ instructions are provided with all products and these must be read and
followed at all times.

6th Edition Emergency Medicine: A Comprehensive Study Guide, 200

Sports Health Care
Section: Administrative Policies and Procedures

Subject: Pain Management

Purpose:

To provide guidance to licensed athletic trainers and staff on dealing with pain, primarily from
musculoskeletal injuries.

Evaluation:

1. Pain screen (upon conducting the therapeutic evaluation)

2. Use of pain rating scale (Wong-Backer, Numerical, or FLACC [face, legs, activity, cry,
consolability] scale)
3. Pain assessment

Management:

1. Formulation and implementation of a specific pain treatment plan

2. Rehabilitation treatment modalities
 Physical therapy (PT)
 Therapeutic exercises
 Manual therapy
 Modalities
 Occupational therapy (OT) (interventions for pain reduction)
 Illustrated home exercise program upon discharge (both physical and
occupational therapy components)
3. Pharmacological interventions
 Non-opioid analgesics
 Opioid analgesics
 Other classes of drugs
4. Alternative interventions
5. Documentation of pain assessment findings, treatment findings, and resident response
6. Education and continuous training
 Facility staff training
 Patient/resident/family education
Major Outcomes Considered
 Pain severity, character, frequency, pattern, location, duration
 Interventions to promote comfort
 Quality of life

Bibliographic Source(s)
Health Care Association of New Jersey (HCANJ). Pain management guideline. Hamilton (NJ):
Health Care Association of New Jersey (HCANJ); 2006 Jul 18. 23 p. [19 references]

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Seizures

Purpose:

Identify what steps the athletic trainers can take in dealing with seizures of student-athletes,
staff and visitors.

Guidelines:

I. RECOGNITION

 Blank stare, dazed, un-responsive, unaware of surroundings (disorientated)

 Clumsy
 Rapid blinking
 Chewing movements
 Rigidity, followed by muscle jerks
 Shallow breathing
 Bluish skin (cyanosis)
 Possible loss of bladder or bowel control (incontinence)
 Jerking of one body segment (spasms)

II. MANAGEMENT

 Protect patient from further injury. Do not forcibly restrain victim.

 Tongue blade of bite stik should not be necessary unless victim constantly opening
and closing mouth.
 Maintain a clear airway. Turn head to side to avoid aspiration of vomitus.
 Talk calmly, reassure victim. Gentle hand holding, no other unnecessary contact.

 Once seizure has subsided:

1. Check vitals
2. Check for injuries
3. Obtain history: Description of seizures, medications
4. It is natural for person to be sleepy after seizure.
5. Refer, as indicated

III. REFERRAL

1. Initial Seizure (no prior history):

Refer for evaluation
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Shock

Purpose:

Provides guidelines to athletic trainers and staff to handle emergencies leading to or resulting in
the victim going into shock.

Guidelines:

I. RECOGNITION

 Restlessness and Anxiety

 Extreme thirst
 Nausea, vomiting
 Cold, clammy skin
 Weak, rapid pulse
 Shallow, rapid respirations
 Alterations in state of consciousness
 Decrease in blood pressure

II. MANAGEMENT

 Maintain airway
 Perform CPR and/or ventilation, if indicated
 Control bleeding, if indicated (see Hemorrhage SOP)
 Maintain body temperature
 Monitor vitals
 Refer

III. REFERRALS

 Immediate
 Activate EMS (911)
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Suture Removal

Purpose:

Present guidelines for suture removal.

Guidelines:

Skin sutures and staples may be removed by the licensed athletic trainer upon a written or
verbal order of the attending physician or other licensed physician (campus or consulting
physicians).

Any sign of active infection or if an area of the wound does not present primary closure, the
athlete will be referred to the student health center or a physician for consultation.

Signs and symptoms

 Increasing local inflammation - rubor, dolour, calor and tumour
 Discharge/collection of pus
 Systemic signs - fever

Various sources and website Patient.co.uk and evidence based references from Cochrane
Database to the International Guidelines Network (2014)
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Eating Disorder Intervention

Purpose:

To define the protocol in the identification and treatment of eating disorders at it applies to the
student-athlete at (COLLEGE/SCHOOL).

Policy:

Any sports related eating disorder is a complex health condition arising from a variety of
potential causes. The student-athlete with an eating disorder will require the guidance and
treatment of the team physician. The team physician will make all recommendations to the
treatment of the student-athlete. The team coach, teammate, or licensed athletic trainer will
make the recognition of a student-athlete with an eating disorder.

If an athlete has any of the following eating disorder signs and symptoms, the athletic trainer
may refer athlete to the team physician for treatment.

1. Student-athlete makes verbal statements about self-image, body size, physical

appearance and/or shape.
2. Student-athlete does not eat meals with the team on away competition.
3. Student-athlete performs binge eating (eating large amounts of food at one meal)
4. Student-athlete performs self-induced or frequent vomiting.
5. Student-athlete has stress fractures that do not heal or multiple stress fractures.
6. Student-athlete has severe dehydration and fatigue.
7. Student-athlete has muscle weakness, muscle cramps or muscle loss.
8. Student-athlete has multiple muscular skeletal injures.
9. Student-athlete body fat composition falls below (5% males / 12% females).

Ref: Worthe S. Holt, Jr. M.D., Nutrition and Athletes, American Family Physician, P. 1757, June 1993.

*Athletes are responsible for medical expenses in the treatment of an eating disorder.
(COLLEGE/SCHOOL) secondary insurance does not cover eating disorders. An athlete that fails
to comply with referral or treatment of an eating disorder will result in disciplinary action by
the (COLLEGE/SCHOOL) Athletics Department.

I, ________________________, have read and agree to the eating disorder protocol.

Print Name

Signature:_______________________________ Date:___________
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Impaired Organ

Purpose:

To define the assumption of risk to the athlete that has either an impaired organ or one of an
organ pair.

Policy:

Any athlete that has an impaired organ or only possesses one of a pair of organs must sign the
following assumption of risk/liability release.

Medical Release of Liability

Impaired Organ

I,________________________________, understand participation in (COLLEGE/SCHOOL)

(Print Name)

athletics could lead to possible loss of function and/or permanent damage of the organ could
result in the death or impairment resulting from the damage to the organ. I understand and
accept this risk by participating in (COLLEGE/SCHOOL) athletics during my entire eligibility.

I release (college/school) and athletics department from any and all medical and legal liability
resulting in an injury to my non-impaired organ.

In sound mind and with the witness of an athletic trainer, I understand and sign this Medical
Release of Liability Impaired Organ form.

Athlete __________________________________________ Date___________

Witness __________________________________________ Date___________

Sports Health Care
Section: Administrative Policies and Procedures

Subject: Exposure to Communicable Disease

Purpose:

To ensure rapid detection and treatment of communicable disease among student athletic
trainers and staff athletic trainers and to facilitate appropriate epidemiological follow-up
actives after exposure to communicable disease.

Policy:

Communicable disease refers to any infectious disease that can be readily transmitted to
another susceptible person by direct and/or indirect contact or airborne routes resulting in the
onset of acute disease. This includes, but is not limited to, tuberculosis, hepatitis A and B,
meningococcal disease, and childhood viral diseases.

All ATC (Licensed Athletic Trainers) exposures to communicable disease during Sports Health
Care must be reported to the Department Chair immediately.

All ATC’s are responsible for reporting suspected or known exposure to a communicable
disease to their immediate supervisor.

The immediate supervisor is responsible for ensuring that the individuals are referred to a
physician for disposition and documentation of the disease and treatment. The Department
Chair will be informed of the exposure at this time.

The physician is responsible for diagnosis and prescription of medications for treatment,
referral of the individual as needed, and restricting the individual from Sports Health Care until
they are non-infectious.

Centers for Disease Control and Prevention. Updated U.S. Public Health Service
Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and
Recommendations for Postexposure Prophylaxis. MMWR 2001;50(No. RR-11):
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Hand Washing

Purpose:

To prevent spread or development of an infections process among athletes, athletic training

students, and staff athletic trainers.

Policy:

Hand washing is regarded as the single most important means of preventing the spread of
infection. A 10 second scrub is appropriate between patients and for non-patient care
departments. Hands must be washed before and after gloving. In case of field washing, alcohol
rinses or germicidal hand rinses are acceptable with rubbing until hands are dry.

1) Stand away from the sink to keep your clothing form touching the sink if at all
possible.
2) Turn the water on and adjust the temperature as warm as tolerable. Keeps the water
running during the entire procedure.
3) Wet hands
4) Apply liquid soap liberally
5) Wash the palms and backs of hands with strong frictional motion.
6) Wash the fingers and web spaces, interlacing the fingers, and rubbing them up and
down. Wash under the nails.
7) Wash wrists and three or four inches above the wrists, using rotary action.
8) Push rings up on fingers and washes under the rings and over the rings. Do not
remove rings, wash, and put contaminated rings back on.
9) Rinse well, run the water from wrist to fingers.
10) Dry hands thoroughly with a paper towel from wrists to fingertips.
11) Turn off water faucet with a paper towel and discard the towel into a receptacle.
12) Use hand lotion if desired.
13) Hand washing when alcohol rinse is used: apply rinse and rub hands until hands are dry.

References

John M. Boyce, M.D. and Didier Pittet, M.D. Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task
Force, MMWR, October 25, 2002 / 51(RR16);1-44
Every athletic trainer knows the importance of hand cleanliness when treating athletes.
However, studies of health care professionals in many different settings have found that proper
hand washing procedures are not always followed, and the result may be an increased risk for
transmitting infections such as MRSA.

Here are some helpful reminders on proper techniques for hand hygiene:

• When using an alcohol-based hand rub, apply the product to the palm of one hand and then
rub both hands together, covering all surfaces of the hands and fingers, until hands are dry.
• When washing hands with soap and water, wet both hands first, apply soap, then rub hands
• together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.
Rinse hands with water.
• Thoroughly dry hands with a disposable towel or one treated with an antimicrobial solution.
Use the disposable or treated towel to turn off the faucet.
• Avoid using very hot water, since repeated exposure to it may increase the risk of
dermatitis.
• If your sink is equipped with bar soap, only use small bars and make sure your soap rack
allows for drainage.
• In between washings, use antimicrobial solutions and products that inhibit the growth of
bacteria.
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Insurance

Purpose:

To define insurance coverage on student-athletes

Policy:

All athletes who have primary insurance will provide an up-to-date copy of the card on file
before they can participate in (COLLEGE/SCHOOL) athletics.

The (COLLEGE/SCHOOL) Athletics Department has a secondary insurance policy that covers
athletic injuries that occur to (COLLEGE/SCHOOL) student athletes only during scheduled
practices, conditioning, and games of their designated sport. The (COLLEGE/SCHOOL) Athletics
Department secondary insurance does not pay/cover the following.

Pre-existing conditions – means the existence of symptoms which would cause a person to
seek diagnosis, care or treatment within one-year period preceding the effective date of the
coverage of the Insured Person, or a condition for which medical advice or treatment was
recommended by a Physician or received from a Physician within one-year period preceding the
effective date of coverage of the Insured Person.

 Sports Physical
 Common illness (colds, flu, allergies, etc.)
 Sexually Transmitted Disease (STD’s)
 Motor vehicle accident
 Dentures or false teeth
 Pregnancy

*Any and all other provisions listed in secondary insurance policy contract.

The (COLLEGE/SCHOOL) student-athletes will be responsible for personal payment of medical

expenses/bills incurred by injuries or illnesses not covered by (COLLEGE/SCHOOL) Athletics
Department secondary insurance policy.

In the event an (COLLEGE/SCHOOL) student-athlete is injured during a scheduled practice,

conditioning, or game, appropriate referral will be made. The athlete’s primary insurance will
be filed first then (COLLEGE/SCHOOL) Athletics Department secondary insurance policy will be
filed.
Student-athlete has 30 days from the date on their medical statements/bills or Explanation of
Benefits (EOB’s) to turn in or a copy of to (COLLEGE/SCHOOL) Athletics Department or fax to
(school or department of athletics fax number).

If student athlete does not turn in or a copy of their medical bills/statements or EOB’s to
(COLLEGE/SCHOOL) Athletics Department within 30 days from the date on medical
statements/bills or EOB’s, the student-athlete will be responsible for personal payment of
medical expenses/bills.

All treatment, includes care provided by the licensed athletic trainer must be initiated within 90
days of the accident date. The student-athlete then has 52 weeks from the date of record to
have a resolution of the condition (surgery and/or rehabilitation).

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Latex Allergies

Purpose:

To provide a plan for the ATC and staff who develop or have latex allergy.

Background

In recent years, an increasing number of people have developed a sensitivity or allergy to latex
products. The University of North Carolina’s School of Dentistry recognizes this major health
concern and outlines a policy to identify patients at risk for latex allergy as well as to decrease
patients' exposure to latex products.

Latex allergy can result from repeated exposure to proteins in natural rubber latex through skin
contact or inhalation. Reactions usually begin within minutes of exposure to latex, but they can
occur hours later. Exposure to latex produces a variety of symptoms, including skin rash and
inflammation, respiratory irritation, asthma, and in rare cases anaphylactic shock. Types of
reactions to latex are classified as follows:

Definitions:

1. Irritant Contact Dermatitis - the most common reaction to latex products and is
characterized by development of dry, itchy, irritated areas on the skin, usually the
hands. This reaction is caused by skin irritations from using gloves, powder in the gloves,
and possibly exposure to other workplace products and chemicals. Irritant contact
dermatitis is not a true allergy.
2. Allergic Contact Dermatitis (delayed hypersensitivity or Type IV hypersensitivity) - results
from exposure to chemicals added to latex during harvesting, processing, or
manufacturing. These chemicals can cause skin reactions similar to those caused by
poison ivy. As with poison ivy, the rash usually begins 24 to 48 hours after contact and
may progress to oozing skin blisters.
3. Latex Allergy (Type I or immediate) - the most serious of the reactions that usually
begins within minutes of exposure to latex, but can occur hours later with a variety of
symptoms. Mild reactions to latex involve skin redness, hives, or itching. More severe
reactions may involve respiratory symptoms such as runny nose, sneezing, itchy eyes,
scratchy throat, and asthma (difficulty breathing, coughing spells, and wheezing). Rarely,
anaphylactic shock may occur; but a life-threatening reaction is seldom the first sign of
latex allergy.

Policy:
ATC’s and staff are to report latex allergies to the university safety officer. Sports Health Care
will provide latex-free gloves to be worn when necessary.

Procedures for Treating Patients

Identification:

Identifying patients at risk should be a specific and integral part of the medical history, both
initial and update. The following questions can help to determine the likelihood of a patient
with a latex allergy:

1. Have you ever had or been told you had an allergy to latex (rubber) products?
2. When exposed to rubber gloves, glove powder, balloons, Band-Aids, rubber toys (such
as a Koosh ball) or other rubber products have you ever experienced: itching, swelling,
sneezing, watery eyes, hives, wheezing, or other breathing difficulties?
3. Have you ever experienced itching, swelling of the lips, or other allergic reaction during
a dental exam or during the use of a dental rubber dam?
4. Have you ever experienced an unexplained allergic reaction during surgery, a urinary
catheterization, barium test, or other medical procedure?
5. Have you ever experienced itching or swelling of the mouth or other allergic reaction
when eating avocados, chestnuts, bananas, kiwi, papaya, or other tropical fruits?

If the patient answers YES to any of these questions, the healthcare provider should consult
with the team physician before proceeding with any care.

Signs and symptoms of allergic reaction to latex may include;

 prurtis,
 urticaria,
 laryngeal swelling,
 hypotension,
 tachycardia,
 erythemia,
 andioedema,
 bronchospasm, a
 anaphlaxis,
 burning,
 tearing eyes.

ATC refer to policy on Hand Washing for guidelines after removal of gloves.

Precautions for Patients Identified as Latex Allergic

1. Obtain latex-free materials from the training room supplies. (See the attached lists of
products containing latex and safe alternatives.)
2. Prior to any contact with the patient, change cover gown and wash hands to remove all
glove powder residue from previous patient.
3. Encourage latex-allergic, latex-sensitive patients to obtain and carry with them at all times
some type of allergy identification such as a medical alert bracelet
4. If a patient demonstrates symptoms of latex allergy, immediately stop procedure and notify
the local EMS team. Remove all potentially problematic items from contact with the patient.

Exposure Control for All Patients

The amount of exposure necessary to sensitize individuals is not known, but reductions in
exposure to latex proteins can result in decreased sensitization and symptoms, according to the
National Institute for Occupational Health and Safety (NIOSH). Care must be taken with all
patients to reduce their levels of exposure to latex by:

1. Wear non-latex gloves when setting up and handling instruments.

2. To reduce the possibility of the latex protein becoming airborne, care must be taken by the
healthcare worker not to snap gloves on and off.
3. By touching any latex object and touching the patient, the healthcare worker can transmit
the latex allergen to the patient. Caution should be taken to keep glove powder away from
the patient since the powder will act as a carrier for the latex protein; hands should be
washed after removing gloves.

Exposure Control for Employees

Implementing the following recommendations outlined by NIOSH (National Institute for

Occupational Safety and Health) can minimize latex exposure in the dental setting:

1. Use non-latex gloves for activities that are not likely to involve contact with infectious
materials, e.g. routine housekeeping.
2. Use powder-free latex gloves for activities that potentially involve contact with infectious
materials.
3. When wearing latex gloves, do not use oil-based hand creams or lotions unless they have
been shown to reduce latex-related problems.
4. Wash hands with a mild soap and dry thoroughly after removing gloves.
5. Frequently clean work areas that may be contaminated with latex dust.
6. If you develop symptoms of latex allergy, avoid direct contact with latex gloves and
products until you can see a physician experienced in treating latex allergy.
7. Attend continuing education programs and review training materials about latex allergy.

References
Spina Bifida Association of America. (1997). Latex Information Page, [Online]. Available:
http://www.sbaa.org/Latex.htm

National Institute for Occupational Safety and Health (NIOSH) Publication No. 97-135. (August
1997). Preventing Allergic Reactions to Natural Rubber Latex in the Workplace, [Online].
Available: http://www.cdc.gov/niosh/docs/97-135/

National Institute for Occupational Safety and Health. (23 June 1997) Alert On Work-Related
Latex Allergy Recommends Steps to Reduce Exposures, [Online]. Available:
http://www.cdc.gov/niosh/docs/98-113/

Berlow, Bruce. (1997). The Newest Epidemic: Latex Allergies, [Online]. Available:
http://www.sansum.com/highlite/1997/2221.htm

American College of Allergy, Asthma, & Immunology Online. (November 20, 1997). Latex
Allergy. [Online]. Available:
http://www.acaai.org/allergist/allergies/Types/latex-allergy/Pages/default.aspx

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Medical Disqualification

Purpose:

To define disqualifying the student-athlete from participating in varsity athletics.

Policy:

The team physician(s) has the final responsibility to determine when a student-athlete is
removed or withheld from participation due to an injury, an illness or pregnancy.

Clearance for that individual to return to activity is also solely the responsibility of the team
physician or that physician’s designated representative – ATC (Licensed Athletic Trainer).

In cases where the team physician is not present, the staff athletic trainer has the responsibility
to determine when a student-athlete is removed or withheld from participation due to an
injury, an illness or pregnancy.
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Sharpe’s Injury (includes needle stick, etc.)

Purpose:

To reduce the risk of sharp’s (inc. needle stick) injury and provide immediate care in case of
sharp’s (needle stick) injury.

Policy:

ATC (Licensed Athletic Trainer) must use appropriate precautions regarding needles or sharps.
The needle should not be recapped when disposing in the sharps container. Do not walk with
an uncapped needle. If possible, bring the sharps container to the patient area and dispose as
soon as it is used.

If an individual is stuck, they are to let the area bleed freely and then wash the area with soap
and water. If the splash was sustained to the eyes, nose or mouth, the area is to be washed out
with copious amounts of water.

The ATC are to immediately notify their supervisor, who is to fill out a Report of Employee
Injury Form. Appropriate action will then be taken.
Sports Health Care
Section: Administrative Policies and Procedures

Subject: No call/ no show to outside services

Purpose:

To define no call no show of scheduled appoints with outside services through the
(COLLEGE/SCHOOL) Athletic Training services department.

Policy:

All student athletes scheduled with physician or other health care professionals due to athletic
injuries will be subject to the following attendance guidelines.

 Athletes missing one appointment with a (no call/no show) with an outside entity will be
subject to paying $50 deductible due to their athletic injury.

 An athlete missing a second appointment with a no call/ no show will be subject to a $500
deductible for the year on all athletic injuries incurred during that school year.

 An athlete missing a third appointment with a no call/ no show will disqualify themselves
from (COLLEGE/SCHOOL) paying for any athletically related injury for the rest of the school
year.

This in no way disqualifies an athlete from receiving treatment by or from the

(COLLEGE/SCHOOL) Athletic Training staff during the school year if they have any of the above
infractions.

If an athlete should get hurt and need medical attention the (COLLEGE/SCHOOL) athletic
training staff will make an appropriate recommendation but will in no way set-up or assist in
paying for their medical treatment after a third missed appointment in one year.

If the (COLLEGE/SCHOOL) Athletic Training staff has deemed the athlete unable to perform or
compete: Athletes under their third violation will be responsible for setting up their own
appointment as well as bringing a clearance to play from a medical doctor signed and dated
with restrictions of any kind.

Name: (Sign) _____________________________________ Date: _________________

(Print) _____________________________________
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Physical rehabilitation referral

Purpose:

To define the procedure for referring a student athlete to physical rehabilitation.

Policy:

Upon evaluation and determination by the ATC that the student-athlete requires physical
rehabilitation, the following procedures need to be followed to meet the policy stated above.

1. Injury evaluation of the student athlete by athletic training staff.

2. If student-athlete is unable to participate or practice in their sport due to the severity of

their injury they will be referred to medical providers for examination and
determination of fitness to participate.

3. ATC under the direction of the attending physician may perform physical rehabilitation
pre and post practice on athletes currently requiring physical rehabilitation.

4. If it becomes necessary for an outside referral for rehabilitation, the athletic trainer
making the referral must follow the following policies; Documentation, Insurance, and
Referral to Specialist.

5. It is the responsibility of the ATC that made the referral to follow the progress of
student-athlete to outside providers and/or other medical services and report student
athlete status to the head coach of that sport.
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Physician Liaison and Protocols

Purpose:

To define the expectation of staff and faculty to maintain the physician protocol with the team
physician/medical director.

Policy:

Each ATC must be licensed with the (State Board of Professional Licensure).

The physician protocol must be signed by the (COLLEGE/SCHOOL) team physician/medical

director. Failure to adhere to the policy and State Practice Act prevents the athletic trainer from
being able to practice athletic training as defined by the NATABOC and NCAA Guidelines.

Any failure to obtain and maintain the physician protocol will be handled by the Director of
Student Life and/or Athletics Director on a case-by-case basis

ATHLETIC TRAINER'S RESPONSIBLE PHYSICIAN and PROTOCOL

Athletic Trainer's Name: ___________________________________________

Responsible Physician's Name: ______________________________________

Under my supervision, the above designated Athletic Trainer will have the authority to act in
my behalf and provide the following care:

1. Perform evaluations, emergency care, and transportation.

2. Perform the application of preventative and protective measures designed to prevent
injuries or protect existing injuries including taping, padding bandaging, dressing skin
wounds and splinting
3. Application of cryotherapy such as cold/ice packs, cold water immersion, ice massage and
spray coolants.
4. Application of thermotherapy such as topical analgesics, moist hot packs, heating pads,
infrared heat, and paraffin baths.
5. Application of hydrotherapy such as whirlpool and contrast bath.
6. Initiate standard treatment procedures of applying cold, compression, elevation and rest to
injured body parts.
7. Application of rehabilitation procedures for post operative injuries and non-operative
injuries.
8. Application of additional clinical contemporary therapeutic modalities including patient
preparation set up, determination of dosage and treatment such as but not limited to
diathermy (shortwave, microwave, ultrasound) and muscle stimulation.
9. Act as an advisor concerning diet, rest, hydration, hygiene, sanitation, injury/illness
prevention and physical fitness development.
10. Application of therapeutic exercise common to athletic training such as stretching,
conditioning, strengthening, and muscle testing.

_________________________________________________ ______________
Signature of Responsible Physician Date

_________________________________________________ ______________
Signature of Athletic Trainer Date

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Record Retention & Dead Records

Purpose:

To define the record keeping procedure for athletes who no longer participate within
(COLLEGE/SCHOOL) Athletics.

Policy:

All records must be kept in a secure location to protect patient confidentiality. These records
must be maintained for a period of 10 years after the student-athlete has completed their
athletic participation at (COLLEGE/SCHOOL).
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Universal Precautions and Infection Control

Purpose:

To reduce the risk of spreading infection

Policy:

BLOOD-BORNE PATHOGENS

Blood-borne pathogens are disease causing microorganisms that may be present in human
blood or fluids. They may be transmitted with any exposure to blood or other body fluids. Two
pathogens of significance are Hepatitis B Virus (HVB) and Human Immunodeficiency Virus (HIV).

All human blood and certain body fluids should be treated as if they are known to contain HIV,
HVB or other blood-borne pathogens.

Materials that require Universal Precautions are the following:

 Blood
 Any body fluid with visible blood
 Any unidentifiable body fluid
 Saliva from dental procedure or injury
 Semen
 Vaginal secretions
 Cerebrospinal fluids
 Pleural fluids

PERSONAL PROTECTIVE EQUIPMENT

Personal protective equipment should be used when handling any of the above materials. This
includes the use of gloves, protective eye wear and mask if projectile blood or fluids are
present. This equipment should be worn until the wound care or procedure is over and/or the
wound is bandaged. Gloves should be changed after treating each athlete. After glove removal,
hands should be washed. Equipment and supplies that should be available to caregivers are
gloves, disinfectant bleach, antiseptics, and designated biohazard containers and sharps
containers.

ATHLETICS HEALTH CARE RESPONSIBILITIES

Pre-event preparation includes proper care for wounds, abrasions, cuts or weeping wounds
that may serve either as a source of bleeding or as a port of entry for blood-borne pathogens.
These wounds should be covered with an occlusive dressing that will withstand the demands of
competition. Likewise, care providers with healing wounds or dermatitis should have these
areas adequately covered to prevent transmission to or from a participant.

When a student-athlete is bleeding, the bleeding must be stopped and the open wound
covered with a dressing sturdy enough to withstand the demands of activity before the
student-athlete may continue participation in practice or competition. Current NCAA policy
mandates the immediate, aggressive treatment of open wounds or skin lesions that are
deemed potential risks for transmission of disease. Participants with active bleeding should be
removed from the event as soon as practical. Return to play is determined by appropriate
medical staff personnel. Any participant whose uniform is saturated with blood, regardless of
the source, must have that uniform evaluated by appropriate medical personnel for potential
infectivity and changed if necessary before return to participation.

References:

Centers for Disease Control (CDC). 1985. Recommendations for preventing transmission of
infection with human T-lymphotropic virus type III/lymphadenopathy-associated virus in the
workplace. MMWR 34(45): 681–686; 691–695.

Universal Precautions for Preventing Transmission of Bloodborne Infections MMWR, June 24,
1988 / 37(24);377-388

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Anabolic Steriod Abuse

Purpose:

To identify a process to manage a situation of possible steroid abuse.

I. RECOGNITION

 A sudden, dramatic weight change; with or without altered lean body mass or edema
 Gynecomastia or sexual dysfunction in a male.
 Virilism in a female; prepubertal in a male
 Mood swings ranging from euphoria to aggression to depression.
 Increased muscle cramping.
 Increased blood pressure
 Baldness/hair loss
 Water retention (puffiness)
 Severe acne (back/shoulders)
 Any sign of liver dysfunction

II. MANAGEMENT

Discuss condition with individual, encourage counseling.

III. REFERRAL

Refer to counseling services.

Sports Health Care
Section: Administrative Policies and Procedures

Subject: Recreational Drug and Alcohol Abuse

Purpose:

Identify the signs and symptoms of abuse and intervention process for athletic trainers and
staff.

Anyone of these signs or symptoms in isolation can exist in any person. It is the frequency and
magnitude which indicates a potential problem.

I. RECOGNITION

1. Physical Signs
 Unexpected bruises; unexpected injuries
 Dry mouth; bad breath
 Poor coordination; muscle twitches
 Problems in gross motor coordination - tripping, falling and bumping
 Restlessness; jittery state
 Drowsiness; constant fatigue
 Nervous; highly talkative; over-active
 Poor attention span; impaired judgment
 Muddled speech
 Heavy sweating, chills, rapid pulse

2. Psychological Factor

 Irritability
 Mood swings
 Explosiveness

3. Behavioral Responses:

 Inconsistent performance; below standard performance

 Unexplained absenteeism
 Frequent requests to be excused
 Frequent medical complaints; high number of accidents
 Chronic lateness
 Dramatic drop or rapid deterioration in academic or work
performance

 Deteriorating hygiene and personal appearance

  Dissension with team members or job associates

II. MANAGEMENT

Discuss condition with individual, encourage counseling.

I I I. REFERRAL

Refer to counseling services.

 SECTION IV
Sports Therapeutic Intervention & Rehabilitative Care
Section Table of Contents
THERAPUETIC MODALITIES
THERAPEUTIC MODALITIES

Cryotherapy
Cold Packs, Ice massage and immersion
Sequential cold compression units
Thermotherapy
Moist heat pack use
Laser therapy
Hydrotherapy (Whirlpool)
Ultrasound
Electrical Muscle Stimulation
Trans-electrical Nerve Stimulation (TENS\MENS)

Phonophoresis
Therapeutic Massage

THERAPEUTIC EXERCISE & REHABILITATION GUIDELINES

Lower Extremity Programs:

Foot and Ankle:

Ankle Rehabilitation
Foot Care Guidelines
Post Operative Ankle Ligament Repair Rehabilitation
Plantar Fasciitis
Turf Toe Injury Care

Lower Extremity:
Anterior Compartment Syndrome
Lateral Compartment Conditions
Posterior Compartment Conditions
Shin Splints
Tibial Stress Syndrome

Knee:
Non-Surgical Management of the ACL Deficient Knee
ACL Patella Tendon Autograft Reconstruction Rehabilitation
ACL Hamstring Tendon Autograft Reconstruction Protocol
ACL Allograft Reconstruction Protocol
Meniscal Repair Rehabilitation
Arthroscopic partial medial or lateral meniscectomy
PCL Reconstruction Protocol
Patellofemoral Pain Syndrome (PFS)
 Upper Leg and Thigh:
Adductor Injuries
Hamstring Injuries
IT Band Syndrome
Quadriceps Injuries

Upper Extremity Programs:

Shoulder:
Arthroscopic Subacromial Decompression Rehabilitation
Arthroscopic Anterior Stabilization (with or without Bankart Repair)
Open Anterior Stabilization (with or without Bankart)
Posterior and Posterior Inferior Capsular Shift Protocol
Arthroscopic Debridement of Type I and III SLAP Lesions Protocol

Arthroscopic Labral Repair Protocol-Type II, IV, and Complex Tears

Acromioclavicular Joint Separation

Elbow:
Tennis Elbow
Ulnar Collateral Ligament Reconstruction Using Autogenous Graft

Hand and Wrist:

Hand and Digit Therapy Guidelines
Thumb and Wrist Therapy Guidelines

Thoraic and Back Rehabilitation:

Lower Abdominal Muscular and Soft Tissue Injuries

Chest Soft Tissue and Muscular Injuries
Lower Back Soft Tissue Therapy
McKenzie Treatment
Williams Series Protocols
Middle and Upper Back Treatments

Cervical and Facial Injury Therapy

Neck Care Program

Facial Muscular Injury Therapy

Additional Guidelines:
Return to Sport after Knee Injury / Surgery Guidelines
Running Injury Prevention & Return to Running Program Guidelines

Running Injury Prevention Tips & Strength Training Program for Runners
Muscle Flexibility and Stretching
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Injury Management – Therapeutic Treatment

Purpose:

Treatment guidelines include the use of therapeutic modalities and the implementation of
therapeutic exercise for the restoration of injured tissue. Treatment guidelines will be followed,
as outlined, in the Standard Operating Procedure, or by written orders by the team physician or
other licensed physician. The athletic trainer may utilize the necessary equipment as indicated
by the condition, and the standards of care outlined in the General Practice Guidelines,
including the use of TENS and such other modalities where authorized by law (see
Administrative SOP). The operational use and safety of all equipment shall be as recommended
by the manufacturer.
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Cryotherapy

Purpose:

To provide guidance and general guidelines for the application and use of cold therapies in
treating sports related injuries.

Guideline:

I. METHODS OF APPLICATION
 Ice Packs
 Ice Massage
 Ice Slush
 Bio-Compression Cryotherapy
 Chemical Spray (Flourimethane, etc.)

II. CRYOTHERAPY APPLICATION

Indications Contraindications
Acute or chronic pain Decreased cold sensitivity and/or hypersensitivity
Acute or chronic muscle spasm/guarding Cold allergy
Acute inflammation or injury Circulatory or sensory impairment
Postsurgical pain and edema Reynaud’s disease or cold urticaria
Superficial first-degree burns Hypertension
Used with exercises to: Uncovered open wounds
Facilitate mobilization Cardiac or respiratory disorders
Relieve pain Nerve palsy
Decrease muscle spasticity Arthritis

III. PRECAUTIONS
 Hypertensive patients
 Cover face, eyes and avoid inhalation of vapors when using vapocollant sprays.

References:

Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue
injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251–261.
Hubbard TJ, Aronson SL, Denegar CR. Does cryotherapy hasten return to participation? A
systematic review. J Athl Train. 2004;39:88–94.
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Bio Compression – Cryotherapy Unit

Purpose:

Establish a set of protocols for the safe use of bio-compression unit combined with cryotherapy.
Provide a set of treatment guidelines for the use of sequential compression unit combined with
cryotherapy for soft tissue edema reduction.

Bio Cryo Cold Compression System is a gradient, sequential, pneumatic compression device,
intended for the primary treatment of Tendinitis, Hamstring Pulls, Joint Inflammation Edema,
Post-op Ankle and Knee Injuries, Soft Tissue Injuries, for acute sprains, bruises and other
musculoskeletal injuries. This device is intended for home or hospital use.

Indications

This state of the art system consists of a sequential circulator and an easy zip-on Biocomfort
garment providing sequential, gradient compression and cold therapy to any extremity. Two
extremities can be treated simultaneously. After removing the garment from the freezer,
BIOCRYO maintains a constant 40ºF skin interface temperature for several hours.

Contraindications

Pneumatic compression is contraindicated for the patients with:

1. Congestive heart failure
2. Deep vein thrombosis
3. Inflammatory phlebitis or episodes of pulmonary embolism
4. Infections in the limb, including cellulitis, without appropriate antibiotic coverage
5. Presence of lymphangiosarcoma

Evaluation

1. Individual has edema of an extremity which has been unsuccessfully managed with
other methods of treatment.

2. Individual does not have a medical condition that would be a contraindication for the
use of a sequential compression device with calibrated gradient pressure, such as:
• Infections of the limb without appropriate antibiotic coverage.
• Presence of Lymphangiosarcoma.
 • Congestive Heart Failure, unresolved.
• Deep Vein Thrombosis, unresolved.
• Inflammatory Phlebitis or during episodes of pulmonary embolism.

Patient Education

1. During evaluation, the patient will be educated in the appropriate use of the Bio
Compression Sequential Circulator, including:
• Operation of the Sequential Circulator
• Specifics regarding the patient’s course of treatment
• Specifics as to proper skin care
• Wear and maintenance of appropriate compression garment
• Exercise appropriate to treating a specific area of body (arm/leg)
• Recognizing adverse signs and symptoms of infection or cellulitis
• Demonstrated knowledge of appropriate prevention measures
• Importance of follow-up in order to evaluate the effectiveness of therapy
• Importance of pre/post-treatment measurements
• Importance of blood pressure measurement as it pertains to setting
• of pump pressures

Treatment Procedures

1. Place patient in a comfortable position on the treatment table. Explain procedure to

patient.
2. Assess skin for any signs or symptoms of infection or cellulitis. If any signs are noticed do
not put patient on the pump. Instead, contact team physician ASAP.
3. Measure swollen limb at appropriate anatomical landmarks. (Use same tape measure
each time). Mark each location on skin to ensure same measurement. Ideally, the same
person should measure the patient each time. A family member can be taught to
measure the patient at home. Measurements should be recorded on the patient’s
treatment chart.
4. Cover limb with cotton stockinette. Remind patient to keep hand flat if using an arm
garment.
5. Help patient apply garment to affected arm or leg. Use zipper to secure garment.
6. Connect appliance to pump via the tubing connector.
7. Turn pump on. Set pressure as first garment chamber is inflating. The pump may have
to run through a couple of cycles before it reaches full pressurization in all chambers of
the garment.
8. Make sure patient is comfortable, using a blanket for warmth, proper lighting, etc.
9. Set up time schedule if necessary to help patient keep track of treatment times.
Treatment schedule may be 1-2 hours or longer, depending on therapy requirements.
10. Instruct the patient to stop treatment immediately should symptoms such as numbness,
loss of sensation, pain, coldness, pins and needles or cramping occur. Investigate cause,
such as pressure set too high, etc.
11. At end of session, turn pump off. Remove appliances and measure limb at the same
location as previously indicated with markings on skin. Record measurements on chart.
Check skin for rashes, blisters or bruises and make note of same.
12. Inquire of patient whether any problems were encountered. If so, deal with them
immediately.
13. After pump cycle is concluded, patient should be fitted with a proper compression
garment to help control edema of limb.

Pressure Settings

ARMS
• Primary & Secondary Arm 20-40mmHg
• Primary—1½ hours daily
• Severe Primary 2 times daily
• Secondary: 1to 1½ Hours Daily
LEGS
• Primary 50-60mmHg
• 1½ Hours Daily
• Severe Primary 2 Times Daily
• Secondary LE 40-50 mmHg
• 1 Hour daily

Additional Assessments:

ABI is the Ankle Brachial Index test. This test is done by measuring blood pressure at the ankle
and in the arm while a person is at rest. Measurements are usually repeated at both sites after
5 minutes of walking on a treadmill. The Ankle Brachial index (ABI) result is used to predict the
severity of peripheral arterial disease (PAD). The Ankle Brachial Index is an important part of
the vascular assessment of the lower leg and should be performed only by a skilled healthcare
practitioner.
Cleaning Instructions

4 and 8 Chamber Sequential Circulator Garments

Exterior Case Cleaning Instructions:
• Clean the exterior case and tubing with a damp (not wet) cloth using a mild soap and water
solution once per month or as needed.
• Do not allow liquids to enter the equipment, an electrical hazard may be presented.
• Always allow the unit to dry before re-using.
• Garment Cleaning/Disinfecting Instructions:
1. Disconnect garment and tubing from device.
2. Open garment to expose all sides either by separating Velcro type hook and loop or by
unzipping (depending on type of garment).
3. Use either a large sink or plastic tub able to hold enough solution (depending on size
and quantity of garments) to completely submerge garment/s under water including
tubing, with the exception of connectors at end of tubing. Solution should consist of 1/3
cup of Tide or equivalent detergent per 1 gallon of warm tap water. NOTE: IT IS
EXTREMELY IMPORTANT THAT CONNECTOR AT END OF TUBING BE KEPT OUT OF
WATER AT ALL TIMES TO AVOID WATER FROM ENTERING INTERIOR PORTION OF
GARMENT/S.
4. Garment/s should be soaked for 1/2 hour with mild agitation of garment every 5 to 10
minutes while keeping it below surface of water. NOTE: Occasionally, harder to remove
soiling on surface of garment may require additional washing by hand with a clean
towel or soft brush while submerged. In all cases, avoid using any abrasive type
materials on the exterior surface of garment.
5. Thoroughly rinse garment with warm tap water.
6. Re-submerge garment in solution consisting of 1 cup of Clorox bleach per gallon of
warm tap water for 1/2 hour, again agitating garment every 5 to 10 minutes while
keeping garment/s below surface (with exception of tubing connector/s).
7. Rinse garment/s thoroughly and allow to air dry.
8. DO NOT place garment in washing machine or submerge in water unprotected from
water entering interior portion of garment where ultimate damage to pump can occur.
9. DO NOT use the tubing or valves as "handles" for carrying, hanging or storing
garment/s.
10. In cases when it is necessary for a garment to be returned to the factory for repair or
evaluation, it is essential that garment/s is thoroughly cleaned and disinfected.

References:
Materials from manufacturer

Chris M Bleakley, Seán O'Connor, Mark A Tully, Laurence G Rocke, Domnhall C MacAuley and
Suzanne M McDonough, The PRICE study (Protection Rest Ice Compression Elevation): design
of a randomised controlled trial comparing standard versus cryokinetic ice applications in the
management of acute ankle sprain; BMC Musculoskeletal Disorders

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Thermotherapy

Purpose:

To provide guidance and general guidelines for the application and use of heat in treating
sports related injuries.

Guideline:

I. METHODS OF APPLICATION
Hydrocollator (steam) packs
Paraffin bath

II. THERMOTHERAPY APPLICATION

Indications:
Sub-acute or chronic injuries, to:
Reduce swelling, edema, and ecchymosis
Reduce muscle spasm/ guarding
Increase blood flow, to:
Increase range of motion prior to activity
Resolve hematoma
Facilitate tissue healing
Relieve joint contractures
Contraindications:
Acute inflammation or injuries
Impaired or poor circulation
Sub-acute or chronic pain
Impaired or poor sensation
Impaired thermal regulation
Malignancy
Fight infection

III. PRECAUTIONS
 Fair skin
 Open wounds
 Sports Health Care

Section: Administrative Policies and Procedures

Subject: Hydrotherapy (Whirlpool)

Purpose:

Provide guidelines for the appropriate use of hydrotherapy in sports injury care and
rehabilitation.

Guidelines:

I. TECHNIQUES FOR USING A WHIRLPOOL BATH

1. Inspect the electrical system. To avoid electrical surges, make sure that ground-
fault circuit breakers are used in the electrical outlet or in the circuit-breaker
box.
2. Apply a povidone-iodine (Betadine) additive, or chloramine-T (Chlorazene) in
concentrations of 100 to 200 parts per million (ppm) to the water as an
antibacterial agent, especially if the athlete has an open wound.
3. Recommended temperature and treatment time include:
Cold whirlpools 55–65°F 5–15 min
Hot whirlpools
Extremity 98–110°F 20–30 min
Full body 98–102°F 10–12 min
4. Assist the patient into the water and provide towels for padding and drying off.
 5. Turn the turbine on and adjust the height to direct the water flow 6 to 8 inches
away from the injury site.
6. Instruct the patient to move the body part through the available range of
motion. This increases blood flow to the area, aids in removal of debris, and
improves balance and proprioception.
7. Turn the turbine off and remove the patient from the water. Dry the treated
area and assist the individual from the whirlpool area.
8. Drain and cleanse the whirlpool tub after each use. Disinfect the hard-to-reach
places with glutaraldehyde, formalin alcohol, ethylene oxide, or beta
propiolactone to kill sport-forming bacteria. A solution of sodium hypochlorite
(chlorine bleach), in concentrations ranging from 500 ppm (1:100 dilution) to
5000 ppm (1:10 dilution) is effective in cleaning surface organic material (blood,
mucus).
9. Cultures for bacterial and fungal agents should be conducted monthly from
water samples in the whirlpool turbine and drain.

II. INDICATIONS
Musculoskeletal conditions
Wound debridement
Pain
Muscle spasm
Facilitate exercise
Cold – acute trauma

III. CONTRAINDICATIONS
A. Hot
 Circulatory impairment
 Areas prone to bleeding
 Malignancy
 Impaired sensation
 Over tape/bandages
B. Cold
 Cold sensitivity symptoms:
Cold urticaria
Cryoglobinlinemia
Cold intolerance
Reynaud’s phenomenon
Paroxysmal cold hemoglobinuria
 Circulatory compromised areas
 Some rheumatoid conditions

IV. PRECAUTIONS
  Full body immersions
 Open wounds

References

Dr. Craig W. Martin, Senior Medical Advisor, Kukuh Noertjojo, Health Care Analyst:
HYDROTHERAPY: Review on the effectiveness of its application in physiotherapy and
occupational therapy. (Evidence Based Study on Effectiveness.) May 2004

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Ultrasound

Purpose:

Provide a set of clinical guidelines for the therapeutic use of ultrasound in treating sports
related soft tissue injuries.

Guidelines:

I. Types

Continuous ultrasound
Thermal effect to warm superficial tissues
Frequency of ultrasound wave’s effects depth of tissues effected
Lower frequency waves penetrate tissues as deep as 2 inches or 5 cm

Pulsed ultrasound
Non-thermal effect theoretically speeds tissue healing at the cellular level

Phonophoresis
Transcutaneous medication (typically Corticosteroid) delivered to tissue via ultrasound

II. ULTRASOUND APPLICATION (GENERAL)

Indications:
Increase deep tissue heating
Decrease inflammation and resolve hematoma
Decrease muscle spasm/spasticity
Decrease pain
Increase extensibility of collagen tissue
Decrease pain of neuromas
Decrease joint adhesions and/or joint
contractures
Treat post-acute myositis ossificans

Contraindications:
Acute and post acute hemorrhage
Infection
Thrombophlebitis
Over suspected malignancy/cancer
Areas of impaired circulation or sensation
Over stress fracture sites
Over epiphyseal growth plates
Over the eyes, heart, spine, or genitals

Dosage Parameters:
Dosage Calculations:
III. PRECAUTIONS
 Acute Trauma
 Over or near bone growth centers
 After exercise
 Fracture
 Impaired sensation
 Reduced circulation

References:

NCRP Report No. 74 (1983), "Biological Effects of Ultrasound: Mechanisms and Clinical
Implications", National Council on Radiation Protection and Measurements, 7910 Woodmont
Avenue, Bethesda, MD, 20814, issued December 30.

Lennart D. Johns, Nonthermal Effects of Therapeutic Ultrasound: The Frequency Resonance

Hypothesis; J Athl Train. 2002 Jul-Sep; 37(3): 293–299.
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Electrical Muscle Stimulation

Purpose:

Provide a set of clinical guidelines for the therapeutic use of electrical muscle stimulation in
treating sports related soft tissue injuries.

Guidelines:

I. APPLICATION OF NEUROMUSCULAR ELECTRICAL STIMULATION

TENS Indications Contraindications
Posttraumatic pain, acute and chronic Patients with pacemakers
Postsurgical pain Pregnancy (abdominal and/or pelvic
Analgesia Pain of unknown origin area)

High–Voltage Pulsed Indications Contraindications

Circulation and joint mobility Pacemakers
Muscle re-education and strength Pain of unknown origin
Wound and fracture healing Pregnancy (abdominal and/or pelvic
Nonunion fracture healing area)
Muscle spasm/spasticity Thrombophlebitis
Pain and edema Superficial skin lesions or infections
Disuse atrophy Cancerous lesions
Denervation of peripheral nerve injuries Over suspected fracture sites

Interferential Indications Contraindications

Circulation and wound healing Pacemakers
Pain, acute and chronic Pregnancy (abdominal and/or pelvic
area)
Reduction of muscle spasm/guarding Thrombophlebitis
Posttraumatic and chronic edema Pain of unknown origin
Abdominal organ dysfunction Prolonged use (may increase
muscle soreness)

Low-Intensity Stim. Indications Contraindications

Nonunion wound healing Malignancy
Fracture healing Hypersensitive skin
Iontophoresis Allergies to certain drugs

II. PRECAUTIONS
 Open wounds
 Acute Trauma

See additional parameters for EMS.

PARAMETER MODIFICATION FOR ELECTROTHERAPY

Desired Effect Current Type Intensity Frequency Duration Electrodes Mode
Muscle contraction Biphasic Motor <15 pps twitch 300–500 us Ends of muscle Duty Cycle
15–25 pps sum motor points
>40 pps tetany

Monophasic Motor <15 pps twitch 300–500 us Negative/ends of Alternate

15–25 pps sum muscle or motor reciprocate
>40 pps tetany points duty cycle

Pain control Gate Biphasic Sensory 110 pps 30–200 us Direct contiguous Modulated
nerve root
dermatomes
Monophasic Sensory 100–150 pps Short Positive/over Continuous
pain site

Opiate release Biphasic Motor 1–5 pps 300-500 us Trigger points Burst
Monophasic Motor 1–5 pps 300–500 us + (acute) – Continuous
chronic)/over
pain site

Central biasing Biphasic Noxious 100–150 pps 250–500 us Trigger points Modulated

Edema reduction Monophasic Sensory 80–150 pps 20–200 us Negative/over Continuous

edema

Note: Interferential stimulation can be used for muscle contraction, gate, and opiate pain control by using similar parameters. Russian current can be
used for muscle contraction by substituting bps for pps. Printed with permission from Holcomb WR. J Sport Rehab 1997;6(3):280.

Dina Brooks, BSc(PT), MSc, PhD , et. Al. ELECTROPHYSICAL AGENTS: Contraindications and
Precautions: An Evidence-Based Approach to Clinical Decision Making in Physical Therapy
Physdiotherapy Canada, VOLUME 62 NUMBER 5 SPECIAL ISSUE 2010

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Trans-electrical Nerve Stimulation (TENS)

Purpose:

Provide a set of clinical guidelines for the therapeutic use of TENS in treating sports related soft
tissue pain.

Guidelines:

I. PROTOCOL FOR TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

APPLICATION
Parameter High TENS Low TENS Brief-Intense
Intensity Sensory Motor Noxious
Pulse frequency 60–100 pps 2–4 pps Variable
Pulse duration 60–100 usec 150–250 usec 300–1000 usec
Mode Modulated rate Modulated burst Modulated amplitude
Duration As needed 30 min 15–30 min
Onset of relief <10 min 20–40 min <15 min
Duration of relief Minutes to hours Hours <30 min

II. INDICATIONS
Pain:
 Chronic
 Acute
 Surgical

III. CONTRAINDICATIONS
Patient with pacemaker
Over carotid sinus

IV. PRECAUTIONS
Pregnancy
Skin irritations

References:

Johnson, M. (2008). TENS In : Electrotherapy: Evidence Based Practice. Ed. Watson. T. Elsevier
Robertson, V. et al (2007). Electrotherapy Explained.  Elsevier.
Walsh, D. (1997). TENS: Clinical Applications and Related Theory. Edinburgh, Churchill
Livingstone.
Sports Health Care
Section: Administrative Policies and Procedures

Subject: Phonophoresis

Purpose:

Provide a set of clinical guidelines for the therapeutic use of a topical selected medication
combined with ultrasound in treating sports related soft tissue pain.

Guidelines:

I. APPLICATION
Modality – Ultrasound
Medium – Hydrocortisone (10% and 1 %) compound in a liquid base with lidocaine.

II. INDICATIONS
Has been used to administer local anesthetics and antibiotics.
Has been used to successfully deliver anti-inflammatory medication to inflamed
subcutaneous tissues.

III. CONTRAINDICATIONS
 Over the site of a fracture or open wound
 Over broken skin
 Allergy to the medication

IV. CONSIDERATIONS
Studies have shown that Ketoprofen concentration was consistently higher in plasma,
fat tissue, and synovial tissue with pulsed ultrasound as opposed to continuous
ultrasound.

V. TREATMENT APPLICATION GUIDELINES

1. For Acute Injuries:
 Prior to applying the topical medication ask the athlete if he has any allergies (if
you are not certain whether or not the drug will cause a reaction contact local
the pharmacists prior to its use.
 For best results clean the area with an alcohol wipe prior to apply the medication
 Apply medication in the single dose syringe to the injury area and rub it in until it
is tacky to the touch and no longer visible.
 Perform a pulsed ultrasound with a duty cycle ranging from 20% - 60%, at either
1MHz or 3MHz (depending on depth desired), and with intensity ranging from
0.8 - 1.5 W/cm2 for 5-7 minutes (DO NOT MOVE THE ULTRASOUND HEAD AT
ALL)

2. For 2-day old +, or Chronic Injuries

  Prior to applying the topical medication ask the athlete if he has any allergies (if
you are not certain whether or not the drug will cause a reaction contact the
local pharmacists prior to its use.
 For best results clean the area with an alcohol wipe prior to apply the medication
 Apply medication in the single-dose syringe to the injury area and rub it in until it
is tacky to the and no longer visible.
 Perform a continuous ultrasound at either 1MHz or 3MHz (depending on depth
desired) with intensity ranging from 1.0-1.5 for 5-7 minutes (Make sure that you
keep the ultrasound head moving and turn it down as needed).

Refetrences

Ultrasound Therapy : The Basics International Society for Electro Physical Agents in Physical
Therapy (ISEAPT), Monograph on website: <http://www.electrotherapy.org/
modalities/ultrasound basics.htm>

Sports Health Care

Section: Administrative Policies and Procedures

Subject: Massage

Purpose:

Provide a set of clinical guidelines for the therapeutic use of massage in treating sports related
soft tissue pain.

Guidelines:

I. TECHNIQUES OF MASSAGE

Technique Use Method of Application

Effleurage (stroking)
Relaxes patient Gliding motion over the skin without any attempt to
Evenly distributes any lubricant move deep muscles
Increases surface circulation Apply pressure with the flat of the hand; fingers
and thumbs spread; stroke toward the heart
Massage begins and ends with stroking

Pétrissage (kneading)
Increases circulation Kneading manipulation that grasps and rolls the
Promotes venous & lymphatic return muscles under the fingers or hands
Breaks up adhesions in superficial
connective tissue
Increases elasticity of skin

Tapotement (percussion) Increases circulation Brisk hand blows in rapid succession:

Stimulates subcutaneous structures
hacking with ulnar border
slapping with flat hand
beating with half-closed fist
tapping with fingertips
cupping with arched hand

Vibration Relaxes limb Fine vibrations made with fingers pressed into a
specific body part

Friction (rubbing) Loosens fibrous scar tissue Small circular motions with the fingers, thumb, or
Aids in absorption of edema heel of hand
Reduces inflammation Transverse friction is done perpendicular to the
Reduces muscular spasm fibers being massaged

II. APPLICATION OF THERAPEUTIC MASSAGE

Indications Contraindications
Increase local circulation Acute contusions, sprains, and strains
Increase venous and Over fracture sites
lymphatic flow Over open lesions or skin
Reduce pain conditions(analgesia) Conditions such as: acute phlebitis, thrombosis, severe varicose veins,
Reduce muscle spasm cellulitis, synovitis, arteriosclerosis, and cancerous regions
Stretch superficial scar tissue
Improve systemic relaxation
Chronic myositis, bursitis, tendinitis
tenosynovitis, fibrositis

III. SPECIAL TECHNIQUES

 Deep Tissue Therapy 
 Neuromuscular Re-Education 
 Trigger Point Therapy 
  Muscle Energy Techniques 
 Assisted Stretching (PNF Stretching)
 Myofascial Release Therapy
 Graston Technique
 Rolfing Deep Tissue Massage

IV. APPLICATION GUIDELINES

Pre-Event Massage:
 This is a short, specific treatment given immediately before ( 30 minutes- 24 hours
before) and event. 
 The goal of treatment is to increase the circulation, flexibility and mental clarity of
the athlete to improve performance. 
 It does not replace the athletes warm up but complements it.  
Post-Event Massage:
 Post Event treatments are done immediately after an event, usually within 1-2
hours. 
 The goal of the session is to flush the tissue of the lactic acid and other by products
of metabolism.
 The intent is to cool down the body and return it to homeostasis. 
 Muscle tension, cramping, and inflammation are also addressed. 

References:

"Policy for Therapeutic Massage in an Academic Health Center: A Model for Standard Policy
Development". The Journal of Alternative and Complementary Medicine. 2007. Retrieved 2007-
09-26. 13 (4) pp.471-475

Verhoef, M. (2005-06-10). "Overview of Manual Therapy in Canada". The National Center for
Complementary and Alternative Medicine (NCCAM). Retrieved 2007-09-26.
 THERAPEUTIC EXERCISE

The following are guidelines for the application of therapeutic methods and techniques for the
restoration of function and the reconditioning of students-athletes after injury. Evidence based
techniques specific to certain injuries are not dealt with in detail in this section. The following
are only general guidelines for the application of the modalities used in rehabilitative care.
 LEVELS OF REHABILITATIVE CARE

REHABILITATION
Level I Emergency Care – Acute Care

Level II Acute Soft Tissue Injury Management

Level III Modality and Exercise Transition

Level IV Strength and Restoration of Range of Motion

Level V Functional Activities

Level VI Sports Specific Strength and Skill Training

RECONDITIONING

Level I Maintenance Activities

Level II Advanced Fitness Training

Level III Performance Enhancement

Section Table of Contents
REHABILITATION GUIDELINES
Ankle Rehabilitation
Post Operative Ankle Ligament Repair Rehabilitation
Plantar Fasciitis
Non-Surgical Management of the ACL Deficient Knee
ACL Patella Tendon Autograft Reconstruction Rehabilitation
ACL Hamstring Tendon Autograft Reconstruction Protocol
ACL Allograft Reconstruction Protocol
Meniscal Repair Rehabilitation
Arthroscopic partial medial or lateral meniscectomy
PCL Reconstruction Protocol
Patellofemoral Pain Syndrome (PFS)
Ulnar Collateral Ligament Reconstruction Using Autogenous Graft
Arthroscopic Subacromial Decompression Rehabilitation
Arthroscopic Anterior Stabilization (with or without Bankart Repair)
Open Anterior Stabilization (with or without Bankart)
Posterior and Posterior Inferior Capsular Shift Protocol
Arthroscopic Debridement of Type I and III SLAP Lesions Protocol
Arthroscopic Labral Repair Protocol-Type II, IV, and Complex Tears
Acromioclavicular Joint Separation
Return to Sport after Knee Injury / Surgery Guidelines
Running Injury Prevention & Return to Running Program Guidelines
Running Injury Prevention Tips & Strength Training Program for Runners
Muscle Flexibility and Stretching
 Sports Health Care

Section: Rehabilitation Guidelines

Subject: Ankle Rehabilitation

Purpose:

Provide a set of clinical guidelines for the therapeutic use of exercise in treating ankle injuries.

Guidelines:

I. CLASSIFICATION OF ANKLE SPRAINS

Grade Signs and symptoms
I: Partial tear of a ligament
II: Incomplete tear of a ligament,
with moderate functional
impairment
III: Complete tear and loss of
integrity of a ligament
Mild tenderness and swelling
Slight or no functional loss (i.e., patient is able to bear weight and ambulate with minimal pain)
No mechanical instability (negative clinical stress examination)
Moderate pain and swelling
Mild to moderate ecchymosis
Tenderness over involved structures
Some loss of motion and function (i.e., patient has pain with weight-bearing and ambulation)
Mild to moderate instability (mild unilateral positivity of clinical stress examination)
Severe swelling (more than 4 cm about the fibula)
Severe ecchymosis
Loss of function and motion (i.e., patient is unable to bear weight or ambulate)
Mechanical instability (moderate to severe positivity of clinical stress examination)

II. CONTRAINDICATIONS / PRECAUTIONS FOR TREATMENT:

• Fracture
• Tumor at ankle or foot
• Tendon tears or tendonitis – current or past
• Avoid positions which increase swelling or pain
• Refer to modality practice standards for other specific contraindications and
precautions

III. COMPONENTS OF EARLY FUNCTIONAL REHABILITATION OF ANKLE SPRAINS

Component Procedure Duration and frequency Comments
Range of Motion
Achilles tendon stretch, non- Use a towel to pull foot toward Pain-free stretch for 15 to 30 Maintain extremity in a non-gravity
weight-bearing face. seconds; five repetitions; repeat position with compression.
three to five times a day.
Achilles tendon stretch, weight- Stand with heel on floor and Pain-free stretch for 15 to 30
bearing bend at knees. seconds; perform five repetitions;
repeat three to five times a day.
Alphabet exercises performed Move ankle in multiple planes of Repeat four to five times a day. Exercises can be in conjunction with
motion by drawing letters of cold therapy.
alphabet (lower case and upper
case).
Muscle Strengthening
Isometric exercises Resistance can be provided by For each exercise, hold 5 seconds; Strengthening exercises should
immovable object (wall or floor) do 10 repetitions; repeat three only be done in positions that do
or contralateral foot. times a day. not cause pain.
Plantar flexion Push foot downward (away
from head).
Dorsiflexion Pull foot upward (toward head).
Inversion Push foot inward (toward
midline of body).
 Component Procedure Duration and frequency Comments
Eversion Push foot outward (away from
midline of body).
Isotonic exercises Resistance can be provided by For each exercise, hold 1 second for Emphasis is placed on the eccentric
contralateral foot, rubber tubing concentric component and perform component; exercises should be
or weights. eccentric component over 4 performed slowly and under
seconds; do three sets of 10 control.
repetitions; repeat two times a day.
Plantar flexion Push foot downward (away from
head).
Dorsiflexion Pull foot upward (toward head).
Inversion Push foot inward (toward midline
of body).
Eversion Push foot outward (away from
midline of body).
Toe curls and marble pickups Place foot on a towel; then curl Two sets of 10 repetitions; repeat Toe curls can be done throughout
toes, moving the towel toward two times a day. the day, at work or at home.
body.
Use toes to pick up marbles or
other small object.
Toe raises, heel walks and toe Lift body by rising up on Three sets of 10 repetitions; Strengthening can occur from using
walks toes.Walk forward and backward repeat two times a day; progress the body as resistance in weight-
on toes and heels. walking as tolerated. bearing position.

IV. COMPONENTS OF ADVANCED FUNCTIONAL REHABILITATION OF ANKLE SPRAINS

Component Procedure Duration and frequency Comments
Proprioceptive Training
Circular wobble In sitting position, rotate board clockwise and Do five to 10 repetitions; Wobble board exercises can be
board counterclockwise using one foot and then both feet; in repeat set two times a day. performed with eyes open or
standing position, rotate board using one leg and then closed and with or without
both legs. resistance.
Walking on Walk in normal or heel-to-toe fashion over various Walk 50 feet two times a day. Walking exercises can be
different surfaces surfaces; progress from hard, flat floor to uneven performed with eyes open or
surface. closed and with or without
resistance.
Training for Return to Activity
Walk-jog Do 50 percent walking and 50 percent jogging in Increase distance in Increase intensity and incorporate
forward direction and backward direction; progress to increments of one-eighth activity-specific training.*
jogging; jog in a pattern (e.g., circle, figure-eight). mile.
Jog-run Do 50 percent jogging and 50 percent running in Increase distance in Increase intensity and incorporate
forward and backward directions; run in a pattern (e.g., increments of one-eighth activity-specific training.*
circle, figure-eight). mile.

V. TRAINING FOR RETURN TO ACTIVITY

 When walking a specified distance is no longer limited by pain, the patient may
progress to a regimen of 50 percent walking and 50 percent jogging.
 When this can be done without pain, jogging eventually progresses to forward,
backward and pattern running.
 Circles and figure-eights are employed for pattern running.
 Use of a stabilizing orthotic device or tape, with subsequent weaning, may be
recommended during the early period of activity-specific training.

VI. SUGGESTED TREATMENT PROGRAM

Acute Phase – Days 1-3:

Goals:
 Decreasing effusion and pain
  Protecting from further injury and allowing protected gait as tolerated.
 Early mobilization to earlier return to activity and patient comfort.
 Early mobilization of joints.
Care Guidelines:
Pain and Swelling Management:
 RICE (rest, ice, compression, elevation)
 Contrast bath “contraindicated” to reduce edema in posterior ankle sprains.
 Ultrasound.
 Electrical stimulation (high volt or interferential).
Protection (taping, splints, AirCast Boot, Air Stirrup, ASO Lace Up splint, cast for severe
injuries):
 ASO Lace Up contraindicated in the acute stage. Use Air Stirrup splint in early
stages.
 ASO effective in subacute and chronic stages.
 AirCast Boot may be needed for severe injuries or fracture.
 Boot may be indicated if patient cannot normalize gait with splint.
 Taping : Open basketweave for acute injuries in athletes.
Gait Training:- weight-bearing as tolerated
 The higher the grade of sprain the longer period of time required for pain-free
weight-bearing.
 May need assistive devices to normalize pain free gait.

Sub-Acute Phase - 2-4 days to 2 weeks:

Goals:
 Focuses on decreasing and eliminating pain
 Increasing pain free ROM
 Protecting from re-injury with bracing or splints
 Limiting loss of strength.
 Modalities to decrease effusion.
Care Guidelines:
Pain and Swelling Management:
 Modalities to decrease pain and swelling: ice, electrical stimulation (Interferential,
HVGS).
 Ultrasound (low intensity)
Joint mobilization: Talocrural and subtalar joints
 Talocrural joint mobilization to RICE protocol for inversion injuries.
ROM within pain-free range:
 Start with dorsiflexion and plantarflexion
 Add inversion and eversion as pain and tenderness over ligaments decrease.
 Stretch gastroc/soleus complex – start with non weight bearing and then progress to
weight bearing positions.
 Toe curls
  Ankle alphabet
 Stationery bike
Progress gait training:
 Increase weight bearing and decrease need for assistive device as tolerated (as pain
decreases and balance allows)
Strengthening:
 Isometrics to limit loss of strength.
Protection:
 Wean from splints or braces as tolerated and as pain and swelling decrease or
provide external support if needed for support or protection.
 Closed weave taping indicated in sub-acute to chronic stages.

Rehabilitative Phase – 2-6 weeks post-injury

Goals:
 The focus on regaining ROM and strength
 Increasing endurance
 Neuromuscular performance.
Care Guidelines:
As patient is able to tolerate full weight-bearing:
ROM:
 Regain full pain-free ROM
Joint Mobilization:
 Continue as needed
Stretching:
 Achilles tendon
 Gastrocnemius
 Soleus (may also need to stretch into plantarflexion, eversion and inversion)
Strengthening Exercises:
 Dorsiflexion
 Plantarflexion
 Eversion
 Inversion
 Open chain progressing to closed chain
 Active progressing to resistive (concentric and eccentric) as pain decreases and
ROM increases.
 Using free weights and exercise bands.
 Closed chain as ability to weight-bear increases, ie bilateral toe raises.
Progressing to single leg, bilateral squats progressing to single leg squats, step-
ups and step-down exercises (preparation for stairs if necessary)
Proprioception Training:
Progress from sitting to standing on both and then single leg, eyes open to eyes closed,
and reaching with dynamic challenge on level and progressing to uneven surfaces
 Wobble Board
  Theraband balance pad
 Foam pad
 Pillow
Gait Training:
 Wean from assistive devices as tolerated.
Endurance Activities:
 Stationary biking, walking, etc.

Functional Phase – 6 weeks post-injury

Goals:
Prepare for return to full activity and function.
Care Guidelines:
 Add sports specific exercises with goal of returning to sports and recreational
activity.
 Return to sports based on patient’s ability to perform sports-specific activities.
 Patient has full ankle ROM,
 Normal ankle strength especially of peroneals and dorsiflexors.
 No pain or tenderness.
Progressive strengthening
Coordination and Agility training :
Activities depending on patient’s ability, recovery and type of sports activity:
 Lunges
 Hopping (progress bilateral, to injured leg only, whole foot to toes only)
 Step exercises – forward, side to side
 Running should be progressed when the patient can walk at a face pace without
pain, starting on smooth surfaces and progressing to uneven surfaces
 Cutting exercises
 Figure 8’s, zig-zags
 Jump rope
Cardiovascular Conditioning:
 Stairmaster, treadmill, exercise biking

Prophylactic Phase - Prevention of Re-Injury

Goals:
• Strengthening including dorsiflexion and peroneals
• Functional proprioceptive drills – speed, balance, coordination and agility.
• Cardiovascular endurance training.
• Stretching to increase dorsiflexion.
• Check to see athlete has the proper footwear.
Prophylactic External Support:
 Determine need (chronic instability and/or decreased proprioception) for brace,
splint, orthotics, or taping.
  Consider lace-up ankle brace (ASO) or ankle taping especially for sports with high
incidence of ankle injuries (basketball, volleyball, soccer, tennis, and other sports
which involve high frequency of stopping, starting and twisting).
 Molded orthotics helped to improve balance scores in the ankle sprain group and to
decrease ankle pain during jogging for those with an ankle sprain.
 Control of the subtalar joint may decrease stress on the injured ligaments (ATFL
stressed with excessive pronation) and lead to decreased pain and increased
function.
 Orthotics may be useful in reducing increased postural sway seen in patients with
ankle injury and facilitating recovery and return to activity.
Frequency and Duration – 2x/week for 4-8 weeks (3x/week for first 2 weeks may be indicated
for severe pain, swelling or functional impairment)
Patient / family education-during each phase include instruction in: Standard of Care: Ankle
 Pain and swelling management
 Re-injury prevention
 Home exercises
 Use of assistive device, brace or splint
 Footwear
Recommendations and referrals to other providers:
 Orthopedist
 Orthotist
 Rheumatologist
 Podiatrist
Re-evaluation / assessment
Standard Time Frame – every 30 days or less
Other Possible Triggers – significant change in symptoms, re-injury, or chronic instability
and or pain after 8-12 weeks of intervention.
Factors which may limit progress or present as complications
Include but not limited to and may require referral back to MD or other specialist:
• Chronic ankle instability- feeling of being unstable, swelling with activity
• Impingement – scarring of ATFL and joint capsule can lead to intra-articular meniscoid
tissue
• Peroneal tendon subluxation –detachment of peroneal retinaculum at insertion on
fibula
• Talar dome fracture
• Anterior process fracture of calcaneous – bony rather than ligament point tenderness
• Chronic Regional Pain Syndrome

Refer also to differential diagnosis above.

Kerkhoffs GM1, et al. Dutch Orthopaedic Society, Academic Medical Center, Amsterdam, The
Netherlands. “Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical
guideline”. British Journal of Sports Medicine. 2012 Sep;46(12):854-60. doi: 10.1136/bjsports-
2011-090490. Epub 2012 Apr 20.

Kaminski TW1, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy

W, Richie D; National Athletic Trainers' Association position statement: conservative
management and prevention of ankle sprains in athletes. Journal of Athletic Training. 2013 Jul-
Aug;48(4):528-45. doi: 10.4085/1062-6050-48.4.02.

Sports Health Care

Section: Rehabilitation Guidelines

Subject: Post Operative Ankle Ligament Repair Rehabilitation

Purpose:

Provide guideline for the rehabilitation of a post surgical ligament repair in the ankle.

APPLICATION:

PHASE I: WEEKS 1-2

Goals
• Rest and recovery from surgery
• Control swelling and pain
• Increase ADL (Activities of daily living)
Guidelines
• PWB (partial weight bearing) to FWB (full weight bearing) in cast.
• Sutures removed @ 10 -16 days. Back into a cast for another 4 weeks
• Education: surgery, healing time, anatomy, rehab phases
• Encourage ADL
• Rest and elevation to control swelling
• Control pain
• Hip and knee AROM

PHASE II: WEEKS 3-6

Goals
• Allow healing while maintaining upper body, core, hip/knee strength and ROM
Guidelines
• WB as tolerated without or with crutches • Massage for swelling
• Elevation to control swelling
• @ 6 weeks: after being removed from the cast: begin gentle AROM (Active range of
motion)ankle PF(plantar flexion)/DF(dorsiflexion)/eversion and toe flexion/extension
• Stationary bicycle with cast
• Core exercises
 abdominal recruitment
 bridging on ball
 ball reach
 arm pulleys or theraband using diagonal patterns
• Hip: AROM
 strength: clam, sidelift, glut max, SLR (straight leg raise)
• Knee: AROM
 strength: SLR, theraband press or leg machine
• Stretching: glut max, glut med, piriformis, rectus femoris, hamstrings
PHASE III: WEEKS 7-10
Goals
• WB with pain and swelling controlled.
Guidelines
• Will be provided with an ankle brace and can start rehab
• Stationary bicycle
• AROM: - begin inversion/eversion
 continue with ankle PF/DF, toe flex/extension
• Continue with
• ◦ core exercises – progress to standing exercises
• ◦ hip strength exercises
• ◦ knee strength exercises
• Manual mobilization to joints not part of ligament reconstruction

PHASE IV: WEEK 11-12

Goals
• Full ROM
Guidelines
• In regular shoe
• Still wearing the ankle brace
• Control swelling +/- pain with elevation or modalities as required
• AROM in WB
• Manual mobilization as required
• Muscle stimulation
 intrinsics
 invertors/evertors if required
• Gait training
• Continue strengthening core, hips and knees .
• Proprioceptive training: single leg stance on even surface.

PHASE V: WEEK 13-16

Goals
• Full ROM in WB
• Good single leg balance
• Near full strength lower extremity
Guidelines
• Still to use the ankle brace for certain sport specific activities (i.e.: basketball)
• Proprioceptive training
 single leg stance on even surface with resistance to arms or weight bearing
leg
 double leg stance on wobble board, or fitter
 single leg weight bearing, fitter with resistance to arms or NWB leg
• Strength
 toe raises, lunges, squats
  hopping, skipping, running @ 14+ weeks
 manual mobilizations if required

PHASE VI: WEEK 16+

Goals
• Full functional return to work +/or activity
Guidelines
• Continue to build endurance
• Work specific or activity specific training
• Plyometric training.
Sports Health Care
Section: Rehabilitation Guidelines

Subject: Plantar Fasciitis

Purpose:

I. GENERAL INFORMATION

Plantar fasciitis is an inflammatory condition that occurs as a result of overstressing the plantar
fascia. It is the most common cause of inferior heel pain and has been diagnosed in patients
from the ages of 8-80. Plantar fasciitis affects approximately 10% of the population and is more
commonly found in middle-aged women and younger male runners. The primary symptom of
plantar fasciitis is pain in the heel when the patient first rises in the morning and when the
plantar fascia is palpated over its origin at the medial calcaneal tuberosity.

The function of the plantar fascia is to augment the biomechanics of the foot during the stance
phase of gait. At heel strike (initial contact), the plantar fascia is in a slack position. This allows
the midfoot to remain flexible so it can conform to uneven surfaces and enhance its ability to
absorb any shock it may encounter as the foot flattens. As one moves through the stance phase
of gait into toe off (pre-swing), the ankle, foot and toes move into a dorsiflexed position. As the
foot and toes dorsiflex, the midtarsal joints are passively extended causing the plantar fascia to
be stretched distally from its origin on the medial calcaneal tubercle. This action approximates
the rear foot and hind foot, increasing the arch height. Subsequently the midtarsal bones
become more stable as a result of the arch heightening. This creates a stiffer lever for more
efficient push off by the foot. This action of the plantar fascia is known as the Windlass
mechanism.

The etiology of plantar fasciitis is multifactorial. The tension placed on the plantar fascia will
increase as a result of anatomical factors such as abnormal foot posture or tight/weak posterior
calf musculature. In addition, environmental factors such as increased frequency/ distance/
speed of walking or running, a change in terrain or changes in foot wear will place abnormal
stress on this tissue structure. However it appears that the combination of both anatomical and
environmental factors eventually leads to dysfunction and overload of the fascia.

The most common risk factors associated with plantar fasciitis are:
• Tightness or weakness of the posterior calf musculature.
• Pes planus or pes cavus foot structures.
• Sudden gain in weight or obesity.
• Unaccustomed walking or running (i.e. increased speed, distance or uphill).
• Change in walking or running surface.
• Occupations involving prolonged weight bearing.
• Shoes with poor cushioning.
Each of the above factors can predispose an individual to plantar fasciitis due to abnormal
biomechanics in the foot.
Indications for Treatment:
• Heel pain
• Arch pain
• Pain in plantar fascia insertion
• Pain with first few steps in the morning or after sitting for an extended period of time
• Contraindications / Precautions for Treatment:
• See appropriate treatment/modality procedures

Medications: Typically NSAIDS for pain/inflammation control

Examination (Physical / Cognitive / applicable tests and measures / other)

This section is intended to capture the most commonly used assessment tools for this case
type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools.

Pain: as measured on the VAS, activities that increase symptoms, decrease symptoms,
location of symptoms.

Palpation: Palpate entire foot/arch. Focus on medial insertion of plantar fascia.

ROM: Ankle Dorsiflexion/Plantarflexion/Inversion/Eversion, Toe Flexion/Extension, Knee

Flexion/Extension, And Hip Flexion/Extension/Abduction/Internal Rotation/External
Rotation. Focus on gastrocnemius/soleus length.

Strength: Ankle DorsiFlexion/PlantarFlexion/Inversion/Eversion, Toe Flexion/Extension,

Knee Flexion/Extension, And Hip Flexion/Extension/Abduction/Internal
Rotation/External Rotation

Sensation: If abnormal as found via dermatomes screen or if diabetic, use Semmes-

Weinstein assessment.

Posture/alignment: Primary f(college/school)s on static foot posture. Tend to be at

extremes of pes planus/cavus. Secondary exam may include assessment in subtalar
neutral.

Gait: F(college/school)s on dynamic foot posture with and without footwear. Tend to
either over or under pronate during stance and through toe off phases of gait. May also
assess running on treadmill if appropriate.

Balance: Single leg stance test, Star Excursion Test

Footwear: Assess type and wearing patterns of footwear, use of orthotics.

Assessment:
Problem List (Identify Impairment(s) and/ or dysfunction(s))
 1. Pain
2. Decreased ROM
3. Decreased Strength
4. Decreased Balance
5. Decreased Function
6. Decreased Foot Biomechanics

Prognosis: Good with patient adherent to stretching program, and use of biomechanical
devices. If chronic, may need to resort to other treatment procedures such as injection, extra-
corporeal shock wave therapy (ECST), plantarfasciotomy if conservative treatment fails.
According to the literature, approximately 80-90% of people suffering from plantar fasciitis will
have a complete resolution of their symptoms in 6-18 months, with or without treatment.

Conservative treatments include non-steroidal anti-inflammatories (NSAIDs), orthotics, heel

cups/cushions, night splints, Achilles tendon stretching and physical therapy treatment
(including exercise and modalities such as ultrasound, phonophoresis, iontophoresis and
friction massage). All of these interventions have demonstrated some positive effect in the
outcome of plantar fasciitis, however there is no consensus as to which modality or
combination of modalities is the most effective. In their systematic review of literature for the
Cochrane Collaborative, Crawford et al.21 concluded there was limited evidence that any of the
conservative treatments were any more effective than no treatment at all.

Goals (Measurable parameters and specific timelines to be included on evaluation form)

1. Decrease Pain
2. Increase ROM
3. Increase Strength
4. Increase Balance
5. Increase Function
6. Correct Foot Biomechanics

Treatment Planning / Interventions

Interventions most commonly used for this case type/diagnosis.
This section is intended to capture the most commonly used interventions for this case
type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate
interventions.
1. Stretching
2. Strengthening
3. Foot Orthotics
4. Ultrasound
5. Phonophoresis
6. Iontophoresis
7. Night Splints
8. Ice
Frequency & Duration: Typically patients are seen 1-2x/wk for 4-6 weeks
Patient / family education:
1. Instruction in home exercise program
2. Instruction in pain control and ways to minimize inflammation
3. Instruction in activity level modification

Recommendations and referrals to other providers.

1. Orthotist
2. Podiatrist
3. Orthopod

Re-evaluation / assessment
• Standard Time Frame- 30 days or less if appropriate
• Other Possible Triggers- A significant change in signs and symptoms, new orthotics may
trigger a gait assessment, change in medication for iontophoresis.

Sports Health Care

Section: Rehabilitation Guidelines

Subject: Knee Rehabilitation – Non surgical Non-Surgical Management of the ACL

Deficient Knee

Purpose:

Provide a set of clinical guidelines for the therapeutic use of exercise in treating non surgical
knee injuries.

Guidelines:

I. INDICATIONS FOR TREATMENT:

Impaired ROM
Knee Instability
Lower Extremity Weakness
Impaired Function

II. CONTRAINDICATIONS / PRECAUTIONS FOR TREATMENT:

Activities that result in continued locking of the knee should be avoided.
Open Chain exercises that may cause excessive anterior translation of the tibia on the femur
should be avoided.
Continued / worsening of pain with progressed physical therapy treatment.
Decreased Balance reactions

III. CARE GUIDELINES:

Sub-Acute Intervention Plan:

Reduce Edema
Restore Patellar Mobility
Reestablish Quad muscle firing
Increase ROM
Gait Training.

Prognosis:
Patient’s prognosis depends upon the level of instability of the knee joint following the
injury.
All patients will be at greater risk for further knee damage such as:
Other ligament injuries
Meniscal injuries
Articular degeneration
Patello-femoral dysfunction.
Goals:
1. Independent with home exercises, including understanding of open chain vs.
closed chain quad strengthening at discharge.
2. Increase strength throughout LE musculature to 5/5 in 8-12 weeks.
3. Full A/PROM Knee in 3-4 weeks
4. Ambulation without device or deviation in 3-4 weeks.
5. Full ADL’s in 6 weeks.
6. Return to Sports activity with brace in 12 weeks.

Interventions most commonly used for this case type/diagnosis.

Edema Control:
Cryotherapy
Strengthening:
 Entire lower extremity should be strengthened. Special attention should be paid to
Quads, Hamstrings for the ability to help stabilize knee in lieu of an intact ACL and
Hip abductors to maintain proper alignment of lower extremity.
 Closed Chain exercises are used for Quadriceps strengthening.
 Open Chain exercises that may cause excessive anterior translation of the tibia on
the femur should be avoided.
Joint ROM/ Muscle Stretching:
 ROM- Active and Passive of knee
 Stretching- Quads, Hamstring and ITB
Proprioception Training:
 Balance Training- incorporating entire Lower extremity.
 Gait Training- Progressing from possible assistive device to walking, ascending and
descending stairs and finally Jogging/ Running.
Endurance Training
 Electrical Stimulation- To strengthen the VMO and to prevent development of
patello-femoral dysfunction.
Bracing:
 Derotational knee brace. Used during athletic activities. (Current studies seem to
indicate that no brace adequately compensation for an ACL deficient knee).
Frequency & Duration:
2-3x/week for 2-3 months as indicated by patient’s status and progression.

Sports Health Care

Section: Rehabilitation Guidelines

Subject: ACL Patella Tendon Autograft Reconstruction Rehabilitation

Purpose:

To provide the clinician with a guideline for the post-operative rehabilitation course of a patient
that has undergone an ACL patellar tendon autograft reconstruction.

I. GENERAL GUIDELINES
• F(college/school)s on protection of graft during primary revascularization (8 weeks)
and graft fixation (4-6 weeks.)
• CPM not commonly used
• For ACL reconstruction performed with meniscal repair or transplant, defer to ROM
and weight bearing precautions outlined in the meniscal repair/transplant protocol.
• The physician may alter time frames for use of brace and crutches.
• Supervised sports therapy takes place for 3-6 months.

II. GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

 No bathing/showering (sponge bath only) until after suture removal. Brace may be
removed for bathing/showering.
 Sleep with brace locked in extension for 1 week or as directed by PT/MD for
maintenance of full extension.
 Driving: 1 week for automatic cars, left leg surgery
 2-4 weeks for standard cars, or right leg surgery
 Weight-bearing as tolerated immediately post-op
 Brace locked in extension for ambulation until patient demonstrates full extension
with good quad control. The brace can then be unlocked based on patient range of
motion.
 Wean from crutches/brace for ambulation by 4 weeks as patient demonstrates
normal gait mechanics and good quad control as defined by absence of quadriceps
lag.
 Return to work as directed by ATC/MD based on school/work demands.

III. REHABILITATION PROGRESSION

PHASE I: Immediately postoperatively to week 4
Goals:
 Protect graft and graft fixation
 Minimize effects of immobilization
 Control inflammation/swelling
 Full active and passive extension/hyperextension range of motion. Caution: avoid
hyperextension greater than 10 degrees.
 Educate patient on rehabilitation progression
 Restore normal gait on level surfaces.
Brace:
 Sleep with brace locked in extension for 1 week or as directed for maintenance of
full extension.
 Brace locked in extension for ambulation until patient demonstrates full extension
with good quad control. The brace can then be unlocked based on patient range of
motion.
Weightbearing Status:
 Weight-bearing as tolerated immediately post-op with crutches and brace
 Wean from crutches/brace for ambulation by 4 weeks as patient demonstrates
normal gait mechanics and good quad control.
Exercises:
 Patellar mobilization/scar mobilization
 Heel slides
 Quad sets (consider NMES for poor quad sets)
 Hamstring curls – add weight as tolerated
 Gastroc/Soleus, Hamstring stretches
 Gastroc/Soleus strengthening
 SLR, all planes, with brace in full extension until quadriceps strength is sufficient to
prevent extension lag – add weight as tolerated to hip abduction, adduction and
extension.
 Closed Kinetic Chain Quadriceps strengthening activities as tolerated (wall sit, step
ups, mini squats, leg press 90-30 degrees)
 Quadriceps isometrics at 60° and 90°
 Single leg balance, proprioception work
 Stationary cycling – initially for promotion of ROM – progress light resistance as
tolerated.

PHASE II: Post-operative weeks 4 to 10

Criteria for advancement to Phase II:
 Full extension/hyperextension.
 Good quad set, SLR without extension lag.
 Minimum of 90° of flexion.
 Minimal swelling/inflammation.
 Normal gait on level surfaces.
Goals:
• Restore normal gait with stair-climbing
• Maintain full extension, progress toward full flexion range of motion
• Protect graft and graft fixation
• Increase hip, quadriceps, hamstring and calf strength
• Increase proprioception.
Brace/Weightbearing Status:
• If necessary, continue to wean from crutches and brace.
Exercises:
• Continue with range of motion/flexibility exercises as appropriate for the patient
• Continue closed kinetic chain strengthening as above, progressing as tolerated – can
include one-leg squats, leg press, step ups at increased height, partial lunges, deeper
wall sits.
• Stairmaster (begin with short steps, avoid hyperextension)
• Stationary biking- progress time and resistance as tolerated; progress to single leg
biking.
• Continue to progress proprioceptive activities – ball toss, balance beam, mini-tramp
balance.
• Continue hamstring, gastroc/soleus stretches.
• Continue to progress hip, hamstring and calf strengthening.

PHASE III: Post-operative weeks 10 to 16

Criteria to advance to Phase III include:
• No patellofemoral pain
• Minimum of 120 degrees of flexion
• Sufficient strength and proprioception to initiate running.
• Minimal swelling/inflammation
Goals:
• Full range of motion
• Improve strength, endurance and proprioception of the lower extremity to prepare
for sport activities.
• Avoid overstressing the graft.
• Protect the patellofemoral joint.
• Normal running mechanics.
Exercises:
• Continue flexibility and ROM exercises as appropriate for patient
• Knee extensions 90°-30°, progress to eccentrics
• If available, isokinetics (with anti-shear device) – begin with mid range speeds
(120o/sec- 240o/sec)
• Progress toward full weight bearing running at 12 weeks.
• Progressive hip, quadriceps, hamstring, calf strengthening.
• Cardiovascular/endurance training via Stairmaster, elliptical, bike
• Advance proprioceptive activities

PHASE IV: Post-operative months 4 through 6

Criteria for advancement to Phase IV:
• No significant swelling/inflammation.
• Full, pain-free ROM
• No evidence of patellofemoral joint irritation.
• Sufficient strength and proprioception to initiate agility activities.
• Normal running gait.
Goals:
 • Symmetric performance of basic and sport specific agility drills.
• Single hop and 3 hop tests 85% of uninvolved lower extremity.
Exercises:
• Continue and progress flexibility and strengthening program based on individual
needs and deficits.
• Initiate plyometric program as appropriate for patient’s athletic goals.
• Agility progression including, but not limited to:
 Side steps
 Crossovers
 Figure 8 running
 Shuttle running
 One leg and two leg jumping
 Cutting
 Acceleration/deceleration/sprints
 Agility ladder drills
• Continue progression of running distance based on patient needs.
• Initiate sport-specific drills as appropriate for patient.

PHASE V: Begins at approximately 6 months post-op

Criteria for advancement to Phase V:
• No patellofemoral or soft tissue complaint.
• Necessary joint ROM, strength, endurance, and proprioception to safely return to
work or athletics.
• Physician clearance to resume partial or full activity.
Goals:
• Safe return to athletics/school/work.
• Maintenance of strength, endurance, proprioception.
• Patient education with regards to any possible limitations.
Exercises:
• Gradual return to sports participation.
• Maintenance program for strength, endurance.
Bracing:
Functional brace generally not used, but may be recommended by the physician on an
individual basis.

Sports Health Care

Section: Rehabilitation Guidelines

Subject: ACL Hamstring Tendon Autograft Reconstruction Protocol

Purpose:

The intent of this protocol is to provide the clinician with a guideline for the post-operative
rehabilitation course of a patient that has undergone an ACL hamstring tendon autograft
reconstruction.

I. GENERAL GUIDELINES
• Focus on protection of graft during primary re-vascularization (8 weeks) and graft fixation
(8 – 12 weeks).
• For ACL reconstruction performed with meniscal repair or transplant, defer to ROM and
weight bearing precautions outlined in the meniscal repair/transplant guidelines.
• The physician may alter time frames for use of brace and crutches.
• Supervised sports therapy takes place for 4 - 7 months.
• Use caution with hamstring stretching/strengthening.

II. REHABILITATION PROGRESSION

PHASE I: Immediately post-operatively to week 4

Goals:
• Protect graft and graft fixation with use of brace and specific exercises.
• Minimize effects of immobilization.
• Control inflammation and swelling.
• Full active and passive extension/hyperextension range of motion.
Caution: avoid hyperextension greater than 10o
• Educate patient on rehabilitation progression.
• Flexion to 90o only in order to protect graft fixation.
• Restore normal gait on level surfaces.
Brace:
• 0 - 1 week- post-op brace locked in full extension for ambulation and sleeping.
• 1 - 3 weeks- unlock brace (<90o) as quad control allows.
• 3 - 4 weeks- wean from brace as patient demonstrates good quad control and normal gait
mechanics.
• 4 - 8 weeks- patient should only use brace in vulnerable situations (e.g. crowds, uneven
terrain, etc).
Weightbearing Status:
• 0 - 1 week - partial weight bearing with two crutches to assist with balance.
• 1 - 4 weeks - partial weight bearing progressing to full weight bearing with normal gait
mechanics.
• Wean from crutches/brace for ambulation by 4 weeks as patient demonstrates normal gait
mechanics and good quad control as defined as lack of quadriceps lag.

Exercises:
• Active-assisted leg curls 0 - 1 week. Progress to active as tolerated after 1 week. Delay
strengthening for 12 weeks.
• Heel slides (limit to 90o).
• Quad sets (consider NMES for poor quad sets).
• Gastroc/Soleus stretching.
• Very gentle hamstring stretching at 1st week .
• Straight leg raises, all planes, with brace in full extension until quadriceps strength is sufficient
to prevent extension lag- add weight as tolerated to hip abduction, adduction and extension.
• Quadriceps isometrics at 60o and 90o.

PHASE II: Post-operative weeks 4 to 12

Criteria for advancement to Phase II:
• Full extension/hyperextension.
• Good quad set, SLR without extension lag.
• Flexion to 90o
• Minimal swelling/inflammation.
• Normal gait on level surfaces.
Goals:
• Restore normal gait with stair climbing.
• Maintain full extension, progress toward full flexion range of motion.
• Protect graft and graft fixation.
• Increase hip, quadriceps, and calf strength.
• Increase proprioception.
Brace/Weightbearing Status:
• If necessary, continue to wean from crutches and brace.
Exercises:
• Continue with range of motion/flexibility exercises as appropriate for the patient.
• Initiate closed kinetic chain quad strengthening and progress as tolerated (wall sits, step-ups,
mini-squats, Leg Press 90o - 30o, lunges).
• Progressive hip, hamstring, calf strengthening (gradually add resistance to open chain
hamstring exercises at week 12).
• Continue hamstring, Gastroc/Soleus stretches.
• Stairmaster (begin with short steps, avoid hyperextension).
• Stationary Biking (progressive time and resistance).
• Single leg balance/proprioception work (ball toss, balance beam, theraband pad balance
work).
Phase III: Post-operative weeks 12 to 18 - 20 (4 ½-5 months)
Criteria to advance to Phase III include:
• No patellofemoral pain.
• Minimum of 120 degrees of flexion.
• Sufficient strength and proprioception to initiate running (unweighted or in pool).
• Minimal swelling/inflammation.

Goals:
• Full range of motion.
• Improve strength, endurance, and proprioception of the lower extremity to prepare for sport
activities.
• Avoid overstressing the graft. Progressively increase resistance for hamstring strengthening.
• Protect the patellofemoral joint.
• Normalize running mechanics.

Exercises:
• Continue flexibility and ROM exercises as appropriate for patient.
• Initiate open kinetic chain leg extension (90o-30o), progress to eccentrics as tolerated.
• Isokinetics (with anti-shear device)- begin with mid range speeds (120o/sec-240o/sec).
• Progress toward full weight bearing running at about 16 weeks.
• Progressive hip, quad, hamstring, calf strengthening.
• Cardiovascular/endurance training via Stairmaster, elliptical, and/or stationary bike.
• Advance proprioceptive activities.

Phase IV: Post-operative months 4 ½ or 5 through 6-7

Criteria for advancement to Phase IV:
• No significant swelling/inflammation.
• Full, pain-free ROM.
• No evidence of patellofemoral joint irritation.
• Sufficient strength and proprioception to initiate agility activities.
• Normal running gait .

Goals:
• Symmetric performance of basic and sport specific agility drills.
• Single hop and three hop tests 85% of uninvolved leg.

Exercises:
• Continue and progress flexibility and strengthening program based on individual needs and
deficits.
• Initiate plyometric program as appropriate for patient’s athletic goals.
• Agility progression including, but not limited to:
 Side steps
 Crossovers
  Figure 8 running
 Shuttle running
 One leg and two leg jumping
 Cutting
 Acceleration/deceleration/springs
 Agility ladder drills
• Continue progression of running distance based on patient needs.
• Initiate sport-specific drills as appropriate for patient.

Phase V: Begins at post-operative months 6 or 7

Criteria for advancement to Phase V:
• No patellofemoral or soft tissue complaints.
• Necessary joint ROM, strength, endurance, and proprioception to safely return to work or
athletics.
• Physician clearance to resume partial or full activity.

Goals:
• Safe return to athletics/work.
• Maintenance of strength, endurance, proprioception.
• Patient education with regards to any possible limitations.

Exercises:
• Gradual return to sports participation.
• Maintenance program for strength, endurance.

Bracing:
• Functional brace generally not used, but may be recommended by the physician on an
individual basis.
 Sports Health Care

Section: Rehabilitation Guidelines

Subject: ACL Allograft Reconstruction Protocol

Purpose:

The intent of these guidelines is to provide the licensed athletic trainer with a guideline for the
post-operative rehabilitation course of a student-athlete that has undergone an ACL allograft
reconstruction.

I. GENERAL GUIDELINES
• Allograft revascularization is slower than for autografts. Therefore, crutches and brace are
continued for 6 weeks.
• CPM not commonly used.
• ACL reconstruction performed with meniscal repair or transplant: follow the ACL protocol
with avoidance of open kinetic hamstring strengthening for 6 weeks. Time frames for use of
brace and crutches may be extended by the physician.
• Supervised physical therapy takes place for 3-9 months.

II. SPORTS THERAPY ATTENDANCE

The following is an approximate schedule for supervised sports therapy visits:
Phase I (0-6 weeks): 1-2 visit/week
Phase II (6-8 weeks): 2-3 visits/week
Phase III (2-6 months): 2-3 visits/week
Phase IV, V (6 months +): Discharge after completion of appropriate functional
progression

III. REHABILITATION PROGRESSION

PHASE I: Immediately postoperatively through approximately week 6
Goals:
• Protect graft fixation
• Minimize effects of immobilization
• Control inflammation
• Full extension range of motion
• Educate patient on rehabilitation progression
• Flexion to 90-degrees
• Normalize gait mechanics in pool (if available).
Brace:
• Post op brace 0-6 weeks.
• 1st week: Locked in full extension for ambulation and sleeping.
• 1-6 weeks: Brace remove for rehab and sleeping.
• 6-12 weeks: To be worn in situations where patient may be at risk for fall (crowds, walking
 on uneven surfaces).
• After 12 weeks brace is optional.

Weightbearing Status
• 0-2 weeks: Touchdown weight bearing with two crutches.
• 2-4 weeks: Partial weight bearing.
• 4-6 weeks: Weight bearing as tolerated.

Therapeutic Exercises: {Reminder: ACL reconstruction performed with meniscal repair or

transplant: follow the ACL protocol with avoidance of open kinetic hamstring strengthening for 6
weeks}
• Initiate active-assisted leg curls; progress to active range of motion when pain free.
• Heel slides.
• Quad sets.
• Patellar mobilization.
• Non-weight bearing gastroc/soleus stretching, begin hamstring stretches at 2 weeks.
• SLR, all planes, with brace in full extension until quadriceps strength is sufficient to prevent
extension lag. Quadriceps isometrics at 60-degrees and 90-degrees.
• At 4-weeks post-op add biking, leg press, quadriceps stretching.
• Partial weight bearing closed chain knee extension 0-45-degrees.
• Theraband
• Leg press
• Mini-squats
• Gentle hamstring stretching

PHASE II: Postoperative weeks 6 to 8

Criteria for advancement to Phase II:
• Good quad set, SLR without extension lag
• Approximately 90° of flexion
• Full active knee extension in sitting
• No signs of active inflammation
Goals:
• Initiate closed kinetic chain exercises
• Restore normal gait
• Protect graft fixation
Brace/Weightbearing status:
• Discontinue use of brace and crutches as allowed by physician when the patient has full
extension and can SLR without extension lag.
• Patient may exhibit antalgic gait pattern. Consider using single crutch or cane until gait is
normalized.
Therapeutic Exercises:
• Wall slides 0-45-degrees, progressing to mini-squats.
• 4-way hip.
• Stationary bike (begin with high seat, low tension to promote ROM, progress to single leg).
• Closed chain terminal extension with resistive tubing or weight machine.
• Toe raises.
• Balance exercises (e.g. single-leg balance).
• Hamstring curls.
• Continue hamstring stretches, progress to weight-bearing gastroc/soleus stretches.

PHASE III: Postoperative week 8 to 6 months

Goals:
• Full range of motion.
• Improve strength, endurance and proprioception of the lower extremity to prepare for
functional activities.
• Avoid overstressing the graft.
• Protect the patellofemoral joint.
Therapeutic Exercises:
• Continue and progress previous flexibility and strengthening activities
• Stairclimber (begin with short steps, avoid hyperextension)
• Knee extensions 90°-45°, progress to eccentrics
• Advance closed kinetic chain activities (leg press, one-leg mini squats 0-45° of flexion, step-ups
begin at 2” progress to 8”, etc.).
• Progress proprioception activities (slide board, use of ball, racquet with balance activities,
etc.)
• Progress aquatic program to include pool running, swimming (no breaststroke)

PHASE IV: Postoperative months 6 to 9

Criteria for advancement to Phase IV:
• Full, pain-free ROM.
• No evidence of patellofemoral joint irritation.
• Strength and proprioception approximately 70% of uninvolved.
• Physician clearance to initiate advanced closed kinetic chain exercises and functional
progression.
Goal:
• Progress strength, power, and proprioception to prepare for return to functional activities.
Therapeutic Exercises:
• Continue and progress previous flexibility and strengthening activities
• Functional progression including:
• Walk/Jog progression
• Forward, backward running, ½, ¾, full speed

PHASE V: Postoperative month 9 +

Criteria for advancement to Phase V:
• No patellofemoral or soft tissue complaint.
• Necessary joint ROM, strength, endurance, and proprioception to safely return to work or
athletics.
• Physician clearance to resume partial or full activity.
Goals:
• Initiate cutting and jumping activities.
• Completion of appropriate functional progression.
• Maintenance of strength, endurance, proprioception.
• Patient education with regards to any possible limitations.
Therapeutic Exercises:
• Functional progression including, but not limited to:
 Walk/jog progression.
 Forward/backward running, ½, ¾, full speed.
 Cutting, crossover, caricoa, etc.
 Plyometric activities as appropriate to patient’s goals.
• Sports-specific drills.
• Safe, gradual return to sports after successful completion of functional progression.
• Maintenance program for strength and endurance.
Bracing:
Functional brace may be recommended by the physician for use during sports for the first 1-2
years after surgery.
 Sports Health Care

Section: Rehabilitation Guidelines

Subject: Meniscal Repair Rehabilitation

Purpose:

These guidelines have been adopted from Brotzman & Wilk, which has been published in
Brotzman SB, Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003:315-
319. The Sports Health Care department at (COLLEGE/SCHOOL) has accepted these guidelines as
our standard guidelines for the management of patients s/p meniscal repair.

The intent of these guidelines is to provide the licensed athletic trainers with a guideline of the
post-operative rehabilitation course of a patient that has undergone a meniscal repair.

I. KEY FACTORS:

Key Factors in determining progression of rehabilitation after Meniscal repair include:

• Anatomic site of tear
• Suture fixation (failure can be caused by too vigorous rehabilitation)
• Location of tear (anterior or posterior)
• Other pathology (ligamentous injury)

II. GUIDELINES:
Phase I –Maximum Protection- Weeks 1-6:
Goals:
• Diminish inflammation and swelling
• Restore ROM
• Reestablish quadriceps muscle activity

Stage 1: Immediate Postoperative Day 1- Week 3

• Ice, compression, elevation
• Electrical muscle stimulation
• Brace locked at 0 degrees
• ROM 0-90
• Motion is limited for the first 7-21 days, depending on the development of scar tissue around
the repair site. Gradual increase in flexion ROM is based on assessment of pain and site of
repair (0-90 degrees).
 Patellar mobilization
 Scar tissue mobilization
 Passive ROM
 Exercises
 Quadriceps isometrics
  Hamstring isometrics (if posterior horn repair, no hamstring exercises for 6 weeks)
 Hip abduction and adduction
• Weight-bearing as tolerated with crutches and brace locked at 0 degrees .
• Proprioception training with brace locked at 0 degrees.

Stage 2: Weeks 4-6

• Progressive resistance exercises (PREs) 1-5 pounds.
• Limited range knee extension (in range less likely to impinge or pull on repair).
• Toe raises.
• Mini-squats less (than 90 degrees flexion).
• Cycling (no resistance).
• PNF with resistance.
• Unloaded flexibility exercises.

Phase II: Moderate Protection- Weeks 6-10

Criteria for progression to phase II:
• ROM 0-90 degrees
• No change in pain or effusion
• Quadriceps control (MMT 4/5)

Goals:
• Increased strength, power, endurance
• Normalize ROM of knee
• Prepare patients for advanced exercises

Exercises:
• Strength- PRE progression
• Flexibility exercises
• Lateral step-ups
• Mini-squats
Endurance Program:
• Cycling
• Stair machine

Coordination Program:
• Balance board
• Pool sprinting- if pool available
• Backward walking
• Plyometrics

Phase III: Advanced Phase- Weeks 11-15

Criteria for progression to phase III:
• Full, pain free ROM
• No pain or tenderness
• Satisfactory clinical examination.
• SLR without lag.
• Gait without device, brace unlocked.

Goals:
• Increase power and endurance.
• Emphasize return to skill activities.
• Prepare for return to full unrestricted activities.

Exercises:
• Continue all exercises.
• Increase plyometrics, pool program.
• Initiate running program.

Return to Activity: Criteria

• Full, pain free ROM.
• Satisfactory clinical examination.

Criteria for discharge from sports therapy:

1) Non-antalgic gait
2) Pain free /full ROM
3) LE strength at least 4/5
4) Normal balance and proprioception
5) Resolved palpable edema
 Sports Health Care

Section: Rehabilitation Guidelines

Subject: Arthroscopic partial medial or lateral meniscectomy, loose body removal or

debridement.

Purpose:

The intent of this protocol is to provide the licensed athletic trainer with a guideline of the post-
operative rehabilitation course of a patient that has undergone a partial meniscectomy, loose
body removal or debridement.

I. GENERAL GUIDELINES

Rehabilitation after meniscectomy may progress aggressively because there is no anatomic

structure that requires protection.

Progression to the next phase is based on clinical criteria and meeting the established goals for
each phase.

II. REHABILITATION PLAN

Phase I – Acute Phase:
Goals:
• Diminish inflammation and swelling.
• Restore knee range of motion (goal 0-115, minimum of 0 degrees extension to 90 degrees of
flexion to progress to phase II).
• Reestablish quadriceps muscle activity/re-education (goal of no quad lag during SLR).
• Educate the patient regarding precautions, activity progression and the rehabilitation process.

Weight bearing:
• Weight bearing as tolerated. Use two crutches initially progressing to weaning crutches as
swelling and quadriceps status dictates.

Modalities:
• Cryotherapy.
• Electrical stimulation to quadriceps for functional retraining as appropriate.
• Electrical stimulation for edema control- high volt galvanic or interferential stimulation as
needed.

Therapeutic Exercise:
• Quadriceps sets
• SLR
• Hip adduction, abduction and extension
• Ankle pumps
• Gluteal sets
• Heel slides
• ½ squats
• Active-assisted ROM stretching, emphasizing full knee extension (flexion to tolerance
• Hamstring and gastroc/ soleus and quadriceps stretches
• Use of compression wrap or brace
• Bicycle for ROM when patient has sufficient knee ROM. May begin partial revolutions to
recover motion if the patient does not have sufficient knee flexion

Phase II: Internal Phase:

Goals:
• Restore and improve muscular strength and endurance.
• Reestablish full pain free ROM.
• Gradual return to functional activities.
• Restore normal gait without an assistive device.
• Improve balance and proprioception.

Weight bearing status:

Patients may progress to full weight bearing as tolerated without antalgia. Patients may require
one crutch or cane to normalize gait before ambulating without assistive device.
Therapeutic exercise:
• Continue all exercises as needed from phase one.
• Toe raises- calf raises.
• Hamstring curls.
• Continue bike for motion and endurance.
• Cardio equipment- Stairmaster, elliptical trainer, treadmill and bike as above.
• Lunges- lateral and front.
• Leg press.
• Lateral step ups, step downs, and front step ups.
• Knee extension 90-40 degrees.
• Closed kinetic chain exercise terminal knee extension.
• Four way hip exercise in standing.
• Proprioceptive and balance training.
• Stretching exercises- as above, may need to add ITB and/or hip flexor stretches.

Phase III – Advanced activity phase:

Goals:
• Enhance muscular strength and endurance.
• Maintain full ROM.
• Return to sport/functional activities/work tasks.

Therapeutic Exercise:
• Continue to emphasize closed-kinetic chain exercises.
• May begin plyometrics/ vertical jumping.
• Begin running program and agility drills (walk-jog) progression, forward and backward running,
cutting, figure of eight and carioca program.
• Sport specific drills.

Criteria for discharge from sports therapy:

1) Non-antalgic gait
2) Pain free /full ROM
3) LE strength at least 4+/5
4) Normal age appropriate balance and proprioception
5) Resolved palpable edema
 Sports Health Care

Section: Rehabilitation Guidelines

Subject: PCL Reconstruction Protocol

Purpose:

The intent of these guidelines is to provide the licensed athletic trainer with a guideline for the
post-operative rehabilitation course of a patient that has undergone a PCL or PCL/ACL
reconstruction.

I. GENERAL GUIDELINES
• No open chain hamstring work.
• Typically it takes 12 weeks for graft to bone healing time.
• Caution against posterior tibial translation (gravity, muscle action).
• PCL with posterolateral corner or LCL repair follows different post-op care (i.e. crutches x 3
months).
• Resistance for hip Progressive Resistance Exercises should be placed above the knee for hip
abduction and adduction; resistance may be placed distally for hip flexion.
• Supervised sports therapy generally takes place for 3-5 months post-operatively.

II. REHABILITATION PROGRESSION

PHASE I: Immediately post-operatively to week 4
Goals:
• Protect healing bony and soft tissue structures.
• Minimize the effects of immobilization:
 Early protected range of motion (protect against posterior tibial sagging).
 PRE’s for quadriceps, hip, and calf with an emphasis on limiting patellofemoral joint
compression and posterior tibial translation.
• Patient education for a clear understanding of limitations and expectations of the
rehabilitation process, and need for supporting proximal tibia/preventing sag.

Brace:
• 0-1 week: post-op brace locked in full extension at all times.
• At 1 week post-op, brace is unlocked for passive ROM performed by the licensed athletic
trainer.
• Technique for passive ROM is as follows:
 Patient supine; licensed athletic trainer maintains anterior pressure on proximal tibia as
knee is flexed (force on tibia is from posterior to anterior).
 For patients with combined PCL/ACL reconstructions, the above technique is modified such
that a neutral position of the proximal tibia is maintained as the knee is flexed.
 It is important to prevent posterior sagging at all times.
Weight-bearing status:
• Weight-bearing as tolerated (WBAT) with crutches, brace locked in extension.

Special considerations:
• Position pillow under proximal posterior tibia at rest to prevent posterior tibial sag.

Therapeutic exercises:
• Patellar mobilization.
• Quadriceps sets.
• Straight leg raise (SLR).
• Hip abduction and adduction.
• Ankle pumps.
• Hamstring and calf stretching.
• Calf press with exercise bands, progressing to standing calf raise with full knee extension.
• Standing hip extension from neutral.
• Functional electrical stimulation (as needed for trace to poor quadriceps contraction).

PHASE II: Post-operative weeks 4 to 12

Criteria for progression to Phase II:
• Good quadriceps control (good quad set, no lag with SLR).
• Approximately 60 degrees knee flexion.
• Full knee extension.
• No signs of active inflammation.

Goals:
• Increase ROM (particularly flexion).
• Normalize gait.
• Continue to improve quadriceps strength and hamstring flexibility.

Brace:
• 4 - 6 weeks: Brace unlocked for gait in controlled environment only (i.e. patient may walk with
brace unlocked while attending therapy or when at home).
• 6 - 8 weeks: Brace unlocked for all activities.
• 8 weeks: Brace discontinued, as allowed by surgeon.
 Note, if PCL or LCL repair, continue brace until cleared by surgeon.

Weight-bearing status:
• 4 -8 weeks: WBAT with crutches.
• 8 weeks: May discontinue crutches if patient demonstrates:
 No quadriceps lag with SLR.
 Full knee extension.
 Knee flexion 90-100 degrees.
 Normal gait pattern (May use 1 crutch/cane until gait normalized).
• If PLC or LCL repair, continue crutches for 12 weeks.
Therapeutic Exercises:
• 4 - 8 weeks:
 Wall slides/mini-squats (0-45 degrees).
 Leg press (0-60 degrees).
 Standing 4-way hip exercise for flexion, extension, abduction, adduction (from neutral,
knee fully extended).
 Ambulation in pool (work on restoration of normal heel-toe gait pattern in chest-deep
water).
• 8 - 12 weeks:
 Stationary bike (foot placed forward on pedal without use of toe clips to minimize
hamstring activity; seat set slightly higher than normal).
 Closed kinetic chain terminal knee extension using resisted band or weight machine. Note:
important to place point of resistance to minimize tibial displacement.
 Stairmaster.
 Elliptical trainer.
 Balance and proprioception exercises.
 Seated calf raises.
 Leg press (0-90 degrees).

PHASE III: Post-operative months 3 to 9

Criteria for progression to Phase III:
• Full, pain free ROM. (Note: it is not unusual for flexion to be lacking 10 - 15 degrees for up to 5
months post-op.)
• Normal gait.
• Good to normal quadriceps control.
• No patellofemoral complaints.
• Clearance by surgeon to begin more concentrated closed kinetic chain progression.

Goals:
• Restore any residual loss of motion that may prevent functional progression.
• Progress functionally and prevent patellofemoral irritation.
• Improve functional strength and proprioception using close kinetic chain exercises.
• Continue to maintain quadriceps strength and hamstring flexibility.

Therapeutic exercises:
• Continue closed kinetic chain exercise progression.
• Treadmill walking.
• Jogging in pool with wet vest or belt.

PHASE IV: Post-operative Month 9 until return to full activity

Criteria for progression to Phase IV:
• Clearance by surgeon to resume full or modified/partial activity (i.e. return to work,
recreational, or athletic activity).
• No significant patellofemoral or soft tissue irritation.
• Presence of necessary joint ROM, muscle strength and endurance, and proprioception to
safely return to athletic participation.
 Full, pain free ROM.
 Satisfactory clinical examination.
 Quadriceps strength 85% of uninvolved leg.
 Functional testing 85% of uninvolved leg.
 No change in laxity testing.

Goals:
• Safe and gradual return to work or athletic participation.
 This may involve sport-specific training, work hardening, or job restructuring as needed.
 Patient demonstrates a clear understanding of their possible limitations.
• Maintenance of strength, endurance, and function.

Therapeutic exercises:
• Continue closed kinetic chain exercise progression.
• Sport-specific functional progression, which may include but is not limited to:
 Slide board.
 Jog/Run progression.
 Figure 8, carioca, backward running, cutting.
 Jumping (plyometrics).
• Sports hardening program as indicated by licensed athletic trainer and/or surgeon
recommendation.
 Sports Health Care

Section: Rehabilitation Guidelines

Subject: Patellofemoral Pain Syndrome (PFPS)

Purpose:

To provide the licensed athletic trainer with a set of clinical guidelines to manage and rehabilitate
Patellofemoral Pain Syndrome in athletes.

Types of PFPS Conditions:

Patellofemoral Pain syndrome – A general category of anterior knee pain from patella mal-
alignment. Also termed anterior knee pain, Patellar mal-alignment, and Patellofemoral
anthralagia.

Chondromalacia – Softening and fissuring of the underside of the patella (1). Chondral lesions
themselves are asymptomatic unless worn down to subchondral bone (2). Chondromalacia can
only be diagnosed by X-ray (Merchant, sun rise, or skyline view) or surgery.

Presentation:
PFS usually presents as an insidious onset of peripatellar or retropatellar pain. Commonly patients
are young, active, and females are affected more than males (9). PFS can also be caused from a
traumatic injury to the patella.

Indications for Treatment:

Knee pain believed to be musculoskeletal in origin, primarily from muscle imbalances and/or poor
biomechanics. Patients report symptoms as general knee pain or ache surrounding the patella.

Contraindications / Precautions for Treatment:

Avoid activities that cause excessive patellofemoral joint reaction forces.

Examination:
Medical History: Review patient’s medical history questionnaire and medical history reported in
LMR computer system. Review any diagnostic imaging, tests, or work up listed under longitudinal
medical record and centricity. Ask about possible lower extremity trauma, injury, or history of
fractures.

History of Present Illness – Most often insidious onset (1), symptoms are worse with prolonged
sitting, squatting, and descending stairs (2,4). Review footwear history and training schedule.
Patient may have a subjective report of anterior knee pain with running, negotiating stairs,
jumping, or prolonged sitting. Information should be gathered regarding what increases or
decreases symptoms.
Social History - Young women effected more often than men due to having a wider pelvis and an
increased Q-angle (9).

Examination -

A. Muscle length – Hamstrings, Iliotibial band, Quadriceps, and Gastrocnemius. Tight

hamstrings will result in the knee remaining in flexion for a longer period of time during
gait and running. The increased amount of time in knee flexion will result in increased
patella femoral joint reaction forces patellofemoral joint reaction forces (PFJRF) A tight
illiotibial band will result in a lateral pull of the patella, and increased PFJRFs. Quadriceps
tightness will also result in increased PFJRFs. A tight gastroc will result in decreased
dorsiflexion at the tal(college/school)ral joint. The foot will compensate by pronating;

B. Patella mobility – Very frequently the lateral retinaculum is tight, therefore limiting
medial glide of the patella. This results in abnormal mechanics at the patellofemoral
joint, and alters the actin myosin length tension relationship.

C. Lower Extremity Posture – Hip anterversion, Patella alta, Patella baja, medial patella,
lateral patella, tibial varum, knee valgum, and foot pronation.

D. Gait – The foot remaining in pronation through push off can contribute to
patellofemoral pain syndrome.

E. Over Pronation – Pronation causes internal rotation of the femur and tibia, resulting in a
lateral pull of the patella.

F. Hip Strength – Gluteus Medius and Maximus. Glut medius and maximus work
eccentrically during gait to control internal rotation of the femur and pronation at the
foot. Able to assess this through a single leg squat. The femur should not internally rotate
while performing single leg squat or step down.

G. Quad Strength – Vastus Medialis Oblique development and density. Observe and
measure atrophy. Test with single leg squat, step down, or manual muscle test.

H. Patella tracking – The patella should move superior, superomedial, and at terminal knee
extension move lateral as the tibia externally rotates.

I. Special tests – Patella apprehension, grind test, lateral tilt test. Ober test, Faber test.

Differential Diagnosis: Referred pain from the low back or hip, osteochondritis dessicans, Osgood-
Schlatter disease, bone tumor, osteoarthitis, inflammatory joint disease, meniscal pathology, and
synovial plica.

Evaluation / Assessment:
1. Establish Diagnosis and Need for Skilled Services.
2. Problem List
• Impaired muscle length: Tight hamstring, Iliotibial band, lateral retinaculum, and
quadriceps.
• Pain: goal to increase joint protection and self-management of sx’s.
• Impaired muscle performance: Muscle imbalance between hip internal rotators and
external rotators. VMO atrophy. Weak quadriceps, hamstrings, and hip abductors.
• Impaired joint mobility: Lateral tracking of the patella.
• Loss of function: Intolerance to…
• Impaired posture: Poor foot/knee/ hip posture during gait/functional activity.

Prognosis – The patient’s prognosis is very dependent upon a through history and examination to
determine predisposing faults contributing to the condition. Approximately 70% of patellofemoral
disorders improve from conservative treatment and time (10).

Goals (with measurable parameters and with specific timelines)

1. Normal muscle length of hamstrings, quadriceps, and iliotibial band in 6-8 weeks.
2. 5/5 hip abduction, hip external rotators, knee flexion, and knee extension strength in 6-8
weeks.
3. Normal medial glide of the patella in 3-4 weeks.
4. Determine need for orthotics 4 weeks.
5. Descending stairs unlimited in 8 weeks.
6. Return to sports or premorbid activity 8-12 weeks.
7. Independent home exercise program in 3-4 weeks.
8. Independent self-management of symptoms/ Independent with home exercise program.

Treatment Planning / Interventions

Interventions most commonly used for this case type/diagnosis. – Stretching, strengthening,
patella joint mobilization, electrical stimulation, biofeedback, and patella taping. It is important to
work within a pain free ROM or the vastus medialis oblique will be inhibited.

Strengthening – Strengthening the gluteus maximus and medius, quadriceps, and hamstrings are
needed. Specifically strengthening hip external rotators eccentrically will help with gait and
stability. Strengthening of the quadriceps needs to be in a pain free ROM. This can be done with
lateral step-ups and limited ROM squats.

Stretching of tight structures – Iliotibial band, Lateral retinaculum.

Stretching of shortened muscles – Hamstrings, quadriceps, hip flexors, and gastroc soleus..
Stabilization – Stabilization/balance/proprioceptive exercises for the hip and knee.
Frequency & Duration 2-3x/wk for 8-12 wks

Section: Rehabilitation Guidelines
Subject: ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING
AUTOGENOUS GRAFT
Purpose:
The intent of this protocol is to provide the clinician with a guideline of the post-operative
rehabilitation course of a patient that has undergone an ulnar collateral ligament reconstruction
without concomitant fracture.
PHASE I (surgery to 3 weeks after surgery)
Rehabilitation Goals
Precautions
Range of Motion (ROM) Exercises
(Please do not exceed the ROM specified for
each exercise and time period)
Suggested Therapeutic Exercise
Cardiovascular Fitness
Sports Health Care
• Gradual increase in elbow range of motion to near full range of
motion by the 9th – 10th week
• Protect reconstruction during continued healing
• Improve muscular strength of the arm, shoulder and trunk
• Week 4 = Functional hinged brace with range of motion from
10° -120°
• Week 5 = Functional hinged brace with range of motion from
5° - 130°
• Week 6 = Functional hinged brace with range of motion from
0° – 130°
• Discontinue brace at 6-8 weeks except in unsafe environments
(this time frame may vary from patient to patient per physician
recommendation)
• Avoid all valgus positions and minimize valgus stress to the
elbow during all rehab exercises
• Gentle active and active assistive range of motion for elbow
and wrist
• Passive range of motion should be initiated if needed in a very
controlled and gentle fashion
• Isotonics with light resistance for shoulder internal
rotation/external rotation, shoulder abduction, elbow
flexion/extension, pronation/supination, wrist flexion/
extension (all in a protected elbow position – hand staying on
the medial side of the elbow for all shoulder rotation exercises)
• Scapular strengthening and stabilization
• Hip, lower extremity and core strengthening
• Cervical spine active range of motion/stretching
• Walking, stationary bike - brace on
• No treadmill
• Avoid running and jumping due to the distractive and
compressive forces that can occur at landing.
PHASE II (begin after meeting Phase 1 criteria, usually 4-8 weeks after surgery)
Rehabilitation Goals
Precautions
Range of Motion (ROM)
Exercises (Please do not exceed the ROM
specified for each exercise and
time period)
Suggested Therapeutic Exercise
PHASE III (begin after meeting Phase II criteria, usually 9–12 weeks after surgery)
Rehabilitation Goals
Precautions
Range of Motion (ROM) Exercises
(Please do not exceed the ROM specified for
each exercise and time period)
Suggested Therapeutic Exercise
Cardiovascular Fitness
PHASE IV (begin after meeting Phase III criteria, usually 13-20 weeks after surgery)
• Protect healing tissues
• Decrease pain and inflammation
• Prevent muscular atrophy
• Initiate elbow range of motion
• Week 1 = immobilized at 90° of elbow flexion in hard brace
• Week 2 = Functional hinged brace with range of motion from
30°-100°
• Week 3 = Functional hinged brace with range of motion from
15°- 110°
• Gentle active and active assistive range of motion for the
elbow and wrist
• Gentle and gradual overpressure to meet range of motion
guidelines
• NOTE: Be sure to avoid valgus force or positioning during range
of motion exercises
• Begin week 2 with sub-maximal isometrics for shoulder
internal rotation, shoulder abduction, biceps, wrist flexors and
extensors
• Hand gripping
• Cervical spine and scapular active range of motion
Cardiovascular Fitness • Walking, stationary bike - brace on
• No treadmill
• Avoid running and jumping due to the distractive and
compressive forces that can occur at landing
• Increase overall strength and endurance
• Achieve and maintain full elbow range of motion
• Transition to entry level plyometrics
• There should be no pain while doing the strengthening
exercises
• Post-exercise soreness, should be less than 4/10 and return to
baseline within 24-36 hours
• Range of motion should be full at post-operative week 10, and
if not, please consult with the physician well in advance of week
12 appointment.
• Progressive isotonics for shoulder and elbow strengthening
with the arm < 45 degrees abduction positions, controlling speed
of the movement and valgus force at the elbow
• Initiate eccentric elbow flexion strengthening
• Assess shoulder mobility and address any imbalances (such as
posterior capsular tightness) which may prevent optimal
throwing biomechanics in the next phase
• Manual resistance diagonal patterns
• Hip, lower extremity and core strengthening
• Scapular strengthening and stabilization
• Walking, stationary bike - brace off
• Continue to avoid running and jumping
Rehabilitation Goals
Precautions
Range of Motion (ROM) Exercises
(Please do not exceed the ROM specified for
each exercise and time period)
Suggested Therapeutic Exercise
Cardiovascular Fitness
PHASE V (begin after meeting Phase IV criteria, usually 21-36 weeks after surgery)
Rehabilitation Goals • Maximize dynamic neuromuscular control with shoulder and
Precautions
Range of Motion (ROM) Exercises
(Please do not exceed the ROM specified for
each exercise and time period)
Suggested Therapeutic Exercise
Cardiovascular Fitness
References:
• Maximize rotator cuff and scapular strength in throwing positions
and postures
• Initiate education on throwing mechanics
• Transition to higher level plyometrics
• There should be no pain while doing the strengthening exercises
• Post-exercise soreness, should be less than 4/10 and return to
baseline within 24-36 hours
• Range of motion should be full at this point, and if not, please
consult with the physician
• Shoulder and elbow strengthening with the arm in > 45 degrees
abducted positions, controlling speed of the movement and valgus
force at the elbow
• Initiate rhythmic stabilization drills for the elbow and shoulder in
protected positions (at athlete’s side)
• Initiate plyometics – 2 hand drills only
• Begin throwing mechanics education – including slow motion “air
throws”, posture and position check points
• Hip, lower extremity and core strengthening
• Scapular strengthening and stabilization
• At week 16 athletes may be running and sprinting at 75% speed,
monitoring the environment to minimize the risk of falls.
elbow stabilization
• Develop biomechanically sound throwing mechanics
• Maximize muscular endurance and strength of the muscles
involved in throwing – including core, upper and lower extremity.
• There should be no pain while throwing or doing sport specific
drills.
• Post-throwing soreness, or post-sport specific drill soreness,
should be less than 4/10 and return to baseline within 24-36 hours.
• Range of motion should be full at this point, and if not please
consult with the physician.
• Multi-joint, multi-planar strengthening program.
• Shoulder and elbow stabilization and proprioceptive drills.
• Plyometric progressions (over several weeks) – transition from 2
arms in the sagittal plane, progressing to 1 arm sagittal plane, to 2
arm rotational movements, to 1 arm rotational movements.
• Initiate interval throwing program, progressing to a position
specific throwing program around week 28 if the athlete has had
no pain or problems with the baseline throwing program.
• Initiate sport specific return program for golf, tennis, basketball
or volleyball.
• Hip, lower extremity and core strengthening.
• Training should be targeted toward sport specific energy
systems.
The above rehabilitation guidelines were developed originally collaboratively by Karl Fry PT, DPT
and Marc Sherry PT, DPT, LAT, CSCS and the UW Health Orthopedic and Rehabilitation physician
staff. Additional Informstion from Brigham and Women’s Hospital, Harvard University School of
Medicine EBM Team (2002) cited in a textbook or physical medicine:
Brotzman & Wilk, which has been published in Brotzman SB, Wilk KE, Clinical Orthopeadic
Rehabilitation. Philadelphia, PA: Mosby Inc; 2003:315-319.

Ulnar Collateral Ligament Reconstuction in High School Baseball Players: Clinical Results and Injury
Risk Factors. AJSM 32(5), pp 1158-1164, 2004.

Current Concepts in the Rehabilitation of the Overhead Throwing Athlete. AJSM 30, pp 136-151,
2002.

Cain EL, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes: a current concepts
review. Am J Sports Med. 2003; 31(4):621-635.

Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in throwing athletes:
surgical treatment by ulnar collateral ligament repair or reconstruction. J Bone Joint Surg Am.
1992; 74:67-83.

Ellenbecker TS, Wilk KE, Altchek DW, Andrews JR. Current concepts in rehabilitation following
ulnar collateral ligament reconstruction. Sports Health. 2009; 1(4):301-313.

Flesig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics of baseball pitching with implications
about injury mechanisms. Am J Sports Med. 1995; 23:233-239.

Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead
athletes: a systematic review. Am J Sports Med. 2008; 36:1193-1205.

Sports Health Care

Section: Rehabilitation Guidelines

Subject: Arthroscopic Sub-Acromial Decompression Rehabilitation

Purpose:

The intent of these guidelines is to provide the licensed athletic trainer with a guideline for the
post-operative rehabilitation of a patient that has undergone a subacromial decompression.

Patients who have undergone concomitant repair of a rotator cuff tear, biceps tendon rupture,
SLAP lesion, bursectomy, and/or synovectomy should be progressed more conservatively, in
collaboration with the surgeon and according to post-operative rehabilitation guidelines.

I. GUIDELINES

Phase I – Immediate Post Surgical Phase (Day 1-14):

Goals:
• Restore non-painful range of motion (ROM)
• Prevent muscular atrophy and inhibition
• Decrease pain/inflammation
• Improve postural awareness
• Minimize stress to healing structures
• Independent with activities of daily living (ADLs)
• Wean from sling
Precautions:
• Care should be taken with abduction (with both active range of motion (AROM) and passive
range of motion (PROM) to avoid unnecessary compression of subacromial structures.
• Creating or reinforcing poor movement patterns, such as excessive scapulothoracic motion
with upper extremity elevation, should be avoided.
Range of Motion:
• PROM (non-forceful flexion and abduction)
• Active assisted range of motion (AAROM)1
• AROM
• Pendulums
• Pulleys
• Cane exercises
• Self stretches, including posterior capsule, upper trapezius, and pectoralis major.
Strengthening:
• Isometrics: scapular musculature, deltoid, and rotator cuff as appropriate
• Isotonic: theraband internal and external rotation in 0 degrees abduction
Modalities:
• Cryotherapy
• Electrical stimulation and/or inferential current to decrease swelling and pain (as indicated
 and/or needed)
Criteria for progression to phase 2:
• Full active and passive ROM
• Minimal pain and tenderness

Phase 2: Intermediate Phase (2-6 Weeks)

Goals:
• Regain and improve muscular strength
• Normalize arthrokinematics
• Improve neuromuscular control of shoulder complex
• Continue to wean from sling if applicable
Precautions:
• Overhead activities
• Heavy lifting
Exercises:
• Initiate isotonic program with dumbbells.
• Strengthen shoulder musculature- isometric, isotonic, Proprioceptive Neuromuscular
Facilitation (PNF).
• Strengthen scapulothoracic musculature- isometric, isotonic, PNF.
• Initiate upper extremity endurance exercises.
Manual Treatment:
• Joint mobilization to improve/restore arthrokinematics if indicated
• Joint mobilization for pain modulation
Modalities:
• Cryotherapy
• Electrical stimulation - interferential current to decrease swelling and pain (as indicated and/or
needed)
Criteria for Progression to Phase 3:
• Full painless ROM
• No pain or tenderness on examination

Phase 3: Dynamic (Advanced) Strengthening Phase: (6 weeks and beyond)

Goals:
• Improve strength, power, and endurance.
• Improve neuromuscular control.
• Prepare athlete to begin to throw, and perform similar overhead activities or other sport
specific activities.
Emphasis of Phase 3:
• High speed, high energy strengthening exercises.
• Eccentric exercises.
• Diagonal patterns.
• Workplace ergonomic assessment and/or work hardening program referral as needed.

Exercises:
• Continue dumbbell strengthening (rotator cuff and deltoid).
• Progress theraband exercises to 90/90 position for internal rotation and external rotation
(slow/fast sets).
• Theraband exercises for scapulothoracic musculature and biceps.
• Plyometrics for rotator cuff.
• PNF diagonal patterns.
• Isokinetics.
• Continue endurance exercises.
Criteria for discharge from sports therapy
• Patient able to maintain non-painful AROM.
• Maximized functional use of upper extremity.
• Maximized muscular strength, power, and endurance.
• Patient has returned to advanced functional activities.
Sports Health Care
Section: Rehabilitation Guidelines

Subject: Arthroscopic Anterior Stabilization (with or without Bankart Repair):

Purpose:

The intent of this protocol is to provide the licensed athletic trainer with a guideline of the post-
operative rehabilitation course of an athlete that has undergone an arthroscopic anterior
stabilization procedure.

I. GUIDELINES
Phase I – Immediate Post Surgical Phase (Day 1-21):
Goals:
• Protect the surgical repair
• Diminish pain and inflammation
• Enhance scapular function
• Achieve appropriate range of motion (ROM)

Precautions:
• Remain in sling, only removing for showering and elbow/wrist ROM.
• Patient education regarding avoidance of abduction / external rotation activity to avoid
anterior inferior capsule stress.
• No Passive Range of Motion (PROM)/Active Range of Motion (AROM) of shoulder.
• No lifting of objects with operative shoulder.
• Keep incisions clean and dry.

Weeks 1-3:
• Sling at all times except where indicated above
• PROM/AROM elbow, wrist and hand only
• Normalize scapular position, mobility, and stability
• Ball squeezes
• Sleep with sling supporting operative shoulder
• Shower with arm held at your side
• Cryotherapy for pain and inflammation
• Patient education: posture, joint protection, positioning, hygiene, etc.
• Begin isometrics week 3.

Phase II – Protection Phase/PROM (Weeks 4 and 5):

Goals:
• Gradually restore PROM of shoulder
• Do not overstress healing tissue

Precautions:
• Follow surgeon’s specific PROM restrictions- primarily for external rotation
• No shoulder AROM or lifting
Criteria for progression to the next phase:
• Full flexion and internal rotation PROM
• PROM 30 degrees of external rotation at the side
• Can begin gentle external rotation stretching in the 90/90 position

Weeks 4-5
• Continue use of sling.
• PROM (gentle), unless otherwise noted by surgeon.
 Full flexion and elevation in the plane of the scapula.
 Full Internal rotation.
 External rotation to 30 degrees at 20 degrees abduction, to 30 degrees at 90 degrees
abduction.
• Pendulums (Codman’s).
• Sub maximal pain free rotator cuff isometrics in neutral.
• Continue cryotherapy as needed.
• Continue all precautions and joint protection.

Phase III – Intermediate phase/AROM (Weeks 6 and 7):

Goals:
• Continue to gradually increase external rotation PROM Full AROM.
• Independence with ADL’s.
• Enhance strength and endurance.

Precautions:
• Wean from Sling.
• No aggressive ROM / stretching.
• No lifting with affected arm.
• No strengthening activities that place a large amount of stress across the anterior aspect of the
shoulder in an abducted position with external rotation (i.e. no pushups, pectoralis flys, etc.)

Weeks 6 and 7
• PROM (gentle), unless otherwise noted by surgeon
 External rotation to 30-50 degrees at 20 degrees abduction, to 45 degrees at 90 degrees
abduction.
• Begin AROM of shoulder
 Progress to full AROM in gravity resisted positions
• Begin implementing more aggressive posterior capsular stretching
 Cross arm stretch.
 Side lying internal rotation stretch.
 Posterior/inferior gleno-humeral joint mobilization.
• Enhance pectoralis minor length.
• Scapular retractor strengthening.
• Begin gentle isotonic and rhythmic stabilization techniques for rotator cuff musculature
strengthening (open and closed chain).
• Continue cryotherapy as necessary.
Phase IV - Strengthening Phase (Week 8 – Week 12)
Goals:
• Continue to increase external rotation PROM gradually.
• Maintain full non-painful AROM.
• Normalize muscular strength, stability and endurance.
• Gradually progressed activities with ultimate return to full functional activities.

Precautions:
• Do not stress the anterior capsule with aggressive overhead strengthening.
• Avoid contact sports/activities.

Weeks 8-10
• Continue stretching and PROM.
 External rotation to 65 degrees at 20 degrees abduction, to 75 degrees at 90 degrees
abduction, unless otherwise noted by surgeon.
• Progress above strengthening program

Weeks 10-12
• Continue stretching and PROM.
 All planes to tolerance.
• Continue strengthening progression program.

Phase V – Return to activity phase (Week 12 - Week 20)

Goals:
• Gradual return to strenuous work activities
• Gradual return to recreational activities
• Gradual return to sports activities

Precautions:
• Do not begin throwing, or overhead athletic moves until 4 months post-op.
• Weight lifting:
 Avoid wide grip bench press.
 No military press or lat pulls behind the head. Be sure to “always see your elbows”.

Weeks 12-16
• Continue progressing stretching and strengthening program.
• Can begin golf, tennis (no serves until 4 mo.), etc.
• Can begin generalized upper extremity weight lifting with low weight, and high repetitions
being sure to follow weight lifting precautions as above.

Weeks 16-20
• May initiate interval sports program if appropriate

Criteria to return to sports and recreational activities:

• Surgeon clearance.
• Pain free shoulder function without signs of instability.
• Restoration of adequate ROM for desired activity.
• Full strength as compared to the non operative shoulder.

Sports Health Care

Section: Rehabilitation Guidelines

Subject: Open Anterior Stabilization (with or without Bankart)

Purpose:

The intent of this protocol is to provide the licensed athletic trainer with a guideline of the post-
operative rehabilitation course of a patient that has undergone an open anterior stabilization.

Guidelines

Phase I – Immediate Post Surgical Phase/PROM (Day 1-21):

Goals:
• Passive Range of Motion (PROM) per orders.
• Diminish pain and inflammation.
• Do not overstress healing tissue.
Precautions:
• Remain in sling, only removing for showering or sports therapy.
• No lifting of objects with operative shoulder.
• Keep incisions clean and dry.
Day 1-14:
• Sling when not doing physical therapy.
• PROM
• Flexion to 90 degrees.
• Internal rotation to posterior belt line.
• External rotation to 0 degrees.
• PROM/Active Range of Motion (AROM) elbow and wrist.
• Ball squeeze.
• Sleep with sling supporting operative shoulder.
• Shower with arm held at your side.
• Cryotherapy for pain and inflammation.
• Patient education: posture, joint protection, positioning, hygiene, etc.
Day 15-21:
• Same as Day 1-14 with the exception of advanced PROM parameters.
• PROM
 Full flexion.
 Full internal rotation.
 External rotation to 30 degrees.

Phase II – Intermediate Phase/AROM (Week 4 and 5):

Goals:
• Continue to increase external rotation PROM to 45 degrees.
• Full AROM to PROM parameters.
Precautions:
• Wean from Sling.
• Can begin gentle external rotation stretching in the 90/90 position.
• No lifting with affected arm.

Week 4 and 5
• AROM, full flexion and internal rotation and external rotation to 45 degrees.
 Progress to full AROM in the against gravity position.
• Begin incorporating more aggressive posterior capsular stretching.
 Cross arm stretch.
 Side lying internal rotation stretch.
 Posterior/inferior gleno-humeral joint mobilization.
• Begin gentle rhythmic stabilization techniques for rotator cuff musculature strength.
• Continue cryotherapy as necessary.

Phase III - Strengthening Phase (Week 6 – Week 10)

Goals:
• Continue to increase external rotation PROM to full gradually.
• Maintain full non-painful AROM.
• Improve muscular strength, stability and endurance.
• Gradual return to full functional activities.

Precautions:
• Be sure not to stress the anterior capsule with aggressive overhead strengthening.
• Avoid contact sports/activities.

Week 6-8
• Continue stretching and PROM as needed/indicated.
• Continue rhythmic stabilization exercises.
• Initiate strengthening program (elastic resistance).
 ER/IR with elbow at the side of the body
 Forward punch
 Seated row
 Shoulder shrug
 Seated row
 Bicep curls
 Lat pulls
 Tricep extensions
 Push-up plus

Week 8-10
• Continue stretching and PROM as needed/indicated
• Continue all exercises listed above
• Begin gentle strengthening overhead, avoiding excessive anterior capsule stress
 ER/IR in the 90/90 position.
 D1/D2 flexion and extension diagonals.

Phase IV – Return to activity phase (Week 10 - Week 20)

Goals:
• Gradual return to strenuous work activities
• Gradual return to recreational activities
• Gradual return to sports activities

Precautions:
• With weight lifting, avoid wide grip bench press, and no military press or lat pulls behind the
head. Be sure to “always see your elbows”.
• Do not begin throwing, or overhead athletic moves until 4 months post-op.

Week 10-16
• Continue stretching and strengthening.
• Can begin golf, tennis (no serves until 4 mo.), etc.
• Can begin weight lifting with low weight, and high repetitions, being sure to follow weight
lifting precautions.

Week 16-20
• May initiate interval sports program if appropriate.
Sports Health Care
Subject: Rehabilitation Guidelines

Section: Posterior and Posterior Inferior Capsular Shift Protocol

Purpose:

This protocol has been modified from Brotzman & Wilk, which has been published in Brotzman SB,
Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003:315-319. The
Sports Health Care department at (COLLEGE/SCHOOL) has accepted a slight modification of this
protocol as our standard guidelines for the management of patient’s s/p posterior capsular shift.

The intent of these guidelines is to provide the licensed athletic trainer with a guideline of the
post-operative rehabilitation course of a patient that has undergone a posterior capsular shift
procedure.

GUIDELINES

Protection Phase (0-6 weeks):

Precautions
• Postoperative brace (typically gunslinger type) in 30-45° abduction, 15° external rotation for 4-
6 weeks.
• Brace to be worn at all times (even when sleeping) with the exception of exercise activity and
bathing.
• No overhead activity.
• No flexion for first 6 weeks.

Goals:
• Allow/promote healing of repaired posterior capsule
• Initiate early protected ROM
• Retard muscular atrophy
• Decrease pain and inflammation

Weeks 0 - 4
Exercises
• Gripping exercises with putty
• Active elbow flexion-extension and pronation-supination
• Active ROM cervical spine
• Passive ROM progressing to active-assisted ROM of GH joint:
 External rotation to 25-30° at 30-45° of abduction.
 Internal rotation to 15-25° at 30-45° of abduction (begin week three)
• Submaximal pain free shoulder isometrics in the plane of the scapula:
 Flexion
 Abduction
  Extension
 External rotation
 Avoid IR at this point

Note: In general all exercises begin with one set of 10 repetitions and should increase by one set of
10 repetitions daily as tolerated to five sets of 10 repetitions.

Cryotherapy:
Ice after exercises for 20 minutes. Ice up to 20 minutes per hour to control pain and swelling.

Weeks 4 - 6
Goals
• Gradual increase in ROM
• Normalize arthrokinematics
• Improve strength
• Decrease pain and inflammation

Range of motion exercises:

• Active-assisted exercises of GH joint.
• External rotation in multiple planes of shoulder abduction (up to 90°).
• Shoulder flexion to tolerance.
• Elevation in the plane of the scapula to tolerance.
• Shoulder abduction (pure) to 90°.
• Internal rotation 35° at 45° of abduction.
• Pulleys (AAROM)
• Shoulder elevation in the plane of the scapula to tolerance.
• Shoulder flexion to tolerance.
• Gentle self-capsular stretches as needed/indicated.

Gentle Joint Mobilization (Grades I-II) to Reestablish Normal Arthrokinematics

• Scapulothoracic joint
• GH joint (avoid posterior glides)
• SC joint
• AC joint

AROM Exercises
• Active abduction to 90°
• Active external rotation to 90°
• IR to 35°
Strengthening Exercises
• Elbow/wrist progressive resistive exercise program

Conditioning Program For:

• Trunk
• Lower extremities
• Cardiovascular endurance

Decrease Pain and Inflammation

• Ice and modalities PRN
Brace
• Discontinue 4-6 weeks post surgery per physicians instruction

Phase 2: Intermediate Phase (Weeks 6-12)

Goals:
• Full, non painful ROM at week eight (patient will not have full IR at this time)
• Normalize arthrokinematics
• Enhance strength
• Improve neuromuscular control

Weeks 6-9
Range of Motion Exercises:
• A/AROM to AROM as appropriate
• External rotation to tolerance
• Shoulder abduction to tolerance
• Shoulder flexion to tolerance
• Pulleys: flexion, abduction, and elevation in the plane of the scapula to tolerance
• Internal rotation to no more than 40°

Joint Mobilization
• Continue as above as indicated

Strengthening Exercises
• Initiate IR isometrics in slight ER (do not perform past neutral).
• Initiate theraband for internal and external rotation at 0° abduction (IR later in the phase).
• Initiate isotonic dumbbell program.
• Shoulder abduction.
• Shoulder flexion.
• Latissimus dorsi.
• Rhomboids .
• Biceps curl.
• Triceps kick-out over table.
• Push-ups into wall (Serratus anterior).

Weeks 10-12
• Continue all exercises listed above
Initiate
• Active internal rotation at 90° GH abduction with elbow at 90° flexion.
• Dumbbell supraspinatus.
• Theraband exercises for rhomboids, latissimus dorsi, biceps, and triceps
• Progressive push-ups

Phase 3: Dynamic Strengthening Program (Weeks 12-18)

Criteria for Progression to Phase 3:
• Full, non painful ROM
• No complaints of pain/tenderness
• Strength 70% of contralateral side

Weeks 13-15
Goals
• Enhance strength, power, and endurance
• Enhance neuromuscular control

Emphasis of Phase 3
• High-speed/high-energy strengthening exercises
• Eccentric training
• Diagonal patterns

Exercises
• Continue internal and external rotation theraband exercises at 0° abduction (arm at side)
• Theraband for rhomboids
• Theraband for latissimus dorsi
• Theraband for a biceps and triceps
• Continue dumbbell exercises for supraspinatus and deltoid
• Progressive serratus anterior push-up-anterior flexion
• Continue trunk and lower extremity strengthening and conditioning exercises
• Continue self-capsular stretches

Progress to:
• Isotonic shoulder strengthening exercises isolating the rotator cuff-including side lying external
rotation, prone arm raises at 0, 90 & 120°, prone external rotation, and internal rotation at 0 &
90°; progress to standing strengthening exercise once able to tolerate resistance against
gravity without substitution.
• Progress scapulothoracic/upper back musculature strengthening exercises.
• Dynamic stabilization exercises.
• Proprioceptive Neuromuscular Facilitation (PNF) exercises.

Phase 4: Return to Activity Phase (Weeks 21-28)

Criteria for Progression to Phase 4
• Full ROM
• No pain or tenderness
• Satisfactory clinical examination
Goal
• Progressively increase activities to prepare patient for unrestricted functional return

Exercises
• Continue theraband, and dumbbell exercises outlined in phase 3.
• Continue ROM exercises.
• Initiate interval programs between weeks 28 and 32 (if patient is a recreational athlete).
• Continue strengthening exercises for scapular and rotator cuff muscles.
• Progress to functional activities needed for ADL’s and sport.
• Thrower’s ten program (see protocol).
Sports Health Care
Section: Rehabilitation Guidelines

Subject: Arthroscopic Debridement of Type I and III SLAP Lesions Protocol

Purpose:

This protocol has been adopted from Brotzman & Wilk, which has been published in Brotzman SB,
Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003. The Athletic
Services Department at (COLLEGE/SCHOOL) has accepted a slight modification of these guidelines
(time frames) as our standard guideline for the management of patient’s s/p arthroscopic
debridement of type I and III SLAP lesions.

The intent of this protocol is to provide the licensed athletic trainer a guideline for the post-
operative rehabilitation course of an athlete that has undergone an arthroscopic debridement of a
type I or III SLAP lesion.

GUIDELINE

Type I SLAP lesions have degenerative fraying of the superior labrum but the biceps attachment to
the labrum is intact. The biceps anchor is intact.

Type III SLAP lesions involve a bucket-handle tear of the superior labrum with an intact biceps
anchor.
Generally, patients with Type I and Type III SLAP lesions typically require simple arthroscopic
debridement of the labrum and do not require anatomic repair. This generally means that
rehabilitation is more accelerated for these repairs. There, however, are cases in which the patient
has other pathology, such as rotator cuff pathology, which may change the rehabilitation plan.

Phase I – Motion Phase (Day 1-14):

Goals:
• Re-establish non-painful range of motion (ROM)
• Minimize muscular atrophy
• Decrease pain/inflammation

Sling
• Patient will be in a sling for 3-4 days postoperatively for comfort.

Passive range of motion/active assisted range of motion (PROM/AAROM)

• Pendulums
• Pulleys (begin when patient has adequate glenohumeral elevation: 90-110°)
• Cane exercises
• flexion/extension
• abduction/abduction
• External rotation/internal rotation (ER/IR) (begin at 0° abduction, progress to 45°, then 90°)
• Self-stretches (capsular stretches)

Strengthening
• Isometrics
• No biceps isometrics for five to seven days postoperative
• May initiate band exercises for ER/IR at 0° abduction late phase (seven to 10 days
postoperative)

Decrease pain and inflammation

• Ice, medication, modalities

Criteria to progress to phase II

• Full PROM
• Minimal pain and tenderness

Phase II – intermediate phase (weeks 2-4)

Goals
• Enhance muscular strength
• Normalize arthrokinematics
• Improve neuromuscular control of shoulder complex

Week 2:
• Begin AROM all directions to tolerance

Week 3:
Exercises
• Initiate isotonic program for shoulder and scapula-thoracic musculature with dumbbells as
appropriate:
 resisted ER/IR at 0° abduction
 side lying ER, abduction, horizontal abduction and adduction
 prone rowing
 PNF manual resistance with dynamic stabilization

Normalize arthrokinematics of shoulder complex:

• Joint mobilization.
• Continue stretching of shoulder (ER/IR at 90° of abduction).
• Initiate neuromuscular control exercises.
• Initiate proprioception training.
• Initiate trunk exercise .
• Initiate UE endurance exercises.

Decrease pain/inflammation
• Continue use of modalities PRN
Week 4:
Exercises
• Begin Thrower's ten program (see protocol)
• Emphasis on rotator cuff and scapular strengthening
• Dynamic stabilization drills

Criteria to enter phase III

• Full non painful AROM and PROM.
• No pain or tenderness.
• 4+/5 strength in deltoid and rotator cuff.

Phase III dynamic strengthening phase, advanced strengthening phase (week 5-7)
Goals
• Enhance strength, power, and endurance.
• Enhance neuromuscular control.
• Begin gentle sport specific preparation activities.

Exercises
• Continue thrower's ten programs (see thrower's ten protocol).
• Continue dumbbell strengthening (rotator cuff, deltoid).
• Initiate strengthening exercises in the 90°/90° for ER/IR (slow/fast sets).
• Strengthening of scapula-thoracic musculature.
• Biceps strengthening.
• Initiate plyometrics (two hand drills progress to one hand drills).
• Diagonal patterns (PNF).
• May initiate isokinetic strengthening.
• Continue endurance exercises: neuromuscular control exercises.
• Continue proprioception exercises.

Criteria for progression to phase IV

• Full ROM
• No pain or tenderness
• Satisfactory clinical examination

Phase IV: Return to Activity Phase (Week 8 and Beyond)

Goal
• Progressively increase activities to prepare patient for full functional return
Exercises
• Initiate intervals sport program (e.g., throwing, tennis).
• Continue all exercises as in phase 3 (throw and train on same day), (lower extremity and UE on
opposite days).
• Progress interval program.
Sports Health Care
Section: Rehabilitation Guidelines

Subject: Arthroscopic Labral Repair Protocol-Type II, IV, and Complex Tears

Purpose:

These guidelines has been adopted from Brotzman & Wilk, which has been published in Brotzman
SB, Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003. The Sports
Health Care Department at (COLLEGE/SCHOOL) has accepted a modification of these guidelines as
our standard protocol for the management of patient’s s/p arthroscopic repair of Type II and IV
SLAP lesions.

The intent of these guidelines is to provide the licensed athletic trainer with a guideline of the
post-operative rehabilitation course of a patient that has undergone an arthroscopic labral repair.
If patient has a concomitant injury/repair (such as a rotator cuff repair) treatment will vary-
consult with surgeon.

Type I SLAP lesions consist of degenerative fraying of the superior labrum but the biceps
attachment to the labrum is intact. The biceps anchor is intact.

Type II SLAP lesions are created when the biceps anchor has pulled away from the glenoid
attachment.

Type III SLAP lesions involve a bucket-handle tear of this superior labrum with an intact biceps
anchor.

Type IV SLAP lesions involve a bucket-handle tear of the superior labrum in which the tear extends
into the biceps tendon. The torn biceps tendon and labrum are displaced into the joint.

Complex SLAP lesions involve a combination of two or more SLAP types, usually II and III or II and
IV.

Repair of Type II SLAP Lesion1:

• Generally the superior labrum should be reattached to the glenoid and the biceps anchor
stabilized.
• Overhead-throwing athletes with this lesion often present with the biceps tendon detached
from the glenoid rim.
• Peel-back lesions are also commonly seen.
• When developing a rehabilitation program it is important to determine the extent of the
lesion, as well as the location and number of sutures.
Repair of Type IV SLAP Lesion1:
• Similar to Type II repair; however, will involve biceps repair, resection of frayed area or
tenodesis.
• Rehabilitation is similar to that for Type II repair except for biceps activity.
• Timeframes for active and resisted biceps activity will vary depending on the extent of bicipital
involvement. Consultation with the surgeon regarding the progression of biceps activity based
on the integrity of the biceps tendon repair is required.
• In cases where the biceps is resected, biceps muscular contractions typically may begin
between six and eight weeks post surgery
• In cases of repair to biceps tears or biceps tenodesis, no resisted biceps activities is typically
advised for three months following surgery.
• Light isotonic strengthening for elbow flexion is initiated between weeks 12 and 16
postoperatively (in cases with a biceps tenodesis surgeon and licensed athletic trainer may
choose to wait until 16 weeks to begin).
• Full resisted biceps activity is not initiated until post op weeks 16 to 20.
• Progression to sport-specific activities, such as plyometrics and interval sport programs,
follows similar guidelines to those outlined for Type II SLAP repairs.

Phase I - Immediate Post Surgical Phase "protected motion" (Day 1-week 6)

Goals:
• Protect the anatomic repair.
• Prevent/minimize the side effects of immobilization.
• Promote dynamic stability.
• Diminish pain and inflammation.

Post op day # 1 to Week 2

• Sling for 4 weeks.
• Sleep in sling for 4 weeks.
• Wrist/ Hand active range of motion (AROM)/ Active Assisted Range of Motion (AAROM).
• Hand-gripping exercises.
• PROM/AAROM:
 Flexion and elevation in the plane of the scapula to 60° (week 2, flexion to 75°).
 External rotation(ER)/internal rotation (IR) with arm in scapular plane.
 ER to 10°-15°.
 IR to 45° .
• No AROM ER, extension, or abduction.
• Submaximal isometrics for all rotator cuff, periscapular, and shoulder musculature.
• No isolated biceps contractions (i. e. no active elbow flexion).
• Cryotherapy, modalities as indicated.

Weeks 3-4
• Discontinue use of sling at 4 weeks.
• Continue gentle PROM/AAROM exercises (Rate of progression based on patient’s tolerance).
 Flexion and elevation in the plane of the scapula to 90°.
 Abduction to 75-85°.
 ER in scapular plane to 25-30°.
 IR in scapular plane to 55-60°.
• No AROM ER, extension, or elevation.
• Initiate rhythmic stabilization drills within above ROM.
• Initiate proprioceptive training within above ROM.
• Progress isometrics as above.
• Continue use of cryotherapy, modalities as indicated.

Weeks 5-6
• Begin AROM of shoulder (all planes, gravity eliminated positions then gravity resisted position
once adequate mechanics).
• Gradually improve PROM and AROM.
 Flexion and elevation in the plane of the scapula to 145°.
 Abduction to 145°.
 External rotation 45-50° at 45° abduction.
 Internal rotation 55-60° at 45° abduction.
 Extension to tolerance.
• May initiate gentle stretching exercises.
• Gentle Proprioceptive Neuromuscular Facilitation (PNF) manual resistance.
• Initiate prone exercise program for periscapular musculature.
• Begin AROM elbow flexion and extension.
• NO biceps strengthening.

Phase II: Intermediate Phase-Moderate Protection Phase (Weeks 7-14)

Goals
• Gradually restore full AROM and PROM (week 10).
• Preserve the integrity of the surgical repair.
• Restore muscular strength and balance.

Weeks 7-9
• Gradually progress P/AROM.
 Flexion, elevation in the plane of the scapula, and abduction to 180°.
 External rotation 90-95° at 90° abduction.
 Internal rotation 70-75° at 90° abduction.
 Extension to tolerance.
• Begin isotonic rotator cuff, periscapular, and shoulder strengthening program.
• Continue PNF strengthening.
• Initiate "Thrower's Ten" program except resisted biceps exercise (see protocol).
• Type II repairs: begin sub maximal pain free biceps isometrics.
• Type IV, and complex repairs: continue AROM elbow flexion and extension, no biceps
isometric or isotonic strengthening.

Weeks 10-12
• Progress ER P/AROM to thrower's motion.
 ER 110-115 at 90° abduction in throwers (weeks 10-12).
• Progress shoulder isotonic strengthening exercises as above.
• Continue all stretching exercises as need to maintain ROM.
• Progress ROM to functional demands (i.e., overhead athlete).
• Type II repairs: begin gentle resisted biceps isotonic strengthening @ week 12.
• Type IV, and complex repairs: begin gentle sub maximal pain free biceps isometrics.

Criteria for Progression to Phase III

• Full non painful ROM.
• Good stability.
• Muscular strength 4/5 or better.
• No pain or tenderness.

Phase III: Minimal Protection Phase (weeks 14-20)

Goals
• Establish and maintain full ROM.
• Improve muscular strength, power, and endurance.
• Gradually initiate functional exercises.

Weeks 14-16
• Continue all stretching exercises (capsular stretches).
• Maintain thrower's motion (especially ER).
• Continue rotator cuff, periscapular, and shoulder strengthening exercises.
• Type II repairs: progress isotonic biceps strengthening as appropriate.
• Type IV, and complex repairs: progress to isotonic biceps strengthening as appropriate.
• "Thrower's Ten" program with biceps exercise or fundamental exercises.
• PNF manual resistance.
• Endurance training.
• Initiate light plyometric program.
• Restricted sports activities (light swimming, half golf swings).

Weeks 16-20
• Continue all exercises listed above.
• Continue all stretching.
• Continue "Thrower's Ten" program.
• Continue plyometric program.
• Initiate interval sport program (e.g. throwing). See interval throwing program.

Criteria for Progression to Phase 4

• Full non painful ROM.
• Satisfactory static stability.
• Muscular strength 75-80% of contralateral side.
• No pain or tenderness

Phase IV: Advanced Strengthening Phase (Weeks 20-26)

Goals
• Enhanced muscular strength, power, and endurance.
• Progress functional activities.
• Maintained shoulder stability.

Weeks 20-26
• Continue flexibility exercises.
• Continue isotonic strengthening program.
• PNF manual resistance patterns.
• Plyometric strengthening.
• Progress interval sports programs.

Phase V: Return to Activity Phase (Months 6-9)

Goals
• Gradually progress sport activities to unrestrictive participation.
• Continue stretching and strengthening program.
Sports Health Care
Section: Rehabilitation Guidelines

Subject: Acromioclavicular Joint Separation

Purpose:

These guidelines are intended to outline the most commonly used interventions. Treatment in this
standard of care is targeted to the conservative management. Close communication with the
surgeon is needed for post-operative rehabilitation.

I. CLASSIFICATION OF AC JOINT SEPARATION - Rockwood Classification, 1990 4, 6

Type I
 Mild sprain of the AC ligament
 No disruption of AC or coracoclavicular ligaments
Type II
 Disruption of the AC joint.
 AC joint wider because of disruption (<4mm or 40% difference).
 Sprained but intact coracoclavicular ligaments with coracoclavicular space essentially the same
as the normal shoulder on radiographs.
 Downward force (weight) may disrupt AC ligament, but not the coracoacromial ligament .
Type III
 Coracoclavicular and AC ligaments disrupted leading to separation of the joint.
 Shoulder complex displaced inferiorly.
 Coracoclavicular interspace 25-100% greater than in normal shoulder, or 4 mm distance
(especially with weights applied).
Type IV
 Clavicle is displaced posteriorly through fibers of trapezius
 AC ligament and coracoclavicular ligaments disrupted
 Deltoid and trapezius muscles detached from distal clavicle
Type V
 Vertical separation of clavicle is greatly separated from scapula over a type III injury (100 to
300% more than normal shoulder).
 Significant prominence of clavicle.
Type VI
 Clavicle is dislocated inferiorly under the coracoid process

II. TREATMENT OPTIONS

Type I and II injuries are usually treated conservatively. There are differing opinions regarding
management of Type III injuries with a shift toward more conservative management. Surgery
should be considered for younger more active patients, in individuals who do heavy repetitive
lifting1, in thin individuals with prominent distal clavicles or those who work with their arms above
90 degrees. Nonsurgical treatment of Type III AC separations was found to be superior to surgical
treatment in the first year after surgery. A prospective study of the natural history of untreated
Grade III AC separations done in 2001 showed a majority (80%) of patients did well without formal
treatment. The authors state that a small percent of patients may require surgery especially in
those who do heavy lifting or repetitive manual labor. The study did not include athletes involved
in overhead activities and did not include conclusions regarding return to sports or information
about surgical outcomes. 10 Those individuals with type IV, V, and VI injuries should have a
surgical consult and often require early surgical intervention with open reduction and internal
fixation.

Indications for Treatment:

The indications for treatment can include:
• Shoulder pain
• Shoulder swelling
• Decreased active and/or passive ROM of upper extremity
• Decreased scapulothoracic rhythm
• Muscle imbalances
• Impaired muscle strength
• Impaired function

Patients can be referred with an acute, sub-acute or chronic injury. Treatment will depend on
injury type, duration and intensity of symptoms. The focus of rehabilitation after shoulder injury is
on pain control and regaining coordinated movement throughout the shoulder complex, then on
muscle strengthening and muscle re-education and return to functional, sports and work activities.

Contraindications / Precautions for Treatment:

• Acute infection
• Acute Fracture – clavicle , coracoid process, acromial process
• Tumor
• Avoid increased pain or swelling

III. ASSESSMENT

Establish Diagnosis and Need for Skilled Services

• Pain
• Swelling
• Impaired ROM
• Impaired strength
• Impaired joint play
• Impaired posture
• Impaired function
• Impaired knowledge: diagnosis, condition, self-management, home program, potential for
deformity, avoiding pain and re-injury .
Prognosis:
Prognosis is dependent on type of injury. Course of recovery is often prolonged if surgery was
required.
• Type I and II injuries usually have good to excellent results with return to full function in 1-3
weeks. Some individuals may have persistent pain or dysfunction. A small percent may need
eventual surgery for degenerative disease of AC joint.
• Type III injuries usually return to full function in 6-12 weeks. Most patients treated
conservatively have excellent functional outcome. Younger patients and heavy laborers may
need surgery to prevent muscle fatigue and discomfort and difficulty lifting due to the
displacement. Type III injuries may develop impingement symptoms, muscle discomfort and
neurovascular symptoms. Late surgery may be required. Surgical outcomes can be acceptable
in more than 90% if treated appropriately.
• Type IV, V, and VI generally require surgery and return to play depends on healing and
restoration of near normal strength and ROM.
• Scapular instability may be a result of disruption the scapula’s articulation with the AC joint
and not due to muscular weakness.

IV. GOALS

• Pain Relief/Reduction.
• Protect injured ligaments against re-injury.
• Increased ROM.
• Increased strength.
• Improved joint play.
• Maximize posture.
• Maximize Functional Independence.
• Independent exercise program, self-management of symptoms, independence with prevention
of re-injury.
• Maximize ability to return to previous recreational activities

V. INTERVENTION GUIDELINES

Acute Stage:
Type I Injury (Days 1 - 7)
 Ice, elevation (sitting up) and shoulder spica.
 NSAID’s
 Shoulder sling for 5-7 days– rest as needed.
 AROM fingers, wrist and elbow.
 Begin Pendulum Exercises – day 2 or 3.
 Shoulder isometrics trapezius and deltoid muscles.

Days 7-10
 Expect symptoms to subside.
 Discontinue sling.
 AROM and strengthening as symptoms allow.

Type II Injury (Day 1)

 Ice for 24-48 hours
 NSAID’s
 Sling for comfort 1-2 weeks.

Day 7
 Gentle ROM of shoulder.
 Allow use of arm for ADL.
 Discontinue sling at 7-14 days .

Type III Injury – Non-operative

 Ice for 24 hours.
 Sling – discontinue as symptoms subside (1-4 weeks).
 Leukotape - may increase comfort and facilitate weaning from sling and allow progression of
ROM and strengthening exercises.
 Begin ADL with arm at 3-4 days.
 Slowly progress functional ROM, gentle PROM at 7 days.

Type IV, V and VI injuries are diagnosed by radiographs and will need surgical consult. Return to
athletics and play depends on healing and restoration of near normal strength and ROM.

Post Acute Stage:

Type I can return to sport when nearly normal ROM and strength. No heavy lifting, stresses, or
contact sports until full painless ROM, and no point tenderness over AC joint (usually by 2-3
weeks).
Type I and Type II injuries can progress to ROM and strength training as symptoms permit.
Type II injuries should avoid heavy lifting, pushing, pulling or contact sports for at least 6 weeks.
Type III injuries typically have full ROM at 2-3 weeks with gentle ROM exercises and return to
activity in 6-12 weeks with protection of AC joint.

 Continue patient education.

 PROM, AAROM, AROM progression.
 Posture training.
 Strengthening of trapezius, deltoid, rotator cuff and scapular musculature – may include
isometrics, exercise bands, active progressing to resistive forward flexion, scapatation, side-
lying external rotation, seated press-ups, push-ups plus.
 Weight bearing scapular stabilization using physioball.
 Joint mobilization if glenohumeral joint limitations; contraindicated at AC joint if
hypermobility.
 Protection of the AC joint with padding if patient will return to collision sports, using a
“doughnut” from foam or felt. A pad can be used beneath the shoulder padding used in the
patient’s sport.
 Modalities as needed– ice, electrical stimulation (refer to each individual practice standard for
procedural guidelines.)

Frequency & Duration:

 1-2 times per week for 2-4 weeks if Type I or II.
 1-2 times per week for 4-12 weeks if Type III, non-operative.

Patient Education
 Role of therapy, therapeutic evaluation findings, plan of care.
 Pain and swelling management – avoid exercises and activities which provoke the pain or
cause swelling.
 Re-injury prevention:
 “Weight lifters should avoid locking the elbows during the bench press, use a narrower grip
on the bar, and avoid bending the elbows below the horizontal.”
 Use of protection if returning to collision sports.
 Avoid repetitive tasks.
 Posture.
 Sports specific training.
 Home exercise program.
 Future complications.
 Patient may develop arthritis as part of normal aging, (50%) or if they are weight lifters, do
upper body workouts, or play sports involving shoulder strength or throwing.
 Patient may have a residual “bump” at AC joint.

Recommendations and referrals to other providers.

• Orthopedic Surgeon
• Physical or Occupational Licensed athletic trainers

Re-evaluation / Assessment:
Standard Time Frame – every 30 days or less if significant change in status.
Other Possible Triggers –
 Significant change in symptoms, fall, re-injury, or pain after 8-12 weeks of intervention.
 Failure to progress per established short-term goals.

VI. DISCHARGE PLANNING

Commonly expected outcomes at discharge:
 Minimal to no pain or swelling.
 Functional ROM and strength.
 Independent functional mobility.
 Independent home exercise program.
 Return to pre-injury function and recreational activities.

Sports Health Care

Section: Rehabilitation Guidelines

Subject: Return to Sport after Knee Injury / Surgery Guidelines

Purpose:

The intent of these guidelines is to provide the athlete with a framework for return to sports
activity following injury. These guidelines should not take the place of medical advice if attempting
to return to sports following an injury. If an athlete requires assistance in the progression of a
return to sport program they should consult with their primary care physician, surgeon, or sports
licensed athletic trainer.

Phase 1: Functional Balance and Core Strengthening

Goals:
• Enhance single leg weight bearing strength at varying angles of knee flexion.
• Improve side to side symmetry in lower extremity running mechanics.
• Improve single leg balance.
• Improve core stability and coordination.

Exercises:
• Lunges
• Single leg squatting exercises
• Treadmill training with a mirror to enhance symmetry in running mechanics.
• Balance activities (level surface, uneven surfaces, soft surfaces).

Criteria to progress to Phase II:

• Able to single leg squat to 60 degrees knee flexion and hold for at least 5 seconds.
• Symmetry in running mechanics on a treadmill (6-10 mph).
• Acceptable single leg balance performance involved extremity compared to uninvolved.

Phase II: Functional Strength

Goals:
• Improve lower extremity strength.
• Enhance force contribution symmetry during bilateral weight bearing activities.
• Enhance single leg landing force.

Exercises:
• High intensity balance training activities.
• Continue lower extremity weight bearing strengthening activities.
• Begin perturbation training.
• Single leg landing activities to improve dynamic muscular control.

Criteria to progress to Phase III:

• Side to side symmetry in peak torque knee flexion and extension.
• Plantar force total-loading symmetry measured during bipedal squat to 90 degrees knee
flexion (less than 20% discrepancy between sides).
• Single-limb peak-landing-force symmetry on a 50 cm hop (less than 3 times body mass and
within 10% in side-to-side measures).
Phase III: Power Phase
Goals:
• Improve single-limb power production.
• Improve lower extremity muscular endurance.
• Improve lower extremity biomechanics during plyometric activities.

Exercises:
• Mid-level intensity double-limb plyometric jumps.
• Low-level intensity single-limb repeated hops.
• Focus on proper technique during plyometric activities.

Criteria to progress to Phase IV:

• Single-leg hop for distance (within 15% on uninvolved side).
• Single-limb crossover triple hop for distance (within 15% on uninvolved side).
• Single-limb timed hop over 6 meters (within 15% on uninvolved side).
• Single-limb vertical power hop (within 15% on uninvolved side).
• Reassessment of tuck jump (either an 80-point score or 15% improvement)

Phase IV: Sport-Specific Symmetry

Goals:
• Equalizing ground reaction force attenuation strategies between limbs.
• Improving confidence and stability with high intensity change of direction activities.
• Improving and equalizing power endurance between limbs.
• Using safe biomechanics (increased knee flexion and decreased knee abduction angles) when
performing high-intensity plyometric exercises.

Exercises:
• Power, cutting and change-of-direction tasks that are modified to the athlete’s individual
sport.
• Provide verbal and visual feedback to assist the athlete develop safe biomechanics during
plyometric moves.

Criteria for integration back to sports:

• Drop vertical jump landing force bilateral symmetry (within 15%).
• Modified agility T-Test (MAT) test time (within 10%).
• Single-limb average peak power test for 10 seconds (bilateral symmetry within 15%).
• Reassessment of tuck jump (either an 80-point score or 20% improvement).
 Sports Health Care

Section: Rehabilitation Guidelines

Subject: Running Injury Prevention & Return to Running Program Guidelines

Purpose:

The intent of these guidelines is to provide the licensed athletic trainer a framework for
developing a individualized program for the student-athlete for return to sports activity following
injury.

I. INJURY PREVENTION GUIDELINES

Steps to reduce tissue trauma / injury:
• Gradual increases in running time / miles (10% rule).
• Be careful of excessive downhill running.
• Reasonable amount of fast paced running.
• Adequate rest between workouts.
• Fewer hard surface runs.
• Proper eating / sleeping.
• Avoidance of complete fatigue.
• Every run should have a purpose.
• Develop stronger tissues – strength training.

Injury Prevention:
• 80% of running injuries are caused by too much of an increase in mileage.
• The cardiovascular system adjusts to stress quicker than the joints.
• Joggers/runners should increase their total weekly running amount by no more than 10%.
• Get a good pair of running sneakers and change them every 300-400 miles.
• Run on soft, flat surfaces whenever possible. Treadmill training if available.
• If the athlete cannot take more than a couple of days per week of impact, they can cross-train
on bike or elliptical trainer to increase fitness level.
• Maintain or achieve ideal body weight to minimize joint stress.
• Stress the need stretch before and after practice regularly.

Warm Up:
• Any cardio exercise should begin easy and gradually increase intensity.
• Should last 3-5 minutes.

Cool Down:
• At the end of the run, walk for around 3-5 minutes to prevent blood from pooling in your legs
and to allow your heart rate to decrease.

Stretching:
• Stress that stretching should be done at the conclusion of any prolonged run.
• Static stretching should be done to the point of tension and held for 20-30 seconds, at least 1x
per muscle group.
• Emphasis that the athlete should not “bounce” when stretching (static vs. ballistic).
• If an athlete has a particular tight spot, they need to stretch that muscle more frequently (after
the initial warm up or even at every mile).

II. WARNING SIGNS OF INJURY:

Pain vs. Discomfort - Normal Patient Complaints:

• General muscle soreness is normal at the onset of exercise programs.
• Slight joint discomfort after workout or next day that is gone in 24 hours.
• Slight stiffness at beginning of run or walk that dissipates after first 10 minutes.

Pain that May Indicate a Problem (restrict or suspend training):

• Pain that is keeping an athlete awake at night.
• Pain that is evident at beginning of run/walk then becomes worse as run/walk continues.
• Pain that changes a runner’s stride.

Acute Pain and Injury Management:

• Ice area: 15-20 minutes several times per day.
• Elevate injured part while icing.
• Rest (at least initially).
• Analyze program for possible causes.
 What did the athlete do differently in training?
 Was there a mileage jump?
 Was there a significant pace increase?
 Shoes condition? Or change in shoe model?
 Change in running surface (from all treadmill or soft surface to road running)?
• Cross-train on non-impact cardio – follow similar minutes that athlete was doing
running/walking (e.g. elliptical trainer – 130 + strides/minute)
• Determine plan to return athlete to full program, return to running very slowly.
• Licensed athletic trainer and/or orthopedic referral.

Warning Signs of Overtraining:

• Difficulty performing typical workouts for more than a week.
• Excessive fatigue.
• Higher resting heart rate.
• Decreased appetite.
• Sore muscles.
• Troubled sleep.
• Irritability.
• Increased perspiration.
• Decreased desire to train.

III. RETURN TO RUNNING PROGRAM:

When beginning a return to running program a runner and licensed athletic trainer working with
the athlete should take into consideration the original injury and current fitness status in order to
modify this program accordingly. A runner should progress through this program one phase at a
time.

Phase I: Walking Program

The athlete should be able to walk, pain free, aggressively (roughly 4.2 to 5.2 miles per hour), in a
controlled environment, preferably on a treadmill, before beginning the plyometric and walk/jog
program.

Phase II: Plyometric Routine

A mile run typically consists of 1500 foot contacts, 750 per foot. This program integrates 470 foot
contacts per leg, which would be equivalent to two thirds of the foot contacts during a mile run.
Upon successful completion of this phase is a good indicator that an athlete is ready to attempt
running a half to three-quarters of a mile distance.

Exercise Sets

Exercise Sets Foot contacts Total foot

per set contacts
Two-leg ankle hops: in place 3 30 90
Two-leg ankle hops: forward/backward 3 30 90
Two-leg ankle hops: side to side 3 30 90
One-leg ankle hops: in place 3 20 60
One-leg ankle hops: forward/backward 3 20 60
One-leg ankle hops: side to side 3 20 60
One-leg leg broad hop 4 5 20
22 470
Rest Intervals: Between Sets 90 seconds
Between Exercises: 3 minutes

IV. GENERAL GUIDELINES:

• Stretch Gastro, Soleus, Quads and Hamstrings between exercises.

• If you experience pain or are unable to complete an exercise, stop, stretch and apply ice to the
involved area. If you are pain free the next day, attempt to re-start the routine.

You may begin this program on level ground if:

1. Successful completion of Phase I and II.
2. You have no pain with normal daily activities.
Walk Jog Repetitions Total time:
Stage I 5 minutes 1 minute 5 times 30 minutes
Stage II 4 minutes 2 minutes 5 times 30 minutes
Stage III 3 minutes 3 minutes 5 times 30 minutes
Stage IV 2 minutes 4 minutes 5 times 30 minutes
Stage V Jog every other day with a goal of reaching 30 consecutive minutes, begin
with 5 minutes of walking, gradually increasing the pace. End with 5
minutes of walking, gradually decreasing the pace to a comfortable walk.

Pain Management:

If the athlete develops swelling in a joint or has muscular pain that lasts longer than 72 hours, the
athlete has done too much and needs to decrease activity (duration and/or intensity) and increase
rest between workouts.

Apply moist heat before activity and stretch thoroughly then ice immediately after activity for 15
to 20 minutes.

If the athlete develops tightness during an activity, have them stop and stretch (3 reps for 30 a
count each) the affected area then resume activity. If tightness returns, have them stop and
stretch again. If pain develops or after three stretching sessions the tightness remains, stop
activity and apply ice to involved area for 20 minutes.

It is important to identify to exact location of the athletes pain . Is it in a constant location or does
it “move around” in a general area?

• Constant location: be very cautious, incorporate more rest between exercise sessions, keep
the intensity low and exercise on level, soft surfaces.
• “Moves around”: continue with progression, but do not increase the intensity.

It is important to identify when athlete have pain:

• Type I: After activity: stretch affected area well (at least 3 to 5 reps, hold each for at least a 30
count), long, slow, gentle stretch, and then ice for 20 minutes. Continue to progress program if
discomfort appears to be muscle soreness. If joint pain and/or swelling develops, increase rest
between exercise sessions and decrease activity level to previous level.
• Type II: During activity, at beginning of exercise then dissipates: maintain same activity level
and low intensity until symptoms dissipate.
• Type III: During activity then gradually develops and intensifies with activity: decrease intensity
of activity, stop and stretch to relief symptoms, stop activity if those do not relief symptoms.
Maintain same activity level; if symptoms continue, decrease activity to previous level.
• Type IV: At night, keeps athlete up or wakes the athlete up: This is a bad indicator, the athlete
is doing too much; total rest until symptom free, decrease activity to previous level and keep
intensity low.
• Upon waking: In the morning, upon waking, then dissipates: this is a warning sign of more
problems to come, decrease activity to previous level and keep intensity low.

It is important to grade the level of pain that athletes experience have over a period of several
days to weeks. Is the pain is getting worse, staying the same or gradually dissipating? Use a pain
scale of 0 to 10, in which 0 is normal and 10 is the worst.

• Getting worse: need total rest, decrease to previous activity level and decrease intensity of
exercise.
• Staying the same: decrease activity level to previous level and maintain until pain decreases.
• If the athlete has no pain when doing this activity level or afterwards, and they have no
discomfort or tightness that limits normal movements the next morning, proceed to the next
stage.

Phase IV: Timed Running Schedule

Program Progression:
• If jogging hurts, have the athlete stop, apply ice and return to the previous stage the next day.
If pain/discomfort remains or increases, continue to return to a previous level until discomfort
stabilizes or decreases.
• If the athlete has no pain when doing this activity level or afterwards, and has no discomfort or
tightness that limits normal movements the next morning, proceed to the next stage.
• Increase the intensity (how hard/fast) of the jog/run before they increase the duration (how
long) of the jog/run.
• When increasing the frequency (how many days per week they jog/run) of the workouts,
decrease the duration of the workout.
• When the athlete begins running multiple days in a row, make the increases (duration or
intensity) on the first day of activity after a day of rest, the decrease the duration of activity to
the previous level.
• Ten Percent Rule: Only increase the weekly mileage by 10 % of the previous week.
• If the athlete develops persistent tightness or increased discomfort during activity to a point of
dysfunction, stop and note the time of onset of symptoms during the exercise session (during
a 30 minute planned exercise session, symptoms develop after 21 minutes).
• Consider splitting the duration of activity between 2 workouts with each exercise session
shorter than the time of the onset of symptoms during the previous attempt.
Example: during a 30 minute planned exercise session, symptoms develop after 24 minutes,
and then each of the 2 exercise sessions would be 20 minutes long. The exercise sessions
should be separated by 6 to 8 hours.
• Have the athlete jog/run on a flat, “forgiving” surface (i.e.-golf course, athletic field) before
hilly courses or uneven surfaces.

Phase IV: Timed Running Schedule-Intermediate

• The Intermediate schedule is designed for the runner who is restarting training or recovering
from an injury, such as a stress fracture or significant illness, which has kept them “off their
feet” or on non-weight bearing activities for 4 weeks or longer.
• The athlete may begin this program on level ground if they have completed Phase I, II and III.
• Run every other day for eight weeks. Cross train, active rest or total rest on days off.
• Estimate a pace between 8 to 9 minutes per mile.

Day 1 2 3 4 5 6 7 Week
Minutes: 30 - 30 - 30 - 35 1
- 30 -3 0 - 35 - 2
35 - 30 - 35 - 35 3
- 35 - 40 - 35 - 4
35 - 40 - 40 - 35 5
- 40 - 40 - 40 - 6
45 - 40 - 40 - 45 7
- 45 - 40 - 45 30 8

Run multiple days in a row after 8 weeks.

Day 1 2 3 4 5 6 7 Week
Minutes: - 45 35 - 45 40 - 9
45 45 - 45 45 30 - 10
45 45 35 - 45 45 40 11
- 45 45 45 - 45 45 12

Phase IV: Timed Running Schedule-Advanced

• The Advanced schedule is designed for the runner who is recovering from a soft tissue injury,
such as a strained muscle, which has forced them to cross train for least than 4 weeks.
• The athlete may begin this program on level ground if they have completed Phase I, II and III.
• Have the athlete run every other day for eight weeks. Cross train, active rest or total rest on
days off.
• Estimate a pace between 7:30 to 8 minutes per mile.

Day 1 2 3 4 5 6 7 Week
Minutes: 30 - 30 30 - 35 30 1
 - 35 35 - 40 35 - 2
40 40 - 45 40 - 45 3
45 - 45 40 30 - 45 4
40 35 - 45 40 40 - 5
45 45 40 - 45 45 45 6
- 50 45 40 - 50 45 7
45 - 50 50 45 - 50 8
50 50 - 55 50 50 - 9
55 55 50 - 55 55 55 10
- 60 55 55 - 60 60 11
55 - 60 60 60 - 65 12

Return to running program based on a program by Steven L. Cole, ATC, CSCS, College of William
and Mary.
Sports Health Care
Section: Rehabilitation Guidelines

Subject: Running Injury Prevention Tips & Strength Training Program for Runners

Purpose:

The intent of these guidelines is to provide the licensed athletic trainer working with an athlete
with a framework for return to sports activity following injury.

Steps to reduce tissue trauma / injury:

• Gradual increases in running time / miles (10% rule).
• Be careful of excessive downhill running.
• Reasonable amount of fast paced running.
• Adequate rest between workouts.
• Fewer hard surface runs.
• Proper eating / sleeping.
• Avoidance of complete fatigue.
• Every run should have a purpose.
• Develop stronger tissues – strength training.

STRENGTH TRAINING PROGRAM FOR RUNNERS

Stronger muscles provide:
• More power for running up hills.
• Better shock absorption, which assists in injury prevention.
• Improved soft tissue / connective tissue integrity.
• UE strength assists with improved UE motion during late stages of a run when legs are
fatigued.

Exercise Parameters:
• 3 x / week.
 (2 x / week has about 85% benefit of 3 / x week)
• 1 set of 12 - 16 of each major muscle group.
 (equal benefit of 2-3 sets)
• Moderate to slow repetitions to focus on control.
 (6 seconds for each repetition)
• 75 % of maximum weight / resistance.
• If able to do 16 reps comfortably then increase resistance by 5%.
• About 25 minutes total per session.

Muscle Group Machine Free Weights

• Quadriceps leg ext. Squat/lunge.
• Hamstrings leg curl Squat/lunge.
• Gluteals hip ext. Squat/lunge.
• Gastrocs Heel ups Heel ups.
• Anterior Tibialis - Toe ups.
• Pectoralis Major - double chest bench press.
• Latissimus dorsi – pullover & bent rowing.
• Deltoids - lateral raises.
• Biceps - bicep curls.
• Triceps - triceps extensor extension.
• Spinal erectors low back -back extensions.
• Abdominals abdominal crunches
• Upper Trapezius neck & shoulder shrug

Injury Prevention:
• 80% of running injuries are caused by too much of an increase in mileage.
• The cardiovascular system adjusts to stress quicker than the joints.
• Joggers/runners should increase their total weekly running amount by no more than 10%.
• A good pair of running sneakers and change them every 300-400 miles.
• Run on soft, flat surfaces whenever possible. Treadmill training is fine.
• If the athlete cannot take more than a couple of days per week of impact training, cross-train
them on a stationary bike or elliptical trainer to increase CV fitness level.
• Maintain or achieve ideal body weight to minimize joint stress.
• Pre and Post exercise stretching on regularly basis.

Warm Up
• Any cardio exercise should begin easy and gradually increase intensity.
• Should last 3-5 minutes.
• Example: If an individual normally runs a 10-minute/mile pace, warm-up running 12-13
minute/mile pace or begin with walking briskly.

Cool Down
• At the end of the run, have the athlete walk for around 3-5 minutes to prevent blood from
pooling in their legs and to allow the heart rate to decrease.

Stretching
• Stretching should be done at the conclusion of the run.
• Stretch to the point of tension and hold for 20-30 seconds, at least 1x per muscle group.
• Do not bounce when stretching.
• If you have a particular tight spot, stretch more frequently (after the initial warm up or even at
every mile).

Warning Signs of Injury

Normal Discomfort From Exercise:
• General muscle soreness.
• Slight joint discomfort after workout or next day that is gone in 24 hours.
• Slight stiffness at beginning of run or walk that dissipates after first 10 minutes.
Pain (You should not train!)
• Pain that is keeping the athlete awake at night.
• Pain that is evident at beginning of run/walk then becomes worse as run/walk continues.
• Pain that changes the athlete’s running stride.

If Symptoms Reoccur:
• Ice area: 15-20 minutes several times per day.
• Elevate the injured part while icing.
• Rest (at least initially).
• Analyze program for possible causes:
 What did the athlete do differently in training?
 Was there a big mileage jump?
 Significant pace increase?
 Shoes beaten up? Or change in shoe model?
 Change from all treadmill or soft surface to road running?
• Cross-train on non-impact cardio – follow similar minutes that athlete was doing
running/walking (elliptical trainer – 130 + strides/minute).
• Determine plan to return to full program, return to running very slowly.
• Licensed athletic trainer and/or orthopedic referral.

Warning Signs of Overtraining

• Difficulty performing typical workouts for more than a week.
• Excessive fatigue.
• Higher resting heart rate.
• Decreased appetite.
• Sorer than usual muscles.
• Troubled sleeping.
• Irritability.
• Increased perspiration.
• Decreased desire to train.
Sports Health Care
Section: Rehabilitation Guidelines

Section: Muscle Flexibility and Stretching

Purpose:

To provide the licensed athletic trainer with general guidelines for the implementation of a
flexibility (stretching) program for sports therapy patients.

I. DEFINITION OF PROCEDURE:

Flexibility: the ability to move a joint through a series of articulations in a full non-restricted,
pain-free range of motion (ROM).

Stretching: techniques used to lengthen shortened soft tissues at the musculotendinous units to
facilitate an increase in ROM.

Stretching has an impact on both contractile and non-contractile soft tissues. Passive stretching to
the elastic limit can allow these tissues to resume the original resting length. Passive stretching
beyond the elastic limit into plasticity will lead to a greater soft tissue length compared to the
original resting length when the stretch is removed. Prolonged lengthening of the contractile units
of muscle, the sarcomeres, into the plastic ROM progressively leads to increased soft tissue length
due to an increased number of sacomeres in series. Non-contractile units of muscle are ligaments,
joint capsule, and fascia which all consist of collagen and elastin fibers. Prolonged lengthening of
collagen up to its yield point leads to tissue lengthening due to permanent tissue deformation.
Elastin fails without deformation with high loads. The more elastin the tissues contain, the more
flexible the tissues. To avoid damaging soft tissues, healing and remodeling time must be allowed
between periods of stretching.

II. INDICATIONS:

• Essential for establishing normal ROM of joints and soft tissue.

• Important decreasing risk of injury to the musculotendinous unit.
• Prevent contractures and adaptive shortening.
• Combats the effects of prolonged immobilization.
• Optimal flexibility will reduce stresses to surrounding joints and tissues.

III. CONTRAINDICATIONS:

• Around acutely inflamed or infected joints.

• Patients who are already hypermobile.
• Across a joint when a bony block prevents motion
IV. GUIDELINES AND PRECAUTIONS:
• It is optimal to warm up before stretching vigorously.
• To increase flexibility, the muscle must be overloaded or stretched beyond its elastic ROM, but
not to the point of pain.
• Exercise caution when stretching muscles around painful joints.
• Avoid over-stretching ligaments and capsules that surround joints.
• Use caution if history of steroid use.
• Stretching should be performed at least 3 times per week, but between 5 and 6 will yield
maximal results.

Equipment/supplies needed: Occasionally towels, buttress material, or straps are used to fixate or
position a body part.

V. STRETCHING METHODS:

Static Stretch: involves stretching a muscle to the point of discomfort and then holding it at that
point for an extended period of time. Can be held between 3 and 60 seconds. Optimal stretch
time is between 15 and 30 seconds.

Advantages:
• Prolonged low load will best facilitate a long lasting change in ROM.
• Least likely to exceed the limits of the tissue extensibility.
• Requires less energy expenditure.
• Produces minimal muscle soreness.

Proprioceptive Neuromuscular Facilitation (PNF) Stretching Techniques: The first three of

the following techniques incorporate use of the stretch reflex. All muscles contain
mechanoreceptors that when stimulated, stimulate the central nervous system. The muscle
spindles and the Golgi tendon organs are sensitive to changes in length. Muscle spindles
immediately increase muscle tension in response to an increase in length and fire for at least 6
seconds. The Golgi tendon organs over-ride the muscle spindles after 6 seconds and cause reflex
relaxation of the antagonistic muscle allowing extensibility limits to be extended.

1) Hold Relax (HR):

a. Passively move limb until the comfortable end range
b. 6-10 sec sub-maximal isometric contraction of the antagonist (muscle to be stretched)
against resistance
c. This is followed by a concentric contraction of the agonist combined with light pressure
from the licensed athletic trainer for a maximal stretch on the antagonist for 6 - 10 sec
d. Repeat b. and c.
2. Contract Relax (CR):
a. Passively move limb until the comfortable end-range.
b. 6 - 10 sec sub-maximal contraction of the antagonist (muscle to be stretched) isotonically
against the resistance of the licensed athletic trainer.
 c. The antagonist relaxes as the licensed athletic trainer moves the limb passively through as
much ROM as possible returning to end-range for 6-10 seconds.
d. Repeat b. and c.
3. Slow Reversal-Hold-Relax (SRHR), also Contract-Relax-Agonist-Contraction (CRAC):
a. Passively move limb until the comfortable end range.
b. Isotonic contraction of the agonist.
c. Followed by isometric contraction of the antagonist (muscle to be stretched) for 6-10
seconds.
d. Repeat b. and c.
4. Rhythmic Initiation: indicated when tone or muscle spasm is sensitive to stretch.
a. Full PROM into the direction desired
b. Commands are given “Relax let me move you,” followed by “now you do it with me.”
5. Rhythmic rotation: indicated when tone or muscle spasm is sensitive to stretch.
a. Supported full PROM into the direction desired
b. Rotation of the body part alternately in both directions in a slow rhythmic manner around
a longitudinal axis for 10 seconds.
c. The command to “Relax and let me move you.” is given.
d. Once relaxation is achieved, the limb is moved passively or actively into the newly gained
range.

VI. PATIENT EDUCATION:

Pt should be instructed in proper techniques for self-stretching.
Documentation:
• Name of muscle(s) to be stretched.
• Method of stretching.
• Position.
• Length of time stretch maintained.
• Frequency stretch is performed.

Alternatives:
Stretching is more effective when the intramuscular temperature is increased. Tissue heated to
103 degrees Farenheit is optimal and can be achieved through either therapeutic modalities or
low-intensity warm-up exercises.
SECTION V ASSESSMENT AND TESTING
 Section Table of Contents
ASSESSMENT GUIDELINES

T-Test for Determing Return to Activity

Return to Competitive Activity after Knee Surgery
Illinois Agility Testing for Athletes
SEMO Agility Test
Ankle Lunge Test
Hop Test – Functional Assessment
Balance Error Scoring System (BESS:NCAA uses for head injury evaluation)
Shoulder flexibility test
Static Flexibility Test - Shoulder & Wrist
Shoulder flexibility test
Static Flexibility Test - Shoulder & Wrist
Shoulder Instability Tests

Evaluation Recommendations – EBM Studies for Carpal Tunnel

Evaluation Recommendations – EBM Studies for Elbow
Evaluation Recommendations – EBM Studies for Hand Assessment
Evaluation Recommendations – EBM Studies for Back Injury
Evaluation Recommendations – EBM Studies for Head and Neck
Evaluation Recommendations – EBM Studies for Face and Eyes
Evaluation Recommendations – EBM Studies for Dental Care
 Sports Health Care Services

Section: Assessment and Testing

Subject: T-Test for Determine Return to Activity

Purpose:

The T-Test is a test of agility for athletes, and includes forward, lateral, and backward running.

Equipment required: tape measure, marking cones, and

stopwatch
Diagram:
Procedure: Set out four cones as illustrated in the
diagram above (5 yards = 4.57 m, 10 yards = 9.14 m).
The subject starts at cone A. On the command of the
timer, the subject sprints to cone B and touches the
base of the cone with their right hand. They then turn
left and shuffle sideways to cone C, and also touch its
base, this time with their left hand. Then shuffling
sideways to the right to cone D and touching the base
with the right hand. They then shuffle back to cone B
touching with the left hand, and run backwards to cone
A. The stopwatch is stopped as they pass cone A.

Shuffle
ss
Shuffle Shuffle
ss ss

Backpedals
Scoring: The trial will not be counted if the subject crosses one foot in front of the other while
shuffling, fails to touch the base of the cones, or fails to face forward throughout the test. Take the
best time of three successful trials to the nearest 0.1 seconds. The table below shows some scores
for adult team sport athletes.

Males (seconds) Females (seconds)

Excellent < 9.5 < 10.5
Good 9.5 to 10.5 10.5 to 11.5
Average 10.5 to 11.5 11.5 to 12.5
Poor > 11.5 > 12.5

Comments:
Ensure that the subjects face forwards when shuffling and do not cross the feet over one another.
For safety, a spotter should be positioned a few meters behind cone A to catch players in case
they fall while running backward through the finish.

Reliability: the type of surface that is used should be consistent to ensure good test-retest
reliability

Advantages: This is a simple agility test to perform, requiring limited equipment and space.

Disadvantages: Only one person can perform the test at a time.

 Sports Health Care Services

Section: Assessment and Testing

Subject Return to Competitive Activity after Knee Surgery

Purpose:

The intent of these guidelines is to provide the athlete with a framework for return to sports
activity following injury. These guidelines should not take the place of medical advice if attempting
to return to sports following an injury. If an athlete requires assistance in the progression of a
return to sport program they should consult with their primary care physician, surgeon, or
licensed athletic trainer/therapist.

Phase 1: Functional Balance and Core Strengthening

Goals:

• Enhance single leg weight bearing strength at varying angles of knee flexion.
• Improve side to side symmetry in lower extremity running mechanics.
• Improve single leg balance.
• Improve core stability and coordination.

Exercises:

• Lunges
• Single leg squatting exercises
• Treadmill training with a mirror to enhance symmetry in running mechanics.
• Balance activities (level surface, uneven surfaces, soft surfaces).

Criteria to progress to Phase II:

• Able to single leg squat to 60 degrees knee flexion and hold for at least 5 seconds.
• Symmetry in running mechanics on a treadmill (6-10 mph).
• Acceptable single leg balance performance involved extremity compared to uninvolved.

Phase II: Functional Strength

Goals:

• Improve lower extremity strength.

• Enhance force contribution symmetry during bilateral weight bearing activities.
• Enhance single leg landing force.
Exercises:
• High intensity balance training activities.
• Continue lower extremity weight bearing strengthening activities.
• Begin perturbation training.
• Single leg landing activities to improve dynamic muscular control.

Criteria to progress to Phase III:

• Side to side symmetry in peak torque knee flexion and extension.

• Plantar force total-loading symmetry measured during bipedal squat to 90 degrees knee flexion
(less than 20% discrepancy between sides).
• Single-limb peak-landing-force symmetry on a 50 cm hops (less than 3 times body mass and
within 10% in side-to-side measures).

Phase III: Power Phase

Goals:

• Improve single-limb power production.

• Improve lower extremity muscular endurance.
• Improve lower extremity biomechanics during plyometric activities.

Exercises:

• Mid-level intensity double-limb plyometric jumps.

• Low-level intensity single-limb repeated hops.
• Focus on proper technique during plyometric activities.

Criteria to progress to Phase IV:

• Single-leg hop for distance (within 15% on uninvolved side).

• Single-limb crossover triple hop for distance (within 15% on uninvolved side).
• Single-limb timed hop over 6 meters (within 15% on uninvolved side).
• Single-limb vertical power hops (within 15% on uninvolved side).
• Reassessment of tuck jump (either an 80-point score or 15% improvement)

Phase IV: Sport-Specific Symmetry

Goals:

• Equalizing ground reaction force attenuation strategies between limbs.

• Improving confidence and stability with high intensity change of direction activities.
• Improving and equalizing power endurance between limbs.
• Using safe biomechanics (increased knee flexion and decreased knee abduction angles) when
performing high-intensity plyometric exercises.

Exercises:

• Power, cutting and change-of-direction tasks that are modified to the athlete’s individual sport.
• Provide verbal and visual feedback to assist the athlete develop safe biomechanics during
plyometric moves.

Criteria for integration back to sports:

• Drop vertical jump landing force bilateral symmetry (within 15%).

• Modified agility T-Test (MAT) test time (within 10%).
• Single-limb average peak power test for 10 seconds (bilateral symmetry within 15%).
• Reassessment of tuck jump (either an 80-point score or 20% improvement).
 Sports Health Care Services

Section: Assessment and Testing

Subject: Illinois Agility Testing for Athletes

Purpose:

To test running agility - Agility is an important

component of many team sports, though it is not
always tested, and is often difficult to interpret
results. The Illinois Agility Test (Getchell, 1979)
is a commonly used test of agility in sports, and
as such there are many norms available.

Equipment required:

Flat non-slip surface, marking cones, stopwatch, and measuring tape.

Procedure:

The length of the course is 10 meters and the width (distance between the start and finish points)
is 5 meters. Four cones are used to mark the start, finish and the two turning points. Another four
cones are placed down the center an equal distance apart. Each cone in the center is spaced 3.3
meters apart. Subjects should lie on their front (head to the start line) and hands by their
shoulders. On the 'Go' command the stopwatch is started, and the athlete gets up as quickly as
possible and runs around the course in the direction indicated, without knocking the cones over,
to the finish line, at which the timing is stopped.
Results: The table below gives some rating scores for the test

Agility Run Ratings (seconds)

Rating Males Females
Excellent < 15.2 < 17.0
Good 16.1-15.2 17.9-17.0
Average 18.1-16.2 21.7-18.0
Fair 18.3-18.2 23.0-21.8
Poor > 18.3 > 23.0

Advantages:

This is a simple test to administer, requiring little equipment. Also, the player’s ability to turn in
different directions and different angles is tested.

Disadvantages:

Choice of footwear and surface of area can effect times greatly. Results can be subject to timing
inconsistencies, which may be overcome by using timing gates. Cannot distinguish between left
and right turning ability.

Variations:

The starting and finishing sides can be swapped, so that turning direction is reversed.
 Sports Health Care

Section: Assessment and Testing

Subject: SEMO Agility Test

Purpose: Test an athletes ability to maintain balance and agility while performing cutting
movements on a basketball court – free throw lane.

Procedure: Athlete starts at point A and continues through the cone box drill as directed on
diagram.

 Timed test
 Most complete the course in 10-15 sec.
 Average of 3 to 5 trials

Normative Values:
Women’s range from 12.19 to 14.50 sec.
Men’s range from 10.72 to 13.80 sec.
 Sports Health Care

Section: Assessment and Testing

Subject: Ankle Lunge Test

Purpose: Lunge Test – a weightbearing assessment of the ankle joint range which factored in
the individuals body weight.
Procedure:

1. Patient stands against wall with about 10cm between feet and wall.
2. They move one foot back a foot’s distance behind the other.
3. They bend the front knee until it touches the wall (keeping the heel on ground).
4. If knee can not touch wall without heel coming off ground, move foot closer to wall then
repeat.
5. If knee can touch wall without heel coming off ground, move foot further away from wall
then repeat.
6. Keep repeating step 5 until can just touch knee to wall and heel stays on ground.
7. Measure either: a) Distance between wall and big toe (<9-10cm is considered restricted) or
b) The angle made by anterior tibia/shin to vertical (<35-38 degrees is considered
restricted)
8. Change the front foot and test the other side (symmetry is ideal)

It is worth remembering that there are some validity issues with the wall to big toe measurement
with respect to the proportions/ratios between an individual’s leg length and foot length.  Anyone
who is very tall is likely to have the minimum distance required and anyone who is very short will
probably not have the minimum distance; therefore it is generally considered better practice to
use the tibial angle when interpreting the results.

Test Interpretation

A restricted Lunge test essentially suggests there in

increased ankle joint dorsiflexion stiffness. 

The test is generally performed when the patient is

wearing both shoes (to allow for the heel height
differential of the shoe) and if applicable – while
the patient is wearing their orthoses; modifications
are made as required in order to achieve an
appropriate tibial angle.  It may also dictate the
appropriateness of concurrent joint mobilizations
or a soft tissue stretching program.
 Sports Health Care

Section: Assessment and Testing

Subject: Hop Test – Functional Assessment

Purpose: A full weight bearing assessment of the ankle which factored in the individual’s
body weight and the ability of the joint to withstand stress of gravity and ground
force reaction.
Procedure:

The four tests included: 1) figure-of-8 hop, 2) side hop, 3) 6-meter crossover hop, and 4) square
hop. The athlete is allowed to practice the hopping test skills (three trials each) before taking the
test.

The figure-of-8 test involved hopping on one foot in a figure-8 pattern around two cones set five
meters apart (about 15 feet). The pattern was repeated two times as fast as possible.

The side-hop test required the test subject to hop on one foot sideways 30 centimeters (eight
inches) and back 10 times (also as fast as possible).

The six-meter crossover hop test required the athlete to hop over a four-inch wide line from the
right side to the left side and back along a path that was eight feet long.

And finally, in the square hop test, a 10-inch by 10-inch square of tape was placed on the floor.
The subjects had to hop in and out of the square all the way around (clockwise for the right
leg/counterclockwise for the left leg).

Each of the four tests was repeated three times and each trial was timed. The athlete is asked if
the ankle on the hopping side felt unstable during any of the trials.
 Sports Health Care

Section: Assessment and Testing

Subject: Balance Error Scoring System (BESS:NCAA uses for head injury evaluation)

Purpose: The BESS is a clinical test that quantifies balance deficits using three stance
conditions and two surface conditions.
Procedure:

The three stance conditions are double leg, single leg, and tandem stances. The surface conditions
include firm and unstable (medium-density foam) surfaces. All stance conditions are performed
without vision, barefoot, and with the hands on the hips. This test requires individuals to remain
as motionless as possible for 20 seconds for each stance condition, while minimizing the number
of balance errors.

Balance errors for the BESS are more than just foot touches and wobbles. They include:

1. lifting the hands off the hips;

2. moving the thigh into more than 30˚ of flexion or abduction;
3. lifting the forefoot or heel;
4. remaining out of the testing position for more than five seconds;
5. opening of the eyes; and
6. Touching the non-weight-bearing foot to the ground.

Errors committed simultaneously are counted as one error. For example, an individual might touch
a foot to the ground and open the eyes at the same time; although two errors were committed,
both happened at approximately the same time and should be counted as one error. Each stance
condition has an error score, and a total error score for all conditions is calculated at the
completion of testing.

The BESS has been recommended as a useful clinical balance assessment because of its ability to
detect balance deficits associated with FAI. More specifically, individuals with FAI have been found
to commit more errors during single leg stance on firm and foam surfaces and during tandem
stance on foam surface and they have greater total error scores than subjects with stable ankles.

On average, patients with FAI commit 1.3 more errors than individuals without FAI during single
leg balance on firm surface. While this test does not perform as well as the FLT or TBT, it has been
recommended that clinicians consider the single leg stance firm condition of this test for assessing
balance deficits.
 Sports Health Care

Section: Testing and Assessment

Subject: Shoulder Flexibility Test

Purpose Adequate range of motion in the shoulder is important for injury prevention and
athletic performance. This test may help determine a person's risk for future pain
and injury.

Procedure The shoulder flexibility test is a simple measurement of the flexibility and mobility
of the shoulder joint.

How to Perform the Shoulder Flexibility Test

 To test left shoulder flexibility, stand and have the patient raise their
right arm straight up overhead.
 Bend the right elbow and let the right palm rest on the back of the
neck and slide it down the back and between the shoulder blades.
 Have the patient reach behind themselves with their left hand so the
back of their hand rests on the middle of their back.
 Now have them slide the right hand down and the left hand up to try
to touch the fingers of both hands.
 Measure the minimum distance between the fingertips of the right
and left hand. Record any overlap as well.
 Switch the hands to perform the test on the opposite shoulder.

Shoulder Flexibility Test Results

Excellent = Fingers overlap

Good = Fingers touch
Average = Fingers are less than two inches apart
Poor = Fingers are more than two inches apart

American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription, 7th
Edition. Lippincott Williams and Wilkins: Philadelphia; 2006.
 Sports Health Care

Section: Assessment and Testing

Subject: Static Flexibility Test - Shoulder & Wrist

Purpose: The objective of this test is to monitor the development of the athlete's shoulder
and wrist flexibility.
Resources:

To undertake this test will require:

 18" Stick
 Meter Ruler
 Assistant

How to conduct the test

 The athlete warms up for 10 minutes

 The athlete lays prone on the floor, forehead on the ground, and arms extended holding the
18” stick with both hands shoulder width apart
 The assistant measures and records the athlete’s arm length from the acromial extremity to
the stick
 The athlete raises the stick as high as possible whilst  keeping their forehead on the ground
 The assistant measures and records the vertical distance from the ground to the bottom of the
stick
 Repeat the test 3 times recording the vertical distance achieved
 The assistant subtracts the longest recorded vertical distance from the recorded arm length
and the result is used to assess the athlete’s performance

Assessment
For an evaluation of the athlete's performance select the gender, enter the distance and then
select the 'Calculate' button.

Normative data for the Shoulder and Wrist flexibility test (Johnson 1986) [1]

Rating Men Women

Poor >12.50 >11.75
Fair 11.50 -12.50 10.75 - 11.75
Average 8.25 - 11.49 7.50 - 10.74
Good 6.00 - 8.24 5.50 - 7.49
xcellent <6.0 <5.50
Sports Health Care
Section: Assessment and Testing

Subject: Shoulder Instability Tests

Purpose:

Laxity Tests:

 These tests examine the amount of translation allowed by the shoulder starting from
positions where the ligaments are normally loose.
 These are tests of laxity, not tests for instability: Many normally stable shoulders, such as
those of gymnasts, will demonstrate substantial translation on these laxity tests even
though they are asymptomatic.
 The amount of translation on laxity testing is determined by the length of the capsule and
ligaments as well as by the starting position (i.e. more anterior laxity will be noted if the
arm is examined in internal rotation - which relaxes the anterior structures, than if it is
examined in external rotation - which tightens the anterior structures).
 Use the contra-lateral shoulder as an example of what is 'normal' for the patient.

1. Drawer Test

The patient is seated with the forearm resting on the lap and the shoulder relaxed. The examiner
stands behind the patient. One of the examiner's hands stabilizes the shoulder girdle (scapula and
clavicle) while the other grasps the proximal humerus. These tests are performed with (1) a
minimal compressive load (just enough to center the head in the glenoid) and (2) with a
substantial compressive load (to gain a feeling for the effectiveness of the glenoid concavity).
Starting from the centered position with a minimal compressive load, the humerus is first pushed
forward to determine the amount of anterior displacement relative to the scapula. The anterior
translation of a normal shoulder reaches a firm end-point with no clunking, no pain and no
apprehension. A clunk or snap on anterior subluxation or reduction may suggest a labral tear or
Bankart lesion. The test is then repeated with a substantial compressive load applied before
translation is attempted to gain an appreciation of the competency of the anterior glenoid lip. The
humerus is returned to the neutral position and the posterior drawer test is performed, with light
and again with substantial compressive loads to judge the amount of translation and the
effectiveness of the posterior glenoid lip, respectively. (Silliman and Hawkins, 1993)

2. Sulcus Test

The patient sits with the arm relaxed at the side. The examiner centers the head with a mild
compressive load and then pulls the arm downward. Inferior laxity is demonstrated if a sulcus or
hollow appears inferior to the acromion. Competency of the inferior glenoid lip is demonstrated
by pressing the humeral head into the glenoid while inferior traction is applied.
3. Push-Pull Test

The patient lies supine with the shoulder off the edge of the table. The arm is in 90 degrees of
abduction and 30 degrees of flexion. Standing next to the patient's hip, the examiner pulls up on
the wrist with one hand while pushing down on the proximal humerus with the other. The
shoulders of normal, relaxed patients often will allow 50 per cent posterior translation on this test.

Stability Tests

 These tests examine the ability of the shoulder to resist challenges to stability in positions
where the ligaments are normally under tension.

1. Fulcrum Test

The patient lies supine at the edge of the examination table with the arm abducted to 90 degrees.
The examiner places one hand on the table under the glenohumeral joint to act as a fulcrum. The
arm is gently and progressively extended and externally rotated over this fulcrum. Maintaining
gentle passive external rotation for a minute fatigues the subscapularis, challenging the capsular
contribution to the anterior stability of the shoulder. The patient with anterior instability will
usually become apprehensive as this maneuver is carried out (watch the eyebrows for a clue that
the shoulder is getting ready to dislocate). In this test, normally no translation occurs because it is
performed in a position where the anterior ligaments are placed under tension.

2. Crank or Apprehension Test

The patient sits with the back toward the examiner. The arm is held in 90 degrees of abduction
and external rotation. The examiner pulls back on the patient's wrist with one hand while
stabilizing the back of the shoulder with the other. The patient with anterior instability usually will
become apprehensive with this maneuver. As for the fulcrum test, no translation is expected in
the normal shoulder because this test is performed in a position where the anterior ligaments are
placed under tension.

3. Jerk Test

The patient sits with the arm internally rotated and flexed forward to 90 degrees. The examiner
grasps the elbow and axially loads the humerus in a proximal direction. While axial loading of the
humerus is maintained, the arm is moved horizontally across the body. A positive test is indicated
by a sudden jerk as the humeral head slides off the back of the glenoid. When the arm is returned
to the original position of 90-degree abduction, a second jerk may be observed, that of the
humeral head returning to the glenoid.
Strength Tests

The strength of abduction and rotation are tested to gauge the power of the muscles contributing
to stability through concavity compression. The strength of the scapular protractors and elevators
are also tested to determine their ability to position the scapula securely.

Shoulder Abduction

The patient is seated either on a chair with a straight firm back or on a table. The arm is abducted
to approximately 90 deg. with the palm facing down. The subject’s contralateral hand grabs the
side of the table to help stabilize. A downward force is administered by the examiner.

Start Position Final Position

POINTS TO REMEMBER: position the curved plate just proximal to the styloid process on the
dorsum of the wrist, do not impact the arm into the patient's side, and be sure the elbow remains
locked.

CLINICAL PEARL: weakness is apparent in this motion in people with rotator cuff tears and
impingement.
 Sports Health Care

Section: Assessment and Testing

Subject: Evaluation Recommendations – EBM Studies for Carpal Tunnel

Evaluation Recommendations – EBM Studies for Carpal Tunnel

 Symptoms: pain/numbness in hand/wrist/forearm, below the elbow, with altered

sensation often described as numbness or tingling that is primarily in thumb, index, and
middle finger (Katz hand diagram and hypesthesia index finger compared to little finger),
with nocturnal awakening, possible impaired dexterity, and often having to shake the hand
for relief (the Flick sign has a sensitivity of 93% and specificity 96%)
 Tests: Phalen's/Tinel's signs not always useful individually but when combined with the
appropriate history have an increased sensitivity and specificity; also consider Semmes
Weinstein monofilament test, compression testing which can be supplemented by doing
Durkan's compression test. (See Table, "Sensitivity and Specificity of Diagnostic Tests for
Carpal Tunnel Syndrome Measured against Nerve Conduction Studies" in the original
guideline document.)
 Recommended: findings that best distinguish between patients with electrodiagnostic
evidence of carpal tunnel syndrome (CTS) and patients without it are hypalgesia in the
median nerve territory, classic or probable Katz hand diagram results, and weak thumb
abduction strength (but weakness can be difficult to determine). See Table, "Sensitivity and
Specificity of Diagnostic Tests for Carpal Tunnel Syndrome Measured against Nerve
Conduction Studies" in the original guideline document.
 Muscle atrophy: mild weakness of the Thenar muscles (thumb abduction)

Tinel's sign test

Your doctor taps on the inside of your wrist over the median nerve. If you feel tingling, numbness,
"pins and needles," or a mild "electrical shock" sensation in your hand when tapped on the wrist,
you may have carpal tunnel syndrome.

Phalen's sign test

You rest your elbows on a flat surface such as a desk, with your elbows bent and your forearms
up. You then flex your wrists, letting your hands hang down for about 60 seconds. If you feel
tingling, numbness, or pain in the fingers within 60 seconds, you may have carpal tunnel
syndrome.

Two-point discrimination test

This test is used when severe carpal tunnel syndrome is suspected. It is not very accurate for mild
carpal tunnel syndrome. To do the test, your doctor has you close your eyes and then uses small
instruments, such as the tips of two opened paper clips, to touch two points (fairly close together)
on your hand or finger. Typically, you would feel separate touches if the two points are at least 0.5
cm (0.2 in.) apart. In severe carpal tunnel syndrome, you may not be able to tell the difference
between the two touches, so it may feel as though only one place is being touched.

A physical exam with a focus on your neck, arms, wrists, and hands is done if there is tingling,
numbness, weakness, or pain of the fingers, thumb, or hand. The examination is to help determine
whether your symptoms are caused by compression of the median nerve as it passes through the
carpal tunnel in the wrist (carpal tunnel syndrome).

Normal

There appears to be no sign of altered or loss of feeling or strength, or pain in the hand, wrist,
arm, or neck during the physical exam.

Abnormal

Tinel's sign and Phalen's tests produce mild to severe signs of tingling, numbness, loss of feeling or
strength, or pain in the hand.
 Sports Health Care

Section: Assessment and Testing

Subject: Evaluation Recommendations – EBM Studies for Elbow

Initial Diagnosis

 Determine cause: Initial Evaluation:

 Determine the type of trauma (e.g., fall, repetitive motion, twisting, etc.)
 Determine whether the problem is acute, subacute, chronic, or of insidious onset.
 Determine the severity and specific anatomic location of the pain.
 Assess the ability of the patient to use the elbow, from no to full ability.
 Search for any evidence of an open or penetrating wound.
 Test the range-of-motion of the joint (normal, mild restriction, severe restriction).
 Search for any evidence of vascular or nerve injury distal to the injury.
 Determine any present medication.
 Determine any previous medical history, history of systemic disease, previous elbow injury or
disability, job requirements, and hobbies.
 Fracture or dislocation
 Sprain or contusion
 Laceration
 Epicondylitis, medial
 Epicondylitis, lateral
 Olecranon bursitis
 Pronator syndrome
 Ulnar nerve entrapment (Cubital tunnel syndrome)
 Radial nerve entrapment

Fracture or Dislocation of Elbow (35% of cases)

Definitive Evaluation:
Search for any evidence of an open wound in the vicinity of the fracture; if there is an open
wound, treat for infection and examine for the presence of foreign bodies (visual, x-ray, etc.)
 Perform a clinical examination for deformity, tenderness, or ecchymosis, or associated nerve,
neurovascular, or tendon injury. Also look for the inability to perform spontaneous movement of
the elbow.
 Search for any evidence of dislocation and arterial vascular compromise (cold, dusky hand and
forearm with loss of sensation). If found, an immediate reduction should take place (prior to x-rays
if necessary).
 X-ray the elbow. Special views should be obtained when necessary.
 Sports Health Care

Section: Assessment and Testing

Subject: Evaluation Recommendations – EBM Studies for Hand Assessment

Examination

An efficient method for evaluating the hand is to begin with a primary survey, then perform a
secondary survey. Summaries of each examination are given in Tables 1 & 2 below.

TABLE 1
Primary Physical Examination of the Hand and Wrist
Examination technique
While the patient's hand is in the
resting position look for fingers that
are flexed or extended
While patient flexes fingers toward
the palm, check that tips of fingers
point toward the scaphoid
Check for changes in skin color or
ability to sweat
Check capillary refill after applying
pressure to distal fingertip or nail
bed
Check two-point discrimination in
distal fingertip using blunt calipers or
a paper clip
Abnormal result
Flexed finger
Extended finger
Fingers extend normally but overlap
when flexed
Part or all of finger has a different
skin color (blanched or hyperemic)
or lacks ability to sweat
Blanching lasts more than two
seconds
Patient cannot distinguish two
points at least 5 mm apart
Possible pathology
Disrupted extensor tendon
Disrupted flexor tendon
Fracture with rotational deformity of
finger
Digital nerve injury
Microvascular compromise
Neurovascular Compromise

PRIMARY EXAMINATION

The primary survey includes evaluation of passive and active range of motion of the fingers and
wrist while noting the resting position of the hand. Manipulation is not always necessary; much
can be noted about the hand and fingers with simple observation.

TABLE 2
Secondary Physical Examination of the Hand and Wrist
 Examination technique Abnormal result Possible pathology
The patient flexes the proximal IP Patient cannot flex joint Disrupted flexor digitorum
joint of the affected finger while the superficialis
other fingers are kept extended.
The patient extends the distal IP joint Patient cannot flex joint Disrupted flexor digitorum profundus
of the affected finger while the other (i.e., jersey finger)
fingers are kept extended.
The patient extends the distal IP joint Patient cannot extend joint or lacks Fracture of distal phalanx or rupture
of the affected finger. complete joint extension of extensor tendon (i.e., mallet
finger)
The patient shakes hands with the Patient has pain or cannot complete Pathology of distal ulnar joint or
examiner, then attempts to pronate the movement triangular fibrocartilage complex (in
and supinate the wrist while the the absence of radiographic findings)
examiner resists movement.
Locate the small, bony prominence Tenderness Trauma to pisiform
on the ulnar aspect of the palm in the
area of the palmar crease.
After pisiform is located, the Tenderness Fracture of hook of the hamate
physician's thumb IP joint is placed
on the pisiform, and the thumb is
directed toward the patient's index
finger. When the patient flexes the
wrist, the hook of the hamate can be
felt with the tip of the thumb.
Follow the extensor carpi radialis Tenderness Fracture of scaphoid tubercle
tendon distally where it intersects
the palmar crease, then palpate the
small protuberance.
Locate the extensor pollicis longus Tenderness Fracture of distal pole
and abductor pollicis longus, then
palpate the depression between
them (the anatomical snuff-box).
Physician's thumb is placed on Pain Fractured scaphoid
scaphoid tubercle while the wrist is
held in ulnar deviation, then the
patient actively radially deviates the
wrist while the physician exerts
pressure on the tubercle.
Patient's wrist is held in flexion while Pain with clunk Scapholunate instability
the physician resists active finger
extension
Patient's wrist is held in flexion while Pain Parascaphoid inflammation,
the physician resists active finger radiocarpal instability, midcarpal
extension instability

IP = interphalangeal.

A patient's inability to assume the “safe hand” position may suggest a tendon or nerve disruption.
If the hand is immobilized in the safe hand position, extension contractures of the
metacarpophalangeal (MCP) joint and flexion contractures of the IP joints can be avoided. In
normal anatomic position, the thumb is slightly abducted, the MCP joint is at 45 to 70 degrees,
and each of the IP joints is slightly flexed at 10 degrees. Physicians should be alerted to the
possibility of tendon disruption if any of the fingers are not maintained in the position. As the
hand is closed, fingers should point toward the base of the scaphoid. The distal nail tips should
align when the fingers are partially flexed.

Subtle skin changes can alert the physician to possible nerve injury. The hand normally has
moisture on it; absence of moisture on the distal phalanx may indicate a digital nerve injury. The
vascular status of the finger is evaluated by blanching the
fingertip; capillaries should refill within two seconds. Sensory
nerve function of the digits can be evaluated with two-point
discrimination using a paper clip or blunt calipers. The patient
should be able to distinguish two points about 5 mm apart.

Normal anatomic position of the hand (the “safe hand” position).

SECONDARY EXAMINATION

The secondary survey should include tests of the superficialis and profundus flexor tendon of each
finger. With practice, each of the flexor tendons of the fingers can be evaluated. Each digit should
flex independently. The patient should be able to actively flex the distal IP joint, indicating an
intact profundus flexor tendon. The superficialis tendon is evaluated by having the patient flex the
proximal joint of the finger while the remaining fingers are extended. If there is any question of
tendon disruption, a simple test can be performed. In this test, the physician grasps the patient's
forearm approximately 6 to 7 cm from the proximal palmar crease of the wrist and squeezes the
forearm As the forearm is grasped, each of the flexor tendons can be identified by passive flexion
of the patient's corresponding digit. Range of motion of the wrist, as well as any deformity or
swelling, should be noted. Full forced pronation and supination of the hand without pain virtually
eliminates pathology of the distal radioulnar joint or triangular fibro-cartilage complex from
consideration.

Signs of tendon injuries. (Left)

Flexor tendon disruption. (Right) Extensor

tendon disruption.

Palpation of the hand usually starts on the ulnar side. The pisiform can be palpated easily in the
hypothenar eminence just distal to the distal wrist crease on the palmar ulnar aspect of the hand.
To locate the hook of the hamate, the physician places his or her thumb's IP joint on the patient's
pisiform and directs the distal aspect of his or her thumb toward the patient's index finger. When
the patient's wrist is flexed, the hook of the hamate can be felt with the tip of the physician's
thumb. A fracture of the hook of the hamate usually is not apparent on typical radiographic
images of the hand; a carpal tunnel view or computed tomographic scan sometimes is necessary.

Approximate location of the scaphoid bone. In the flexed position, all fingers
should point to the scaphoid.

The flexor carpi ulnaris, the flexor carpi radialis, and the palmaris longus tendons usually can be
observed by having the patient oppose the thumb and fifth finger while flexing the wrist. The
flexor carpi ulnaris inserts on the pisiform. Because 12 to 15 percent of people lack a palmaris
longus tendon, care must be taken not to confuse the flexor carpi radialis for the missing tendon.
The flexor carpi radialis can be seen distally on the volar radial aspect of the wrist as it crosses the
distal palmar crease. In this area, the proximal tubercle of the scaphoid is a prominence that can
be palpated easily. If the thumb is placed on the scaphoid tubercle, four fingers can wrap around
the distal radius while the wrist is held in ulnar deviation. As the patient radially deviates the wrist,
the scaphoid tubercle will volarflex into the physician's thumb. If pressure is directed dorsally with
the thumb, pain may be elicited. This reaction may indicate a fractured scaphoid, or a
scapholunate instability if an associated “clunk” is noted. This maneuver is termed the Watson or
Scaphoid Shift Test

On the dorsum of the wrist, the anatomical snuff-box can be identified easily as the patient
abducts and extends the thumb. The extensor pollicis longus tendon can be identified on the
radial aspect of the wrist by having the patient raise the thumb with the palm pronated on a
surface. The waist of the scaphoid is located just radial in a depression in the wrist. Pain in this
area can be an indication of a scaphoid fracture. The patient's wrist is then held in flexion, and
active finger extension with resistance is tested. Significant parascaphoid inflammation, radial
carpal, or midcarpal instability will cause considerable pain with this maneuver, known as the

Shuck Test
The Watson or Scaphoid Shift Test. (Left) The physician's thumb is placed on the scaphoid tubercle while the patient's
wrist is in ulnar deviation. Pressure is applied dorsally. (Right) The patient radially deviates the wrist. Great pain
indicates ligamentous instability of the wrist between the scaphoid and the lunate.

The triscaphe joint is located by following the dorsal side of the second finger proximally; the
physician's thumb will fall into a recess. The scapholunate joint can be palpated by following the
third finger proximally until the thumb falls into a recess, just distal to Lister's tubercle dorsally.
Lister's tubercle is a small, mast-like protuberance in the center of the distal radius that is
identified by palpating the distal radius while the patient flexes the wrist. The lunate is the most
prominent area on the dorsum of a flexed wrist. Kienböck's disease, a post-traumatic avascular
necrosis of the lunate, is present in up to 20 percent of patients with lunate fractures.

The Shuck Test for

perilunate instability.
(Left) The wrist is held
in flexion by the
physician, and the
patient extends his or
her fingers. (Right) The
physician resists this
movement. Significant
parascaphoid
inflammation, radial
carpal, or mid-carpal
instability may cause considerable pain with this maneuver.

Pathology

Understanding the surface anatomy of the hand and wrist allows the physician to evaluate
common injuries and appreciate less common injuries that might be overlooked on examination.
The scaphoid is the most commonly fractured bone of the wrist. Most of these fractures are
caused by falling on an outstretched hand. Depending on the patient's age, bone density, and
reaction time, this type of fall can result in a fractured scaphoid, scapholunate dislocation, or distal
radius fracture.

Patients with pain over the anatomical snuff-box should be treated for a possible scaphoid
fracture, and a radiograph in what is called the “stretch or navicular view” should be obtained.
This type of fracture carries a high likelihood of nonunion. To prevent supination and pronation of
the wrist, the patient should be put into a long arm cast, or a short arm thumb spica splint or cast
and shoulder sling; a simple palmar splint or “sugar-tong” splint is inadequate.

Patients with negative radiographs should be put into a temporary thumb spica splint for two
weeks. When they are reexamined, another radiograph should be taken. If the patient's wrist is
not tender and the second A gap of more than 3 mm in the scapholunate joint in a symptomatic
patient should alert the physician to consider scapholunate instability until proven otherwise.
radiograph is negative, the patient can be instructed to return only if symptoms recur. If the wrist
is still tender, further evaluation and a surgical consultation are warranted even if the second
radiograph is negative.

A fractured hook of the hamate is a less common injury of the wrist that often is not diagnosed
because it is not apparent on standard radiographic views. This injury may occur when a patient
falls while holding an object, and the object lands between the ground and the ulnar side of the
palm. It also may be caused when a bat hits a ball or a golf club catches the ground, and the
hypothenar eminence is struck. Standard radiographs and a “carpal tunnel” view should be
obtained in patients with tenderness over the hook of the hamate, and the ulnar nerve should be
tested. These patients can be put in an ulnar gutter splint or simple volar splint and referred to a
surgeon, because treatment often requires removal of a bone chip.

The most common ligamentous instability of the wrist occurs between the scaphoid and the
lunate. Patients with injuries of these ligaments often have a high degree of pain even though
initial radiographs may appear normal. A gap of more than 3 mm in the scapholunate joint is
considered abnormal, and a comparison radiograph of the opposite wrist should be obtained.
Physicians should suspect this type of injury if a patient has wrist effusion and pain that is
seemingly out of proportion to the injury. Patients with this type of injury often will not tolerate a
Watson test. These injuries require an immediate consultation but can be stabilized with a thumb
spica splint.
 Sports Health Care

Section: Assessment and Testing

Subject: Evaluation Recommendations – EBM Studies for Back Injury

Differential Diagnosis of Low Back Pain

Condition (prevalence*) Signs and symptoms

Mechanical low back pain (97%)
Lumbar strain or sprain (≥ 70%)
Degenerative disk or facet process
(10%)
Herniated disk (4%)
Osteoporotic compression fracture
(4%)
Spinal stenosis (3%)
Spondylolisthesis (2%)
Nonmechanical spinal conditions (1%)
Neoplasia (0.7%)
Inflammatory arthritis (0.3%)
Infection (0.01%)
Nonspinal/visceral disease (2%)
Pelvic organs—prostatitis, pelvic
inflammatory disease, endometriosis
Renal organs—nephrolithiasis,
pyelonephritis
Aortic aneurysm
Gastrointestinal system—pancreatitis,
cholecystitis, peptic ulcer
Shingles
Diffuse pain in lumbar muscles; some radiation to buttocks
Localized lumbar pain; similar findings to lumbar strain
Leg pain often worse than back pain; pain radiating below
knee
Spine tenderness; often history of trauma
Pain better when spine is flexed or when seated,
aggravated by walking downhill more than uphill;
symptoms often bilateral
Pain with activity, usually better with rest; usually detected
with imaging; controversial as cause of significant pain
Spine tenderness; weight loss
Morning stiffness, improves with exercise
Spine tenderness; constitutional symptoms
Lower abdominal symptoms common
Usually involves abdominal symptoms; abnormal urinalysis
Epigastric pain; pulsatile abdominal mass
Epigastric pain; nausea, vomiting
Unilateral, dermatomal pain; distinctive rash

*— Estimated percentage of patients with this condition among all adult patients with low back
pain in primary care.

“Red Flag” Findings and Evaluation Strategies for Patients with Low Back Pain
 Diagnosis of concern Evaluation strategy*
Cauda
equina Plain
Finding syndrome FractureCancerInfectionCBC/ESR/CRPradiography MRI
Age > 50 years X X 1† 1 2
Fevers, chills, recent urinary X 1 1 1
tract or skin infection,
penetrating wound near spine
Significant trauma X 1 2
Unrelenting night pain or pain X X 1† 1 2
at rest
Progressive motor or sensory X X 1E
deficit
Saddle anesthesia, bilateral X 1E
sciatica or leg weakness,
difficulty urinating, fecal
incontinence
Unexplained weight loss X 1† 1 2
History of cancer or strong X 1† 1 2
suspicion for current cancer
History of osteoporosis X 1 2
Immunosuppression X 1 1 2
Chronic oral steroid use X X 1 1 2
Intravenous drug use X 1 1 2
Substance abuse X X 1 1 2
Failure to improve after six X X 1† 1 2‡
weeks of conservative therapy

CBC = complete blood count; ESR = erythrocyte sedimentation rate; CRP = C-reactive protein; MRI
= magnetic resonance imaging.
note: “Red flag” findings indicate the possibility of a serious underlying condition.
*— 1 = first-line evaluation in most situations; 2 = follow-up evaluation; E = emergent evaluation
required.
†— Prostate-specific antigen testing may be indicated in men in whom cancer is suspected.
‡— Or unnecessary.

Physical Examination Findings in Nerve Root Impingements

 Nerve root Sensory Screening
Herniationaffected loss Motor weakness examination Reflex
L3-L4 disk L4 Medial foot Knee extension Squat and rise Patellar
L4-L5 disk L5 Dorsal foot Dorsiflexion ankle/great Heel walking None
toe
L5-S1 disk S1 Lateral foot Plantarflexion ankle/toes Walking on toes Achilles

Return-to-Work Guidelines for Patients with Acute Low Back Pain

Expected return to
unmodified work with:
Mild
low Severe
back low back
Activity level pain pain Sciatica Typical modified duty
Light work (i.e., mostly sitting, 0 days 0 to 3 2 to 5 No lifting more than 5 lb (2.25
occasional standing and walking, lifting days days kg) three times per hour
and carrying up to 20 lb [9 kg]) No prolonged sitting, standing,
or walking without a five-minute
break every 30 minutes
Medium work (i.e., equal standing, — 14 to 17 21 days —
sitting, and walking; occasional days
bending, twisting, or stooping; lifting
and carrying up to 50 lb [22.5 kg])
Heavy work (i.e., constant standing or Up to 7 35 days 35 days No lifting more than 25 lb (11.25
walking; frequent bending, twisting, or to 10 kg) 15 times per hour
stooping; lifting up to 100 lb [45 kg]) days No prolonged standing or
walking without a 10-minute
break every hour
Driving car or light truck up to
six hours per day; driving heavy
vehicle or equipment up to four
hours per day

Note: Times until return to full duty will vary with severity and role and are typical for ages 35 to
55 years. Times for younger workers are approximately 20 to 30 percent shorter.

Psychosocial Factors Associated with an Increased Likelihood of Developing Chronic Back Pain
Disputed compensation claims
Fear avoidance (exaggerated pain or fear that activity will cause permanent damage)
Job dissatisfaction
Pending or past litigation related to the back pain
Psychological distress and depression
Reliance on passive treatments rather than active patient participation
Somatization

References

SCOTT KINKADE, M.D., M.S.P.H., is an assistant professor of family medicine and director of predoctoral education at
the University of Texas Southwestern Medical School in Dallas. He received his medical degree from the University of
Texas Medical School in Houston. Dr. Kinkade completed a family medicine residency at Martin Army Community
Hospital in Fort Benning, Ga., and a medical education fellowship at the University of Missouri–

SCOTT KINKADE, M.D., M.S.P.H., University of Texas Southwestern Medical School, Dallas, Texas Am Fam
Physician. 2007 Apr 15;75(8):1181-1188.

Sports Health Care

Section: Assessment and Testing

Subject: Evaluation Recommendations – EBM Studies for Head and Neck

Current recommendations from the NCAA® and NATA® indicate that the best practices in
concussion management rely on The Rule of Three:

 A symptoms checklist: Used immediately after the possibility of a concussion as well as in

follow-up settings
 A neurocognitive assessment: Tests attention span, memory, response rates and more
 A BALANCE ASSESSMENT

Recognition and Management

If an athlete exhibits any signs, symptoms, or behaviors that make you suspicious that he or she
may have had a concussion, that athlete must be removed from all physical activity, including
sports and recreation. Continuing to participate in physical activity after a concussion can lead to
worsening concussion symptoms, increased risk for further injury, and even death.

SYMPTOMS REPORTED BY ATHLETE

Headache
Nausea
Balance problems or dizziness
Double or fuzzy vision
Sensitivity to light or noise
Feeling sluggish
Feeling foggy or groggy
Concentration or memory problems
Confusion

When you suspect that a player has a concussion, follow the “Heads Up” 4-step Action Plan.
1. Remove the athlete from play.
2. Ensure that the athlete is evaluated by an appropriate health-care professional.
3. Inform the athlete’s parents or guardians about the possible concussion and give them
information on concussion.
4. Keep the athlete out of play the day of the injury and until an appropriate health-care
professional says he or she is symptom-free and gives the okay to return to activity.

The signs, symptoms, and behaviors of a concussion are not always apparent immediately after a
bump, blow, or jolt to the head or body and may develop over a few hours. An athlete should be
observed following a suspected concussion and should never be left alone.

Grading Concussions
The usefulness of a grading scale has been well established in sports medicine to determine the
severity of a concussion. This practice parameter presents the following grading scale arrived at
by a consensus of experts who reviewed all existing scales, including the recommendations in the
Colorado Medical Society Guidelines.

Grade 1

1. Transient confusion
2. No loss of consciousness
3. Concussion symptoms or mental status abnormalities on examination resolve in less than
15 minutes.

Grade 1 concussion is the most common yet the most difficult form to recognize. The athlete
is not rendered unconscious and suffers only momentary confusion (e.g., inattention, poor
concentration, inability to process information or sequence tasks) or mental status alterations.
Players commonly refer to this state as having been "dinged" or having their "bell rung."

Grade 2
1. Transient confusion
2. No loss of consciousness
3. Concussion symptoms or mental status abnormalities on examination last more than 15
minutes

With Grade 2 concussion, the athlete is not rendered unconscious but experiences symptoms
or exhibits signs of concussion or mental status abnormalities on examination that last longer
than 15 minutes (e.g., poor concentration or post-traumatic amnesia). Any persistent Grade 2
symptoms (greater than 1 hour) warrant medical observation.

Grade 3
1. Any loss of consciousness, either brief (seconds) or prolonged (minutes)

Grade 3 concussion is usually easy to recognize—the athlete is unconscious for any period of time.
Refer to table 1 for details about behavioral features of concussion. A sideline evaluation to
assess the status of the athlete suspected of having a concussion appears in table 3. This
evaluation should be performed by individuals properly trained in the administration of the
examination. Timing of initial management and return to play are outlined in tables 4 and 5.

Sideline Evaluation Mental status testing

 Orientation Time, place, person, and situation (circumstances
of injury)
Concentration Digits backward (e.g., 3-1-7, 4-6-8-2, 5-3-0-7-4);
Months of the year in reverse order
Memory Names of teams in prior contest;
Recall of 3 words and 3 objects at 0 and 5
minutes;
Recent newsworthy events;
Details of the contest (plays, moves, strategies,
etc.)
External provocative
Tests 40-yard sprint;
5 push ups;
5 sit ups;
5 knee bends;
(any appearance of associated symptoms is
abnormal, e.g. headaches, dizziness, nausea,
unsteadiness, photophobia, blurred or double
vision, emotional lability, or mental status
changes)
Neurologic tests
Pupils Symmetry and reaction
Coordination Finger-nose-finger, tandem gait
Sensation Finger-nose (eyes closed) and Romberg

Initial management following On-site evaluation Neurologic evacuation Same day return to
first event Grade play
Grade 1 Yes Not required, but may be Yes if normal sideline
pursued depending on assessment while at
clinical evaluation rest and with exertion,
including detailed
mental status
examination
Grade 2 Yes Yes No
Grade 3 Yes Yes No

Cognitive Rest

A concussion can interfere with school, work, sleep and social interactions. Many athletes who
have a concussion will have difficulty in school with short- and long-term memory, concentration
and organization. These problems typically last no longer than a week or two, but for some these
difficulties may last for months. It is best to lessen the student’s class load early on after the injury.
Most students with concussion recover fully. However, returning to sports and other regular
activities too quickly can prolong the recovery.
The first step in recovering from a concussion is rest. Rest is essential to help the brain heal.
Students with a concussion need rest from physical and mental activities that require
concentration and attention as these activities may worsen symptoms and delay recovery.
Exposure to loud noises, bright lights, computers, video games, television and phones (including
texting) all may worsen the symptoms of concussion. As the symptoms lessen, increased use of
computers, phone, video games, etc., may be allowed.

Return to Play

After suffering a concussion, no athlete should return to play or practice on that same day.
Previously, athletes were allowed to return to play if their symptoms resolved within 15 minutes
of the injury. Newer studies have shown us that the young brain does not recover quickly enough
for an athlete to return to activity in such a short time.

When to return to play after removal from contest Grade of Time until return to play*
concussion
Multiple Grade 1 concussion 1 week
Grade 2 concussion 1 week
Multiple Grade 2 concussions 2 weeks
Grade 3—brief loss of consciousness (seconds) 1 week
Grade 3—prolonged loss of consciousness (minutes) 2 weeks
Multiple Grade 3 concussions 1 month or longer, based on clinical decision of
evaluating physician
*Only after being asymptomatic with normal neurologic assessment at rest and with exercise.

Once an athlete no longer has signs, symptoms, or behaviors of a concussion and is cleared to
return to activity by a health-care professional, he or she should proceed in a step-wise fashion
to allow the brain to re-adjust to exercise. In most cases, the athlete will progress one step each
day. The return to activity program schedule may proceed as below following medical clearance:

Progressive Physical Activity Program

Step 1: Light aerobic exercise- 5 to 10 minutes on an exercise bike or light jog; no
weight lifting, resistance training, or any other exercises.
Step 2: Moderate aerobic exercise- 15 to 20 minutes of running at moderate
intensity in the gym or on the field without a helmet or other equipment.
Step 3: Non-contact training drills in full uniform. May begin weight lifting,
resistance training, and other exercises.
Step 4: Full contact practice or training.
Step 5: Full game play.
Concussion in the Classroom

Following a concussion, many athletes will have difficulty in school. These problems may last from
days to months and often involve difficulties with short- and long-term memory, concentration,
and organization. In many cases, it is best to lessen the student’s class load early on after the
injury. This may include staying home from school for a few days, followed by a lightened schedule
for a few days, or longer, if necessary. Decreasing the stress on the brain early on after a
concussion may lessen symptoms and shorten the recovery time.

What to do in an Emergency

Although rare, there are some situations where you will need to call 911 and activate the
Emergency Medical System (EMS). The following circumstances are medical emergencies:
1. Any time an athlete has a loss of consciousness of any duration. While loss of
consciousness is not required for a concussion to occur, it may indicate more
serious brain injury.
2. If an athlete exhibits any of the following: decreasing level of consciousness, looks
very drowsy or cannot be awakened, if there is difficulty getting his or her attention,
irregularity in breathing, severe or worsening headaches, persistent vomiting, or
any seizures.

Suggested Concussion Management

1. No athlete should return to play (RTP) or practice on the same day of a concussion.
2. Any athlete suspected of having a concussion should be evaluated by an
appropriate health-care professional that day.
3. Any athlete with a concussion should be medically cleared by an appropriate
health-care professional prior to resuming participation in any practice or
competition.
4. After medical clearance, RTP should follow a step-wise protocol with provisions for
delayed RTP based upon return of any signs or symptoms.

Recommendations

Based on the literature review and expert consensus, the following recommendations for return
to competition after concussion should be considered practice options.

Grade 1
If the injured athlete's condition fits the description of a Grade 1 injury as described previously:
1. Remove from contest.
2. Examine immediately and at 5 minute intervals for the development of mental status
abnormalities or post-concussive symptoms at rest and with exertion.
3. May return to contest if mental status abnormalities or post-concussive symptoms clear
within 15 minutes.
4. A second Grade 1 concussion in the same contest eliminates the player from competition
that day, with the player returning only if asymptomatic for one week at rest and with
exercise.

Grade 2
If the injured athlete's condition fits the description of a Grade 2 injury as described previously:
1. Remove from contest and disallow return that day.
2. Examine on-site frequently for signs of evolving intracranial pathology.
3. A trained person should reexamine the athlete the following day.
4. A physician should perform a neurologic examination to clear the athlete for return to play
after 1 full asymptomatic week at rest and with exertion.
5. CT or MRI scanning is recommended in all instances where headache or other associated
symptoms worsen or persist longer than one week.
6. Following a second Grade 2 concussion, return to play should be deferred until the athlete
has had at least two weeks symptom-free at rest and with exertion.
7. Terminating the season for that player is mandated by any abnormality on CT or MRI scan
consistent with brain swelling, contusion, or other intracranial pathology.

Grade 3
If the injured athlete's condition fits the description of a Grade 3 injury as described previously:
1. Transport the athlete from the field to the nearest emergency department by ambulance if
still unconscious or if worrisome signs are detected (with cervical spine immobilization, if
indicated).
2. A thorough neurologic evaluation should be performed emergently, including appropriate
neuroimaging procedures when indicated.
3. Hospital admission is indicated if any signs of pathology are detected, or if the mental
status of the athlete remains abnormal.
4. If findings are normal at the time of the initial medical evaluation, the athlete may be sent
home. Explicit written instructions will help the family or responsible party observe the
athlete over a period of time.
5. Neurologic status should be assessed daily thereafter until all symptoms have stabilized or
resolved.
6. Prolonged unconsciousness, persistent mental status alterations, worsening
postconcussion symptoms, or abnormalities on neurologic examination require urgent
neurosurgical evaluation or transfer to a trauma center.
7. After a brief (seconds) Grade 3 concussion, the athlete should be withheld from play until
asymptomatic for 1 week at rest and with exertion.
8. After a prolonged (minutes) Grade 3 concussion, the athlete should be withheld from play
for 2 weeks at rest and with exertion.
9. Following a second Grade 3 concussion, the athlete should be withheld from play for a
minimum of 1 asymptomatic month. The evaluating physician may elect to extend that
period beyond 1 month, depending on clinical evaluation and other circumstances.
10. CT or MRI scanning is recommended for athletes whose headache or other associated
symptoms worsen or persist longer than 1 week.
11. Any abnormality on CT or MRI consistent with brain swelling, contusion, or other
intracranial pathology should result in termination of the season for that athlete and
return to play in the future should be seriously discouraged in discussions with the athlete.

References
Guskiewicz KM, et al. National Athletic Trainers’ Association position statement:management of sport-related
concussion. Journal of Athletic Training 2004; 39:280-297.
McCrory P, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport
held in Zurich, November 2008. Journal of Athletic Training 2009; 44:434-48.
Kelly JP, Rosenberg JH. The diagnosis and management of concussion in sports. Neurology 1997;48:575-580.
Report of the Sports Medicine Committee. Guidelines for the management of concussion in sports. Colorado Medical
Society, 1990. (Revised May 1991). Class III.
Saunders RL, Harbaugh RE. The second impact in catastrophic contact sports head trauma. JAMA 1984;252:538-539.
McQuillen JB, McQuillen EN, Morrow P. Trauma, sports, and malignant cerebral edema. Amer J Forensic Med Pathol
1988; 9:12-15.
Kelly JP, Nichols JS, Filley CM, Lillehei KO, Rubinstein D, Kleinschmidt-Demasters BK. Concussion in sports: guidelines for
the prevention of catastrophic outcome. JAMA 1991;226: 2867-2869.
Gronwall D, Wrightson P. Cumulative effect of concussion. Lancet 1975;2:995-997.
Jordon BD, Zimmerman RD. Computed tomography and magnetic resonance imaging comparisons in boxers. JAMA
1990;263:1670-1674.
Unterharnscheidt F. About boxing: review of historical and medical aspects. Texas Reports Biol Med 1970;28:421-495.
Fisher CM. Concussion amnesia. Neurology 1966;16:826-830.
Yarnell PR, Lynch S. Retrograde memory immediately after concussion. Lancet 1970;1:863-864.
Hugenholtz H, Richard MT. Return to athletic competition following concussion. Can Med Assoc J 1982,127:827-829.
Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Physician Sports Med 1986;14:75-83.

Additional Resources
Heads Up: Concussion in High School Sports
http://www.cdc.gov/concussion/headsup/high_school.html
Concussion in Sports- What you need to know.
http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000
NFHS Sports Medicine Handbook, 4th Ed, 2011.
 Sports Health Care

Section: Assessment and Testing

Subject: Evaluation Recommendations – EBM Studies for Facial & Eye

Common Facial Injuries

Facial Fractures

Common symptoms of facial fractures include:

 swelling and bruising, such as a black eye
 pain or numbness in the face, cheeks or lips
 double or blurred vision
 nosebleeds
 changes in teeth structure or ability to close mouth properly

It is important to pay attention to swelling because it may be masking a more serious injury.
Applying ice packs and keeping the head elevated may reduce early swelling.

If any of these symptoms occur, be sure to visit the emergency room or the office of a facial plastic
surgeon (such as an otolaryngologist-head and neck surgeon) where x-rays may be taken to
determine if there is a fracture.

Upper Face

When you are hit in the upper face (by a ball for example) it can fracture the delicate bones
around the sinuses, eye sockets, bridge of the nose or cheek bones. A direct blow to the eye may
cause a fracture, as well as blurred or double vision. All eye injuries should be examined by an eye
specialist (ophthalmologist).

Lower Face

When your jaw or lower face is injured, it may change the way your teeth fit together. To restore a
normal bite, surgeries often can be performed from inside the mouth to prevent visible scarring of
the face; and broken jaws often can be repaired without being wired shut for long periods. Your
doctor will explain your treatment options and the latest treatment techniques.

Soft Tissue Injuries

Bruises cuts and scrapes often result from high speed or contact sports, such as boxing, football,
soccer, ice hockey, bicycling skiing, and snowmobiling. Most can be treated at home, but some
require medical attention.
You should get immediate medical care when you have:
 deep skin cuts
 obvious deformity or fracture
 loss of facial movement
 persistent bleeding
 change in vision
 problems breathing and/or swallowing
 alterations in consciousness or facial movement

Bruises

Also called contusions, bruises result from bleeding underneath the skin. Applying pressure,
elevating the bruised area above the heart and using an ice pack for the first 24 to 48 hours
minimizes discoloration and swelling. After two days, a heat pack or hot water bottle may help
more. Most of the swelling and bruising should disappear in one to two weeks.

Cuts and Scrapes

The external bleeding that results from cuts and scrapes can be stopped by immediately applying
pressure with gauze or a clean cloth. When the bleeding is uncontrollable, you should go to the
emergency room.

Scrapes should be washed with soap and water to remove any foreign material that could cause
infection and discoloration of the skin. Scrapes or abrasions can be treated at home by cleaning
with 3% hydrogen peroxide and covering with an antibiotic ointment or cream until the skin is
healed. Cuts or lacerations, unless very small, should be examined by a physician. Stitches may be
necessary, and deeper cuts may have serious effects. Following stitches, cuts should be kept clean
and free of scabs with hydrogen peroxide and antibiotic ointment. Bandages may be needed to
protect the area from pressure or irritation from clothes. You may experience numbness around
the cut for several months. Healing will continue for 6 to 12 months. The application of sunscreen
is important during the healing process to prevent pigment changes. Scars that look too obvious
after this time should be seen by a facial plastic surgeon.

Nasal Injuries

The nose is one of the most injured areas on the face. Early treatment of a nose injury consists of
applying a cold compress and keeping the head higher than the rest of the body. You should seek
medical attention in the case of:
 breathing difficulties
 deformity of the nose
 persistent bleeding
 cuts
 Bleeding
Nosebleeds are common and usually short-lived. Often they can be controlled by squeezing the
nose with constant pressure for 5 to 10 minutes. If bleeding persists, seek medical attention.
Bleeding also can occur underneath the surface of the nose. An otolaryngologist/facial plastic
surgeon will examine the nose to determine if there is a clot or collection of blood beneath the
mucus membrane of the septum (a septal hematoma) or any fracture. Hematomas should be
drained so the pressure does not cause nose damage or infection.

Fractures

Some otolaryngologist-head and neck specialists set fractured bones right away before swelling
develops, while others prefer to wait until the swelling is gone. These fractures can be repaired
under local or general anesthesia, even weeks later.

Ultimately, treatment decisions will be made to restore proper function of the nasal air passages
and normal appearance and structural support of the nose. Swelling and bruising of the nose may
last for 10 days or more.

Neck Injuries

Whether seemingly minor or severe, all neck injuries should be thoroughly evaluated by an
otolaryngologist -- head and neck surgeon. Injuries may involve specific structures within the neck,
such as the larynx (voicebox), esophagus (food passage), or major blood vessels and nerves.

Throat Injuries

The larynx is a complex organ consisting of cartilage, nerves and muscles with a mucous
membrane lining all encased in a protective tissue (cartilage) framework.

The cartilages can be fractured or dislocated and may cause severe swelling, which can result in
airway obstruction. Hoarseness or difficulty breathing after a blow to the neck are warning signs of
a serious injury and the injured person should receive immediate medical attention.

Evaluation of Facial Injury

Evaluation of the facial injuries should follow the principles of trauma evaluation and should begin
with airway, breathing, circulation, and disability. Examinations of vital signs and mental status are
also crucial parts of the initial assessment. After the initial assessment and stabilization, the facial
examination is then performed in a systematic manner with particular attention paid to important
bony landmarks, neurovascular structures, and soft tissues.

Airway

Patients with sports-related facial injuries are usually able to maintain protective oral and
pharyngeal reflexes and can clear their own airway of saliva, blood, or vomitus. Dislodged tooth
fragments, dental appliances, or mandibular structural collapse may compromise the airway and
should be noted. Emergent tracheostomy is seldom needed, even in severe facial fractures, unless
a concomitant injury to the cranium, neck, or chest exists.

Control bleeding

Extensive arterial hemorrhage from facial wounds usually results from injury to the maxillary
artery, the superficial temporal artery, or the angular artery. Direct pressure is usually sufficient
for initial hemostasis, followed by ligation of the bleeding vessel through the wound if it is clearly
visible. If no clear source of bleeding is identified, the airway should be protected, a compressive
facial dressing applied, and the athlete transferred to the nearest acute care center.

Neurologic evaluation 

Every maxillofacial injury should be considered a head injury, and patients with such injuries
should be given the appropriate neurologic evaluation. The unconscious athlete is assumed to
have head and neck injuries, and proper immobilization of the neck and spine should be applied
immediately.

Detailed examination

Once the potentially life-threatening injuries are excluded, any soft tissue injuries and obvious
asymmetries of the facial contour (suggesting underlying bony fractures) are
d(college/school)mented. A detailed examination of the face follows. Each health care provider
should develop a systematic routine in order to provide a thorough examination. A common
approach is starting at the scalp and working down.

Examination of the upper third of the face

Examination of the upper third of the face aims at confirming the integrity of the frontal branch of
the facial nerve and the stability of the supraorbital rims. Having patients elevate their eyebrows is
sufficient to confirm the integrity of the nerve and the frontalis muscle. Lightly touch the forehead
to test for ophthalmic division of the trigeminal nerve. Gentle palpation over the supraorbital rims
that elicits pain, crepitus, or the presence of a step-off suggests underlying fractures. Examine for
laceration and hematoma of the scalp that may indicate underlying skull fracture.

Examination of the middle third of the face

The eyes, the nose, the zygoma, and the maxilla make up the middle third of the face. The
examination of the eyes is the most important, as injuries such as hyphema, ruptured globe, or
retrobulbar hematoma are ophthalmologic emergencies. Initial determination of vision is
imperative; practical methods are to ask the athletes to read the scoreboard or any printed
material. Gross discrepancy of visual acuity is highly indicative of the presence of an injury. The
athletes should be able to close their eyes tightly, which tests for facial nerve and orbicularis
(college/school)li muscles. Have the patients gaze in all directions in an "H" pattern to test the
extra(college/school)lar muscles. Limitation of or diplopia with upward gaze often suggests orbital
floor fractures. Use a penlight to look for pupillary symmetry and light response. Epiphora, pain, or
photophobia may indicate corneal abrasion.

Palpate the infraorbital rims for stability. Look for discrepancy of globe position in the bony orbit
(exophthalmos, enophthalmos, vertical dystopia, and telecanthus), which also suggests fracturing
of the orbit.

Gently press over closed eyelids to feel for the turgidity of the globes. A flaccid (ruptured) or a
tense (proptotic) globe mandates further evaluation by an ophthalmologist. The globe should be
protected with an eye shield during the transfer.

The examination of the nose includes the nasal bone, the septum, and the cartilage. The
prominence of the nose leads to its frequent injuries. Therefore, discerning preexisting deformities
from acute injuries is important. Deviation of the nasal dorsum, epistaxis, and edema should
prompt the examiner to look for septal dislocation and septal hematoma. Failure to identify a
septal hematoma may result in necrosis of the septal cartilage and subsequent perforation and
collapse.

The examination of zygoma looks for flattening of the zygomatic arch and the widening of the mid
face associated with fractures. Viewing the mid face from an inferior view facilitates the detection
of these asymmetries. Lightly touch the malar region to test for dysesthesia of the trigeminal
nerve infraorbital branch.

Abnormal mobility of the maxilla or hard palate can be detected by grasping the anterior maxillary
teeth and firmly attempting to move the maxilla in all directions while stabilizing the forehead.
Examination of teeth occlusion is combined with examination of the mandible.

Examination of the lower third of the face

The lips, tongue, and cheeks are very susceptible to lacerations when compressed against the
dentition. Lacerations involving the vermillion border of the lip require delicate reapproximation
to avoid a visible cosmetic defect. Ask patients to pucker their lips, grin, and show their teeth to
test the facial nerve branches to this area. The oral cavity must be cautiously inspected for the
presence of sublingual ecchymosis, which is the pathognomic sign of a mandibular fracture.

Mandibular injuries are often accompanied by pain, numbness of the jaw and teeth, trismus, and
malocclusion with the maxillary teeth. The inability of an injured athlete to close his or her mouth
should alert the examiner to the possibility of temporomandibular joint dislocation or fracture.
Dentition should be inspected for instability or tooth fracture.
Examination of the ear

The external ears are susceptible to hematoma formation when punched or compressed. If this
hematoma is not evacuated, long-term "cauliflower" deformation occurs. [1] Gross hearing should
be intact to a mere whisper near the ear. The external auditory canals and tympanic membranes
should also be otoscopically inspected for the presence of blood, cerebrospinal fluid, canal
laceration, or tympanic membrane perforation. Any fluid collection in the ear canal or behind the
tympanic membrane may be indicative of underlying fractures of the skull base.

Treatment of Facial Injuries

Universal precautions

Because of the marked vascularity of the face, many facial injuries involve blood and other
secretions. Although the risk of disease transmission from contacting blood with intact skin is
minimal, universal precautions must be followed whenever possible. When contact with blood or
body fluids is likely, gloves, eyewear, and gowns represent standard protective equipment and
should be used. Medical personnel who render care must strive to establish a clean area for
treatment in the midst of the contaminated environment associated with a sports arena.

Contusions and abrasions

Contusions represent injury of the soft tissue layers between the underlying facial skeleton and
the overlying skin and are associated with varying degrees of tenderness, swelling, and
ecchymosis. Keeping the head elevated and applying ice to the affected area for 15-20 minutes
every 2 hours is the mainstay of treatment for facial contusions. These injuries can be expected to
resolve over several days to weeks. Abrasions are partial-thickness losses of skin caused by
shearing forces within the compressed epidermal and dermal layers. Adequate cleansing with an
antiseptic or antibacterial soap followed by twice-daily topical antibiotic ointment is usually
adequate. Patients who have abrasions that do not heal after 14 days or appear to be full-
thickness should be referred to a plastic surgeon for further treatment.

Lacerations

Lacerations represent the most common type of facial injury encountered in the athletic setting.
When blunt trauma occurs over a bony prominence of the facial skeleton, a linear or stellate
laceration may result. The latter is termed a burst-type laceration and, with its jagged skin edges,
repair and a good aesthetic outcome are more challenging.

Because of the abundant blood supply to the facial soft tissues, bleeding from a laceration may be
brisk and copious. Immediate management is directed toward achieving hemostasis by applying
direct pressure over the involved area with a sterile gauze pad. Once hemostasis is obtained,
underlying structures can be seen more easily and should be examined carefully. Facial lacerations
may be adequately cleaned with sterile saline delivered under pressure via an 18-gauge needle
attached to a 20-mL syringe. This adequately removes bacteria and other debris from the wound.
After appropriate cleansing, superficial lacerations without separation of the wound edges may be
closed using adhesive bandages (eg, Steri-Strips) or by applying a skin adhesive. For deeper
lacerations with separated or jagged wound edges, precise alignment and reapproximation by a
plastic surgeon ensures the best functional and aesthetic outcome.

Intraoral lacerations are treated much like skin lacerations. Following thorough irrigation,
reapproximate the intraoral mucosa with absorbable suture material. Because delayed healing
and excessive scar tissue may occur, primarily repair mucosal lacerations, including those of the
tongue, whenever possible.

Although the routine use of antibiotics is not warranted, contaminated wounds may require them.
Determine tetanus immunization status, and administer tetanus toxoid (0.5 mL) when indicated.
For athletes who plan to return to contact sports with a repaired laceration, an adhesive and
adequately padded bandage must be applied to prevent wound disruption.

Nasal bleeding

Most cases of simple epistaxis involve disruption of the Kiesselbach plexus in the anterior chamber
of the nose. This is usually expediently controlled with direct pressure (ie, pinching the nares
together) or the application of a vasoconstrictive spray (eg, oxymetazoline hydrochloride [Afrin],
phenylephrine hydrochloride [Neo-Synephrine]). Brisk nasopharyngeal bleeding may occur from
disruption of the sphenopalatine artery as it enters the lateral wall of the nasal cavity. This
posterior epistaxis requires nasal packing and transfer to emergency centers for further
treatment.

Hematomas

A collection of blood within the muscle, fascial, and dermal layers represents hematomas, which
are generally seen over the zygomatic and periorbital regions. These generally resolve with the
application of ice and compression.

Auricular and septal hematomas deserve special attention because of their potential for
perichondral injury and subsequent necrosis. A septal hematoma appears as a purple, grapelike
swelling from the nasal septum. Incision and drainage followed by anterior nasal packing may
prevent the possibility of septal necrosis, impaired breathing, and altered cosmesis.

An auricular hematoma may result from blunt trauma as might be sustained in a boxing or
wrestling match. It is noted as a firm, ecchymotic collection in the helical portion of the ear.
Treatment is by incision and drainage of the hematoma, closure of incision with fine monofilament
interrupted sutures, and a compressive dressing conforming to the helix and antihelix for 3 days.
Facial Fractures

General Guidelines and Initial Evaluation

Most athletes who sustain facial bones fractures should not return to the game. A second impact
to a facial bone that is already fractured may compound the fracture and convert a simple
nonoperative fracture into a complex and disfiguring surgical challenge.

When evaluating an athlete with a potential facial fracture, the care provider should maintain a
high index of suspicion and promptly refer the patient to a facility that can adequately image and
manage the injury. The following fractures discussed are those most commonly encountered in
sports-related facial trauma.

Nasal Fractures

Because of its prominent location of the face, the nose is the most commonly fractured facial
structure. Nasal fractures account for approximately 50% of sports-related facial fractures; 15% of
those fractures are recurrent. The common perception of the broken nose as
inn(college/school)ous may account for its high rate of undertreatment. However, a poorly
managed acute nasal fracture leads to chronic nasal deformities and, sometimes, breathing
difficulties that may impair the performance of competitive athletes.

Examination and diagnosis

The diagnosis of a nasal fracture is made clinically. The most common findings in a nasal fracture
include epistaxis, swelling and tenderness of the nasal dorsum, bruising around the eyes, and an
obvious nasal deformity. Palpation of the nasal bones can demonstrate mobility, irregular surface,
or crepitus. If the injured athlete reports a nasal obstruction during inspiration, the examiner
should strongly consider a nasal/septal fracture or dislocation.

The intranasal examination should be conducted under proper lighting with a nasal speculum. The
examiner can spray the intranasal structures with a vasoconstrictor such as phenylephrine or
oxymetazoline if that would allow for better visualization.

Treatment

The indications for treatment of nasal/septal injuries by a physician are persistent bleeding and
obvious external nasal deformity. Treat any open wounds with copious irrigation, and apply ice to
minimize swelling. In the sport of amateur boxing, a diagnosis of a nasal fracture is cause for
immediate cessation of the match.

Swelling that occurs over time obscures the deformity and makes acute closed reduction difficult.
If swelling has also occurred, waiting at least 4-7 days for the swelling to subside before treating
the nasal fracture is prudent. Treatment can be limited to a simple closed reduction of the nasal
bones using topical and local anesthesia in a physician's office setting or can be a more involved
open reduction of a fractured or severely dislocated septum in the operating room. The realigned
septum or nasal bones are then splinted externally and internally. The splints are usually removed
in 7-10 days.

Carefully consider the decision to return the athlete to competition and the need for nasal
protection. The nasal bones generally heal sufficiently within 4-8 weeks, allowing the athlete to
return to competition in contact sports. If the athlete resumes competition soon after repair,
strongly recommend that he or she use a protective facial device of sufficient strength to prevent
further injury.

Orbital Fractures

Although common in athletes, eye injuries can almost always be prevented with the use of
protective eyewear. The risk of injury to the eye is highly related to the type of sport. High-risk
sports are those with high-speed projectile objects, clubs, or aggressive body contacts.

Examination and diagnosis

When an injury occurs near the eye, a thorough eye examination should be performed as
described in Evaluation of facial injuries.

A circumferential bony framework protects the vital structures of the orbital complex. The
aperture of the circumferential bony rim does not allow objects with a radius greater than 5 cm to
penetrate to the globe. During the examination, the circumferential bony rim should be palpated.
Fractures of the orbital rim can occur at any point on the rim; however, fractures of the inferior
rim are most common. These fractures can occur independently or in combination with interior
wall fractures; interior wall fractures can also occur alone.

Sometimes a blow to the eye can cause an increase in intraorbital pressure, with or without
fracturing the orbital rim. The thin bones of the orbital floor actually fracture to increase the
volume of the orbit and dissipate the pressure that would otherwise rupture the globe. This
protective fracturing is the so-called orbital blowout fracture. It can manifest with ecchymosis,
enophthalmos, vertical dystopia, and numbness of the area on the ipsilateral cheek supplied by
the infraorbital nerve.

Diplopia upon upward gaze can be due to a restriction of movement of the eye because of
herniation of orbital fat and inferior rectus muscle through the orbital floor or due to swelling or
contusion of the muscle. A facial bone CT scan with coronal views evaluating the floor of the orbit
can help to differentiate the causes. Forced duction test is also helpful in differentiating the causes
of diplopia and gaze limitation. In the forced duction test, the affected eye is anesthetized with a
topical anesthetic, the sclera is grasped with a fine-toothed forceps at the level of the insertion of
the inferior rectus muscle, and the eye is gently moved in a superior and inferior direction. If the
globe moves easily, entrapment of the (college/school)lar contents can be excluded.
Treatment

Absolute indications for surgical repair include noticeable enophthalmos, limitation in

extra(college/school)lar movements, and persistent diplopia due to entrapment of the orbital
contents in the fracture line.

After the injury, if the player returns to competition before 4-8 weeks have passed, strongly
recommend protective facial devices sufficient to prevent reinjury. When protective eyewear has
been used in racquet sports and face protection devices have been used in hockey, eye injuries
have been virtually eliminated.

Zygomaticomaxillary Complex Fractures

The bones of the zygomaticomaxillary complex (ZMC) make up the prominences of the face known
as the cheekbones. Fractures of this bony complex account for approximately 10% of sports-
related facial fractures. The zygomatic bone articulates with the frontal bone, maxilla, temporal
bone, and the wing of the sphenoid, and fractures of this complex usually involve several of these
articulations. This type of fracture typically occurs when significant force is directed at the
prominence of the cheekbone. The bony complex is forced posteriorly and rotates laterally and
inferiorly. Although several attempts have been made to classify the various patterns of ZMC
fracture, the Manson classification system, based on CT scan findings, is possibly the most
straightforward and sensible. The fracture patterns found most commonly on CT scan images are
classified as low-, medium-, or high-velocity. Most sports-related cheekbone fractures are low- or
medium-velocity injuries.

Examination and diagnosis

A thorough examination of the head and neck should be conducted when a ZMC fracture is
suggested. Clinical findings commonly associated with ZMC fractures are periorbital ecchymosis,
numbness in the distribution of the infraorbital nerve over the cheek, enophthalmos, restriction of
movement of the eye upon upward gaze, and depression of the cheekbone with an associated
downward slant of the eye. The medial and lateral canthal tendons that support the eye attach to
the medial and lateral orbital rims, respectively, so that any change in the position of the rim
bones changes the axis of the intercanthal line. Any combination of these signs and symptoms
may be evident. The most accurate and most commonly used radiologic examination to diagnose
and delineate ZMC fractures is a CT scan.

If a cheekbone fracture is suggested, the player should not return to competition and a specialist
should be consulted. If the results of an eye examination are abnormal, an ophthalmologist should
be consulted.
Treatment

Treatment varies depending on the severity of the fracture. If surgical repair is needed, perform it
within 7-10 days to prevent early fracture consolidation. Rigid fixation of these fractures is usually
obtained with titanium miniplates and screws specifically designed to be used on the facial bones,
using surgical approaches that minimize facial scars.

The use of rigid fixation has decreased the need for extended intermaxillary fixation and resulted
in more predictable, stable, long-term results. However, research has shown that rigid internal
fixation is not as strong as the patient's own intact facial skeleton. A similar blow to the repaired
fracture site before the bones have healed puts the athlete at risk for a more severe fracture
pattern than the initial injury, and the risk of damage to the underlying vital structures is
significant. Therefore, strongly recommend that the athlete refrain from practice or competition
for at least 6-8 weeks to allow the fractured bones to heal. Protective facial devices, if properly
constructed, may allow the athlete to return to competition earlier.

Mandibular Fractures

Fractures of the mandible comprise approximately 10% of all sports-related facial fractures.
Results from a recent study in Austria indicate that sports accidents are the most common cause
of mandibular fractures, occurring in 31.5% of the patients in that series.

The mandible is a horseshoe-shaped structure that articulates with the base of the skull at the
temporomandibular joints. It is a strong cortical bone that has several weak areas. It is thin at the
angles, at the neck of the condyles, and at the distal body where the long root of the canine tooth
and the mental foramen are located. Because of the mandible's arched shape and several weak,
thin areas, the mandible commonly fractures in more than one place.

The tongue is attached to the lingual surface of the anterior mandible; therefore, the anterior
segment of a bilateral fracture in the parasymphysial region has the potential to shift posteriorly,
causing the tongue to block the airway. The simple act of pulling the tongue or the anterior jaw
forward can open the airway. The tongue or jaw should be stabilized in this position, and the
athlete should be transported to the emergency department, with proper cervical spine
immobilization if necessary.

Examination and diagnosis

Malocclusion, pain, swelling, difficulty opening the mouth, and intraoral bleeding are the most
common signs and symptoms of a lower jaw fracture. Palpation of the mandible, visible step-offs
between the teeth, and pain upon stressing the mandible also aid in the diagnosis of a fracture.
Panorex view and facial bone CT (combined) are the reliable image modalities for diagnosing even
the smallest mandibular fractures.
The subcondylar regions are the most commonly fractured areas of the lower jaw. These areas are
thinner than the rest of the mandible, and forces generated at impact are transmitted to these
areas. Subcondylar fractures can have devastating, long-term functional and cosmetic sequelae.
The condylar region of the lower jaw is considered a growth center. Fractures of this region in a
younger athlete who has not completed growth can result in a shortened height of the mandible
with associated occlusal problems. Injuries to this region can also result in hemorrhage into the
temporomandibular joint spaces and lead to fibrosis and possibly ankylosis with associated
inability to move the joint.

Treatment

Special referral may be required for adolescent athletes. Prior to the full eruption of permanent
dentition, referral to a craniofacial or pediatric plastic surgeon may be warranted, since the
unerupted teeth are vulnerable to damage with conventional fixation techniques.

Athletes with fractured jaws should not be allowed to return to play until healing has occurred and
they are out of maxillomandibular fixation (which generally takes 6-8 weeks). A protective cage or
helmet with a jaw extension can allow athletes in selected sports to return to competition earlier.

References

The National Guideline Clearinghouse (NGC) on Eye, Face and Nasal Injuries, 2000-04

Work Loss Data Institute. Head (trauma, headaches, etc., not including stress & mental disorders). Encinitas (CA): Work
Loss Data Institute; 2011. Various p.

Scottish Intercollegiate Guidelines Network (SIGN). Early management of patients with a head injury. A national clinical
guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2009 May. 78 p. (SIGN publication;
no. 110).  [143 references]

Sports-Related Facial Trauma, Mimi T Chao, MD; Chief Editor: Al Aly, MD, FACS Medscape 2013
 Sports Health Care

Section: Assessment and Testing

Subject: Evaluation Recommendations – EBM Studies for Dental Care

Dentoalveolar Injuries

As reported by Guyette in 1993, injuries to the mouth are particularly common in team sports.
Results of studies reported in "Best face forward: Athletic facial injuries" published by the
University of Pittsburgh Medical Center indicate that 13-39% of all dental injuries are related to
sports. According to Rampton et al, of these, 80% occur in the area of the 4 anterior maxillary
teeth. Any trauma to the lower face can result in an injury to this dentoalveolar complex.

Lacerations of the lips and intraoral mucosa are frequently associated with injury to the tooth and
its supporting structures.

Examination and diagnosis

Mandibular and maxillary fractures are often associated with dentoalveolar fractures and vice
versa. Injuries to the dentoalveolar structures can include one or all of the components of the
associated structures. As reported by Ranalli, signs and symptoms of dentoalveolar trauma include
intraoral bleeding, tooth malposition, malocclusion, mobility of the affected structures, pain, and
altered sensation of the teeth.

The examiner should always count the athlete's teeth after an injury. If any teeth are missing,
every effort should be made to retrieve them. Teeth may lodge in the surrounding soft tissues
such as the lips and tongue. Teeth also may be lodged in the airway or aspirated into the lungs.
Appropriate airway precautions should be taken and radiographs obtained to exclude these
possibilities. The potential for permanent loss of a tooth is high in more severe injuries.

Dentoalveolar fractures are fractures of the alveolar bone and the associated teeth. The involved
teeth may or may not have associated fractures of the crown or root, or they may be luxated or
avulsed. Treat dentoalveolar fractures as open fractures. A specialist must address tetanus
prophylaxis, antibiotic coverage, and reduction and fixation of the fracture.

Tooth Fractures

Tooth fractures can involve the crown or the root. The most common traumatic injury seen by the
general dentist is the crown fracture. Fractures of the crown in which only the enamel is fractured
do not usually require urgent attention. Treatment for this includes smoothing any sharp edges
and relieving the occlusion of the athlete's tooth.
However, if the fracture involves the neurovascular tissue, these fractures expose the vital nerve
center (pulp) of the tooth and can be quite painful. Treatment includes covering the exposed pulp
of the tooth with calcium hydroxide within 24 hours and acid-etch bonding of the fractured piece
of tooth with a composite resin. If the fractured piece of crown is retrieved, it may be saved by
placing it in water or milk, and it may then be rebonded directly to the fractured tooth by means
of acid-etch bonding or light-cured glass ionomer resin material. This treatment alleviates
discomfort and allows healing to begin.

Root fractures are more difficult to diagnose. They usually occur in teeth that are fully formed. Any
mobility of a tooth, pain upon palpation, or movement suggests a root fracture. The athlete
should be referred to a dentist for dental radiographs, definitive testing of the involved teeth, and
management of these types of injuries.

Tooth Displacement

Luxation, or displacement of a tooth, occurs when the tooth is malpositioned in its bone socket.
Malposition generally indicates some damage to the periodontal ligaments and neurovascular
structures. Treatment for subluxation (loosening) is occlusal adjustment, observation, and vitality
testing. Treatment for luxations (labial or lingual) is repositioning and splinting, with periodic
vitality testing. Treatment for extrusion (partial avulsion) is repositioning and splinting, periodic
vitality testing, and possible root canal intervention. Treatment of luxation and extrusion usually
requires the use of a local anesthetic because manipulation can be quite painful. Lastly, intrusion
of a tooth with incomplete root development, as in a child, is treated by allowing the tooth to re-
erupt. Teeth with complete root development are repositioned and possibly treated with calcium
hydroxide root canal therapy.

Tooth Avulsion

Avulsion is the complete separation of the tooth from the alveolus (socket). This is an urgent
situation. The prognosis for viability of the tooth and successful replantation is inversely
proportional to the length of time the tooth is out of the socket. Treatment principles are to
replant and stabilize the avulsed permanent tooth as quickly as possible. According to the
American Academy of Pediatric Dentistry 2001-2002 Reference Manual, pulp and periodontal
healing are more likely to occur when the permanent tooth is replanted immediately (< 5 min).
General guidelines are replantation within 2 hours. The key to successful replantation is the
continued nourishment and maintenance of the periodontal ligament of the tooth. If the
periodontal ligament fibers become desiccated, necrotic, or are removed as a result of rough
handling, the tooth may undergo resorption or can ankylose to the surrounding bone and may
ultimately be lost. Gentle handling of the root of the tooth at the point where the ligaments are
attached is imperative.

The athletic trainer should not scrub or brush the root of the avulsed tooth; instead, he or she
should gently handle the tooth by its crown and irrigate it with normal saline, if available. If the
tooth cannot be immediately replanted into its socket, it should be cleaned gently and simply
placed in the buccal vestibule of the mouth (between the cheek and gums), and the athlete should
be immediately transported to a dentist.

Rampton et al suggest that if the athlete is unable to hold the tooth this way, the tooth should be
placed in fresh cold milk, sterile saline, or cool tap water. According to the article "Best face
forward: Athletic facial injuries" published by the University of Pittsburgh Medical Center, milk is
an ideal storage medium; mitotic activity in periodontal cells has been maintained for up to 6
hours when a tooth is stored in milk. Commercially available transport systems for avulsed teeth
are also available. Treatment by a dentist involves replanting the tooth into its socket and splinting
the tooth or teeth with acid-etch composite resin in conjunction with orthodontic wire or
reinforced composite fibers.

A diet of soft foods and analgesics should be prescribed for the management of pain. According to
the American Academy of Pediatric Dentistry, antibiotic therapy should be considered and tetanus
immunization status should be addressed. Additionally, often the tooth requires endodontic
therapy (root canal therapy) for ultimate salvage. Generally, primary teeth should not be
replanted because of possible developmental defects of the permanent tooth.

References

THE DENTAL TRAUMA GUIDE: A source of evidence based treatment guidelines for dental trauma, International Association
of Dental Traumatology, et.al. (2013)
 SECTION VI
SUPPORTING MATERIALS AND REFERENCES
 Sports Health Care

Section: Supporting Materials and References

Subject: Care and Cleaning of Your Hydrocollator Heating Unit

Purpose:

To establish guidelines for the maintenance and cleaning of the hydrocollator units in the athletic
training rooms.

Description:

The Hydrocollator is equipped with an immersion type heating element and a hydraulic capillary
type thermostat which evenly maintains the HotPac temperature in the water and provides a
ready supply of heated packs. It is critical to maintain the water level over the top of the HotPac to
avoid damage to the heating element, the stainless steel, or the HotPac. Water is constantly lost
during operation due to evaporation. Therefore, it is essential that water be added daily. The tank
should also be drained and cleaned systematically, at a minimum every two (2) weeks.

Always unplug the unit from its electrical service when emptying or cleaning the unit. Drain unit by
the drain valve located at the bottom rear of the unit. Either move the unit to a floor drain or
attach the extension hose to it when draining.

Your Hydrocollator Heating Unit is made of high quality stainless steel that should last a lifetime.
That is Stainless, not Stainproof steel. You must properly care for your Hydrocollator Heating Unit
if you wish for it to last a lifetime. And it will.

Follow these steps to maintain the Hydrocollator Heating Units:.

1. Chlorine is harmful to stainless steel. No bleach or any cleaner with high chlorine content.
2. Clean the unit on a regular schedule:
 Thanksgiving Break
 Christmas Break
 Spring Break
 Conclusion of May Term – drained and shut down until August 15th

NOTE: Failure to maintain your equipment (including regular cleaning) will void your
warranty.

3. Check and Fill units daily with clean, fresh water. Water is constantly lost during operation
due to evaporation.
4. Chlorine in regular tap water may be present in high enough concentrations to damage
your unit by causing rust. Leaving water in a container overnight will clear chlorine from
water.

If you suspect high levels of chlorine in your Hydrocollator Heating Unit, the manufacturer
recommend the addition of a dechlorinator.

5. Certain additives (such as herbal teas, essential oils, etc.) will damage the components of
the heating unit, including the stainless steel. The Hydrocollator Heating Unit was designed
to heat water and HotPacs only.

To avoid potential for rusting:

1. Do not use bleach or cleaners with high chloride content.

2. Do not use paper clips, safety pins, staples, coat hangers, etc., in or on the unit.
3. Do not clean the unit with steel wool or a carbon steel brush.
4. Do not use abrasive cleaners which tend to disturb the grain in the finish.
5. Water level is critical: Add water daily and keep it full.
6. Do regular cleaning and draining of the tank (every two weeks).
7. Remove all deposits from interior surfaces and parts (including heating element). The
deposits are concentrations of chlorine that allow rusting to begin. If allowed to
accumulate on the heating element, these deposits will lower
the efficiency of the element and increase the power consumption of the unit.
8. If you suspect that you have "hard water," you may need to change your water more
frequently. Salt deposits are an indication of hard water that will eventually cause rust.

Cleaning Tips:

1. The interior of the unit should be scoured, usually every two weeks, using a low abrasive
bathroom cleaner. Check for low or no chlorine content in your cleaner and make sure that
the residue is thoroughly rinsed away with water.
2. A strong solution of vinegar and water will usually dissolve away deposits, which then must
be thoroughly rinsed away with water.
3. To maintain the high luster of the stainless steel exterior, use Hydrocollator Stainless Steel
Cleaner and Polish.

Care of HotPacs

ALWAYS return the Hydrocollator HotPac to the hot water of the heating unit after each
treatment. There it is heated, kept clean and ready for immediate use. The HotPac may be boiled.
However, this hastens the deterioration of the pack. The pack may also be cleaned by scrubbing
the pack with soap and water. The simplified method of keeping the pack clean is to keep it
immersed in water.
The Hydrocollator HotPac, under constant daily use, should have a useful life of at least one year.
When the pack begins to wear out, the filler oozes and leaks through the fabric of the cloth and
sections of the pack appear to be loose and empty and will not retain heat properly. The pack
should be replaced when it reaches this state.

NOTE: If HotPacs are to be stored for extended periods, they may be placed - while wet - in plastic
bags and stored in a freezer.
 Sports Health Care

Section: Supporting Materials and References

Subject: Cleaning of Training Rooms

Purpose:

To establish guidelines for the maintenance and cleaning of the athletic training rooms at the
Gymnasium on the (COLLEGE/SCHOOL) Campus.

Policy:

In order to maintain the physical intergrity and cleanliness of the athletic training room on campus
the licensed profesional staff is responsible to maintain the athletic training rooms and report any
substantial maintenance issues to campus housekeeping and the maintenace department (see
procedure below).

Procedures:

1. Daily routine housekeeping:

a. Fill hydrocollator units with fresh water.
b. Clean tables after each patient use if possible and at end of day.
c. Clean counter tops and dust off container tops and polish faucets/sinks as needed.
d. Empty garbage if needed.
e. Wash towels as needed.
f. Fill drawers in dispenser unit.
g. Clean off cuff weights after use.
2. End of shift cleaning daily and as needed.
a. Sweep or clean floors
b. Clean pillow cases with spray disinfectant
c. Clean up US/EMS units
d. Clean and rinse out whirlpool
e. Clean out water coolers
f. Clean exterior of hydrocollator unit and ice machins with SS Cleaner.
3. Restock supplies as needed:
a. Taping tables
b. Field Kits
c. Cabinets
d. Check cups and paper towel supply
4. Monthly
a. Check paper work and forms
b. Clean equipment cart
c. Clean shelves
Appendix A - Supporting Materials

Head Injury and Concussions (aslo see Team Physician Concensus Statements)

 National Athletic Trainer’s Associationb Position Statement: Management of Sports-Related

Concussion.
 Balance Error Scoring System (BESS)
 SCAT2 – Sports Concussion Assessment Tool
Appendix B - Supporting Materials

Environmental Illness (aslo see Team Physician Concensus Statements)

 National Athletic Trainer’s Associationb Position Statement: Exterional Heat Illnesses

 National Athletic Trainer’s Associationb Position Statement: Fluid Replacement for Athletes
 Inter-Association Task Force on Exertiobnal Heat Illnesses: Concensus Statement
 National Athletic Trainer’s Associationb Position Statement: Environmental Cold Injuries
Appendix C - Supporting Materials

Infection Conttrol and Disease Management

 National Athletic Trainer’s Associationb Position Statement: Community-Acquired MRSA

Infections
 National Athletic Trainer’s Associationb Position Statement: Management of the Athlete
with Type I Diabetes Mellitus
 National Athletic Trainer’s Associationb Position Statement: Sickle Cell Trait and the Athlete
 National Athletic Trainer’s Associationb Position Statement: Steriods and Performance
Enhancing Substances
 National Athletic Trainer’s Associationb Position Statement: Management of Asthma in
Athletes
 USHEW Placacrd – How To Control Things That Make Your Asthma Worse
 Asthma Action Plan
 Management of asthma exacerbations: School Treatment
 Guidelines for the Diagnosis and Management of Asthma 2007
 Steps to Follow for an Asthma Episode in the School Setting When a Nurse is Not Available
 Asthma Action Plan (Sample)
 Colorado Allergy and Asthma Centers: Exercise Inuced Asthma Management in Athletes
 IOC Concensus Statement on Asthma in Elite Athletes
 About Spaces (used with aerosol inhalers)
Appendix D - Supporting Materials

EMERGENCY MANAGEMENT

 What to Do If You See Someone Having A Seizure

 National Athletic Trainers Association Position Statement: Emergency Planning in Athletes
 National Athletic Trainers Association Position Statement: Automated Defibrillators
 National Athletic Trainers Association Concensus Statement: Inter-Association Task Force
Recommendations on Emergency Prepardedness and Management of Sudden Cardiac Arrest
in High School and College Athletic Programs
 National Athletic Trainers Association: Inter-Association Task Force for Appropriate Care for
the Spine-Injured Athlete
Appendix D - Supporting Materials

SAFETY AND RISK MANAGEMENT

 National Athletic Trainers Association Position Statement: Ligthening Safety for Athletics and
Recreation
 Athletics Program Risk Checklist
 Safety Quarterly Highlight – Facility and Emergency Planning
 Safety Quarterly Highlight – Planning for Meet Safety
 Safety Quarterly Highlight – Facilty Safety Audit
Appendix E - Supporting Materials

PSYCHOSOCIAL ISSUES

 National Athletic Trainers Association Position Statement: Preventing, Detecting and Managing
Disordered Eating in Athletes
Appendix F - Supporting Materials

TEAM PHYSICIAN RESOURCES

 Team Physician Consensus Statement

 AAOS – Sideline Preparedness for Team Physician: Conesus Statement
 Selected Issues in Injury and Illness Prevention and the Team Physician: Conesus Statement
 Psychological Issues Related to Injury in Athletes and Team Physician: A Consensus Statement
 Concussion (Mild Traumatic Brain Injury) and the Team Physician: Consensus Statement
 Mass Participation Event Management for the Team Physician: Consensus Statement
 Female Athletes Issues for the Team Physician: A Consensus Statement
 The Team Physician and Return to Play Issues: A Consensus Statement
 The Team Physician and Conditioning of Athletes for Sports: A Consensus Statement
 A Consensus Statement on Overtraining In Athletes