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This consensus statement is an update of the 1987 American College of Sports Medicine (ACSM) position stand on the use of anabolic-androgenic steroids (AAS). Substantial data have been collected since the previous position stand, and AAS use patterns have changed significantly. The ACSM acknowledges that lawful and ethical therapeutic use of AAS is now an accepted mainstream treatment for several clinical disorders; however, there is increased recognition that AAS are commonly used illicitly to enhance performance and appearance in several segments of the population, including competitive athletes. The illicit use of AAS by competitive athletes is contrary to the rules and ethics of many sport governing bodies. Thus, the ACSM deplores the illicit use of AAS for athletic and recreational purposes. This consensus statement provides a brief history of AAS use, an update on the science of how we now understand AAS to be working metabolically/biochemically, potential side effects, the prevalence of use among athletes, and the use of AAS in clinical scenarios.

Objective First, we will update recommendations for the prehospital management and care of patients with exertional heat stroke (EHS) in the secondary school setting. Second, we provide action items to aid clinicians in developing best-practice documents and policies for EHS. Third, we supply practical strategies clinicians can use to implement best practice for EHS in the secondary school setting. Data Sources An interdisciplinary working group of scientists, physicians, and athletic trainers evaluated the current literature regarding the prehospital care of EHS patients in secondary schools and developed this narrative review. When published research was nonexistent, expert opinion and experience guided the development of recommendations for implementing life-saving strategies. The group evaluated and further refined the action-oriented recommendations using the Delphi method. Conclusions Exertional heat stroke continues to be a leading cause of sudden death in young athletes and the physically active. This may be partly due to the numerous barriers and misconceptions about the best practice for diagnosing and treating patients with EHS. Exertional heat stroke is survivable if it is recognized early and appropriate measures are taken before patients are transported to hospitals for advanced medical care. Specifically, best practice for EHS evaluation and treatment includes early recognition of athletes with potential EHS, a rectal temperature measurement to confirm EHS, and cold-water immersion before transport to a hospital. With planning, communication, and persistence, clinicians can adopt these best-practice recommendations to aid in the recognition and treatment of patients with EHS in the secondary school setting.

Many young athletes are pursuing high-intensity training and choosing to specialize in a single sport before high school. However, a growing body of literature suggests that this approach places children and adolescents at increased risk for physical and mental harm, and does not confer the desired benefit in the development of sport-specific skills. This article reviews concerns associated with early sport specialization, outlines principles of developmentally appropriate physical activity and athletic development, and provides practical guidance and resources to assist clinicians in counseling young athletes and their families.

Data on the psychosocial implications of sport specialization in pediatric athletes are lacking. Sport specialization often requires increased training hours and may predispose young athletes to social isolation, poor academic performance, increased anxiety, greater stress, inadequate sleep, decreased family time, and burnout. Sport specialization frequently introduces multiple stressors that could be expected to adversely affect mental health and function in young athletes and may increase the risk for burnout. This may be confounded by altered sleep duration and quality, increased drive for elite status, and perfectionistic personality types. The signs and symptoms of burnout in young athletes can be difficult to detect. It is important to be aware of the possible diagnosis of burnout in young athletes who display vague symptoms and a decrease in academic performance. The purpose of this review was to survey the available literature on sport specialization in young athletes and its association with mental health, sleep, the drive for success in sport, and burnout.

* Abbreviation: PES — : performance-enhancing substance The use of legal performance-enhancing substances (PESs) is common among adolescents, particularly boys.1 Approximately one-third of all youth use creatine, protein powders, or dietary supplements,2–4 and an even greater proportion of athletes and college students do so.5,6 Although previous studies have correlated legal PES use with future use of illegal PESs,7,8 in a study in this issue of Pediatrics , Ganson et al9 explore a broader role for PESs as a gateway to alcohol and other substance use. There are 2 key points to recognize when addressing this topic: 1. “PES” is a misleading term. Most legal supplements marketed for athletic performance enhancement are ineffective at increasing muscle mass or athletic performance beyond what can be achieved through appropriate nutrition and training.1,10 They are not truly performance enhancing. 2. Many adolescents, both athletes and nonathletes, are using PESs primarily in pursuit of a more muscular appearance, rather than for performance-oriented goals. This recognition has spurred an evolution of terminology, with increasing use of “appearance and PESs” in place of the … Address correspondence to Steven Cuff, MD, FAAP, Division of Sports Medicine, Nationwide Children’s Hospital, 584 County Line Rd West, Westerville, OH 43082. E-mail: steven.cuff{at}nationwidechildrens.org

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a position statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the task force used an iterative process and expert consensus to finalize the position statement. The objective of this position statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport.

Sport participation directly impacts the mental health of young athletes. Physical activity and team culture are two features that shape the influence of sport on self-esteem and mental health. Children and adolescents with anxiety, depression, attention deficit hyperactivity disorder (ADHD), and conduct disorder (CD) benefit when parents, coaches, and healthcare providers are knowledgeable on how to adapt the sporting experience to the needs of young athletes with mental illness.

Youth athletics can provide numerous benefits to children. Until recently, athletics have been relatively free from scrutiny over the ways they put participants at risk. While it was often disregarded in early childhood research, athletics emerged as an avenue of child abuse in the 1980s. Individual cases reporting maltreatment of children participating in sports certainly existed, but these were felt to be single instances, not sentinel events. By the 1990s a small body of research had been established showing a pattern of abuse, spurring sporting organizations and governing bodies to assess their own policies and produce rough standards for safeguarding children against abuse. While multiple strides have been taken, there still exist gaps in knowledge surrounding abuse of child and adolescent athletes. This article reviews the scope and prevalence of abuse in youth athletics, definitions and what ultimately constitutes "abuse," the unique aspects of abuse in sport, and recognition and preventative efforts.

Exertional heat stroke (EHS) is one of the most common causes of sudden death in athletes. It also represents a unique medical challenge to the prehospital healthcare provider due to the time sensitive nature of treatment. In cases of EHS, when cooling is delayed, there is a significant increase in organ damage, morbidity, and mortality after 30 minutes, faster than the average EMS transport and ED evaluation window. The purpose of this document is to present a paradigm for prehospital healthcare systems to minimize the risk of morbidity and mortality for EHS patients. With proper planning, EHS can be managed successfully by the prehospital healthcare provider.

The use of performance enhancing drugs and supplements in sport and physical activity has been around for decades; however, the impact of these drugs and supplements on performance in the heat has been garnering new attention. Although there are some drugs and supplements that can enhance performance in the heat, there are also many that may hinder performance, even potentially increasing the risk of serious illness or death in select circumstances. This chapter will describe and discuss specific drugs and supplements and their effects on performance and safety in the heat.

American football remains one of the most popular sports for young athletes. The injuries sustained during football, especially those to the head and neck, have been a topic of intense interest recently in both the public media and medical literature. The recognition of these injuries and the potential for long-term sequelae have led some physicians to call for a reduction in the number of contact practices, a postponement of tackling until a certain age, and even a ban on high school football. This statement reviews the literature regarding injuries in football, particularly those of the head and neck, the relationship between tackling and football-related injuries, and the potential effects of limiting or delaying tackling on injury risk.

The number of anterior cruciate ligament (ACL) injuries reported in athletes younger than 18 years has increased over the past 2 decades. Reasons for the increasing ACL injury rate include the growing number of children and adolescents participating in organized sports, intensive sports training at an earlier age, and greater rate of diagnosis because of increased awareness and greater use of advanced medical imaging. ACL injury rates are low in young children and increase sharply during puberty, especially for girls, who have higher rates of noncontact ACL injuries than boys do in similar sports. Intrinsic risk factors for ACL injury include higher BMI, subtalar joint overpronation, generalized ligamentous laxity, and decreased neuromuscular control of knee motion. ACL injuries often require surgery and/or many months of rehabilitation and substantial time lost from school and sports participation. Unfortunately, regardless of treatment, athletes with ACL injuries are up to 10 times more likely to develop degenerative arthritis of the knee. Safe and effective surgical techniques for children and adolescents continue to evolve. Neuromuscular training can reduce risk of ACL injury in adolescent girls. This report outlines the current state of knowledge on epidemiology, diagnosis, treatment, and prevention of ACL injuries in children and adolescents.

For this issue of BJSM , we were charged with crafting a systematic review of how well the preparticipation physical evaluation (PPE) meets its objectives in paediatric athletes. According to the fourth edition PPE monograph, the primary objectives for the PPE are to screen for conditions that may be life-threatening, disabling or predispose to injury or illness.1 While substantial literature has emerged on cardiac and musculoskeletal screening in this group, there was insufficient information on the remainder of the evaluation, particularly in preadolescents, to produce a meaningful systematic review. This lack of evidence, and the evolution of the healthcare landscape, raises concern about resources currently used to conduct PPEs as a discrete clinical service, particularly when separated from broader preventive and screening services delivered by primary care providers (PCPs). Current recommendations are for children and adolescents to accumulate 60 min of moderate to vigorous physical activity per day, with an emphasis on the need to include vigorous levels of exertion. Therefore, assessments to enhance safety during high-intensity physical activity and sport should …

Performance-enhancing substances (PESs) are used commonly by children and adolescents in attempts to improve athletic performance. More recent data reveal that these same substances often are used for appearance-related reasons as well. PESs include both legal over-the-counter dietary supplements and illicit pharmacologic agents. This report reviews the current epidemiology of PES use in the pediatric population, as well as information on those PESs in most common use. Concerns regarding use of legal PESs include high rates of product contamination, correlation with future use of anabolic androgenic steroids, and adverse effects on the focus and experience of youth sports participation. The physical maturation and endogenous hormone production that occur in adolescence are associated with large improvements in strength and athletic performance. For most young athletes, PES use does not produce significant gains over those seen with the onset of puberty and adherence to an appropriate nutrition and training program.

Preparticipation physical evaluations are often a challenge for physicians. A recent study examined the PPE in clinical practice among pediatricians and family physicians in the state of Washington. Unfortunately, many physicians in this study perceived significant barriers to effective performance of the PPE. These barriers included uncertainty about how to perform the PPE, the relative importance of each PPE component, and the lack of a standardized approach and time for appropriate performance of the PPE. Although these concerns are shared by physicians beyond the borders of Washington, those who are aware of the information contained in the PPE monograph are able to use current best practices to enhance the effectiveness and efficiency of this examination and report greater comfort and satisfaction with these evaluations.

Preparticipation physical evaluations are often a challenge for physicians. A recent study examined the PPE in clinical practice among pediatricians and family physicians in the state of Washington. Unfortunately, many physicians in this study perceived significant barriers to effective performance of the PPE. These barriers included uncertainty about how to perform the PPE, the relative importance of each PPE component, and the lack of a standardized approach and time for appropriate performance of the PPE. Although these concerns are shared by physicians beyond the borders of Washington, those who are aware of the information contained in the PPE monograph are able to use current best practices to enhance the effectiveness and efficiency of this examination and report greater comfort and satisfaction with these evaluations.

Objective: The purpose of this study was to compare the incidence of prior head injury reported on preparticipation physical evaluation (PPE) history forms with a retrospective symptom-based survey. Design: A comparison of 2 retrospective survey instruments. Setting: NCAA Division I varsity athletic program. Participants: A total of 93 male and 79 female athletes participating in intercollegiate contact/collision sports. Main Outcome Measures: Athletes were administered a concussion symptom survey (CSS) with questions about symptom incidence after head injury. These responses were compared with answers given about previous concussion/head injury on the university's PPE history form. The numbers of positive responses were analyzed using descriptive statistics, and differences between the PPE medical history form and the concussion symptom survey were assessed using χ2 analysis. Factor analysis was performed to assess for possible variance structure between reported symptoms. Results: Seventy-one percent of athletes reporting symptoms consistent with concussion were not identified as having a history of head injury on the PPE medical history form. The most common symptom on the CSS was headache, which accounted for 46 (56.1%) positive responses. Conclusions: The CSS revealed greater numbers of athletes experiencing symptomatic head injuries than the screening questions on the PPE history form. Screening for signs and symptoms of concussion may enhance the sensitivity of the PPE in detecting a prior history of concussion.

Ice hockey is an increasingly popular sport that allows intentional collision in the form of body checking for males but not for females. There is a two- to threefold increased risk of all injury, severe injury, and concussion related to body checking at all levels of boys' youth ice hockey. The American Academy of Pediatrics reinforces the importance of stringent enforcement of rules to protect player safety as well as educational interventions to decrease unsafe tactics. To promote ice hockey as a lifelong recreational pursuit for boys, the American Academy of Pediatrics recommends the expansion of nonchecking programs and the restriction of body checking to elite levels of boys' youth ice hockey, starting no earlier than 15 years of age.

Despite previous recommendations from the American Academy of Pediatrics discouraging home use of trampolines, recreational use of trampolines in the home setting continues to be a popular activity among children and adolescents. This policy statement is an update to previous statements, reflecting the current literature on prevalence, patterns, and mechanisms of trampoline-related injuries. Most trampoline injuries occur with multiple simultaneous users on the mat. Cervical spine injuries often occur with falls off the trampoline or with attempts at somersaults or flips. Studies on the efficacy of trampoline safety measures are reviewed, and although there is a paucity of data, current implementation of safety measures have not appeared to mitigate risk substantially. Therefore, the home use of trampolines is strongly discouraged. The role of trampoline as a competitive sport and in structured training settings is reviewed, and recommendations for enhancing safety in these environments are made.

Sports and energy drinks are being marketed to children and adolescents for a wide variety of inappropriate uses. Sports drinks and energy drinks are significantly different products, and the terms should not be used interchangeably. The primary objectives of this clinical report are to define the ingredients of sports and energy drinks, categorize the similarities and differences between the products, and discuss misuses and abuses. Secondary objectives are to encourage screening during annual physical examinations for sports and energy drink use, to understand the reasons why youth consumption is widespread, and to improve education aimed at decreasing or eliminating the inappropriate use of these beverages by children and adolescents. Rigorous review and analysis of the literature reveal that caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents. Furthermore, frequent or excessive intake of caloric sports drinks can substantially increase the risk for overweight or obesity in children and adolescents. Discussion regarding the appropriate use of sports drinks in the youth athlete who participates regularly in endurance or high-intensity sports and vigorous physical activity is beyond the scope of this report.

Most patients who have patellofemoral syndrome can be successfully treated once contributing factors are identified during history taking and physical examination. After pain and inflammation are treated, patients are encouraged to start activities that do not provoke pain. Exercise programs should be implemented that address underlying strength and flexibility deficits. Return to play primarily relies on advancement of pain-free activity, with some allowance for patients' competitive goals. Patients remaining symptomatic after compliance with a structured rehabilitation program or those with indicators of other intra-articular pathology should be referred to an orthopedist.

To determine the prevalence and pattern of creatine use among varsity athletes at a National Collegiate Athletic Association (NCAA) Division I athletic program.Anonymous descriptive survey.Institutional.Collegiate varsity and junior varsity athletes.Self-reports of creatine use, including pattern of use and dose, source of information on creatine, and expected and perceived effects from creatine use.Surveys were obtained from 93% of 806 eligible athletes. Overall, 68% of athletes had heard of creatine and 28% reported using it. Forty-eight percent of men reported having used creatine as compared with 4% of women. With two exceptions, all men's teams had at least 30% of athletes who reported a history of creatine use. Of athletes that had used creatine, about one-third had first used it in high school. Friends and teammates were the most common sources of creatine information. Increased strength and muscle size were the most common effects the athletes expected and perceived from creatine use.In this population of collegiate athletes, creatine use was widespread among men but was minimal among women. Athletes learned about creatine supplementation primarily from their peers, and substantial numbers began to take creatine while still in high school. Most athletes could not report their dosing of creatine. This study reported findings at one location for one academic year. Studies are needed at multiple locations and over time to further delineate creatine use patterns.

Purpose: The purpose of this report was to review three cases of clinically significant rhabdomyolysis that developed in research subjects after completing an eccentric exercise protocol. All three cases occurred in subjects who reported use of selective serotonin reuptake inhibitors (SSRI). Methods: Sixty-three subjects enrolled in the study. Subjects performed 15 sets of 15 repetitions of maximal eccentric contractions of the elbow flexors. Subjects were then monitored on a daily basis for development of delayed onset muscle soreness (DOMS). Subjects received either microcurrent electrical neuromuscular stimulation (MENS) or sham treatment. Results: Three subjects developed clinically significant rhabdomyolysis after performing this exercise protocol. Affected subjects were the only subjects who reported use of SSRI during the study period. Conclusion: This report raises suspicion of SSRI use as a predisposing factor to muscle injury after eccentric exercise.

Exercise-induced asthma (EIA) is a complex disorder affecting a sizeable minority of athletes. Proper pharmacologic management allows most every athlete at any level to participate with EIA. This article briefly addresses the pathophysiology, diagnosis, and basic treatment principles, including nonpharmacologic management for EIA. Most of the article details the current treatment strategies and provides information on experimental treatments being investigated. In addition, ergogenic concerns and problems in treating elite athletes are discussed.

Patellofemoral syndrome (PFS) is one of the most common causes of knee pain in active patients and stems from problems with the kneecap (patella) as it moves over the front of the knee. PFS causes pain in the front of one or both knees, especially after either exercising or sitting for prolonged periods. Some patients will experience minor swelling and the feeling that their knee "catches" or gives way.