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Effective regulation of pace enables the majority of runners to complete competitive endurance events without mishap. However, some runners do experience exercise-induced collapse associated with postural hypotension, which in rare cases results from life-threatening conditions such as cardiac disorders, cerebral events, heat stroke and hyponatraemia. Despite the experience of either catastrophic system failure or extreme peripheral muscle fatigue, some runners persist in attempting to reach the finish line, and this often results in a sequence of dynamic changes in posture and gait that we have termed the 'Foster collapse positions'. The initial stage involves an unstable gait and the runner assumes the 'Early Foster' collapse position with hips slightly flexed and their head lowered. This unstable gait further degrades into a shuffle referred to as the 'Half Foster' collapse position characterized by hip flexion of approximately 90° with the trunk and head parallel to the ground. At this point, the muscles of postural support and the co-ordination of propulsion begin to be compromised. If the condition worsens, the runner will fall to the ground and assume the 'Full Foster' collapse position, which involves crawling forwards on knees and elbows towards the finish line, with their trunk angled such that the head is at a lower angle than the hips. Upon reaching the finish line, or sometimes before that, the runner may collapse and remain prone until recovering either with or without assistance or medical treatment. The Foster collapse positions are indicative of a final, likely primordial, protective mechanism designed to attenuate postural hypotension, cardiac 'pump' insufficiency or cerebral blood flow deficiency. Continuing to attempt to reach the finish line in this impaired state is also perhaps indicative of a high psychological drive or a variety of neurological and psychological pathologies such as diminished sensitivity to interoceptive feedback, unrealistic situational appraisal or extreme motivational drives. A better understanding of the physiological, neurological and psychological antecedents of the Foster collapse sequence remains an important issue with practical implications for runner safety and theoretical understanding of collapses during exercise.

Objective: To determine the incidence of sudden cardiac arrest (SCA) and sudden cardiac death (SCD) in men and women., Design: Retrospective cohort study., Setting: Two popular urban 42 km marathons., Participants: 1982 to 2009 finishers., Assessment of Risk Factors: Race records were assessed for finishers, age distribution and cardiac events by sex., Main Outcome Measures: The SCA/SCD incidence for all (total), male and female finishers., Results: There were 548,092 finishers with women finishers increasing from 10% to 40% over the first 18 years and remaining near 40% for the last decade. There were 14 SCA events (1 woman, 13 men) with seven successful resuscitations yielding an all finishers SCA rate of 2.6 per 100,000 finishers. The SCA rates (per 100,000) for men and women were 3.4 (95% CI: 1.8 to 5.9) and 0.6 (95% CI: 0.0 to 3.3), respectively (p=0.079). The male SCA rate for the 2000-2009 decade was 4.6 per 100,000 finishers (95% CI: 1.8 to 9.5). Eleven of 13 men were >39 years old. The OR of a man experiencing SCA compared with woman was 5.7., Conclusions: As the number of women participating in these two marathons has increased, the difference between the men's and total SCA and SCD incidence has increased for men, especially >39 years old, from coronary artery disease with men's incidence for SCA of 1 in 22,000 and SCD at 1 in 50,000 finishers over past decade.

PURPOSE OF THE STATEMENT: ▸ To provide an evidence-based, best practises summary to assist physicians with the evaluation and management of sports concussion. ▸ To establish the level of evidence, knowledge gaps and areas requiring additional research., Importance of an Amssm Statement: ▸ Sports medicine physicians are frequently involved in the care of patients with sports concussion. ▸ Sports medicine physicians are specifically trained to provide care along the continuum of sports concussion from the acute injury to return-to-play (RTP) decisions. ▸ The care of athletes with sports concussion is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion. Competence should be determined by training and experience, not dictated by specialty. ▸ While this statement is directed towards sports medicine physicians, it may also assist other physicians and healthcare professionals in the care of patients with sports concussion., Definition: ▸ Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process. Concussion is a subset of mild traumatic brain injury (MTBI) which is generally self-limited and at the less-severe end of the brain injury spectrum., Pathophysiology: ▸ Animal and human studies support the concept of postconcussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell. ▸ Experimental evidence suggests the concussed brain is less responsive to usual neural activation and when premature cognitive or physical activity occurs before complete recovery the brain may be vulnerable to prolonged dysfunction., Incidence: ▸ It is estimated that as many as 3.8 million concussions occur in the USA per year during competitive sports and recreational activities; however, as many as 50% of the concussions may go unreported. ▸ Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer and basketball. RISK FACTORS FOR SPORT-RELATED CONCUSSION: ▸ A history of concussion is associated with a higher risk of sustaining another concussion. ▸ A greater number, severity and duration of symptoms after a concussion are predictors of a prolonged recovery. ▸ In sports with similar playing rules, the reported incidence of concussion is higher in female athletes than in male athletes. ▸ Certain sports, positions and individual playing styles have a greater risk of concussion. ▸ Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury. ▸ Preinjury mood disorders, learning disorders, attention-deficit disorders (ADD/ADHD) and migraine headaches complicate diagnosis and management of a concussion., Diagnosis of Concussion: ▸ Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion. ▸ Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations. ▸ Standardised assessment tools provide a helpful structure for the evaluation of concussion, although limited validation of these assessment tools is available., Sideline Evaluation and Management: ▸ Any athlete suspected of having a concussion should be stopped from playing and assessed by a licenced healthcare provider trained in the evaluation and management of concussions. ▸ Recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (including orientation, past and immediate memory, new learning and concentration), balance tests and further neurological physical examination. ▸ While standardised sideline tests are a useful framework for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined. Their practical usefulness with or without an individual baseline test is also largely unknown. ▸ Balance disturbance is a specific indicator of a concussion, but not very sensitive. Balance testing on the sideline may be substantially different than baseline tests because of differences in shoe/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injury. ▸ Imaging is reserved for athletes where intracerebral bleeding is suspected. ▸ There is no same day RTP for an athlete diagnosed with a concussion. ▸ Athletes suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status., Neuropsychological Testing: ▸ Neuropsychological (NP) tests are an objective measure of brain-behaviour relationships and are more sensitive for subtle cognitive impairment than clinical exam. ▸ Most concussions can be managed appropriately without the use of NP testing. ▸ Computerised neuropsychological (CNP) testing should be interpreted by healthcare professionals trained and familiar with the type of test and the individual test limitations, including a knowledgeable assessment of the reliable change index, baseline variability and false-positive and false-negative rates. ▸ Paper and pencil NP tests can be more comprehensive, test different domains and assess for other conditions which may masquerade as or complicate assessment of concussion. ▸ NP testing should be used only as part of a comprehensive concussion management strategy and should not be used in isolation. ▸ The ideal timing, frequency and type of NP testing have not been determined. ▸ In some cases, properly administered and interpreted NP testing provides an added value to assess cognitive function and recovery in the management of sports concussions. ▸ It is unknown if use of NP testing in the management of sports concussion helps prevent recurrent concussion, catastrophic injury or long-term complications. ▸ Comprehensive NP evaluation is helpful in the post-concussion management of athletes with persistent symptoms or complicated courses., Return to Class: ▸ Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from a concussion., Return to Play: ▸ Concussion symptoms should be resolved before returning to exercise. ▸ A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact. ▸ If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step. ▸ RTP after concussion should occur only with medical clearance from a licenced healthcare provider trained in the evaluation and management of concussions. SHORT-TERM RISKS OF PREMATURE RTP: ▸ The primary concern with early RTP is decreased reaction time leading to an increased risk of a repeat concussion or other injury and prolongation of symptoms. LONG-TERM EFFECTS: ▸ There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae. ▸ Some studies have suggested an association between prior concussions and chronic cognitive dysfunction. Large-scale epidemiological studies are needed to more clearly define risk factors and causation of any long-term neurological impairment., Disqualification From Sport: ▸ There are no evidence-based guidelines for disqualifying/retiring an athlete from a sport after a concussion. Each case should be carefully deliberated and an individualised approach to determining disqualification taken., Education: ▸ Greater efforts are needed to educate involved parties, including athletes, parents, coaches, officials, school administrators and healthcare providers to improve concussion recognition, management and prevention. ▸ Physicians should be prepared to provide counselling regarding potential long-term consequences of a concussion and recurrent concussions., Prevention: ▸ Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play. ▸ Helmets, both hard (football, lacrosse and hockey) and soft (soccer, rugby) are best suited to prevent impact injuries (fracture, bleeding, laceration, etc.) but have not been shown to reduce the incidence and severity of concussions. ▸ There is no current evidence that mouth guards can reduce the severity of or prevent concussions. ▸ Secondary prevention may be possible by appropriate RTP management., Legislation: ▸ Legislative efforts provide a uniform standard for scholastic and non-scholastic sports organisations regarding concussion safety and management., Future Directions: ▸ Additional research is needed to validate current assessment tools, delineate the role of NP testing and improve identification of those at risk of prolonged post-concussive symptoms or other long-term complications. ▸ Evolving technologies for the diagnosis of concussion, such as newer neuroimaging techniques or biological markers, may provide new insights into the evaluation and management of sports concussion.

Purpose: There is no reporting system for marathon-associated sudden cardiac arrest (SCA) or sudden cardiac death in the United States. The purpose of this study was to estimate and characterize the risk of marathon-related SCA to assist with emergency planning., Methods: A retrospective Web-based survey was sent out to all US marathon medical directors (n = 400) to gather details of SCA including demographics, resuscitation efforts, mortality, and autopsy results, if available., Results: A total of 88 surveys (22%) were returned from marathons run from 1976 to 2009 for a total of 1,710,052 participants. Risks of SCA and sudden cardiac death were 1 in 57,002 and 1 in 171,005, respectively. Men made up the vast majority of SCA victims (93%, mean age = 49.7 yr, range = 19-82 yr). Arrest site distributions were 0-5, 6-14, 15-22, and 23-26.2 miles. CAD was reported as the cause of death at autopsy in 7 of the 10 fatalities. An automated external defibrillator (AED) was used in 20/30 cases and associated with a higher survival (17/20 survivors vs 3/10 deaths, P = 0.0026)., Conclusions: SCA occurs in approximately 1 in 57,000 marathon runners, is more common in older males, and usually occurs in the last 4 miles of the racecourse. Prompt resuscitation including early use of an AED improves survival. Emergency planning to include trained medical staff and sufficient AEDs throughout the racecourse is recommended.

Unlabelled: OBJECTIVEL To investigate the influence of playing multiple games on multiple days on youth soccer medical encounter rates., Design: Prospective cohort survey study., Setting: Medical facility at the 2008 Schwan's USA Cup soccer tournament., Participants: Players presenting to the medical facility for game-related medical evaluation., Assessment of Risk Factors: Date, game and half of game for each medical encounter., Main Outcome Measures: Game play-related medical encounters per 1000 match hours (MH)., Results: 211 players surveyed with 195 eligible and completed questionnaires. There were 4.06, 5.14 and 3.92 medical encounters/1000 MH on 11, 12 and 13 July, respectively, with no significant difference in injury incidence. There was no difference in medical encounter rates of second games compared with first games of the day (p=0.126). Daily medical encounter rates were 5.65, 8.95, 7.83, 6.94 and 4.62/1000 MH on 15, 16, 17, 18 and 19 July, respectively, with statistically significant differences on 16 July (p<0.001) and 17 July (p=0.022) compared with 15 July. Encounter rates of second games compared with first games of the day showed no difference (p=0.385). A linear test for trend from 15 to 19 July was not significant (p=0.092)., Conclusions: The USA Cup format did not show either increased medical encounter rates from the cumulative total of games played or a consistently increased rate in the second game of the day compared with the first. Players, coaches, parents and administrators can feel confident that this tournament format does not pose an additional risk of injury.

Background: Approximately 2 million people participate in long-distance running races in the United States annually. Reports of race-related cardiac arrests have generated concern about the safety of this activity., Methods: We assessed the incidence and outcomes of cardiac arrest associated with marathon and half-marathon races in the United States from January 1, 2000, to May 31, 2010. We determined the clinical characteristics of the arrests by interviewing survivors and the next of kin of nonsurvivors, reviewing medical records, and analyzing postmortem data., Results: Of 10.9 million runners, 59 (mean [±SD] age, 42-13 years; 51 men) had cardiac arrest (incidence rate, 0.54 per 100,000 participants; 95% confidence interval [CI], 0.41 to 0.70). Cardiovascular disease accounted for the majority of cardiac arrests. The incidence rate was significantly higher during marathons (1.01 per 100,000; 95% CI, 0.72 to 1.38) than during half-marathons (0.27; 95% CI, 0.17 to 0.43) and among men (0.90 per 100,000; 95% CI, 0.67 to 1.18) than among women (0.16; 95% CI, 0.07 to 0.31). Male marathon runners, the highest-risk group, had an increased incidence of cardiac arrest during the latter half of the study decade (2000-2004, 0.71 per 100,000 [95% CI, 0.31 to 1.40]; 2005-2010, 2.03 per 100,000 [95% CI, 1.33 to 2.98]; P=0.01). Of the 59 cases of cardiac arrest, 42 (71%) were fatal (incidence, 0.39 per 100,000; 95% CI, 0.28 to 0.52). Among the 31 cases with complete clinical data, initiation of bystander-administered cardiopulmonary resuscitation and an underlying diagnosis other than hypertrophic cardiomyopathy were the strongest predictors of survival., Conclusions: Marathons and half-marathons are associated with a low overall risk of cardiac arrest and sudden death. Cardiac arrest, most commonly attributable to hypertrophic cardiomyopathy or atherosclerotic coronary disease, occurs primarily among male marathon participants; the incidence rate in this group increased during the past decade.

Heat stroke is defined as a condition in which body temperature is elevated to such a level that it becomes a noxious agent causing body tissue dysfunction and damage with a characteristic multi-organ clinical and pathological syndrome. Marked hyperthermia, usually above 40.5°C and associated encephalopathy, occurs after thermoregulation is subordinated to circulatory and metabolic demands and to the associated systemic inflammatory reaction. Exertional heat stroke is a function of both intrinsic and extrinsic modulators. Intrinsic modulators like genetics, fitness, acclimatization, illness, medications, and sleep quality can alter individual risk and outcomes, while extrinsic modulators like exercise intensity and duration, clothing and equipment, ambient temperature, relative humidity, and solar radiation can affect the group risk and outcomes. This review integrates the current theoretical and accepted knowledge of physiological alterations into one model that depicts a common pathway from heat stress to heat stroke., (© 2011 John Wiley & Sons A/S.)

Background: Despite the increasing popularity of marathons, little research has examined the training habits of nonelite marathon runners. Given that nonelite runners, particularly those with a competitive motive, have a higher risk for injury than experienced elite runners, it is important for physicians to understand the training program and features that might distinguish running performance and injury rates in this population., Hypothesis: We hypothesized that nonelite runners who qualify for the Boston Marathon ("qualifers") would have higher running volumes, more running sessions per week, lower injury rates, and lower body mass index (BMI) than nonqualifying runners., Study Design: A cross-sectional Web-based survey of runners (convenience sample) at 1 month (n = 50) and 6 months (n = 41) after participation in the 2008 Twin Cities Marathon (TCM) that acquired data on anthropometric measures, demographic data, finishing time, premarathon/current training program, and self-reported injury., Results: Thirteen of 50 initial survey respondents were classified as a "qualifier" based on their finishing time. Mean BMI was significantly lower in the qualifiers at 1 month (22.0 versus 23.9 kg/m(2), P = 0.0267) but not 6 months postmarathon. There were no significant differences in training volume (running frequency, run length, or cross-training volume) or injury rates between qualifiers and nonqualifiers. Prior to the 2008 TCM, 54% of runners included cross-training in their exercise program, which increased significantly to 74% 1 month postmarathon (P = 0.0039) and 71% 6 months postmarathon (P = 0.0325). There was no association between cross-training and injury rates., Conclusions: Nonelite marathon runners had a high degree of cross-training in their training program. Qualifiers for the Boston Marathon did not significantly differ in running frequency, run length, or cross-training volume compared with nonqualifiers. Whether changes in the training program at an individual level might facilitate a change in qualifying status remains to be determined.

Objective: To report the number of marathon finishers younger than 18 years and race day medical encounters at the same site and to compare them with adult finishers., Design: Retrospective cohort study., Setting: Urban 42-km road race., Participants: Twin Cities Marathon finishers., Assessment of Risk Factors: The race records from 1982 to 2007 were assessed for finishers younger than 18 years to determine the number of finishers and medical encounters, incidence of race-related medical encounters, and type and severity of medical problems., Main Outcome Measures: Age group marathon finishers and medical encounters., Results: Three hundred ten marathon (225 boys and 85 girls) aged 7 to 17 years finished the race with times ranging from 2:53:22 to 6:10:00. There were 4 medical encounters (minor in nature and required no intervention beyond a short period of rest) for an incidence of 12.9 per 1000 finishers. The odds ratio for youth compared with adult finish line medical encounters was 0.52 (P = 0.2658; 95% confidence interval, 0.19-1.39)., Conclusions: Three hundred ten youth marathon successfully finished Twin Cities Marathon over 26 years with only 4 requiring post-race medical evaluations. The relative risk of requiring acute race day medical attention was less than, but not statistically different from, adult finishers.

Exertional heat illness can affect athletes during high-intensity or long-duration exercise and result in withdrawal from activity or collapse during or soon after activity. These maladies include exercise associated muscle cramping, heat exhaustion, or exertional heatstroke. While certain individuals are more prone to collapse from exhaustion in the heat (i.e., not acclimatized, using certain medications, dehydrated, or recently ill), exertional heatstroke (EHS) can affect seemingly healthy athletes even when the environment is relatively cool. EHS is defined as a rectal temperature greater than 40 degrees C accompanied by symptoms or signs of organ system failure, most frequently central nervous system dysfunction. Early recognition and rapid cooling can reduce both the morbidity and mortality associated with EHS. The clinical changes associated with EHS can be subtle and easy to miss if coaches, medical personnel, and athletes do not maintain a high level of awareness and monitor at-risk athletes closely. Fatigue and exhaustion during exercise occur more rapidly as heat stress increases and are the most common causes of withdrawal from activity in hot conditions. When athletes collapse from exhaustion in hot conditions, the term heat exhaustion is often applied. In some cases, rectal temperature is the only discernable difference between severe heat exhaustion and EHS in on-site evaluations. Heat exhaustion will generally resolve with symptomatic care and oral fluid support. Exercise associated muscle cramping can occur with exhaustive work in any temperature range, but appears to be more prevalent in hot and humid conditions. Muscle cramping usually responds to rest and replacement of fluid and salt (sodium). Prevention strategies are essential to reducing the incidence of EHS, heat exhaustion, and exercise associated muscle cramping.

Unlabelled: Marathon running performance slows in warm weather conditions, but the quantitative impact of weather has not been established., Purpose: To quantify the impact of weather on marathon performance for different populations of runners., Methods: Marathon results and weather data were obtained for the Boston, New York, Twin Cities, Grandma's, Richmond, Hartford, and Vancouver Marathons for 36, 29, 24, 23, 6, 12, and 10 yr, respectively. The race results were broken into quartiles based on the wet-bulb globe temperature (Q1 5.1-10 degrees C, Q2 10.1-15 degrees C, Q3 15.1-20 degrees C, and Q4 20.1-25 degrees C). Analysis of the top three male and female finishers as well as the 25th-, 50th-, 100th-, and 300th-place finishers were compared with the course record and then contrasted with weather., Results: Marathon performances of top males were slower than the course record by 1.7 +/- 1.5, 2.5 +/- 2.1, 3.3 +/- 2.0, and 4.5 +/- 2.3% (mean +/- SD) for Q1-Q4, respectively. Differences between Q4 and Q1, Q2, and between Q3, and Q1 were statistically different (P < 0.05). The top women followed a similar trend (Q1 3.2 +/- 4.9, Q2 3.2 +/- 2.9, Q3 3.8 +/- 3.2, and Q4 5.4 +/- 4.1% (mean +/- SD)), but the differences among quartiles were not statistically significant. The 25th-, 50th-, 100th-, and 300th-place finishers slowed more than faster runners as WBGT increased. For all runners, equivalence testing around a 1% indifference threshold suggests potentially important changes among quartiles independently of statistical significance., Conclusion: There is a progressive slowing of marathon performance as the WBGT increases from 5 to 25 degrees C. This seems true for men and women of wide ranging abilities, but performance is more negatively affected for slower populations of runners.

Exertional heat stroke (EHS) during or following a marathon race can be fatal if not promptly recognised and treated. EHS is a true medical emergency and immediate cooling markedly improves the outcomes. It is critical to recognise EHS and stop the cell damage before the cascade of heat-induced tissue changes becomes irreversible. The goal is to keep the area that is >40.5 degrees C under the body temperature versus time curve at <60 degree-minutes. Measuring the rectal temperature is the only precise estimate of core temperature available for field use. The field treatment of EHS is immediate, total-body cooling with ice-water tub immersion or rapidly rotating ice-water towels to the trunk, extremities and head, combined with ice packing of the neck, axillae and groin. Any combination of delayed recognition or cooling increases the potential for morbidity and mortality. For optimal outcomes, it is best to treat immediately with on-site whole-body cooling if cardiorespiratory status is 'stable' and then to transfer the runner for additional evaluation and care.

Exercise-associated collapse (EAC) was developed as a marathon collapse classification matrix to speed clinical decision making and improve care. The definition was simply stated as the need for assistance during or immediately after endurance activity that specifically excluded cardiac arrest, insulin shock, anaphylaxis, trauma, skin conditions and orthopedic injuries. The presenting symptoms were neither specific nor sensitive and the initial classification, based on presenting rectal temperature, neurological status and ability to walk, was intended to shape the on-site medical intervention. The treatment of EAC centres on fluid redistribution and replacement to improve cerebral and core organ circulation and body temperature correction if needed. Most runners are discharged from the medical area in the company of another person.

There are few data on youth marathon runners and the most commonly asked questions of "can children run marathons?" and "what are the health consequences?" remain unanswered. Expert opinion is split with regard to running this distance at a young age. There have been many thousands of finishers <18 years old at the Los Angeles Marathon in an organised programme for youth running and nearly 300 finishers in at the Twin Cities Marathon. The youngest child in these data sets was 7 years old. There has not been any significant medical injury at these events. Children who choose of their own accord to participate in marathon training should be allowed to do so as long as their social, academic, psychological and physiological development is not disrupted. Follow-up studies of these young runners would help evaluate the long-term health consequences of long distance running and shape future recommendations.

The differentiation of physiological left ventricular hypertrophy (LVH) from hypertrophic cardiomyopathy (HCM) can prove challenging for even the most experienced cardiologists. The case is presented of a 17 year old elite swimmer who had electrocardiographic and echocardiographic features that were highly suggestive of HCM. However, indices of diastolic function were normal and cardiopulmonary exercise testing revealed high peak oxygen consumption in keeping with physiological LVH. To resolve the diagnostic dilemma, the patient underwent detraining for eight weeks, after which, there was complete resolution of the changes seen on electrocardiogram and echocardiogram, indicating physiological LVH rather than HCM.

A well-trained male runner in his late 30s collapsed 10 m before the finish line, nearly completing the 42.1-km marathon course in 3 h, 15 min. He was responsive to pain, agitated, diaphoretic, and unable to walk. The race start temperature was 6 degrees C (43 degrees F) with relative humidity of 99% and the 3-h temperature was 9.5 degrees C (49 degrees F) with a 62% relative humidity. Approximately 27 min after his collapse, his rectal temperature in the emergency department was 40.7 degrees C (105.3 degrees F), and his failing respiratory status required intubation. His initial Glasgow coma score was 6-7 of 15. His renal output was minimal until he was cooled and given a large fluid flush. His initial echocardiogram showed a "stunned" myocardium with an ejection fraction of 35%. He had a viral syndrome the week prior to the race and was paced by a "fresh" runner the last 16 km of the race. He left the hospital in 5 d and has now returned to running without problems, although several months passed before he felt well while exercising. Exertional heat stroke can occur in cool conditions, and rectal temperature should be checked in all collapsed runners who do not progress with rapid recovery of vital signs and cognitive function. Runners should be instructed not to compete when ill and should not use nonparticipant pacers during the runs.

This case report presents a high-level female runner with a history of more than 25 years of recurrent lower extremity (LE) injuries and LE malalignment problems during running. Due to her LE malalignment, she has been unable to run for the past 3 years. A definitive diagnosis was not found for her inability to run so by exclusion we diagnosed dysfunction of the hip, spine, and pelvic stabilizers that resulted in her in LE malalignment. To treat this muscle weakness, we designed a Pilates-evolved functional movement intervention to improve the control and strength of the proximal stabilizers and regain normal LE alignment. The Pilates-evolved treatment approach involved a series of functional and progressive resistance exercises designed to dynamically stabilize the spine, pelvis, and hip through all planes of motion. After 1 year of Pilates-evolved training, the athlete's disabling movement pattern resolved and she has returned to a regular running program. The purpose of this case report is to describe a Pilates-evolved functional movement intervention that resolved this runner's LE malalignment and returned her to running when other traditional treatment approaches were not effective in doing so.

Issues surrounding heat illness remain somewhat controversial, and our understanding of exertional heatstroke is evolving. The ability of humans to compete and work in hot, humid conditions with a low incidence of exertional heatstroke demonstrates tremendous adaptability. On the other hand, the occurrence of exertional heatstroke in conditions that should be prime for all-out physical effort remains puzzling and problematic.

From a primary care perspective, I believe the philosophy that "every patient is an athlete" sums up the changes in sports medicine since the advent of this journal. The emphasis has changed in three decades from "Johnny's ruin't knee" to the importance of exercise for general health and the inclusion of the entire population. Sports medicine treats competitive athletes, but it also crosses into the realm of activity and health.

Lateral epicondylitis, also known as tennis elbow, is a restricting injury for active people that sometimes requires an injection of corticosteroid and local anesthetic for pain relief. The chief symptom is that activities that supinate or dorsiflex the wrist usually cause pain at the origin of the extensor muscle group (figure 1: not shown). This muscle group acts in extension of the wrist, hand, and digits, and in supination of the wrist. Medial to the lateral epicondyle are the radial nerve and the radial recurrent artery.

Emergency care of a collapsed athlete begins with the ABC basic: A (airway), B (breathing) and C (circulation). Without an effective airway, all other interventions will fail. Cricothyrotomy is an emergency procedure that sideline providers should know and be ready to perform if airway access cannot be accomplished by positioning, rescue breathing, or endotracheal intubation.

Dental injuries occur frequently in contact sports, and some require immediate attention.

The "big hit" is glorified in professional ice hockey. But body checking is unnecessary for the quality of the game and demonstrably dangerous for most amateur players at the youth, high school, and college levels.

Plantar fasciitis is a major cause of heel pain in athletes and active people. The pain can usually be controlled with conservative measures, such as stretching, the use of arch supports, night splinting, and short-term activity modification, which allow the injured tissue to heal. However, persistent cases sometimes require an injection of a corticosteroid and local anesthetic into the calcaneal origin of the plantar fascia to relieve pain and promote healing.

Some of the most common presentations in a primary care office relate to shoulder pain; disorders of the rotator cuff and potential look-alikes such as referred neck pain or acromioclavicular (AC) joint arthritis are chief among the causes. The differential diagnosis can be difficult, particularly among older patients. And, of course, patients want relief of pain. Subacromial space injection using anesthetic with or without corticosteroid can assist in both phases of management.

Objective: To prospectively document the incidence of game injury rates in youth ice hockey tournaments to compare with season-long game injury rates and to analyze the injuries occurring at tournaments by mechanism, type, body location, severity, player position, and period of play., Design: A prospective injury report form completed for injured players by the tournament athletic trainer., Setting: Four boys' tournaments and one girls' tournament during the 1993-94 season., Participants: 807 boys and girls, ages 9-19., Measurements/main Results: 60 injuries occurred in boys and 4 occurred in girls. There were 26 boys with significant injuries and no girls with significant injuries. The significant game injury rates per 1000 player hours were 50.9 for boys combined, 57.9 for boys' Peewee A, 42.7 for boys' Bantam A, 64.8 for boys' varsity high school, 44.8 for boys' Junior Gold, and 0 for girls' Peewee A and B. Cerebral concussion comprised 15% of boys' injuries., Conclusions: The significant injury rate for boys' tournament game play was 4-6 times higher than the season game injury rates in two previous season-long studies. In boys' games, 65% of "all" injuries and 77% of "significant" injuries were related to collisions. The girls' rules of play do not allow body checking, and there were no significant injuries in girls' games. The boys had high rates of cerebral concussion injury at all age levels. Minimizing the frequency and intensity of collisions in the boys' game may decrease the injury rates, especially in the tournament setting.

High school and college wrestlers often attempt to "cut weight" before a tournament in an effort to wrestle in the lightest possible weight class and thereby gain an edge on opponents. Some wrestlers use unhealthy weight-loss practices, and last fall three college wrestlers died after extreme weight cutting.

When an ice hockey player hits the boards head-first after a hard body check or a football defensive back doesn't get up after a head-on tackle, the initial response is critical. If the player is unconscious or not breathing, it may be necessary to remove his or her helmet to access the airway. Helmet removal requires a careful, methodical approach to avoid compounding a suspected injury to the spinal cord.

For an athlete who has exertional heatstroke, every minute counts: Rapid cooling can mean the difference between walking away from the event medical area and being hospitalized with potential sequelae. The fastest and simplest way to cool a dangerously overheated athlete is to put him or her in an ice-water bath. This method reduces body temperature by an average of 17 degrees F an hour ((1)).

The image is familiar and dramatic. An elite athlete is injured, and a sports medicine physician is at his or her side while the athlete is carried from the field or arena to the sidelines and perhaps to a waiting ambulance. Thousands in the stands and millions more in front of televisions watch the physician practicing sports medicine in a most public way and are reminded that sports participation is a risky business.

A hand-based thumb spica cast can be used to protect the metacarpophalangeal (MCP) and interphalangeal (IP) joints of the thumb after uncomplicated ulnar collateral ligament (UCL) sprains and certain other thumb injuries. The cast allows continued participation in many activities, letting the patient grip an implement and move the wrist joint but immobilizing the thumb joints.

Injection and aspiration of a knee joint is a useful procedure for the office, especially in a practice involving many physically active patients. Common reasons for aspirating or injecting a knee include local anesthesia, diagnosis of an unexplained effusion, evacuation of a painful effusion, and injection of a corticosteroid.

Many recreational and elite runners participate in distance races each year. When these events are conducted in hot or cold conditions, the risk of environmental illness increases. However, exertional hyperthermia, hypothermia, dehydration, and other related problems may be minimized with pre-event education and preparation. This position stand provides recommendations for the medical director and other race officials in the following areas: scheduling; organizing personnel, facilities, supplies, equipment, and communication; providing competitor education; measuring environmental stress; providing fluids; and avoiding potential legal liabilities. This document also describes the predisposing conditions, recognition, and treatment of the four most common environmental illnesses: heat exhaustion, heatstroke, hypothermia, and frostbite. The objectives of this position stand are: 1) To educate distance running event officials and participants about the most common forms of environmental illness including predisposing conditions, warning signs, susceptibility, and incidence reduction. 2) To advise race officials of their legal responsibilities and potential liability with regard to event safety and injury prevention. 3) To recommend that race officials consult local weather archives and plan events at times likely to be of low environmental stress to minimize detrimental effects on participants. 4) To encourage race officials to warn participants about environmental stress on race day and its implications for heat and cold illness. 5) To inform race officials of preventive actions that may reduce debilitation and environmental illness. 6) To describe the personnel, equipment, and supplies necessary to reduce and treat cases of collapse and environmental illness.

Objectives: This analysis was performed to quantitatively assess the relative risks, associated with underlying cardiovascular disease, incurred in the course of intense competitive sports., Background: Sudden cardiac death during athletic activities is a highly visible event, and controversy persists regarding the true risks associated with participation in sports., Methods: The prevalence of sudden death was assessed in two systematically tabulated groups of endurance runners competing in the annual Marine Corps (1976 to 1994) and Twin Cities (1982 to 1994) marathons, held over a cumulative 30-year period., Results: A total of 215,413 runners completed the races, and four exercise-related sudden deaths occurred, each due to unsuspected structural cardiovascular disease. Three deaths occurred during the race (after 15 to 24 miles [24 to 38.4 km]) and the other immediately after its completion. The ages were 19 to 58 years (average 37), and three were men. Three of the sudden deaths were due to atherosclerotic coronary artery disease (narrowing of two or three vessels) and one to anomalous origin of the left main coronary artery from the right sinus of Valsalva. None of the four runners had prior documentation of heart disease or experienced prodromal symptoms, and two had previously completed three marathon races each. The overall prevalence of sudden cardiac death during the marathon was only 0.002%, strikingly lower than for several other variables of risk for premature death calculated for the general U.S. population., Conclusions: Although highly trained athletes such as marathon runners may harbor underlying and potentially lethal cardiovascular disease, the risk for sudden cardiac death associated with such intense physical effort was exceedingly small (1 in 50,000) and as little as 1/100th of the annual overall risk associated with living, either with or without heart disease. The low risk for sudden death identified in long-distance runners from the general population suggests that routine screening for cardiovascular disease in such athletic populations may not be justifiable.

Severe exercise-induced hyperthermia requires rapid cooling. Of the many cooling modalities available, there is disagreement over which is the most effective. The purpose of this field study was to compare two cooling therapies for hyperthermic distance runners who had completed an 11.5-km summer foot race. Twenty-one distance runners (mean [+/- SE] initial rectal temperature 41.2 +/- 0.2 degrees C) were treated either by ice water immersion (1 to 3 degrees C, n = 14) or by air exposure while wrapped in wet towels (24.4 degrees C ambient, n = 7). Ice water immersion versus air exposure resulted in significantly different (P < .005) pretherapy to posttherapy changes in rectal temperature (-3.0 +/- 0.3 v -1.4 +/- 0.3 degrees C) and mean cooling rate (0.20 +/- 0.02 v 0.11 +/- 0.02 degrees C/min). Ice water immersion cooled approximately twice as fast as air exposure. These data refute the theory that ice water immersion is an inefficient cooling modality.