Contraindications to Athletic Participation: Spinal, Systemic, Dermatologic, Paired-Organ, and Other Issues
James L. Moeller, MDTHE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 9 - SEPTEMBER 96
This is the second of two articles on contraindications to athletic participation. The first, on cardiac, respiratory, and central nervous system conditions, appeared in the August issue.
In Brief: Physicians perform a delicate balancing act when they weigh a patient's medical condition against the safety of sports participation. This article, the second of a two-part series on contraindications to activity, examines the sensory, spinal, gastrointestinal, systemic, hematologic, and dermatologic conditions that warrant activity disqualification and provides guidelines about when it's safe to participate. Also discussed are activity considerations for patients who have lost a paired organ.
This second and concluding article on contraindications to athletic participation addresses various medical problems, orthopedic disorders of the spine, and controversies regarding the loss of a paired organ. Regardless of the condition in question, the recommendations presented here are not hard-and-fast rules; decisions about the safety of sports participation should be made case by case. Most of the recommendations refer to classes of sports, which are listed in table 1 (not shown) (1).
Detached retina. A detached retina warrants disqualification from contact and strenuous noncontact sports. Even after surgical correction, patients should be disqualified from these activities because of the risk of redetachment and blindness (2).
Severe myopia. For safe participation, especially in collision and contact sports, corrected vision should be better than 20/40 (3). However, under adequate supervision, many people who are blind may participate in certain limited-contact and many noncontact sports.
Severe hearing loss. Hearing may help athletes anticipate or avoid contact, and some experts argue that athletes who have profound hearing loss risk injury when competing with normal-hearing athletes. However, an increased injury risk has not been proved (2). Athletes who have hearing impairments may be disadvantaged when the start of an event depends on auditory signals such as a whistle or a gun.
There are several back conditions that may limit sports participation. When considering whether a sport is appropriate for a patient who has a back problem, it's important to consider the types of motions involved and the degree of stress to which the patient's back will likely be subjected.
Spondylolysis. In younger athletes, spondylolysis is usually due to a stress fracture of the pars interarticularis (4,5), though it may result from an acute fracture (5). Sports most often implicated in pars injuries involve weight-loading, rotation, or back-arching (4). Compared to a spondylolysis prevalence in the general population of 5%, the prevalence in divers is 63%; weight lifters, 36%; wrestlers, 33%; gymnasts, 32%; and track and field athletes, 23% (4).
Asymptomatic patients may participate fully in athletics. Activity should be restricted if pain is present, especially if the activity requires extension and hyperextension of the spine. Flexion exercises should be incorporated in the treatment regimen (4). If pain persists despite conservative treatment, immobilization and activity restriction for 6 to 12 weeks should be considered (5). Surgery may be necessary for some patients (4,5).
Spondylolisthesis. This entity is defined as the forward slippage of one vertebral body in relation to the one below it. The severity grade depends on the percentage of slippage; grade 1 spondylolisthesis represents at least 25% slippage; grade 2, 50%; grade 3, 75%; and grade 4, 100% (6). The percentage of slippage is determined by dividing the sacrum (or inferior vertebral body) as visualized on a lateral radiograph into quarters and assigning the grade according to the fraction of slippage of the superior vertebral body on the inferior segment.
Patients may be asymptomatic or have intractable back pain. Asymptomatic patients who have less than 25% slippage may participate fully in athletics. Symptomatic patients who have a grade 1 spondylolisthesis should be restricted from vigorous activity until pain and muscle spasm subside. Patients who have grade 2 or higher spondylolisthesis should avoid vigorous high-risk sports, including gymnastics, diving, and contact sports. Surgery should be considered if the condition is grade 3 or higher (6).
Cervical spine instability. Patients who have cervical spine instability should be disqualified from contact/collision sports and limited contact/impact sports (7,8). They should also be disqualified from certain swimming activities: butterfly and breast strokes and diving starts.
Atlantoaxial instability is very common in athletes who have Down syndrome. In 120213, the Special Olympics began requiring screening radiographs of the cervical spine for athletes who have Down syndrome (9). In 120214, the American Academy of Pediatrics (AAP)10 stated that Down syndrome patients who participate in sports posing a risk of head and neck trauma should undergo lateral-view plain radiography in neutral, flexion, and extension before training or competing. This recommendation applied to all participants in high-risk sports (ie, gymnastics, diving, pentathlon, butterfly stroke in swimming, diving starts in swimming, high jump, and soccer) who had not previously had normal radiographic findings. Patients who have no evidence of atlantoaxial instability could participate in all sports. Follow-up was not required unless the patient developed musculoskeletal or neurologic signs and symptoms. But recently, after reviewing the data that led to those recommendations, the AAP determined that the screening value of cervical spine radiographs is uncertain and withdrew the recommendations (9). The Special Olympics, however, has not removed its requirement that all athletes with Down syndrome receive screening radiographs of the cervical spine.
Functional cervical spine stenosis. In patients who have functional cervical spine stenosis, the cervical spinal canal is so small that it obliterates the protective cushion of cerebrospinal fluid around the spinal cord or deforms the spinal cord. Magnetic resonance imaging (11-13) and computed tomography myelogram (11) are more sensitive than plain films for this condition. Functional cervical stenosis contraindicates participation in contact and collision sports (11-13).
Spear tackler's spine. Described by Torg et al (14), spear tackler's spine is an absolute contraindication to collision sports. The condition involves (a) developmental stenosis of the cervical canal, (b) persistent straightening or reversal of the normal cervical lordotic curve, (c) post-traumatic radiographic abnormalities of the cervical spine, and (d) documented use of spear tackling techniques.
Herniated disc with cord compression. Because the risk of permanent neurologic injury is greatly increased, athletes who have a herniated disc with cord compression should not compete in contact sports. This holds true for both cervical and lumbar cord compression (13).
Hepatomegaly and splenomegaly. Normally, the liver and spleen are protected by the rib cage, but conditions that produce liver or spleen enlargement make the organs vulnerable to injury in contact sports because they are no longer protected. When an athlete has hepatomegaly or splenomegaly, the cause needs to be determined. Those who have hepatomegaly should avoid contact sports until the liver has returned to its normal size or is nonpalpable. Patients who have splenomegaly should avoid contact and strenuous noncontact sports until the spleen has returned to normal size or is nonpalpable (2). Certain conditions such as active hepatitis and infectious mononucleosis contraindicate participation even if the organ has returned to its normal size. The usefulness of serial measurements of the spleen by ultrasound is controversial; the spleen may be significantly enlarged but completely protected by the rib cage.
Active hepatitis. Active hepatitis may cause hepatomegaly, which can increase the risk of liver injury, as mentioned above. A position statement (15) from the American Medical Society for Sports Medicine (AMSSM) and the American Orthopaedic Society for Sports Medicine states that acute hepatitis B infection should be viewed like other viral infections, and that activity recommendations should be based on clinical signs and symptoms such as fever, fatigue, or hepatomegaly. The statement points to a lack of evidence that intense, highly competitive training is a problem for the acute or chronic asymptomatic hepatitis B carrier.
Inguinal hernia. Patients who have small inguinal hernias may participate in all sports. Surgical repair should be considered for patients who have large or symptomatic inguinal hernias because of the increased risk of incarceration and strangulation of herniated tissue (2).
General Illness Questions
Certain systemic metabolic or infectious conditions have activity-limiting implications. Except for Marfan syndrome, exercise is generally safe as long as the condition is under control or has been resolved.
Infectious mononucleosis. This infectious disease, caused by the Epstein-Barr virus, is very common in teenagers and young adults (16,17). Symptoms include headache, fatigue, anorexia, malaise, myalgias (17), and sore throat (16,17). Physical exam may reveal enlarged lymph tissue and an enlarged spleen. Splenomegaly is the main cause of concern when considering the safety of athletic participation. Though rare, splenic rupture is the most common cause of death in patients who have infectious mononucleosis. It typically occurs in the first 3 weeks of the illness.
Patients who have infectious mononucleosis should be disqualified from contact and strenuous noncontact sports for the first 3 weeks. After 3 weeks, patients may return to strenuous noncontact sports if they feel up to activity and their spleens are nonpalpable. Contact sports are contraindicated for an additional week or 1 full month after the onset of illness (or longer if the spleen remains palpable). Some authors (16,17) advocate ultrasound measurement of the spleen before allowing the patient to return to activity.
Diabetes mellitus. Patients with well-controlled disease should be allowed to participate in all activities. Special attention to the precompetition diet and insulin dosage is necessary to avoid hypoglycemia. Location of the injection site for the insulin dosage is also important. Patients who have poorly controlled disease should not participate in contact or strenuous noncontact sports until they achieve better control (2).
Marfan syndrome. Marfan syndrome is a hereditary disorder characterized by musculoskeletal, cardiovascular, and ocular abnormalities. Athletes who have Marfan syndrome are restricted from vigorous contact and noncontact competitive sports, but participation recommendations should be individualized. Patients who have an enlarged aortic root on echocardiogram should certainly be disqualified from any type of strenuous activity because of the increased risk of aortic rupture (18,19).
Acute febrile illness. Many physicians disqualify athletes who have fevers from all sports until the fever clears, though the rationale is more empiric than scientific. Patients who have viral upper respiratory infection symptoms and low grade fever can participate in mildly to moderately strenuous activity without difficulty. If symptoms are more systemic, patients should avoid activity until they clear (2).
Hyperthyroidism. Patients who have symptomatic hyperthyroidism should be disqualified from athletic competition until the condition is corrected or controlled.
Human immunodeficiency virus (HIV). A policy statement from AMSSM (15) states that there is no evidence that moderate exercise is harmful for patients who are infected with HIV and that, in view of current medical and epidemiologic information, HIV infection is insufficient grounds to prohibit athletic competition. A statement from the AAP (20) agrees, but adds that this position will need to be reconsidered if HIV transmission is found to occur in sports. The report advises physicians to inform athletes who have HIV infection and play sports involving blood exposure of the theoretical risk of transmission to other participants, and to strongly encourage them to consider another sport. Routine testing of athletes for HIV infection is not recommended (20-24).
Anemia. Activity recommendations for patients who have anemia are based on the cause of the disease and the presence or absence of symptoms.
Hemophilia and bleeding tendencies. Hemophiliacs should be restricted to noncontact sports. Patients with von Willebrand's disease may participate at any level of athletic competition. Clotting factor supplements are available that decrease the bleeding tendency; therefore, decisions regarding this disease should be made case by case (2).
Sickle cell trait. Patients who have the sickle cell trait are considered healthy (25,26). Many elite athletes have sickle cell trait and train and perform without incident. Sickle cell trait has been associated with an increased risk of sudden death during activity, but an analysis of these studies (26) demonstrated that patients in the study groups were suddenly subjected to vigorous activity. Certain circumstances may promote red blood cell sickling in patients who have sickle cell trait: hypoxia, low blood pH, dehydration (25-27), high altitude, and hemoconcentration (26,27).
Infections are the main concern when considering the skin. Disqualification from participation for the reasons listed below should be continued until the lesion is felt to be noncontagious. This terminology allows the examining physician great latitude for interpretation. Waiting until a skin lesion has disappeared will decrease the risk of spreading the infection, but may unnecessarily keep an athlete with a noncontagious lesion from participating.
Herpes simplex. Patients who have active skin lesions should avoid sports that require skin contact. Also, these patients should be disqualified from activities that use a mat, such as wrestling (28,29), gymnastics, karate, or judo. In sports that involve less contact or more protective clothing, disqualification may be unnecessary (29). The athlete may return to activity when the lesions are healed or a physician confirms that they are not contagious (17,28,29).
Impetigo. As in herpes simplex, patients who have impetigo should be disqualified from participation in sports that involve skin or mat contact until the lesions are healed (17,29,30).
Tinea corporis. Activity recommendations for patients who have active tinea corporis lesions are the same as noted above for herpes simplex (17).
In the past, the loss of a paired organ routinely resulted in disqualification from contact sports. However, developments in protective equipment have allowed many athletes to participate in some contact sports.
Eye. AMA guidelines suggest that athletes who have one eye avoid contact sports. However, many experts now feel that people who have one eye can participate in contact sports if they wear proper eye protection (31,32). Wearing facial protection such as a mask or cage is also helpful (31-33).
Boxing and wrestling are contraindicated for people who have one eye because protective eye devices are not available for these sports and the risk of eye injury is high (31).
Kidney. Individual assessment is recommended for patients who have solitary kidneys, especially when the kidney is pelvic, iliac, multicystic, or anatomically abnormal (1). Though contact sports place the remaining kidney at very little risk, participation in contact/collision and limited contact sports should be individually assessed. People who have disabilities and have sued for the right to participate in contact sports have successfully cited the Federal Rehabilitation Act of 1973, and athletes who previously had been disqualified from participation are now able to compete (32). Protective equipment such as flak jackets may make limited contact/impact sports very safe (32,33).
Testicle. The absence of one testicle still keeps many athletes from engaging in certain sports (33); however, wearing a protective cup enables them to participate safely in all types of sports. Specifically, a cup would be required for all contact/collision sports and for most limited contact/impact sports (32,33). Because of the widespread use of protective cups, sports participation for single-testicle athletes has become less controversial.
Weighty Activity Issues
It is the responsibility of the physician to identify situations that may put the patient or other participants at risk and act accordingly (2,34). But the physician must balance health concerns with patients' need to participate in athletics whenever possible (2,32), and this may include suggesting alternative activities for particular patients (34).
Dr Moeller is director of Primary Care Sports Medicine and an assistant professor in the departments of family medicine and orthopaedic surgery at the University of Pittsburgh Medical Center in Pittsburgh. He is a member of the American College of Sports Medicine and the American Medical Society for Sports Medicine. Address correspondence to James L. Moeller, MD, University Orthopaedics, Inc, Kaufman Bldg, Suite 1010, 3471 Fifth Ave, Pittsburgh, PA 15213; e-mail to [email protected].
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