Confronting the risk of high school athletics.

There are mental, physical, economic and spectator benefits derived from high school sports that give them value to which we rarely give a great deal of thought.

However, if we are responsible, we should also consider the possible cost or hazard of athletic participation. This is not to say that the risks and costs are likely to lead to a decision to shut down any of our sports programs, but rather that we should evaluate realistically the risks as opposed to the benefits, and reduce, insofar as possible, the former.

The article by Aukerman et al (1) in this issue of the SMJ addresses one aspect of this problem, while simultaneously stimulating thought about a wider range of possible problems. We tend to concentrate on mechanical injuries, such as ligament or cartilage ruptures, or articular surface injuries, and perhaps we do not give enough attention to the less common but potentially catastrophic medical disorders sometimes associated with unusual physical exertion. Particularly during afternoon practice sessions in late summer, dehydration and heatstroke are possible killers, sometimes completely unexpected.

Less common, but nonetheless occurring with enough frequency to justify our attention as physicians responsible for the life and health of young athletes, is a cardiac disorder that, because it is asymptomatic most of the time, most young victims may not even be aware is a threat to their well-being: hypertrophic cardiomyopathy is a disorder that can occur in several different forms. Unfortunately the young athlete may not feel in any way impaired, having experienced nothing more then perhaps brief fainting spells, some mild chest pain or shortness of breath, or tachycardia that resolves spontaneously and without aggressive intervention.

Physicians are not usually sufficiently alarmed by these manifestations; they try earnestly to persuade the athlete to have the tests necessary to confirm or rule out the diagnosis--such as simple sonography and electrocardiograms. When the warning signs are present, however, the tests should be undertaken, and also perhaps even when they are not.

The disorders are rare, and the cost of tests are not negligible, which is why the tests are not routinely done. But if your adolescent or mine collapses on the playing field, then is urgently removed to a hospital emergency room, the event is no longer rare and certainly not trivial. It is commonly fatal.

We must learn to set priorities. Perhaps we cannot schedule sonograms for all high school athletes, but parents can be given hand-outs on the disorder, and they can make decisions as to whether to arrange and pay for further testing if they feel it is justified.

To help prevent mechanical injuries, schools can arrange for careful and detailed evaluations by qualified orthopaedic surgeons to determine if a youngster's lower extremities show the contours or ligamentous laxities that might create greater susceptibility to ligament injuries. Similarly, a young athlete who on careful interview admits to fainting spells, chest pain, or shortness of breath might justify greater attention to the possibility of potentially dangerous cardiac disorders.

A young man or woman who experiences acute neck pain after a relatively minor injury deserves a careful evaluation of his or her skeletal neck structures to determine if there is any likely instability.

In evaluation of the young athlete, one must, in setting priorities, consider the cost of professional evaluations and imaging studies. One should also, however, consider what is at stake. For a 16-year-old with hypertrophic cardiomyopathy, what is at stake is a lifetime. For a 16-year-old with an unstable congenital malformation in his cervical spine, a lifetime of quadriplegia may be the risk.

Having coverage at practice sessions and games by a professional is certainly of value, and it might very well prevent catastrophe. If such services are offered by qualified individuals without charge, they should be accepted.

It should not be assumed, however, that such coverage will necessarily prevent disaster. If a young athlete admits that he or she gets fainting spells with exertion, or a little chest pain, the time and money for more extensive evaluation should be made available. A neck injury--any neck injury, however slight--must be taken seriously.

Having a professional provide "coverage" from the sidelines can be a valuable protection for our young athletes. It does not, however, address the entire problem. A serious and careful evaluation of the entire spectrum of possible hazards, both mechanical and medical, of sports, with the development of a plan for allocation of resources, based on relative risk, might prevent an avoidable catastrophe.

References

1. Aukerman DF, Aukerman MM, Browning D. Medical coverage of high school athletics in North Carolina. South Med J 2006;99:132-136.

James H. Lipsey, MD

From Waynesville, NC.

Reprint requests to James H. Lipsey, MD, 449 Flying Hawk Trail, Waynesville, NC. Email: [e-mail]

Accepted October 25, 2005.