EKG Screens help prevent Sudden Cardiac Death for athletes

During last Friday’s high school football match up between Warren County and Smith County, there were a couple plays that could have given any body a heart attack. One heart breaking play was an attempted interception by Tyler Worthingham that bobbled into the hands of a Smith County offensive receiver for a touchdown.

Tim McIntosh (WCHS trainer), the Rotary Club, Warren County EMS, River Park Hospital, and the St. Thomas Heart Group have teamed up to provide cardiac screening for all WCHS athletes in an attempt to avoid a tragic heartbreaking loss of a young athlete to sudden cardiac death caused by hyptrophic cardiomyopathy.

Cardiac screens are expensive and this financial burden is often a reason that cardiac screen is quickly removed from budgets. Due to the volunteer efforts of individuals within the organizations above and donations of supplies, cardiac screening for all WCHS athletes is being provided at no cost to WCHS or the athlete.

There is another controversial debate with cardiac screening: Does the EKG provide quality information about an athlete’s heart?

Electrocardiograms (EKGs) are not sensitive tests. Sensitivity is a test’s ability to confidently rule out a condition if the result is a negative test. An example of poor sensitivity is if the grass is wet in the morning, it does not mean that it rained during the night.

In 1987, Maron etal. stated in the Journal of American College of Cardiology, “This failure to identify [hypertrophic cardiomyopathy] could have been due to a lack of sensitivity of the screening tests or to the low frequency with which these diseases occur in youthful healthy athletes. A systematic pre-participation screening program does not appear to be an efficient means of detecting clinically important cardiovascular disease in young athletes.”

The results of this study mean that if a WCHS athlete receives a negative result from the EKG test, the athlete may still have hypertrophic cardiomyopathy. The prevalence of hypertrophic myopathy is 1/600 and the risk of death is from this condition in high school age athletes is 1:100,000. Even if an athlete receives a negative EKG test, coaches, parents, and athletes should never ignore cardiac symptoms such as shortness of breath, chest pain, or light-headness. Furthermore, budget cuts should never consider eliminating the need for a Certified Athletic Trainer like Tim McIntosh, ATC on-site during athletic programs.

If the EKG testing has such limitations, why is UTK and WCHS making this test mandatory for all athletes?

EKGs are highly specific. A specific study means that if an athlete has a positive test for hypertophic cardiomyopathy, the physician will be certain that the athlete has this condition. In cases of acute cardiac failure, EMS and sports medicine staff have approximately 6 minutes to save a life, but with the EKG, prevention can occur and less invasive life-saving measures can be taken.

In a 1997 article in the journal, Medicine and Science in Sports and Exercise, Fuller etal stated, “Cardiac history led to detection of outcome measures in 0 athletes, auscultation/inspection in 1/6,000 athletes, blood pressure measurement in 1/1,000 athletes, and the EKG in 1/350 athletes.” Translation: EKG is much better than the traditional pre-prarticipation physical for finding this deathly condition.

In a 2011 article in the British Journal of Sports Medicine, Hevia etal conclude their study stating, “Given the ability of 12-lead EKG to detect individuals with structural heart disease, we suggest its inclusion as a part of pre-participation screening programs.” The American Heart Association also supports the use of EKG to detect hypertrophic cardiomyopathy.

Additionally, there is evidence in recent medical literature that supports mandatory cardiac testing. Since Italy implemented mandatory EKG testing for all athletes in 1982, Italy has demonstrated an 89% reduction in sudden cardiac death.

EKG testing for athletes does not abolish the risk and warning sign always need to be examined by a medical professional. However, when an athlete is identified with EKG to have the life threatening condition of hypertrophic cardiomyopathy, there will be no doubt or speculation about the finding and the athlete will be safer for it.

Fall sports face histology

There are some physically rugged sports currently going on in Warren County this fall including football, soccer, and volleyball. Regardless of the scoreboard, these athletes have physical contact with other players and the ground and are at risk daily to sustain contusions.

Contusions are also known as bruises. Contusions occur when two things collide together and the result is damage. Contusions can occur because of a knee to the gym floor, a helmet to an elbow, or a foot to a shin.

The human body is made up of thousands of cells. Cells contain many functioning parts, but the cytoplasm, the liquid-like filling, is what makes up the majority of the cell. When these collisions occur, the cell walls and plasma membranes break and the cytoplasm leaks into the body. This leaking process is called exudation. Lots of leaking results in swelling occurs.

The damage of these cells initiates the inflammatory process. Often the word inflammatory is considered bad or harmful, but the inflammatory process is actually the start of the healing process. Anti-inflammatory medicines shut down the inflammatory process and thus shut down the initiation of the healing process. Therefore, anti-inflammatory medicines such as Ibuprofen and Motrin are not recommend during the first 24-48 hours after injury unless directed by a physician.

A good analogy for a contusion and the resultant healing process that occurs is a car wreck or fender-bender. The contusion, the act of collision, is much like the wreck with damage to the car’s body and the engine often leaks fluid.

After the accident, the body shop first removes the damaged parts such as the bumper and the hood. The human body has special cells called leukocytes that do the same thing as the body shop, removing the proteins and other parts of the broken and leaking cells.

The body shop orders a new hood and fender, while also repairing any other dents to the remaining body parts of the car. Within the human body, cells called cytoblasts replace and repair damaged parts at the site of the contusion.

And as with a car wreck, the more damage that occurs with the collision, the longer our body takes to repair contusion.

Athletes can help the body recover from contusions by using R.I.C.E. (rest, ice, compression, elevation) and performing gentle movement exercises in the joints above and below the contusion. These activities help increase blood flow and nutrient exchange at the site of the contusion.

Most contusions resolve with our body’s independent response, however, if the contusion causes numbness or severe and throbbing pain, consult your sports medicine professional or physician. These symptoms can be serious. These symptoms are often due to swelling that occurs against a nerve or within a tight space, leading to additional damage to other cells. Interventions that may be recommended to treat the contusion may include anti-inflammatory medicine and modalities that help exchange cells such as therapeutic ultrasound.

One final though about contusions. As with any other aspect of sport medicine, an ounce of prevention is worth a pound of cure. Protective equipment has been designed to protect athletes. Contusions can result from athletes not wearing protective or wearing it improperly.

Carlene W. Brown, CPRP joins team at McMinnville Physical Therapy

To help Christi Gilliam, PT and Zach Sutton, PT, OCS, achieve McMinnville Physical Therapy's mission of patient-center care, McMinnvillePT added a new team member. Mrs. Carlene W. Brown, CPRP, will serve as McMinnville Physical Therapy’s Clinic Coordinator.

Carlene joins the McMinnvillePT team with 31 years of experience in management and recreation. She holds a bachelors of science degree in Parks and Recreation Administration and a minor in Business Management. In addition to being a Certified Parks and Recreation Professional, she is a Certified Aquatic Facility Operator, and has multiple wellness certifications. She has a passion for helping people enhance the quality of their life, which is in-line with McMinnvillePT’s patient-centered care mission.

Carlene’s main role will be assuring that the patient’s experience at McMinnville Physical Therapy is about them feeling better and not about the headaches of insurance, scheduling, or paperwork. Additionally, she will also help facilitate communication with physicians about the progress of their patients.

Christi and I are also proud to have Carlene as part of our team due to her community involvements including Warren County Health Council, Breakfast Rotary, Evening Exchange, Main Street McMinnville Board, and Chamber of Commerce, just to name a few.

All of us at McMinnvillePT welcome any questions regarding the progress of the business or about physical therapy at 931-474-7755 or at info@McMinnvillePT.com. Best wishes and Happy New Year!

Meniscal Injuries

Another knee article? What is left to talk about in the knee? The meniscus is a piece of cartilage and has a number of important responsibilities.

First, it is a shock absorber. It is not hard like bone, but softer like the discs in our back. When we walk, run and jump, the bones transfer force up the limb and the meniscus help decrease the impact when the force is transferred from bone to bone.

Second, it helps with stabilization. The knee joint is a stable joint by design with the ligaments and muscles, but not because of the bone structure. It is not a deep socket like the hip but much flatter joint surface like our fingers. The meniscus is thicker on the outside of the knee than the inside, so it helps deepen the rather shallow knee joint.

Third, it reduces arthritis to the articular cartilage, the smooth lining of the ends of the knee bones. Without the meniscus there is more bone to bone contact which leads to quicker breakdown of the smooth lining. For this reason, orthopedic surgeons always attempt to repair a meniscus if able, rather that taking it out. The articular cartilage actually does not have pain receptors in it, so the reason why articular damage hurts is because of the bone structure under the articular cartilage that does have pain receptors.

The meniscus can get damaged two ways. First, is trauma. Meniscal damage is very common when ACL tears occur. The ACL injury occurs generally with twisting and twisting with compression also shears the meniscus potentially causing a tear. The second way is with degeneration and general wear and tear. As we age, our body tissues get dehydrated. I am not talking about whether you drink enough water --although everyone should stay hydrated and yes, that level does affect cartilagenous tissues in our body--but just like foam around handles and rubber seals around car doors shrink and breakdown, so do these types of cartilage. This lack of hydration leads to increased potential for meniscus breakdown.

There are a number of signs of meniscal issues. First, joint line pain is generally present. The pain though can be deeper though. Second, catching or locking. If the tear causes a big flap, the flap can get folded over and block the knee bones from moving in a certain direction. Either of these symptoms warrant a discussion with your primary care physician and or orthopedist.

Meniscal tears can heal, but where the tear is located is a very important part of this determination. If the tear is in a place that can heal, a surgeon can repair it with staples or stitches. If is located on the more inside of the knee, where circulation is poor, it will not heal and more than likely, the surgeon will remove the torn portion. Although a repair of a meniscus will require a number of weeks with crutches while removal of the menicus will have no weight bearing restrictions, the weight bearing limitations of the repair are worth the benefits in the long run.

There are non-surgical options that may be considered prior to undergoing the knife, and yes, physical therapy is one of them. Physical therapy focuses on improving the circulation to the knee joint with low resistance cyclical motion, improving the strength around the knee and assuring good alignment with the hip and foot.

To avoid mensical damage, avoid deep knee squats and lifts is the main prevention point. While activity will increase wear and tear, not performing physical activity to "save" your meniscus is not a good alternative! If you knee is limiting your physical activity, please consult your primary care, orthopedist or physical therapist, so you can get back to your favorite sport, recreational activity or simply back to getting around the house. Do not let knee pain hinder you getting benefits for your heart and other joints.

Ankle Injuries Article for Southern Standard

Although the UT-Knoxville Volunteers shut out the UT-Martin Shyhawks, 50-0, it was not without a little suffering. In addition to other injuries, two Volunteers suffered from ankle injuries. While Jarrod Shaw, offensive lineman, and Denarius Moore, wide receiver, were questionable, they played against Oregon.

The University of Tennessee Department of Sports Medicine does not release specific injury reports or more specificity beyond: Out, Questionable, Probable, or Active, so lets speculate what injuries these athletes could have sustained.

The most common ankle injury is a “sprain” resulting from a twist in the ankle. The most common are call inversion ankle sprains and is when the heel and bottom of the foot roll inwards. This can happen when a player steps on another foot, the player cuts but the player’s weight is on the outside of the foot, or when the player gets tackled low. Another name for these sprains is lateral ankle sprains. Lateral means outside, most of the damage with ankle sprains is on the outside of the ankle.

Inversion or Lateral ankle sprains have three grades of severity. The severity is dependent on how many ligaments are damaged. If you make the “OK” sign with you hand and then place it on the outside of you ankle with palm in and fingers down, your three fingers are roughly in the places of the three outside ligaments. For any future anatomists out there they are call (from front to back): the anterior talofibular ligament, calcaneal fibular ligament, and posterior talofibular ligament.

There are a couple grading systems for ankle sprains, but for simplicity, grade 1 is when the front ligament is injured, grade 2 is when the front two are injured, and grade 3 is when all three are injured.

Often athletes can get back in the game with a grade 1 ankle sprain, but grade 2 ankle sprains require more time off due to the increased instability. Acute treatment for ankle sprains, whether you are a Volunteer on the field or a Volunteer fan that stepped off the tailgate wrong, is RICE: Rest, Ice, Compression, and Elevation. The next step is getting motion and mobility back. Specific training of the outside muscles with strengthening and balance exercises are crucial to increasing the bodies ability to protect the damaged ankle.

Ligaments unfortunately do not shrink once stretched, so often the strengthening and balance is the most important to prevention and is often overlooked because it is generally after the pain has diminished and people return to general activity.

A couple newspapers reported that Denarius Moore was using a walking boot, a big bulky immobilizer that covers the entire foot and shin, but can be used with walking. This is a form of rest. By allowing the ankle not to have to control shifting while walking, there is decreased stress to the ankle joints.

Although ankle sprains generally pull all at the ligaments on the outside to cause the damage, the inside of the ankle can often have damage because of the compression, which results in swelling and bruising, but does not hurt the stability of the inside of the ankle.

Two other somewhat common results can occur with a lateral ankle sprain: a fracture of the fibula, the outside bone at the ankle, or a “high” ankle sprain. The fracture of the fibula will require cast immobilization or a surgical fixation.

The high ankle sprain is a tear in the ligament between the two bones of the lower leg, the tibia and the fibula. While these bones do spread as our ankle moves, too much will cause a tear. High ankle sprains generally occur with grade 2 or 3 ankle sprains and will require a much longer healing time. If the high ankle sprain is very unstable, it is not uncommon for an orthopedist to place a temporary screw to hold the two bones together to allow for healing.

Because of the quick return to active status, as a spectator in the peanut gallery, I assume that the ankle injuries sustained by Jarrod Shaw and Denarius Moore were grade 1 or 2 with no high ankle sprain involvement.

The Volunteers will see many more ankle injuries this year, lets just hope that they don’t make the grading scale and they get back to the field ASAP. Go Vols!

Zach Sutton, PT
Doctor of Physical Therapy
Master of Exercise Science
Board Certified Orthopaedic Specialist
Certified Athletic Trainer

Prenatal and Postpartum Exercise

On the first weekend of college football, you may ask, why in the world is there an article on prenatal and postpartum women in this week's sports medicine moment? Well, last week I became a proud father of a little baby girl, who was born at River Park Hospital’s awesome Family Birth Center.

To my wife and all mothers, you have my respect and admiration and therefore this sports medicine moment is dedicated to you.

I think it is obvious that I a proponent of exercise, and the benefits of exercise do not skip prenatal and postpartum women. During these times, exercise helps decrease low back and pelvic pain, maintain appropriate weight and increase Endorphins that lower risk of depression.

Recreational exercise such as walking, running and swimming can be continued throughout the prenatal period, but women should check with their OB specialist before beginning any new exercise program. Weight lifting for “toning” can often be continued during the first two trimesters. Team sports and recreational activities that have a higher risk for trauma, such as softball and bicycling, should be limited, but are best if avoided.

Robin Bell, a certified nurse midwife with Innovative Women's Health and Dr. Rene del Valle, endorses exercise, but states that exercise should be avoided if you experience extreme fatigue, have been placed on bed rest or have poorly controlled disorders such as blood pressure, diabetes, or seizures.

Recent medical literature links unnecessary pregnancy weight gain to childhood obesity. The Kaiser Foundation estimates that 36% of all children in Tennessee are overweight or obese. Childhood obesity increases many medical risk factors including diabetes, premature joint pain, and cardiovascular diseases.

Robin Bell states that she individually determines for her patients what amount of weight gain is necessary for a healthy baby utilizing a Body Mass Index (BMI) calculation. Generally, if a person is overweight prior to the pregnancy, less weight gain is necessary and but more weight gain may be recommended for someone who is underweight.

Low back pain is a common complaint due to the increased looseness of the pelvic bones from the hormone called Relaxin. Relaxin increases as early as 14 weeks and can remain into postpartum as long as breastfeeding is occurring.

Christi Gilliam, PT, who specializes in orthopedics and women's health at River Park Hospital, recommends an evaluation with a women's health physical therapist for women who experience pelvic or low back pain during the prenatal or postpartum period. She states that specific pelvic exercises during prenatal and postpartum can help control these episodes of back pain.

If you are expecting, talk with your OB specialist because prenatal and postpartum exercise could play a major role in the health and well being of you and your baby!

Zach Sutton, DPT, MS, OCS

Osteoarthritis

Osteoarthritis

What is osteoarthritis? Osteoarthritis is literally arthritic inflammation of the bone. Our bones are highly structural, but are quite rough, so there is covering layer at the ends of all our bones called cartilage. This cartilaginous covering normally wears away in all of us throughout our lives, but some quicker than others.

There are some new procedures like hyalgine injections and glucosamine and chondrotine sulfate that attempt to improve the layer, but ultimately this layer is not replaceable.

People with osteoarthritis often feel limited, wanting to exercise but are concerned about experiencing more pain or causing more damage. This double edge sword situation can be challenging and often leads people to consider knee and hip replacements.

This limitation, avoiding weight-bearing exercise, often limits people in their ability to exercise, which affects not just their muscle strength and bone integrity, but also lung and heart function. Do not let osteoarthritis keep you avoiding exercise because it will affect your entire body, your health, and your lifespan.

Starting an exercise regime with osteoarthritis should focus on ways to increase the pounding of your heart rate without the pounding on the joints. Water exercise and aerobics is a wonderful alternative because of the buoyancy eliminates the pounding on your joints, but the water also gives resistance for strengthening.

You do not need to know how to swim, you can do all these exercises standing up and in the shallow end of a pool! The Civic Center has instructors certified to assist you, so why wait!

Alternatives to running, walking and water programs are the elliptical, bicycling, and the rowing, the later two can be performed in the gym or out in nature. There is a great benefit to joints with cyclical motions that are performed with the bicycle and the elliptical. Our joints actually get very little circulation and blood flow and rely on movement to get nutrients into the joint and inflammation out of the joint. Do you ever wonder why your joints are so stiff after sleeping or sitting for along time? Not moving is the reason. I frequently use the analogy of a pond with my patients to explain how cyclical motion improves joints. Ponds that are stagnant with little movement of the water become very thick with algae. Ponds that have movement of the water from a spring or stream stay clear and do not get bogged down. So find a way to keep moving!

Strength training can also provide benefit to decrease pain with osteoarthritis. By increasing muscle around the arthritic joint, the muscle will increase its sock absorption ability causing less stress to the joint bones.

There are many exercise professionals and facilities in Warren County. The Civic Center does not require a membership, so you can pay as go. So if you have osteoarthritis, do not eliminate all exercise, just work with a healthcare professional to determine the right exercises to help your condition.

Zach Sutton, DPT, MS, OCS