Figure Skating Medical SymposiumIthaca, NY December 6, 2010

Andrew Getzin, MDagetzin@cayugamed.org

www.cayugamed.org/sportsmedicine

Program

• Andrew Getzin, MD, Medical Treatment of figure skaters

• Jake Veigel, MD, Injury Prevention

• Deb King, PhD, Figure Skating Stretching and Warm Up

• Discussion

Incidence of Injuries in Elite Junior Figure Skaters- Acute Injuries

Dubravcic-Simunjak, AJSM 2003

Ankle SprainLaceration,LegHead InjuryFracture, armFracture, legKnee ligament sprainKnee injuryShoulder dislocationFracture, wristFracture, finger

Incidence of Injuries in Elite Junior Figure Skaters- Overuse Injuries

Dubravcic-Simunjak, AJSM 2003

Stress FractureJumper's kneeShin splintsOsgood SchlatterGroin painHamstring SyndromeAchilles tendonitisAnkle ImpingementPlantar fasciitis

What is a Concussion?• Mild traumatic brain

injury• A disruption in

normal brain function due to a blow or jolt to the head

• CT or MRI is normal

• Invisible injury

Neurometabolic Cascade(Giza and Hovda 2001)

• Abrupt neuronal depolarization• Release of excitatory neurotransmitters• Changes in glucose metabolism• Altered cerebral blood flow• The brain goes into an ENERGY

CRISIS that usually last up to 7 – 10 days

Vulnerable Period

• There exists a window period when individual is at increased risk

• Should factor in return to play decision

Common Physical Symptoms• Headache• Nausea and vomiting• Clumsiness and poor balance• Dizziness and

lightheadedness• Blurred vision and light

sensitivity• Fatigue and lack of energy• Sleep disturbance• Symptoms often get worse

before they get better

Common Emotional Symptoms• Irritability• Anxiety• More extreme moods• Easily overwhelmed• Personality change• Lack of motivation

• Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’• Easily confused• Slowed processing• Easily distracted • Memory problems• Trouble reading• Poor mental stamina

Common Cognitive Symptoms

Predictions

• Outcome after concussion is difficult to predict

• Don’t be fooled by severity of injury at the time of injury

Physical Exam• Regular physical exam including HEENT,

neck, and neurological exam• 5 Word Recall- immediate and 5 minutes• Months of the year backwards• Digits backwards• Speech• Pronator drift: Rhomberg• Finger-to-nose• Gentle push with their eyes closed

Neuropsychological Testing• Computerized tests that measure

attention, memory, and processing speed (reaction time)

• Sensitive to effects of concussions• Tests can be repeated multiple times to

monitor recovery• Ideally, a baseline is done but there is

normative date for ImPACT

Who Should Have a CT Scan?

• GCS < 15• LOC• History of emesis• Severe headaches• Signs of basilar skull fracture• Severe mechanism

Kuppermann Lancet 2009

Principles of Concussion Treatment

• No cure for concussion, but treatment can help the person feel better and function better while symptomatic

• Early diagnosis and education is critical, and can improve outcome

• Rest early (7-10 days?) and then gradually increase activity

Treatment Strategy

• Education and reassurance• Medications for sleep, headache, etc.• Physical & Occupational Therapy

• Neck & back problems• Balance (fall prevention)• Vision and Cognition

• Neuropsychological Testing

Academic Accommodations

• Out of school if necessary• Communicate!• Limit study time• Possibly hold on testing

Stress Fractures

• Overuse from attempted skill over and over again

• Usually insidious onset

• Most common location is long bones of the feet

Pecina, Stress Fractures in Figure Skaters. AJSM 1990

Stress Fracture Treatment

• Unload the affected area

• Pain is a helpful guide• What can the skater

do while he/she heals?

Stress Fracture Prevention• Listen to your body for warning signs• Ensure good bone health

– Sufficient Vitamin D– Calcium– Energy balance

• Increase activity by <10%/week• Jump counts?• Biomechanics

Asthma in Figure Skating

• 1/3 – ½ of all figure skaters suffer from exercise induced bronchospasm

• Symptoms exacerbated by cold, dry air, and chemicals

• Skaters may present with chronic cough, decreased aerobic capacity or wheezing

McFadden E and Gilbert I. N Engl J Med 1994;330:1362-1367

Effect of the Interaction between the Intensity of Exercise and the Thermal Environment on the Pulmonary Mechanical Response

EIB Treatment- Non pharmacologic

• Increase physical fitness• Warm up for at least 10 minutes at sub-threshold level (60-70%

VO2max) before exercise begins (refractory period)• Cover mouth and nose with a scarf or mask (balaclava) during cold

weather• Exercise short bouts in warm, humidified environment• Avoid aeroallergens and pollutants• Cool down or gradually lower the intensity of exercise before

stopping• Wait at least 2 hours after a meal before exercising• Low salt diet?, Fish Oil Supplementation?

Tan and Spector, Exercise-Induced Asthma, Sports Med. 1998;25(1):1-6

EIB Treatment-pharmacologic• Inhaled beta 2

agonists• Inhaled

corticosteroids• Inhaled cromolyn• Inhaled nedocromil• Inhaled ipatropium• Oral leukotriene

agonist

Not All Shortness of Breath is Asthma

• Exercise Induced Brochospasm• Vocal Cord Dysfunction/Paradoxical Vocal Cord Motion• Asthma• Lack of Fitness• Bronchitis/URI• Anemia• Reflux• Panic Attack• Overtraining syndrome• Cardiac abnormalities

Thank You