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2011-12 NCAA Sports Medicine Handbook

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					2011-12 NCAA
           ®




      Sports
  Medicine
 Handbook
THE NATIONAL COLLEGIATE ATHLETIC ASSOCIATION
P.O. Box 6222
Indianapolis, Indiana 46206-6222
317/917-6222
NCAA.org

Twenty-second Edition
July 2011


Compiled By: David Klossner, Director of Student-Athlete Affairs.

Distributed to head athletic trainers. Available online at NCAA.org/health-safety.

Note: Revisions to the guidelines contained in the NCAA Sports Medicine
Handbook may be made on a yearly basis. Between printings of the handbook,
revisions will be published on NCAA.org. It is important that persons using this
handbook be aware of any such revisions. The NCAA Committee on
Competitive Safeguards and Medical Aspects of Sports suggests that such revi-
sions be recorded in the handbook, thereby keeping this publication current.
New guidelines and major revisions have been highlighted with orange shading.

NCAA, NCAA logo and NATIONAL COLLEGIATE ATHLETIC
ASSOCIATION are registered marks of the Association and use in any manner
is prohibited unless prior approval is obtained from the Association.

Member institutions and conferences may reproduce information in this publica-
tion for their own use, provided the NCAA copyright is included on the material.

Also found on the NCAA website at the following address:
NCAA.org/health-safety.

Copyright, 2011, by the National Collegiate Athletic Association. Printed in the
United States of America.




                                                                                     1
    PREFACE
    The health and safety principle of the        ics program. In some instances,              letic health care team that is consistent
    National Collegiate Athletic                  accompanying best practices, and ref-        with sound principles of sports medi-
    Association’s constitution provides that      erences to sports medicine or legal          cine care. These recommendations pro-
    it is the responsibility of each member       resource materials are provided for fur-     vide guidance for an institution’s athlet-
    institution to protect the health of,         ther guidance. These recommendations         ics administrators and sports medicine
    and provide a safe environment for,           are not intended to establish a legal        staff in protecting student-athletes’
    each of its participating student-ath-        standard of care that must be strictly       health and safety, but do not establish
    letes. To provide guidance in accom-          adhered to by member institutions. In        any rigid requirements that must be
    plishing this objective and to assist         other words, these guidelines are not        followed in all cases.
    member schools in developing a safe           mandates that an institution is required
    intercollegiate athletics program, the        to follow to avoid legal liability or dis-   This handbook is produced annually,
    NCAA Committee on Competitive                 ciplinary sanctions by the NCAA.             sent to head athletic trainers, and made
    Safeguards and Medical Aspects of             However, an institution has a legal duty     available online to directors of athletics,
    Sports creates a Sports Medicine              to use reasonable care in conducting its     senior woman administrators, faculty
    Handbook. The committee has agreed            intercollegiate athletics program, and       athletics representatives, athletic train-
    to formulate guidelines for sports med-       guidelines may constitute some evi-          ers, team physicians, Life Skills coordi-
    icine care and protection of student-         dence of the legal standard of care.         nators, and student-athlete advisory
    athletes’ health and safety for topics                                                     committees at each member institution,
    relevant to intercollegiate athletics,        These general guidelines are not             and conference commissioners. Please
    applicable to a large population of stu-      intended to supersede the exercise of        view the NCAA Sports Medicine
    dent-athletes, and not accessible in          medical judgment in specific                 Handbook as a tool to help your institu-
    another easily obtainable source.             situations by a member institution’s         tion develop its sports medicine admin-
                                                  sports medicine staff. In all instances,     istrative policies. Such policies should
    This handbook consists of guidelines          determination of the appropriate care        reflect a commitment to protecting your
    for each institution to consider in           and treatment of student-athletes must       student-athletes’ health and well-being
    developing sports medicine policies           be based on the clinical judgment of         as well as an awareness of the guide-
    appropriate for its intercollegiate athlet-   the institution’s team physician or ath-     lines set forth in this handbook.




2
2011-12
Sports Medicine Guidelines
Foreword ........................................................................................................................................................ 4
1. Administrative Issues
   a. Sports Medicine Administration ........................................................................................................ 6
   b. Medical Evaluations, Immunizations and Records........................................................................... 8
   c. Emergency Care and Coverage.......................................................................................................... 11
   d. Lightning Safety ................................................................................................................................. 13
   e. Catastrophic Incident in Athletics...................................................................................................... 16
   f. Dispensing Prescription Medication.................................................................................................. 18
   g. Nontherapeutic Drugs ........................................................................................................................ 20
   h. NCAA Alcohol, Tobacco and Other Drug Education Guidelines ................................................... 21
   i. Preseason Preparation ........................................................................................................................ 23
2. Medical Issues
   a. Medical Disqualification of the Student-Athlete .............................................................................. 28
   b. Cold Stress and Cold Exposure ......................................................................................................... 29
   c. Prevention of Heat Illness .................................................................................................................. 33
   d. Weight Loss—Dehydration................................................................................................................ 37
   e. Assessment of Body Composition .................................................................................................... 38
   f. Nutrition and Athletic Performance................................................................................................... 43
   g. Dietary Supplements .......................................................................................................................... 47
   h. “Burners” (Brachial Plexus Injuries) ................................................................................................. 50
   i. Concussion or Mild Traumatic Brain Injury in the Athlete.............................................................. 53
   j. Skin Infections in Athletics ................................................................................................................ 59
   k. Menstrual-Cycle Dysfunction ............................................................................................................ 66
   l. Blood-Borne Pathogens and Intercollegiate Athletics ...................................................................... 68
   m. The Use of Local Anesthetics in College Athletics .......................................................................... 74
   n. The Use of Injectable Corticosteroids in Sports Injuries ................................................................. 75
   o. Depression: Interventions for Intercollegiate Athletics .................................................................... 77
   p. Participation by the Student-Athlete with Impairment ..................................................................... 82
   q. Pregnancy in the Student-Athlete ...................................................................................................... 84
   r. The Student-Athlete with Sickle Cell Trait ....................................................................................... 86
3. Equipment
   a. Protective Equipment ......................................................................................................................... 90
   b. Eye Safety in Sports ........................................................................................................................... 96
   c. Mouthguards ....................................................................................................................................... 98
   d. Use of the Head as a Weapon in Football and Other Contact Sports .............................................. 100
   e. Guidelines for Helmet Fitting and Removal in Athletics ................................................................. 101
   f. Use of Trampoline and Minitramp .................................................................................................... 104
Appendixes
   a. Banned-Drug Classes ......................................................................................................................... 108
   b. NCAA Legislation Involving Health and Safety Issues ................................................................... 109
   c. NCAA Injury Surveillance Program Summary................................................................................ 115
   d. Acknowledgements ............................................................................................................................ 119
  New or significantly revised guidelines are highlighted on this page.
  Limited revisions are highlighted within the specific guideline.                                                                                                    3
    FOREWORD
    Shared Responsibility for Intercollegiate Sports Safety



    Participation in intercollegiate athletics   director, is responsible for establishing
    involves unavoidable exposure to an          a safe environment for its student-ath-
    inherent risk of injury. However, stu-       letes to participate in its intercollegiate
    dent-athletes rightfully assume that         athletics program.
    those who sponsor intercollegiate ath-
    letics have taken reasonable precau-         Coaches should appropriately warn stu-
    tions to minimize the risks of injury        dent-athletes about the sport’s inherent
    from athletics participation. In an          risks of injury and instruct them how to
    effort to do so, the NCAA collects           minimize such risks while participating
    injury data in intercollegiate sports.       in games, practices and training.
    When appropriate, the NCAA
    Committee on Competitive Safeguards          The team physician and athletic health
    and Medical Aspects of Sports makes          care team should assume responsibility
    recommendations to modify safety
                                                 for developing an appropriate injury
    guidelines, equipment standards, or a
                                                 prevention program and providing
    sport’s rules of play.
                                                 quality sports medicine care to injured
                                                 student-athletes.
    It is important to recognize that rule
    books, safety guidelines and equipment
    standards, while helpful means of pro-       Student-athletes should fully under-
    moting safe athletics participation, are     stand and comply with the rules and
    themselves insufficient to accomplish        standard of play that govern their sports
    this goal. To effectively minimize the       and follow established procedures to
    risks of injury from athletics participa-    minimize their risk of injury.
    tion, everyone involved in intercolle-
    giate athletics must understand and          In summary, all persons participating
    respect the intent and objectives of         in, or associated with, an institution’s
    applicable rules, guidelines                 intercollegiate athletics program share
    and standards.                               responsibility for taking steps to reduce
                                                 effectively the risk of injury during
    The institution, through its athletics       intercollegiate athletic competition.




4
                                                            1
Adminstrative
issues
Also found on the NCAA website at: NCAA.org/health-safety
                                      GUIDELINE 1a
    Sports Medicine
    Administration
     October 1977 • Revised July 2011



    The following components of a          3. Preseason Preparation. The           practice, competition and travel.
    safe athletics program are an          student-athlete should be protected
    important part of injury prevention.   from premature exposure to the full     6. Minimizing Potential Legal
    They should serve both as a            rigors of sports. Preseason condi-      Liability. Liability must be a
    checklist and as a guideline for use   tioning should provide the student-     concern of responsible athletics
                                           athlete with optimal readiness by       administrators and coaches. Those
    by athletics administrators in the
                                           the first practice (see Guideline 1i,   who sponsor and govern athletics
    development of safe programs.
                                           Preseason Preparation).                 programs should accept the
    1. Preparticipation Medical                                                    responsibility of minimizing the
    Exam. Before student-athletes          4. Acceptance of Risk. Any              risk of injury.
    accept the rigors of any organized     informed consent or waiver by
                                           student-athletes (or, if minors, by     7. Equitable Medical Care.
    sport, their health should be
                                           their parents) should be based on       Member institutions should neither
    evaluated by qualified medical
                                           an awareness of the risks of partic-    practice nor condone illegal
    personnel. Such an examination
                                           ipating in intercollegiate sports.      discrimination on the basis of race,
    should determine whether the
                                                                                   creed, national origin, sex, age,
    student-athlete is medically cleared   5. Planning/Supervision. Safety in      disability, social status, financial
    to engage in a particular sport (see   intercollegiate athletics can be        status, sexual orientation or
    NCAA Bylaw 17.1.5).                    attained only by appropriate            religious affiliation within their
                                           planning for and supervision of         sports medicine programs.
    Division I requires student-athletes
    new to their campus to complete a
    sickle cell solubility test, show
    results of a prior test, or sign a
    written release declining the test.

    2. Health Insurance. Each
    student-athlete should be covered
    by individual, parental or
    institutional medical insurance to
    defray the costs of significant
    injury or illness.

    NCAA institutions must certify
    insurance coverage for medical
    expenses resulting from athletically
    related injuries in a covered event
    (see Bylaw 3.2.4).


6
                                                                     Sports Medicine Administration

Availability and accessibility to       10. Blood-Borne Pathogens. In
medical resources should be based       1992, the Occupational Safety and
on established medical criteria         Health Administration (OSHA)
(e.g., injury rates, rehabilitation)    developed a standard directed to
rather than the sport itself.           minimizing or eliminating
                                        occupational exposure to blood-
Member institutions should not          borne pathogens. Each member
place their sports medicine staffs in   institution should determine the
compromising situations by having       applicability of the OSHA standard
them provide inequitable treatment      to its personnel and facilities.
in violation of their medical codes
of ethics.                              11. Emergency Care. See
                                        Guideline 1c.
Institutions should be encouraged to
incorporate questions regarding         12. Concussion Management
adequacy of medical care, with          Plan. NCAA member institutions
special emphasis on equitable           must have a concussion
treatment, in exit interviews with      management plan for their student-
student-athletes.                       athletes on file with specific
                                        components as described in Bylaw
8. Equipment. Purchasers of             3.2.4.16 (see Guideline 2i).
equipment should be aware of and
use safety standards. In addition,      13. Drug Testing. NCAA member
attention should be directed to         institutions are responsible for
maintaining proper repair and           ensuring compliance with NCAA
fitting of equipment at all times in    drug testing program requirements
all sports. Student-athletes should:    (see NCAA Drug Testing Program
                                        book and Appendix A).
a. Be informed what equipment is
   mandatory and what constitutes       14. Legislation. NCAA member
   illegal equipment;                   institutions are responsible for
                                        ensuring compliance with the
b. Be provided the mandated             NCAA bylaws relevant to health
   equipment;                           and safety as outlined in the
                                        division manuals (see Appendix B
c. Be instructed to wear and how to
                                        for a quick reference guide).
   wear mandatory equipment
   during participation; and

d. Be instructed to notify the
   coaching staff when equipment
   becomes unsafe or illegal.

9. Facilities. The adequacy and
conditions of the facilities used for
particular intercollegiate athletics
events should not be overlooked,
and periodic examination of the
facilities should be conducted.
Inspection of the facilities should
include not only the competitive
area, but also warm-up and
adjacent areas.

                                                                                                      7
                                         GUIDELINE 1b
    Medical Evaluations,
    Immunizations and
    Records
      July 1977 • Revised June 2011



    Preparticipation medical                   In a five-year review of sudden           off-season;
    evaluation. A preparticipation             deaths involving NCAA student-
    medical evaluation should be               athletes, the incidence of SCD was        2. Referrals for and feedback from
    required upon a student-athlete’s          approximately one in every 40,000         consultation, treatment or
    entrance into the institution’s inter-     student-athletes per year. The            rehabilitation;
    collegiate athletics program (see          American Heart Association has
                                                                                         3. Subsequent care and clearances;
    NCAA Bylaw 17.1.5). Division I             modified its 1996 recommendation
    requires student-athletes new to their     for a cardiovascular screening            4. A comprehensive entry-year
    campus to complete a sickle cell           every two years for collegiate            health-status questionnaire and an
    solubility test, show results of a prior   athletes.2 The revision3                  updated health-status questionnaire
    test, or sign a written release            recommends cardiovascular screen-         each year thereafter. Components of
    declining the test. This initial           ing as a part of the physical exam        the questionnaire should consider
    evaluation should include a                required upon a student-athlete’s         recommendations from the American
    comprehensive health history,              entrance into the intercollegiate         Heart Association (see reference Nos.
    immunization history as defined by         athletics program. In subsequent          2 and 3) and the 4th Edition
    current Centers for Disease Control        years, an interim history and blood       Preparticipation Physical Evaluation
    and Prevention (CDC) guidelines            pressure measurement should be            (see reference No. 5).
    and a relevant physical exam, with         made. Important changes in
    strong emphasis on the                     medical status or abnormalities           5. Immunizations. It is recommended
    cardiovascular, neurologic and             may require more formal                   that student-athletes be immunized
    musculoskeletal evaluation. After the      cardiovascular evaluation.                for the following:
    initial medical evaluation, an updated
    history should be performed                Medical records. Student-athletes           a. Measles, mumps, rubella
    annually. Further preparticipation         have a responsibility to truthfully         (MMR);
    physical examinations are not              and fully disclose their medical
                                               history and to report any changes           b. Hepatitis B;
    believed to be necessary unless
    warranted by the updated history or        in their health to the team’s health-       c. Diptheria, tetanus (and boosters
    the student-athlete’s medical              care provider. Medical records              when appropriate); and
    condition.                                 should be maintained during the
                                               student-athlete’s collegiate career         d. Meningitis.
    Cardiac. Sudden cardiac death              and should include:
    (SCD) is the leading medical cause                                                   6. Written permission, signed
    of death in NCAA athletes and              1. A record of injuries, illnesses, new   annually by the student-athlete,
    represents 75 percent of all sudden        medications or allergies, pregnancies     which authorizes the release of
    death cases that occur during              and operations, whether sustained         medical information to others.
    training, exercise or competition.         during the competitive season or the      Such permission should specify all
8
                                                  Medical Evaluations, Immunizations and Records

persons to whom the student-               solely the responsibility of the team      incapacitation. Three key
athlete authorizes the information         physician or that physician’s              components need to be included in
to be released. The consent form           designated representative.                 this documentation:
also should specify which
                                           Medical Hardship Waivers.                  1. Contemporaneous diagnosis of
information may be released and to
                                           Documentation standards should                injury/illness;
whom.
                                           assist conferences and institutions in     2. Acknowledgement that the
Note: Records maintained in the            designing a medical treatment                 injury/illness is incapacitating;
athletic training facility are medical     protocol that satisfies all questions of      and
records, and therefore subject to state    incapacitation and reflects such in the
and federal laws with regard to            records. To clarify:                       3. Length of incapacitation.
confidentiality and content. Each                                                     For more information about
institution should obtain from                h
                                           •	 	 ardship	waiver:	A	hardship	waiver	    medical hardship waivers, read the
appropriate legal counsel an opinion          deals with a student-athlete’s          complete article at NCAA.org/
regarding the confidentiality and             seasons of competition and may
                                                                                      health-safety or contact the
content of such records in its state.         only be granted if a student-athlete
                                                                                      NCAA’s student-athlete
                                              has competed and used one of the
                                                                                      reinstatement staff.
Medical records and the information           four seasons of competition.
they contain should be created,
                                              e
                                           •	 	 xtension	waiver:	An	extension	
maintained and released in
                                              waiver deals with time on a
accordance with clear written
                                              student-athlete’s eligibility clock
guidelines based on this opinion. All
                                              and may be granted if, within a
personnel who have access to a
                                              student-athlete’s period of
student-athlete’s medical records
                                              eligibility (five years or 10
should be familiar with such
                                              semesters), he or she has been
guidelines and informed of their role
                                              denied more than one participation
in maintaining the student-athlete’s
                                              opportunity for reasons beyond the
right to privacy.
                                              student-athlete’s and the
Institutions should consider state            institution’s control.
statutes for medical records retention     In order to demonstrate that an injury
(e.g., 7 years, 10 years); institutional   or illness prevented competition and
policy (e.g., insurance long term          resulted in incapacitation for the
retention policy); and professional        remainder of the playing season, an
liability statute of limitations.          institution needs to provide objective
                                           documentation to substantiate the
Follow-up examinations. Those who
have sustained a significant injury or
illness during the sport season should
be given a follow-up examination to
re-establish medical clearance before
resuming participation in a particular
sport. This policy also should apply
to pregnant student-athletes after
delivery or pregnancy termination.
These examinations are especially
relevant if the event occurred before
the student-athlete left the institution
for summer break. Clearance for
individuals to return to activity is


                                                                                                                             9
     Medical Evaluations, Immunizations and Records



         Medical Documentation Standards Guidelines (from the NCAA)
         Contemporaneous Diagnosis of Injury
         ____ Contemporaneous medical documentation that validates timing of injury or illness (Required)
         ____ Contemporaneous medical documentation that verifies initial severity of injury or illness (demonstrates
                incapacitation likely results for remainder of season) (Recommended)
         ____ Operation report(s) or surgery report(s) or emergency room document(s) (Recommended)
         Acknowledgement that the Injury is Incapacitating
         ____ Contemporaneous letter or diagnosis from treating physician identifying injury or illness as “incapacitat-
                ing” OR
         ____ Non-contemporaneous letter or diagnosis from treating physician identifying injury or illness as “inca-
                pacitating” AND
         ____ Treatment logs or athletic trainer’s notes (indicating continuing rehabilitation efforts)
         Length of Incapacitaion (verifying opportunity for injured student-athlete to resume playing within cham-
         pionship season in question is medically precluded)
         ____ Estimated length of incapacitation or recovery time range contained within original contemporaneous
                medical documentation AND
         ____ Contemporaneous documentation of follow-up doctors visits (within the estimated time range) in which
                student-athlete is not cleared to resume playing OR
         ____ Treatment logs or athletic trainer’s notes (indicating continuing rehabilitation efforts)




     References

     1. Cook LG, Collins M, Williams WW,          4. Hepatitis B Virus: a comprehensive      2010. Available at ppesportsevaluation.
     et. al.: Prematriculation Immunization       strategy for eliminating transmission in   org.
     Requirements of American Colleges and        the United States through universal        6. Eligibility Recommendations for
     Universities. Journal of American            childhood vaccination: recommendations     Competitive Athletes with Cardiovascular
     College Health 42:91-98, 1993.               of the Immunization Practices Advisory     Abnormalities. 36th Bethesda Conference.
     2. Recommendations and Considerations        Committee. Morbidity and Mortality         Journal of American College of
     Related to Pre-Participation Screening for   Weekly Report 40 (RR-13), 1991.            Cardiology, 45(8), 2005.
     Cardiovascular Abnormalities in              5. Preparticipation Physical Evaluation.   7. Harmon KG, Asif IM, Klossner D,
     Competitive Athletics: 2007 Update:          4th Ed. American Academy of Family         Drezner JA. Incidence of Sudden Cardiac
     Circulation. Mar 2007; 115:1643-1655.        Physicians, American Academy of            Death in NCAA Athletes. Circulation. Apr
     3. Gardner P, Schaffner W: Immuni-           Pediatrics, American Medical Society of    2011.
     zations of Adults. The New England Jour-     Sports Medicine, American Orthopaedic
     nal of Medicine 328(17):1252-1258,           Society of Sports Medicine. Published by
     1993.                                        the American Academy of Pediatrics,




10
                                  GUIDELINE 1c
Emergency Care
and Coverage
October 1977 • Revised July 2004


Reasonable attention to all possible    whether fixed or mobile, should be     8. Certification in cardiopulmonary
preventive measures will not            assured;                               resuscitation techniques (CPR),
eliminate sports injuries. Each                                                first aid, and prevention of disease
                                        5. All necessary emergency
scheduled practice or contest of an                                            transmission (as outlined by OSHA
                                        equipment should be at the site or
institution-sponsored intercollegiate                                          guidelines) should be required for
                                        quickly accessible. Equipment
athletics event, and all out-of-                                               all athletics personnel associated
                                        should be in good operating
season practices and skills sessions,                                          with practices, competitions, skills
                                        condition, and personnel must be
should include an emergency plan.                                              instruction, and strength and
                                        trained in advance to use it
Like student-athlete well-being in                                             conditioning. New staff engaged in
                                        properly. Additionally, emergency
general, a plan is a shared                                                    these activities should comply with
                                        information about the student-
responsibility of the athletics
                                        athlete should be available both at    these rules within six months of
department; administrators,
                                        campus and while traveling for use     employment. Refer to Appendix B
coaches and medical personnel
                                        by medical personnel;                  for NCAA Coach Sport Safety
should all play a role in the
                                        6. An inclement weather policy         legislative requirements.
establishment of the plan,
procurement of resources and            that includes provisions for           9. A member of the institution's
understanding of appropriate            decision-making and evacuation         sports medicine staff should be
emergency response procedures by        plans (See Guideline 1d);              empowered to have the
all parties. Components of such a                                              unchallengeable authority to cancel
                                        7. A thorough understanding by all
plan should include:                                                           or modify a workout for health and
                                        parties, including the leadership of
1. The presence of a person             visiting teams, of the personnel and   safety reasons (i.e., environmental
qualified and delegated to render       procedures associated with the         changes), as he or she deems
emergency care to a stricken            emergency-care plan; and               appropriate.
participant;
2. The presence or planned access
to a physician for prompt medical
evaluation of the situation, when
warranted;
3. Planned access to early
defibrillation;
4. Planned access to a medical
facility, including a plan for
communication and transportation
between the athletics site and the
medical facility for prompt medical
services, when warranted. Access
to a working telephone or other
telecommunications device,                                                                                            11
     Emergency Care and Coverage



       Guidelines to Use During a Serious On-Field Player Injury:
       These guidelines have been recommended for National Football League (NFL) officials and have been shared with
       NCAA championships staff.
       1. Players and coaches should go to and remain in the bench area once medical assistance arrives. Adequate lines
       of vision between the medical staffs and all available emergency personnel should be established and maintained.
       2. Players, parents and nonauthorized personnel should be kept a significant distance away from the seriously
       injured player or players.
       3. Players or non-medical personnel should not touch, move or roll an injured player.
       4. Players should not try to assist a teammate who is lying on the field (i.e., removing the helmet or chin strap, or
       attempting to assist breathing by elevating the waist).
       5. Players should not pull an injured teammate or opponent from a pile-up.
       6. Once the medical staff begins to work on an injured player, they should be allowed to perform services without
       interruption or interference.
       7. Players and coaches should avoid dictating medical services to the athletic trainers or team physicians or taking
       up their time to perform such services.



     References

     1. Halpern BC: Injuries and emergencies    4. Van Camp SP, et al: Nontraumatic         7. Laws on Cardiac Arrest and
     on the field. In Mellion MB, Shelton GL,   sports death in high school and college     Defibrillators, 2007 update. Available at:
     Walsh WM (eds): The Team Physician's       athletics. Medicine and Science in Sports   www.ncsi.org/programs/health/aed.htm.
     Handbook St. Louis, MO: Mosby-             and Exercise 27(5):641-647, 1995.           8. Inter-Association Task Force
     Yearbook, 1990, pp. 128-142.               5. Mass Participation Event                 Recommendations on Emergency
     2. Harris AJ: Disaster plan—A part of      Management for the Team Physician: A        Preparedness and Management of
                                                Consensus Statement. Medicine and           Sudden Cardiac Arrest in High School
     the game plan. Athletic Training
                                                                                            and College Athletic Programs: A
     23(1):59, 1988.                            Science in Sports and Exercise
                                                                                            Consensus Statement. Journal of Athletic
     3. Recommendations and Guidelines for      36(11):2004-2008, 2004.
                                                                                            Training. 42:143-158. 2007.
     Appropriate Medical Coverage of            6. Sideline Preparedness for the Team
                                                                                            9. National Athletic Trainers’ Association
     Intercollegiate Athletics. National        Physician: A Consensus Statement.           Position Statement: Acute Management of
     Athletic Trainers’ Association, (2952      Medicine and Science in Sports and          the Cervical Spine-Injured Athlete. Journal
     Stemmons Freeway, Dallas, Texas) 2003.     Exercise 33(5):846-849, 2001.               of Athletic Training. 44:306-331. 2009.




12
                                  GUIDELINE 1d
Lightning Safety
July 1997 • Revised June 2007



The NCAA Committee on Com-              place. The following steps are          weather has been reported in an
petitive Safeguards and Medical         recommended by the NCAA and             area and for everyone to take the
Aspects of Sports acknowledges the      NOAA to mitigate the lightning          proper precautions. A NOAA
significant input of Brian L.           hazard:                                 weather radio is particularly helpful
Bennett, formerly an athletic                                                   in providing this information.
trainer with the College of William     1. Designate a person to monitor
and Mary Division of Sports             threatening weather and to make         4. Know where the closest “safer
Medicine, Ronald L. Holle, a            the decision to remove a team or        structure or location” is to the field
meteorologist, formerly of the          individuals from an athletics site or   or playing area, and know how
                                        event. A lightning safety plan          long it takes to get to that location.
National Severe Storms Laboratory
                                        should include planned instructions     A safer structure or location is
(NSSL), and Mary Ann Cooper,
                                        for participants and spectators,        defined as:
M.D., Professor of Emergency
                                        designation of warning and all
Medicine of the University of                                                     a. Any building normally
                                        clear signals, proper signage, and
Illinois at Chicago, in the                                                       occupied or frequently used by
                                        designation of safer places for
development of this guideline.                                                    people, i.e., a building with
                                        shelter from the lightning.
                                                                                  plumbing and/or electrical
Lightning is the most consistent
                                        2. Monitor local weather reports          wiring that acts to electrically
and significant weather hazard that
                                        each day before any practice or           ground the structure. Avoid
may affect intercollegiate athletics.
                                        event. Be diligently aware of             using the shower or plumbing
Within the United States, the Nat-
                                        potential thunderstorms that may          facilities and contact with
ional Oceanic and Atmospheric
                                        form during scheduled                     electrical appliances during a
Administration (NOAA) estimates
                                        intercollegiate athletics events or       thunderstorm.
that 60 to 70 fatalities and about 10
                                        practices. Weather information can
times as many injuries occur from                                                 b. In the absence of a sturdy,
                                        be found through various means
lightning strikes every year. While                                               frequently inhabited building,
                                        via local television news coverage,
the probability of being struck by                                                any vehicle with a hard metal
                                        the Internet, cable and satellite
lightning is low, the odds are                                                    roof (neither a convertible, nor a
                                        weather programming, or the
significantly greater when a storm                                                golf cart) with the windows shut
                                        National Weather Service (NWS)
is in the area and proper safety                                                  provides a measure of safety.
                                        website at www.weather.gov.
precautions are not followed.                                                     The hard metal frame and roof,
                                        3. Be informed of National Weather        not the rubber tires, are what
Education and prevention are the        Service (NWS) issued                      protects occupants by dissipating
keys to lightning safety. The           thunderstorm “watches” or                 lightning current around the
references associated with this         “warnings,” and the warning signs         vehicle and not through the
guideline are an excellent              of developing thunderstorms in the        occupants. It is important not to
educational resource. Prevention        area, such as high winds or               touch the metal framework of
should begin long before any            darkening skies. A “watch” means          the vehicle. Some athletics
intercollegiate athletics event or      conditions are favorable for severe       events rent school buses as safer
practice by being proactive and         weather to develop in an area; a          shelters to place around open
having a lightning safety plan in       “warning” means that severe               courses or fields.


                                                                                                                         13
     Lightning Safety

                                              recommend that by the time the       significant threat. At night, be
      Dangerous Locations                     monitor observes 30 seconds          aware that lightning can be
      Outside locations increase the          between seeing the lightning         visible at a much greater
      risk of being struck by lightning       flash and hearing its associated     distance than during the day as
      when thunderstorms are in the           thunder, all individuals should      clouds are being lit from the
      area. Small covered shelters are        have left the athletics site and     inside by lightning. This greater
      not safe from lightning. Dug-           reached a safer structure or         distance may mean that the
      outs, rain shelters, golf shelters      location.                            lightning is no longer a
      and picnic shelters, even if they                                            significant threat. At night, use
                                              b. Please note that thunder may      both the sound of thunder and
      are properly grounded for
                                              be hard to hear if there is an       seeing the lightning channel
      structural safety, are usually not
                                              athletics event going on,            itself to decide on re-setting the
      properly grounded from the
                                              particularly in stadia with large    30-minute “return-to-play” clock
      effects of lightning and side
                                              crowds. Implement your               before resuming outdoor
      flashes to people. They are
                                              lightning safety plan                athletics activities.
      usually very unsafe and may
                                              accordingly.
      actually increase the risk of                                                f. People who have been struck
      lightning injury. Other                 c. The existence of blue sky and     by lightning do not carry an
      dangerous locations include             the absence of rain are not          electrical charge. Therefore,
      areas connected to, or near,            guarantees that lightning will       cardiopulmonary resuscitation
      light poles, towers and fences          not strike. At least 10 percent of   (CPR) is safe for the responder.
      that can carry a nearby strike to       lightning occurs when there is       If possible, an injured person
      people. Also dangerous is any           no rainfall and when blue sky is     should be moved to a safer
      location that makes the person          often visible somewhere in the       location before starting CPR.
      the highest point in the area.          sky, especially with summer          Lightning-strike victims who
                                              thunderstorms. Lightning can,        show signs of cardiac or
     5. Lightning awareness should be         and does, strike as far as 10 (or    respiratory arrest need prompt
     heightened at the first flash of         more) miles away from the rain       emergency help. If you are in a
     lightning, clap of thunder, and/or       shaft.                               911 community, call for help.
     other criteria such as increasing                                             Prompt, aggressive CPR has
                                              d. Avoid using landline
     winds or darkening skies, no matter                                           been highly effective for the
                                              telephones, except in emergency
     how far away. These types of                                                  survival of victims of lightning
                                              situations. People have been
     activities should be treated as a                                             strikes.
                                              killed while using a landline
     warning or “wake-up call” to             telephone during a thunderstorm.     Automatic external defibrillators
     intercollegiate athletics personnel.     Cellular or cordless phones are      (AEDs) have become a
     Lightning safety experts suggest         safe alternatives to a landline      common, safe and effective
     that if you hear thunder, begin          phone, particularly if the person    means of reviving persons in
     preparation for evacuation; if you       and the antenna are located          cardiac arrest. Planned access
     see lightning, consider suspending       within a safer structure or          to early defibrillation should be
     activities and heading for your          location, and if all other           part of your emergency plan.
     designated safer locations.              precautions are followed.            However, CPR should never be
     The following specific lightning                                              delayed while searching for an
                                              e. To resume athletics activities,   AED.
     safety guidelines have been
                                              lightning safety experts
     developed with the assistance of
                                              recommend waiting 30 minutes         Note: Weather watchers, real-
     lightning safety experts. Design
                                              after both the last sound of         time weather forecasts and
     your lightning safety plan to consider
                                              thunder and last flash of            commercial weather-warning
     local safety needs, weather patterns
                                              lightning. If lightning is seen      devices are all tools that can be
     and thunderstorm types.
                                              without hearing thunder,             used to aid in decision-making
       a. As a minimum, lightning             lightning may be out of range        regarding stoppage of play,
       safety experts strongly                and therefore less likely to be a    evacuation and return to play.
14
                                                                                                    Lightning Safety


References

1. Cooper MA, Andrews CJ, Holle RL,       2006; 22: 67-78.                           Cooper MA, Kithil R. National Athletic
Lopez RE. Lightning Injuries. In:         4. National Lightning Safety Institute     Trainer's Association Position Statement.
Auerbach, ed. Management of               website: www.lightningsafety.com.          Lightning Safety for Athletics and
Wilderness and Environmental              5. Uman MA. All About Lightning.           Recreation. Journal of Athletic Training.
Emergencies. 5th ed. C.V. Mosby,          New York: Dover Publications. 1986.        35(4);471-477. 2000.
2007:67-108.                              6. NOAA lightning safety website: www.     9. Holle RL. 2005: Lightning-caused
2. Bennett BL. A Model Lightning          lightningsafety.noaa.gov.                  recreation deaths and injuries.
Safety Policy for Athletics. Journal of   7. Walsh KM, Hanley MJ, Graner SJ,         Preprints, 14th Symposium on Education,
Athletic Training. 32(3):251-253. 1997.   Beam D, Bazluki J. A Survey of             January 9-13, San Diego, California,
3. Price TG, Cooper MA: Electrical and    Lightning Safety Policy in Selected        American Meteorological Society, 6 pp.
Lightning Injuries. In: Marx et al.       Division I Colleges. Journal of Athletic   10. The Weather Channel on satellite or
Rosen’s Emergency Medicine, Concepts      Training. 32(3);206-210. 1997.             cable, and on the Internet at www.
and Clinical Practice, Mosby, 6th ed.     8. Walsh KM, Bennett BL, Holle RL,         weather.com.




                                                                                                                                 15
                                      GUIDELINE 1e
     Catastrophic
     Incident in
     Athletics
      July 2004 • Revised July 2008


     The NCAA Committee on Comp-             members are aware of the               checklist of whom to call and
     etitive Safeguards and Medical          guideline.                             immediate steps to secure facts and
     Aspects of Sports acknowledges the                                             offer support are items to be
     significant input of Timothy Neal,      Components of a catastrophic           included.
     ATC, Syracuse University, who           incident guideline should include:
     originally authored this guideline.                                            4. Chain of command/role
                                             1. Definition of a catastrophic        delineation: This area outlines
     Catastrophes such as death or           incident: The sudden death of a        each individual’s responsibility
     permanent disability occurring in       student-athlete, coach or staff        during the aftermath of the
     intercollegiate athletics are rare.     member from any cause, or              catastrophe. Athletics
     However, the aftermath of a             disabling and/or quality of life       administrators, university
     catastrophic incident to a student-     altering injuries.                     administrators and support services
     athlete, coach or staff member can                                             personnel should be involved in
     be a time of uncertainty and            2. A management team: A select         this area.
     confusion for an institution. It is     group of administrators who
     recommended that NCAA member            receive all facts pertaining to the    5. Criminal circumstances:
     institutions develop their own                                                 Outline the collaboration of the
                                             catastrophe. This team works
     catastrophic incident guideline to                                             athletics department with
                                             collaboratively to officially
     provide information and the                                                    university, local and state law
                                             communicate information to family
     support necessary to family                                                    enforcement officials in the event
                                             members, teammates, coaches,
     members, teammates, coaches and                                                of accidental death, homicide or
                                             staff, the institution and media.
     staff after a catastrophe.                                                     suicide.
                                             This team may consist of one or
     Centralizing and disseminating the      more of the following: director of
     information is best served by                                                  6. Away contest responsibilities:
                                             athletics, head athletic trainer,
     developing a catastrophic incident                                             Catastrophes may occur at away
                                             university spokesperson, director of   contests. Indicate who should stay
     guideline. This guideline should be     athletic communications and
     distributed to administrative, sports                                          behind with the individual to
                                             university risk manager. This team     coordinate communication and act
     medicine and coaching staffs            may select others to help facilitate
     within the athletics department.                                               as a university representative until
                                             fact finding specific to the           relieved by the institution.
     The guideline should be updated         incident.
     and reviewed annually with the
     entire staff to ensure information is                                          7. Phone list and flow chart:
                                             3. Immediate action plan: At the       Phone numbers of all key
     accurate and that new staff             moment of the catastrophe, a           individuals (office, home, cell)


16
                                                                      Catastrophic Incident in Athletics

involved in the management of the       spouse of the victim. The director      Catastrophic Injury
catastrophe should be listed and        of athletics, head coach and others     Insurance Program
kept current. Include university        deemed necessary, will inform the       The NCAA sponsors a catastrophic
legal counsel numbers and the           team, preferably in person, as soon     injury insurance program that
NCAA catastrophic injury service        as possible and offer counseling        covers a student-athlete who is
line number (800/245-2744). A           services and support.                   catastrophically injured while
flow chart of who is to be called in                                            participating in a covered
the event of a catastrophe is also      10. Assistance to Visiting Team’s       intercollegiate athletic activity. The
useful in coordinating                  Catastrophic Incident as Host           policy has a $90,000 deductible
communication.                          Institution: In the event that a        and provides benefits in excess of
                                        visiting team experiences a             any other valid and collectible
8. Incident Record: A written           catastrophic incident, the host         insurance. The policy will pay
chronology by the management            institution may offer assistance by     $25,000 if an insured person dies
team of the catastrophic incident is                                            as a result of a covered accident or
                                        alerting the director of athletics or
recommended to critique the                                                     sustains injury due to a covered
                                        another member of the catastrophic
process and provide a basis for
                                        incident management team in order       accident which, independent of all
review and enhancement of
                                        to make as many resources               other causes, results directly in the
procedures.
                                        available as possible to the visiting   death of the insured person within
                                        team. The host institution may          twelve (12) months after the date
9. Notification Process: After the
                                        assist in contacting the victim’s       of such injury. Both catastrophic
catastrophic incident, the director
                                        institution and athletics               injuries and sudden deaths should
of athletics, assistant director of
athletics for sports medicine (head     administration, as well as              be reported to the NCAA national
athletic trainer), head coach           activating, as appropriate, the host    office insurance staff. For more
(recruiting coach if available), and    institution’s catastrophic incident     information, visit NCAA.org.
university risk manager/legal           guideline to offer support to the
counsel, as available, will contact     visiting team’s student-athletes,       Sample guidelines may be found
the parents/legal guardians/            coaches and staff.                      at NCAA.org/health-safety.

                                                                                 References
  Dr. Fred Mueller at the National Center for Catastrophic Sports Injury
  Research continues to research catastrophic injuries in sports through
                                                                                1. Neal, TL: Catastrophic
  funding by the NCAA and the American College Football Coaches
                                                                                Incident Guideline Plan. NATA
  Association. The football fatality research and data collection has
  been done since 1931. The football catastrophic research started in           News: 12, May 2003.
  1977 at the University of North Carolina, Chapel Hill, and the                2. Neal, TL: Syracuse University
  research on fatalities and catastrophic injuries in all other sports was      Athletic Department
  added beginning in 1982. Reports can be found on the NCCSI                    Catastrophic Incident Guideline,
  website at www.unc.edu/depts/nccsi/.                                          2003.
  Catastrophic injuries include the following:
  1. Fatalities.
  2. Permanent disability injuries.
  3. Serious injuries (fractured neck or serious head injury) even
  though the athlete has a full recovery.
  4. Temporary or transient paralysis (athlete has no movement for a
  short time but has a complete recovery).

  Please contact Dr. Mueller at the National Center for Catastrophic
  Sports Injury Research to report an incident at 919/962-5171 or via
  email at mueller@email.unc.edu.

                                                                                                                         17
                                      GUIDELINE 1f
     Dispensing
     Prescription
     Medication
      May 1986 • Revised June 2008



     Research sponsored by the NCAA          to athletic trainers the authority for   must comply with the applicable
     has shown that prescription             dispensing prescription medications      state and federal laws for doing so.
     medications have been provided to       under current medication-dis-            It is strongly encouraged that
     student-athletes by individuals other   pensing laws, since athletic trainers    athletics departments and their team
     than persons legally authorized to      are not authorized by law to             physicians work with their on-site or
     dispense such medications. This is      dispense these drugs under any           area pharmacists to develop
     an important concern because the        circumstances. The improper              specific policies.
     improper dispensing of both             delegation of authority by the
     prescription and nonprescription        physician or the dispensing of           The following items form a minimal
     drugs can lead to serious medical       prescription medications by the          framework for an appropriate drug-
     and legal consequences.                 athletic trainer (even with              distribution program in a college-
                                             permission of the physician), place      athletics environment. Since there is
     Research also has shown that state      both parties at risk for legal           extreme variability in state laws, it
     and federal regulations regarding       liability.                               is imperative for each institution to
     packaging, labeling, records keeping                                             consult with legal counsel in order
     and storage of medications have         If athletics departments choose to       to be in full compliance.
     been overlooked or disregarded in       provide prescription and/or
     the dispensing of medications from      nonprescription medications, they        1. Drug-dispensing practices are
     the athletic training facility.
     Moreover, many states have strict
     regulations regarding packaging,
     labeling, records keeping and
     storage of prescription and
     nonprescription medications.
     Athletics departments must be
     concerned about the risk of harm to
     the student-athletes when these
     regulations are not followed.

     Administering drugs and dispensing
     drugs are two separate functions.
     Administration generally refers to
     the direct application of a single
     dose of drug. Dispensing is defined
     as preparing, packaging and
     labeling a prescription drug or
     device for subsequent use by a
18   patient. Physicians cannot delegate
                                                                          Dispensing Prescription Medication

subject to and should be in                  be created and maintained where            6. All emergency and travel kits
compliance with all state, federal           dispensing occurs in accordance            containing prescription and OTC
and Drug Enforcement Agency                  with appropriate legal guidelines.         drugs should be routinely inspected
(DEA) regulations. Relevant items            The record should be current and           for drug quality and security.
include appropriate packaging, label-        easily accessible by appropriate
ing, counseling and education,               medical personnel.                         7. Individuals receiving medication
records keeping, and accountability                                                     should be properly informed about
for all drugs dispensed.                     4. All prescription and over-the-          what they are taking and how they
                                             counter (OTC) medications should           should take it. Drug allergies, chronic
2. Certified athletic trainers should        be stored in designated areas that         medical conditions and concurrent
not be assigned duties that may be           ensure proper environmental (dry           medication use should be documented
performed only by physicians or              with temperatures between 59 and           in the student-athlete’s medical record
pharmacists. A team physician                86 degrees Fahrenheit) and security        and readily retrievable.
cannot delegate diagnosis,                   conditions.
prescription-drug control or                                                            8. Follow-up should be performed to
prescription-dispensing duties to            5. All drug stocks should be               be sure student-athletes are
athletic trainers.                           examined at regular intervals for          complying with the drug regimen
                                             removal of any outdated, deteriorated      and to ensure that drug therapy is
3. Drug-distribution records should          or recalled medications.                   effective.


 References

1. Adherence to Drug-Dispensation and        Publications, 1991, pp. 215-224.           Distribution System for Athletics
Drug-Administration Laws and                 4. Huff PS: Drug Distribution in the       Programs. Unpublished report, 1991.
Guidelines in Collegiate Athletic Training   Training Room. In Clinics in Sports        (128 Miller Hall, Department of Phar-
Rooms. Journal of Athletic Training.         Medicine. Philadelphia, WB Saunders        macy Care Systems, Auburn University,
38(3): 252-258, 2003.                        Co: 211-228, 1998.                         Auburn, AL 36849-5506)
2. Anderson WA, Albrecht RR, McKeag          5. Huff PS, Prentice WE: Using Phar-       7. Price KD, Huff PS, Isetts BJ, et.al:
DB, et al.: A national survey of alcohol     macological Agents in a Rehabilitation     University-based sports pharmacy
and drug use by college athletes. The        Program. In Rehabilitation Techniques in   program. American Journal Health-
Physician and Sportsmedicine 19:91-          Sports Medicine (3rd Ed.) Dubuque, IA,     Systems Pharmacy 52:302-309, 1995.
104, 1991.                                   WCB/McGraw-Hill 244-265, 1998.             8. National Athletic Trainers’ Association
3. Herbert DL: Dispensing prescription       6. Laster-Bradley M, Berger BA: Eval-      Consensus Statement: Managing
medications to athletes. In Herbert, DL      uation of Drug Distribution Systems in     Prescriptions and Non-Prescription
(ed): The Legal Aspects of Sports Medi-      University Athletics Programs: Develop-    Medication in the Athletic Training
cine Canton, OH: Professional Sports         ment of a Model or Optimal Drug            Facility. NATA News. January 2009.




                                                                                                                                     19
                                        GUIDELINE 1g
     Nontherapeutic Drugs
      July 1981 • Revised June 2002



     The NCAA and professional                1997. Use of spit tobacco is down in         Sports. While not all member
     societies such as the American           all divisions, but more so in                institutions have enacted their own
     Medical Association (AMA) and the        Divisions II and III. Cocaine use is         drug-testing programs, it is essential
     American College of Sports               up slightly in all divisions since           to have some type of drug-education
     Medicine (ACSM) denounce the             2001. The full results of the 2005           program as outlined in Guideline 1h.
     employment of nontherapeutic drugs       and past surveys are available to all        Drug testing should not be viewed as
     by student-athletes. These include       member institutions and can be used          a replacement for a solid drug-
     drugs that are taken in an effort to     to educate staff and plan educational        education program.
     enhance athletic performance, and        and treatment programs for its
     those drugs that are used                student-athletes.                            All medical staff should be familiar
     recreationally by student-athletes.                                                   with the regulations regarding
     Examples include, but are not            The NCAA maintains a banned drug             dispensing medications as listed in
     limited to, alcohol, amphetamines,       classes list and conducts drug testing       Guideline 1f.
     ephedrine, ma huang, anabolic-           at championship events and year-
     androgenic steroids, barbiturates,       round random testing in sports.              All member institutions, their
     caffeine, cocaine, heroin, LSD, PCP,     Some NCAA member institutions                athletics staff and their student-
     marijuana and all forms of tobacco.      have developed drug-testing                  athletes should be aware of current
     The use of such drugs is contrary to     programs to combat the use of                trends in drug use and abuse, and the
     the rules and ethical principles of      nontherapeutic substances. Such              current NCAA list of banned drug
     athletics competition.                   programs should follow best practice         classes. It is incumbent upon NCAA
                                              guidelines established by the NCAA           member institutions to act as a
     The patterns of drug use and the                                                      positive influence in order to combat
                                              Committee on Competitive
     specific drugs change frequently,
                                              Safeguards and Medical Aspects of            the use of drugs in sport and society.
     and it is incumbent upon NCAA
     member institutions to keep abreast
     of current trends. The NCAA
     conducts drug-use surveys of
     student-athletes in all sports and
     across all divisions every four years.    References
     According to the 2005 NCAA Study
     of Substance Use Habits of College       1. American College of Sports Medicine,      Compendium, Policy Statement: Non-
     Student-Athletes, the percentage of      Position Stand: The Use of Anabolic-         Therapeutic Use of Pharmacological
     student-athletes who use alcohol         Androgenic Steroids in Sports, 1984. (P.O.   Agents by Athletes (105.016), 1990. (P.O.
     decreased by 12 percent (88.9-76.9)      Box 1440, Indianapolis, IN 46206-1440)       Box 10946, Chicago, IL 60610)
     during the last 16 years, while the      2. American Medical Association              4. NCAA Study of Substance Use Habits
     percentage of student-athletes who
                                              Compendium, Policy Statement: Medical        of College Student-Athletes. NCAA, P.O.
     use marijuana during those same 16
                                              and Non-Medical Use of Anabolic-             Box 6222, Indianapolis, Indiana 46206-
     years also decreased (27.5-20.3).
     Among the entire group of student-       Androgenic Steroids (105.001), 1990.         6222, June 2006. Available at www.
     athletes, the use of amphetamines        (P.O. Box 10946, Chicago, IL 60610)          NCAA.org.
     has continually increased since          3. American Medical Association


20
                                   GUIDELINE 1h
NCAA Alcohol,
Tobacco and Other
Drug Education
Guidelines
August 2000 • Revised June 2003, June 2009, June 2010



NCAA bylaws require that the             program policies and update         Tasks and Timelines
director of athletics or his or her      handbook materials accordingly.     for educating
designee disseminate the list of                                             student-athletes
banned drug classes to all student-       I
                                       •	 	 nclude	the	NCAA	list	of	banned	
athletes and educate them about           drug classes and NCAA written     By July 1:
products that might contain banned        policies in the student-athlete
                                          handbook.                            S
                                                                            •	 	 end	out	the	NCAA	list	of	
drugs. The following provides a
                                                                               banned drug classes, the dietary
framework for member schools to
                                       •	 	 dentify	NCAA,	conference	and	
                                          I                                    supplement warning and REC*
assure they are conducting adequate
                                          institutional rules regarding the    information to all returning
drug education for all student-
                                          use of street drugs, performance     student-athletes and known
athletes. Athletics administrators,
coaches and sports medicine               enhancing substances, and            incoming student-athletes.
personnel should also participate in      nutritional supplements, and
                                          consequences for breaking the     Orientation at Start
drug-education sessions. Campus                                             of Academic Year:
colleagues may provide additional         rules.
support for your efforts.                                                       E
                                                                             •	 	 nsure	that	student-athletes	sign	
                                          D
                                       •	 	 isplay	posters	and	other	NCAA	
                                          educational materials in high-        NCAA compliance forms.
In preparation for
institution drug-                         traffic areas.                        P
                                                                             •	 	 rovide	student-athletes	with	a	
education programs,                                                             copy of the written drug policies
                                          I
                                       •	 	 nclude	the	following	printed	
annually:                                                                       as outlined prior.
                                          warning in the student-athlete
•	 	 evelop	a	written	policy	on	
   D                                      handbook:                             S
                                                                             •	 	 how	NCAA	Drug-Education	
   alcohol, tobacco and other drugs.                                            and Testing video.
   This policy should include a        Before consuming any nutritional/
   statement on recruitment            dietary supplement product, review       V
                                                                             •	 	 erbally	explain	all	relevant	drug	
   activities, drug testing,           the product and its label with your      policies with student-athletes
   disclosure of all medications and   athletics department staff. Dietary      and staff:
   supplements, discipline, and        supplements are not well regulated
   counseling or treatment options.    and may cause a positive drug test         N
                                                                             	 •	 	 CAA	banned	drug	classes	
                                       result. Any product containing a           (note that all related
   R
•	 	 eview	the	NCAA,	conference	       dietary supplement ingredient is           compounds under each class
   and institutional drug-testing      taken at your own risk.*                   are banned, regardless if they
                                                                                                                       21
     NCAA Alcohol, Tobacco and Other Drug Education Guidelines


          are listed as an example.)

          N
     	 •	 	 CAA	drug-testing	policies	
          and consequences for testing
          positive, including failure to
          show or tampering with a
          urine sample.

          R
     	 •	 	 isks	of	using	nutritional/
          dietary supplements – read
          the dietary-supplement
          warning.

          N
     	 •	 	 CAA	tobacco	use	ban	
          during practice or
          competition.

          C
     	 •	 	 onference	and	institutional	
          drug-testing program policies,
          if appropriate.

          S
     	 •	 	 treet	drug	use	policies	and	
          institutional sanctions for
          violations, if appropriate.

     Team Meetings:                         Throughout the Year:

     •	 	 epeat	the	information	from	the	
        R                                      P
                                            •	 	 rovide	additional	drug-
        orientation at team meetings           education opportunities using
        throughout the year.                   NCAA resources found at www.
                                               NCAA.org/drugtesting.
     Start of Each New
     Academic Term:                         *For authoritative information on
                                            NCAA banned substances,
     •	 	 epeat	the	information	from	the	
        R                                   medications and nutritional
        orientation at the start of new     supplements, contact the Resource
        academic terms to reinforce         Exchange Center (REC) at
        messages and to ensure transfer     877/202-0769 or www.
        student-athletes are exposed to     drugfreesport.com/rec (password
        this information.                   ncaa1, ncaa2 or ncaa3).




22
                                     GUIDELINE 1i
Preseason
Preparation
 July 2011

Athletic performance training is often    Specifically, student-athletes should        on-campus experience, athletes
divided into separate segments:           know that the designated preseason           should be encouraged to improve
preparation segment, competitive          practice period might be considered          fitness through a progressive
segment and offseason segment. The        part of the competitive season and           training and conditioning program
NCAA Sports Medicine Handbook             therefore a time when they may               at least four weeks before starting
Guideline 1a notes that the student-      practice at contest-level intensities.       the preseason segment.
athlete should be protected from          A shortened preseason period based
premature exposure to the full rigors     only on time spent on campus or              The preparatory and preseason
of sports. Optimal readiness for the      coach expectations for contest-level         phases provide ample time to
first practice and competition is often   intensities during the preparation           improve fitness and skill; however,
individualized to the student-athlete     period often increases the time              performing novel exercise or
rather than a team as a whole.            spent practicing sport-specific skills       actively doing too much too soon
However, there is a lack of scientific    without ample opportunity for                can result in a disparity between
evidence to set a specific number of      preparatory conditioning exercises           workload and load tolerance, thus
days of sport practice that is needed     and can lead to injury and                   increasing risk for injury. In
for the first sport competition.          overtraining. If this is the                 addition, a student-athlete’s
                                          expectation for the preparatory              psychological well-being can be
It is commonly accepted that
student-athletes should participate
in at least six to eight weeks of
                                          Practice Injury Rates for Fall Sports
preseason conditioning. Gradual           (2004-05 to 2008-09 NCAA Injury Surveillance)
progression of type, frequency,               Preseason              In-Season
intensity, recovery and duration of
training should be the focus of the
                                                                                                                      9.6
preparation segment. In addition to                       Football
these areas warranted for                                                               3.2
progression, 10 to14 days are
needed for heat acclimatization                                                                                  8.9
                                          Women’s Field Hockey
when applicable (see Guideline 2c).                                                     3.3
The fall sport preseason period is
often challenging as August                                                                                    8.2
                                                    Men’s Soccer
presents added heat risks for sports                                                     3.6
and there is a lack of time limits for
practice activities (with the                                                            7.8                    8.7
exception of football).                         Women’s Soccer
                                                                                       3.0
Changes to practice opportunities
or the preseason period should be                                                4.7                 6.5
                                              Women’s Volleyball
accompanied by an educational                                                           3.2
campaign for both coaches and
                                                                      0      2           4       6         8         10
student-athletes as to the
expectations for the sport season.                                    Injury rate (per 1,000 athlete-exposures)
                                                                                                                             23
     Preseason Preparation

     directly dependent on the level of        intensity, long duration exercise          between multiple practice sessions
     fatigue driven by volume (quantity)       training or competition.                   on the same calendar day.
     and intensity of training. Similarly,                                              •	 Subsequent	to	the	initial	
     the incidence in stress-related         Fall Preseason Period. Institutions
                                             are encouraged to regularly review            acclimatization period, an
     injuries (e.g., stress fractures,                                                     institution should consider a
     tendinitis) can be proportional to      their preseason policies for fall sports
                                             and consider the following points of          practice model that promotes
     the work-rest ratio of the athlete.                                                   recovery if practice sessions are to
                                             emphasis for protecting the health of
     Preparatory Phase. The following        and providing a safe environment for          occur on consecutive days (e.g.,
     are general concepts to consider        all student-athletes participating in         two-one-two-one format).
     during the preparatory phase of         preseason workout sessions.                •	 Student-athletes	should	be	
     training:                               •	 Before	participation	in	any	               provided at least one recovery
                                                preseason-practice activities, all         day per week on which no
     •	 Training	should	be	periodized	so	                                                  athletics-related activities are
                                                student-athletes should have
        that variation in the volume and                                                   scheduled, similar to the regular
                                                completed the medical
        intensity occurs in a scheduled                                                    playing season.
                                                examination process administered
        manner.
                                                by medical personnel (see Bylaw         •	 Coaches	are	encouraged	to	
     •	 Plan	recovery	to	allow	for	growth	      17.1.5).                                   consult with healthcare staff (e.g.,
        and development while avoiding       •	 Institutions	should	implement	an	          athletic trainer) in the
        acute and overtraining injuries.        appropriate rest and recovery plan         development of the conditioning
                                                that includes a hydration strategy.        sessions. All personnel should be
     •	 A	proper	heat	acclimatization	                                                     aware of the impact of exercise
        plan is essential to minimize the    •	 Preseason	practice	should	begin	
                                                                                           intensity and duration, heat
        risk of exertional heat illness         with an acclimatization period for
                                                                                           acclimatization, hydration,
        during the fall preseason practice      first-time participants, as well as
                                                                                           medications and drugs, existing
        period. Minimizing exertional           continuing student-athletes.
                                                                                           medical conditions, nutritional
        heat illness risk requires           •	 During	the	acclimatization	                supplements, and equipment on
        gradually increasing athletes’          period, an institution should              student-athletes’ health while
        exposure to the duration and            conduct only one practice per              participating in strenuous
        intensity of physical activity and      calendar day.                              workouts.
        to the environment over a period
                                             •	 Practice	sessions	should	have	          •	 Appropriate	on-field	personnel	
        of 10 to 14 days.                       maximum time limits based on               should review, practice and
     •	 Prolonged,	near-maximal	                sport and individual needs, as             follow their venue emergency
        exertion should be avoided              well as environmental factors.             plan, as well as be trained in
        before acquired physical fitness     •	 An	institution	should	ensure	              administering first aid,
        and heat acclimatization are            student-athletes have continuous           cardiopulmonary resuscitation
        sufficient to support high-             recovery time (e.g., three hours)          (CPR) and AED use.




24
                                                                                             Preseason Preparation


 References

1. Joy, EA, Prentice, W, and Nelson-Steen,   5. Herring et al. The team physician and    [part 1-2]. Strength & Conditioning
S. Coaching and Training. SSE                conditioning of athletes for sports: A      Journal, 26(1): 50-69
Roundtable #44: Conditioning and             consensus statement.                        10. Plisk, S and Stone, MH. (2003).
nutrition for football. GSSI: Sports         6. United Educators. (2006). Putting        Periodization strategies. Strength &
Science Library. Available Online: www.      safety before the game: College and high    Conditioning Journal, 25(6): 19-37.
gssiweb.com/Article_Detail.aspx?articleid    school athletic practices. Risk Research    11. Armstrong et al. (2007). ACSM
=277&level=2&topic=14 .                      Bulletin, Student Affairs, June/July.       Position Stand: Exertional heat illness
2. Bompa, Tudor O. (2004). Primer on         Available online: www.ue.org.               during training and competition.
Periodization. Olympic Coach, 16(2):         7. National Athletic Trainer’s              Medicine & Science in Sports & Exercise.
4-7.                                         Association. Pre-Season heat                Available Online: www.acsm-msse.org
3. Kraemer, WJ and Ratamess, NA. 2004.       acclimatization practice guidelines for
Fundamentals of resistance training:         secondary school athletics. J Athl Train.
Progression and exercise prescription.       2009 May-June; 44(3): 332–333.
Medicine & Science in Sports & Exercise.     8. Hartmann, U and Mester, J. (2000).
Available Online: www.acsm-msse.org.         Training and overtraining markers in
4. Pearson et al. (2000). The national       selected sports events. Medicine &
strength and conditioning association’s      Science in Sports & Exercise, 32(1): 209
basic guidelines for the resistance          – 215.
training of athletes. Strength and           9. Haff, G et al. (2004). Roundtable
Conditioning Journal, 22(4): 14-27.          discussion: Periodization of training




                                                                                                                                    25
     Preseason Preparation



       NCAA Football Preseason Model (see Bylaw 17).

       The following concepts outline the legislation involving the NCAA football preseason period. Institutions
       should refer to division-specific legislation for exact requirements.

       Five-Day Acclimatization Period.

       In football, preseason practice begins with a five-day acclimatization period for both first-time participants
       (e.g., freshmen and transfers) and continuing student-athletes. All student-athletes, including walk-ons who
       arrive to preseason practice after the first day of practice, are required to undergo a five-day acclimatization
       period. The five-day acclimatization period should be conducted as follows:

         (a) Before participation in any preseason practice activities, all prospects and student-athletes initially
         entering the intercollegiate athletics program shall be required to undergo a medical examination
         administered by a physician.

         (b) During the five-day period, participants shall not engage in more than one on-field practice per day, not
         to exceed three hours in length.

         (c) During the first two days of the acclimatization period, helmets shall be the only piece of protective
         equipment student-athletes may wear. During the third and fourth days of the acclimatization period,
         helmets and shoulder pads shall be the only pieces of protective equipment student-athletes may wear.
         During the final day of the five-day period and on any days thereafter, student-athletes may practice in
         full pads.

       The remaining preseason practice period is conducted as follows:

         (a) After the five-day period, institutions may practice in full pads. However, an institution may not
         conduct multiple on-field practice sessions (e.g., two-a-days or three-a-days) on consecutive days;

         (b) Student-athletes shall not engage in more than three hours of on-field practice activities on those days
         during which one practice is permitted;

         (c) Student-athletes shall not engage in more than five hours of on-field practice activities on those days
         during which more than one practice is permitted; and

         (d) On days that institutions conduct multiple practice sessions, student-athletes must be provided with at
         least three continuous hours of recovery time between the end of the first practice and the start of the last
         practice that day. During this time, student-athletes may not attend any meetings or engage in other
         athletically related activities (e.g., weightlifting); however, time spent receiving medical treatment and
         eating meals may be included as part of the recovery time.




26
                                                            2
Medical
issues
Also found on the NCAA website at: NCAA.org/health-safety
                                        GUIDELINE 2a
     Medical
     Disqualification of
     the Student-Athlete
      January 1979 • Revised June 2004



     Withholding a student-athlete from       physically fit to participate in its     student-athlete’s on-site team
     activity. The team physician has the     championships and have valid             physician can determine whether a
     final responsibility to determine        medical clearance to participate in      student-athlete with an injury or
     when a student-athlete is removed        the competition.                         illness should continue to participate
     or withheld from participation due       1. The NCAA tournament                   or is disqualified. In the absence of
     to an injury, an illness or pregnancy.   physician, as designated by the host     a team physician, the NCAA
     In addition, clearance for that          school, has the unchallengeable          tournament physician will examine
     individual to return to activity is      authority to determine whether a         the student-athlete and has valid
     solely the responsibility of the team    student-athlete with an injury,          medical authority to disqualify him
     physician or that physician’s            illness or other medical condition       or her if the student-athlete’s injury,
     designated representative.               (e.g., skin infection) may expose        illness or medical condition poses a
     Procedure to medically disqualify a      others to a significantly enhanced       potentially life threatening risk to
                                              risk of harm and, if so, to disqualify   himself or herself.
     student-athlete during an NCAA
     championship. As the event               the student-athlete from continued       3. The chair of the governing sports
     sponsor, the NCAA seeks to ensure        participation.                           committee (or a designated
     that all student-athletes are            2. For all other incidents, the          representative) shall be responsible
                                                                                       for administrative enforcement of
                                                                                       the medical judgment, if it involves
                                                                                       disqualification.


                                                                                       References

                                                                                       1. Team Physician Consensus Statement.
                                                                                       Project-based alliance for the
                                                                                       advancement of clinical sports medicine
                                                                                       composed of the American Academy of
                                                                                       Family Physicians, the American
                                                                                       Academy of Orthopedic Surgeons, the
                                                                                       American College of Sports Medicine
                                                                                       (ACSM), the American Medical Society
                                                                                       for Sports Medicine, and the American
                                                                                       Osteopathic Academy of Sports
                                                                                       Medicine, 2000. Contact ACSM at 317/
28                                                                                     637-9200.
                               GUIDELINE 2b
Cold Stress and
Cold Exposure
  June 1994 • Revised June 2002, June 2009


Any individual can lose body heat     exposure are due to a combination     factors are, but not limited to,
when exposed to cold air, but when    of low air or water temperatures      previous cold weather injury
the physically active cannot          and the influence of wind on the      (CWI), race, geological origin,
maintain heat, cold exposure can      body’s ability to maintain a          ambient temperature, use of
be uncomfortable, impair              normothermic core temperature,        medications, clothing attire,
performance and may be life-          due to localized exposure of          fatigue, hydration, age, activity,
threatening. A person may exhibit     extremities to cold air or surface.   body size/composition, aerobic
cold stress due to environmental or   The variance in the degree, signs     fitness level, clothing,
non-environmental factors. The        and symptoms of cold stress may       acclimatization and low caloric
NATA position statement (2008)        also be the result of non-            intake. Nicotine, alcohol and
states that injuries from cold        environmental factors. These          other drugs may also contribute


                                      Wind Chill Chart




See reprint access permission for .gov websites: http://www.weather.gov/om/reprint.shtml                         29
     Cold Stress and Cold Exposure

     to how the person adapts to the         symptoms include edema, redness          hour in endurance and alpine
     stresses of cold.                       or mottled gray skin, and transient      events, and team sports, in which
                                             tingling and burning.                    clothing remains wet. The feet and
     Early recognition of cold stress is
                                                                                      hands are usually affected.
     important. Shivering, a means for       Hypothermia
     the body to generate heat, serves as    Hypothermia is a significant drop
                                                                                      Prevention of
     an early warning sign. Excessive        in body temperature [below 95
     shivering contributes to fatigue and    degrees Fahrenheit (35 degrees
                                                                                      Cold Exposure
     makes performance of motor skills       Celsius)] as the body’s heat loss        and Cold Stress
     more difficult. Other signs include     exceeds its production. The body is      Educating all participants in proper
     numbness and pain in fingers and        unable to maintain a normal core         prevention is the key to decreasing
     toes or a burning sensation of the      temperature. An individual may           the possibility of cold exposure
     ears, nose or exposed flesh. As cold    exhibit changes in motor function        injury or illness. Individuals
     exposure continues, the core            (e.g., clumsiness, loss of finger        unaccustomed to cold conditions
     temperature drops. When the cold        dexterity, slurred speech), cognition    participating at venues that may
     reaches the brain, a victim may         (e.g., confusion, memory loss) and       place them at risk for cold stress
     exhibit sluggishness, poor              loss of consciousness (e.g., drop in     may need to take extra
     judgment and may appear                 heart rate, stress on the renal          precautionary measures (e.g.,
     disoriented. Speech becomes slow        system, hyperventilation, sensation      proper clothing, warm-up routines,
     and slurred, and movements              of shivering). The signs and             nutrition, hydration, sleep).
     become clumsy. If the participant       symptoms of hypothermia will vary
                                                                                      The sports medicine staff and
     wants to lie down and rest, the         with each individual, depending
                                                                                      coaches should identify
     situation is a medical emergency        upon previous cold weather injury
                                                                                      participants or conditions that may
     and the emergency action plan           (CWI), race, geological origin,
                                                                                      place members of their teams at a
     should be activated.                    ambient temperature, use of
                                                                                      greater risk (e.g., predisposing
                                             medications, clothing attire,
     Cold injuries can be classified into                                             medical conditions, physiological
                                             fatigue, hydration, age, activity, and
     three categories: freezing or                                                    factors, mechanical factors,
                                             others.
     nonfreezing of extremities and                                                   environmental conditions).
     hypothermia.                            Hypothermia can occur at
                                                                                      Clothing
                                             temperatures above freezing. A wet
                                                                                      Individuals should be advised to
     Definitions of Common                   and windy 30- to 50-degree
                                                                                      dress in layers and try to stay dry.
     Cold Injuries in Sports                 exposure may be as serious as a
                                                                                      Moisture, whether from
                                             subzero exposure. As the Wind-
     Frostbite                                                                        perspiration or precipitation,
                                             Chill Equivalent Index (WCEI)
     Frostbite is usually a localized                                                 significantly increases body heat
                                             indicates, wind speed interacts with
     response to a cold, dry                                                          loss. Layers can be added or
                                             ambient temperature to
     environment, but in some incidents,                                              removed depending on
                                             significantly increase body cooling.
     moisture may exacerbate the                                                      temperature, activity and wind
                                             When the body and clothing are
     condition. Frostbite can appear in                                               chill. Begin with a wicking fabric
                                             wet, whether from sweat, rain,
     three distinct phases: frostnip, mild                                            next to the skin; wicking will not
                                             snow or immersion, the cooling is
     frostbite and deep frostbite.                                                    only keep the body warm and dry,
                                             even more pronounced due to
                                                                                      but also eliminates the moisture
     Frostnip, also known as prefreeze,      evaporation of the water held close
                                                                                      retention of cotton. Polypropylene
     is a precursor to frostbite and many    to the skin by wet clothing.
                                                                                      or wool wick moisture away from
     times occurs when skin is in
                                             Chilblain and Immersion                  the skin and retain insulating
     contact with cold surfaces (e.g.,
                                             (Trench) Foot                            properties when wet. Add
     sporting implements or liquid). The
                                             Chilblain is a non-freezing cold         lightweight pile or wool layers for
     most characteristic symptom is a
                                             injury associated with extended          warmth and use a wind-blocking
     loss of sensation.
                                             cold and wet exposure and results        garment to avoid wind chill.
     Frostbite is the actual freezing of     in an exaggerated or inflammatory        Because heat loss from the head
     skin or body tissues, usually of the    response. Chilblain may be               and neck may account for as much
     face, ears, fingers and toes, and can   observed in exposure to cold, wet        as 40 percent of total heat loss, the
30   occur within minutes. Signs and         conditions extending beyond one          head and ears should be covered
                                                                       Cold Stress and Cold Exposure

during cold conditions. Hand           Practice and                           When traveling to areas of adverse
coverings should be worn as            Competition Sessions                   weather conditions, the following
needed and in extreme conditions,      The following guidelines, as           terms will be consistently referred
a scarf or facemask should be          outlined in the 2008 NATA position     to in weather forecasting.
worn. Mittens are warmer than          statement, can be used in planning
                                                                              Wind Chill
gloves. Feet can be kept dry by        activity depending on the wind-
                                                                              Increased wind speeds accelerate
wearing moisture-wicking or wool       chill temperature. Conditions
                                                                              heat loss from exposed skin, and
socks that breathe and should be       should be constantly re-evaluated
                                                                              the wind chill is a measure of this
dried between wears.                   for change in risk, including the
                                                                              effect. No specific rules exist for
                                       presence of precipitation:
Energy/Hydration                                                              determining when wind chill
Maintain energy levels via the            3
                                       •	 	 0	degrees	Fahrenheit	and	         becomes dangerous. As a general
use of meals, energy snacks and           below: Be aware of the potential    guideline, the threshold for
carbohydrate/electrolyte sports           for cold injury and notify          potentially dangerous wind chill
drinks. Negative energy balance           appropriate personnel of the        conditions is about minus-20
increases the susceptibility to           potential.                          degrees Fahrenheit.
hypothermia. Stay hydrated, since      •	 	 5	degrees	Fahrenheit	and	
                                          2                                   Wind Chill Advisory
dehydration affects the body’s            below: Provide additional           The National Weather Service
ability to regulate temperature           protective clothing; cover as       issues this product when the wind
and increases the risk of frostbite.      much exposed skin as practical;     chill could be life threatening if
Fluids are as important in the            provide opportunities and           action is not taken. The criteria for
cold as in the heat. Avoid alcohol,       facilities for re-warming.          this warning vary from state to
caffeine, nicotine and other drugs
                                       •	 	 5	degrees	Fahrenheit	and	
                                          1                                   state.
that cause water loss,
vasodilatation or vasoconstriction        below: Consider modifying           Wind Chill Factor
of skin vessels.                          activity to limit exposure or to    Increased wind speeds accelerate
                                          allow more frequent chances to      heat loss from exposed skin. No
Fatigue/Exhaustion                        re-warm.                            specific rules exist for determining
Fatigue and exhaustion deplete
                                       •	 	 	degrees	Fahrenheit	and	below:	
                                          0                                   when wind chill becomes
energy reserves. Exertional fatigue
                                          Consider terminating or             dangerous. As a general rule, the
and exhaustion increase the
                                          rescheduling activity.              threshold for potentially dangerous
susceptibility to hypothermia, as                                             wind chill conditions is about
does sleep loss.
                                       Environmental                          minus-20 degrees Fahrenheit.
Warm-Up                                Conditions                             Wind Chill Warning
Warm-up thoroughly and keep
                                       To identify cold stress conditions,    The National Weather Service
warm throughout the practice or
                                       regular measurements of                issues this product when the wind
competition to prevent a drop in
                                       environmental conditions are           chill is life threatening. The criteria
muscle or body temperature. Time
                                       recommended during cold                for this warning vary from state to
the warm-up to lead almost
                                       conditions by referring to the         state.
immediately to competition. After
competition, add clothing to avoid     Wind-Chill Equivalent Index            Blizzard Warning
rapid cooling. Warm extremely          (WCEI)	(revised	November	1,	           The National Weather Service
cold air with a mask or scarf to       2001).	The	WCEI	is	a	useful	tool	      issues this product for winter
prevent bronchospasm.                  to monitor the air temperature         storms with sustained or frequent
                                       index that measures the heat loss      winds of 35 miles per hour or
Partner                                from exposed human skin surfaces.      higher with considerable falling
Participants should never train        Wind chill is the temperature it       and/or blowing snow that
alone. An injury or delay in           “feels like” outside, based on the     frequently reduces visibility to one-
recognizing early cold exposure        rate of heat loss from exposed skin    quarter of a mile or less.
symptoms could become life-            caused by the effects of the wind
threatening if it occurs during a      and cold. Wind removes heat from
cold-weather workout on an             the body in addition to the low
isolated trail.                        ambient temperature.                                                             31
     Cold Stress and Cold Exposure




     References

     1. Cappaert, Thomas A etal: National      4. Askew EW: Nutrition for a cold            cold. The Physician and Sportsmedicine
     Athletic Trainers’ Association Position   environment. The Physician and               20(1):61-65, 1992.
     Statement: Environmental Cold Injuries.   Sportsmedicine 17(12):77-89, 1989.           8. Thornton JS: Hypothermia shouldn’t
     Journal of Athletic Training              5. Frey C: Frostbitten feet: Steps to        freeze out cold-weather athletes. The
     2008:43(6):640-658                        treatment and prevention. The Physician      Physician and Sportsmedicine 18(1):
     2. Prevention of Cold Injuries During     and Sportsmedicine 21(1):67-76, 1992.        109-114, 1990.
     Exercise. ACSM Position Stand.            6. Young, A.J., Castellani, J.W., O’Brian,   9. NOAA National Weather Service, www.
     Medicine & Science in Sports &            C. et al., Exertional fatigue, sleep loss,   weather.gov/om/windchill/images/wind-
     Exercise. 2006: 2012-2029.                and negative-energy balance increases        chill-brochure.pdf.
     3. Armstrong, LE: Performing in           susceptibility to hypothermia. Journal of    10. Street, Scott, Runkle, Debra. Athletic
     Extreme Environments. Champaign, IL:      Applied Physiology. 85:1210-1217, 1998.      Protective Equipment: Care, Selection,
     Human Kinetics Publishers.                7. Robinson WA: Competing with the           and Fitting. McGraw-Hill, 2001.




32
                                   GUIDELINE 2c
Prevention
of Heat Illness
 June 1975 • Revised June 2002, June 2010



Practice or competition in hot and/or     that likely to occur in competition.        it may be advisable to use a mini-
humid environmental conditions            When environmental conditions are           mum of protective gear and clothing
poses special problems for student-       extreme, training or competition            and to practice in T-shirts, shorts,
athletes. Heat stress and resulting       should be held during a cooler time         socks and shoes. Rubberized suits
heat illness is a primary concern in      of day. Hydration should be main-           should not be worn.
these conditions. Although deaths         tained during training and acclimati-
                                                                                      4. To identify heat stress conditions,
from heat illness are rare, exertional    zation sessions.
                                                                                      regular measurements of environ-
heat stroke (EHS) is the third-lead-
                                          3. Clothing and protective equip-           mental conditions are recommended.
ing cause of on-the-field sudden
                                          ment, such as helmets, shoulder pads        The wet-bulb globe temperature
death in athletes. There have been
                                          and shin guards, increase heat stress       (WBGT), which includes the mea-
more deaths from heat stroke in the
                                          by interfering with the evaporation         surement of wet-bulb temperature
last five-year block (2005-2009)
                                          of sweat and inhibiting other path-         (humidity), dry-bulb temperature
than any other five-year block dur-
                                          ways needed for heat loss. Dark-            (ambient temperature) and globe
ing the past 35 years. Constant sur-
                                          colored clothing increases the body’s       temperature (radiant heat), assesses
veillance and education are neces-
                                          absorption of solar radiation, while        the potential impact of environmen-
sary to prevent heat-related prob-
                                          moisture wicking-type clothing              tal heat stress. A WBGT higher than
lems. The following practices should
                                          helps with the body’s ability to dissi-     82 degrees Fahrenheit (28 degrees
be observed:
                                          pate heat. Frequent rest periods            Celsius) suggests that careful control
1. An initial complete medical histo-     should be scheduled so that the gear        of all activity should be undertaken.
ry and physical evaluation, followed      and clothing can be removed and/or          Additional precautions should be
by the completion of a yearly health-     loosened to allow heat dissipation.         taken when wearing protective
status questionnaire before practice      During the acclimatization process,         equipment (see reference No. 6).
begins, is required, per Bylaw
17.1.5.	A	history	of	previous	heat	ill-
nesses, sickle cell trait and the type       Intense exercise, hot and humid weather and dehydration can seriously
and duration of training activities for      compromise athlete performance and increase the risk of exertional heat
the previous month, should also be           injury. Report problems to medical staff immediately.
considered.
                                             Protect Yourself and Your teammates:
2. Prevention of heat illness begins
with gradual acclimatization to envi-        Know the signs                         report your symptoms
ronmental conditions. Student-               •	 Muscle	cramping.                    •	 High	body	temperature.
athletes should gradually increase           •	 Decreased	performance.              •	 Nausea.
exposure to hot and/or humid envi-           •	 Unsteadiness.                       •	 Headache.
ronmental conditions during a mini-          •	 Confusion.                          •	 Dizziness.
mum	period	of	10	to	14	days.	Each	           •	 Vomiting.                           •	 Unusual	fatigue.
exposure should involve a gradual            •	 Irritability.                       •	 Sweating	has	stopped.
increase in the intensity and duration       •	 Pale	or	flushed	skin.               •	 Disturbances	of	vision.
of exercise and equipment worn               •	 Rapid	weak	pulse.                   •	 Fainting.
until the exercise is comparable to                                                                                            33
     Prevention of Heat Illness

     The American College of Sports           duration, most weight loss represents     out, practice and competition. This
     Medicine	has	recently	(2007)	revised	    water loss, and that fluid loss should    procedure can detect progressive
     its guidelines for conducting athletic   be replaced as soon as possible.          dehydration and loss of body fluids.
     activities in the heat (see              After activity, the student-athlete       Those who lose five percent of their
     reference	No.	1).                        should rehydrate with a volume that       body weight or more should be evalu-
                                              exceeds the amount lost during the        ated medically and their activity
     5. EHS has the greatest potential of
                                              activity.	In	general,	16-24	ounces	of	    restricted until rehydration has
     occurrence at the start of preseason     fluid should be replaced for every
     practices and with the introduction                                                occurred. For prevention, the routine
                                              pound lost. Urine volume and color        measurement of pre- and post-exer-
     of protective equipment during prac-     can be used to assess general hydra-
     tice sessions. The inclusion of mul-                                               cise body weights is useful for deter-
                                              tion. If output is plentiful and the      mining sweat rates and customizing
     tiple practice sessions during the       color is “pale yellow or straw-col-
     same day may also increase the risk                                                fluid replacement programs.
                                              ored,” the student-athlete is not dehy-
     of EHS. Ninety-six percent of all        drated. As the urine color gets dark-     8. Some student-athletes may be
     heat illnesses in football occur         er, this could represent dehydration      more susceptible to heat illness.
     in August.                               of the student-athlete. Water and         Susceptible individuals include those
     6. Hydration status also may influ-      sport drinks are appropriate for          with: sickle cell trait, inadequate
     ence the occurrence of EHS, there-       hydration and rehydration during          acclimatization or aerobic fitness,
     fore fluid replacement should be         exercise in the heat. Sport drinks        excess body fat, a history of heat ill-
     readily available. Student-athletes      should contain carbohydrates and          ness, a febrile condition, inadequate
     should be encouraged to drink fre-       electrolytes to enhance fluid con-        rehydration, and those who regularly
     quently throughout a practice ses-       sumption. In addition, the carbohy-       push themselves to capacity. Also,
     sion. They should drink two cups or      drates provide energy and help main-      substances with a diuretic effect or
                                              tain immune and cognitive function.       that act as stimulants may increase
     more of water and/or sports drink in
     the hour before practice or competi-     7. During the preseason period or         risk of heat illness. These substances
     tion, and continue drinking during       periods of high environmental stress,     may be found in some prescription
     activity	(every	15	to	20	minutes).	      the student-athletes’ weight should be    and over-the-counter drugs, nutri-
     For activities up to two hours in        recorded before and after every work-     tional supplements and foods.


        Tips for student-athletes
        and coaches                                                Acclimatize
        Stay cool                                                  √ Avoid workouts during unusually hot temperatures
                                                                     by picking the right time of day.
        √ Conduct warm-ups in the shade.
                                                                   √ Progress your exercise time and intensity slowly
        √ Schedule frequent breaks.
                                                                     during a two-week period before preseason.
        √ Break in the shade.
                                                                   √ Reduce multiple workout sessions; if multiple
        √ Use fans for cooling.
                                                                     sessions are performed, take at least three hours
        √ Take extra time – at least three hours – between           of recovery between them.
           two-a-day practices.
        √ Wear light-colored, moisture-wicking,                    Coaches be prepared
           loose-fitting clothing.                                 √ Use appropriate medical coverage.
        √ Increase recovery interval times between                 √ Have a cell phone on hand.
           exercise bouts and intervals.                           √ Know your local emergency numbers and
        Stay hydrated                                                program them in your phone.
        √ Drink before you are thirsty (20 oz. two to three        √ Report problems to medical staff immediately.
           hours before exercise).                                 √ Schedule breaks for hydration and cooling
        √ Drink early (8 oz. every 15 minutes during                 (e.g., drinks, sponges, towels, tubs, fans).
           exercise).                                              √ Provide ample recovery time in practice and
        √ Replace fluids (20 oz. for every pound lost).              between practices.
        √ Lighter urine color is better.                           √ Monitor weight loss.
34      √ Incorporate sports drinks when possible.                 √ Encourage adequate nutrition.
                                                                                        Prevention of Heat Illness
9. Student-athletes should be edu-
cated on the signs and symptoms of                             POTENTIAL RISK FACTORS
EHS, such as: elevated core temper-
                                            As	identified	throughout	Guideline	2c,	the	following	are	potential	risk	factors	
ature, weakness, cramping, rapid and
                                            associated with heat illness:
weak pulse, pale or flushed skin,
                                            1. Intensity of exercise.	This	is	the	leading	factor	that	can	increase	core	body	
excessive fatigue, nausea, unsteadi-
                                            temperature	higher	and	faster	than	any	other.		
ness, disturbance of vision, mental
confusion and incoherency. If heat          2. environmental conditions.	Heat	and	humidity	combine	for	a	high	wet-bulb	
                                            globe	temperature	that	can	quickly	raise	the	heat	stress	on	the	body.		
stroke is suspected, prompt emer-
gency treatment is recommended.             3. duration and frequency of exercise.	Minimize	multiple	practice	
When training in hot and/or humid           sessions	during	the	same	day	and	allow	at	least	three	hours	of	recovery	
                                            between sessions.
conditions, student-athletes should
train with a partner or be under            4. dehydration.	Fluids	should	be	readily	available	and	consumed	to	aid	in	the	
observation by a coach or                   body’s	ability	to	regulate	itself	and	reduce	the	impact	of	heat	stress.
athletic trainer.                           5. nutritional supplements.	Nutritional	supplements	may	contain	stimulants,	
                                            such	as	ephedrine,	ma	huang	or	high	levels	of	caffeine.*	These	substances	can	
First aid for                               have	a	negative	impact	on	hydration	levels	and/or	increase	metabolism	and	heat	
heat illness                                production.		They	are	of	particular	concern	in	people	with	underlying	medical	
                                            conditions such as sickle cell trait, hypertension, asthma and thyroid dysfunction.
Heat exhaustion—Heat exhaustion
                                            6. medication/drugs.	Certain	medications	and	drugs	have	similar	effects	as	
is a moderate illness characterized
                                            nutritional	supplements.	These	substances	may	be	ingested	through	over-the-
by the inability to sustain adequate        counter	or	prescription	medications,	recreational	drugs,	or	consumed	in	food.	
cardiac output, resulting from stren-       Examples	include	antihistamines,	decongestants,	certain	asthma	medications,	
uous physical exercise and environ-         Ritalin, diuretics and alcohol.
mental heat stress. Symptoms usual-         7. medical conditions.	Examples	include	illness	with	fever,	gastro-intestinal	
ly include profound weakness and            illness,	previous	heat	illness,	obesity	or	sickle	cell	trait.
exhaustion, and often dizziness, syn-
                                            8. acclimatization/fitness level.	Lack	of	acclimatization	to	the	heat	or	poor	
cope, muscle cramps, nausea and a           conditioning.
core	temperature	below	104	degrees	
                                            9. clothing.		Dark	clothing	absorbs	heat.	Moisture	wicking-type	material	
Fahrenheit with excessive sweating
                                            helps dissipate heat.
and flushed appearance. First aid
should include removal from activi-         10. Protective equipment.	Helmets,	shoulder	pads,	chest	protectors,	and	thigh	
                                            and	leg	pads	interfere	with	sweat	evaporation	and	increase	heat	retention.
ty, taking off all equipment and plac-
ing the student-athlete in a cool,          11. limited knowledge of heat illness.	Signs	and	symptoms	can	include	
shaded environment. Fluids should           elevated	core	temperature,	pale	or	flushed	skin,	profound	weakness,	muscle	
                                            cramping,	rapid	weak	pulse,	nausea,	dizziness,	excessive	fatigue,	fainting,	
be given orally. Core temperature
                                            confusion,	visual	disturbances	and	others.
and vital signs should be serially
assessed. The student-athlete should        *NOTE:	Stimulant	drugs	such	as	amphetamines,	ecstasy,	ephedrine	and	caffeine	are	on	
be cooled by ice immersion and ice          the	NCAA	banned	substance	list	and	may	be	known	by	other	names.		A	complete	list	of	
towels, and use of IV fluid replace-        banned	drug	classes	can	be	found	on	the	NCAA	website	at	NCAA.org/health-safety.
ment should be determined by a
physician. Although rapid recovery
is typical, student-athletes should not   student-athlete likely will still be         immediate cooling of the body with
be allowed to practice or compete         sweating profusely at the time of            cold water immersion. Another
for the remainder of that day.            collapse, but may have hot, dry skin,        method for cooling includes using
                                          which indicates failure of the               cold, wet ice towels on a rotating
Exertional Heatstroke—Heatstroke          primary temperature-regulating               basis. Student-athletes who incur
is a medical emergency. Medical           mechanism (sweating), and CNS                heatstroke should be hospitalized and
care should be obtained at once; a        dysfunction (e.g., altered                   monitored carefully. The NATA’s
delay in treatment can be fatal. This     consciousness, seizure, coma). First         Inter-Association Task Force
condition is characterized by a very      aid includes activation of the               recommends, “cool first, transport
high	body	temperature	(104	degrees	       emergency action plan, assessment            second” in these situations (see
Fahrenheit or greater) and the            of core temperature/vital signs and          reference	No.	7).
                                                                                                                                   35
     Prevention of Heat Illness


     References

     1. American College of Sports Medicine        8. Casa DJ, Armstrong LE, Ganio MS,
     Position Stand: Exertional Heat Illness       Yeargin SW. Exertional Heat Stroke in
     during Training and Competition. Med:         Competitive Athletes. Current Sports
     Sci Sport Exerc. 2007;39(3):556-72.           Medicine Reports 2005, 4:309–317.
     2. Armstrong LE, Maresh CM: The               9. Casa DJ, McDermott BP, Lee EC,
     induction and decay of heat                   Yeargin SW, Armstrong LE, Maresh CM.
     acclimatization in trained athletes. Sports   Cold Water Immersion: The Gold
     Medicine 12(5):302-312, 1991.                 Standard for Exertional Heatstroke
     3. Armstrong, LE: Performing in Extreme       Treatment. Exercise and Sport Sciences
     Environments. Champaign, IL: Human            Reviews. 2007. 35:141-149.
     Kinetics Publishers, pp 64, 2000.             10. Casa DJ, Becker SM, Ganio MS, et al.
     4. Haynes EM, Wells CL: Heat stress and       Validity of Devices That Assess Body
     performance. In: Environment and Human        Temperature During Outdoor Exercise in
     Performance. Champaign, IL: Human             the Heat. Journal of Athletic Training
     Kinetics Publishers, pp. 13-41, 1986.         2007; 42(3):333–342.
     5. Hubbard RW and Armstrong LE: The           11. National Athletic Trainers’ Association
     heat illness: Biochemical, ultrastructural    Position Statement: Exertional Heat
     and fluid-electrolyte considerations. In      Illnesses. Journal of Athletic Training
     Pandolf KB, Sawka MN and Gonzalez RR          2002; 37(3):329–343.
     (eds): Human Performance Physiology           12. American College of Sports Medicine
     and Environmental Medicine at Terrestial      Position Stand: Exercise and Fluid
     Extremes. Indianapolis, IN: Benchmark         Replacement. Med: Sci Sport Exerc.
     Press, Inc., 1988.                            2007; 384-86.
     6. Kulka TJ and Kenney WL: Heat
     balance limits in football uniforms. The
     Physician and Sportsmedicine. 30(7):
     29-39, 2002.
     7. Inter-Association Task Force on
     Exertional Heat Illnesses Consensus
     Statement. National Athletic Trainers’
     Association, June 2003.




36
                                     GUIDELINE 2d
Weight Loss–
Dehydration
  July 1985 • Revised June 2002


There are two general types of              muscular endurance, reduced plasma       practices, student-athletes and
weight loss common to student-              and blood volume, compromised            coaches should be educated about
athletes who participate in                 cardiac output (elevated heart rate,     the physiological and pathological
intercollegiate sports: loss of body        smaller stroke volume), impaired         consequences of dehydration. The
water or loss of body weight (fat and       thermoregulation, decreased kidney       use of laxatives, emetics and
lean tissue). Dehydration, the loss of      blood flow and filtration, reduced       diuretics should be prohibited.
body water, leads to a state of             liver glycogen stores, and loss of       Similarly, the use of excessive food
negative water balance called               electrolytes. Pathological responses     and fluid restriction, self-induced
dehydration. It is brought about by         include life-threatening heat illness,   vomiting, vapor-impermeable suits
withholding fluids and                      rhabdomyolysis (severe muscle            (e.g., rubber or rubberized nylon),
carbohydrates, the promotion of             breakdown), kidney failure and           hot rooms, hot boxes and steam
extensive sweating and the use of           cardiac arrest.                          rooms should be prohibited.
emetics, diuretics or laxatives. The        With extensive dehydration, attempts     Excessive food restriction or self-
problem is most evident in those who        at acute rehydration usually are         induced vomiting may be symptoms
must be certified to participate in a       insufficient for body fluid and          of serious eating disorders (see
given weight class, but it also is          electrolyte homeostasis to be restored   Guideline 2f).
present in other athletics groups.          before competition. For example, in      Dehydration is a potential health hazard
There is no valid reason for                wrestling this is especially true        that acts with poor nutrition and intense
subjecting the student-athlete’s body       between the official weigh-in and        exercise to compromise health and
to intentional dehydration, which can       actual competition.                      athletic performance. The sensible
lead to a variety of adverse                All respected sports medicine            alternative to dehydration weight loss
physiological effects, including                                                     involves: preseason determination of an
                                            authorities and organizations have
significant pathology and even death.                                                acceptable (minimum) competitive
                                            condemned the practice of fluid
Dehydration in excess of 3 to 5             deprivation. To promote sound            weight, gradual weight loss to achieve
percent leads to reduced strength and                                                the desired weight, and maintenance of
                                                                                     the weight during the course of the
References                                                                           competitive season. Standard body
                                                                                     composition procedures should be used
1. American College of Sports Medicine,     Box 9005, Chicago, IL 60604-9005).       to determine the appropriate
Position Stand: Weight Loss in Wrestlers,   4. Hyphothermia and Dehydration-         competitive weight. Spot checks (body
1995. (P.O. Box 1440, Indianapolis, IN      Related Deaths Associated with           composition or dehydration) should be
46206-1440).                                Intentional Rapid Weight Loss in Three   used to ensure compliance with the
                                                                                     weight standard during the season.
2. Armstrong, LE. Performing in Extreme     Collegiate Wrestlers. Morbidity and
Environments. Champaign, IL: Human          Mortality Weekly 47(6):105-108, 1998.    Student-athletes and coaches should
Kinetics Publishers, pp 15-70, 2000.                                                 be informed of the health
                                            5. Sawka, MN (chair): Symposium—         consequences of dehydration,
3. Horswill CA: Does Rapid Weight Loss      Current concepts concerning thirst,      educated in proper weight-loss
by Dehydration Adversely Affect High-       dehydration, and fluid replacement.      procedures, and subject to
Power Performance? 3(30), 1991.             Medicine and Science in Sports and       disciplinary action when approved           37
(Gatorade Sports Science Institute, P.O.    Exercise 24(6):643-687, 1992.            rules are violated.
                                     GUIDELINE 2e
     Assessment of
     Body Composition
      June 1991 • Revised June 2002


     The NCAA Committee on
     Competitive Safeguards and
     Medical Aspects of Sports
     acknowledges the significant input
     of Dr. Dan Benardot, Georgia State
     University, who authored a revision
     of this guideline.

     Athletic performance is, to a great
     degree, dependent on the ability of
     the student-athlete to overcome
     resistance and to sustain aerobic
     and/or anaerobic power. Both of
     these elements of performance
     have important training and
     nutritional components and are, to     football teams have different          body fat percentage and lower
     a large degree, influenced by the      responsibilities than receivers, and   muscle mass inevitably results in a
     student-athlete’s body composition.    this difference is manifested in       performance reduction that
     Coupled with the common                physiques that are also different.     motivates the student-athlete to
     perception of many student-athletes                                           follow regimens that produce even
     who compete in sports in which         Besides the aesthetic and              greater energy deficits. This
     appearance is a concern                performance reasons for wanting to     downward energy intake spiral may
     (swimming, diving, gymnastics,         achieve an optimal body                be the precursor to eating disorders
     skating, etc.), attainment of an       composition, there may also be         that place the student-athlete at
     ‘ideal’ body composition often         safety reasons. A student-athlete      serious health risk. Therefore,
     becomes a central theme of             who is carrying excess weight may      while achieving an optimal body
     training.                              be more prone to injury when           composition is useful for high-level
                                            performing difficult skills than the   athletic performance, the processes
     Successful student-athletes achieve    student-athlete with a more optimal    student-athletes often use to attain
     a body composition that is within a    body composition. However, the         an optimal body composition may
     range associated with performance      means student-athletes often use in    reduce athletic performance, may
     achievement in their specific sport.   an attempt to achieve an optimal       place them at a higher injury risk
     Each sport has different norms for     body composition may be                and may increase health risks.
     the muscle and fat levels associated   counterproductive. Diets and
                                            excessive training often result in     Purpose of Body
     with a given height, and the                                                  Composition
     student-athlete’s natural genetic      such a severe energy deficit that,
                                            while total weight may be reduced,     Assessment
     predisposition for a certain body
     composition may encourage them         the constituents of weight also        The purpose of body composition
     to participate in a particular sport   change, commonly with a lower          assessment is to determine the
     or take a specific position within a   muscle mass and a relatively higher    student-athlete’s distribution of lean
38   sport. For instance, linemen on        fat mass. The resulting higher         (muscle) mass and fat mass. A
                                                                    Assessment of Body Composition

high lean mass to fat mass ratio is     determine the appropriateness of
often synonymous with a high            their training schedule and nutrient
strength to weight ratio, which is      intake. In addition, it is important
typically associated with athletic      for coaches and student-athletes to
success. However, there is no           use functional performance
single ideal body composition for       measures in determining the
all student-athletes in all sports.     appropriateness of a student-          In the absence of
Each sport has a range of lean          athlete’s body composition.
mass and fat mass associated with                                              published standards for
                                        Student-athletes outside the normal
it, and each student-athlete in a       range of body fat percent for the      a sport, one strategy for
sport has an individual range that is   sport may have achieved an             determining if a
ideal for him or her. Student-          optimal body composition for their
athletes who try to achieve an          genetic makeup, and may have           student-athlete is
arbitrary body composition that is      objective performance measures         within the body
not right for them are likely to        (e.g., jump height) that are well
place themselves at health risk and                                            composition standards
                                        within the range of others
will not achieve the performance        on the team.                           for the sport is to
benefits they seek. Therefore, a
key to body composition                                                        obtain a body fat
                                        Body composition can be measured
assessment is the establishment of      indirectly by several methods,         percent value for each
an acceptable range of lean and fat     including hydrostatic weighing,        student-athlete on a
mass for the individual student-        skinfold and girth measurements
athlete, and the monitoring of lean     (applied to a nomogram or
                                                                               team (using the same
and fat mass over regular time          prediction equation), bioelectrical    method of assessment),
intervals to assure a stability or      impedance analysis (BIA), dual-
growth of the lean mass and a                                                  and obtaining an
                                        energy x-ray absorptiometry
proportional maintenance or             (DEXA), ultrasound, computerized       average and standard
reduction of the fat mass.              tomography, magnetic-resonance         deviation for body fat
Importantly, there should be just as    imagery, isotope dilution, neutron-
much attention given to changes in      activation analysis, potassium-40      percent for the team.
lean mass (both in weight of lean       counting, and infrared interactance.
mass and proportion of lean mass)       The most common of the methods
as the attention traditionally given    now used to assess body
to body fat percent.                    composition in student-athletes are
                                        skinfold measurements, DEXA,
In the absence of published             hydrostatic weighing and BIA.
standards for a sport, one strategy     While hydrostatic weighing and
for determining if a student-athlete    DEXA are considered by many to
is within the body composition          be the “gold standards” of the
standards for the sport is to obtain    indirect measurement techniques,
a body fat percent value for each       there are still questions regarding
student-athlete on a team (using the    the validity of these techniques
same method of assessment), and         when applied to humans. Since
obtaining an average and standard       skinfold-based prediction equations
deviation for body fat percent for      typically use hydrostatic weighing
the team. Student-athletes who are      or DEXA as the criterion methods,
within	1	standard	deviation	(i.e.,	a	   results from skinfolds typically
Z-score	of	±	1)	of	the	team	mean	       carry the prediction errors of the
should be considered within the         criterion methods plus the added
range for the sport. Those greater      measurement errors associated with
than	or	less	than		±	1	standard	        obtaining skinfold values. BIA has
deviation should be evaluated to        become popular because of its non-                                 39
     Assessment of Body Composition

     invasiveness and speed of              body composition values with other      the student-athlete can return to
     measurement, but results from this     student-athletes, but this              training after an injury, reduce
     technique are influenced by            comparison is not meaningful and        performance and increase the risk
     hydration state. Since student-        it may drive a student-athlete to       of an eating disorder. Body
     athletes have hydration states that    change body composition in a way        composition values should be
     are in constant flux, BIA results      that negatively impacts both            thought of as numbers on a
     may be misleading unless strict        performance and health. Health          continuum that are usual for a
     hydration protocols are followed.      professionals involved in obtaining     sport. If a student-athlete falls
     In general, all of the commonly        body composition data should be         anywhere on that continuum, it is
     used techniques should be viewed       sensitive to the confidentiality of     likely that factors other than body
     as providing only estimates of body    this information, and explain to        composition (training, skills
     composition, and since these           each student-athlete that               acquisition, etc.) will be the major
     techniques use different theoretical   differences in height, age and          predictors of performance success.
     assumptions in their prediction of     gender are likely to result in
     body composition, values obtained      differences in body composition,        4. Frequency of Body
     from one technique should not be       without necessarily any differences     Composition Assessment—
     compared with values obtained          in performance. Strategies for          Student-athletes who have frequent
     from another technique.                achieving this include:                 weight and/or skinfolds taken are
                                            	      O
                                                 •		 btaining	body	composition	     fearful of the outcome, since the
     Concerns with                                 values with only one             results are often (inappropriately)
     Body Composition                              student-athlete at a time, to    used punitively. Real changes in
     Assessment                                    limit the chance that the data   body composition occur slowly, so
                                                   will be shared.                  there is little need to assess
     1. Using Weight as a Marker of         	      G
                                                 •		 iving	student-athletes	        student-athletes weekly, biweekly
     Body Composition—While the                    information on body              or even monthly. If body
     collection of weight data is a                composition using phrases        composition measurements are
     necessary adjunct to body                     such as “within the desirable    sufficient and agreed upon by all
     composition assessment, by itself             range” rather than a raw         parties, measurement frequency of
     weight may be a misleading value.             value, such as saying “your      twice a year should be sufficient.
     For instance, young student-                  body	fat	level	is	18	percent.”   In some isolated circumstances in
     athletes have the expectation of       	      P
                                                 •		 roviding	athletes	with	        which a student-athlete has been
     growth and increasing weight, so              information on how they          injured or is suffering from a
     gradual increases in weight should            have changed between             disease state, it is reasonable for a
     not be interpreted as a body                  assessments, rather than         physician to recommend a more
     composition problem. A student-               offering the current value.      frequent assessment rate to control
     athlete who has increased              	      I
                                                 •		 ncreasing	the	focus	on	        for changes in lean mass. Student-
     resistance training to improve                muscle mass, and decreasing      athletes and/or coaches who desire
     strength may also have a higher               the focus on body fat.           more frequent body composition or
     weight, but since this increased       	      U
                                                 •		 sing	body	composition	         weight measurement should shift
     weight is likely to result from more          values as a means of helping     their focus to assessments of
     muscle, this should be viewed as a            to explain changes in            objective performance-related
     positive change. The important                objectively measured             measurers.
     consideration for weight is that it           performance outcomes.
     can be (and often is) misused as a     3. Seeking an Arbitrarily Low           Summary
     measure of body composition, and       Level of Body Fat—Most student-
     this misuse can detract from the       athletes would like their body fat      The assessment of body
     purpose of body composition            level to be as low as possible.         composition can be a useful tool in
     assessment.                            However, student-athletes often try     helping the student-athlete and
                                            to seek a body fat level that is        coach understand the changes that
     2. Comparing Body Composition          arbitrarily low and this can increase   are occurring as a result of training
     Values with Other Athletes—            the frequency of illness, increase      and nutritional factors. However,
40   Student-athletes often compare         the risk of injury, lengthen the time   the body composition measurement
                                                       Assessment of Body Composition


For each student-athlete, there may be a unique         Health
optimal body composition for performance, for
health and for self-esteem. However, in most
cases, these three values are NOT identical.           Optimal
Mental and physical health should not be sacri-
ficed for performance. An erratic or lost men-    ≠      Body           ≠
strual cycle, sluggishness or an obsession with
achieving a number on a scale may be signs
that health is being challenged.                      Composition
                                       Performance          ≠        Self-Esteem




                                                                                        41
     Assessment of Body Composition

     process and the values obtained can         permitted to discuss the results with       stress. This stress can lead to the
     be a sensitive issue for the student-       the student-athlete and what                development or enhancement of
     athlete. A legitimate purpose for           frequency of body composition               eating disorders in the student-
     body composition assessment                 measurement is appropriate. The             athlete (see Guideline 2f). All
     should dictate the use of these             student-athlete should not feel             coaches (sport or strength/
     measurement techniques. Health                                                          conditioning) should be aware of
                                                 forced or obligated to undergo body
     professionals involved in obtaining                                                     the sizable influence they may have
                                                 composition or weight
     body composition data should focus                                                      on the behaviors and actions of
                                                 measurement.                                their student-athletes. Many
     on using the same technique with
     the same prediction equations to            Everyone involved directly or               student-athletes are sensitive about
     derive valid comparative data over          indirectly with body composition            body fat, so care should be taken to
     time. Institutions should have a            measurement should understand               apply body composition
     protocol in place outlining the             that inappropriate measurement and          measurement, when appropriate, in
     rationale for body composition              use of body composition data might          a way that enhances the student-
     measurements, who is allowed to             contribute to the student-athlete           athlete’s well-being.
     measure the student-athlete, who is         experiencing unhealthy emotional


      References

     1. Benardot D: Working with young           7. Houtkooper LB and Going SB. Body         13. Manore M, Benardot D, and Love P.
     athletes: Views of a nutritionist on the    composition: How should it be               Body measurements. In: Benardot D
     sports medicine team. Int. J. Sport Nutr.   measured? Does it affect sport              (Ed). Sports Nutrition: A Guide for
     6(2):110-120, 1996.                         performance? Sports Science Exchange        Professionals Working with Active
                                                 SSE#52(7):1-15, 1994.                       People Chicago, IL: American Dietetic
     2. Boileau RA and Lohman TG. The
                                                                                             Association, pp 70-93, 1993.
     measurement of human physique and its       8. Houtkooper LB, Going SB, Lohman
     effect on physical performance.             TG, Roche AF, and Van Loan M.               14. Melby CL and Hill JO. Exercise,
     Orthopedic Clin. N. Am. 8:563-              Bioelectrical impedance estimation of       macronutrient balance, and body weight
     581,1977.                                   fat-free body mass in children and          regulation. Sports Science Exchange
                                                 youth: a cross-validation study. J. Appl.   SSE#72(12): 1-16, 1999.
     3. Clarkson PM. Nutritional
                                                 Physiol. 72:366-373, 1992.                  15. Thomas BJ, Cornish BH, Ward LC,
     supplements for weight gain. Sports
     Science Exchange SSE#68(11): 1-18,          9. Jackson AS and Pollock ML.               and Jacobs A. Bioimpedance: is it a
     1998.                                       Generalized equations for predicting        predictor of true water volume? Ann.
                                                 body density in men. Br. J. Nutr.           N.Y. Acad. Sci. 873:89-93, 1999.
     4. Clasey JL, Kanaley JA, Wideman L,
                                                 40:497-504, 1978.
     Heymsfield SB, Teates CD, Gutgesell
     ME, Thorner MO, Hartman ML, and             10. Jackson AS, Pollock ML, and Ward
     Weltman A. Validity of methods of body      A. Generalized equations for predicting
     composition assessment in young and         body density of women. Med. Sci.
     older men and women. J. Appl. Physiol.      Sports Exerc. 12:175-182, 1980.
     86(5):1728-38, 1999.                        11. Lukaski HC. Methods for the
     5. Fleck SJ. Body composition of elite      assessment of human body
     American athletes. Am. J. Sports Med.       composition—traditional and new. Am.
     11:398-403, 1983.                           J. Clin. Nutr. 46:537-56, 1987.
     6. Heymsfield SB and Want Z.                12. Malina RM and Bouchard C.
     Measurement of total-body fat by            Characteristics of young athletes. In:
     underwater weighing: new insights and       Growth, Maturation and Physical
     uses for old method. Nutrition 9:472-       Activity. Champaign, IL: Human
42   473, 1993.                                  Kinetics Books, pp. 443-463, 1991.
                                 GUIDELINE 2f
Nutrition
and Athletic
Performance
 January 1986 • Revised June 2002, May 2009


Athletic performance and recovery       continued throughout the year.          training and performance.
from training are enhanced by                                                   Carbohydrate intake has been well
                                        The competitive phase usually
attention to nutrient intake.                                                   documented to have a positive
                                        reflects a decrease in training
Optimal nutrition for health and                                                impact on adaptation to training,
                                        volume, and perhaps higher-
performance includes the                                                        performance and improved immune
                                        intensity training sessions with
identification of both the quantity                                             function.
                                        extended periods of tapering
and quality of food and fluids
                                        leading up to competition and           During base training, a daily intake
needed to support regular training
                                        travel. During the competitive          of	between	5	to	7	grams	of	
and peak performance. As training
                                        phase, athletes should adjust           carbohydrate per kilogram of body
demands shift during the year,
                                        calorie and macronutrient intake to     weight per day is advised. As
athletes need to adjust their caloric
                                        prevent unwanted weight gain, and       training intensity and/or volume
intake and macronutrient
                                        learn how to eat before competition     increase, carbohydrate need may
distribution while maintaining a
                                        and while traveling, and how to         easily	exceed	10	grams	of	
high nutrient-dense diet that
                                        adjust fluid needs based on             carbohydrate per kilogram of body
supports their training and
                                        environmental impacts. Athletes         weight. Athletes should begin to
competition nutrient needs. The
                                        who consume a balanced, adequate        think about fueling for their next
following key points summarize
                                        diet will likely exhibit the best       athletics activity immediately after
the impacts of training on energy,
                                        performance, and experience less        the one they just completed.
nutrient and fluid recommendations
                                        illness during the competitive          Recovery carbohydrate, to replace
for competitive student-athletes as
                                        phase.                                  glycogen stores, can be calculated
recommended by the American
College of Sports Medicine              The transition phase, during which      based	on	1	to	1.2	grams	of	
(ACSM) and the American Dietetic        athletes’ training volume and           carbohydrate per kilogram of body
Association (ADA).                      intensity are likely at their lowest,   weight and should be consumed
                                        requires some attention to the          immediately after training sessions
It is helpful to think of collegiate
                                        prevention of unwanted changes in
athletes’ training year as including
                                        body weight (increased body fat or
three phases: base, competition and
                                        decreased muscle mass). During
transition. During base training
                                        this phase, athletes may need to
when training volume is high
                                        decrease total calorie intake and
(practices are longer and/or more
                                        resist overindulging while still
frequent), athletes’ energy needs
                                        maintaining a nutrient-dense diet.
are likely to be at their highest. A
high-quality nutritional plan is key    Carbohydrate, the primary fuel
during this phase. Base training is     for higher intensity activity, is
also the best phase to experiment       required to replenish liver and
with and define event fueling and       glycogen stores and to prevent low
hydration strategies that can be        blood sugar (hypoglycemia) during       NCAA.org/nutritionandperformance
                                                                                                                       43
     Nutrition and Athletic Performance


                                     longer than 90 minutes or high-        of foods to maintain body weight.
                                     intensity, shorter-duration training   However, the risk of micronutrient
                                     sessions. Within two hours after       deficiencies is greatest in student-
                                     training, additional carbohydrate      athletes who are restricting
                                     will help continue glycogen            calories, engaging in rapid weight-
                                     repletion.                             loss practices or eliminating
                                     The U.S. Dietary Guidelines and        specific foods or food groups from
                                     experts in performance nutrition       their diet. A multivitamin
                                     recommend that athletes focus          providing	not	more	than	100	
                                     their food choices on less-refined     percent of the daily recommended
                                     types of carbohydrate, as these        intake can be considered for these
                                     contain essential micronutrients       student-athletes. Female student-
                                     vital to health and performance.       athletes are especially prone to
                                     Whole grains, breads, pasta, whole     deficiencies in calcium and iron
                                     fruits and vegetables are excellent    due to the impacts of regular
                                     sources of high-quality                menstrual cycles, avoidance of
                                     carbohydrate.                          animal products and/or energy
                                                                            restriction. The diets and iron
                                     Protein requirements are slightly      status of endurance athletes and
                                     higher	in	both	endurance	(1.2	to	      vegetarians (especially females)
                                     1.4	grams	per	kilogram	body	           should be evaluated. However,
                                     weight) and strength-training          megadoses of specific vitamins or
                                     student-athletes	(1.6	to	1.7	grams	
                                                                            minerals	(10	to	100	times	the	dose	
     Available online at NCAA.org/   per kilogram body weight), above
                                                                            of daily requirements) are not
     health-safety.                  the typical recommended daily
                                                                            recommended.
                                     intake (0.8 grams per kilogram
                                     body weight). Fortunately, the         Hydration status impacts health
                                     higher intakes recommended for         and performance. Athletes should
                                     athletes are easily achieved in a      consume fluids throughout their
                                     well-balanced diet without the         day	(water,	low	fat	milk,	100	
                                     use of additional supplements.         percent fruit juices) and before,
                                                                            during and after training.
                                     Fat intake is an important source
                                     of essential fatty acids and carrier   Fluids containing electrolytes and
                                     for fat-soluble vitamins necessary     carbohydrates are a good source of
                                     for optimal physiological function.    fuel and re-hydration. Fluids (e.g.,
                                     During prolonged, lower-intensity      energy drinks) containing
                                     training, fats are a major energy      questionable supplement
                                     contributor and are stored in          ingredients and high levels of
                                     muscle as triglyceride for use         caffeine or other stimulants may be
                                     during activity. Dietary intake is     detrimental to the health of the
                                     suggested to be between 20 to 35       competitive athlete and are not
                                     percent of total daily caloric         effective forms of fuel or
                                     intake. Diets low in fat intake can    hydration.
                                     negatively impact training, nutrient   Adequate overall energy intake
                                     density of the diet and the ability    spread out across the day is
                                     to consistently improve                important for all student-athletes.
                                     performance.                           Insufficient energy intakes (due to
                                     In general, vitamin and mineral        skipped meals or dieting) will have
                                     supplements are not required if a      a rapid negative impact on training
                                     student-athlete is consuming           and performance, and over time, on
44                                   adequate energy from a variety         bone, immune function and injury
                                                                     Nutrition and Athletic Performance

risk. Inadequate energy intakes          psychological and nutritional
increase fatigue, deplete muscle         therapy.
glycogen stores, increase the risk of    A more prevalent issue is the large
dehydration, decrease immune             number of sub-clinical or
function, increase the risk of injury    chronically dieting athletes.
and result in unwanted loss of           Department-wide efforts to educate       Eating disorders are
muscle mass. A low caloric intake        staff and student-athletes should
in female student-athletes can lead                                               often an expression of
                                         include addressing the negative
to menstrual dysfunction and             impacts of under-fueling and             underlying emotional
decreased bone mineral density.          weight/food preoccupation on the         distress that may have
The maintenance or attainment of         athletes’ performance and overall        developed long before
an ideal body weight is sport-           well-being. Although dysfunctional
                                         eating is much more prevalent in         the individual was
specific and represents an
important part of a nutritional          women (approximately 90 percent          involved in athletics.
program. However, student-athletes       of the reports in the NCAA studies       Eating disorders can be
in certain sports face a difficult       were in women’s sports),
                                         dysfunctional eating also occurs in      triggered in
paradox in their training/nutrition
regimen, particularly those              men. Female athletes who miss            psychologically
competing in “weight class” sports       three or more menstrual cycles in a      vulnerable individuals
(e.g., wrestling, rowing), sports that   year, are preoccupied with weight,
                                         experience rapid changes in body
                                                                                  by a single event or
favor those with lower body weight
(e.g., distance running,                 weight, avoid eating with others, or     comments (such as
gymnastics), sports requiring            are over-focused on shape and food       offhand remarks about
student-athletes to wear body            are exhibiting warning signs worth
                                                                                  appearance, or
contour-revealing clothing (track,       addressing, if prevention of eating
diving, swimming, volleyball) and        disorders is desired. The medical        constant badgering
sports with subjective judging           examination and updated history          about a student-
related to “aesthetics” (gymnastics,     (Bylaw	17.1.5)	is	an	opportunity	to	
                                                                                  athlete’s body weight,
diving). These student-athletes are      assess athletes for these risk factors
encouraged to eat to provide the         and refer them to appropriate            body composition or
necessary fuel for performance, yet      professionals for further evaluation     body type) from a
they often face self- or team-           and diagnosis.                           person important to
imposed weight restrictions.             Eating disorders are often an
Emphasis on low body weight or
                                                                                  the individual.
                                         expression of underlying emotional
low body fat may benefit                 distress that may have developed
performance only if the guidelines       long before the individual was
are realistic, the calorie intake is     involved in athletics. Eating
reasonable and the diet is               disorders can be triggered in
nutritionally well-balanced.             psychologically vulnerable
The use of extreme weight-control        individuals by a single event or
measures can jeopardize the health       comments (such as offhand remarks
of the student-athlete and possibly      about appearance, or constant
trigger behaviors associated with        badgering about a student-athlete’s
eating disorders. NCAA studies           body weight, body composition or
have shown that at least 40 percent      body type) from a person important
of member institutions reported at       to the individual. Coaches, athletic
least one case of anorexia nervosa       trainers, sport dietitians and
or bulimia nervosa in their athletics    supervising physicians must be
programs. Once identified, these         watchful for student-athletes at
individuals should be referred for       higher risk for eating disorders.
medical evaluation and                   Disordered eating can lead to                                      45
     Nutrition and Athletic Performance


     dehydration, resulting in loss of         should not be used as the main                personnel, with consultation
     muscular strength and endurance,          criteria for participation in sports.         from the coach.
     decreased aerobic and anaerobic           Decisions regarding weight loss             4. Weight-loss plans should be
     power, loss of coordination, impaired     should be based on the following               individualized and realistic.
     judgment, and other complications         recommendations to reduce the risk
     that decrease performance and                                                         For each student-athlete, there may
                                               of disordered eating.
     impair health. These symptoms may                                                     be a unique optimal body
                                               1. Frequent weigh-ins (either as a          composition for performance, for
     be readily apparent or may not be
                                                  team or individually) are                health and for self-esteem.
     evident for an extended period of
                                                  discouraged unless part of               However, in most cases, these three
     time. Many student-athletes have
                                                  strategies outlined in Guideline 2c.     values are NOT identical. Mental
     performed successfully while
                                                                                           and physical health should not be
     experiencing an eating disorder.          2. Weight loss (fat loss) should be
                                                                                           sacrificed for performance. An
     Therefore, diagnosis of this problem         addressed during base or
                                                                                           erratic or lost menstrual cycle,
     should not be based entirely on a            transition phases.
                                                                                           sluggishness or an obsession with
     decrease in athletic performance.         3. Weight-loss goals should be              achieving a number on a scale may
     Body composition and body weight             determined by the student-athlete        be signs that a student-athlete's
     can affect exercise performance but          and medical and nutritional              health is being challenged.

      References

     1. Nutrition and Athletic Performance.    5. Dale, KS, Landers DM. Weight
     American College of Sports Medicine,      control in wrestling: eating disorders or
     American Dietetic Association, and        disordered eating? Medicine and
     Dietitians of Canada, Joint Position      Science in Sports and Exercise 31:1382-
     Stand, Medicine and Science in Sports     1389, 1999.
     and Exercise. 109:3:509-527, March        6. Dick RW: Eating disorders in NCAA
     2009                                      athletics programs. Athletic Training
     2. The Female Athlete Triad. American     26:136-140, 1991.
     College of Sports Medicine (ACSM)         7. Sandborn CF, Horea M, Siemers BJ,
     Position Stand, Medicine and Science in   Dieringer KI. Disordered eating and the
     Sports and Exercise, 39:10: 1-10 2007.    female athlete triad. Clinics in Sports
     3. Exercise and Fluid Requirements.       Medicine:19:199-213, 2000.
     American College of Sports Medicine
     (ACSM) Position Stand. 2007
     4. Brownell KD, Rodin J, Wilmore JH:
     Eating, Body Weight, and Performance in
     Athletes: Disorders of Modern Society
     Malvern, PA: Lea and Febiger, 1992.




46
                                 GUIDELINE 2g
Dietary Supplements
 January 1990 • Revised June 2004, June 2009



Nutritional and dietary                 It is well known that a high-          decreases, and fatigue rapidly
supplements are marketed to             carbohydrate diet is associated with   increases. A high-carbohydrate diet
student-athletes to improve             improved performance and               consisting of complex
performance, recovery time and          enhanced ability to train.             carbohydrates, fruits, vegetables,
muscle-building capability. Many        Carbohydrates in the form of           low-fat dairy products and whole
student-athletes use nutritional        glycogen are the body's main fuel      grains (along with adequate
supplements despite the lack of         for high-intensity activity. A large   protein) is the optimal diet for peak
proof of effectiveness. In addition,    number of student-athletes only        performance. (See Guideline 2f,
such substances are expensive and       consume 40 to 50 percent of their      Nutrition and Athletic
may potentially be harmful to           total calories from carbohydrates,     Performance.)
health or performance. Of greater       versus the recommended 55 to 65
                                                                               Protein and amino acid
concern is the lack of regulation       percent for most people (about 5 to
                                                                               supplements are popular with
                                        10	gm/kg	body	weight).	The	lower	
and safety in the manufacture of                                               bodybuilders and strength-training
                                        end of the range should be ingested
dietary supplements. Many                                                      student-athletes. Although protein
                                        during regular training; the high
compounds obtained from specialty                                              is needed to repair and build
                                        end during intense training.
“nutrition” stores and mail-order                                              muscles after strenuous training,
businesses may not be subject to        High-carbohydrate foods and            most studies have shown that
the strict regulations set by the       beverages can provide the              student-athletes ingest a sufficient
U.S. Food and Drug                      necessary amount of carbohydrate       amount without supplements. The
Administration. Therefore, the          for the high caloric demand of         recommended amount of protein in
contents of many of these               most sports to optimize                the	diet	should	be	12	to	15	percent	
compounds are not represented           performance. Low-carbohydrate          of	total	energy	intake	(about	1.4	to	
accurately on the list of ingredients   diets are not advantageous for         1.6	gm/kg	of	body	weight)	for	all	
and may contain impurities or           athletes during intense training and   types of student-athletes. Although
banned substances, which may            could result in a significantly        selected amino acid supplements
cause a student-athlete to test         reduced ability to perform or train    are purported to increase the
positive. Positive drug-test appeals    by the end of an intense week of       production of anabolic hormones,
based on the claim that the student-    training. When the levels of           studies using manufacturer-
athletes did not know the               carbohydrate are reduced, exercise     recommended amounts have not
substances they were taking             intensity and length of activity       found increases in growth hormone
contained banned drugs have not
been successful. Student-athletes
should be instructed to consult with       The NCAA subscribes to the Resource Exchange Center (REC).
the institution's sports medicine          The REC (www.drugfreesport.com/rec) provides accurate
staff before taking ANY nutritional        information on performance-enhancing drugs, dietary supplements,
supplement. Reference NCAA                 medications, new ingredients and validity of product claims, and
Banned Drug Classes in                     whether a substance is banned by the NCAA. This service is
Appendix A.                                provided 24 hours a day via a password-protected website for all
                                           NCAA member schools and their student-athletes and athletics
Member institutions are restricted         personnel. To access the REC, go to www.drugfreesport.com/rec.
in the providing of nutritional            The	password	is	ncaa1,	ncaa2,	or	ncaa3,	depending	on	your	
supplements – see NCAA bylaws              divisional classification.
for divisional regulations.                                                                                            47
     Dietary Supplements

                                            Other substances naturally           associated with use of certain
     or muscle mass. Ingesting high
     amounts of single amino acids is       occurring in foods, such as          amino acid supplements. Creatine
     contraindicated because they can       carnitine, herbal extracts and       has been found in some laboratory
     affect the absorption of other         special enzyme formulations, do      studies to enhance short-term,
     essential amino acids, produce         not provide any benefit to           high-intensity exercise capability,
     nausea, and/or impair kidney           performance. The high-protein diet   delay fatigue on repeated bouts of
     function and hydration status.         has received recent attention, but   such exercise and increase strength.
                                            data showing that this diet will     Several studies have contradicted
     Other commonly advertised                                                   these claims, and, moreover, the
                                            enhance performance are weak.
     supplements are vitamins and                                                safety of creatine supplements has
                                            High-protein diets are discouraged
     minerals. Most scientific evidence                                          not been verified. Weight gains of
                                            by most nutrition experts due to
     shows that selected vitamins and                                            one to three kilograms per week
                                            increased stress placed on the
     minerals will not enhance                                                   have been found in creatine users,
     performance provided no                kidneys. Mild to severe stomach
                                                                                 but the cause is unclear.
     deficiency exists. Some vitamins       cramping and diarrhea,
     and minerals are marketed to           dehydration, and gout have been      Many other “high-tech” nutritional
     student-athletes for other benefits.
     For example, the antioxidants,
     vitamins E and C, and beta-
     carotene, are used by many
     student-athletes because they
     believe that these antioxidants will
     protect them from the damaging
     effects of aerobic exercise.
     Although such exercise can cause
     muscle damage, studies have found
     that training will increase the
     body’s natural antioxidant defense
     system so that mega doses of
     antioxidants may not be needed.
     Supplementation in high dosages
     of antioxidants, such as vitamins E
     and C, and beta-carotene, could
     disrupt the normal balance of these
     compounds and the balance of free
     radicals in the body and cause
     more harm than good. (American
     Council on Science and Health)
     The mineral chromium has been
     suggested to increase muscle mass
     and decrease fat; these claims have
     little, if any, credible support. In
     fact, the Federal Trade Commission
     has declared such claims to be
     unsubstantiated and deceptive.
     Similarly, magnesium is purported,
     but not proven, to prevent cramps.
     To obtain necessary vitamins and
     minerals, student-athletes should
     eat a wide variety of foods because
     not all vitamins and minerals are
48   found in every food.
                                                                                              Dietary Supplements

or dietary supplements may seem             performance and may contain
to be effective at first, but this is       banned substances. Member                      Caution: “Nutritional/
likely a placebo effect — if student-       institutions should review NCAA                dietary supplements may
athletes believe these substances           Bylaw	16.5.2,	educational	columns	             contain NCAA banned
will enhance performance, they              and interpretations for guidance on            substances. The U.S.
may train harder or work more               restrictions on providing                      Food and Drug
efficiently. Ultimately, most               supplements to student-athletes.               Administration does not
nutritional supplements are                                                                strictly regulate the sup-
                                            Institutions should designate an
ineffective, costly and unnecessary.                                                       plement industry; there-
                                            individual (or individuals) as the
Student-athletes should be aware            athletics department resource for              fore, purity and safety of
that nutritional supplements are not        questions related to NCAA banned               nutritional/dietary sup-
                                            drugs and the use of nutritional               plements cannot be
limited to pills and powders;
                                            supplements. In addition,                      guaranteed. Impure sup-
“energy” drinks that contain
                                            institutions should educate athletics          plements may lead to a
stimulants are popular. Many of
                                            department staff members who                   positive NCAA drug test.
these contain large amounts of
                                            have regular interaction with                  The use of supplements
either caffeine or other stimulants,
                                            student-athletes that the NCAA                 is at the student-athlete’s
both of which can result in a
                                            maintains a list of banned drug                own risk. Student-
positive drug test. Student-athletes
                                            classes and provides examples of               athletes should contact
should be wary of drinks that
                                            banned substances in each drug                 their institution’s team
promise an “energy boost,” because                                                         physician or athletic
they may contain banned                     class on the NCAA website; any
                                            nutritional supplement use may                 trainer for further infor-
stimulants. In addition, the use of                                                        mation.”
stimulants while exercising can             present risks to a student-athlete’s
increase the risk of heat illness.          health and eligibility; and questions
                                            regarding NCAA banned drugs and
Student-athletes should be provided         the use of nutritional supplements
accurate and sound information on           should be referred to the
nutritional supplements. It is not          institution’s designated department
worth risking eligibility for               resource individual (or individuals).
products that have not been                 See Appendix B for Division I
scientifically proven to improve            legislative requirements.

References

1. Burke L: Practical issues in nutrition   and Science in Sports and Exercise. 32     8. The National Center for Drug Free
for athletes. Journal of Sports Sciences    (3): 706-717, 2000.                        Sport, Inc., 810 Baltimore, Suite 200,
13:S83-90, 1995.                            5. Lemon PWR: Do athletes need more        Kansas City, Missouri. 64105; 816/474-
                                            dietary protein and amino acids?           8655.
2. Clarkson PM, Haymes EM: Trace
Mineral Requirements for Athletes.          International Journal of Sport Nutrition   9. ACSM JOINT POSITION
International Journal of Sport Nutrition    5:S39-61, 1995.                            STATEMENT, Nutrition and Athletic
                                            6. Volek JS, Kraemer WJ: Creatine          Performance, 2000. Available at www.
4:104-19, 1994.
                                            supplementation: Its effect on human       acsm-msse.org.
3. Clarkson PM: Micronutrients and
                                            muscular performance and body              10. Nutritional Supplements, The NCAA
exercise: Antioxidants and minerals.        composition. Journal of National           News, April 15, 2005.
Journal of Sports Sciences 12:S11-24,       Strength and Conditioning Research         11. IOC study, 2001.
1995.                                       10:200-10, 1996.
                                                                                       12. HFL study, 2007.
4. American College of Sports Medicine.     7. Williams C: Macronutrients and
The physiological and health effects of     performance. Journal of Sports Sciences
oral creatine supplementation. Medicine     13:S1-10, 1995.                                                                     49
                                GUIDELINE 2h
     “Burners”
     (Brachial Plexus
     Injuries)
      June 1994 • Revised June 2003



                                 “Burners” or “stingers” are so          on the opposite side. Contact to
                                 named because the injuries can          the side of the neck may cause a
     The majority of stingers    cause a sudden pain and numbness        direct contusion to the brachial
     occur in football. Such     along the forearm and hand. The         plexus. In football, improper
                                 more formal medical terminology         blocking and tackling techniques
     injuries have been
                                 is transient brachial plexopathy or     may result in a brachial plexus
     reported in 52 percent      an injury to the brachial plexus. A     injury. Coaches, parents and stu-
     of college football         brachial plexus injury may also         dent-athletes should be cautioned
     players during a single     involve injury to a cervical root.      regarding the consequences of
                                 An injury to the spinal cord itself     improper techniques, which may
     season. As many as 70
                                 is more serious and frequently does     result in cervical spine injuries or
     percent of college          not fall under this category of inju-   trauma to the brachial plexus.
     football players have       ry, although it shares certain symp-
     experienced stingers.       toms; therefore, spinal cord injuries   Symptoms and Severity
     Stingers also can occur     should be ruled out when diagnos-       Student-athletes who suffer burn-
                                 ing stingers.                           ers may be unable to move the
     in a variety of other
                                                                         affected arm from their side and
     sports, including           The majority of stingers occur in
                                                                         will complain of burning pain,
                                 football. Such injuries have been
     basketball, ice hockey,                                             and potentially, numbness travel-
                                 reported in 52 percent of college
     wrestling and some field                                            ing from the injured side of the
                                 football players during a single
                                                                         neck through the shoulder down
     events in track.            season.	As	many	as	70	percent	of	
                                                                         the arm and forehand, and some-
                                 college football players have
                                                                         times into the hand. Weakness
                                 experienced stingers. Stingers
                                                                         may be present in the muscles of
                                 also can occur in a variety of
                                                                         the shoulder, elbow and hand.
                                 other sports, including basketball,
                                 ice hockey, wrestling and some          Brachial plexus injuries can be
                                 field events in track.                  classified into three categories.
                                                                         The	mildest	form	(Grade	1)	are	
                                 Mechanism                               neuropraxic injuries that involve
                                 The most common mechanism for           demyelination of the axon sheath
                                 stingers is head movement in an         without intrinsic axonal disruption.
                                 opposite direction from the shoul-      Compete recovery typically occurs
                                 der either from a hit to the head or    in	a	few	seconds	to	days.		Grade	1	
                                 downward traction of the shoulder.      injuries are the most common in
                                 This can stretch the nerve roots on     athletics. Grade 2 injuries involve
                                 the side receiving the blow (trac-      axonotmesis or disruption of the
50                               tion), or compress or pinch those       axon and myelin sheath with pres-
“Burners” (Brachial Plexus Injuries)

ervation of the epineurium, peri-      extent of injury. However, an EMG
neurium, and endoneurium,              should not be used for return-to-
which can serve as the conduit         play criteria, as EMG changes may
for the regenerating axon as it        persist for several years after the
re-grows	at	1	to	7	millimeters	        symptoms have resolved. Shoulder
per day. Weakness can last for         injuries (acromioclavicular separa-    All athletes sustaining
weeks but full recovery typical-       tion, shoulder subluxation or dislo-   burners or stingers
ly occurs. Grade 3 in juries,          cation, and clavicular fractures)
neurotmesis or complete nerve                                                 should undergo a
                                       should be considered in the differ-
transections are rare in athletes.     ential diagnosis of the athlete with   physical rehabilitation
Surgical repair of the nerve is        transient or prolonged neurologic      program that includes
required in these cases and com-
                                       symptoms of the upper extremity.       neck and trunk
plete recovery may not occur.
                                       Any injured athlete who presents       strengthening exercises.
These classifications have more        with specific cervical-point tender-
                                                                              The fit of shoulder pads
meaning with regard to anticipated     ness, neck stiffness, bony deformi-
recovery of function than a grading    ty, fear of moving his/her head and/   should be re-checked and
on the severity of symptoms at the     or complains of a heavy head           consideration of other
time of initial injury.                should be immobilized on a spine       athletic protective
                                       board (as one would for a cervical     equipment, such as neck
Treatment and                          spine fracture) and transported to a
Return to Play                                                                rolls and/or collars,
                                       medical facility for a more thor-
Burners and stingers typically         ough evaluation.                       should be given. The
result in symptoms that are sensory                                           athlete’s tackling
in nature, frequently involving the    Bilateral symptoms indicate that
                                                                              techniques should be
C5 and C6 dermatomes. All ath-
                                                                              reviewed.
letes sustaining burners should be
removed from competition and
examined thoroughly for injury to
the cervical spine and shoulder.
All cervical roots should be
assessed for motor and sensory
function. If symptoms clear within
seconds to several minutes and are
not associated with any neck pain,
limitation of neck movement or
signs of shoulder subluxation or
dislocation, the athlete can safely
return to competition. It is impor-
tant to re-examine the athlete after
the game and for a few successive
days to detect any reoccurrence of
weakness or alteration in sensory
exam.
If sensory complaints or weakness
persists for more than a few min-
utes, a full medical evaluation with
radiographs and consideration for a
MRI should be done to rule out
cervical disk or other compressive
pathology. If symptoms persist for
more than 2 to 3 weeks, an EMG
                                                                                                         51
may be helpful in assessing the
     “Burners” (Brachial Plexus Injuries)
     the cord itself has been traumatized       Although rare, risk of permanent
     and may suggested transient quadri-        nerve injury exists for those with
     plegia. These athletes should also         recurrent burners. Therefore, partic-
     be immobilized and transported to a        ipants should report every occur-
     medical facility for a more thor-          rence to their certified athletic train-
     ough evaluation.                           ers or team physician. Any player
     All athletes sustaining burners or         with persistent pain, burning, numb-
     stingers should undergo a physical         ness and/or weakness (lasting longer
     rehabilitation program that includes       than two minutes) should be held out
     neck and trunk strengthening exer-         of competition and referred to a phy-
     cises. The fit of shoulder pads            sician for further evaluation.
     should be re-checked and consider-
     ation of other athletic protective         A Word of Caution
     equipment, such as neck rolls and/         Management of the student-athlete
     or collars, should be given. The           with recurrent burners can be diffi-
     athlete’s tackling techniques should       cult. There are no clear guidelines
     be reviewed.                               concerning return to play. Although
                                                some risk of permanent nerve inju-
     Stinger assessment should be part of
                                                ry exists, a review of the literature
     the student-athletes’ preseason phys-
                                                shows this risk to be small for those
     ical and mental history (see hand-
                                                with recurrent episodes. The most
     book	Guideline	No.	1b)	so	that	these	
     “at-risk” athletes can be instructed in    important concern for student-ath-
     a prevention preventative exercise         letes with recurrent burners is to
     program and be provided with prop-         stress the importance of reporting
     er protective equipment.                   all symptoms to the attending
                                                medical personnel so that a
     Recurrent Burners                          thorough physical examination,
     Recurrent burners may be common;           with particular attention to strength
     87	percent	of	athletes	in	one	study	       and sensory changes, can be
     had experienced more than one.             obtained. Any worsening of symp-
     Medical personnel should pay spe-          toms should provoke a more
     cial attention to this condition.          thorough evaluation.

      References

     1. Meyer S, Schulte K, et al: Cervical     Football Players. American Journal of      8. Weinstein S: Assessment and
     Spinal Stenosis and Stingers in            Sports Medicine 22(2), 1994.               Rehabilitation of the Athlete with a
     Collegiate Football Players. American      5. Cantu R: Stingers, Transient            Stinger. A Model for the Management of
     Journal of Sports Medicine 22(2):158-      Quadriplegia, and Cervical Spinal          Non-catastrophic Athletic Cervical Spine
     166, 1994.                                 Stenosis: Return-to-Play Criteria.         Injury. Clinic and Sports Medicine
     2. Torg J, et al: Cervical Cord            Medicine and Science of Sports and         17(1), 1998.
     Neuropraxia: Classification Pathomech-     Exercise 7(Suppl):S233-235, 1997.          9. Shannon B, Klimkiewicz J, Cervical
     anics, Morbidity and Management            6. Levitz C, et al: The Pathomechanics     Burners in the Athlete. Clinic and Sports
     Guidelines. Journal of Neurosurgery        of Chronic Recurrent Cervical Nerve        Medicine 21(1):29-35 January 2002.
     87:843-850, 1997.                          Root Neuropraxia, the Chronic Burner       10. Koffler K, Kelly J, Neuro-
     3. Feinberg J, et al: Peripheral Nerve     Syndrome. American Journal of Sports       vascular Trauma in Athletes. Orthop
     Injuries in the Athlete. Sports Medicine   Medicine 25(1), 1997.                      Clin N Am 33: 523-534(2002).
     12(6):385-408, 1997.                       7. Castro F, et al: Stingers, the Torg     11. Feinberg J, Burners and Stingers,
     4. Meyer S, et al: Cervical Spinal         Ratio, and the Cervical Spine. American    Phys Med Rehab N Am 11(4): 771-783
52   Stenosis and Stingers in Collegiate        Journal of Sports Medicine 25(5), 1997.    Nov 2000.
                                   GUIDELINE 2i
Concussion or Mild
Traumatic Brain Injury
(mTBI) in the Athlete
 June 1994 • Revised July 2004, 2009, July 2010, July 2011



Estimates	suggest	that	1.6	to	3.8	        account for a significant percentage    soccer	1.4,	for	women’s	lacrosse	
million concussions occur from            of injuries in men’s and women’s        1.2,	for	field	hockey	1.2,	for	
participation in sports- and              basketball, women’s lacrosse, and       women’s	basketball	1.2,	and	for	
recreation-related activities every       other sports traditionally              men’s basketball 0.6, accounting
year	(see	reference	No.	18).	These	       considered “noncontact.”                for	between	4	and	16.2	percent	of	
injuries are often difficult to detect,                                           the injuries for these sports as
with athletes often underreporting        The incidence in helmeted versus        reported by the NCAA Injury
their injury, minimizing their            nonhelmeted sports is also similar.     Surveillance Program by the
importance or not recognizing that        In the years 2004 to 2009, the rate     Datalys Center.
an injury has occurred. At the            of concussion during games per
                                          1,000	athlete	exposures	for	football	   Assessment and management of
college level, these injuries are
                                          was	3.1,	for	men’s	lacrosse	2.6,	for	   concussive injuries, and return-to-
more common in certain sports,
                                          men’s ice hockey 2.4, for women's       play decisions remain some of the
such as football, ice hockey, men’s
                                          ice hockey 2.2, for women's soccer      most difficult responsibilities
and women’s soccer, and men’s
                                          2.2,	for	wrestling	1.4,	for	men's	      facing the sports medicine team.
lacrosse. However, they also
                                                                                  There are potentially serious
                                                                                  complications of multiple or severe
                                                                                  concussions, including second
                                                                                  impact syndrome, postconcussive
                                                                                  syndrome, or post-traumatic
                                                                                  encephalopathy. Though there is
                                                                                  some controversy as to the
                                                                                  existence of second impact
                                                                                  syndrome, in which a second
                                                                                  impact with potentially
                                                                                  catastrophic consequences occurs
                                                                                  before the full recovery after a first
                                                                                  insult, the risks include severe
                                                                                  cognitive compromise and death.
                                                                                  Other associated injuries that can
                                                                                  occur in the setting of concussion
                                                                                  include seizures, cervical spine
                                                                                  injuries, skull fractures and/or
                                                                                  intracranial bleed. Due to the
                                                                                  serious nature of mild traumatic
                                                                                  brain injury, and these serious
                                                                                  potential complications, it is           53
     Concussion or Mild Traumatic Brain Injury

     imperative that the health care        injuries of skull fracture,              noted. These sideline tests should
     professionals taking care of           intracranial bleeding and seizures,      be performed and repeated as
     athletes are able to recognize,        when there is concern for structural     necessary, but do not take the place
     evaluate and treat these injuries in   abnormalities or when the                of other comprehensive
     a complete and progressive             symptoms of an athlete persist or        neuropsychological tests.
     fashion.	In	April	2010,	the	NCAA	      deteriorate.
     Executive Committee adopted a                                                   Once an injury occurs and an
                                            Concussion is associated with            initial assessment has been made, it
     policy that requires NCAA
                                            clinical scenarios that often clear      is important to determine an initial
     institutions to have a concussion
                                            spontaneously, and may or may not        plan of action, which includes
     management plan on file. (See
                                            be associated with loss of               deciding on whether additional
     information box on page 56.)
                                            consciousness (LOC).                     referral to a physician and/or
     Concussion or mild traumatic brain                                              emergency department should take
                                            The sideline evaluation of the
     injury (mTBI) has been defined as                                               place, and determining the follow-
                                            brain-injured athlete should include
     “a complex pathophysiological                                                   up care. The medical staff should
                                            an assessment of airway, breathing
     process affecting the brain, induced                                            also determine whether additional
                                            and circulation (ABCs), followed
     by traumatic biomechanical                                                      observation or hospital admission
                                            by an assessment of the cervical
     forces.” Although concussion most                                               should be considered.
                                            spine and skull for associated
     commonly occurs after a direct
                                            injury. The sideline evaluation          Follow-up care and instructions
     blow to the head, it can occur after
                                            should also include a neurological       should be given to the athlete, and
     a blow elsewhere that is transmitted
                                            and mental status examination and        ensuring that they are not left alone
     to the head. Concussions can be
                                            some form of brief neurocognitive        for an initial period of time should
     defined by the clinical features,
                                            testing to assess memory function        be considered. Athletes should
     pathophysiological changes and/or
                                            and attention. This can be in the        avoid alcohol or other substances
     biomechanical forces that occur,
                                            form of questions regarding the          that will impair their cognitive
     and these have been described in
                                            particular practice or competition,      function, and also avoid aspirin and
     the literature. The neurochemical
                                            previous game results, and remote        other medications that can increase
     and neurometabolic changes that
                                            and recent memory, and questions         their risk of bleeding.
     occur in concussive injury have
                                            to test the athlete’s recall of words,
     been elucidated, and exciting                                                   As mentioned previously,
                                            months of the year backwards and
     research is underway describing the                                             conventional imaging studies such
                                            calculations. Special note should
     genetic factors that may play a role                                            as MRI and CT scans are usually
                                            be made regarding the presence
     in determining which individuals                                                normal in mTBI. However, these
                                            and duration of retrograde or
     are at an increased risk for                                                    studies are considered an adjunct
                                            anterograde amnesia, and the
     sustaining brain injury.                                                        when any structural lesion, such as
                                            presence and duration of confusion.
     Most commonly, concussion is           A timeline of injury and the             an intracranial bleed or fracture, is
     characterized by the rapid onset of    presence of symptoms should be           suspected. If an athlete
     cognitive impairment that is self
     limited and spontaneously resolves.
                                                                                Table 1
     The acute symptoms of concussion,
                                                              SIGNS AND SYMPTOMS OF mTBI
     listed below, are felt to reflect a
                                              Loss of consciousness (LOC)            Visual Disturbances
     functional disturbance in cognitive
                                              Confusion                                 (Photophobia, blurry Phono/
     function instead of structural
                                              Post-traumatic amnesia (PTA)              photophobia vision,
     abnormalities, which is why
                                              Retrograde amnesia (RGA)                  double vision)
     diagnostic tests such as magnetic
                                              Disorientation                         Disequilibrium
     resonance imaging (MRI) and
                                              Delayed verbal and motor               Feeling “in a fog,” “zoned out”
     computerized tomography (CT)                responses                           Vacant stare
     scans are most often normal.             Inability to focus                     Emotional lability
     These studies may have their role        Headache                               Dizziness
     in assessing and evaluating the          Nausea/Vomiting                        Slurred/incoherent speech
     head-injured athlete whenever there      Excessive drowsiness
54   is concern for the associated
                                                           Concussion or Mild Traumatic Brain Injury

experiences prolonged loss of
consciousness, confusion, seizure             1. NCAA Concussion Fact Sheets and Video for Coaches
activity, focal neurologic deficits or        and Student-Athletes
                                              Available at www.NCAA.org/health-safety.
persistent clinical or cognitive
                                              2. Heads Up: Concussion Tool Kit
symptoms, then additional testing             CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm.
may be indicated.                             3. Heads Up Video
                                              NATA. Streaming online at www.nata.org/consumer/headsup.htm.
There are several grading systems
and return-to-play guidelines in the
literature regarding concussion in       individual	fashion	(Cantu	‘01,	         needed to understand the complete
sport (AAN, Torg, Cantu). However,       Zurich Conference, NATA ‘04).           role of neuropsychological testing.
there may be limitations because
they presume that LOC is associated      Several recent publications have        Given these limitations, it is
with more severe injuries. It has        endorsed the use of neurocognitive      essential that the medical care team
been demonstrated that LOC does          or neuropsychological testing as the    treating athletes continue to rely on
not correlate with severity of injury    cornerstone of concussion               its clinical skills in evaluating the
in patients presenting to an             evaluation. These tests provide a       head-injured athlete to the best of its
emergency department with closed         reliable assessment and                 ability. It is essential that no athlete
head injury, and has also been           quantification of brain function by     be allowed to return to participation
demonstrated in athletes with            examining brain-behavior                when any symptoms persist, either
concussion (Lovell ‘99). It has been     relationships. These tests are          at rest or during exertion. Any
further demonstrated that retrograde     designed to measure a broad range       athlete exhibiting an injury that
amnesia (RGA), post-traumatic            of cognitive function, including        involves significant symptoms, long
amnesia (PTA), and the duration of       speed of information processing,        duration of symptoms or difficulties
confusion and mental status changes      memory recall, attention and            with memory function should not be
are more sensitive indicators of         concentration, reaction time,           allowed to return to play during the
injury severity (Collins ‘03), thus an   scanning and visual tracking ability,   same day of competition. The
athlete with these symptoms should       and problem solving ability. Several    duration of time that an athlete
not be allowed to return to play         computerized versions of these tests    should be kept out of physical
during the same day. These athletes      have also been designed to improve      activity is unclear, and in most
should not return to any                 the availability of these tests, and    instances, individualized return-to-
participation until cleared by a         make them easier to distribute and      play decisions should be made.
physician. More recent grading           use. Ideally, these tests are           These decisions will often depend
systems have been published that         performed before the season as a        on the clinical symptoms, previous
attempt to take into account the         “baseline” with which post-injury       history of concussion and severity
expanding research in the field of       tests can be compared. Despite the      of previous concussions. Additional
mTBI in athletes. Though it is           utility of neuropsychological test      factors include the sport, position,
useful to become familiar with these     batteries in the assessment and         age, support system for the athlete
guidelines, it is important to           treatment of concussion in athletes,    and the overall “readiness” of the
remember that many of these              several questions remain                athlete to return to sport.
injuries are best treated in an          unanswered. Further research is
                                                                                 Once an athlete is completely
                                                                                 asymptomatic, the return-to-play
                                    Table 2                                      progression should occur in a step-
        SYMPTOMS OF POST-CONCUSSION SYNDROME                                     wise fashion with gradual
  Loss of intellectual capacity          Fatigue                                 increments in physical exertion and
  Poor recent memory                     Irritability                            risk of contact. After a period of
  Personality changes                    Phono/photophobia                       remaining asymptomatic, the first
  Headaches                              Sleep disturbances                      step is an “exertional challenge” in
  Dizziness                              Sleep disturbances                      which	the	athlete	exercises	for	15	
  Lack of concentration                  Depressed mood                          to 20 minutes in an activity such as
  Poor attention                         Anxiety                                 biking or running in which he/she
                                                                                 increases his/her heart rate and           55
     Concussion or Mild Traumatic Brain Injury

     breaks a sweat. If he/she does not
     experience any symptoms, this can            The NCAA Executive Committee adopted
     be followed by a steady increase in          (April 2010) the following policy for
     exertion, followed by return-to-
                                                  institutions in all three divisions.
     sport-specific activities that do not
     put the athlete at risk for contact.         “Institutions shall have a concussion management plan on file such
     Examples include dribbling a ball            that a student-athlete who exhibits signs, symptoms or behaviors con-
     or shooting, stickwork or passing,           sistent with a concussion shall be removed from practice or competi-
     or other agilities. This allows the          tion and evaluated by an athletics healthcare provider with experience
     athlete to return to the practice            in the evaluation and management of concussions. Student-athletes
     setting, albeit in a limited role.           diagnosed with a concussion shall not return to activity for the
     Finally, the athlete can be                  remainder of that day. Medical clearance shall be determined by the
     progressed to practice activities            team physician or his or her designee according to the concussion
     with limited contact and finally full        management plan.
     contact. How quickly one moves               “In addition, student-athletes must sign a statement in which they ac-
     through this progression remains             cept the responsibility for reporting their injuries and illnesses to the
     controversial.                               institutional medical staff, including signs and symptoms of concus-
                                                  sions. During the review and signing process, student-athletes should
                                                  be presented with educational material on concussions.”




        NCAA Adopted Concussion Management Plan Legislation.
        Concussion Management Plan. An active member institution shall have a concussion management plan for
        its student-athletes. The plan shall include, but is not limited to, the following:
        (a) An annual process that ensures student-athletes are educated about the signs and symptoms of concussions.
            Student-athletes must acknowledge that they have received information about the signs and symptoms
            of concussions and that they have a responsibility to report concussion-related injuries and illnesses to a
            medical staff member;
        (b) A process that ensures a student-athlete who exhibits signs, symptoms or behaviors consistent with a
            concussion shall be removed from athletics activities (e.g., competition, practice, conditioning sessions) and
            evaluated by a medical staff member (e.g., sports medicine staff, team physician) with experience in the
            evaluation and management of concussions;
        (c) A policy that precludes a student-athlete diagnosed with a concussion from returning to athletic activity
            (e.g., competition, practice, conditioning sessions) for at least the remainder of that calendar day; and
        (d) A policy that requires medical clearance for a student-athlete diagnosed with a concussion to return to
            athletics activity (for example, competition, practice, conditioning sessions) as determined by a physician
            (e.g., team physician) or the physician’s designee.
        3.2.4.16.1 Effect of Violation.	A	violation	of	Constitution	3.2.4.16	shall	be	considered	an	institutional	violation	
        per	Constitution	2.8.1;	however,	the	violation	shall	not	affect	the	student-athlete’s	eligibility.




56
                                                                Concussion or Mild Traumatic Brain Injury

 References

1. Cantu RC: Concussion severity should     and Neuropsychological Performance in       13. Makdissi M, Collie A, Maruff P et al:
not be determined until all                 College Football Players. JAMA              Computerized cognitive assessment of
postconcussion symptoms have abated.        282:964-970, 1999.                          concussed Australian Rules footballers.
Lancet 3:437-8, 2004.                       8. Guskiewicz KM, Bruce SL, Cantu R,        Br. J Sports Med 35(5):354-360, 2001.
2. Cantu RC: Recurrent athletic head        Ferrara MS, Kelly JP, McCrea M,             14. McCrea M: Standardized mental
injury: risks and when to retire. Clin      Putukian M, McLeod-Valovich TC;             status assessment of sports concussion.
Sports Med. 22:593-603, 2003.               National Athletic Trainers’ Association     Clin J Sport Med 11(3):176-181, 2001.
3. Cantu RC: Post traumatic (retrograde/    Position Statement: Management of
                                            Sport-related Concussion: Journal of        15. McCrea M, Hammeke T, Olsen G,
anterograde) amnesia: pathophysiology
                                            Athletic Training. 39(3): 280-297, 2004.    Leo , Guskiewicz K: Unreported
and implications in grading and safe
return to play. Journal of Athletic                                                     concussion in high school football
                                            9. Guskiewicz KM: Postural stability        players. Clin J Sport Med 2004;14:13-
Training. 36(3): 244-8, 2001.               assessment following concussion: One
                                            piece of the puzzle. Clin J Sport Med       17.
4. Centers for Disease Control and
Prevention. Sports-related recurrent        2001; 11:182-189.                           16. McCrory P, Meeuwisse W, Johnston
brain injuries: United States. MMWR         10. Hovda DA, Lee SM, Smith ML et al:       K, Dvorak J, Aubry M, Molloy M, Cantu
Morb Mortal Wkly Rep 1997; 46:224-          The Neurochemical and metabolic             R. Concensus Statement on Concussion
227.                                        cascade following brain injury: Moving      in Sport: the Third International
5. Collie A, Darby D, Maruff P:             from animal models to man. J                Conference on Concussion in Sport.
Computerized cognitive assessment of        Neurotrauma 12(5):143-146, 1995.            Zurich, Switzerland, 2008. Br J Sports
athletes with sports related head injury.   11. Johnston K, Aubry M, Cantu R et al:     Med 2009;43:i76-i84.
Br. J Sports Med 35(5):297-302, 2001.       Summary and Agreement Statement of          17. Torg JS: Athletic Injuries to the Head,
6. Collins MW, Iverson GL, Lovell MR,       the First International Conference on       Neck, and Face. St. Louis, Mosby-Year
McKeag DB, Norwig J, Maroon J: On-          Concussion in Sport, Vienna 2001, Phys      Book, 1991.
field predictors of neuropsychological      & Sportsmed 30(2):57-63, 2002.              18. Langlois JA, Rutland-Brown LV, Wald
and symptom deficit following sports-       12. Lovell MR, Iverson GL, Collins MW       MM. The Epidemiology and Impact of
related concussion. Clin J Sport Med        et al: Does loss of consciousness predict   Traumatic Brain Injury. J Head Trauma
2003; 13:222-229.                           neuropsychological decrements after         Rehabil. 2006; 21:375-8.
7. Collins MW, Grindel SH, Lovell MR et     concussion? Clin J Sport Med 9:193-
al: Relationship Between Concussion         198, 1999.




                                                                                                                                      57
     Concussion or Mild Traumatic Brain Injury


       In Addition to the Executive Committee Policy Requirements,
       Additional Best Practices for a Concussion Management Plan
       Include, but are not Limited to:
       1. Although sports currently have rules in place,                   for each student-athlete before the first practice
          athletics staff, student-athletes and officials should           in the sports of baseball, basketball, diving,
          continue to emphasize that purposeful or flagrant                equestrian, field hockey, football, gymnastics,
          head or neck contact in any sport should not be per-             ice hockey, lacrosse, pole vaulting, rugby,
          mitted and current rules of play should be strictly              soccer, softball, water polo and wrestling, at
          enforced.                                                        a minimum. The same baseline assessment
       2. Institutions should have on file and annually update             tools should be used post-injury at appropriate
          an emergency action plan for each athletics venue                time intervals. The baseline assessment should
          to respond to student-athlete catastrophic injuries              consist of one or more of the following areas of
          and illnesses, including but not limited to, con-                assessment.
          cussions, heat illness, spine injury, cardiac arrest,           1) At a minimum, the baseline assessment should
          respiratory distress (e.g., asthma), and sickle cell               consist of the use of a symptoms checklist and
          trait collapses. All athletics healthcare providers                standardized cognitive and balance assess-
          and coaches should review and practice the plan at                 ments [e.g., SAC; SCAT; SCAT II; Balance
          least annually.                                                    Error Scoring System (BESS)].
       3. Institutions should have on file an appropriate                 2) Additionally, neuropsychological testing (e.g.,
          healthcare plan that includes equitable access to                  computerized, standard paper and pencil) has
          athletics healthcare providers for each NCAA sport.                been shown to be effective in the evaluation
       4. Athletics healthcare providers should be empowered                 and management of concussions. The develop-
          to have the unchallengeable authority to determine                 ment and implementation of a neuropsycho-
          management and return-to-play of any ill or injured                logical testing program should be performed
          student-athlete, as the provider deems appropriate.                in consultation with a neuropsychologist who
          For example, a countable coach should not serve as                 is in the best position to interpret NP tests by
          the primary supervisor for an athletics healthcare                 virtue of background and training. However,
          provider, nor should the coach have sole hiring or                 there may be situations in which neuropsy-
          firing authority over a provider.                                  chologists are not available and a physician ex-
                                                                             perienced in the use and interpretation of such
       5. The concussion management plan should outline                      testing in an athletic population may perform
          the roles of athletics healthcare staff (e.g., physician,          or interpret NP screening tests.
          certified athletic trainer, nurse practitioner, physician
          assistant, neurologist, neuropsychologist). In addi-          d. The student-athlete should receive serial
          tion, the following components have been specifi-                monitoring for deterioration. Athletes should be
          cally identified for the collegiate environment:                 provided with written instructions upon dis-
                                                                           charge, preferably with a roommate, guardian or
         a. Institutions should ensure that coaches have ac-               someone who can follow the instructions.
            knowledged that they understand the concussion
            management plan, their role within the plan and              e. The student-athlete should be evaluated by a
            that they received education about concussions.                 team physician as outlined within the concus-
                                                                            sion management plan. Once asymptomatic
         b. Athletics healthcare providers should practice                  and post-exertion assessments are within normal
            within the standards as established for their                   baseline limits, return-to-play should follow a
            professional practice (e.g., physician, certified               medically supervised stepwise process.
            athletic trainer, nurse practitioner, physician as-
                                                                      6. Institutions should document the incident, evalua-
            sistant, neurologist, neuropsychologist).
                                                                         tion, continued management and clearance of the
         c. Institutions should record a baseline assessment             student-athlete with a concussion.

         For references, visit www.NCAA.org/health-safety.
58
                                   GUIDELINE 2j
Skin Infections
in Athletics
July 1981 • Revised June 2008



Skin infections may be transmitted by        b. scabies;                             as performing hand hygiene before
both direct (person to person) and        3. Viral skin infections                   and after changing bandages and
indirect (person to inanimate surface        a. herpes simplex;                      throwing used bandages in the trash
to person) contact. Infection control                                                should be stressed to the athlete.
                                             b. herpes zoster (chicken pox);
measures, or measures that seek to
prevent the spread of disease, should
                                             c. molluscum contagiosum; and           Antibiotic Resistant
be used to reduce the risks of disease    4. Fungal skin infections                  Staph Infections
transmission. Efforts should be made         a. tinea corporis (ringworm).           There is much concern about the
to improve student-athlete hygiene        Note: Current knowledge indicates          presence and spread of antibiotic-
practices, to use recommended             that many fungal infections are easily     resistant Staphylococcus aureus in
procedures for cleaning and               transmitted by skin-to-skin contact. In    intercollegiate athletics across sports.
disinfection of surfaces, and to handle   most cases, these skin conditions can      Athletes are at-risk due to presence of
blood and other bodily fluids             be covered with a securely attached        open wounds, poor hygiene practices,
appropriately. Suggested measures         bandage or nonpermeable dressing to        close physical contact, and the sharing
include: promotion of hand and            allow participation.                       of towels and equipment. Institutions
personal hygiene practices; educating                                                and conferences should continue
                                          Open wounds and infectious skin
athletes and athletics staff; ensuring                                               efforts and support for the education
                                          conditions that cannot be adequately
recommended procedures for cleaning                                                  of staff and student-athletes on the
                                          protected should be considered cause
and disinfection of hard surfaces are                                                importance of proper hygiene and
                                          for medical disqualification from
followed; and verifying clean up of                                                  wound care to prevent skin infections
                                          practice or competition (see Guideline
blood and other potentially infectious                                               from developing and infectious
                                          2a). The term “adequately protected”
materials is done, according to the                                                  diseases from being transmitted.
                                          means that the wound or skin
Occupational Health and Safety            condition has been deemed as non-          Staphylococcus aureus, often referred
Administration (OSHA) Blood-borne         infectious and adequately treated as       to as “staph,” are bacteria commonly
Pathogens Standard #29 CFR                deemed appropriate by a health care        carried on the skin or in the nose of
1910.1030.		                              provider and is able to be properly        healthy people. Occasionally, staph can
Categories of skin conditions and         covered. The term “properly covered”       cause an infection. Staph bacteria are
examples include:                         means that the skin infection is           one of most common causes of skin
                                          covered by a securely attached             infections in the U.S. Most infections are
1.	 Bacterial	skin	infections
                                          bandage or dressing that will contain      minor, typically presenting as skin and
    a. impetigo;                          all drainage and will remain intact        soft tissue infections (SSTI) such as
    b. erysipelas;                        throughout the sport activity. A health    pimples, pustules and boils. They may
    c. carbuncle;                         care provider might exclude a student-     be red, swollen, warm, painful or
    d. staphylococcal disease, MRSA;      athlete if the activity poses a risk to    purulent. Sometimes, athletes confuse
                                          the health of the infected athlete (such   these lesions with insect bites in the early
    e. folliculitis (generalized);
                                          as injury to the infected area), even      stages of infection. A purulent lesion
    f. hidradentitis suppurativa;         though the infection can be properly       could present as draining pus; yellow or
2. Parasitic skin infections              covered. If wounds can be properly         white center; central point or “head”; or a
    a. pediculosis;                       covered, good hygiene measures such        palpable fluid-filled cavity.
                                                                                                                                    59
     Skin Infections in Athletics

     In the past, most serious staph          the full course and consult             indirect contact by touching objects
     bacterial infections were treated with   physicians if the infection does not    contaminated by the infected skin of a
     antibiotics related to penicillin. In    get better. The Centers for Disease     person with MRSA or staph bacteria
     recent years, antibiotic treatment of    Control and Prevention (CDC),           (e.g. towels, sheets, wound dressings,
     these infections has changed             American Medical Association            clothes, workout areas, sports
     because staph bacteria have become       (AMA), and Infectious Diseases          equipment).
     resistant to various antibiotics,        Society of America (IDSA) have          If a lesion cannot be properly
     including the commonly used              developed a treatment algorithm that    covered for the rigors of the sport,
     penicillin-related antibiotics. These    should be reviewed; it is accessible    consider excluding players with
     resistant bacteria are called            at www.cdc.gov/ncidod/dhqp/ar_          potentially infectious skin lesions
     methicillin-resistant Staphylococcus     mrsa_ca_skin.html.                      from practice and competition until
     aureus, or MRSA. Fortunately, the
                                              Staph bacteria including MRSA can       lesions are healed.
     first-line treatment for most purulent
     staph, including MRSA, skin and          spread among people having close        Staph bacteria including MRSA can
     soft tissue infections is incision and   contact with infected people. MRSA      be found on the skin and in the nose
     drainage with or without antibiotics.    is almost always spread by direct       of some people without causing
     However, if antibiotics are              physical contact, and not through the   illness. The role of decolonization is
     prescribed, patients should complete     air. Spread may also occur through      still under investigation. Regimens


          Some common recommendations include:
          A. Keep hands clean by washing thoroughly with soap and warm water or using
             an alcohol-based sanitizer routinely
          B.   Encourage good hygiene
          	    •	 immediate	showering	after	activity
          	    •	 ensure	availability	of	adequate	soap	and	water
          	    •	 pump	soap	dispensers	are	preferred	over	bar	soap
          C. Avoid whirlpools or common tubs
               i
          	 •	 	ndividuals	with	active	infections,	open	wounds,	scrapes	or	scratches	could	infect	others	or	
               become infected in this environment
          D. Avoid sharing towels, razors, and daily athletic gear
               a
          	 •	 	 void	contact	with	other	people’s	wounds	or	material	contaminated	from	wounds
          E. Maintain clean facilities and equipment
          	 •	 wash	athletic	gear	and	towels	after	each	use	
          	 •	 establish	routine	cleaning	schedules	for	shared	equipment
          F. Inform or refer to appropriate health care personnel for all active skin lesions and lesions
             that do not respond to initial therapy
                t
          	 •	 	rain	student-athletes	and	coaches	to	recognize	potentially	infected	wounds	and	seek	first	aid	
                e
          	 •	 	 ncourage	coaches	and	sports	medicine	staff	to	assess	regularly	for	skin	lesions
                e
          	 •	 	 ncourage	health	care	personnel	to	seek	bacterial	cultures	to	establish	a	diagnosis
          G. Care and cover skin lesions appropriately before participation
          	 •	 keep	properly	covered	with	a	proper	dressing	until	healed
               “
          	 •	 	 properly	covered"	means	that	the	skin	infection	is	covered	by	a	securely	attached	bandage	or	
               dressing that will contain all drainage and will remain intact throughout the sport activity
               i
          	 •	 	f	wounds	can	be	properly	covered,	good	hygiene	measures	should	be	stressed	to	the	student-
               athlete such as performing hand hygiene before and after changing bandages and throwing
               used bandages in the trash
               i
          	 •	 	f	wound	cannot	be	properly	covered,	consider	excluding	players	with	potentially	infectious	skin	
               lesions from practice and/or competition until lesions are healed or can be covered adequately

60
                                                                                     Skin Infections in Athletics
intended to eliminate MRSA                 precautions if suspicious skin            Recognition of MRSA is critical to
colonization should not be used in         infections appear, and immediately        clinical management. Education is
patients with active infections.           contact their health care provider.       the key, involving all individuals
Decolonization regimens may have a                                                   associated with athletics, from
                                           Individual cases of MRSA usually are
role in preventing recurrent infections,                                             student-athletes to coaches to medical
                                           not required to be reported to most
but more data are needed to establish                                                personnel to custodial staff.
                                           local/state health departments; howev-
their efficacy and to identify optimal                                               Education should encompass proper
                                           er, most states have laws that require
regimens for use in community
                                           reporting of certain communicable         hygiene, prevention techniques and
settings. After treating active
                                           diseases, including outbreaks regard-     appropriate precautions if suspicious
infections and reinforcing hygiene and
                                           less of pathogens. So in most states if   wounds appear. Each institution
appropriate wound care, consider
consultation with an infectious disease    an outbreak of skin infections is         should develop prevention strategies
specialist regarding use of                detected, the local and/or state health   and infection control policies and
decolonization when there are              department should be contacted.           procedures.
recurrent infections in an individual
patient or members of a
defined group.
MRSA infections in the community
are typically SSTI, but can also cause
severe illness such as pneumonia.
Most transmissions appear to be from
people with active MRSA skin
infections. Staph and MRSA
infections are not routinely reported to
public health authorities, so a precise
number is not known. It is estimated
that as many as 300,000
hospitalizations are related to MRSA
infections each year. Only a small
proportion of these have disease onset
occurring in the community. It has
also been estimated that there are
more	than	12	million	outpatient	(i.e.,	
physician offices, emergency and
outpatient departments) visits for
suspected staph and MRSA SSTIs in
the U.S. each year. Approximately 25
to 30 percent (80 million persons) of
the population is colonized in the nose
with staph bacteria at a given time and
approximately	1.5	percent	(4.1	million	
persons) is colonized with MRSA.
In an effort to educate the public
about the potential risks of MRSA,
organizations such as the CDC,
NCAA and the National Athletic
Trainers’ Association (NATA) have
issued official statements
recommending all health care
personnel and physically active adults
and children take appropriate
                                                                                                                              61
     Skin Infections in Athletics

     Skin Infections                          remain intact throughout the sport
                                              activity. A health care provider might
     in Wrestling
                                              exclude a student-athlete if the activ-
     Data from the NCAA Injury                ity poses a risk to the health of the
     Surveillance Program indicate that       infected athlete (such as injury to the
     skin infections are associated with at   infected area), even though the
     least	17	percent	of	the	practice	time-   infection can be properly covered. If
     loss injuries in wrestling.              wounds can be properly covered,
     It is recommended that qualified per-    good hygiene measures such as per-
     sonnel, including a knowledgeable,       forming hand hygiene before and
     experienced physician, examine the       after changing bandages and throw-
     skin of all wrestlers before any par-    ing used bandages in the trash
     ticipation (practice and competition).   should be stressed to the athlete.
     Male student-athletes shall wear         (See	Wrestling	Rule	WA-15.)		
     shorts and female student-athletes
     should wear shorts and a sports bra      Medical Examinations
     during medical examinations.             Medical examinations must be con-
                                              ducted by knowledgeable physicians
     Open wounds and infectious skin
                                              and/or certified athletic trainers. The
     conditions that cannot be adequately                                                status of these individuals should be
                                              presence of an experienced dermatol-
     protected should be considered                                                      decided before the screening of the
                                              ogist is recommended. The examina-
     cause for medical disqualification                                                  entire group. The decision made by a
                                              tion should be conducted in a system-
     from practice or competition (see                                                   physician and/or certified athletic
                                              atic fashion so that more than one
     Guideline 2a). The term “adequately                                                 trainer “on site” should be considered
                                              examiner can evaluate problem cases.
     protected” means that the wound or                                                  FINAL.
                                              Provisions should be made for appro-
     skin condition has been deemed as
     non-infectious and adequately treat-
                                              priate lighting and the necessary facil-   Guidelines for
     ed as deemed appropriate by a
                                              ities to confirm and diagnose skin         Disposition
     health care provider and is able to be
                                              infections.                                of Skin Infections
     properly covered. The term “proper-      Wrestlers who are undergoing treat-        Unless a new diagnosis occurs at the
     ly covered” means that the skin          ment for a communicable skin disease       time of the medical examination con-
     infection is covered by a securely       at the time of the meet or tournament      ducted at the meet or tournament, the
     attached bandage or dressing that        shall provide written documentation        wrestler presenting with a skin lesion
     will contain all drainage and will       to that effect from a physician. The       shall provide a completed Skin




62
                                                                                        Skin Infections in Athletics

Evaluation and Participation Status               new	blisters	for	72	hours	before	     or tournament time and have no evi-
Form from the team physician docu-                the examination.                      dence of secondary bacterial infection.
menting clinical diagnosis, lab and/or         3. Wrestler must have no moist
culture results, if relevant, and an out-         lesions; all lesions must be dried    MOLLUSCUM CONTAGIOSUM
line of treatment to date (i.e., surgical         and surmounted by a FIRM              1. Lesions must be curetted or
intervention, duration, frequency, dos-           ADHERENT CRUST.                          removed before the meet or
ages of medication).                           4. Wrestler must have been on               tournament.
BACTERIAL INFECTIONS                              appropriate dosage of systemic        2. Solitary or localized, clustered
(Furuncles, Carbuncles, Folliculitis,             antiviral	therapy	for	at	least	120	      lesions can be covered with a
Impetigo, Cellulitis or Erysipelas,               hours before and at the time of          gaspermeable membrane, followed
Staphylococcal disease, MRSA)                     the meet or tournament.                  by tape.
1. Wrestler must have been without             5. Active herpetic infections shall
   any new skin lesion for 48 hours               not be covered to allow               VERRUCAE
   before the meet or tournament.                 participation.                        1. Wrestlers with multiple digitate ver-
2. Wrestler must have no moist, exu-        See above criteria when making deci-           rucae of their face will be disquali-
   dative or purulent lesions at meet or    sions for participation status.                fied if the infected areas cannot be
   tournament time.                         Recurrent Infection                            covered with a mask. Solitary or
3. Gram stain of exudate from ques-                                                        scattered lesions can be curetted
                                               1. Blisters must be completely dry
   tionable lesions (if available).                                                        away before the meet or tourna-
                                                  and covered by a FIRM
                                                                                           ment.
4. Active purulent lesions shall not be           ADHERENT CRUST at time of
   covered to allow participation. See            competition, or wrestler shall not    2. Wrestlers with multiple verrucae
   above criteria when making deci-               participate.                             plana or verrucae vulgaris must
   sions for participation status.                                                         have the lesions “adequately
                                               2. Wrestler must have been on
                                                                                           covered.”
                                                  appropriate dosage of systemic
HIDRADENITIS SUPPURATIVA                          antiviral	therapy	for	at	least	120	
                                                                                        TINEA INFECTIONS (ringworm)
1. Wrestler will be disqualified if               hours before and at the time of
   extensive or purulent draining                 the meet or tournament.               1. 	 	minimum	of	72	hours	of	topical	
                                                                                           A
   lesions are present.                                                                    therapy is required for skin lesions.
                                               3. Active herpetic infections shall
2. Extensive or purulent draining                 not be covered to allow participa-    2. A minimum of two weeks of sys-
   lesions shall not be covered to allow          tion.                                    temic antifungal therapy is required
   participation.                                                                          for scalp lesions.
                                            See above criteria when making deci-
                                            sions for participation status.             3. Wrestlers with extensive and active
PEDICULOSIS                                                                                lesions will be disqualified. Activity
                                            Questionable Cases
Wrestler must be treated with appro-                                                       of treated lesions can be judged
                                               1. Tzanck prep and/or HSV antigen           either by use of KOH preparation or
priate pediculicide and re-examined               assay (if available).
for completeness of response before                                                        a review of therapeutic regimen.
                                               2. Wrestler’s status deferred until         Wrestlers with solitary, or closely
wrestling.
                                                  Tzanck prep and/or HSV assay             clustered, localized lesions will be
                                                  results complete.                        disqualified if lesions are in a body
SCABIES
                                            Wrestlers with a history of recurrent          location that cannot be “properly
Wrestler must have negative scabies
                                            herpes labialis or herpes gladiatorum          covered.”
prep at meet or tournament time.
                                            could be considered for season-long         4. The disposition of tinea cases will
                                            prophylaxis. This decision should be           be decided on an individual basis as
HERPES SIMPLEX
                                            made after consultation with the team          determined by the examining physi-
Primary Infection                           physician.                                     cian and/or certified athletic trainer.
   1. Wrestler must be free of system-
      ic symptoms of viral infection        HERPES ZOSTER (chicken pox)
      (fever, malaise, etc.).               Skin lesions must be surmounted by a
   2. Wrestler must have developed no       FIRM ADHERENT CRUST at meet

                                                                                                                                     63
     Skin Infections in Athletics

     References

     1. Descriptive Epidemiology of Collegiate    7. Cozad, A. and Jones, R. D. Disinfection   13. Vasily DB, Foley JJ.: More on Tinea
     Men’s Wrestling Injuries: National           and the prevention of disease. American      Corporis Gladiatorum. J Am Acad
     Collegiate Athletic Association Injury       Journal of Infection Control, 31(4): 243-    Dermatol 2002, Mar.
     Surveillance System, 1988–1989 Through       254, 2003.                                   14. Vasily DB, Foley JJ, First Episode
     2003–2004. Journal of Athletic Training      8. Centers for Disease Control and           Herpes Gladiatorum: Treatment with
     2007;42(2):303–310.                          Prevention (CDC) Division of Healthcare      Valacyclovir (manuscript submitted for
     2. Adams, BB.: Transmission of cutaneous     Quality Promotion. (2002). Campaign to
     infection in athletics. British Journal of                                                publication). Weiner, R. Methicillin-
                                                  prevent antimicrobial resistant in health
     Sports Medicine 34(6):413-4, 2000 Dec.                                                    Resistant Staphylcoccus aureus on
                                                  care settings. Available at www.cdc.gov/
     3. Anderson BJ.: The Effectiveness of                                                     Campus: A new challenge to college
                                                  drugresistance/healthcare/.
     Valacyclovir in Preventing Reactivation of                                                health. Journal of American College
                                                  9. Dorman, JM.: Contagious diseases in
     Herpes Gladiatorum in Wrestlers. Clin J                                                   Health. 56(4):347-350.
                                                  competitive sport: what are the risks?
     Sports Med 9(2):86-90, 1999 Apr.             Journal of American College Health           15. Zinder SM, Basler RS, Foley J,
     4. Association for Professionals in          49(3):105-9, 2000 Nov.                       Scarlata C, Vasily DB. National Athletic
     Infection Control and Epidemiology           10. Mast, E. and Goodman, R.:                Trainers’ Association Position Statement;
     (APIC). 1996. APIC infection control and     Prevention of Infectious Disease             Skin Diseases. Journal of Athletic
     applied epidemiology principles and                                                       Training. 2010; 95 (H);411-428.
                                                  Transmission in Sports. SportsMedicine
     practice. St. Louis: Mosby.
                                                  24(1):1-7,1997.
     5. Beck, CK.: Infectious diseases in
                                                  11. Kohl TD, Martin DC, Nemeth R, Hill
     sports: Medicine and Science in Sports
                                                  T, Evans D.: Fluconazole for the
     and Exercise 32(7 Suppl):S431-8,
                                                  prevention and treatment of tinea
     2000 Jul.
                                                  gladiatorum. Pediatric Infectious Disease
     6. Belongia EA, Goodman JL, Holland
                                                  Journal 19(8):717-22, 2000 Aug.
     EJ, et. al.: An outbreak of herpes
     gladiatorium at a high school wrestling      12. Lindenmayer JM, Schoenfeld S,
     camp. The New England Journal of             O’Grady R, Carney JK.: Methicillin-
     Medicine. 325(13):906-910, 1991.             resistant Staphylococcus aureus in a high
                                                  school wrestling team and the
     Cordoro, KM and Ganz, JE. Training
     room management of medical condition:        surrounding community. Archives of
     Sports Dermatology. Clinics in Sports        Internal Medicine 158(8):895-9,
     Medicine. 24: 565-598, 2005.                 1998 Apr.




64
                                                                                                                         Skin Infections in Athletics

                                                    National Collegiate Athletic Association
                                               SKIN EVALUATION AND PARTICIPATION STATUS
                                                 (Physician Release for Student-Athlete to Participate with Skin Lesion)

Student-Athlete: ______________________________________________                                            Date of Exam: ____ / ____ / ____

Institution: __________________________________________________                                            Please Mark Location of Lesion(s):

Dual(s)/Tournament: __________________________________________

Number of Lesion(s): __________________________________________

Cultured:       No
                No        Yes
                         Yes     _______________________________________

Diagnosis: ___________________________________________________
___________________________________________________________

Medication(s) used to treat lesion(s): ________________________________
___________________________________________________________

Date Treatment Started: ____ / ____ / ____                       Time: ________________

Earliest Date student-athlete may return to participation: ____ / ____ / ____

Physician Name (Printed): ________________________________________

Physician Signature:_____________________________________________ Specialty: _______________________________________
                                               (M.D. or D.O.)

Office Address: _______________________________________________ Contact #: ______________________________________

Institution Certified Athletic Trainer Notified:                No
                                                                No    Yes
                                                                     Yes     Signature: _____________________________________________________
Note to Physician:
Note to Physicians: Non-contagious lesions do not require treatment prior to return to participation (e.g. eczema, psoriasis, etc.). Please familiarize yourself with
NCAA Wrestling Rules which state: (refer to the NCAA Wrestling Rules and Interpretations publication for complete information)
       “9.6.4 … The presence of a communicable skin disease … shall be full and sufficient reason for disqualification.”
       “9.6.5 … If a student-athlete has been diagnosed as having such a condition, and is currently being treated by a physician (ideally a dermatologist) who has
       determined that it is safe for that individual to compete without jeopardizing the health of the opponent, the student-athlete may compete. However, the student-
       athlete or his/her coach or athletic trainer shall provide current written documentation from the treating physician to the medical professional at the medical
       examination, … ”
       “9.6.6 … Final determination of the participant’s ability to compete shall be made by the host site’s physician or certified athletic trainer who conducts the medical
       examination after review of any such documentation and the completion of the exam.”
Below are some treatment guidelines that suggest MINIMUM TREATMENT before return to wrestling: (please refer to the NCAA Sports Medicine Handbook
for complete information)
Bacterial Infections (Furuncles, Carbuncles, Folliculitis, Impetigo, Cellulitis or Erysipelas, Staphylococcal disease, CA-MRSA): Wrestler must have been without any new
skin lesion for 48 hours before the meet or tournament; completed 72 hours of antibiotic therapy and have no moist, exudative or draining lesions at meet or tournament time.
Gram stain of exudate from questionable lesions (if available). Active bacterial infections shall not be covered to allow participation.
Herpetic Lesions (Simplex, fever blisters/cold sores, Zoster, Gladiatorum): Skin lesions must be surmounted by a FIRM ADHERENT CRUST at competition time, and
have no evidence of secondary bacterial infection. For primary (first episode of Herpes Gladiatorum) infection, the wrestler must have developed no new blisters for 72 hours
before the examination; be free of signs and symptoms like fever, malaise, and swollen lymph nodes; and have been on appropriate dosage of systemic antiviral therapy for at
least 120 hours before and at the time of the competition. Recurrent outbreaks require a minimum of 120 hours of oral anti-viral treatment, again so long as no new lesions
have developed and all lesions are scabbed over. Active herpetic infections shall not be covered to allow participation.
Tinea Lesions (ringworm): Oral or topical treatment for 72 hours on skin and 14 days on scalp. Wrestlers with solitary, or closely clustered, localized lesions will be
disqualified if lesions are in a body location that cannot be adequately covered.
Molluscum Contagiosum: Lesions must be curetted or removed before the meet or tournament and covered.
Verrucae: Wrestlers with multiple digitate verrucae of their face will be disqualified if the infected areas cannot be covered with a mask. Solitary or scattered lesions can be
curetted away before the meet or tournament. Wrestlers with multiple verrucae plana or verrucae vulgaris must have the lesions adequately covered.
Hidradenitis Suppurativa: Wrestler will be disqualified if extensive or purulent draining lesions are present; covering is not permissible.
Pediculosis: Wrestler must be treated with appropriate pediculicide and re-examined for completeness of response before wrestling.
Scabies: Wrestler must have negative scabies prep at meet or tournament time.
DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made herein, or exam performed in
connection therewith, by the above named physician/provider, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information
                                                                                                                                                                                     65
provided herein.
                                        GUIDELINE 2k
     Menstrual-Cycle
     Dysfunction
     January 1986 • Revised June 2002


     The NCAA Committee on                     tion appear to be reversible. Another      neither change has been shown to
     Competitive Safeguards and Medical        medical consequence is skeletal            result in complete recovery of the
     Aspects of Sports acknowledges the        demineralization, which occurs in          lost bone mass. Additional research
     significant input of Dr. Anne Loucks,     hypoestrogenic women. Skeletal             is necessary to develop a specific
     Ohio University, in the revision of       demineralization was first observed        prognosis for exercise-induced men-
     this guideline.                           in	amenorrheic	athletes	in	1984.	          strual dysfunction.
     In 80 percent of college-age women,       Initially, the lumbar spine appeared
                                                                                          All student-athletes with menstrual
     the length of the menstrual cycle         to be the primary site where skeletal      irregularities should be seen by a
     ranges from 23 to 35 days.                demineralization occurs, but new           physician. General guidelines
     Oligomenorrhea refers to a menstru-       techniques for measuring bone min-         include:
     al cycle that occurs inconsistently,      eral density show that demineraliza-
                                               tion occurs throughout the skeleton.       1. Full medical evaluation, including
     irregularly and at longer intervals.
                                               Some women with menstrual distur-          an endocrine work-up and bone min-
     Amenorrhea is the cessation of the
                                               bances involved in high-impact             eral density test;
     menstrual cycle with ovulation
     occurring infrequently or not at all.     activities, such as gymnastics and         2. Nutritional counseling with spe-
     A serious medical problem of amen-        figure skating, display less deminer-      cific emphasis on:
     orrhea is the lower level of circulat-    alization than women runners.
                                               Despite resumption of normal men-            a. Total caloric intake versus
     ing estrogen (hypoestrogenism), and
                                               ses, the loss of bone mass during            energy expenditure.
     its potential health consequences.
                                               prolonged hypoestrogenemia is not            b. Calcium	intake	of	1,200	to	
     The prevalence of menstrual-cycle         completely reversible. Therefore,          	 1,500	milligrams	a	day;	and
     irregularities found in surveys           young women with low levels of cir-
     depends on the definition of men-         culating estrogen, due to menstrual        3. Routine monitoring of the diet,
     strual function used, but has been        irregularities, are at risk for low peak   menstrual function, weight-training
     reported to be as high as 44 percent                                                 schedule and exercise habits.
                                               bone mass which may increase the
     in athletic women. Research sug-
                                               potential for osteoporotic fractures       If this treatment scheme does not
     gests that failure to increase dietary
                                               later in life. An increased incidence      result in regular menstrual cycles,
     energy intake in compensation for
                                               of stress fractures also has been          estrogen-progesterone supplementa-
     the expenditure of energy during
                                               observed in the long bones and feet        tion should be considered. This
     exercise can disrupt the hypothalam-
                                               of women with menstrual irregulari-        should be coupled with appropriate
     ic-pituitary-ovarian (HPO) axis.
                                               ties.                                      counseling on hormone replacement
     Exercise training appears to have no
     suppressive effect on the HPO axis        The treatment goal for women with          and review of family history.
     beyond the impact of its strain on                                                   Hormone-replacement therapy is
                                               menstrual irregularities is the re-
     energy availability.                                                                 thought to be important for amenor-
                                               establishment of an appropriate hor-
                                                                                          rheic women and oligomenorrheic
                                               monal environment for the mainte-
     There are several important reasons                                                  women whose hormonal profile
     to discuss the treatment of menstru-      nance of bone health. This can be
                                                                                          reveals an estrogen deficiency.
     al-cycle irregularities. One reason is    achieved by the re-establishment of
     infertility; fortunately, the long-term   a regular menstrual cycle or by hor-       The relationship between amenor-
66   effects of menstrual cycle dysfunc-       mone replacement therapy, although         rhea, osteoporosis and disordered
                                                                                        Menstrual-Cycle Dysfunction

eating is termed the “female athlete            pressuring female athletes to diet
triad.”	In	1997,	the	American	                  and lose weight and should be edu-
College of Sports Medicine issued a             cated about the warning signs of
position stand calling for all individ-         eating disorders.
uals working with physically active
girls and women to be educated                 •	Sports	medicine	professionals,	ath-
about the female athlete triad and               letics administrators and officials
develop plans for prevention, recog-             of sport governing bodies share a
nition, treatment and risk reduction.            responsibility to prevent, recognize
Recommendations are that any stu-                and treat this disorder.
dent-athlete who presents with any
                                               •	Sports	medicine	professionals,	ath-
one component of the triad be
                                                 letics administrators and officials
screened for the other two compo-
                                                 of sport governing bodies should
nents and referred for
                                                 work toward offering opportunities
medical evaluation.
                                                 for educating and monitoring
Other recommendations include:                   coaches to ensure safe training
•	All	sports	medicine	professionals,	            practices.
  including coaches and athletic               •	Young,	physically	active	females	
  trainers, should learn to recognize            should be educated about proper
  the symptoms and risks associated              nutrition, safe training practices,
  with the female athlete triad.
                                                 and the risks and warning signs of
•	Coaches	and	others	should	avoid	               the female athlete triad.


References

1. American Academy of Pediatrics              4. Otis CT, Drinkwater B, Johnson M,
Committee on Sports Medicine:                  Loucks A, Wilmore J: American College
Amenorrhea in adolescent athletes.             of Sports Medicine Position Stand on the
Pediatrics 84(2):394-395, 1989.                Female Athlete Triad. Medicine and
2. Keen AD, Drinkwater BL: Irreversible        Science in Sports and Exercise 29(5):i-ix,
bone loss in former amenorrheic                1997.
athletes. Osteoporosis International           5. Shangold M, Rebar RW, Wentz AC,
7(4):311-315, 1997.                            Schiff I: Evaluation and management of
3. Loucks AB, Verdun M, Heath EM: Low          menstrual dysfunction in athletes.
energy availability, not stress of exercise,   Journal of American Medical Association
alters LH pulsatility in exercising            262(12):1665-1669, 1990.
women. Journal of Applied Physiology
84(1):37-46, 1998.




                                                                                                                      67
                                      GUIDELINE 2l
     Blood-Borne
     Pathogens and
     Intercollegiate
     Athletics
      April 1988 • Revised August 2004


     Blood-borne pathogens are disease-      traditional routes of transmission        household contacts with chronic
     causing microorganisms that can be      from behaviors off the athletics field.   HBV carriers can lead to infection
     potentially transmitted through blood   Experts have concurred that the risk      without having had sexual
     contact. The blood-borne pathogens      of transmission on the athletics field    intercourse or sharing of IV needles.
     of concern include (but are not         is minimal.                               These rare instances probably occur
     limited to) the hepatitis B virus                                                 when the virus is transmitted through
     (HBV) and the human                     Hepatitis B Virus (HBV)                   unrecognized-wound or mucous-
     immunodeficiency virus (HIV).           HBV is a blood-borne pathogen that        membrane exposure.
                                  ,
     Infections with these (HBV HIV)
                                             can cause infection of the liver. Many
     viruses have increased throughout                                                 The incidence of HBV in student-
                                             of those infected will have no
     the last decade among all portions of                                             athletes is presumably low, but those
                                             symptoms or a mild flu-like illness.
     the general population. These                                                     participating in risky behavior off the
                                             One-third will have severe hepatitis,
     diseases have potential for                                                       athletics field have an increased
                                             which will cause the death of one
     catastrophic health consequences.                                                 likelihood of infection (just as in the
                                             percent of that group. Approximately      case of HIV). An effective vaccine to
     Knowledge and awareness of
                                             300,000 cases of acute HBV                prevent HBV is available and
     appropriate preventive strategies are
     essential for all members of society,   infection occur in the United States      recommended for all college students
     including student-athletes.             every year, mostly in adults.             by the American College Health
                                             Five	to	10	percent	of	acutely	            Association. Numerous other groups
     The particular blood-borne patho-                                                 have recognized the potential
     gens HBV and HIV are transmitted        infected adults become chronically
                                             infected with the virus (HBV              benefits of universal vaccination of
     through sexual contact (heterosexual                                              the entire adolescent and young-adult
     and homosexual), direct contact with    carriers). Currently in the United
                                             States there are approximately one        population.
     infected blood or blood components,
     and perinatally from mother to baby.    million chronic carriers. Chronic
                                             complications of HBV infection
                                                                                       HIV (AIDS Virus)
     In addition, behaviors such as body
     piercing and tattoos may place          include cirrhosis of the liver and        The Acquired Immunodeficiency
     student-athletes at some increased      liver cancer.                             Syndrome (AIDS) is caused by the
     risk for contracting HBV HIV or
                              ,                                                        human immunodeficiency virus
     Hepatitis C.                            Individuals at the greatest risk for      (HIV), which infects cells of the
                                             becoming infected include those           immune system and other tissues,
     The emphasis for the student-athlete    practicing risky behaviors of having      such as the brain. Some of those
     and the athletics health-care team      unprotected sexual intercourse or         infected with HIV will remain
     should be placed predominately on       sharing intravenous (IV) needles in       asymptomatic for many years.
68   education and concern about these       any form. There is also evidence that     Others will more rapidly develop
                                             Blood-Borne Pathogens and Intercollegiate Athletics

manifestations of HIV disease (i.e.,       Testing of Student-                     carrier presents a more distinct
AIDS). Some experts believe                Athletes                                transmission risk than the HIV
virtually all persons infected with        Routine mandatory testing of            carrier (see previous discussion of
HIV eventually will develop AIDS           student-athletes for either HBV or      comparison of HBV to HIV) in
and that AIDS is uniformly fatal. In       HIV for participation purposes is not   sports with higher potential for blood
the United States, adolescents are at      recommended. Individuals who            exposure and sustained, close body
special risk for HIV infection. This       desire voluntary testing based on       contact. Within the NCAA, wrestling
age group is one of the fastest            personal reasons and risk factors,      is the sport that best fits this
growing groups of new HIV                  however, should be assisted in          description.
infections.	Approximately	14	percent	      obtaining such services by
of all new HIV infections occur in                                                 The specific epidemiologic and
                                           appropriate campus or public-health     biologic characteristics of hepatitis B
persons	aged	between	12	to	24	years.	      officials.
The risk of infection is increased by                                              virus form the basis for the following
having unprotected sexual                                                          recommendation: If a student-athlete
                                           Student-athletes who engage in high-
intercourse, and the sharing of IV                                                 develops acute HBV illness, it is
                                           risk behavior are encouraged to seek
needles in any form. Like HBV there
                                 ,                                                 prudent to consider removal of the
                                           counseling and testing. Knowledge
                                                                                   individual from combative, sustained
is evidence that suggests that HIV         of one’s HBV and HIV infection is
                                                                                   close-contact sports (e.g., wrestling)
has been transmitted in household-         helpful for a variety of reasons,
                                                                                   until loss of infectivity is known.
contact settings without sexual            including the availability of
                                                                                   (The best marker for infectivity is the
contact or IV needle sharing among         potentially effective therapy for
                                                                                   HBV antigen, which may persist up
those household contacts5,6. Similar       asymptomatic patients, and
                                                                                   to 20 weeks in the acute stage).
        ,
to HBV these rare instances probably       modification of behavior, which can
                                                                                   Student-athletes in such sports who
occurred through unrecognized-             prevent transmission of the virus to    develop chronic HBV infections
wound or mucous-membrane                   others. Appropriate counseling          (especially those who are e-antigen
exposure.                                  regarding exercise and sports           positive) should probably be
                                           participation also can be               removed from competition
Comparison of HBV/HIV                      accomplished.                           indefinitely, due to the small but
Hepatitis B is a much more “sturdy/                                                realistic risk of transmitting HBV to
durable” virus than HIV and is much        Participation by the                    other student-athletes.
more concentrated in blood. HBV has        Student-Athlete with
a much more likely transmission with       Hepatitis B (HBV)                       Participation of the
exposure to infected blood;                Infection                               Student-Athlete with HIV
particularly parenteral (needle-stick)     Individual’s Health––In general,        Individual’s Health—In general, the
exposure, but also exposure to open        acute HBV should be viewed just as      decision to allow an HIV-positive
wounds and mucous membranes.               other viral infections. Decisions       student-athlete to participate in
There has been one well-documented         regarding ability to play are made      intercollegiate athletics should be
case of transmission of HBV in the         according to clinical signs and symp-   made on the basis of the individual’s
athletics setting, among sumo              toms, such as fatigue or fever. There   health status. If the student-athlete is
wrestlers in Japan. There are no           is no evidence that intense, highly     asymptomatic and without evidence
validated cases of HIV transmission in     competitive training is a problem for   of deficiencies in immunologic
the athletics setting. The risk of         the asymptomatic HBV carrier            function, then the presence of HIV
transmission for either HBV or HIV         (acute or chronic) without evidence     infection in and of itself does not
on the field is considered minimal;        of organ impairment. Therefore, the     mandate removal from play.
however, most experts agree that the       simple presence of HBV infection
specific epidemiologic and biologic        does not mandate removal from play.     The team physician must be
characteristics of the HBV virus make                                              knowledgeable in the issues
it a realistic concern for transmission    Disease Transmission—The                surrounding the management of
in sports with sustained, close physical   student-athlete with either acute or    HIV-infected student-athletes. HIV
contact, such as wrestling. HBV is         chronic HBV infection presents very     must be recognized as a potentially
considered to have a potentially higher    limited risk of disease transmission    chronic disease, frequently affording
risk of transmission than HIV   .          in most sports. However, the HBV        the affected individual many years of      69
     Blood-Borne Pathogens and Intercollegiate Athletics

                                    excellent health and productive life                         ,
                                                                              infected with HIV although one
                                    during its natural history. During this   court has upheld the exclusion of an
                                    period of preserved health, the team      HIV-positive athlete from the contact
                                    physician may be involved in a            sport of karate19.
                                    series of complex issues surrounding
                                    the advisability of continued             Administrative Issues
     The identity of individuals    exercise and athletics competition.       The identity of individuals infected
     infected with a blood-                                                   with a blood-borne pathogen must
                                    The decision to advise continued
     borne pathogen must                                                      remain confidential. Only those
                                    athletics competition should involve
     remain confidential. Only      the student-athlete, the student-         persons in whom the infected
     those persons in whom          athlete’s personal physician and the      student-athlete chooses to confide
                                    team physician. Variables to be           have a right to know about this
     the infected student-
                                    considered in reaching the decision       aspect of the student-athlete’s
     athlete chooses to                                                       medical history. This confidentiality
                                    include the student-athlete’s current
     confide have a right to        state of health and the status of his/    must be respected in every case and
     know about this aspect of      her HIV infection, the nature and         at all times by all college officials,
     the student-athlete’s          intensity of his/her training, and        including coaches, unless the
                                    potential contribution of stress from     student-athlete chooses to make the
     medical history. This
                                    athletics competition to deterioration    fact public.
     confidentiality must be        of his/her health status.
     respected in every case                                                  Athletics Health-Care
     and at all times by all        There is no evidence that exercise        Responsibilities
                                    and training of moderate intensity is     The following recommendations are
     college officials, including
                                    harmful to the health of HIV-             designed to further minimize risk of
     coaches, unless the            infected individuals. What little data    blood-borne pathogens and other
     student-athlete chooses        that exists on the effects of intense     potentially infectious organisms
     to make the fact public.       training on the HIV-infected
                                                                              transmission in the context of
                                    individual demonstrates no evidence
                                                                              athletics events and to provide
                                    of health risk. However, there is no
                                                                              treatment guidelines for caregivers.
                                    data looking at the effects of long-
                                                                              In the past, these guidelines were
                                    term intense training and
                                                                              referred to as “Universal (blood and
                                    competition at an elite, highly
                                                                              body fluid) Precautions.” Over time,
                                    competitive level on the health of the
                                                                              the recognition of “Body Substance
                                    HIV-infected student-athlete.
                                                                              Isolation,” or that infectious diseases
                                    Disease Transmission—Concerns             may also be transmitted from moist
                                    of transmission in athletics revolve      body substances, has led to a
                                    around exposure to contaminated           blending of terms now referred to as
                                    blood through open wounds or              “Standard Precautions.” Standard
                                    mucous membranes. Precise risk of         precautions apply to blood, body
                                    such transmission is impossible to        fluids, secretions and excretions,
                                    calculate, but epidemiologic and          except sweat, regardless of whether
                                    biologic evidence suggests that it is     or not they contain visible blood.
                                    extremely low (see section on             These guidelines, originally
                                    comparison of HBV/HIV). There             developed for health-care, have
                                    have been no validated reports of         additions or modifications relevant to
                                    transmission of HIV in the athletics      athletics. They are divided into two
                                    setting3,13. Therefore, there is no       sections — the care of the student-
                                    recommended restriction of student-       athlete, and cleaning and disinfection
                                    athletes merely because they are          of environmental surfaces.
70
                                         Blood-Borne Pathogens and Intercollegiate Athletics

Care of the Athlete:                    with an occlusive dressing that will   NCAA policy mandates the
1. All personnel involved in sports     withstand the demands of               immediate, aggressive treatment of
who care for injured or bleeding        competition. Likewise, care            open wounds or skin lesions that
student-athletes should be properly     providers with healing wounds or       are deemed potential risks for
trained in first aid and standard       dermatitis should have these areas     transmission of disease. Partici-
precautions.                            adequately covered to prevent          pants with active bleeding should
                                        transmission to or from a              be removed from the event as soon
2. Assemble and maintain                participant. Student-athletes may      as is practical. Return to play is
equipment and/or supplies for           be advised to wear more protective     determined by appropriate medical
treating injured/bleeding athletes.     equipment on high-risk areas, such     staff personnel and/or sport
Items may include: Personal             as elbows and hands.                   officials. Any participant whose
Protective Equipment (PPE)                                                     uniform is saturated with blood
[minimal protection includes            4. The necessary equipment and/or      must change their uniform before
gloves, goggles, mask, fluid-           supplies important for compliance      return to participation.
resistant gown if chance of splash      with standard precautions should
or splatter]; antiseptics;              be available to caregivers. These      6. During an event, early
antimicrobial wipes; bandages or        supplies include appropriate gloves,   recognition of uncontrolled
dressings; medical equipment            disinfectant bleach, antiseptics,      bleeding is the responsibility of
needed for treatment; appropriately     designated receptacles for soiled      officials, student-athletes, coaches
labeled “sharps” container for          equipment and uniforms, bandages       and medical personnel. In
disposal of needles, syringes and       and/or dressings, and a container      particular, student-athletes should
scalpels; and waste receptacles         for appropriate disposal of needles,   be aware of their responsibility to
appropriate for soiled equipment,       syringes or scalpels.                  report a bleeding wound to the
uniforms, towels and other waste.                                              proper medical personnel.
                                        5. When a student-athlete is
3. Pre-event preparation includes       bleeding, the bleeding must be         7. Personnel managing an acute
proper care for wounds, abrasions       stopped and the open wound             blood exposure must follow the
or cuts that may serve as a source      covered with a dressing sturdy         guidelines for standard precaution.
of bleeding or as a port of entry for   enough to withstand the demands        Gloves and other PPE, if necessary,
blood-borne pathogens or other          of activity before the student-        should be worn for direct contact
potentially infectious organisms.       athlete may continue participation     with blood or other body fluids.
These wounds should be covered          in practice or competition. Current    Gloves should be changed after
                                                                               treating each individual participant.
                                                                               After removing gloves, hands should
                                                                               be washed.

                                                                               8. If blood or body fluids are
                                                                               transferred from an injured or
                                                                               bleeding student-athlete to the intact
                                                                               skin of another athlete, the event
                                                                               must be stopped, the skin cleaned
                                                                               with antimicrobial wipes to remove
                                                                               gross contaminate, and the athlete
                                                                               instructed to wash with soap and
                                                                               water as soon as possible. NOTE:
                                                                               Chemical germicides intended for
                                                                               use on environmental surfaces should
                                                                               never be used on student-athletes.

                                                                               9. Any needles, syringes or scalpels
                                                                               should be carefully disposed of in an
                                                                               appropriately labeled “sharps”
                                                                               container. Medical equipment,            71
     Blood-Borne Pathogens and Intercollegiate Athletics

     bandages, dressings and other waste       3. Put on disposable gloves.              used for treating student-athletes and
     should be disposed of according to                                                  the cleaning and disinfection of
     facility protocol. During events,         4. Remove visible organic material        environmental surfaces.
     uniforms or other contaminated            by covering with paper towels or
     linens should be disposed of in a         disposable cloths. Place soiled towels    3. Occupational Safety and Health
                                               or cloths in red bag or other waste       Administration (OSHA) standards for
     designated container to prevent
                                               receptacle according to facility          Bloodborne Pathogens (Standard #29
     contamination of other items or
                                               protocol. (Use additional towels or       CFR	1910.1030)	and	Hazard	
     personnel. At the end of
                                               cloths to remove as much organic          Communication (Standard #29 CFR
     competition, the linen should be
                                               material as possible from the surface     1910.1200)	should	be	reviewed	for	
     laundered and dried according to
                                               and place in the waste receptacle.)       further information.
     facility protocol; hot water at
     temperatures	of	71	degrees	Celsius	       5. Spray the surface with a properly      Member institutions should ensure
     (160	degrees	Fahrenheit)	for	25-	         diluted chemical germicide used           that policies exist for orientation and
     minute cycles may be used.                according to manufacturer’s label         education of all health-care workers
                                               recommendations for disinfection,         on the prevention and transmission of
     Care of Environmental                     and wipe clean. Place soiled towels       blood-borne pathogens. Additionally,
     Surfaces:                                 in waste receptacle.                      in	1992,	the	Occupational	Safety	and	
     1. All individuals responsible for                                                  Health Administration (OSHA)
                                               6. Spray the surface with either a        developed a standard directed to
     cleaning and disinfection of blood
                                               properly diluted tuberculocidal           eliminating or minimizing
     spills or other potentially infectious
                                               chemical germicide or a freshly           occupational exposure to blood-borne
     materials (OPIM) should be properly
                                               prepared bleach solution diluted          pathogens. Many of the
     trained on procedures and the use of
                                               1:100,	and	follow	manufacturer’s	         recommendations included in this
     standard precautions.
                                               label directions for disinfection; wipe   guideline are part of the standard.
     2. Assemble and maintain supplies         clean. Place towels in waste              Each member institution should
     for cleaning and disinfection of hard     receptacle.                               determine the applicability of the
     surfaces contaminated by blood or                                                   OSHA standard to its personnel
                                               7. Remove gloves and wash hands.
     OPIM. Items include: Personal                                                       and facilities.
     Protective Equipment (PPE) [gloves,       8. Dispose of waste according to
     goggles, mask, fluid-resistant gown if    facility protocol.
     chance of splash or splatter]; supply
     of absorbent paper towels or              Final Notes:
     disposable cloths; red plastic bag        1. All personnel responsible for
     with the biohazard symbol on it or        caring for bleeding individuals should
     other waste receptacle according to       be encouraged to obtain a Hepatitis B
     facility protocol; and properly diluted   (HBV) vaccination.
     tuberculocidal disinfectant or freshly
     prepared bleach solution diluted          2. Latex allergies should be
     (1:100	bleach/water	ratio).               considered. Non-latex gloves may be




72
                                               Blood-Borne Pathogens and Intercollegiate Athletics


References

1. AIDS education on the college             11. United States Olympic Committee
campus: A theme issue. Journal of Ameri-     Sports Medicine and Science Committee:
can College Health 40(2):51-100, 1991.       Transmission of infectious agents during
2. American Academy of Pediatrics:           athletic competition, 1991. (1750 East
Human immunodeficiency virus (AIDS           Boulder Street, Colorado Springs, CO
virus) in the athletic setting. Pediatrics   80909)
88(3):640-641, 1991.                         12. Update: Universal precautions for
3. Calabrese L, et al.: HIV infections:      prevention of transmission by human
                                             immunodeficiency virus, hepatitis B
exercise and athletes. Sports Medicine
                                             virus, and other blood borne pathogens
15(1):1-7, 1993.
                                             in health care settings. Morbidity and
4. Canadian Academy of Sports Medi-          Mortality Weekly Report 37:377-388,
cine position statement: HIV as it relates   1988.
to sport. Clinical Journal of Sports
                                             13. When sports and HIV share the bill,
Medicine 3:63-68, 1993.
                                             smart money goes on common sense.
5. Fitzgibbon J, et al.: Transmissions       Journal of American Medical Association
from one child to another of human           267(10):1311-1314, 1992.
immunodeficiency virus type I with
                                             14. World Health Organization
azidovudine-resistance mutation.             consensus statement: Consultation on
New England Journal of Medicine 329          AIDS and sports. Journal of American
(25):1835-1841, 1993.                        Medical Association 267(10):1312, 1992.
6. HIV transmission between two              15. Human immunodeficiency virus
adolescent brothers with hemophilia.         (HIV) and other blood-borne pathogens
Morbidity and Mortality Weekly Report        in sports. Joint position statement by the
42(49):948-951, 1993.                        American Medical Society for Sports
7. Kashiwagi S, et al.: Outbreak of          Medicine (AMSSM) and the American
hepatitis B in members of a high-school      Academy of Sports Medicine (AASM).
sumo wrestling club. Journal of American     The American Journal of Sports
Medical Association 248 (2):213-214,         Medicine 23(4):510-514, 1995.
1982.                                        16. Most E, et al.: Transmissions of
8. Klein RS, Freidland GH: Transmission      blood-borne pathogens during sport: risk
of human immunodeficiency virus type 1       and prevention. Annals of Internal
(HIV-1) by exposure to blood: defining the   Medicine 122(4):283-285, 1995.
risk. Annals of Internal Medicine            17. Brown LS, et al.: Bleeding injuries in
113(10):729-730, 1990.                       professional football: estimating the risk
9. Public health services guidelines for     for HIV transmission. Annals of Internal
counseling and antibody testing to           Medicine 122(4):271-274, 1995.
prevent HIV infection and AIDS.              18. Arnold BL: A review of selected
Morbidity and Mortality Weekly Report        blood-borne pathogen statements and
36(31):509-515, 1987.                        federal regulations. Journal of Athletic
10. Recommendations for prevention of        Training 30(2):171-176, 1995.
HIV transmission in health care settings.    19. Montalov v. Radcliffe, 167 F. 3d 873
Morbidity and Mortality Weekly Report        (4th Cir. 1999), cert. denied, 120 S Ct. 48
36(25):3S-18S, 1987.                         1999.                                                   73
                                          GUIDELINE 2m
     The Use of Local
     Anesthetics in
     College Athletics
       June 1992 • Revised June 2004



     The use of local injectable                 3. These agents should only be
     anesthetics to treat sports-related         administered when medically
     injuries in college athletics is            justified, when the risk of
     primarily left to the discretion of the     administration is fully explained to
     physician treating the individual,          the patient, when the use is not
     since there is little scientific research   harmful to continued athletics
     on the subject. This guideline              activity and when there is no
     provides basic recommendations for          enhancement of a risk of injury.
     the use of these substances, which          The following procedures are not
     commonly include lidocaine (Xylo-           recommended:
     caine), one or two percent;
     bupivacaine (Marcaine), 0.25 to 0.50        1. The use of local anesthetic
     percent; and mepivacaine (Carbo-            injections if they jeopardize the
     caine), three percent. The following        ability of the student-athlete to protect
     recommendations do not include the          himself or herself from injury.
     use of corticosteroids.                     2. The administration of these drugs
     It is recommended that:                     by anyone other than a qualified
                                                 clinician licensed to perform this
     1. These agents should be                   procedure.
     administered only by a qualified
     clinician who is licensed to perform        3. The use of these drugs in
     this procedure and who is familiar          combination with epinephrine or
     with these agents’ actions, reactions,      other vasoconstrictor agents in
     interactions and complications. The         fingers, toes, earlobes and other
     treating clinician should be well           areas where a decrease in circulation,
     aware of the quantity of these agents       even if only temporary, could result
     that can be safely injected.                in significant harm.
     2. These agents should only be
     administered in facilities equipped to
     handle any allergic reaction,
     including a cardiopulmonary
     emergency, which may follow
     their use.



74
                                   GUIDELINE 2n
The Use of Injectable
Corticosteroids
in Sports Injuries
 June 1992 • Revised June 2004



Corticosteroids, alone or in             use of corticosteroids in athletics is   corticosteroid.
combination with local anesthetics,      the treatment of chronic overuse         There is still much to be learned
have been used for many years to         syndromes such as bursitis,              about the effects of intra-articular,
treat certain sports-related injuries.   tenosynovitis and muscle origin pain     intraligamentous or intratendinous
This guideline is an attempt to          (for example, lateral epicondylitis).    injection of corticosteroids.
identify specific circumstances in       They have also been used to try to       Researchers have noted reduced
which corticosteroids may be             prevent redevelopment of a               synthesis of articular cartilage after
appropriate and also to remind both      ganglion, and to reduce keloid scar      corticosteroid administration in both
physicians and student-athletes of       formation. Rarely is it appropriate to   animals and human models.
the inherent dangers associated          treat acute syndromes such as            However, a causal relationship
with their use.                          acromio-clavicular (AC) joint            between the intra-articular
The most common reason for the           separations or hip pointers with a       corticosteroid and degeneration of




                                                                                                                           75
     The Use of Injectable Corticosteroids in Sports Injuries

     articular cartilage has not been         administered when medically               References
     established. Research also has           justified, when the risk of
     shown that a single intraligamentous     administration is fully explained to
     or multiple intra-articular injections   the patient, when the use is not          1. Corticosteroid injections: balancing
     have the potential to cause              harmful to continued athletics            the benefits. The Physician and Sports
     significant and long-lasting             activity and when there is no             Medicine 22(4):76, 1994.
     deterioration in the mechanical          enhancement of a risk of injury.
                                                                                        2. Corticosteroid Injections: Their Use
     properties of ligaments and
                                              The following procedures are not          and Abuse. Journal of the American
     collagenous tissues in animal
                                              recommended:                              Academy of Orthopaedic Surgeons
     models. Finally, studies have shown
     significant degenerative changes in      1. Intra-articular injections,            2:133-140, 1994.
     active animal tendons treated with a     particularly in major weight-bearing
                                                                                        3. Kennedy JC, Willis RD: The effects of
     corticosteroid as early as 48 hours      joints. Intra-articular injections have
                                              a potential softening effect on           local steroid injections on tendons: A
     after injection.
                                              articular cartilage.                      biomechanical and microscopic
     This research provides the basis for
                                              2. Intratendinous injections, since       correlative study. American Journal of
     the following recommendations
     regarding the administration of          such injections have been associated      Sports Medicine 4:11-21, 1970.
     corticosteroids in college athletics.    with an increased risk of rupture.        4. Leadbetter WB: Corticosteroid
     It is recommended that:                  3. Administration of injected             injection therapy in sports injuries. In:
                                              corticosteroids immediately before a      Sports Induced Inflammation Park Ridge,
     1. Injectable corticosteroids should
                                              competition.                              IL: American Academy of Orthopedic
     be administered only after more
     conservative treatments, including       4. Administration of corticosteroids      Surgeons, pp. 527-545, 1990.
     nonsteroidal anti-inflammatory           in acute trauma.                          5. Mankin HJ, Conger KA: The acute
     agents, rest, ice, ultrasound and        5. Administration of corticosteroids      effects of intra-articular hydrocortisone
     various treatment modalities, have       in infection.
     been exhausted.
                                                                                        on articular cartilage in rabbits. Journal
                                                                                        of Bone and Joint Surgery 48A:1383-
     2. Only those physicians who are
                                                                                        1388, 1966.
     knowledgeable about the chemical
     makeup, dosage, onset of action,                                                   6. Noyes FR, Keller CS, Grood ES, et
     duration and potential toxicity of                                                 al.: Advances in the understanding of
     these agents should administer                                                     knee ligament injuries, repair and reha-
     corticosteroids.                                                                   bilitation. Medicine and Science in
     3. These agents should be                                                          Sports and Exercise 16:427-443, 1984.
     administered only in facilities that
                                                                                        7. Noyes FR, Nussbaum NS, Torvik PT,
     are equipped to deal with allergic
     reactions, including                                                               et al.: Biomechanical and ultrastructural
     cardiopulmonary emergencies.                                                       changes in ligaments and tendons after
     4. Repeated corticosteroid injections
                                                                                        local corticosteroid injections. Abstract,
     at a specific site should be done only                                             Journal of Bone and Joint Surgery
     after the consequences and benefits                                                57A:876, 1975.
     of the injections have been                                                        8. Pfenninger JL: Injections of joints and
     thoroughly evaluated.
                                                                                        soft tissues: Part I. General guidelines.
     5. Corticosteroid injections only                                                  American Family Physician 44(4):1196-
     should be done if a therapeutic effect                                             1202, 1991.
     is medically warranted and the
     student-athlete is not subject to                                                  9. Pfenninger JL: Injections of joints and
     either short- or long-term significant                                             soft tissues: Part II. Guidelines for
     risk.                                                                              specific joints. American Family
76   6. These agents should only be                                                     Physician 44(5):1690-1701, 1991.
                                GUIDELINE 2o
Depression:
Interventions
for Intercollegiate
Athletics
 June 2006



The NCAA Committee on Com-             though the majority of peoples’         physical demands of their sport, and
petitive Safeguards and Medical        depressive disorders can be             the time commitment of
Aspects of Sports acknowledges the     improved, most people with              participation, strength and
significant input of Sam Maniar,       depression do not seek help.            conditioning, and skill instruction.
Licensed Psychologist, The Ohio        Depression is important to assess       Most athletes participate almost
State University; Margot Putukian,     among student-athletes because it       year-round, often missing holidays,
Team Physician, Princeton              impacts overall personal well-being,    school and summer breaks, classes
University; and the National           athletic performance, academic          and even graduation. In addition, if
Institute of Mental Health,            performance and injury healing. No      they struggle in their performance,
Bethesda, Maryland; for their          two people become depressed in
original content.                                                              have difficulty interacting with the
                                       exactly the same way, but with the      coach or teammates, or they lose
Depression is more than the blues,     proper treatment 80 percent of those    their passion for their sport, it can
let-downs from a game loss, or the     who seek help get better, and many      be very difficult to handle. Many
normal daily ups and downs. It’s       people begin to feel better in just a   athletes also define themselves by
feeling “down” and “low” and           few weeks.                              their role as an athlete, and an injury
“hopeless” for weeks at a time.                                                can be devastating.
                                       Depression and
Depression is a serious medical
                                       Intercollegiate Athletics               Some attributes of athletics and
condition.
                                       Student-athletes may experience         competition can make it extremely
Little research has been conducted                                             difficult for student-athletes to
                                       depression because of genetic
on depression among student-                                                   obtain help. They are taught to “play
                                       predisposition, developmental
athletes; however, preliminary data                                            through the pain,” struggle through
                                       challenges of college transitions,
indicate that student-athletes                                                 adversity, handle problems on their
                                       academic stress, financial pressures,
experience depressive symptoms
                                       interpersonal difficulties and grief    own and “never let your enemies
and illness at similar or increased
                                       over loss/failure.                      see you cry.” Seeking help is seen as
rates than non-athlete students.
                                                                               a sign of weakness, when it should
Approximately 9.5 percent of the       Participation in athletics does not
                                                                               be recognized as a sign of strength.
population	—	or	one	out	of	10	         provide student-athletes any
people — suffer from a depressive      immunity to these stresses, and it      Team dynamics also may be a
illness during any given one-year      has the potential to pose additional    factor. Problems often are kept “in
period. Women are twice as likely to   demands. Student-athletes must          the family,” and it is common for
experience depression as men;          balance all of the demands of being     teams to try to solve problems by
however, men are less likely to        a college student along with            themselves, often ignoring signs or
admit to depression. Moreover, even    athletics demands. This includes the    symptoms of more serious issues.          77
     Depression: Intervention for Intercollegiate Athletics

                                     Depression	affects	approximately	19	         Types of Depressive
                                     million Americans, and for many,             Illness
                                     the symptoms first appear before or          Depressive illnesses come in
                                     during college.                              different forms. The following are
                                     Early identification and intervention        general descriptions of the three
                                     (referral/treatment) for depression          most prevalent, though for an
                                     or other mental illness is extremely         individual the number, severity and
                                     important, yet may be inhibited              duration of symptoms will vary.
                                     within the athletics culture for the         Major Depression, or “clinical
                                     following reasons:                           depression,” is manifested by a
                                     •	 Physical	illness	or	injury	is	more	       combination of symptoms that
                                        readily measured and treated              interfere with a person’s once
                                        within sports medicine, and often         pleasurable activities (school, sport,
                                        there is less comfort in addressing       sleep, eating, work). Student-
                                        mental illness.                           athletes experiencing five or more
                                                                                  symptoms	as	noted	in	Table	1	for	
                                     •	 Mental	wellness	is	not	always	            two weeks or longer, or noticeable
                                        perceived as necessary for                changes in usual functioning, are
                                        athletic performance.                     factors that should prompt referral
                                     •	 The	high	profile	of	student-              to the team physician or mental
     Available online at NCAA.org/      athletes may magnify the                  health professional. Fifteen percent
     health-safety.                     attention paid on campus and in           of people with major depression die
                                        the surrounding community when            by suicide. The rate of suicide in
                                        an athlete seeks help.                    men is four times that of women,
                                                                                  though more women attempt it
                                     •	 History	and	tradition	drive	              during their lives.
                                        athletics and can stand as barriers
                                        to change.                                Dysthymia is a less severe form of
                                                                                  depression that tends to involve
                                     •	 The	athletics	department	may	             long-term, chronic depressive
                                        have difficulty associating mental        symptoms. Although these
                                        illness with athletic participation.      symptoms are not disabling, they do
                                     Enhancing knowledge                          affect the individual’s overall
                                     and awareness of                             functioning.
                                     depressive disorders                         Bipolar Disorder, or “manic-
                                     Sports medicine staff, coaches and           depressive illness,” involves cycling
                                     student-athletes should be                   mood swings from major depressive
                                     knowledgeable about the types of             episodes to mania. Depressive epi-
                                     depression and related symptoms.             sodes may last as little as two
                                     Men may be more willing to report            weeks, while manic episodes may
                                     fatigue, irritability, loss of interest in   last as little as four days. Manic
                                     work or hobbies and sleep                    signs and symptoms are presented
                                     disturbances, rather than feelings of        in Table 2.
                                     sadness, worthlessness and                   In addition to the three types of
                                     excessive guilt, which are                   depressive disorders, student-
                                     commonly associated with                     athletes may suffer from an Adjust-
                                     depression in women. Men often               ment Disorder. Adjustment
                                     mask depression with the use of              disorders occur when an individual
                                     alcohol or drugs, or by the socially         experiences depressive (or anxious)
                                     acceptable habit of working                  symptoms in response to a specific
78                                   excessively long hours.                      event or stressor (e.g., poor
                                            Depression: Intervention for Intercollegiate Athletics


performance, poor relationship with      from the team and catastrophic           counseling and medication appears
a coach). An adjustment disorder         events. Members of the sports            to be the most effective treatment
can also progress into major             medicine team and/or licensed            for moderately and severely
depressive disorder.                     mental health professionals should       depressed individuals. Although
                                         also screen athletes for depression at   some improvement in mood may
Establishing a
                                         pre-established points in time (e.g.,    occur in the first few weeks, it
relationship with mental
                                         pre-participation, exit interviews).     typically takes three to four weeks
health services
                                         Research indicates that sports           of treatment to obtain the full
Athletics departments should             medicine professionals are better        therapeutic effect. Medication
identify and foster relationships        equipped to assess depression with       should only be taken and/or stopped
with mental health resources on          the use of appropriate mental health     under the direct care of a physician,
campus or within the local               instruments; simply asking about         and the team physicians should
community that will enable the           depression is not recommended.           consult with psychiatrists regarding
development of a diverse and                                                      complex mental health issues.
                                         A thorough assessment on the part
effective referral plan addressing the
                                         of a mental health professional is       A referral should be made to a
mental well-being of their student-
                                         also imperative to differentiate         licensed mental health professional
athletes and staff. Because student-
                                         major depression from dysthymia          when coaches or sports medicine
athletes are less likely to use          and bipolar disorder, and other          staff members witness any of the
counseling than nonathlete students,     conditions, such as medication use,      following with their student-
increasing interaction among mental      viral illness, anxiety disorders,        athletes:
health staff members, coaches and        overtraining and illicit substance
student-athletes will improve            use. Depressive disorders may            •	 Suicidal	thoughts.	
compliance with referrals. Athletics     co-exist with substance-abuse            •	 Multiple	depressive	symptoms.	
departments can seek psychological       disorders, panic disorder, obsessive-
services and mental health                                                        •	 A	few	depressive	symptoms	that	
                                         compulsive disorder, anorexia
professionals from the following                                                     persist for several weeks.
                                         nervosa, bulimia nervosa and
resources.                               borderline personality disorder.         •	 Depressive	symptoms	that	lead	to	
•	 Athletics	department	sports	                                                      more severe symptoms or
                                         For depression screening, it is
   medicine services.                                                                destructive behaviors.
                                         recommended that sports medicine
•	 Athletics	department	academic	        teams use the Center for Epi-            •	 Alcohol	and	drug	abuse	as	an	
   services.                             demiological Studies Depression             attempt at self treatment.
                                         (CES-D) Scale published by the           •	 Overtraining	or	burnout,	since	
•	 University	student	health	and	
                                         National Institute for Mental Health        depression has many of the same
   counseling services.
                                         (NIMH). The CES-D is free to use            symptoms.
•	 University	medical	school.            and available at www.nimh.nih.gov.
                                         Other resources include such             Coaches and sports medicine staff
•	 University	graduate	programs	                                                  members should follow the
                                         programs as QPR (Question,
   (health sciences, education,                                                   following guidelines in order to help
                                         Persuade, Refer) Gatekeeper
   medical, allied health).                                                       enhancing student-athlete
                                         training; the Jed Foundation U
•	 Local	community.                      Lifeline; and the Screening for          compliance with mental health
                                         Mental Health Depression and             referrals:
Screening for
depression and related                   Anxiety Screenings. Information          •	 Express	confidence	in	the	mental	
risk for suicide                         about these programs, and ways to           health professional (e.g., “I know
                                         incorporate them into student-              that other student-athletes have
One way to ensure an athletics           athlete check-ups, can be found at          felt better after talking to Dr.
department is in tune with student-      NCAA.org/health-safety.                           ”
                                                                                     Kelly. ).
athletes’ mental well-being is to
systematically include mental health     Seeking help                             •	 Be	concrete	about	what	
check-ups, especially around high-       Most individuals who suffer from            counseling is and how it could
risk times such as the loss of a         depression will fully recover to lead       help (e.g., “Amy can help you
coach, significant injury, being cut     productive lives. A combination of                                       ”
                                                                                     focus more on your strengths. ).     79
     Depression: Intervention for Intercollegiate Athletics

     •	 Focus	on	similarities	between	the	
        student-athlete and the mental                                     Table 1
        health professional (e.g., “Bob
        has a sense of humor that you
                                                   DEPRESSIVE SIGNS AND SYMPTOMS
        would appreciate. “Dr. Jones is
                          ”                  Individuals might present:
        a former college student-athlete     •	 Decreased	performance	in	school	or	sport.
        and understands the pressures        •	 Noticeable	restlessness.
        student-athletes face. ).
                             ”               •	 Significant	weight	loss	or	weight	gain.
                                                D
                                             •	 	 ecrease	or	increase	in	appetite	nearly	every	day	
     •	 Offer	to	accompany	the	student-         (fluctuating?).
        athletes to their initial
        appointment.                         Individuals might express:
                                             •	 Indecisiveness.	
     •	 Offer	to	make	the	appointment	       •	 Feeling	sad	or	unusually	crying.
        (or have the student-athlete make    •	 Difficulty	concentrating.
        the appointment) while in your          L
                                             •	 	 ack	of	or	loss	of	interest	or	pleasure	in	activities	that	were	
        office.                                 once enjoyable (hanging out with friends, practice, school, sex).
     •	 Emphasize	the	confidentiality	of	       D
                                             •	 	 epressed,	sad	or	“empty”	mood	for	most	of	the	day	and	
        medical care and the referral           nearly every day.
        process.                                R
                                             •	 	 ecurrent	thoughts	of	death	or	thoughts	about	suicide.
                                                F
                                             •	 	 requent	feelings	of	worthlessness,	low	self-esteem,	hopeless-
     The following self-help strategies         ness, helplessness or inappropriate guilt.
     may improve mild depression
     symptoms:
     •	 Reduce	or	eliminate	the	use	of	
        alcohol and drugs.                              Table 2
     •	 Break	large	tasks	into	smaller	          MANIC SIGNS
        ones; set realistic goals.              AND SYMPTOMS
     •	 Engage	in	regular,	mild	exercise.    Individuals might present:
                                                A
                                             •	 	 bnormal	or	excessive	
     •	 Eat	regular	and	nutritious	meals.
                                                elation.
     •	 Participate	in	activities	that	      •	 Unusual	irritability.
        typically make you feel better.      •	 Markedly	increased	energy.
     •	 Let	family,	friends	and	coaches	     •	 Poor	judgment.
        help you.                               I
                                             •	 	nappropriate	social	
                                                behavior.
     •	 Increase	positive	or	optimistic	     •	 Increased	talking.
        thinking.
                                             Individuals might express:
     •	 Engage	in	regular	and	adequate	      •	 Racing	thoughts.
        sleep habits.                        •	 Increased	sexual	desire.	
                                             •	 Decreased	need	for	sleep.
                                             •	 Grandiose	notions.




80
                                                   Depression: Intervention for Intercollegiate Athletics

Using a simple tool such as this can help students
and staff look for signs of depression.
Put a check mark by each sign that describes you:
 I am really sad most of the time.
 I don’t enjoy doing the things I’ve always enjoyed doing.
 I don’t sleep well at night and am very restless.
 I am always tired. I find it hard to get out of bed.
 I don’t feel like eating much.
 I feel like eating all the time.
 I have lots of aches and pains that don’t go away.
 I have little to no sexual energy.
 I find it hard to focus and am very forgetful.
 I am mad at everybody and everything.
 I feel upset and fearful, but can’t figure out why.
 I don’t feel like talking to people.
 I feel like there isn’t much point to living, nothing good is going to happen to me.
 I don’t like myself very much. I feel bad most of the time.
 I think about death a lot. I even think about how I might kill myself.
If you checked several boxes, call your doctor. Take the list to show the doctor. You
may need to get a check-up and find out if you have depression.


References


1. Backmand J, et. al. Influence of physical   Available from www.nimh.nih.gov/publicat/        college student-athlete: Psychological
activity on depression and anxiety of          nimhdepression.pdf.                              considerations and interventions. Journal
former elite athletes. International Journal   4. Maniar SD, Chamberlain R, Moore N.            of American College Health.
of Sports Medicine. 2003. 24(8):609-919.       Suicide risk is real for student-athletes. The   1989;37(5):218-26.
2. Hosick, M. Psychology of sport more         NCAA News. November 7, 2005. Available           7. Putukian, M, Wilfert, M. Student-
than performance enhancement. The NCAA         online.                                          athletes also face dangers from depression.
News. March 14, 2005. Available online.        5. Maniar SD, Curry LA, Sommers-                 The NCAA News. April 12, 2004. Available
3. National Institute of Mental Health.        Flanagan J, Walsh JA. Student-athlete            online.
Depression. Bethesda (MD): National            preferences in seeking help when                 8. Schwenk, TL. The stigmatization and
Institute of Mental Health, National           confronted with sport performance                denial of mental illness in athletes. British
Institutes of Health, US Department of         problems. The Sport Psychologist.                Journal of Sports Medicine. 2000. 34:4-5.
Health and Human Services; 2000. (NIH          2001;15(2):205-23.
Publication No 02-3561). 25 pages.             6. Pinkerton RS, Hinz LD, Barrow JC. The




                                                                                                                                                81
                                         GUIDELINE 2p
     Participation by
     the Student-Athlete
     with Impairment
       January 1976 • Revised August 2004


     In accordance with the                    significant risk of substantial harm     his or her parent(s) or guardian.
     recommendations of major medical          to the health or safety of the           The following factors should be
     organizations and pursuant to the         student-athlete and/or other             considered on an individualized
     requirements of federal law (in           participants that cannot be              basis in determining whether he or
     particular, the Rehabilitation Act of     eliminated or reduced by                 she should participate in a
     1976	and	The	Americans	With	              reasonable accommodations.               particular sport:
     Disabilities Act), the NCAA               Recent judicial decisions have
                                               upheld a university’s legal right to     1. Available published information
     encourages participation by
                                               exclude a student-athlete from           regarding the medical risks of
     student-athletes with physical or
                                               competition if the team physician        participation in the sport with the
     mental impairments in
                                               has a reasonable medical basis for       athlete’s mental or physical
     intercollegiate athletics and
                                               determining that athletic                impairment;
     physical activities to the full extent
     of their interests and abilities. It is   competition creates a significant
                                                                                        2. The current health status of the
     imperative that the university’s          risk of harm to the student-athlete
                                                                                        student-athlete;
     sports medicine personnel assess a        or others. When student-athletes
     student-athlete’s medical needs and       with impairments not otherwise           3. The physical demands of the
     specific limitations on an                qualified to participate in existing     sport and position(s) that the
     individualized basis so that              athletics programs are identified,       student-athlete will play;
     needless restrictions will be             every means should be explored by
     avoided and medical precautions           member institutions to provide           4. Availability of acceptable
                                               suitable sport and recreational          protective equipment or measures
     will be taken to minimize any
                                               programs in the most appropriate,        to reduce effectively the risk of
     enhanced risk of harm to the
                                               integrated settings possible to meet     harm to the student-athlete or
     student-athlete or others from
                                               their interests and abilities.           others; and
     participation in the subject sport.
                                               Participation                            5. The ability of the student-athlete
     A student-athlete with impairment
                                               Considerations                           [and, in the case of a minor, the
     should be given an opportunity to
                                                                                        parent(s) or guardian] to fully
     participate in an intercollegiate         Before allowing any student-athlete      understand the material risks of
     sport if he or she has the requisite      with an impairment to participate        athletic participation.
     abilities and skills in spite of his or   in an athletics program, it is
     her impairment, with or without a         recommended that an institution          Organ Absence
     reasonable accommodation.                 require joint approval from the          or Non-function
     Medical exclusion of a student-           physician most familiar with the
     athlete from an athletics program         student-athlete’s condition, the         When the absence or non-function
     should occur only when a mental           team physician, and an appropriate       of a paired organ constitutes the
     or physical impairment presents a         official of the institution as well as   impairment, the following specific
82
Participation by the Student-Athlete with Impairment

issues need to be addressed with          References
the student-athlete and his/her
parents or guardian (in the case of       1. American Academy of
a minor). The following factors           Pediatrics, Committee on Sports
should be considered:                     Medicine and Fitness. Medical
1. The quality and function of the        Conditions Affecting Sports
remaining organ;                          Participation. Pediatrics. 94(5):
                                          757-60, 1994.
2. The probability of injury to the
remaining organ; and                      2. Mitten, MJ. Enhanced risk of
3. The availability of current            harm to one’s self as a
protective equipment and the likely       justification for exclusion from
effectiveness of such equipment to        athletics. Marquette Sports Law
prevent injury to the remaining           Journal. 8:189-223, 1998.
organ.

Medical Release
When a student-athlete with
impairment is allowed to compete
in the intercollegiate athletics
program, it is recommended that a
properly executed document of
understanding and a waiver release
the institution for any legal liability
for injury or death arising out of
the student-athlete’s participation
with his or her mental or physical
impairment/medical condition.
The following parties should sign
this document: the student-athlete,
his or her parents/guardians, the
team physician and any consulting
physician, a representative of the
institution’s athletics department,
and the institution’s legal counsel.
This document evidences the
student-athlete’s understanding of
his or her medical condition and
the potential risks of athletic
participation, but it may not
immunize the institution from legal
liability for injury to the
student-athlete.




                                                                              83
                                       GUIDELINE 2q
     Pregnancy in the
     Student-Athlete
      January 1986 • Revised June 2009



     The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports acknowledges the
     significant input of Dr. James Clapp, FACSM, in the revision of this guideline.

     Pregnancy Policies
     Pregnancy places unique challeng-
     es on the student-athlete. Each
     member institution should have a
     policy clearly outlined to address
     the rights and responsibilities of
     the pregnant student-athlete. The
     policy should address:
     •	 Where	the	student-athlete	can	
     receive confidential counseling;
     •	 Where	the	student-athlete	can	
     access timely medical and
     obstetrical care;
     •	 How	the	pregnancy	may	affect	
     the student-athlete’s team standing
     and institutional grants-in-aid;
                                              aid based in any degree on athletics    when there is medical reason to
     •	 That	pregnancy	should	be	             ability may not be reduced or           withhold the student-athlete from
     treated as any other temporary           canceled during the period of its       competition.
     health condition regarding receipt       award because of an injury, illness
     of institutional grants-in-aid; and      or physical or mental medical           Exercise in Pregnancy
     •	 That	NCAA	rules	permit	a	one-         condition.
                                                                                      Assessing the risk of intense,
     year extension of the five-year          The team’s certified athletic trainer   strenuous physical activity in
     period of eligibility for a female       or team physician is often              pregnancy is difficult. There is some
     student-athlete for reasons of           approached in confidence by the         evidence that women who exercise
     pregnancy.                               student-athlete. The sports             during pregnancy have improved
     Student-athletes should not be           medicine staff should be well-          cardiovascular function, limited
     forced to terminate a pregnancy          versed in the athletics department’s    weight gain and fat retention,
     because of financial or                  policies and be able to access the      improved attitude and mental state,
     psychological pressure or fear of        identified resources. The sports        easier and less complicated labor,
     losing their institutional grants-in-    medicine staff should respect the       and enhanced postpartum recovery.
     aid.		See	Bylaw	15.3.4.3,	which	         student-athlete’s requests for          There is no evidence that increased
84   specifies that institutional financial   confidentiality until such time         activity increases the risk of
Participation by the Pregnant Student-Athlete
spontaneous abortion in
uncomplicated pregnancies. There                                            Table 1
are, however, theoretical risks to the
                                                    Warning Signs to Terminate Exercise
fetus associated with increased core
body temperatures that may occur                              While Pregnant
with exercise, especially in the heat.                             Vaginal Bleeding
                                                          Shortness of Breath Before Exercise
The fetus may benefit from
exercise during pregnancy in                                           Dizziness
several ways, including an                                             Headache
increased tolerance for the                                           Chest Pain
physiologic stresses of late                                     Calf Pain or Swelling
pregnancy, labor and delivery.                                      Pre-term Labor
                                                              Decreased Fetal Movement
The safety of participation in
individual sports by a pregnant                                 Amniotic Fluid Leakage
woman should be dictated by the                                   Muscle Weakness
movements and physical demands
required to compete in that sport
and the previous activity level of       need to modify their activity as        References
the individual. The American             medically indicated and require
College of Sports Medicine               close supervision.
discourages heavy weight lifting or                                              1. Pregnant & Parenting Student-
similar activities that require          If a student-athlete chooses to         athletes: Resources and Model Policies.
straining or valsalva.                   compete while pregnant, she should:     2009. NCAA.org/health-safety.
Exercise in the supine position          •	 Be	made	aware	of	the	potential	      2. American College of Obstetrics and
after the first trimester may cause      risks of her particular sport and       Gynecology Committee on Obstetric
venous obstruction and                   exercise in general while pregnant;     Practice: Exercise During Pregnancy and
conditioning or training exercises                                               the Postpartum Period. Obstetrics and
                                         •	 Be	encouraged	to	discontinue	
in this position should be avoided.      exercise when feeling over-exerted      Gynecology 99(1) 171-173, 2002.
Sports with increased incidences of      or when any warning signs (Table        3. American College of Sports Medicine:
bodily contact (basketball, ice          1)	are	present;                         Exercise During Pregnancy. In: Current
hockey, field hockey, lacrosse,          •	 Follow	the	recommendations	of	       Comment from the American College of
soccer, rugby) or falling                her obstetrical provider in             Sports Medicine, Indianapolis, IN,
(gymnastics, equestrian, downhill        coordination with the team              August 2000.
skiing) are generally considered         physician; and                          3. Clapp JF: Exercise During Pregnancy,
higher risk after the first trimester
                                         •	 Take	care	to	remain	well-            A Clinical Update. Clinics in Sports
because of the potential risk of
abdominal trauma. The student-           hydrated and to avoid over-heating.     Medicine 19(2) 273-286, 2000.
athlete’s ability to compete may also    After delivery or pregnancy
be compromised due to changes in         termination, medical clearance is
physiologic capacity, and                recommended to ensure the
musculoskeletal issues unique to         student-athlete’s safe return to
pregnancy. There is also concern that    athletics. (See Follow-up Exam-
in the setting of intense competition    inations	section	of	Guideline	1b.)	
a pregnant athlete will be less likely   The physiologic changes of
to respond to internal cues to           pregnancy persist four to six weeks
moderate exercise and may feel           postpartum, however, there have
pressure not to let down the team.       been no known maternal
The American College of                  complications from resumption of
Obstetrics and Gynecology states         training. Care should be taken to
that competitive athletes can            individualize return to practice and
remain active during pregnancy but       competition.                                                                      85
                                       GUIDELINE 2r

     The Student-Athlete
     with Sickle Cell Trait
      October 1975 • Revised June 2008



     Sickle cell trait is not a disease. It   and consistent with a long, healthy     Exertional rhabdomyolysis can be
     is the inheritance of one gene for       life. As they get older, some           life-threatening. During intense
     normal hemoglobin (A) and one            persons with the trait become           exertion and hypoxemia, sickled
     gene for sickle hemoglobin (S),          unable to concentrate urine             red cells can accumulate in the
     giving the genotype AS. Sickle           normally, but this is not a key         blood. Dehydration worsens
     cell trait (AS) is not sickle cell       problem for college athletes. Most      exertional sickling. Sickled red
     anemia (SS), in which two                athletes complete their careers         cells can “logjam” blood vessels in
     abnormal genes are inherited.            without any complications.              working muscles and provoke
     Sickle cell anemia causes major          However, there are three constant       ischemic rhabdomyolysis.
     anemia and many clinical                 concerns that exist for athletes with   Exertional rhabdomyolysis is not
     problems, whereas sickle cell trait      sickle cell trait: gross hematuria,     exclusive to athletes with sickle
     causes no anemia and few clinical        splenic infarction, and exertional      cell trait. Planned emergency
     problems. Sickle cell trait will not                                             response and prompt access to
                                              rhabdomyolysis, which can
     turn into the disease. However, it is                                            medical care are critical
                                              be fatal.
     possible to have symptoms of the                                                 components to ensure adequate
     disease under extreme conditions         Gross hematuria, visible blood in       response to a collapse or athlete in
     of physical stress or low oxygen         the urine, usually from the left        distress.
     levels. In some cases, athletes with     kidney, is an occasional
     the trait have expressed significant                                             The U.S. Armed Forces linked
                                              complication of sickle cell trait.      sickle trait to sudden unexplained
     distress, collapsed and even died        Athletes should consult a physician
     during rigorous exercise.                                                        death during basic training.
                                              for return-to-play clearance.           Recruits with sickle cell trait were
     People at high risk for having                                                   about 30 times more likely to die
                                              Splenic infarction can occur in
     sickle cell trait are those whose                                                than other recruits. The deaths were
                                              people with sickle cell trait,
     ancestors come from Africa, South                                                initially classified as either acute
                                              typically at altitude. The risk may
     or Central America, the Caribbean,                                               cardiac arrest of undefined
                                              begin at 5,000 feet and increases
     Mediterranean countries, India, and                                              mechanism or deaths related to
                                              with rising altitude. Vigorous
     Saudi Arabia. Sickle cell trait                                                  heat stroke, heat stress, or
                                              exercise (e.g., skiing, basketball,     rhabdomyolysis. Further analysis
     occurs in about 8 percent of the
                                              football, hiking, anaerobic             showed that the major risk was
     U.S. African-American population
                                              conditioning) may increase the          severe exertional rhabdomyolysis, a
     and rarely (between one in 2,000 to
                                              risk. Splenic infarction causes left    risk that was about 200 times
     one	in	10,000)	in	the	Caucasian	
                                              upper quadrant or lower chest pain,     greater for recruits with sickle cell
     population. It is present in athletes
                                              often with nausea and vomiting. It      trait. Deaths among college athletes
     at all levels, including high school,
                                              can mimic pleurisy, pneumothorax,       with sickle cell trait, almost
     collegiate, Olympic and
     professional. Sickle cell trait is no    side stitch, or renal colic. Splenic    exclusively in football dating back
     barrier to outstanding athletic          infarction at altitude has occurred     to	1974,	have	been	from	exertional	
     performance.                             in athletes with sickle trait.          rhabdomyolysis, including early
                                              Athletes should consult a physician     cardiac death from hyperkalemia
86   Sickle cell trait is generally benign    for return-to-play clearance.           and lactic acidosis and later
                                                           The Student-Athlete with Sickle Cell Trait

metabolic death from acute              NCAA Fact Sheets and Video for Coaches and Student-
myoglobinuric renal failure.            Athletes are available at www.NCAA.org/health-safety.

In other cases, athletes have
survived collapses while running a
distance race, sprinting on a
basketball court or football field,
and running timed laps on a track.
The harder and faster athletes go,
the earlier and greater the sickling.
Sickling can begin in only two to
three minutes of sprinting, or in
any other all-out exertion of
sustained effort, thus quickly
increasing the risk of collapse.
Athletes with sickle cell trait
cannot be “conditioned” out of the
trait and coaches pushing these
athletes beyond their normal
physiological response to stop and      student-athlete or student-athlete
recover place these athletes at an      declines the test and signs a written     Beginning August 1,
increased risk for collapse.            release. The references allude to         2010, Division I requires
                                        growing support for the practical         student-athletes new to
A sickling collapse is a medical        benefits of screening and campuses        their campus to complete
emergency. Even the most fit            that screen are increasing in             a sickle cell solubility
athletes can experience a sickling      frequency. Screening can be
                                                                                  test, show results of
collapse. Themes from the               accomplished with a simple blood
literature describe sickling athletes                                             a prior test, or sign a
                                        test that is relatively inexpensive.
with ischemic pain and muscle           Although sickle cell trait screening      written release declining
weakness rather than muscular           is normally performed on all U.S.         the test. See Division I
cramping or “locking up.” Unlike        babies at birth, many student-            Bylaw 17.1.5.1.
cardiac collapse (with ventricular      athletes may not know whether
fibrillation), the athlete who          they have the trait. Following the
slumps to the ground from sickling      recommendations of the National         Screening can be used as a gateway
can still talk. This athlete is         Athletic Trainers Association           to targeted precautions.
typically experiencing major lactic     (NATA) and the College of
acidosis, impending shock, and          American Pathologists (CAP), if         Precautions can enable student-
imminent hyperkalemia from              the trait is not known, the NCAA        athletes with sickle cell trait to
sudden rhabdomyolysis that can          requires athletics departments to       thrive in their sport. These
lead to life-threatening                confirm sickle cell trait status in     precautions are outlined in the
complications or even sudden            all student-athletes, or have           references	and	in	a	2007	NATA	
death. The emergent management          student-athletes sign a written         Consensus Statement on Sickle
of a sickling collapse is covered in    release declining the sickle cell       Cell Trait and the Athlete.
the references.                         solubility test, during the medical     Knowledge of a student-athlete’s
                                        examination	(Bylaw	17.1.5)	period.	     sickle cell status should facilitate
Screening for sickle cell trait as                                              prompt and appropriate medical
part of the medical examination         If a test is positive, the student-     care during a medical emergency.
process is required in Division I       athlete should be offered
institutions unless documented          counseling on the implications of       Student-athletes with sickle cell
results of a prior test are provided    sickle cell trait, including health,    trait should be knowledgeable of
to the institution or the prospective   athletics and family planning.          these precautions and institutions
                                                                                                                       87
                                                                     The Student-Athlete with Sickle Cell Trait

     should provide an environment in           between repetitions, especially             or breathlessness.
     which these precautions may be             during “gassers” and intense station
                                                                                            •	Stay	well	hydrated	at	all	times,	
     activated. In general, these               or “mat” drills.
     precautions suggest student-athletes                                                   especially in hot and humid conditions.
                                                •	Not	be	urged	to	perform	all-out	
     with sickle cell trait should:                                                         •	Maintain	proper	asthma	
                                                exertion of any kind beyond two to
     •	Set	their	own	pace.                      three minutes without a breather.           management.
     •	Engage	in	a	slow	and	gradual	            •	Be	excused	from	performance	              •	Refrain	from	extreme	exercise	
     preseason conditioning regimen to be       tests such as serial sprints or timed       during acute illness, if feeling ill, or
     prepared for sports-specific               mile runs, especially if these are          while experiencing a fever.
     performance testing and the rigors of      not normal sport activities.
     competitive intercollegiate athletics.                                                 •	Access	supplemental	oxygen	at	
                                                •	Stop	activity	immediately	upon	
     •	Build	up	slowly	while	training	                                                      altitude as needed.
                                                struggling or experiencing
     (e.g., paced progressions).                symptoms such as muscle pain,               •	Seek	prompt	medical	care	when	
     •	Use	adequate	rest	and	recovery	          abnormal weakness, undue fatigue            experiencing unusual distress.

     References

     1. NATA Consensus Statement: Sickle        training. N Engl J Med 1987;317:781-        trait: A risk factor for life-threatening
     cell trait and the athlete, June 2007.     787.                                        rhabdomyolysis? Phys Sportsmed
     2. Clarke CE, Paul S, Stilson M, Senf J:   6. Gardner JW, Kark JA: Fatal               1993;21(6):80-88.
     Sickle cell trait preparticipation         rhabdomyolysis presenting as mild heat      10. Dincer HE, Raza T: Compartment
     screening practices of collegiate          illness in military training. Milit Med     syndrome and fatal rhabdomyolysis in
     physicians. Clin J Sport Med               1994;159:160-163.                           sickle cell trait. Wisc Med J
     2007;16:440a                               7. Bergeron MF, Gannon JG, Hall EL,         2005;104:67-71.
     3. Eichner ER: Sickle cell trait. J        Kutlar A: Erythrocyte sickling during       11. Makaryus JN, Catanzaro JN, Katona
     Sport Rehab 2007;16:197-203.               exercise and thermal stress. Clin J Sport   KC: Exertional rhabdomyolysis and
     4. Eichner ER: Sickle cell trait and       Med 2004;14:354-356.                        renal failure in patients with sickle cell
     athletes: three clinical concerns. Curr    8. Eichner ER: Sickle cell trait and the    trait: Is it time to change our approach?
     Sports Med Rep 2007;6:134-135.             athlete. Gatorade Sports Science            Hematology 2007;12:349-352.
     5. Kark JA, Posey DM, Schumacher           Institute Sports Science Exchange 2006;     12. Mitchell BL: Sickle cell trait and
     HR, Ruehle CJ: Sickle-cell trait as a      19(4):1-4.                                  sudden death – bringing it home. J Nat
     risk factor for sudden death in physical   9. Browne RJ, Gillespie CA: Sickle cell     Med Assn 2007;99:300-305.




88
Equipment
Also found on the NCAA website at: NCAA.org/health-safety




                                                            3
                                      GUIDELINE 3a
     Protective Equipment
      June 1983 • Revised June 2007



     Rules governing mandatory               equipment standards should adhere         its maintenance, the
     equipment and equipment use vary        to those standards.                       student-athlete also is complying
     by sport. Athletics personnel should                                              with the purpose of the standard.
     be familiar with what equipment is      The NOCSAE mark on a helmet or
     mandatory by rule and what              HECC seal on an ice hockey face           The following list of mandatory
     constitutes illegal equipment; how to   mask indicates that the equipment         equipment and rules regarding pro-
     wear mandatory equipment during         has been tested by the manufacturer       tective equipment use is based on
     the contest; and when to notify the     in accordance with NOCSAE or              NCAA sports rules. The most
     coaching staff that the equipment       HECC test standards. By keeping a         updated information should be
     has become illegal during               proper fit, by not modifying its          obtained from relevant NCAA rules
     competition. Athletics personnel        design, and by reporting to the coach     committees.
     involved in sports with established     or equipment manager any need for

                                             Mandatory Protective                      Rules Governing Special
     Sport                                   Equipment*                                Protective Equipment

     1. Baseball                             1. A double ear-flap protective           None
                                             helmet while batting, on deck and
                                             running bases. Helmets must carry
                                             the NOCSAE mark.
                                             2. All catchers must have a built-in or
                                             attachable throat guard on their
                                             masks.
                                             3. All catchers are required to wear a
                                             protective helmet when fielding their
                                             position.

     2. Basketball                           None                                      Elbow, hand, finger, wrist or forearm
                                                                                       guards, casts or braces made of
                                                                                       fiberglass, plaster, metal or any other
                                                                                       nonpliable substance shall be
                                                                                       prohibited. Pliable (flexible or easily
                                                                                       bent) material covered on all exterior
                                                                                       sides and edges with no less than
                                                                                       0.5-inch thickness of a slow-
                                                                                       rebounding foam shall be used to
                                                                                       immobilize and/or protect an injury.
                                                                                       The prohibition of the use of hard-
                                                                                       substance material


90
                                                                       Protective Equipment

                         Mandatory Protective                    Rules Governing Special
Sport                    Equipment*                              Protective Equipment

Basketball (continued)                                           does not apply to the upper arm,
                                                                 shoulder, thigh or lower leg if the
                                                                 material is padded so as not to create
                                                                 a hazard for other players.
                                                                 Equipment that could cut or cause an
                                                                 injury to another player is prohibited,
                                                                 without respect to whether the equip-
                                                                 ment is hard.

                                                                 Equipment that, in the referee’s
                                                                 judgment, is dangerous to other
                                                                 players, may not be worn.

3. Fencing               1. Masks with meshes (space
                         between the wires) of maximum
                         2.1 mm and from wires with
                         a minimum gauge of 1 mm
                         diameter.
                         2. Gloves, of which the gauntlet
                         must fully cover approximately
                         half the forearm of the
                         competitor’s sword arm.
                         3. Jacket or vest and metallic lames.
                         4. Ladies’ chest protectors
                         made of metal or some other
                         rigid material.
                         5. Underarm protector.

4. Field Hockey          1. The following equipment is per-      Players shall not wear anything
                         mitted for use only by goal-            that may be dangerous to other
                         keepers: body and wrap-around           players. Players have the option
                         throat protectors, pads, kickers,       of wearing soft headgear subject
                         gauntlet gloves, helmet                 to game official approval.
                         incorporating fixed full-face
                         protection and cover for the head,
                         and elbow pads.
                         2. Mouthguards for all players
                         including goalkeepers.
                         3. Wrap-around throat protector
                         and helmet for player designated
                         as a “kicking back.” In the event of
                         a defensive penalty corner, the
                         “kicking back” must also wear a
                         chest protector and distinguishing
                         jersey.


                                                                                                           91
     Protective Equipment




                            Mandatory Protective                     Rules Governing Special
     Sport                  Equipment*                               Protective Equipment

     5. Football            1. Soft knee pads at least ½-inch        Illegal equipment includes the
                            thick that are covered by pants. It is   following:
                            strongly recommended that they           1. Equipment worn by a player,
                            cover the knees. No pads or              including artificial limbs, that
                            protective equipment may be worn         would endanger other players.
                            outside the pants.                       2. Hard, abrasive or unyielding
                            2. Face masks and helmets with a         substances on the hand, wrist,
                            secured four- or six-point chin strap.   forearm or elbow of any player,
                            All players shall wear helmets that      unless covered on all exterior sides
                            carry a warning label regarding the      and edges with closed-cell, slow-
                            risk of injury and a manufacturer’s or   recovery foam padding no less than
                            reconditioner’s certification            ½-inch thick, or an alternate material
                            indicating satisfaction of NOCSAE        of the same minimum thickness and
                            test standards.                          similar physical properties. Hard or
                            3. Shoulder pads, hip pads with          unyielding substances are permitted,
                            tailbone protectors and thigh guards.    if covered, only to protect an injury.
                                                                     Hand and arm protectors (covered
                            4. An intra-oral mouthpiece of any       casts or splints) are permitted only to
                            readily visible color (not white or      protect a fracture or dislocation.
                            transparent) with FDA-approved
                                                                     3. Thigh guards of any hard
                            base materials (FDCS) that covers all
                                                                     substances, unless all surfaces are
                            upper teeth. It is recommended that
                                                                     covered with material such as closed-
                            the mouthpiece be properly fitted.
                                                                     cell vinyl foam that is at least ¼-inch
                                                                     thick on the outside surface and at
                                                                     least 3/8-inch thick on the inside
                                                                     surface and the overlaps of the edges;
                                                                     shin guards not covered on both sides
                                                                     and all edges with closed-cell, slow-
                                                                     recovery foam padding at least ½-inch
                                                                     thick, or an alternate material of the
                                                                     same minimum thickness having
                                                                     similar physical properties; and
                                                                     therapeutic or preventive knee braces,
                                                                     unless worn under the pants and
                                                                     entirely covered from direct external
                                                                     exposure.




92
                                                                         Protective Equipment




                       Mandatory Protective                       Rules Governing Special
Sport                  Equipment*                                 Protective Equipment
Football (continued)                                              4. Projection of metal or other hard
                                                                  substance from a player’s person
                                                                  or clothing.
6. Gymnastics          None                                       None
7. Ice Hockey          1. Helmet with chin straps securely        1. The use of pads or protectors made
                       fastened. It is recommended that the       of metal or any other material likely
                       helmet meet HECC standards.                to cause injury to a player is
                       2. An intra-oral mouthpiece that           prohibited.
                       covers all the upper teeth.                2. The use of any protective
                       3. Face masks that have met the            equipment that is not injurious to the
                       standards established by the HECC-         player wearing it or other players is
                       ASTM F 513-89 Eye and Face                 recommended.
                       Protective Equipment for Hockey            3. Jewelry is not allowed, except for
                       Players Standard.                          religious or medical medals, which
                                                                  must be taped to the body.

8. Women’s Lacrosse    1. The goalkeeper must wear a helmet       Protective devices necessitated on
                       with face mask, separate throat            genuine medical grounds must be
                       protector, a mouth piece, a chest          approved by the umpires. Close-
                       protector.                                 fitting gloves, nose guards, eye
                       2. All field players shall wear            guards and soft headgear may be
                       properly an intra-oral mouthpiece          worn by all players. These devices
                       that covers all upper teeth.               must create no danger to other
                                                                  players.
                       3. All field players shall wear
                       protective eyewear that meets current
                       ASTM lacrosse standards (effective
                       January 1, 2005).


9. Men’s Lacrosse      1. Protective helmet that carries the      1. A player shall not wear any
                       NOCSAE mark, equipped with face            equipment that, in the opinion of the
                       mask and chin pad, with a cupped           official, endangers the individual or
                       four-point chin strap (high-point          others.
                       hookup).                                   2. The special equipment worn by the
                       2. Intra-oral mouthpiece that covers all   goalkeeper shall not exceed standard
                       the upper teeth and is yellow or any       equipment for a field player, plus
                       other highly visible color.                standard goalkeeper equipment,
                       3. Protective gloves, shoulder pads,       which includes shin guards, chest
                       shoes and jerseys. Shoulder pads           protectors and throat protectors.
                       shall not be altered.
                       4. Throat protector and chest
                       protector are required for the goalie.


                                                                                                           93
     Protective Equipment




                               Mandatory Protective                   Rules Governing Special
     Sport                     Equipment*                             Protective Equipment

     10. Rifle                 Shooters and range personnel in        None
                               the immediate vicinity of the range
                               required to wear hearing protection
                               during smallbore. Shooters urged
                               to wear shatterproof eye protection.

     11. Soccer                Players shall wear shin guards under   1. A player shall not wear anything
                               the stockings in the manner intend-    that is dangerous to another player.
                               ed, without exception. The shin        2. Knee braces are permissible pro-
                               guards shall be professionally manu-   vided no metal is exposed.
                               factured, age and size appropriate     3. Casts are permitted if covered
                               and not altered to decrease protec-    and not considered dangerous.
                               tion. The shin guards must meet
                                                                      4. A player shall not wear any jewel-
                               NOCSAE standards.
                                                                      ry of any type whatsoever. Excep-
                                                                      tion: Medical alert bracelets or neck
                                                                      laces may be worn but must be
                                                                      taped to the body.

     12. Skiing                Helmets manufactured for ski racing None
                               are required in all Alpine events and
                               event training.

     13. Softball              1. Catchers must wear foot-to-knee     Casts, braces, splints and
                               shin guards; NOCSAE-approved           protheses must be well-padded to
                               protective helmet with face mask       protect both the player and opponent
                               and built-in or attachable throat      and must be neutral in color. If worn
                               guard; and chest protector.            by pitcher, cannot be distracting on
                               2. A NOCSAE-approved double-ear        nonpitching arm. If worn on
                               flap protective helmet must be         pitching arm, may not cause safety
                               worn by players while batting,         risk or unfair competitive advantage.
                               running the bases or warming-up
                               in the on-deck circle.


     14. Swimming and Diving   None                                   None




94
                                                               Protective Equipment




                      Mandatory Protective              Rules Governing Special
Sport                 Equipment*                        Protective Equipment

15. Track and Field   None                              1. No taping of any part of the
                                                        hand, thumb or fingers will be per-
                                                        mitted in the discus and javelin
                                                        throws, and the shot put, except to
                                                        cover or protect an open wound. In
                                                        the hammer throw, taping of indi-
                                                        vidual fingers is permissible. Any
                                                        taping must be shown to the head
                                                        event judge before the event starts.
                                                        2. In the pole vault, the use of a
                                                        forearm cover to prevent injuries is
                                                        permissible.


                                                        1. It is forbidden to wear any
16. Volleyball        None
                                                        object that may cause an injury or
                                                        give an artificial advantage to the
                                                        player, including but not limited to
                                                        headgear, jewelry and unsafe casts
                                                        or braces. Religious medallions or
                                                        medical identifications must be
                                                        removed from chains and taped or
                                                        sewn under the uniform.
                                                        2. All jewelry must be removed.
                                                        Earrings must be removed. Taping
                                                        of earrings or other jewelry is not
                                                        permitted.
                                                        3. Hard splints or other potentially
                                                        dangerous protective devices worn
                                                        on the arms or hands are prohibit-
                                                        ed, unless padded on all sides with
                                                        at least ½-inch thick of slow
                                                        rebounding foam.

17. Water Polo        Cap with protective ear guards.   None

18. Wrestling         Protective ear guard.             1. Anything that does not allow
                                                        normal movement of the joints and
                                                        prevents one’s opponent from
                                                        applying normal holds shall be
                                                        barred.
                                                        2. Any legal device that is hard
                                                        and abrasive must be covered and
                                                        padded. Loose pads are prohibited.
                                                        It is recommended that all wres-
                                                        tlers wear a protective mouth
                                                        guard.
                                                        3. Jewelry is not allowed.             95
                                        GUIDELINE 3b
     Eye Safety in Sports
      January 1975 • Revised August 2001



     Eye injuries in sports are relatively     athletes who wear contact lenses for    Summary
     frequent, sometimes catastrophic,         corrective vision should wear
     and almost completely preventable         appropriate sports safety eyewear       1. Appropriate for eye protection
     with the use of appropriate               for ocular protection.                  in sports:
     protective devices. A sports eye                                                    a. Safety sports eyewear that
     protector may be a spectacle, a           The American Academy of                   conforms to the requirements of
     goggle, a face-supported protector,       Opthalmology recommends that              the American Society for Testing
     or a protector attached to a helmet.      head, face and eye protection             and Materials (ASTM) Standard
     It comes with or without lenses, is       should be certified by either             F803 for selected sports (racket
     capable of being held securely in         the Protective Eyewear Certifi-           sports, basketball, women’s
     place, and may protect the face as        cation Council (PECC — www.               lacrosse, and field hockey).
     well as the eyes. Some forms can be       protecteyes.org/), the Hockey             b. Sports eyewear that is attached
     worn over regular glasses. Sports         Equipment Certification Council           to a helmet or is designed for
     eye protectors are specially              (HECC — www.hecc-hockey.org/),            sports for which ASTM F803
     designed, fracture-resistant units that   the National Operating Committee on       eyewear alone provides
     comply with the American Society          Standards for Athletic Equipment          insufficient protection. Those for
     for Testing and Materials (ASTM),         (NOCSAE — www.                            which there are standard
     or the National Operating                 nocsae.org/), or the Canadian             specifications include: skiing
     Committee on Standards for                Standards Association (CSA —              (ASTM 659), and ice hockey
     Athletic Equipment (NOCSAE)
                                               www.csa-international.org/). The          (ASTM F513). Other protectors
     standards for specific sports.
                                               cited websites will have more             with NOCSAE standards are
                                               specific information on these             available for football and men’s
     Approximately one-third of all
                                               standards. Certification ensures that     lacrosse.
     persons participating in sports
                                               the protective device has been          2. Not appropriate for eye
     require corrective lenses to achieve
                                               properly tested to current standards.   protection in sports:
     the visual acuity necessary for
     proper and safe execution of their                                                  a. Streetwear (fashion) spectacles
     particular sports activity. Athletes      Protective eyewear should be              that conform to the requirements
     who need corrective eyewear for           considered for all sports that have a     of American National Standards
     participation should use lenses and       projectile object (ball/stick) whose      Institute (ANSI) Standard Z80.3.
     frames that meet the appropriate          size and/or speed could potentially
                                                                                         b. Safety eyewear that conforms to
     safety standards. At this time,           cause ocular damage. Eye
                                                                                         the requirements of ANSI Z87.1,
     polycarbonate plastic is the only         protection is especially important
                                                                                         mandated by OSHA for industrial
     clear lens material that has been         for functionally one-eyed sports
                                                                                         and educational safety eyewear.
     tested for sports and is                  participants (whose best corrected
     recommended for all sports with the       vision in their weaker eye is 20/40
     potential for impact. Other impact-       or worse). Eye protection devices
     resistant lens materials may be           are designed to significantly reduce
     available in the near future. Contact     the risk of injury, but can never
     lenses are not capable of protecting      provide a guarantee against such
     the eye from direct blows. Student-       injuries.

96
                                                                     Eye Safety in Sports




References

1. Prevent Blindness America:      4. Vinger PF Parver L, Alfaro
                                                ,
1998 Sports and Recreational          ,
                                   DV Woods T, Abrams BS. Shatter
Eye Injuries. Schaumburg, IL:      resistance of spectacle lenses.
Prevent Blindness America;         JAMA 1997; 277:142-144.
1999.
                                   5. Vinger PF A practical guide
                                                .
2. Napier SM, Baker RS,            for sports eye protection.
Sanford DG, et al.: Eye Injuries   Physician and Sportsmedicine,
in Athletics and Recreation.       2000;28;49-69.
Survey of Opthalmology.
                                   6. Play hard—play safe. San
41:229-244, 1996.
                                   Francisco, CA: American
3. Vinger PF: The Eye and          Academy of Ophthalmology,
Sports Medicine.In Duane TD,       2001.
Jaeger EA (eds): Clinical
Ophthalmology, vol. 5, chapter
45, J.B. Lippincott,
Philadelphia, PA 1994.




                                                                                            97
                         GUIDELINE 3c

     Mouthguards
     January 1986 • Revised August 2007



                             The NCAA Committee on                   2. “Properly fitted mouthguards”
                             Competitive Safeguards and              could protect the lip and cheek
                             Medical Aspects of Sports               tissues from being impacted and
                             acknowledges the significant input      lacerated against tooth edges.
                             of Dr. Jack Winters, past president
                             of the Academy of Sports Dentistry,     3. “Properly fitted mouthguards”
                             in the revision of this guideline.      could reduce the incidence of a
                                                                     fractured jaw caused by a blow
                             The NCAA has mandatory                  delivered to the chin or head.
                             equipment rules, including the use
                             of mouthguards for selective            4. “Properly fitted mouthguards”
                             sports. Various studies of              could provide protection to
                             “properly fitted mouthguards”           toothless spaces, so support is
                             indicate that they may reduce           given to the missing dentition of
                             dental injuries when blows to the       the student-athlete.
                             jaws or head are received.
                                                                     Stock, mouth-formed and custom-
                             The American Dental Association         fitted are three types of
                             has urged the mandatory use of          mouthguards recognized by the
                             mouthguards for those engaged in        American Dental Association. All
                             athletics activities that involve       need to be properly fitted for
                             body contact and endorsed their         maximum protection. Student-
                             use “in sporting activities in which    athletes should be advised as to
                             a significant risk of oral injury may   which “properly fitted
                             occur.” It is important when            mouthguard” is best for them and
                             considering the optimum protection      how it is best maintained to ensure
                             for an athlete that a thorough          the maximum fit and protection for
                             medical history be taken and the        daily practices and game-day wear.
                             demands of his or her position and      Medical staff personnel should
                             sporting activity be considered.        regularly oversee and observe the
                                                                     student-athletes and the “properly
                             Specific objectives for the use of      fitted mouthguards.”
                             “properly fitted mouthguards” as
                             protective devices in sports are        In order to realize fully the benefits
                             as follows:                             of wearing a mouthguard, the
                                                                     coach, student-athlete and medical
                             1. “Properly fitted mouthguards”        staff need to be educated about the
                             could reduce the potential chipping     protective functions of a
                             of tooth enamel surfaces and            mouthguard and the game rules
                             reduce fractures of teeth, roots        regarding mouthguard use must
                             or bones.                               be enforced.
98
                                                                                                      Mouthguards

  Sport          Position      Intra-oral Mouthguard             Color       Covers All Upper Teeth        When
Field Hockey      Field     Mandatory (NCAA Mod. 8.1.b);     Not specified         Not specified       Regular Season
                               strongly recommended                                                     Competition
                                   for goalkeepers                                                      and NCAA
                                                                                                       Championships
Football           All        Mandatory (NCAA 1.4.4.d) Readily Visible Color            Yes            Regular Season
                                                      (not white or transparent)                        Competition,
                                                                                                         Postseason
                                                                                                      Competition and
                                                                                                     NCAA Championships
Ice Hockey         All         Mandatory (NCAA 3.2)          Recommended            Covers all the     Regular Season
                                                                                   remaining teeth     Competition and
                                                                                     of one jaw.     NCAA Championships
Women’s            All         Mandatory (NCAA 2.8)          Not specified              Yes            Regular Season
Lacrosse                                                                                              Competition and
                                                                                                     NCAA Championships
Men’s Lacrosse     All         Mandatory (NCAA 1.20)         Yellow or any              Yes            Regular Season
                                                           other visible color                        Competition and
                                                                                                     NCAA Championships


 References

1. Using mouthguards to reduce            physiological parameters. MSSE.           October. Revised 2000, April).
the incidence and severity of             (38)8: 1500-1504.                         Dental Clinics of North America.
sports-related oral injuries.             4. Academy for Sports Dentistry.          7. American Dental Association.
American Dental Association.              “Position Statement: ‘A Properly
                                          Fitted Mouthguard’ Athletic               (1999). “Your Smile with a
2006.
2. Kumamoto, D and Maeda, Y. A            Mouthguard Mandates. Available
                                                                 ”                                ”
                                                                                    Mouthguard. (211 East Chicago
literature review of sports-related       at www.acadsportsdent.org.                Avenue, Chicago, IL, 60611)
orofacial trauma. General                 5. Stenger, J.M. (1964).                  8. Winters, J.E. (1996, June).
Dentistry. 2004:270-281.                  “Mouthguards: Protection Against          “The Profession’s Role in
3. Bourdin M, Brunet-Patru I,             Shock to Head, Neck and Teeth. ”
                                          Journal of the American Dental                     ”
                                                                                    Athletics. Journal of the
         ,
Hager P Allard Y, Hager J, Lacour
J, Moyen B. 2006. Influence of            Association. Vol. 69 (3). 273-281.        American Dental Association. Vol.
maxillary mouthguards on                  6. “Sports Dentistry. (1991,
                                                              ”                     127. 810-811.




                                                                                                                          99
                                             GUIDELINE 3d
      Use of the Head as a
      Weapon in Football and
      Other Contact Sports
        January 1976 • Revised June 2002



      Head and neck injuries causing                brunt of contact in the teaching of       inflicting instrument is illegal, and
      death, brain damage or paralysis              blocking or tackling;                     should be strongly discouraged by
      occur each year in football and                                                         coaches and game officials. This
      other sports. While the number of             2. Self-propelled mechanical ap-          concern is not only in football, but
      these injuries each year is relatively        paratuses shall not be used in the        also in other contact sports in which
      small, they are devastating occur-            teaching of blocking and tackling; and    helmets are used (e.g., ice hockey
      rences that have a great impact.                                                        and men’s lacrosse).
      Most of these catastrophic injuries           3. Greater emphasis by players,
      result from initiating contact with           coaches and officials should be placed    Football and all contact sports should
      the head. The injuries may not be             on eliminating spearing.                  be concerned with the prevention of
      prevented due to the forces encoun-                                                     catastrophic head injuries. The rules
                                                    Proper training in tackling and           against butting, ramming and spearing
      tered during collisions, but they can
      be minimized by helmet manufac-               blocking techniques, including a “see     with the helmet are for the protection
      turers, coaches, players and officials        what you hit approach,” constitutes       of the helmeted player and the
      complying with accepted safety                an important means of minimizing          opponent. A player who does not
      standards and playing rules.                  the possibility of catastrophic injury.   comply with these rules in any sport
                                                    Using the helmet as an injury-            is a candidate for a catastrophic injury.
      The American Football Coaches
      Association, emphasizing that the               1. NCAA Concussion Fact Sheets and Video
      helmet is for the protection of the             Available at www.NCAA.org/health-safety.
      wearer and should not be used as a              2. Heads Up: Concussion Tool Kit
      weapon, addresses this point                    CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm.
      as follows:                                     3. Heads Up Video
                                                      NATA. Streaming online at www.nata.org/consumer/headsup.htm.
      1. The helmet shall not be used as the

      References

      1. Kleiner, D.M., Almquist, J.L., Bailes,     2. LaParade RF, Schnetzler KA,            4. Thomas BE, McCullen GM, Yuan HA:
      J., Burruss, P., Feurer, H., Griffin, L.Y.,   Broxterman RJ, Wentorf F, Wendland E,     Cervical Spine Injuries in Football
      Herring, S., McAdam, C., Miller, D.,          Gilbert TJ: Cervical Spine Alignment in   Players: J Am Acad Orthop Surg Sept-
      Thorson, D., Watkins, R.G., Weinstein, S.     the Immobilized Ice Hockey Player: A      Oct; 7 (5), 338-47, 1999.
      Prehospital Care of the Spine-Injured         Computer Tomographic Analysis of the      5. Wojtys EM, Hovda D, Landry G,
      Athlete: A Document from the Inter-
                                                    Effects of Helmet Removal: Am J Sports    Boland A, Lovell M, McCrea M, Minkoff
      Association Task Force for Appropriate
                                                    Med 27: 177-180, 1999.                    J: Concussion in Sports: Am J Sports
      Care of the Spine-Injured Athlete. Dallas,
100   National Athletic Trainers’ Association,      3. The Spine Injury Management Video      Med 27: 676-687, 1999.
      March, 2001.                                  Human Kinetics, Champaign, Illinois.
                                  GUIDELINE 3e
Guidelines for Helmet
Fitting and Removal
in Athletics
 June 1990 • Revised June 2006



Several sports, including football,      between the medical staff and           or turn the helmet with the wearer
men’s lacrosse and ice hockey,           emergency-transportation personnel      resisting the movement.
require wearing tight-fitting,           should be maintained. It is
similarly constructed helmets. The       important that those involved in the    With a properly fitted helmet, the
following guidelines, while focused      medical management of teams             top of the head is separated from
on football, are applicable to           engaged in collision and contact        the helmet shell by a uniform,
periodic evaluation, fitting and         sports, and the student-athlete be      functional, shock-absorbing
removal of protective helmets worn       knowledgeable about the helmet.         support lining. Daily evaluation of
in any sport. These guidelines           The student-athlete should be           this support mechanism, including
represent minimal standards of care      instructed in the fitting, care and     cheek and brow pads, for
that are designed to assist              use of the helmet. Helmet               placement and resiliency should be
physicians, coaches, athletic            manufacturer guidelines should be       taught to the student-athlete. Hel-
trainers, paramedics, EMTs and           reviewed and followed for proper        mets that require air inflation
hospital personnel who care for          fitting and care techniques.            should be inflated and inspected
student-athletes.                                                                daily by the student-athlete. Helmet
                                         The resilient plastic shell is shaped   shells should be examined weekly
Medical coverage of interscholastic      spherically to deflect impacts.         for cracking and be inspected
and intercollegiate teams entails        Interior suspension pads are            closely again if the face mask has
many routine preventive and acute        designed to match the skull contour     been bent out of shape. All helmets
health-care duties for dedicated         to ensure a snug crown fit. Various     need to be reconditioned and the
practicing professionals; however,       rigid and removable jaw and brow        attachments of the mask replaced
an occasional, serious, on-the-field,    pads, along with the chin strap,        on a yearly basis.
life-threatening head and/or neck        help to hold the sides of the helmet
injury poses a difficult challenge. It   firmly against the mandible and the     Although the helmet is designed
is incumbent upon those                  forehead. When in place, the front      for a stable fit for protection during
individuals assigned to provide          edge of the helmet should be            play, removal of the helmet by
medical coverage to be prepared to       positioned about a finger’s breadth     others is relatively difficult. In the
handle each situation efficiently        above the eyebrows. Pressure on         case of a head or neck injury,
and expertly.                            the helmet crown should be              jostling and pulling during removal
                                         dissipated through the interior         presents high potential for further
Proper on-the-field management of        suspension padding over the top of      trauma.
head and neck injuries is essential      the head.
to minimize sequelae, expedite                                                   Unless there are special
emergency measures and to prepare        The helmet should fit snugly            circumstances such as
for transportation. The action of        without dependence on the chin          respiratory distress coupled with
those in attendance must not             strap. The helmet should not twist      an inability to access the airway,
compound the problem. For this           or slide when an examiner grasps        the helmet should never be
reason, clear communication              the face mask and attempts to rock      removed during the pre-hospital          101
      Guidelines for Helmet Fitting and Removal in Athletics

      care of the student-athlete with       necessitating the use of PVC pipe        •	 By	rotating	the	helmet	slightly	
      a potential head/neck                  cutters, garden shears or a              forward, it should now slide off the
      injury unless:                         screwdriver. Those involved in the       occiput. If the helmet does not
                                             pre-hospital care of the injured         move with this action, slight
      1. The helmet does not hold the        student-athlete should have readily      traction can be applied to the
      head securely, such that               available proper tools for easy          helmet as it is carefully rocked
      immobilization of the helmet does      facemask removal and should              anteriorly and posteriorly, with
      not immobilize the head;               frequently practice removal              great care being taken not to move
                                             techniques for facemasks and             the head/neck unit.
      2. The design of the sport helmet is   helmets. It should be noted that         •	 The	helmet	should	not	be	spread	
      such that even after removal of the    cold weather and old loops may           apart by the earholes, as this
      facemask, the airway cannot be         make cutting difficult. The chin         maneuver only serves to tighten the
      controlled or ventilation provided;    strap can be left in place unless        helmet on the forehead and on the
                                             resuscitative efforts are necessary.     occipital regions.
      3. After a reasonable period of        For resuscitation, the mouthpiece        •	 All	individuals	participating	in	
      time, the facemask cannot be           needs to be manually removed.            this important maneuver must
      removed; or                                                                     proceed with caution and
                                             Once the ABCs are stabilized,            coordinate every move.
      4. The helmet prevents                 transportation to an emergency
      immobilization for transportation      facility should be conducted with
                                                                                      If the injured student-athlete, after
      in an appropriate position.            the head secure in the helmet and
                                                                                      being rehabilitated fully, is allowed
                                             the neck immobilized by strapping,
                                                                                      to participate in the sport again,
      When such helmet removal is            taping and/or using lightweight          refitting his/her helmet is
      necessary in any setting, it should    bolsters on a spine board. When          mandatory. Re-education about
      be performed only by personnel         moving an athlete to the spine           helmet use as protection should be
      trained in this procedure.             board, the head and trunk should be      conducted. Using the helmet as an
                                             moved as a unit, using the lift/slide    offensive, injury-inflicting
      Ordinarily, it is not necessary to     maneuver or a log-roll technique.        instrument should be
      remove the helmet on the field to                                               discouraged.
      evaluate the scalp. Also, the helmet   At the emergency facility,
      can be left in place when              satisfactory initial skull and
      evaluating an unconscious student-     cervical X-rays usually can be
      athlete, an individual who             obtained with the helmet in place.
      demonstrates transient or persistent   Should removal of the helmet be
      neurological findings in his/her       needed to initiate treatment or to
      extremities, or the student-athlete    obtain special X-rays, the following
      who complains of continuous or         protocol should be considered:
      transient neck pain.                   •	 With	the	head,	neck	and	helmet	
                                             manually stabilized, the chin strap
      Before the injured student-athlete     can be cut.
      is moved, airway, breathing and        •	 While	maintaining	stability,	the	
      circulation (ABCs) should be           cheek pads can be removed by
      evaluated by looking, listening and    slipping the flat blade of a
      palpation. To monitor breathing,       screwdriver or bandage scissor
      care for facial injury, or before      under the pad snaps and above the
      transport regardless of current        inner surface of the shell.
      respiratory status, the facemask       •	 If	an	air	cell-padding	system	is	
      should be removed by cutting or        present, it can be deflated by
      unscrewing the loops that attach       releasing the air at the external port
      the mask to the helmet. These          with an inflation needle or large-
      loops may be difficult to cut,         gauge hypodermic needle.
102
                                          Guidelines for Helmet Fitting and Removal in Athletics




References

1. Anderson C: Neck Injuries—Back-        Cervical Spine. National Athletic Trainers’   6. US Lacrosse. www.uslacrosse.org.
board, bench or return to play? The       Association, 2000. (2952 Stemmons Free-       Lacrosse Helmet Facemask/Chinguard
Physician and Sports Medicine 21(8):      way, Dallas, Texas 75247, www.nata.org)       Removal Hints for Certified Athletic
23-34, 1993.                              4. AOSSM Helmet Removal Guidelines.           Trainers. US Lacrosse, 2008. Available
2. Guidelines for Helmet Fitting and      The American Orthopedic Society for           at www.uslacrosse.org/safety.
Removal in Athletics. Illinois State      Sports Medicine. (6300 N. River Road,         7. National Operating Committee on
Medical Society, 1990. (20 North          Suite 200, Rosemont, Illinois 60018           Standards for Athletic Equipment
Michigan Avenue, Chicago, Illinois        www.sportsmed.org).                           (NOCSAE). www.nocsae.org.
60602)                                    5. The Hockey Equipment Certification
3. Inter-Association Task Force for the   Council Inc. www.hecc.net.




                                                                                                                                 103
                                      GUIDELINE 3f
      Use of Trampoline
      and Minitramp
       June 1978 • Revised June 2002


      The NCAA recognizes that the              persons controlling the safety       and name of inspector, should be
      coaches and student-athletes in           harness should have the              kept on file.
      selected sports use the trampoline        necessary strength, weight and
      and minitramp for developing              training for that responsibility;    Minitramp
      skills. The apparent safety record
      accompanying such use has been            c. Skills being encouraged           The minitramp, while different in
      good, but the use of the trampoline       should be commensurate with          nature and purpose from the
      can be dangerous. Therefore, these        the readiness of the student-        trampoline, shares its association
      guidelines should be followed in          athlete, and direct observation      with risk of spinal cord injury from
      those training activities in which        should confirm that the student-     poorly executed and/or spotted
      student-athletes use the trampoline:      athlete is not exceeding his or      tricks. Like the trampoline, the
                                                her readiness; and                   minitramp requires competent
      1. Trampolines should be                                                       instruction and supervision,
      supervised by persons with                d. Spotters are aware of the         spotters trained for that purpose
      competence in the use of the              particular skill or routine being    (spotting somersaults on the
      trampoline for developing athletics       practiced and are in an
                                                                                     minitramp differs from the
      skills. This implies that:                appropriate position to spot
                                                                                     trampoline because of the running
                                                potential errors. Accurate
                                                                                     action preceding the somersault),
         a. Fellow coaches, student-            communication is important to
                                                                                     emphasis on the danger of
         athletes, managers, etc., are          the successful use of these
                                                                                     somersaults and dive rolls, security
         trained in the principles and          techniques.
                                                                                     against unsupervised use, proper
         techniques of spotting with the                                             erection and maintenance of the
         overhead harness, “bungee           2. Potential users of the trampoline
                                             should be taught proper procedures      apparatus, a planned procedure for
         system” and/or hand spotting on                                             emergency care should an accident
         the trampoline;                     for folding, unfolding, transporting,
                                             storing and locking the trampoline.     occur, and documentation of
                                                                                     participation and any accidents that
         b. New skills involving
                                             3. The trampoline should be             occur. In addition, no single or
         somersaults should be learned
                                             erected in accordance with              multiple somersault should be
         while wearing an overhead
                                             manufacturer’s instructions. It         attempted unless:
         safety harness. (Exception: Use
         of the overhead system is not       should be inspected regularly and
                                             maintained according to established     1. The student-athlete has
         recommended for low-level
                                             standards. All inspection reports,      demonstrated adequate progression
         salto activities such as saltos
                                             including the date of inspection        of skill before attempting any
         from the knees or back.) Those




104
                                                                            Use of Trampoline and Minitramp

somersault (i.e., on the trampoline
with a safety harness, off a diving
board into a swimming pool or
tumbling with appropriate
spotting);

2. One or more competent spotters
who know the skill being attempted
are in position and are physically
capable of spotting an improper
execution;

3. The minitramp is secured
reasonably or braced to prevent
slipping at the time of execution in
accordance with recommendations
in the USA Gymnastics Safety
Handbook; and

4. A mat is used that is sufficiently
wide and long to prevent the
performer from landing on the
mat’s edge and to provide proper
footing for the spotter(s).




References

1. American Alliance for Health,           related injuries. J Bone Joint Surg Am.
Physical Education, Recreation and         1995; 77:1174-1178.
Dance: The use of the trampoline for the   4. Trampolines at Home, School and
development of competitive skills in       Recreational Centers Policy Statement of
sports. Journal of Physical Education,     the American Academy of Pediatrics.
Recreation and Dance 49(8):14, 1978.       Pediatrics Vol. 103 (5) 1999 pp. 1053-
2. Hennessy JT: Trampoline safety and      1056. (www.aop.org/policy/re9844.html).
diving programs. U.S. Diving Safety        5. USA Gymnastics: USA Gymnastics
Manual. Indianapolis, IN: U.S. Diving      Safety Handbook, 1994. (201 S. Capitol
Publications, 1990.                        St., Ste. 300, Indianapolis, IN 46225)
3. Larson BJ, Davis JW. Trampoline-
                                                                                                              105
Appendixes
Also found on the NCAA website at: NCAA.org/health-safety
                                          Appendix A
      2011-12 NCAA
      Banned Drugs
      The NCAA bans the following classes of drugs:
      a.   Stimulants;
      b.   Anabolic Agents;
      c.   Alcohol and Beta Blockers (banned for rifle only);
      d.   Diuretics and Other Masking Agents;
      e.   Street Drugs;
      f.   Peptide Hormones and Analogues;
      g.   Anti-Estrogens; and
      h.   Beta-2 Agonists.
      Note: Any substance chemically related to these classes is also banned. The institution and
      the student-athlete shall be held accountable for all drugs within the banned-drug class
      regardless of whether they have been specifically identified.


      Drugs and Procedures Subject to Restrictions:
      •	   Blood	Doping.
      •	   Local	Anesthetics	(under	some	conditions).
      •	   Manipulation	of	Urine	Samples.
      •	   Beta-2	Agonists	permitted	only	by	prescription	and	inhalation.		
      •	   Caffeine	–	if	concentrations	in	urine	exceed	15	micrograms/ml.


      NCAA Nutritional/Dietary Supplements Warning:
         B
      •	 	 efore	consuming	any	nutritional/dietary	supplement	product,	review	the	product	and	
         its	label	with	your	athletics	department	staff!		
      •	 Dietary	supplements	are	not	well	regulated	and	may	cause	a	positive	drug	test	result.	
      •	 Student-athletes	have	tested	positive	and	lost	their	eligibility	using	dietary	supplements.			
      •	 Many	dietary	supplements	are	contaminated	with	banned	drugs	not	listed	on	the	label.
      •	 Any	product	containing	a	dietary	supplement	ingredient	is	taken	at	your	own	risk.	
      Information	 about	 ingredients	 in	 medications	 and	 nutritional/dietary	 supplements	 can	 be	
      obtained by contacting	the	Resource	Exchange	Center	(REC)	at	877/202-0769	or	www.
      drugfreesport.com/rec	(password	ncaa1,	ncaa2	or	ncaa3).




108
                                   Appendix B
NCAA Legislation
Involving Health and
Safety Issues
This	chart	should	be	used	as	a	quick	reference	for	NCAA	legislation	involving	health	and	safety	issues	that	appears	in	
the	2011-12	NCAA	Divisions	I,	II	and	III	Manuals.		The	comment	section	does	not	capture	the	full	scope	of	the	
legislation; users are encouraged to review the full bylaw in the appropriate divisional manual. Because of the dynamic
nature	of	the	NCAA	legislative	process,	the	most	current	information	on	these	and	any	new	legislation	should	be	
obtained through the institution's athletics department compliance staff.

Regulations Involving Health and Safety Issues

Topic		           Issue	                                   NCAA	           Comments
	                 	                                        Bylaw	Cite
                   List	of	Banned	Drug	Classes              31.2.3.4       Lists	all	drug	classes	currently	banned	by	
                                                                           the	NCAA.

     Banned	       Drugs and Procedures Subject to          31.2.3.4.1     List	of	drugs	and	procedures	that	are	
      Drugs        Restrictions                                            restricted.

                   Effect on Eligibility                    18.4.1.5       A positive test for use of a banned
                                                                           (performance enhancing or "street") substance
                                                                           results in loss of eligibility.

                   Effect	on	Championship	Eligibility       18.4.1.5       A positive test for a banned (performance
                                                                           enhancing or "street") substance results in
                                                                           loss	of	eligibility,	including	eligibility	for	
                                                                           participation in postseason competition.

                   Transfer While Ineligible Due to         13.1.1.3.5     Institution at which student-athlete tested
                   Positive Drug Test                       (Div.	I),	     positive for use of a banned substance must
                                                            13.1.1.2.4	    report the test result to the institution to which
                                                            (Div.	II),	    the student-athlete is transferring.
                                                            13.1.1.2.6	
                                                            (Div. III)

                   Knowledge	of	Use	of	Banned	Drugs         10.2	          Athletics department staff members or others
                                                                           employed by intercollegiate athletics
                                                                           department with knowledge of a student-
                                                                           athlete's use of a banned substance must
                                                                           follow institutional policies.

                   Athletics Department Resource            3.2.4.7	       Institutions must designate an individual (or
                   for Banned Drugs and Nutritional         (Div. I)       individuals) as an athletics department
                   Supplements                                             resource	for	questions	related	to	NCAA	
                                                                           banned drugs and nutitional supplements.
                                                                                                                                109
      NCAA Legislation Involving Health and Safety Issues


                        Banned Drugs and Drug-Testing       18.4.1.5.2    NCAA	Executive	Committee	is	charged	with	
                        Methods                                           developing a list of banned substances and
           Drug                                                           approving all drug-testing procedures.
          Testing
                        Consent	Form:	Content	and	Purpose   14.1.4.1      Consent	must	be	signed	before	competition	or	
                                                                          practice or before the Monday of fourth week
                                                                          of classes. Failure to sign consent results in
                                                                          loss of eligibility.

                        Consent	Form:	Administration        14.1.4.2,     Institution must administer consent form to
                                                            3.2.4.7       all student-athletes each academic year at the
                                                            (Div. I);     time the intercollegiate squads report for
                                                            14.1.4.2,     practice.	At	this	time,	institutions	must	also	
                                                            3.2.4.6       distribute to student-athletes the list of banned
                                                            (Div. II);    drug classes.
                                                            14.1.4.3,
                                                            3.2.4.6
                                                            (Div. III)


                        Consent	Form:	Exception,	           14.1.4.3      Student-athletes who are trying out must sign
                        14-Day	Grace	Period                 (Div. I)                                           a
                                                                          the	form	within	14	days	of	the	first		 thletics-
                                                            14.1.4.2                                      c
                                                                          related	activity	or	before	they		 ompete,	
                                                            (Div. II)     whichever occurs first.

                        Effect	of	Non-NCAA	Athletics	       18.4.1.5.3    A student-athlete under a drug-test suspension
                        Organization's Positive Drug Test                 from a national or international sports
                                                                          governing	body	shall	not	compete	in	NCAA	
                                                                          intercollegiate competition.

                        Failure To Properly Administer      14.1.4.4      Failure to properly administer drug-testing
                        Drug-Testing	Consent	Form                         consent form is considered an institutional
                        (Div. I and Div. II only)                         violation.

                        Drug Rehabilitation Program         16.4.1        Permissible for institution to cover the costs
                        Expenses                            (Div. I and   of a student-athlete's drug rehabilitation
          Drug                                              Div.	II),	    program.
       Rehabilitation                                       16.4
                                                            (Div. III)

                        Travel To and From Drug             16.12.1       Permissible to file a waiver under Bylaw
                        Rehabilitation Program                            16.12.1	to	cover	costs	associated	with	a	drug	
                                                                          rehabilitation program.

                        Permissible Supplements             16.5.2(g)     Institution may provide only permissible
        Nutritional                                         (Div.	I),     nutritional supplements that do not contain
       Supplements                                          16.5.1(h)     any	NCAA	banned	substances.	See	Bylaw	
                                                            (Div. II)     for details.




110
                                          NCAA Legislation Involving Health and Safety Issues

              Restricted Advertising and Sponsorship   31.1.14.1      No	tobacco	advertisements	in,	or	sponsorship	
              Activities                               (Div.	I),      of,	NCAA	championships	or	regular-season	
 Tobacco                                               31.1.12.1      events.
   Use                                                 (Div. II)
                                                       31.1.11.1
                                                       (Div. III)

              Tobacco	Use	at	Member	Institution        11.1.5	(Div.	I Use	of	tobacco	products	is	prohibited	by	all	
                                                       and	Div.	II), game personnel and all student-athletes in all
                                                       17.1.8	(Div.	I), sports during practice and competition.
                                                       17.1.9	(Div.	II),
                                                       17.1.11
                                                       (Div. III)

              Permissible Medical Expenses             16.4.1(Div.	I	 Permissible	medical	expenses	are	outlined.		If	
                                                       and	Div.	II),	 expense	is	not	on	the	list,	refer	to	Bylaw	
 Medical                                               16.4	(Div.	III) 16.12.1	for	waiver	procedure.
 Expenses
              Eating Disorders                         16.4.1         Institution	may	cover	expenses	of	counseling	
              (Div. I and Div. II only)                               related to the treatment of eating disorders.

              Transportation for Medical Treatment     16.4.1         Institution may cover or provide transportation
              (Div. I and Div. II only)                               to and from medical appointments.

              Summer	Conditioning	-	Football           13.2.7         Institution	may	finance	medical	expenses	for	
                                                                      a prospect who sustains an injury while
              Summer	Conditioning	-	Sports	other	      13.2.8         participating in nonmandatory summer
              than Football (Div. I only)                             conditioning activities that are conducted by
                                                                      an institution's strength and
                                                                      conditioning coach.

              Hardship Waiver                          14.2.4         Under	certain	circumstances,	a	student-athlete	
                                                       (Div.	I),      may be awarded an additional season of
 Medical                                               14.2.5         competition to compensate for a season that
 Waivers                                               (Div. II and   was not completed due to incapacitating
                                                       Div. III)      injury or illness.

              Five-Year/10-Semester	Rule	Waiver        14.2.1.5.1	    Under	certain	circumstances,	a	student-athlete	
                                                       (Div.	I),	     may be awarded an additional year of
                                                       14.2.2.3	      eligibility if he or she was unable to participate
                                                       (Div. II)      in intercollegiate athletics due to incapacitating
                                                       14.2.2.4	      physical or mental circumstances.
                                                       (Div. III)

              HIPAA/Buckley	Amendment	Consent	         3.2.4.9,	      The	authorization/consent	form	shall	be	
  Medical     Forms                                    14.1.6	        administered individually to each student-
Records and                                            (Div. I);      athlete by the athletics director or the athletics
 Consent                                               3.2.4.7,       director's designee before the student-athlete's
  Forms                                                14.1.5	        participation in intercollegiate athletics each
                                                       (Div. II);     academic	year.	Signing	the	authorization/
                                                       3.2.4.7,       consent shall be voluntary and is not required
                                                       14.1.6         by the student-athlete's institution for medical
                                                       (Div. III)     treatment,	payment	for	treatment,	enrollment	
                                                                      in a health plan or for any benefits (if
                                                                      applicable) and is not required for the student-
                                                                      athlete to be eligible to participate. Any
                                                                      signed	authorization/consent	forms	shall	be	         111
                                                                      kept on file by the director of athletics.
      NCAA Legislation Involving Health and Safety Issues

                        Time Restrictions on Athletics-         17.1.6         All	NCAA	sports	are	subject	to	the	time	
      Student-Athlete   Related Activities                                     limitations	in	Bylaw	17.
        Welfare and     (Div. I and Div. II only)
          Safety
                        Daily/Weekly	Hour	Limitation	–	Inside	 17.1.6.1        During	the	playing	season,	a	student-athlete	
                        Playing Season                                         cannot engage in more than 20 hours of
                        (Div. I and Div. II only)                              athletics-related	activity	(see	Bylaw	17.02.1)	
                                                                               per	week,	with	not	more	than	four	hours	of	
                                                                               such activity in any one day.

                        Weekly	Hour	Limitations	–	Outside	      17.1.6.2       Outside	of	the	playing	season,	student-athletes	
                        Playing Season                                         cannot engage in more than eight hours of
                        (Div. I and Div. II only)                              conditioning activities per week.

                        Skill	Instruction	Exception             17.1.6.2.2,	   Outside	of	the	playing	season,	two	of	the	
                        (Div. I and Div. II only)               17.1.6.2.3     student-athlete's eight hours of conditioning
                        See	Bylaws	17.1.6.2.2	and	17.1.6.2.3	   (Div.	I),      activity may be skill-related instruction with
                        (Div.	I)	for	additional	exceptions.     17.1.6.2,      coaching staff.
                                                                17.1.6.2.1
                                                                (Div. II)

                        Required	Day	Off	–	Playing	Season       17.1.6.4       During	the	playing	season,	each	student-
                                                                (Div. I and    athlete must be provided with one day per
                                                                Div.	II),      week on which no athletics-related activities
                                                                17.1.6         are scheduled.
                                                                (Div. III)

                        Required	Days	Off	–	Outside	Playing	    17.1.6.5       Outside	the	playing	season,	each	student-
                        Season (Div. I and Div. II only)                       athlete must be provided with two days per
                                                                               week on which no athletics-related activities
                                                                               are scheduled.

                        Voluntary	Summer	Conditioning           13.11.3.8      Prospective	student-athletes,	who	signed	an	NLI	
                        (Div. I only)                           (basketball)   or enrolled in the institution's summer term prior
                                                                               to	initial,	full-time	enrollment,	may	engage	in	
                                                                               voluntary summer workouts conducted by an
                                                                               institution's strength and conditioning coach with
                                                                               department-wide duties.

                        Voluntary	Summer	Conditioning           13.11.3.7      Prospective	student-athletes,	who	signed	an	
                        (Div. I only)                           (football)     NLI	or	enrolled	in	the	institution's	summer	
                                                                               term	prior	to	initial,	full-time	enrollment,	may	
                                                                               engage in voluntary summer workouts
                                                                               conducted by an institution's strength and
                                                                               conditioning coach with department-wide
                                                                               duties (FBS) or a countable coach who is a
                                                                               certified strength and conditioning coach
                                                                               (FCS).




112
                                           NCAA Legislation Involving Health and Safety Issues

                  Voluntary Summer                 13.11.3.9		       In	sports	other	than	football	and	basketball,	
                  Conditioning		                   (Sports Other     a prospective student-athlete may engage in
Student-Athlete
                  (Div. I only)                    Than Football     voluntary summer workouts conducted by
  Welfare and
                                                   and Basketball)   an institution's strength and conditioning
    Safety
                                                                     coach with department-wide duties and may
                                                                     receive workout apparel (on an issuance and
                                                                     retrieval	basis),	provided	he	or	she	is	
                                                                     enrolled in the institution's summer term
                                                                     prior to the student's initial full-time
                                                                     enrollment at the certifying institution. Such
                                                                     a prospective student-athlete may engage in
                                                                     such workouts only during the period of the
                                                                     institution's summer term or terms (opening
                                                                     day of classes through last day of final
                                                                     exams)	in	which	he	or	she	is	enrolled.	

                  Voluntary Weight-Training        13.11.3.9.4       A strength and conditioning coach who conducts
                  or	Conditioning	Activities		                       voluntary weight-training or conditioning
                  (Div. I only)                                      activities is required to maintain certification in
                                                                     first aid and cardiopulmonary resuscitation.

                                                                     If a member of the institution's sports medicine
                                                                     staff	(e.g.,	athletic	trainer,	physician)	is	present	
                                                                     during voluntary conditioning activities
                                                                     conducted	by	a	strength	and	conditioning	coach,	
                                                                     the sports medicine staff member must be
                                                                     empowered with the unchallengeable authority
                                                                     to cancel or modify the workout for health and
                                                                     safety	reasons,	as	he	or	she	deems	appropriate.

                  Sports-Safety Training           11.1.6	           Each head coach and all other coaches who
                                                   (Div. II)         are employed full time at an institution shall
                                                                     maintain	current	certification	in	first	aid,	
                                                                     cardiopulmonary	resuscitation	(CPR)	and	
                                                                     automatic	external	defibrillator	(AED)	use.

                                                   11.1.6	           Each head coach shall maintain current
                                                   (Div. III)        certification	in	first	aid,	cardiopulmonary	
                                                                     resuscitation	(CPR)	and	automatic	external	
                                                                     defibrillator (AED) use.

                  Discretionary Time               17.02.14          Student-athletes may only participate in
                  (Div. I only)                                      athletics activities at their initiative during
                                                                     discretionary time.

                  Mandatory Medical                17.1.5            All student-athletes beginning their initial
                  Examinations                                       season of eligibility and students who are
                                                                     trying out for a team must undergo a medical
                                                                     exam	before	they	are	permitted	to	engage	in	
                                                                     any	physical	activity.	The	exam	must	take	
                                                                     place	within	six	months	before	the	physical	
                                                                     activity.	Each	subsequent	year,	an	updated	
                                                                     medical history must be administered by an
                                                                     institutional medical staff member.


                                                                                                                             113
      NCAA Legislation Involving Health and Safety Issues

                        Mandatory Medical                    17.1.5.1	              The	examination	or	evaluation	of	student-
      Student-Athlete   Examinations                         (Div. I)               athletes who are beginning their initial season
        Welfare and                                                                 of eligibility and students who are trying out
          Safety                                                                    for a team shall include a sickle cell solubility
                                                                                    test,	unless	documented	results	of	a	prior	test	
                                                                                    are provided to the institution or the
                                                                                    prospective student-athlete or student-athlete
                                                                                    declines the test and signs a written release.

                        Five-Day	Acclimatization	Period	–	   17.9.2.3	              Five-day acclimatization for conducting
                        Football                             (Div.	I),              administrative and initial practices is required
                                                             17.9.2.2               for first-time participants (freshmen and
                                                             (Div. II and           transfers) and continuing student-athletes.
                                                             Div. III)

                        Preseason	Practice	Activities	–      17.9.2.4               Preseason practice time limitations and
                        Football                             (Div.	I),              general regulations.
                                                             17.9.2.3	(Div.	II	
                                                             and Div. III)

                        Out-of-Season Athletics-Related      17.9.6                 Permissible summer conditioning activities.
                        Football Activities                  (Div. I and
                                                             Div.	III),
                                                             17.9.8	(Div.	II)

                        Sports-Specific	Safety	Exceptions	   13.11.3.10             A coach may be present during voluntary
                        (Equestrian;	Fencing;	Gymnastics;	   (Div. I);              individual workouts in the institution’s regular
                        Rifle; Women’s Rowing; Skiing;       17.6.7;17.7.7;         practice facility (without the workouts being
                        Swimming; Track and Field;           17.11.7;	17.14.7;	     considered as countable athletics-related
                        Water Polo; and Wrestling.)          17.15.7	(Div.	         activities) when the student-athlete uses sport-
                        (Div. I and Div. II only)            I);17.15.9	(Div.	      specific equipment. The coach may provide
                                                             II);	17.18.7;          safety or skill instruction but cannot conduct
                                                             17.24.7	(Div.	I);	     the individual’s workouts.
                                                             17.24.8	(Div.	II);	
                                                             17.26.8;	17.27.7	
                                                             (Div. I and Div. II)

                        Playing Rules Oversight Panel        21.1.4                 The panel shall be responsible for resolving
                                                                                    issues	involving	player	safety,	financial	impact	
                                                                                    or image of the game.

                        Concussion	Management	Plan           3.2.4.17	(Div.	I	   Institutions must have a concussion
                                                             and Div. II);       management plan for student-athletes. See
                                                             3.2.4.16	(Div.	III) Guideline	2i.




114
                                     Appendix C
NCAA Injury
Surveillance
Program Summary
The	NCAA	Injury	Surveillance	              Surveillance Program supports rule       Two easy ways
Program	was	developed	in	1982	to	          and policy changes that improve stu-     to participate:
provide current and reliable data on       dent-athlete health and safety. In
                                                                                    The	Injury	Surveillance	Tool (IST)
injury trends in intercollegiate athlet-   addition,	program	participation	pro-     facilitates the workflow in the ath-
ics. It collects injury and activity       vides a number of benefits to athletic   letic training room and supports an
information in order to identify and       trainers	and	their	institutions:         enhanced level of documentation
highlight potential areas of concern
                                           Safer	participation	in	collegiate	       and record keeping. The IST is
and interest related to student-
                                           sports.	In	some	cases,	surveillance	     designed as a free injury incident
athlete health and safety.                                                          report,	and	allows	documentation	of	
                                           information has led to a mitigation
                                           of	injuries	and	treatments	(e.g.,	       injuries.	In	doing	so,	the	IST	pro-
Injury data are collected yearly by                                                 vides important injury information
                                           heat illness episodes).
the	Datalys	Center	from	a	sample	of	                                                to	the	Datalys	Center	and	helps	to	
NCAA	member	institutions,	and	the	         Resource Justification and
                                                                                    initiate a paper record keeping pro-
resulting data summaries are               Allocation. Surveillance informa-        cess for the athletic trainer.
reviewed	by	the	NCAA	Committee	            tion has been used in the NATA’s
                                                                                    The	Export	Engine	Program
on	Competitive	Safeguards	and	             Recommendations	and	Guidelines	
                                                                                    (EE) is a public data transmission
Medical Aspects of Sports. The com-        for	Appropriate	Medical	Coverage	
                                                                                    standard that commercial vendors
mittee’s goal continues to be to           of Intercollegiate Athletics
                                                                                    can voluntarily adopt. Through the
reduce injury rates through suggested      (AMCIA)	document.	
                                                                                    Export	Engine	Program,	athletic	
changes	in	rules,	protective	equip-
                                           Supports	Clinical	Best	Practices.        trainers can directly and easily sub-
ment	or	coaching	techniques,	based	
                                           Regional and national injury rate        mit data from their vendor systems
on the data.
                                           comparisons allow a university to        to the Injury Surveillance Program.
                                           explore	relevant	clinical	best	prac-     If you are considering a new sys-
In	some	instances,	the	evaluation	of	
                                           tices with appropriate peer groups.      tem,	be	sure	to	look	for	the	Datalys	
the injury surveillance information
                                                                                    Certified	logo.	Its	certified	vendors	
has	led	the	NCAA	to	commission	            Supports	Risk	Management	Best	
                                                                                    currently	include	ATS,	Nextt	
research studies to better understand      Practice. The electronic documen-
                                                                                    Solutions and SIMS.
the underlying factors that have con-      tation	of	injuries	(e.g.,	through	an	
tributed to the observed surveillance      Export	Engine	Certified	vendor	or	       Data	Availability	and	Access.	
findings. To support the objective and     the Injury Surveillance Tool) is a       Injury surveillance data collected
nature	of	the	NCAA’s	Injury	               recognized risk management best          through	the	NCAA’s	Injury	
Surveillance	Program	–	monitoring	to	                                               Surveillance Program is available
                                           practice.
identify areas of concern for potential                                             to the public through the Datalys
                                           Facilitates	Paper	Record	Keeping	        Injury	Statistics	Clearinghouse	
further	investigation	–	the	Datalys	       Processes. For institutions manag-       (DISC),	a	web-based	research	por-
Center	does	not	collect	identifiable	
                                           ing their health records via a paper     tal.	DISC	provides	a	searchable	
information or treatment information.
                                           process,	the	Injury	Surveillance	        Document	Library	for	published	
                                           Tool facilitates the workflow and        reports and data on sports injuries.
Program Benefits                           supports an enhanced level of doc-       DISC	also	provides	an	interactive	
Participation	in	the	NCAA’s	Injury	        umentation and record keeping.           Query Tool for public use that           115
      NCAA Injury Surveillance System Summary


      allows registered users to interac-
      tively query available datasets for
      summary	information,	such	as	
      national	injury	rates,	injury	rates	by	
      sports,	and	injury	rates	by	type	of	
      injury.		DISC	will	be	launched	
      in	the	fall	of	2010	and	
      can be found at www.disc.
      datalyscenter.org.
      Sampling
      Since	its	inception,	the	surveillance	
      program has depended on a volun-
      teer “convenience sample” of
      reporting schools. Participation is
      available to the population of insti-
      tutions sponsoring a given sport.
      Schools qualifying for inclusion in
      the final sample are selected from
      the total participating schools for
      each	NCAA	sport,	with	the	goal	of	
      representation	of	all	three	NCAA	
      divisions. A school is selected as
      qualifying for the sample if they
      meet the minimum standards for
      data collection.
      It is important to recognize that this
      system does not identify every inju-
      ry	that	occurs	at	NCAA	institutions	
      in	a	particular	sport.	Rather,	the	       Exposures (Activity)                    All Sports Figures
      emphasis is collecting all injuries       An	athlete	exposure	is	defined	as	      The following figures outline
      and	exposures	from	schools	that	          one athlete participating in one        selected information from the
      voluntarily participate in the Injury     practice or competition in which he     sports currently reported by the
      Surveillance Program. The Injury          or	she	is	exposed	to	the	possibility	   NCAA	Injury	Surveillance	Program	
      Surveillance Program attempts to          of athletics injury.                    from	2004	to	2009.		Complete	sum-
      balance the dual needs of maintain-       Injury Rate                             mary reports for each sport are
      ing a reasonably representative                                                   available online at www.disc.
                                                An injury rate is simply a ratio of
      cross-section	of	NCAA	institutions	                                               datalyscenter.org.
                                                the number of injuries in a particu-
      while accommodating the needs of                                                  Any	questions	regarding	the	NCAA	
                                                lar category to the number of ath-
      the voluntary participants.                                                       Injury Surveillance Program or its
                                                lete	exposures	in	that	category.	
      Injuries                                  This	value	is	expressed	as	injuries	    data	reports	should	be	directed	to:	
      A reportable injury in the Injury         per	1,000	athlete	exposures.            Megan	McGrath,	Manager	of	
      Surveillance Program is defined as        Historical Data                         Collegiate	Engagement,	Datalys	
      one	that:                                                                         Center	for	Sports	Injury	Research	
                                                The	NCAA	published	16	years	of	
      1. Occurs as a result of participa-       injury	data	in	15	sports	in	the	        and	Prevention,	Indianapolis,	
      tion in an organized intercollegiate      Journal of Athletic Training            Indiana	(317/275-3665).
      practice or competition; and              National Collegiate Athletic            David	Klossner,	Director	of	Student-
      2. Requires medical attention by a        Association Injury Surveillance,        Athlete	Affairs,	NCAA,	P.O.	Box	
      team athletic trainer or physician        1988-1989 Through 2003-2004. J          6222,	Indianapolis,	Indiana	46206-
116   regardless of time loss.                  Athl Train. 2007;42(2).                 6222	(317/917-6222).
Figure 1
Competition and Practice Injury Rates Summary (25 Sports)

    Competition Injury Rate                Practice Injury Rate


              Men’s Football                                                                                           36.5
                                                   5.4

             Men’s Wrestling                                                                    26.6
                                                           7.8

               Men’s Soccer                                                    16.9
                                                   5.1

             Men’s Lacrosse                                                   16.4
                                                4.7                                                    Figure illustrates the
           Men’s Ice Hockey                                                  15.5                      average injury rates
                                     2.3                                                               for 25 sports from
        Women’s Gymnastics                                                   15.5                      2004-05 to 2008-09
                                                           7.8                                         unless otherwise
            Women’s Soccer
                                                                        14.4                           noted below.
                                                5.0

            Men’s Basketball                                      9.9                                  * Available data from
                                                4.7                                                    2005-06 to 2008-09
                                                                  9.8                                  **Available data from
      Women’s Field Hockey
                                                   5.1                                                 2006-07 to 2008-09
         Men’s Indoor Track*                                     9.1
                                          3.3                                                          If a sport is not
                                                                 9.0                                   included, it is
         Women’s Basketball
                                               4.5                                                     because there was
                                                           7.5                                         not enough data
        Women’s Ice Hockey
                                     2.1                                                               collected to report
                                                          7.4                                          that sport.
     Women’s Cross Country*
                                          3.3

       Men’s Outdoor Track*                              6.9
                                            4.1
                                                         6.8
          Women’s Lacrosse
                                         2.8
                                                     5.9
             Men’s Baseball
                                     2.4
                                                     5.8
     Women’s Outdoor Track*
                                          3.2
                                                    5.7
       Men’s Cross Country*           2.7
                                                   5.1
            Women’s Tennis*
                                      2.4
                                             4.3
           Women’s Softball
                                          3.2
                                            4.2
          Women’s Volleyball                4.4
                                           3.5
      Women’s Indoor Track*               2.8
                                      2.4
               Men’s Tennis*          2.5
                                   1.4
Women’s Swimming & Diving**        1.1
                                    1.3
   Men’s Swimming& Diving**        .8

                               0               5                 10     15            20   25          30         35          40
                               Injury Rate (per 1,000 athlete-exposures)
                                                                                                                                   117
                Figure 2
                Percentage of All Injuries Occurring in Practices and Competition
                     Competition Injuries            Practice Injuries

                 Men’s Ice Hockey        66.8                                      33.2

                   Men’s Baseball        55.1                                      44.9

              Women’s Ice Hockey         53.2                                      46.8

                  Women’s Soccer         48.6                                      51.5

                 Women’s Softball        48.5                                      51.5     Figure represents the
                                                                                            national estimates of
                     Men’s Soccer        48.3                                      51.7     injury percentages for
                                                                                            25 sports from 2004
                  Women’s Tennis*        42.5                                      57.4     to 2009 unless
                                                                                            otherwise noted
                   Men’s Lacrosse        39.9                                      60.1     below.

            Women’s Field Hockey         39.2                                      60.8     * Sports with data
                                                                                            from 2005-06 to
                    Men’s Football       38.6                                      61.4     2008-09 (4 years
                                                                                            only).
                Women’s Lacrosse         37.6                                      62.4
                                                                                            **Sports with data
               Women’s Basketball        36.5                                      63.5     from 2006-07 to
                                                                                            2008-09 (3 years
                  Men’s Basketball       34.7                                      65.3     only).

                   Men’s Wrestling       31.6                                      68.4     If a sport is not
                                                                                            included in the gure,
                                         29.1                                      70.9     it is because there
                Women’s Volleyball
                                                                                            was not enough data
                                         24.3                                      75.7     collected to report on
           Women’s Outdoor Track*
                                                                                            that sport.
                     Men’s Tennis*       23.6                                      76.4


               Men’s Indoor Track*       23.1                                      76.9


             Men’s Outdoor Track*        21.9                                      78.1


              Women’s Gymnastics         19.5                                      80.6


           Women’s Cross Country*        16.7                                      83.3


        Men’s Swimming & Diving**        15.7                                      84.3


             Men’s Cross Country*        14.9                                      85.1


      Women’s Swimming & Diving**        13.5                                      86.5


            Women’s Indoor Track*        13.4                                      86.6


                                     0          20             40        60   80      100
                                     Percentage of All Injuries

118
                                Appendix D
Acknowledgements
From	1974	to	2011,	the	following	individuals	have	served	on	the	NCAA	Committee	on	Competitive	Safeguards	and	
Medical	Aspects	of	Sports	and	contributed	to	the	information	in	the	NCAA	Sports	Medicine	Handbook:

John R. Adams                        Marino	H.	Casem                      Paul	W.	Gikas,	M.D.
Western Athletic Conference          Southern University, Baton Rouge     University of Michigan
Ken Akizuki                          Nicholas	J.	Cassissi,	M.D.           Pamela	Gill-Fisher
University of San Francisco          University of Florida                University of California, Davis
Jeffrey Anderson                     Rita	Castagna                        Gordon	L.	Graham
University of Connecticut            Assumption College                   Minnesota State University Mankato
James	R.	Andrews,	M.D.               Charles	Cavagnaro                    Gary	A.	Green,	M.D.
Troy University                      University of Memphis                University of California,
Elizabeth	Arendt,	M.D.               Kathy	D.	Clark                          Los Angeles
University of Minnesota,             University of Idaho                  Letha	Griffin,	M.D.
   Twin Cities                       Kenneth	S.	Clarke                    Georgia State University
William F. Arnet                     Pennsylvania State University        Eric Hall
University of Missouri, Columbia     Priscilla	M.	Clarkson                Elon University
James A. Arnold                      University of Massachusetts,         Eric Hamilton
University of Arkansas,                 Amherst                           The College of New Jersey
   Fayetteville                      Bob	Colgate                          Kim Harmon
Janet Kay Bailey                     National Federation of State High    University of Washington
Glenville State College                 School Associations               Richard J. Hazelton
Dewayne Barnes                       Donald	Cooper,	M.D.                  Trinity College (Connecticut)
Whittier College                     Oklahoma State University            Larry	Holstad
Amy Barr                             Kip	Corrington                       Winona State University
Eastern Illinois University          Texas A&M University, College        Maria J. Hutsick
Fred	L.	Behling                         Station                           Boston University
Stanford University                  Lauren	Costello,	M.D.                Nell	C.	Jackson
Daphne Benas                         Princeton University                 Binghamton University
Yale University                      Ron	Courson                          John K. Johnston
John S. Biddiscombe                  University of Georgia                Princeton University
Wesleyan University (Connecticut)    Carmen	Cozza                         Don Kaverman
Carl	S.	Blyth                        Yale University                      Southeast Missouri State University
University of North Carolina,        Scot Dapp                            Janet R. Kittell
   Chapel Hill                       Moravian College                     California State University, Chico
Cindy	D.	Brauck                      Bernie DePalma                       Fran Koenig
Missouri Western State University    Cornell University                   Central Michigan University
Donald	Bunce,	M.D.                   Jerry	L.	Diehl                       Olav B. Kollevoll
Stanford University                  National Federation of State High    Lafayette College
Elsworth R. Buskirk                     School Associations               Jerry Koloskie
Pennsylvania State University        Randy Eichner                        University of Nevada, Las Vegas
Peter	D.	Carlon                      University of Oklahoma               Roy F. Kramer
University of Texas, Arlington       Brenna Ellis                         Vanderbilt University
Gene	A.	Carpenter                    University of Texas                  Michael	Krauss,	M.D.
Millersville University of              at San Antonio                    Purdue University
   Pennsylvania                      Larry	Fitzgerald                     Carl	F.	Krein
Frank	Carr                           Southern Connecticut State           Central Connecticut State
Earlham College                         University                           University
                                                                                                                119
      Acknowledgements

      Russell	M.	Lane,	M.D.                          .
                                           Joseph V Paterno                    Willie	G.	Shaw
      Amherst College                      Pennsylvania State University       North Carolina Central University
      Kelsey	Logan                         Marc Paul                           Jen Palancia Shipp
      The Ohio State University            University of Nevada, Reno          University of North Carolina,
      John	Lombardo,	M.D.                  Daniel Pepicelli                       Greensboro
      The Ohio State University            St. John Fisher College             Gary	Skrinar
      Scott	Lynch                          Frank	Pettrone,	M.D.                Boston University
      Pennsylvania State University        George Mason University             Andrew Smith
      William B. Manlove Jr.               Marcus	L.	Plant                     Canisius College
      Delaware Valley College              University of Michigan              Bryan	W.	Smith,	M.D.
      Jeff Martinez                        Sourav Poddar                       University of North Carolina,
      University of Redlands               University of Colorado, Boulder        Chapel Hill
      Lois	Mattice                         Nicole Porter                       Michael Storey
      California State University,         Shippensburg University             Bridgewater State University
      Sacramento                               of Pennsylvania                 Grant	Teaff
      Arnold	Mazur,	M.D.                   James	C.	Puffer,	M.D.               Baylor University
      Boston College                       University of California,           Carol	C.	Teitz,	M.D.
      Chris	McGrew,	M.D.                       Los Angeles                     University of Washington
      University of New Mexico             Margot Putukian                     Patricia Thomas
      William D. McHenry                   Princeton University                Georgetown University
      Washington and Lee University        Ann Quinn-Zobeck                    Susan S. True
      Malcolm	C.	McInnis	Jr.               University of Northern Colorado     National Federation of State High
      University of Tennessee, Knoxville   Tracy Ray                              School Associations
      Douglas	B.	McKeag,	M.D.                                                  Laurie	Turner
                                           Samford University
      Michigan State University                                                University of California, San Diego
                                           Butch Raymond
      Kathleen M. McNally                                                      Christopher	Ummer
                                           Northern Sun Intercollegiate
                                                                               Lyndon State College
      La Salle University                      Conference
                                                                               Jerry Weber
      Robin Meiggs                         Joy	L.	Reighn
                                                                               University of Nebraska, Lincoln
      Humboldt State University            Rowan University
                                                                               Christine	Wells
      Dale P. Mildenberger                 Frank J. Remington
                                                                               Arizona State University
      Utah State University                University of Wisconsin, Madison
                                                                               Kevin M. White
      Melinda	L.	Millard-Stafford          Rochel Rittgers                     Tulane University
      Georgia Institute of Technology      Augustana College (Illinois)        Robert	C.	White
      Fred	L.	Miller                       Darryl D. Rogers                    Wayne State University
      Arizona State University             Southern Connecticut State             (Michigan)
      Matthew Mitten                           University                      Sue Williams
      Marquette University                 Yvette Rooks                        University of California, Davis
      James Morgan                         University of Maryland,             Charlie	Wilson
      California State University, Chico       College Park                    Olivet College
      Frederick O. Mueller                 Debra Runkle                        G.	Dennis	Wilson
      University of North Carolina,        University of Dubuque               Auburn University
         Chapel Hill                       Felix	Savoie                        Mary Wisniewski
      David M. Nelson                      Tulane University                   University of Chicago
      University of Delaware               Richard D. Schindler                Glenn	Wong
      William E. Newell                    National Federation of State High   University of Massachusetts,
      Purdue University                        School Associations                Amherst
      Jeffrey	O’Connell                    Kathy Schniedwind                   Joseph P. Zabilski
      University of Virginia               Illinois State University           Northeastern University
      Roderick Paige                       Brian J. Sharkey                    Connee	Zotos
      Texas Southern University            University of Montana               Drew University

120
The NCAA salutes the more than
   400,000 student-athletes
participating in 23 sports at more
 than 1,000 member institutions


                                     NCAA 81688-7/11   MD 11

				
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posted:3/22/2012
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pages:122
Description: 2011-12 NCAA Sports Medicine Handbook