Solar protection in athletes

Sports MedicineF O R T H E P R I M A R Y C A R E P R O V I D E R

SUMMER 2013

Solar protection in athletesBY GALEN FOULKE, M.D., AND DAVID SHUPP, M.D.

Dear Health Care Provider,

My name is Matthew Silvis. I am medical director of primary care sports medicine at Penn State Hershey. I have enclosed the summer edition of our Primary Care Sports Medicine Newsletter, a biannual newsletter of seasonal sports topics. We hope you find the information useful, and would appreciate any feedback you have to enhance our efforts. We have selected a variety of topics for this issue. Our guest writers are David Shupp, M.D., and Galen Foulke, M.D. Dr. Shupp is board-certified in both internal medicine and dermatology, and practices in State College, Pennsylvania. Dr. Foulke is a first-year dermatology resident particularly interested in autoimmune and medical dermatology. If you’d like to receive this newsletter by email, please send your email address to my administrative assistant, Jeanne Laicha at [email protected]. Please send any future topic ideas to Jeanne or myself at [email protected].

Enjoy the sunshine,

Matthew Silvis, M.D.ASSOCIATE PROFESSORPENN STATE HERSHEY FAMILY AND COMMUNITY MEDICINE PENN STATE HERSHEY ORTHOPAEDICS AND REHABILITATIONPENN STATE MILTON S. HERSHEY MEDICAL CENTER

Skin cancer was probably far from kicker John Bruno’s mind as he played a pivotal role in the Nittany Lions’ dramatic National Championship victory over Miami in 1986. However, the affable record-holding kicker, well known for his pre-game antics before the Fiesta Bowl, developed malignant melanoma at age 26, and tragically died one year later. More recently, a 20-year-old Nittany Lion softball player visited Penn State Hershey Dermatology for a stubborn pink papule on her nose. Shocked by her diagnosis of basal cell carcinoma, she related years of chronic sun exposure from games, practice and other outdoor activities.

The road to collegiate athletics is long, requiring intense focus and years of preparation. For athletes participating in sports like football or softball, this translates to long hours of practice outdoors, often during mid-day when ultra-violet radiation (UVR) is at its peak intensity.

Though much effort is focused on preventing traumatic injury such as concussions, little attention is given to the increased risk of skin cancer posed by chronic UV exposure.

Skin cancer is far and away the most common malignancy in humans, occurring more frequently than all other cancers combined. Basal cell carcinoma has the highest incidence, with 2 to 3 million new cases each year. Squamous cell carcinoma will strike between 250,000 and 500,000 with several thousand dying from extensive disease. Malignant melanoma is rapidly increasing in incidence, and approximately 80,000 new cases will be identified this year with 9,000 subsequent deaths. Tragically, these occurrences are preventable, and it is estimated that 90 percent of skin cancers are the result of chronic UVR exposure.

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Athletes and EKG screeningBY MATTHEW SILVIS, M.D.

You have been reading about EKG screening of athletes recently and question whether this process should begin in your local school district. You wonder, what are the pros and cons of EKG screening?

More than 6 million high school, 500,000 collegiate, and 5,000 professional athletes participate in organized sports each year in the United States. Athletes have two and a half times the risk of sudden cardiac death (SCD) as age-matched, non-athletic peers. Given the significant impact of SCD, there is now a heightened interest in preventive strategies, such as pre-participation cardiovascular screening.

Currently, the American Heart Association (AHA) endorses twelve screening recommendations (eight questions, four physical examination findings) as part of the pre-participation evaluation (PPE) of athletes. SCD is rare in athletes but unfortunately is the first manifestation of cardiac disease in 60 to 80 percent of cases limiting this approach (majority of athletes with SCD had no red flag symptoms or signs). Screening with vital signs (blood pressure, heart rate, body

habitus) has also not been shown to be predictive of SCD. Given these limitations, incorporating screening EKGs into the PPE has been suggested as an approach to determine which athletes are at risk for SCD.

In Italy, all athletes are mandated to have a complete physical examination, screening twelve lead EKG, and four minute step test performed by sports physicians with four years of extra training in sports cardiology. After instituting this approach thirty years ago, there has been more than a 90 percent decrease in SCD. However, critical review of the Italian data demonstrates a variety of limitations: observational study (not randomized), no separate comparison of usual care (AHA recommendations) versus EKG screening, best SCD rate after screening in Italy for the past thirty years approximates the SCD rate in the United States currently, high false positive rate for EKGs (5 to 10 percent) which leads to further testing (expensive, anxiety provoking), lack of trained providers to read pediatric

EKGs in the United States, and disease prevalence differences (hypertrophic cardiomyopathy is the number one reason for SCD in the United States versus ARVC in Italy).

One of the key aspects in mandating any screening test is a general understanding of incidence. Unfortunately, we have a very poor understanding of the true incidence of SCD in the United States (1:23,000 to 1:300,000 cited) and currently no national registry. We also don’t understand the natural history of detected cardiac disorders and the potential health consequences of disqualification.

For now, the debate on EKG screening in the United States continues. The future of EKG screening will be determined after further research focused on improving false positive rates (mildly abnormal EKG findings are common in athletes), accurately determining the incidence of sudden cardiac death, equipping family physicians and pediatricians to read pediatric athlete EKGs, and performing natural history studies. Stay tuned!

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New studies present alarming trends in sun exposure in athletes. Data show that up to 88 percent of outdoor athletes practice and compete outside seven months per year. During this time, the majority of athletes are outside three or more hours per day, most often during peak UVR hours. Worse, evidence reveals that most athletes (perhaps as high as 85 percent) do not use any sunscreen while competing or practicing. Combined with sweating, which reduces the stratum corneum’s ability to scatter light

and UVR, it’s no surprise that almost 90 percent of athletes report sunburn in the last year.

Chronic sun exposure is the single most important risk factor for developing skin cancer, and it is readily modified. There is insufficient awareness of the additional risk outdoor training is placing on athletes. Change can begin with education. There is good evidence that counseling from coaches has impressive influence over athlete behavior in preventing high-risk behaviors (i.e. binge drinking and eating disorders).

This influence could be leveraged to include solar protection counseling. Athletes need to be educated on the risks of skin cancer and photodamage, along with strategies for UVR protection. These include special clothing, avoiding peak hours of UVR, and sunscreen. Sunscreen should have a sun protection factor (SPF) of at least 30, and needs to be reapplied every two hours. Just like shoulder pads and helmets, adequate solar protection allows athletes to compete safely and promote long-term health.

BY BRET JACOBS, D.O.

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Fitness Tips for the Golfer

Golf is a popular sport reaching more than 27 million participants in the United States and 50 to 60 million participants worldwide. Golf transcends age and can be played by anyone in their early years and even late in life. It is feasible for someone to play golf for fifty years or more. Golf is not as physically demanding as other sports, but is a great way to stay active and satisfies the Surgeon General’s recommendations for low-intensity exercise.

Studies show 60 percent of professional and 40 percent of amateur players sustain an injury from golf each year. In 2007, golf injuries accounted for approximately 53,000 emergency room visits. The most common areas injured include the low back (muscle strain, muscle spasm, disc herniation), shoulders (bursitis, tendonitis arthritis), elbows (medial and lateral epicondylitis), and wrist (sprains, tendonitis). Injuries can be related to overuse, poor technique, poor flexibility, poor conditioning, or a combination of these factors.

Most amateur golfers do not regularly train for the golf season. Most have a relatively sedentary off-season, and then rush to the driving range with the first hint of warm weather. They generally omit a good warm-up and take little or no rest between shots. Surveys show 80 percent of golfers spend fewer than ten minutes warming up before play. Lower handicap golfers are twice as likely to spend more than ten minutes for warm-up before playing.

The golf swing is a complex motion requiring the activation and movement of most of the major muscle groups and joints in the body. If the body is not prepared, the golfer is at risk for injury. Golfers can benefit from a fitness program focused on flexibility, strength, and endurance. Below are some suggestions to help golfers prepare in the off-season.

Flexibility

Good flexibility is necessary for a fluid golf swing. A daily routine of stretching, both on and off the course, can be beneficial. A routine focusing on the neck and upper extremities can easily be adapted to a good warm-up regimen. Start with neck and shoulder rolls; then stretch the back and shoulders. Hold a golf club at both ends and raise it over the head, then do some trunk rotations and side bending. Grab the club at both ends behind the back to stretch the shoulders.

The shoulders can also be stretched by grabbing opposite elbow and pulling arm across the body until a stretch is felt. Stretch the forearms by reaching straight out with elbow extended and palm up, grasp the hand and extend the wrist to stretch forearm flexors. Next, with elbow in same position, rotate hand so palm is down, then flex the wrist to stretch forearm extensors. Each stretch position should be held for twenty to thirty seconds and repeated two to three times. Now take a club and take several practice swings focusing on form and swing technique.

Strength

Weight lifting and resistance training is also beneficial. A well-developed program for the trunk and core should be the foundation for any strengthening program for golf. This routine should also have exercises for the upper and lower extremities. Each exercise should include three sets of twelve to fifteen repetitions.

Endurance

Golfers should not neglect cardiovascular fitness. Walking eighteen-holes of golf is the equivalent of walking about three miles. Aerobic endurance can be developed with a walking routine or using a stationary bike. Endurance training not only improves cardiovascular fitness, but decreases risk of and recurrence of low back pain, which is highly prevalent in golfers.

All injuries cannot be prevented with a fitness program and warm-up routine. It may be necessary to consult a professional golf instructor to improve set-up and swing mechanics, which could lead to injury. While on the range or on the course, players should try to think about their posture, swinging smoothly, and not over-swinging. These things can help prevent injury and improve performance.

4U.Ed. MED 13-8988 FAM

BY ROBERT KELLY, P.T., A.T.C.

The goal of the rehabilitation specialist is to help patients safely return to sports as quickly as possible, while minimizing the risk of re-injury. Many of our patients are referred to physical therapy to address soft tissue injuries, both acute and chronic. After the acute phase of injury, the goal of physical therapy is to provide mechanical stress to the injured tissue to promote optimal healing and eliminate soft tissue restrictions, which may cause persistent pain and compromised function.

One such therapeutic intervention to treat soft tissue injuries is instrument-assisted soft tissue mobilization. This approach utilizes instruments made from stainless steel, synthetic, or natural materials to provide mechanical forces to soft tissue to release myofascial restrictions and fibrotic tissue. Providing a mechanical force to the soft tissue is also theorized to improve alignment and strength of new collagen and regenerate degenerated or incompletely healed soft tissue.

The Graston Technique is a form of instrument-assisted soft tissue mobilization which uses six patented stainless steel instruments to evaluate and treat soft tissue restrictions. This technique has expanded on the concept of transverse tissue massage originally made popular by James Cyriax, M.D. The stainless steel instruments amplify the feel of soft tissue restrictions, aiding in the detection of restrictions at the injury site, as well as along the kinetic chain. By using various strokes, varying pressure, and incorporating muscle activity and joint movement during treatment, the clinician can release scar tissue and myofascial restrictions. Physiologically, the Graston Technique also recreates the normal inflammatory response leading to a more aggressive healing response including fibroblastic proliferation.

Instrument-assisted soft tissue mobilization, including The Graston Technique, is used as an adjunct to other forms of mechanical

therapy. Instrument-assisted soft tissue mobilizations are followed by therapeutic exercises including stretching, and eccentric and high-repetition strength training to promote maximal tissue mobility and strength.

Examples of soft tissue injuries that can be successfully treated with The Graston Technique and other myofascial release techniques, include lower extremity injuries such as plantar fasciitis, achilles tendinosis, patellar tendinosis, and iliotibial band syndrome. Patients with upper extremity injuries such as tennis elbow and rotator cuff tendinopathy, patients with lumbar and cervical injuries—including those with muscle spasms, and patients with postoperative scarring with myofascial restrictions also may benefit from this approach.

Most injuries require repeated treatments over three to six weeks for maximal benefit, although it is not uncommon for patients to experience significant improvement in just one or two treatments. Treatments are always combined with daily home exercises which may include self myofascial release techniques, frequent stretching, and progressive resistive exercise.

PRIMARY CARE SPORTS MEDICINEMatthew Silvis, M.D. [email protected] Associate Professor, Departments of Family and Community Medicine and Orthopaedics Medical Director, Primary Care Sports MedicinePenn State Hershey Medical Group—Palmyra, 717-838-6305 Penn State Hershey Bone and Joint Institute, 717-531-5638

Bret Jacobs, [email protected] Professor, Departments of Family and Community Medicine and OrthopaedicsPenn State Hershey—Middletown, 717-948-5180Penn State Hershey Bone and Joint Institute, 717-531-5638

Cayce Onks, [email protected] Professor, Departments of Family and Community Medicine and OrthopaedicsPenn State Hershey—Camp Hill, 717-691-1212Penn State Hershey Bone and Joint Institute, 717-531-5638

George Pujalte, [email protected] Professor, Department of Family and Community Medicine and OrthopaedicsPenn State Hershey Medical Group—Fishburn Road, 717-531-8181 Penn State Hershey Bone and Joint Institute, 717-531-5638

Andrew Wren, D.O. [email protected] Associate Professor, Department of Family and Community Medicine Medical Director, Penn State Hershey Medical Group— Elizabethtown, 717-361-0666

ORTHOPAEDIC SPORTS MEDICINEKevin Black, M.D. [email protected] Professor and C. McCollister Evarts Chair Penn State Hershey Orthopaedics Penn State Hershey Bone and Joint Institute, 717- 531-5638

Robert Gallo, [email protected] Professor, Penn State Hershey OrthopaedicsPenn State Hershey Bone and Joint Institute, 717-531-5638

Scott Lynch, [email protected] Professor, Director of Sports Medicine ServicePractice Site Clinical Director of Adult Bone and Joint Institute Associate Director of Orthopaedic Residency Education, 717-531-5638 Penn State Hershey Bone and Joint Institute, 717-531-5638

SPORTS MEDICINE PHYSICAL THERAPYRobert Kelly, PT, ATC Physical Therapist, Certified Athletic Trainer Team Physical Therapist, Hershey Bears Hockey Club

Scott Deihl, ATC, PTAPhysical Therapist Assistant, Certified Athletic Trainer

Tanya Deihl, ATC, PTAPhysical Therapist Assistant, Certified Athletic Trainer, Athletic Trainer, Annville Cleona High School

John Wawrzyniak, MA, ATC, PT, CSCS Physical Therapist, Certified Athletic Trainer Strength & Conditioning Specialist, Hershey Bears Hockey Club

Treating Soft Tissue Injuries: A Hands-On Approach