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Venous thromboembolism (VTE) is not rare and is becoming more recognized in our athletic population. This diagnosis can be elusive. A provider must have a high clinical suspicion and use pretest probabilities to order the appropriate studies and accurately diagnose a VTE. Treatment using direct oral anticoagulants for 3 months is recommended in most cases. Gradual return to play can be achieved after treatment is complete. Some athletes, however, may require lifelong anticoagulation. Return to collision sports may be possible using a timed dose strategy if long-term anticoagulation is needed. The management of an athlete with a VTE should include an individualized treatment plan and involve shared decision making with the athlete, team physicians, and hematologic specialists.

Exercise-induced asthma (EIA) and exercise-induced bronchospasm (EIB)/bronchoconstriction (EIC) describes two clinical entities by which exercise triggers bronchial hyperresponsiveness. Exercise is a common trigger of bronchospasm in the asthmatic (EIA), as well as athletes without the underlying inflammation associated with asthma (EIC/EIB). Approximately 10% to 20% of the general population have EIA or EIB (). The approach to the diagnosis and subsequent management relies on the clinician's ability to recognize clinical signs and symptoms, then selecting the correct diagnostic test. A baseline spirometry/pulmonary function test is recommended for all athletes to evaluate for underlying asthma. Subsequent direct or indirect bronchial provocation testing is recommended to correctly diagnose EIA or EIB (). Athletes should not be treated empirically with bronchodilators based on symptoms alone without confirmatory spirometry and provocative testing.

Foot friction blisters in military personnel lessen a soldier's mobility, concentration, and critical decision-making skills.To determine the prevalence of and factors associated with friction blisters during deployment in all military personnel who nonurgently presented to the 28th Combat Support Hospital.A cross-sectional survey was performed at the 28th Combat Support Hospital. Statistical tests used included descriptive statistics, chi-square tests, and logistic regression for nominal data.The response rate was 97% with 872 surveys completed. Blister prevalence was 33% (95% confidence interval [CI] = 30.0-36.4). Eleven percent of these sought treatment (p0.001). Factors increasing the risk of developing blisters include female sex (prevalence ratio [PR] = 1.55, 95% CI = 1.27-1.91), wearing boots not broken in (PR = 1.52, CI = 1.26-1.85), longer than 6 months in theater (PR = 1.33, CI = 1.09-1.63), and history of prior blisters (PR = 2.08, CI = 1.69-2.56).The prevalence of foot friction blisters was 33% during a 12-month block of Operation Iraqi Freedom I. Of these, 11% required medical care. The group most likely to develop blisters is women, ages 26 to 34, who are unable to break in their boots and have a past history of blisters.

Background: To sustain progress toward injury reduction and other health promotion goals, public health organizations need a systematic approach based on data and an evaluation of existing scientific evidence on prevention. This paper describes a process and criteria developed to system- atically and objectively define prevention program and policy priorities. Methods: Military medical surveillance data were obtained and summarized, and a working group of epidemiology and injury experts was formed. After reviewing the available data, the working group used predefined criteria to score leading military unintentional injury causes on five main criteria that assessed factors contributing to program and policy success: (1) importance of the problem, (2) effectiveness of existing prevention strategies, (3) feasibility of establishing programs and policies, (4) timeliness of implementation and results, and (5) potential for evaluation. Injury problems were ranked by total median score. Results: Causes with the highest total median scores were physical training (34 points), military parachuting (32 points), privately-owned vehicle crashes (31 points), sports (29 points), falls (27 points), and military vehicle crashes (27 points). Conclusions: Using a data-driven, criteria-based process, three injury causes (physical training, military parachuting, and privately owned-vehicle crashes) with the greatest potential for successful program and policy implementation were identified. Such information is useful for public health practitioners and policymakers who must prioritize among health problems that are competing for limited resources. The process and criteria could be adapted to systematically assess and prioritize health issues affecting other communities.

Chronic exertional compartment syndrome of the lower leg is a well-described and documented cause of exercise-related pain in recreational, elite, and military athletes. Although this condition is common, the exact underlying mechanisms, those most at risk, long-term effects on muscular strength if unrecognized, and prevention strategies are relatively uncertain. Runners are most commonly affected and can be markedly impaired by the recurrent, often predictable pain that develops with exercise. An accurate history, high index of suspicion, and compartment pressure testing before and after symptomatic exercise confirms the diagnosis. Conservative therapy is minimally effective. Fasciotomy is the treatment of choice for athletes who are unwilling to modify their exercise or sport.

IN BRIEF: Exercise is perhaps the best ‘medication’ healthcare providers can prescribe fior their geriatric patients. Increasing fitness by participating in a regular exercise program can reduce the effects of aging that lead to functional declines and poor health. By exercising modestly and regularly, elderly patients can substantially lower their risk of death from coronary artery disease, colon cancer, and complications of diabetes. Even for those who start between the ages of 60 and 75, regular exercise can reduce overall mortality rates. Elderly patients can benefit tremendously from a comprehensive exercise prescription.

Physicians providing medical coverage at endurance events know that athletes often collapse during the race or shortly after crossing the finish line. An athlete who collapses during a race may have an ominous condition, such as a cardiac or neurologic event. The most common reason that athletes collapse at or shortly after the finish line is exercise-associated collapse, a benign postural hypotensive episode that resolves with rest, oral fluids, and elevation of the lower extremities. Volunteer clinicians at races must be able to quickly determine the cause of collapse and take appropriate steps to ensure that athletes receive proper initial care.

To sustain progress toward injury reduction and other health promotion goals, public health organizations need a systematic approach based on data and an evaluation of existing scientific evidence on prevention. This paper describes a process and criteria developed to systematically and objectively define prevention program and policy priorities.Military medical surveillance data were obtained and summarized, and a working group of epidemiology and injury experts was formed. After reviewing the available data, the working group used predefined criteria to score leading military unintentional injury causes on five main criteria that assessed factors contributing to program and policy success: (1) importance of the problem, (2) effectiveness of existing prevention strategies, (3) feasibility of establishing programs and policies, (4) timeliness of implementation and results, and (5) potential for evaluation. Injury problems were ranked by total median score.Causes with the highest total median scores were physical training (34 points), military parachuting (32 points), privately-owned vehicle crashes (31 points), sports (29 points), falls (27 points), and military vehicle crashes (27 points).Using a data-driven, criteria-based process, three injury causes (physical training, military parachuting, and privately owned-vehicle crashes) with the greatest potential for successful program and policy implementation were identified. Such information is useful for public health practitioners and policymakers who must prioritize among health problems that are competing for limited resources. The process and criteria could be adapted to systematically assess and prioritize health issues affecting other communities.

Exertional rhabdomyolysis (ER) is a condition characterized by muscle pain, swelling, and weakness following some exertional stress, with or without concomitant heat stress. Athletes who experience ER often present to the emergency department, the training room, or the physician's office seeking guidance and care for this condition, often feeling it is simply normal delayed onset muscle soreness. The astute clinician must perform a thorough history and focused exam, in addition to ordering a serum creatine kinase (CK) and urinalysis. In this clinical setting, a CK equal to or greater than five times normal or a urine dipstick testing positive for blood with no demonstrable red blood cells upon microscopic assessment confirms the diagnosis. A urine or serum myoglobin is more definitive when expeditiously available. After treatment for ER, the provider must risk-stratify the athlete for risk of recurrence, consider further testing, and make the difficult decision on when, if, and under what conditions the athlete can safely return to play.

Thousands of young athletes receive preparticipation evaluations each year in the United States. One objective of these evaluations is to detect underlying cardiovascular abnormalities that may predispose an athlete to sudden death. The leading cardiovascular causes of sudden death in young athletes include hypertrophic cardiomyopathy, congenital coronary artery anomalies, repolarization abnormalities, and Marfan syndrome. Because these abnormalities are rare and difficult to detect clinically, it is recommended that family physicians use standardized history questions and examination techniques. Athletes, accompanied by their parents, if possible, should be asked about family history of cardiac disease and sudden death; personal cardiac history; and exercise-related symptoms, specifically syncope, chest pain, and palpitations. The physical examination should include blood pressure measurement, palpation of radial and femoral pulses, dynamic cardiac auscultation, and evaluation for Marfan syndrome. Athletes with "red flag" signs or symptoms may need activity restriction, special testing, and referral if the diagnosis is unclear.

Friction blisters can have a negative effect on an individual's ability to perform his or her sport or duties. In a recent study, 69% of soldiers participating in a 20-km road march were found to have blisters, 10% of whom required medical intervention. Blistering of the feet is one of the most common injuries sustained by runners while training and racing. Although most blisters are minor and can be treated conservatively, others can lead to intense pain, cellulitis, and even sepsis. The best way to treat friction blisters is to prevent them; however, if they do occur, timely and effective treatment will help prevent the complications that can impede athletic performance.

Myocarditis is a pathologic entity that has serious potential consequences for competitive athletes. Myocarditis is an inflammation of the myocardium accompanied by myocellular necrosis. Cardiotropic viruses, in particular the Coxsackie B virus, have been implicated as the most common cause of acute myocarditis in the United States. A thorough history, physical examination, electrocardiogram, echocardiogram, elevated cardiac enzymes, and an elevated sedimentation rate help make the diagnosis. Athletes recovering from acute myocarditis should abstain from moderate to vigorous activity for 6 months, have normal cardiac function, and have no demonstrable arrhythmia before returning to sports.