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Medical coverage of high school athletics in North Carolina.

Background: A significant percentage of high school students participate in athletics, and of those participating, at least one third will experience a sport-related injury. Despite the high risk of injury, there are few guidelines on what type of medical coverage should be provided for high school athletics. Although vague recommendations are present, it is not known to what extent high schools comply with these guidelines. The primary objective of this cross-sectional study cross-sectional study
See synchronic study.

cross-sectional study,
n the scientific method for the analysis of data gathered from two or more samples at one point in time.
 was to assess the quality and extent of medical coverage at high school athletic events in North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures

Area, 52,586 sq mi (136,198 sq km). Pop.

Methods: A questionnaire, mailed to all athletic directors Athletic director (commonly, "athletics director") is a position at many American colleges and universities, as well as in larger high schools and middle schools, which oversees the work of the coaches and related staff involved in intercollegiate or interscholastic athletic  at public and private North Carolina high school members of the North Carolina High School Athletic Association, was used to assess medical coverage.

Results: Only 56% of the schools had coverage by either nationally or state certified athletic trainers An athletic trainer is an allied (non-physician) health care provider capable of performing immediate and emergency injury management, injury assessment, and rehabilitation. . Although 71% of schools had physician coverage at some athletic events, less than 10% of physician coverage included monitoring of athletic practices. Only 27% of the schools surveyed felt that their existing medical coverage of athletic events could be considered adequate.

Conclusions: These preliminary findings suggest that medical coverage of high school athletics in North Carolina, as in other states, is lacking and inconsistent.

Key Words: high school athletics, competitive sports, sports medicine sports medicine, branch of medicine concerned with physical fitness and with the treatment and prevention of injuries and other disorders related to sports. Knee, leg, back, and shoulder injuries; stiffness and pain in joints; tendinitis; "tennis elbow"; and , medical coverage


Recent epidemiologic data indicates that 55.1% of American high American High School may refer to the following:
  • American High School (Fremont, California), the school in Fremont, California
  • American High School (Miami-Dade County, Florida), the school in unincorporated Miami-Dade County, Florida
 school students participated on at least one sports team. (1) In addition, of those children surveyed, 37.7% reported seeking medical treatment as a result of their activities. (1) Existing data is limited but shows that the quality of medical care for high school athletics is frequently inadequate, (2-4) with larger schools receiving better coverage than smaller schools. (5) Furthermore, the majority of existing data on medical coverage of high school athletics focuses on football, with very little mention of women's sports or other popular men's sports, such as soccer. Finally, few guidelines exist which outline recommendations for medical coverage of high school athletic events, and little is known about compliance of schools with existing medical recommendations. The difficult task of injury evaluation and the decision to return the athlete to competition may significantly impact the athlete if done poorly. Inexperienced in·ex·pe·ri·ence  
1. Lack of experience.

2. Lack of the knowledge gained from experience.

 and or unqualified providers might put the athlete at risk for a negative outcome, such as re-injury. The external pressure from fans, coaches and parents make this task more difficult. Despite this caveat, having medical care present to care for serious injuries would be a desirable state as opposed to having no qualified provider present.

The primary purpose of this study was to quantitatively assess the quality and extent of on site, or sideline sideline

See on the sidelines.
, medical coverage in high school athletics. A secondary aim was to explore any differences in coverage among men and women's sports. A tertiary aim was to identify any relationships between quality of coverage and high school size.



A letter with an enclosed en·close   also in·close
tr.v. en·closed, en·clos·ing, en·clos·es
1. To surround on all sides; close in.

2. To fence in so as to prevent common use: enclosed the pasture.
 survey was sent to the athletic director of every public and private high school in North Carolina (n = 343). The letter described the purpose of the study and gave brief instructions for completing the attached survey. The athletic directors were instructed to return the survey via the provided stamped, self-addressed envelope. The survey assessed demographic data, including sports division Sports Division was one of the biggest sports retailers in the United Kingdom during the 1990s. In 1998 it was sold to its main competitor, JJB Sports for approximately £295 Million.

It was set up by Sir Tom Hunter in 1984, to sell trainers, see article about him for more information.
, number of students, and the size of surrounding community. The survey was designed to collect information regarding 1) extent of medical coverage for individual athletic games and practices; 2) qualifications of those personnel providing medical coverage; and 3) financial compensation to medical personnel. A copy of the survey is provided in appendix A. In addition, athletic directors were asked to comment on their perceived adequacy of the medical coverage and also to report coverage separately for football, men's sports other than football, and women's sports.

Data Analysis

Descriptive statistics descriptive statistics

see statistics.
, including measures of central tendency, dispersion, and skewness Skewness

A statistical term used to describe a situation's asymmetry in relation to a normal distribution.

A positive skew describes a distribution favoring the right tail, whereas a negative skew describes a distribution favoring the left tail.
 were computed for school size. A square root transformation was performed on the variable representing number of students because it was found to be not normally distributed. Spearman spear·man  
A man, especially a soldier, armed with a spear.
 rank order correlations were used to examine the relationship between school size and coverage of athletic events by sports medicine personnel.


Demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data.  

The response rate for the survey was 40%, with 139 of the high schools returning completed, interpretable surveys. The average size of the high schools was 1,132 students ([+ or -] 613.74). Characteristics of the participating high schools are provided in Table 1. Seventy-one percent of the surveys were completed by the school's athletic director, 1% were completed by the assistant athletic director, 6% by a coach, 21% by an athletic trainer, and 2% by another unspecified individual.

Coverage of Athletic Events by Athletic Trainers

Forty-eight percent (n = 65) of schools did not report access to a nationally certified athletic trainer, and only 20% (n = 29) of schools had a state certified athletic trainer. More than half (59%, n = 81) of the schools involved student trainers in the care of their athletes.

Coverage of Athletic Events by Physicians

Seventy-eight percent (n = 109) of schools reported having physician coverage at some athletic events. Of those schools reporting some physician coverage, 52% (n = 72) had orthopaedic coverage and 35% (n = 49) had coverage by a primary care physician (Table 2).

Other Medical Coverage

Twenty-six percent (n = 36) of the schools reported that they did not have ambulance coverage of football games. Close to half of the schools relied on ambulances to volunteer their services (n = 55, 42%). In addition, 14% (n = 19) of schools reported coverage by chiropractors. Many schools (51%, n = 72) relied on coverage by nonlicensed, noncertified sports medicine personnel.

Gender Comparisons

The majority of schools (78%, n = 108) reported physician coverage of football games, with only a few reporting physician coverage of men's sports other than football (13%, n = 18) and women' sports (12%, n = 16). There was a strong correlation between physician coverage of men's sports other than football and women's sports (r = 0.935, P < 0.001). More schools reported having men's coaches certified in CPR Cardiopulmonary Resuscitation (CPR) Definition

Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation for a person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac
 than women's coaches (71% v. 59%, respectively). The reverse was true for first aid, with 71% of women's coaches certified and 63% of men's coaches certified.

Size of School Relationships

There was a significant relationship between school size and presence of a nationally certified athletic trainer (r = -0.292, P = 0.001). No such relationship existed for state certified athletic trainers or student trainers. There was a significant correlation between school size and coverage of athletic events by physicians (r = 0.391, P < 0.001). In addition, there was a significant correlation between school size and coverage of athletic events by an orthopaedic surgeon (r = 0.428, P < 0.001). No significant relationship existed between school size and coverage by primary care providers or chiropractors, although there was a trend for coverage by primary care doctors and chiropractors at small schools. There was no relationship between size of school and certification of coaches in first aid or CPR. Finally, there was no relationship between school size and coverage by nonlicensed, noncertified personnel.

Perception of Coverage

The person completing the questionnaire was asked if they felt their school's medical coverage of athletics was adequate. Answers were nearly equally distributed; with 49% (n = 67) reporting inadequate coverage and 51% (n = 70) reporting at least adequate coverage. A few schools did not answer this question (n = 3). Stepwise stepwise

incremental; additional information is added at each step.

stepwise multiple regression
used when a large number of possible explanatory variables are available and there is difficulty interpreting the partial regression
 multiple regression Multiple regression

The estimated relationship between a dependent variable and more than one explanatory variable.
 analysis was performed to determine the significant independent predictors of perception of medical coverage of athletics. Presence of a nationally certified athletic trainer was the only significant independent predictor of perception of adequate medical coverage (r = 0.274, P = 0.006), while controlling for school size, presence of a physician, and person completing the survey. In addition, there was a significant trend for schools with orthopaedic surgeons covering events to report medical coverage as inadequate (r = -0.189, P = 0.028).


These findings represent the first known study of medical coverage of high school athletic events in the state of North Carolina. This study contains data from 139 high schools with a total student population of 229,466. In this study, only half (52%, n = 71) of schools had a nationally certified athletic trainer. In addition, 51% (n = 72) of schools relied on noncertified, nonlicensed sports medicine personnel. This is disconcerting dis·con·cert  
tr.v. dis·con·cert·ed, dis·con·cert·ing, dis·con·certs
1. To upset the self-possession of; ruffle. See Synonyms at embarrass.

 due to the nationwide initiative to have licensed, certified personnel in all high schools. In this study, approximately half of the athletes were cared for by nonlicensed, noncertified sports medicine personnel, which may increase their risk of receiving improper care, as it is estimated that as many as one-third of high school athletes will become injured in·jure  
tr.v. in·jured, in·jur·ing, in·jures
1. To cause physical harm to; hurt.

2. To cause damage to; impair.

 and lose time in their sport in any given season. (6) The lack of qualified caregivers is especially alarming given the recent increase in catastrophic sports-related injuries. (7) Recent media and position statements by The National Athletic Trainers' Association The National Athletic Trainers' Association (NATA) is the professional membership association for certified athletic trainers and others who support the athletic training profession.  (NATA NATA National Athletic Trainers' Association
NATA National Association of Testing Authorities (Australia)
NATA National Air Transportation Association (Alexandria, VA, USA) 
) (8) and the American Academy The American Academy in Berlin is a non-partisan academic institution in Berlin. It was founded in September 1994 by a group of prominent Americans and Germans, among them Richard Holbrooke, Henry Kissinger, Richard von Weizsäcker, Fritz Stern and Otto Graf Lambsdorff and opened in  of Family Practice (AAFP AAFP American Academy of Family Physicians.

American Academy of Family Physicians

AAFP, See American Academy of Family Physicians.
) (9) have highlighted the need for licensed, certified sports medicine personnel, particularly athletic trainers. This notion is reinforced by the fact that in this study, schools with nationally certified athletic trainers reported adequate medical coverage significantly more than schools without.

Approximately half of the schools relied on student trainers to augment coverage of athletic teams, and student training programs were not limited to large schools. This is a positive finding, as student trainers can help reduce the workload of staff trainers. While not licensed or qualified to provide medical coverage independently, student trainers can operate under the supervision of a licensed athletic trainer and perform such tasks as icing injuries after games or practice, assisting athletes with rehabilitative re·ha·bil·i·tate  
tr.v. re·ha·bil·i·tat·ed, re·ha·bil·i·tat·ing, re·ha·bil·i·tates
1. To restore to good health or useful life, as through therapy and education.

 exercises, and general training room maintenance. In addition, by incorporating a student training program, young people will be exposed to the field of sports medicine as a possible career choice.

Although physician involvement was more widespread than the researchers expected, it was still mainly limited to larger high schools. Even at high schools with physician coverage, that coverage was usually provided solely to football (65%, n = 91). In addition, very few physicians in training were providing medical coverage. Given the large number of medical schools (n = 4) and primary care residency A duration of stay required by state and local laws that entitles a person to the legal protection and benefits provided by applicable statutes.

States have required state residency for a variety of rights, including the right to vote, the right to run for public office, the
 programs (n = 14) in North Carolina, only 3% (n = 5) of the high schools reported coverage by a medical student or resident physician. Several programs in other states, such as the LOCUS program in Wisconsin, encourage medical students to become involved in youth sports. (10) It appears from this survey, however, that residents are not actively providing coverage for local high school sports in North Carolina Despite having over eight million people, the disbursement of North Carolina's population over three major metropolitan areas precluded attracting any major professional sports league teams until recently. . The utilization of this resource would provide additional immediate coverage for some high schools, and expand the amount of coverage in the future by encouraging these physicians to continue their involvement with local high school athletics as they go into practice. Encouraging physicians to volunteer for the medical coverage of events of a high school helps to further strengthen the bond between the community and the medical providers and does not increase the financial cost to the school.

The largest disparity in coverage was not between men's and women's sports, but between football and all other sports, regardless of gender. This sentiment of interest in football is echoed in the scientific literature, whereas a disproportionate number of manuscripts have been published on high school football in comparison with women's sports and men's sports other than football. Since the passage of federal Title IX legislation in 1972, the number of females participating in high school athletics has increased dramatically. (7) While the majority of injury rates for males and females are equivalent, the rate of ACL injuries ACL injury See Anterior cruciate ligament injury.  has been found to be up to eight times the rate in females as compared with males. Such differences in injury rates may necessitate ne·ces·si·tate  
tr.v. ne·ces·si·tat·ed, ne·ces·si·tat·ing, ne·ces·si·tates
1. To make necessary or unavoidable.

2. To require or compel.
 the redistribution of personnel and resources for the treatment and prevention of such injuries. (11,12)

Fewer schools than expected returned Expected Return

The average of a probability distribution of possible returns, calculated by using the following formula:
 the study questionnaire. Several factors may assist in explaining the reduced response rate. Many high school athletic directors serve in multiple capacities in their schools; for example, some may also be teachers or guidance counselors guidance counselor Child psychology A school worker trained to screen, evaluate and advise students on career and academic matters . Time constraints In law, time constraints are placed on certain actions and filings in the interest of speedy justice, and additionally to prevent the evasion of the ends of justice by waiting until a matter is moot.  imposed on these personnel may have limited their ability to complete and return the survey within the study period. This may be evidenced by the large portion of surveys that were filled out by someone other than the athletic director (30%), even though the introductory letter specified that the athletic director should complete them. The low response rate for this study may limit the representativeness of the sample; however, we did have reasonable representation of school settings (rural, small city, etc.) and athletic divisions. In addition to the low response rate, athletic directors from schools known to the researchers to utilize residents did not correctly identify the resident involvement in the coverage for their school. While this may be an oversight, it may reduce the reporting of resident and medical coverage that actually exists at the schools surveyed.

Confusion over what type of medical coverage actually existed was more apparent at schools where the athletic director, and not an athletic trainer, completed the questionnaire. This seems to demonstrate that allied health personnel such as certified and/or licensed athletic trainers may be better trained to understand and predict the needs and requirements for event coverage than the athletic director, who has multiple responsibilities. The ideal model would thus be to have a certified athletic trainer on staff to advise the athletic director on decisions regarding the medical coverage of events.


The Healthy People 2010 initiative has included reducing injury rates as one of its 28 focus areas. (13) Injury treatment and prevention provided by qualified personnel will help reduce morbidity and disability among high school athletes by making accurate diagnosis and treatment available in a timely manner. High school sporting events have comparable injury rates to intercollegiate in·ter·col·le·giate  
Involving or representing two or more colleges.

Adj. 1. intercollegiate - used of competition between colleges or universities; "intercollegiate basketball"
 athletics, and receive far less medical coverage. In addition, a disparity exists between football and other sports in terms of extent and quality of medicine coverage. Finally, many high schools rely on noncertified sports medicine personnel to provide medical coverage, which may place athletes at increased risk for improper treatment. In addition, this lack of certified medical providers may increase the high school's assumed liability.


High schools should focus on hiring trained, certified athletic trainers and qualified sports medicine providers. As this is a costly endeavor, it would be beneficial for local medical communities to become involved, on a volunteer basis, in providing coverage for high school sporting events. This is especially true in smaller communities, where our survey indicated there was a lack of orthopaedic physician involvement. Increasing the utilization of student athletic trainers, medical students, and physicians in training should significantly expand the availability of medical coverage and expose these groups to the field of sports medicine. Finally, high schools and the local medical communities should work to provide coverage for all high school sports and not limit their coverage to football. Physicians in the community should be open to voluntarily providing medical coverage to the local schools.

The treatment of sideline injuries is an important aspect for the prevention of catastrophic injuries. One might argue that it is more important to focus on the primary prevention of injury and catastrophic deaths in athletics. A complete preparticipation examination and cardiac screening is the accepted practice in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . The involvement and open communication between the physician, parent, athlete, coach and training staff is vital to screen and diagnose medical problems of the athlete before and throughout the season. Having a medical team in place for all athletes will help to increase the likelihood of proper evaluation of symptoms that are harbingers of conditions which might lead to sudden death, such as cardiac disease, heat illness and uncontrolled respiratory problems.

Approximately half of the responding schools in this study did not feel that their sports-related medical coverage was sufficient. Furthermore, half the participating schools relied on noncertified, nonlicensed personnel to provide sports medicine care. Involvement of physicians and other qualified sports medicine personnel from preparticipation screening to sideline coverage is one possible avenue for improving athletes' health and reducing the risk of sports-related injuries, including catastrophic events (Figure 1).


1. Kann L, Kinchen SA, Williams BI, et al. State and Local YRBSS YRBSS Youth Risk Behavior Surveillance System  Coodinators. Youth Risk Behavior Surveillance System. Youth risk behavior surveillance-UnitedStates, 1999. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg,  CDC See Control Data, century date change and Back Orifice.

CDC - Control Data Corporation
 Surveill Summ 2000;49:1-32.

2. Vangsness CT Jr, Hunt T, Uram M, et al. Survey of health care coverage of high school football in southern California Southern California, also colloquially known as SoCal, is the southern portion of the U.S. state of California. Centered on the cities of Los Angeles and San Diego, Southern California is home to nearly 24 million people and is the nation's second most populated region, . Am J Sports Med 1994;22:719-722.

3. Rutherford DS, Niedfeldt MW, Young CC. Medical coverage of high school football in Wisconsin in 1997. Clin J Sport Med 1999;9:209-215.

4. Lindaman LM. Physician care for interscholastic in·ter·scho·las·tic  
Existing or conducted between or among schools.

 athletes in Michigan. Am J Sports Med 1991;19:82-87.

5. Carek PJ, Dunn J, Hawkins A. Health care coverage of high school athletics in South Carolina South Carolina, state of the SE United States. It is bordered by North Carolina (N), the Atlantic Ocean (SE), and Georgia (SW). Facts and Figures

Area, 31,055 sq mi (80,432 sq km). Pop. (2000) 4,012,012, a 15.
: does school size make a difference? J S C Med Assoc 1999;95:420-5.

6. Weaver NL, Marshall SW, Miller MD. Preventing sports injuries Sports Injuries Definition

Sports injuries result from acute trauma or repetitive stress associated with athletic activities. Sports injuries can affect bones or soft tissue (ligaments, muscles, tendons).
: opportunities for intervention in youth athletics. Patient Educ Couns 2002;46:199-204.

7. National Center for Catastrophic Sport Injury Research Data Tables. Twenty-first Annual Report. Available at: Accessed February 11, 2005.

8. National Athletic Trainers' Association. Official statement on ATC's in high schools. Available at: Accessed May 6, 2004.

9. American Academy of Family Practice. Athletic Trainers for High School Athletes. Available at: Accessed May 6, 2004.

10. Haq C, Grosch M, Carufel-Wert D. Leadership Opportunities with Communities, the Medically Underserved, and Special Populations (LOCUS). Acad Med 2002;77:740.

11. Arendt E, Dick R. Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer: NCAA NCAA
National Collegiate Athletic Association
 Data and Review of Literature. Am J Sports Med 1995;23:694-701.

12. Arendt EA, Agel, Dick R. Anterior Cruciate Ligament Injury anterior cruciate ligament injury Sports medicine An injury most common in sports characterized by abrupt changes of direction–eg, football, skiing, tennis, soccer Clinical Swelling, tenderness of knee Management ACL reconstruction via arthroscopy  Patterns Among Collegiate Men and Women. J Athletic Training athletic training Sports medicine The practice of physical conditioning and reconditioning of athletes and prevention of injuries incurred by athletes. See Athlete, Athletic trainer.  1999;34:86-92.

13. US Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS
. Healthy People 2010, 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC, US Government Printing Office, 2000.</p> <pre> Silence is argument carried out by other means. --Che Guevara </pre> <p>Douglas F. Aukerman, MD, Melissa McManama Aukerman, MS, and Douglas Browning, MD, ATC-L

From the Department of Orthopaedics and Sports Medicine and Family Medicine and the Department of Kinesiology kinesiology

Study of the mechanics and anatomy of human movement and their roles in promoting health and reducing disease. Kinesiology has direct applications to fitness and health, including developing exercise programs for people with and without disabilities, preserving
, the Pennsylvania State University Pennsylvania State University, main campus at University Park, State College; land-grant and state supported; coeducational; chartered 1855, opened 1859 as Farmers' High School. , University Park, PA; and the Department of Family and Community Medicine, Wake Forest University, Winston-Salem, NC.

Reprint reprint An individually bound copy of an article in a journal or science communication  requests to Douglas F. Aukerman, MD, Assistant Professor, Department of Orthopaedics, The Pennsylvania State University, 1850 East Park Avenue, Suite 112 University Park, Pennsylvania 16805. Email:

Accepted October 10, 2005.


* The majority of high schools that participated in this study did not have physician coverage of sporting events other than football games.

* Most of the coaches at the participating high schools did not have CPR or first aid certification.

* Only about half of the high schools employed board certified board certified,
adj the status of a dental specialist such as an orthodontist who has become a board diplomate by successfully completing the certification program of the recognized certification board in that area of practice.
, licensed sports medicine personnel (e.g. ATC-L). The remainder of these schools relied on unlicensed personnel, such as teachers and coaches to provide sports medicine care.

* Adequate sports medicine care of high school athletes, including qualified physicians and licensed athletic trainers, will assist in 1) decreased injury rates, 2) decreased loss of playing time due to accurate diagnosis and treatment, and 3) decreased rate of re-injury due to proper rehabilitation rehabilitation: see physical therapy. .
Table 1. Demographics of participating high schools

Characteristic        Percent (n)

Athletic division
  1A                   4 (6)
  2A                  25 (34)
  3A                  26 (36)
  4A                  45 (63)
Community descriptor
  Rural town          28
  Small town          24
  Small city          17
  Medium city         13
  Large city          18

Table 2. Specialty of physicians providing coverage for participating
high schools

Medical specialty    Percent (n)

Orthopaedics         52 (72)
Primary care         35 (49)
  Family medicine    30 (41)
  Internal medicine   5 (7)
  Pediatrics          3 (4)
  General medicine    5 (7)
Other specialty       7 (10)
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Title Annotation:Original Article
Author:Browning, Douglas
Publication:Southern Medical Journal
Geographic Code:1U5NC
Date:Feb 1, 2006
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