Sports Medicine

01 Musculoskeletal Anatomy & Exercise Physiology

Sports medicine is the diagnosis, treatment, rehabilitation, and prevention of injuries related to physical activity. The field spans nonoperative orthopedics, primary care sports medicine, athletic training, and return-to-play decision-making. A scribe in a sports medicine clinic will hear joint-by-joint anatomy, tendon and ligament names, and mechanism-of-injury terminology constantly. Mastering the major structures up front is mandatory.

Bones, Joints & The Kinetic Chain

The skeleton has 206 bones organized into axial (skull, spine, thorax) and appendicular (limbs, girdles) components. Joints are classified functionally as synarthroses (immovable, e.g., skull sutures), amphiarthroses (slightly movable, e.g., pubic symphysis), and diarthroses (freely movable synovial joints — the joints sports medicine cares about). Synovial joints contain articular (hyaline) cartilage, synovial fluid, a fibrous capsule, and stabilizing ligaments. The kinetic chain is the concept that force generated in one segment (e.g., the hip) transfers through the trunk to produce motion at a distal segment (e.g., the shoulder in throwing). Breakdown anywhere in the chain — weak hips, poor core, scapular dyskinesis — shifts load and causes injury.

Muscle, Tendon & Ligament

Skeletal muscle is composed of type I (slow-twitch, oxidative, endurance) and type II (fast-twitch, glycolytic, power) fibers. Muscles attach to bone via tendons (dense regular connective tissue, collagen type I) at the myotendinous junction, which is the most common site of muscle strain. Ligaments connect bone to bone and stabilize joints; they are less vascular than tendons and heal slowly. Sprains are ligament injuries; strains are muscle/tendon injuries.

Key Regional Anatomy Cheat Sheet

• Shoulder: glenohumeral (GH) joint, acromioclavicular (AC) joint, sternoclavicular (SC) joint, scapulothoracic articulation. Rotator cuff = SITS (supraspinatus, infraspinatus, teres minor, subscapularis). Long head of biceps tendon runs in the bicipital groove.
• Elbow: humeroulnar, radiocapitellar, and proximal radioulnar joints. UCL (ulnar collateral ligament) resists valgus stress; LCL complex resists varus/posterolateral rotatory instability. Common extensor tendon origin at lateral epicondyle; common flexor/pronator origin at medial epicondyle.
• Wrist/hand: distal radius, distal ulna, 8 carpal bones (mnemonic: Some Lovers Try Positions That They Cannot Handle — scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate). TFCC (triangular fibrocartilage complex) stabilizes the ulnar wrist.
• Spine: 7 cervical, 12 thoracic, 5 lumbar vertebrae plus sacrum/coccyx. Pars interarticularis is the bony bridge whose stress fracture = spondylolysis.
• Hip/pelvis: ball-and-socket femoroacetabular joint with labrum. Hip flexors = iliopsoas; adductors arise from pubis; hamstrings originate at ischial tuberosity.
• Knee: tibiofemoral and patellofemoral joints. Four major ligaments: ACL, PCL, MCL, LCL. Two menisci (medial, lateral). Extensor mechanism: quadriceps → patella → patellar tendon → tibial tubercle.
• Ankle/foot: Lateral ligaments = ATFL, CFL, PTFL (anterior talofibular, calcaneofibular, posterior talofibular). Medial deltoid ligament. Syndesmosis (high ankle) = AITFL + interosseous membrane. Plantar fascia spans calcaneus to metatarsal heads.

Exercise Physiology Essentials

Aerobic energy production uses oxidative phosphorylation to sustain prolonged, low-to-moderate intensity activity; anaerobic glycolysis fuels short bursts via lactate production. VO2max is the peak rate of oxygen consumption and the benchmark of aerobic fitness. Lactate threshold, heart rate reserve, and rating of perceived exertion (RPE) are practical tools for exercise prescription. Strength training produces hypertrophy (fiber size increase) and neural adaptation. Adequate recovery (sleep, nutrition, hydration) is essential; failure of recovery produces overtraining syndrome.

02 Scribe Documentation Framework

The Sports Medicine SOAP Note

Sports medicine visits are usually structured as SOAP notes with strong emphasis on mechanism of injury, sport/position, training volume, and return-to-play timeline. The HPI is often longer and more mechanism-focused than a typical primary care visit.

03 Shoulder Injuries Upper Extremity

The shoulder is the most mobile joint in the body and the most commonly injured upper extremity region in overhead athletes. Injuries fall into overuse tendinopathies, traumatic tears, and instability events.

Rotator Cuff Tendinopathy & Tears

The rotator cuff (SITS muscles) stabilizes the humeral head in the glenoid and powers rotation. Supraspinatus is the most commonly injured — it runs beneath the acromion and is compressed by repetitive overhead motion. Tendinopathy is a degenerative, noninflammatory process characterized by disorganized collagen. Tears are classified as partial-thickness (bursal, articular, or intrasubstance) or full-thickness (small <1 cm, medium 1-3 cm, large 3-5 cm, massive >5 cm or involving ≥ 2 tendons per the Cofield classification).

Patients present with lateral deltoid pain, night pain (classic red flag for cuff pathology), weakness with overhead activity, and inability to sleep on the affected side. Exam shows positive Jobe (empty can), Neer, and Hawkins-Kennedy signs; weakness on external rotation (infraspinatus) or internal rotation lift-off (subscapularis) localizes the torn tendon. Diagnosis is confirmed with MRI or ultrasound. Management for tendinopathy and small partial tears is nonoperative (PT, NSAIDs, subacromial corticosteroid injection). Full-thickness tears in active patients are usually referred for arthroscopic repair, guided in part by AAOS clinical practice guidelines on rotator cuff injury.

Subacromial Impingement

Mechanical compression of the supraspinatus and subacromial bursa between the humeral head and the acromion, classically worsened by repetitive overhead activity. Neer described an impingement continuum from edema (stage I) to fibrosis (stage II) to tear (stage III). Treatment is rehab-focused with scapular stabilization and posterior capsule stretching.

SLAP Lesion

Superior labrum anterior to posterior tear, most common in throwers and patients with a fall on outstretched arm. Causes deep shoulder pain, painful popping/clicking, and decreased throwing velocity. O'Brien active compression test is classic. MRA is the imaging gold standard. Type II (detachment of biceps anchor) is most common.

AC Joint Sprain / Separation

Direct blow to the lateral shoulder (fall, football tackle). Classified Rockwood I-VI (see classification section). Grades I-II managed in a sling with early ROM; grades IV-VI typically surgical.

Biceps Tendinopathy, Long Head Rupture

Anterior shoulder pain at the bicipital groove; Speed and Yergason tests positive. Rupture of the long head of biceps produces the classic "Popeye deformity" and is usually managed nonoperatively in older patients because the short head preserves most function.

Glenohumeral Instability

Anterior dislocations account for 95% (force on abducted, externally rotated arm). A Bankart lesion (anteroinferior labral tear) or Hill-Sachs lesion (posterolateral humeral head impaction) is typical. First-time dislocation in young athletes has a >80% recurrence rate and is often referred for arthroscopic stabilization.

Thrower's Shoulder (Internal Impingement, GIRD)

Pitchers and overhead throwers develop posterior capsule tightness and humeral retroversion, causing glenohumeral internal rotation deficit (GIRD). Leads to posterosuperior labral contact, SLAP lesions, and partial undersurface cuff tears.

Adhesive Capsulitis (Frozen Shoulder)

Progressive stiffening with loss of both active and passive ROM, especially external rotation. Three phases: freezing (painful, 2-9 months), frozen (stiff, 4-12 months), thawing (gradual recovery, 12-24+ months). Associated with diabetes and thyroid disease. Managed with PT, injection, and occasionally capsular release or hydrodilation.

04 Elbow Injuries Upper Extremity

Lateral Epicondylitis (Tennis Elbow)

Tendinopathy of the common extensor origin (extensor carpi radialis brevis most involved). Pain over the lateral epicondyle reproduced with resisted wrist extension or middle finger extension (Maudsley test) and with a handshake grip. Managed with counterforce brace, eccentric wrist extensor strengthening, NSAIDs, and occasional corticosteroid or PRP injection. Recent evidence supports PRP over corticosteroid for durable relief, reflected in updated AMSSM positioning.

Medial Epicondylitis (Golfer's Elbow)

Common flexor/pronator origin tendinopathy. Pain with resisted wrist flexion and pronation. Frequently coexists with ulnar neuropathy at the cubital tunnel.

UCL Injury (Tommy John)

Valgus overload in overhead throwers (especially pitchers) causes ulnar collateral ligament injury. Patients describe a pop, sudden loss of velocity, and medial elbow pain. Milking maneuver and moving valgus stress test are classic. MRI or MRA defines the tear. Nonoperative rehab is possible for low-grade injuries; competitive throwers usually undergo UCL reconstruction ("Tommy John surgery") with palmaris longus or gracilis graft.

Olecranon Bursitis

Swelling of the olecranon bursa from direct trauma (wrestler, hockey player) or repetitive friction. Must distinguish septic from aseptic — aspiration with cell count, Gram stain, and culture is indicated if warm, red, or febrile.

Distal Biceps Rupture

Forced eccentric load on the flexed elbow (classically catching a falling object). "Reverse Popeye deformity," positive hook test. Surgical repair within 2-3 weeks recommended in active patients to restore supination strength.

Little League Elbow

Medial epicondyle apophysitis or avulsion in skeletally immature pitchers from repetitive valgus stress. USA Baseball pitch-count guidelines exist to prevent this. Rest and pitch-count education are key.

05 Wrist & Hand Injuries Upper Extremity

TFCC Injury

The triangular fibrocartilage complex stabilizes the distal radioulnar joint and the ulnar carpus. Ulnar-sided wrist pain with gripping and forearm rotation; positive TFCC load and press tests. Palmer classification (I traumatic, II degenerative). MRA is diagnostic.

Scaphoid Fracture

Fall on outstretched hand with anatomic snuffbox tenderness. Initial plain films miss up to 20%. If exam is consistent with scaphoid fracture, thumb spica splint and repeat imaging or MRI in 10-14 days. Proximal pole fractures carry high nonunion/avascular necrosis risk because blood supply is retrograde from the distal pole.

Hook of Hamate Fracture

Classic in baseball, golf, tennis (bat or club strikes hypothenar eminence). Hypothenar pain with gripping. Carpal tunnel view or CT confirms. Often requires excision if symptomatic.

Trigger Finger

Stenosing tenosynovitis at the A1 pulley. Painful catching or locking during finger flexion. Managed with splinting and corticosteroid injection; surgical release for refractory cases.

Mallet, Jersey, and Jammed Finger

Mallet finger = forced flexion of extended DIP avulses the terminal extensor tendon; patient cannot extend DIP. Splint in extension 6-8 weeks continuously. Jersey finger = forced extension of flexed DIP avulses FDP tendon (ring finger most common, "grabbing a jersey"); requires surgical repair within 1-2 weeks for best outcome. Jammed finger is the catch-all for PIP sprains — buddy tape after excluding volar plate injury, fracture, or dislocation.

Boxer's Fracture

Fifth metacarpal neck fracture from a closed-fist punch. Acceptable angulation ≤40 degrees in the small finger. Ulnar gutter splint, orthopedic follow-up if rotational deformity or significant angulation.

06 Cervical & Lumbar Spine Injuries Spine

Cervical Strain / Sprain (Whiplash)

Acceleration-deceleration mechanism (football tackle, MVC). Paraspinal pain and limited ROM without neurologic findings. Imaging only if red flags (NEXUS or Canadian C-spine rule positive). Short course of NSAIDs, soft collar <72 hours, early mobilization, PT.

Stinger / Burner

Transient unilateral upper extremity burning, numbness, and weakness following a tackle. Mechanism is brachial plexus traction or nerve root compression (C5-C6). Symptoms typically resolve within minutes to hours. Bilateral or prolonged symptoms require cervical imaging and neurosurgical evaluation — this is never a stinger and raises concern for transient quadriparesis or cord injury.

Transient Quadriparesis / Cervical Cord Neurapraxia

Bilateral burning, numbness, or weakness in all four extremities after axial cervical load. Associated with congenital cervical stenosis (Pavlov ratio <0.8). MRI is mandatory. Return to contact sport is controversial and requires stability of the cervical spine and absence of cord signal change.

Lumbar Strain / Sprain

Most common cause of low back pain in athletes. Paraspinal tenderness without radicular symptoms. Activity modification, NSAIDs, PT with core stabilization.

Spondylolysis & Spondylolisthesis

Spondylolysis is a pars interarticularis stress fracture, most common at L5, and the leading cause of low back pain in adolescent athletes (gymnasts, divers, football linemen, cheerleaders). Pain with lumbar extension, positive single-leg hyperextension (stork) test. Plain films may be normal; MRI with STIM or SPECT/CT is sensitive. Spondylolisthesis is forward slippage of one vertebra on another (usually L5 on S1), graded Meyerding I-IV (see classification section). Treatment is activity modification, bracing (controversial), core rehab; surgery for slips progressing beyond grade II or with neurologic deficit.

Lumbar Disc Herniation

Radicular pain following a dermatomal pattern, with positive straight leg raise. MRI confirms. Most (>80%) resolve nonoperatively over 6-12 weeks. Surgery indicated for progressive neurologic deficit, cauda equina syndrome, or refractory pain.

Sacroiliac Dysfunction

Unilateral buttock pain localized to the SI joint. FABER (Patrick), Gaenslen, thigh thrust, compression, and distraction tests. Three positive provocation tests increases likelihood. Managed with PT, NSAIDs, and occasionally fluoroscopy-guided SI joint injection.

07 Hip & Pelvis Injuries Lower Extremity

Hip Flexor & Adductor Strains

Iliopsoas or rectus femoris strains present with anterior hip/groin pain after sprinting or kicking. Adductor strains produce medial groin pain. Graded I-III. Managed with rest, ice, progressive PT; most return to play in 2-6 weeks depending on grade.

Sports Hernia / Athletic Pubalgia

Chronic groin pain from posterior inguinal wall weakness or rectus abdominis/adductor longus aponeurosis disruption. No true hernia is present. Pain with resisted sit-up and adduction. MRI may show pubic bone edema or aponeurotic tear. Initial PT; refractory cases referred for surgical repair.

Hip Labral Tear & Femoroacetabular Impingement (FAI)

FAI is abnormal contact between the femoral head-neck and acetabulum, classified as cam (aspherical femoral head), pincer (over-coverage by the acetabulum), or mixed. Chronic impingement tears the labrum. Patients present with anterior groin pain, a positive FADIR (flexion-adduction-internal rotation) test, and a "C sign" when describing pain location. MRA is diagnostic. Management is PT first; arthroscopic labral repair and osteoplasty for refractory symptomatic cases.

Iliopsoas Snapping (Internal Snapping Hip)

Audible, palpable snap of the iliopsoas tendon over the iliopectineal eminence. Usually painless and managed with PT.

Piriformis Syndrome

Deep gluteal pain with sciatic nerve irritation as it passes through/around the piriformis. Pain with prolonged sitting, positive FAIR test. Stretching, PT, occasional injection.

Gluteus Medius Tendinopathy (Greater Trochanteric Pain Syndrome)

Lateral hip pain with side-lying and single-leg stance. Tendinopathy of the gluteus medius/minimus at the greater trochanter. PT focusing on hip abductor strengthening.

Hamstring Strain

Posterior thigh pain with sprinting, typically at the biceps femoris myotendinous junction. Graded I-III. Recurrent hamstring strain is extremely common — inadequate rehab is the main risk. British Athletics classification (BAMIC) categorizes by location and grade.

Avulsion Fractures of the Pelvis

Adolescent athletes avulse apophyses at muscle origins: ASIS (sartorius), AIIS (rectus femoris), ischial tuberosity (hamstrings), lesser trochanter (iliopsoas), pubic symphysis (adductors), iliac crest (abdominal wall). Plain films diagnostic. Most treated nonoperatively.

08 Knee Injuries Lower Extremity

The knee is the highest-volume body part in most sports medicine clinics. Scribes should become fluent in ACL, meniscus, and patellofemoral vocabulary before anything else.

ACL Tear

Noncontact pivot (plant-and-cut), audible pop, immediate hemarthrosis (within 2 hours), and inability to return to play. Lachman test is the most sensitive exam; anterior drawer and pivot shift support the diagnosis. MRI confirms and evaluates associated meniscus and MCL injury (O'Donoghue's unhappy triad: ACL + MCL + medial meniscus). Young, active athletes are typically offered ACL reconstruction with autograft (bone-patellar tendon-bone, hamstring, or quadriceps tendon). Return to sport is typically 9-12 months per AMSSM consensus on ACL return to sport.

MCL, LCL, and PCL Injuries

MCL sprains result from valgus load; LCL from varus. Most isolated MCL injuries heal nonoperatively with hinged knee brace. PCL tears occur with direct anterior blow to the proximal tibia (dashboard injury, falling on flexed knee). Posterior drawer is the key exam. Most isolated PCL injuries are treated nonoperatively.

Meniscus Tears

Acute tears (twisting injury) vs degenerative tears (no clear trauma, middle-aged). Joint line tenderness, McMurray and Thessaly tests positive. MRI confirms and characterizes (bucket handle, radial, horizontal, root tear). Root tears and displaced bucket handles warrant early surgical consideration; many degenerative tears are managed nonoperatively per contemporary evidence.

Patellar Tendinopathy (Jumper's Knee)

Infrapatellar pain in jumping athletes. Eccentric decline squats are first-line rehab; PRP or surgery for refractory cases.

Patellofemoral Pain Syndrome (Runner's Knee)

Anterior knee pain worse with stairs, squatting, prolonged sitting ("theater sign"). Often multifactorial: weak hip abductors, quad tightness, overpronation. PT with hip/core strengthening is first-line.

IT Band Syndrome

Lateral knee pain at the lateral femoral epicondyle in runners and cyclists. Ober test tight. Foam rolling, hip strengthening, mileage reduction.

Patellar Dislocation / Subluxation

Usually lateral dislocation in young females with patellar maltracking. Relocates with knee extension. First-time dislocation managed nonoperatively; recurrent instability may warrant MPFL reconstruction.

Osteochondritis Dissecans (OCD)

Subchondral bone lesion (most often medial femoral condyle) in adolescents. May cause locking or effusion. Stable lesions heal with activity restriction; unstable lesions require surgical fixation.

Plica Syndrome

Inflammation of a synovial plica (medial most common). Medial snapping and pain. PT first; arthroscopic resection occasionally.

Osgood-Schlatter & Sinding-Larsen-Johansson

Apophysitis of the tibial tubercle (Osgood-Schlatter) and inferior pole of the patella (Sinding-Larsen-Johansson), both in adolescent athletes. Activity modification, ice, and stretching. Self-limited with skeletal maturity.

09 Lower Leg & Stress Injuries Lower Extremity

Medial Tibial Stress Syndrome (Shin Splints)

Diffuse tenderness along the posteromedial tibia in runners, usually early in training. Rest, ice, gait analysis, gradual return. If focal tenderness and night pain, suspect tibial stress fracture.

Stress Fractures

Overuse bone injuries from repetitive loading. Low-risk sites (posteromedial tibia, fibula, most metatarsals) heal well with rest. High-risk sites (anterior tibial cortex, femoral neck tension side, navicular, proximal fifth metatarsal (Jones), great toe sesamoids, talus, medial malleolus) can progress to complete fracture, nonunion, or avascular necrosis and often need non-weight-bearing or surgical fixation. MRI is the most sensitive imaging; plain films may show periosteal reaction or the "dreaded black line" on the anterior tibial cortex. Always assess for the female athlete triad in recurrent stress fractures.

Chronic Exertional Compartment Syndrome

Exercise-induced muscle compartment pain that resolves with rest. Compartment pressure testing pre- and post-exercise is diagnostic (post-exercise >30 mmHg at 1 min or >20 mmHg at 5 min). Fasciotomy is the definitive treatment if refractory.

10 Ankle & Foot Injuries Lower Extremity

Lateral Ankle Sprain

Inversion mechanism. ATFL injured most often, then CFL, rarely PTFL. Use the Ottawa ankle rules to decide on radiographs. Grade I-III based on ligament disruption and instability. Functional rehab with bracing, proprioceptive training, and early weight-bearing is superior to prolonged immobilization per NATA position statement on ankle sprain.

Medial (Deltoid) Ankle Sprain

Eversion mechanism, less common than lateral. Always rule out syndesmotic injury and Maisonneuve fracture (proximal fibula + deltoid).

High Ankle / Syndesmotic Sprain

External rotation with a dorsiflexed foot. Pain with the squeeze test, external rotation stress, and proximal to the joint line. Longer recovery than lateral sprain (6-12+ weeks). Unstable injuries require surgical stabilization.

Achilles Tendinopathy & Rupture

Tendinopathy: midportion (2-6 cm above insertion) or insertional. Eccentric loading (Alfredson protocol) is evidence-based first-line therapy. Acute Achilles rupture: sudden "kick to the back of the leg" sensation, positive Thompson test (no plantarflexion with calf squeeze), palpable gap. Operative and functional nonoperative protocols both yield good results in selected patients.

Plantar Fasciitis

Heel pain, worst with first steps in the morning. Tenderness at the medial calcaneal tuberosity. Stretching, night splints, heel cushions, and plantar-specific stretching protocols; injection and extracorporeal shock wave therapy for refractory cases.

Peroneal Tendon Subluxation

Posterolateral ankle pain and popping, usually after forced dorsiflexion/inversion. SPR (superior peroneal retinaculum) injury. Brace trial; surgery for recurrent subluxation.

Sinus Tarsi Syndrome

Lateral foot pain after recurrent ankle sprains. Tenderness at the sinus tarsi. PT, bracing, occasional injection.

Lisfranc Injury

Tarsometatarsal joint complex disruption from axial load on a plantarflexed foot. Plantar ecchymosis is pathognomonic. Weight-bearing radiographs may show widening between the first and second metatarsals. CT or MRI clarifies. Most require surgical fixation — missed Lisfranc injuries produce chronic midfoot arthritis.

Turf Toe

Hyperextension injury to the first MTP capsuloligamentous complex, common on artificial turf. Graded I-III. Grade III requires prolonged immobilization or surgery.

Sesamoiditis & Morton's Neuroma

Sesamoiditis: pain under the first metatarsal head from repetitive loading (runners, dancers). Rest, offloading pad. Morton's neuroma: interdigital nerve (usually 3rd webspace), pain with walking and a "rock in the shoe" sensation, positive Mulder's click. Metatarsal pad, wide toe box, corticosteroid injection, surgical excision for refractory cases.

11 Concussion & Head Injury Neurologic

Concussion is a traumatic brain injury induced by biomechanical forces, producing a functional disturbance without structural abnormality on standard imaging. It is a clinical diagnosis. Sports concussion management is governed by the 2023 Amsterdam CISG Consensus Statement on Concussion in Sport, which updates the Berlin 2016 framework.

Clinical Presentation

Symptoms cluster into four domains: somatic (headache, dizziness, nausea, photophobia, phonophobia), cognitive (fogginess, slowed processing, poor concentration), emotional (irritability, sadness), and sleep (insomnia, hypersomnia). Loss of consciousness occurs in only ~10%. Red flags that demand emergency imaging and neurosurgical evaluation include GCS <15, focal deficit, seizure, repeated vomiting, worsening headache, and signs of cervical spine injury.

SCAT6 / Child SCAT6 Sideline Assessment

The Sport Concussion Assessment Tool (currently version 6, formerly SCAT5) is the sideline standard. Components include:

• Red flag screen and cervical spine assessment
• Immediate observable signs (loss of consciousness, balance problems, blank stare, impact seizure)
• Glasgow Coma Scale
• Maddocks questions (orientation: venue, quarter, last scorer, last game, did we win?)
• Symptom evaluation (22-item checklist, 0-6 severity each)
• Cognitive screening (orientation, immediate memory, concentration, delayed recall)
• Neurologic screen (reading, balance, coordination)
• Balance examination via modified Balance Error Scoring System (mBESS) — double leg, single leg, and tandem stance with errors counted

Historical Concussion Grading

Modern practice has moved away from grading toward symptom-based individualized management, but historical scales still appear in documentation:

Graduated Return-to-Sport Protocol (6 Stages)

Each stage is at least 24 hours; if symptoms recur, the athlete drops back to the previous asymptomatic stage. Return to learn precedes return to play. The Zackery Lystedt Law in Washington was the first state law mandating concussion education, removal from play, and written clearance — all 50 states now have similar legislation.

Second Impact Syndrome

Catastrophic cerebral edema and loss of autoregulation after a second head impact before a first concussion has fully resolved. Rare but devastating. Rigid enforcement of return-to-play rules is the only prevention.

12 Medical Issues in Athletes Medical

Exercise-Induced Bronchoconstriction (EIB)

Transient airway narrowing triggered by exercise. Common in endurance and cold-weather athletes. Symptoms: cough, wheeze, chest tightness 5-15 minutes after exercise onset, resolving with rest. Diagnosis by exercise challenge or eucapnic voluntary hyperventilation (not peak flow alone). Pre-exercise short-acting beta-agonist (albuterol) 15 minutes prior is first-line; daily inhaled corticosteroid if frequent.

Exercise-Induced Anaphylaxis

Urticaria, angioedema, wheezing, hypotension during or after exertion, sometimes with a cofactor (food, NSAID). Epinephrine autoinjector carriage is mandatory.

Anemia in Athletes

Differentiate dilutional "sports anemia" (plasma volume expansion, benign) from true iron-deficiency anemia (low ferritin, microcytic). Common in distance runners and female athletes. Treat iron deficiency; avoid empiric supplementation without labs.

Overtraining Syndrome

Chronic fatigue, performance decline, mood disturbance, sleep disruption after sustained high training load with inadequate recovery. Diagnosis of exclusion. Treatment is extended rest (weeks to months).

Exertional Sickling

Sickle cell trait athletes can develop rhabdomyolysis, collapse, and death during intense conditioning, especially in heat or altitude. NCAA mandates universal sickle cell trait screening. Education and graduated conditioning are key.

Exertional Rhabdomyolysis

Muscle breakdown with CK elevation, myoglobinuria ("tea-colored urine"), and acute kidney injury. Aggressive IV hydration and electrolyte monitoring. Return to activity is cautious and graduated.

13 Cardiovascular Issues & Sudden Cardiac Death Cardiac

Sudden cardiac death (SCD) in athletes is rare (~1 per 50,000-80,000 per year) but catastrophic. The preparticipation physical evaluation (PPE) is the primary screening tool. The AHA/ACC 14-element cardiovascular screening guides history and exam; ECG screening remains controversial in the US and routine in many European and FIFA programs.

Causes of SCD

• Hypertrophic cardiomyopathy (HCM) — most common cause in US athletes. Asymmetric septal hypertrophy, dynamic LVOT obstruction, risk of ventricular arrhythmia.
• Coronary artery anomalies — anomalous origin from the opposite sinus, interarterial course.
• Arrhythmogenic right ventricular cardiomyopathy (ARVC) — fibrofatty RV replacement.
• Long QT, Brugada, CPVT — primary electrical channelopathies.
• Commotio cordis — blunt chest trauma during vulnerable repolarization phase inducing VF. Baseball, lacrosse, hockey.
• Myocarditis — viral or post-viral; exercise restriction 3-6 months. COVID-19 updates have shaped contemporary return-to-play protocols.

Athletic Heart Syndrome

Physiologic cardiac adaptations to sustained endurance training: increased LV wall thickness, chamber enlargement, resting bradycardia. Benign and reversible with detraining. Must distinguish from pathologic hypertrophy — echo, cardiac MRI, detraining response, and genetic testing may be needed.

14 Female Athlete Triad / RED-S & Eating Disorders Medical

The female athlete triad describes the interrelationship among low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density. The broader Relative Energy Deficiency in Sport (RED-S) framework from the IOC acknowledges that both sexes are affected and that the consequences extend to immune, endocrine, cardiovascular, hematologic, and psychological function.

Management is multidisciplinary: sports medicine physician, sports dietitian, mental health, and coach. Increasing energy availability is the foundation. Estrogen-progestin therapy has not been shown to restore bone density in FHA and is not the preferred treatment — correcting energy deficit is. Eating disorders (anorexia nervosa, bulimia, binge-eating, OSFED) are overrepresented in aesthetic and weight-class sports; use validated screening tools.

15 Environmental & Exertional Illness Emergency

Exertional Heat Illness Spectrum

Never use oral temperature or axillary temperature to evaluate suspected exertional heat stroke — always rectal. Every venue for football practice in August should have an ice immersion tub ready.

Other Environmental Concerns

Hyponatremia (especially overhydration in marathons), hypothermia and frostbite in winter sports, altitude illness (AMS, HAPE, HACE) in trekking and training at altitude, and lightning safety protocols ("30-30 rule": seek shelter when flash-to-bang ≤30 sec, resume 30 min after last thunder).

16 Procedures & Office-Based Interventions Procedures

Pre-Participation Physical Evaluation (PPE)

The PPE clears athletes for sport and identifies at-risk individuals. Uses the PPE Monograph (AAP/ACSM/AMSSM/AOSSM/AAFP). History is more sensitive than exam; the 14-element AHA cardiovascular screen is embedded. Must document personal and family history of syncope, chest pain, palpitations, SCD <50, known heart disease, and Marfanoid features.

Joint & Soft Tissue Injections

Ultrasound-Guided Injections

Musculoskeletal ultrasound allows real-time, needle-tip visualization for accurate placement in small or deep targets (biceps tendon sheath, piriformis, glenohumeral joint, peroneal tendon sheath, plantar fascia). High-frequency linear probe (10-15 MHz) for superficial structures; curvilinear for hip. Scribes document laterality, target, needle approach (in-plane vs out-of-plane), agent, volume, tolerance, and post-injection sensory/motor status.

Casting, Splinting, Taping, Bracing

Common immobilization: thumb spica (scaphoid), ulnar gutter (boxer's fracture), sugar tong (distal radius), short leg walking boot (metatarsal fractures, mild ankle sprain), stirrup brace (lateral ankle sprain). Kinesiotaping and athletic taping techniques: ankle taping with basketweave, patellar taping (McConnell), shoulder dyskinesis tape. Functional bracing: hinged knee brace (MCL), ACL functional brace, CAM walker.

Cardiac Clearance & Exercise Stress Testing

Bruce protocol is standard for exercise ECG. Indications include chest pain with exertion, syncope, suspected CAD prior to return to competitive sport, and evaluation of athletes with equivocal screening findings. Echocardiogram and cardiac MRI used when structural disease is suspected.

Concussion Baseline & Post-Injury Testing

Computerized neurocognitive tools (ImPACT, CNS Vital Signs, Axon) test memory, attention, processing speed, and reaction time. Baseline values in preseason allow post-injury comparison. SCAT6 is performed acutely; BESS balance testing complements the cognitive assessment. None of these replace clinical judgment.

17 Imaging & Diagnostics Imaging

Plain Radiographs

First-line for fracture, dislocation, arthritis, and bony alignment. Specific views: Ottawa knee/ankle rules (decide if XR is needed), sunrise/Merchant (patellofemoral), stress views (AC joint, syndesmosis), weight-bearing views (Lisfranc, knee OA), scaphoid view (snuffbox tenderness). Key findings the scribe documents: fracture line, displacement, angulation, joint space, effusion (fat pad sign at elbow, suprapatellar at knee), cortical irregularity.

MRI

Gold standard for ligament, tendon, cartilage, and bone marrow pathology. MRA (arthrogram) used for labral tears of shoulder and hip. Key terms scribes document: signal intensity (T2 bright = fluid/edema), bone marrow edema (stress reaction/fracture), complete vs partial tear, retraction, chondral lesion grade, meniscal tear pattern (radial, horizontal, complex, bucket handle, root).

Musculoskeletal Ultrasound

Dynamic assessment of tendons, muscles, bursae, nerves, and effusions. Real-time guidance for injections. Advantages: portable, no radiation, cheaper than MRI, dynamic. Limitations: operator-dependent, limited for deep structures.

CT

Used when fine bone detail is needed: comminuted fractures, occult scaphoid, complex articular fracture patterns, spondylolysis.

DEXA

Bone mineral density screening in female athlete triad/RED-S, recurrent stress fractures, and amenorrhea. Z-score is used in premenopausal athletes (not T-score).

18 Medications You Must Know Medications

19 Classification & Outcome Scales Classification

Muscle & Ligament Injury Grading

Rockwood AC Joint Separation

Meyerding Spondylolisthesis Grading

Glasgow Coma Scale (GCS)

Eye (1-4): 4 spontaneous, 3 to voice, 2 to pain, 1 none. Verbal (1-5): 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor (1-6): 6 obeys, 5 localizes, 4 withdraws, 3 flexion (decorticate), 2 extension (decerebrate), 1 none. Total 3-15. TBI severity: severe 3-8, moderate 9-12, mild 13-15.

Outcome & Activity Scales

• Tegner Activity Scale (0-10): 0 = disability, 10 = competitive soccer/rugby/football at national/international level.
• IKDC: International Knee Documentation Committee subjective knee form.
• KOOS: Knee injury and Osteoarthritis Outcome Score (pain, symptoms, ADL, sport, QoL).
• HAGOS: Hip and Groin Outcome Score.
• DASH / QuickDASH: Disabilities of the Arm, Shoulder and Hand.
• Lower Extremity Functional Scale (LEFS).
• Lysholm Knee Score: Historical, still encountered.

Ankle-Brachial Index in Sports

ABI is occasionally used in sports medicine to work up exertional leg pain when vascular etiology (iliac artery endofibrosis in cyclists, popliteal entrapment) is suspected. Normal resting ABI with post-exercise drop is classic for dynamic obstruction.

20 Physical Exam — Special Tests by Joint Exam

21 Return-to-Play Frameworks RTP

Return-to-play decisions integrate tissue healing, rehab milestones, sport demands, psychological readiness, and legal/medical considerations. A "shared decision-making" model between physician, athlete, family, athletic trainer, and coach is standard.

Specific examples: ACL reconstruction 9-12 months with functional testing; lateral ankle sprain 1-6 weeks by grade; concussion graduated 6-stage protocol; hamstring strain when strength returns to >95% contralateral and sport-specific drills tolerated without guarding; stress fracture when pain-free, tenderness resolved, progressive loading tolerated.

22 Abbreviations Master List Reference

Anatomy

Diagnoses

Procedures / Exam

Medications / Labs

23 Sample HPI Templates Templates

These templates illustrate the rhythm and depth of a sports medicine HPI. Use them as patterns during your first weeks in clinic.

24 References & Sources

Clinical Practice Guidelines & Position Statements

Diagram & Figure Sources