ARTICLE 34 MEDICAL POSITION STATEMENTS OF THE RHODE ISLAND INTERSCHOLASTIC LEAGUE
The following position statements were developed by the Rhode Island Interscholastic League's Sports Medicine Advisory Committee and approved by the RILL Principals' Committee on Athletics:
Section I. CARDIOVASCULAR DISEASE IN ATHLETES
The Rhode Island Interscholastic League in an attempt to emphasize the importance of screening for cardiovascular diseases in young student-athletes has developed the following position on a prudent approach to this important problem. Sudden death in young athletes has become a highly visible health concern in our country. Unfortunately, most of these deaths are most often congenital cardiovascular malformations. The most common lesion is hypertrophic cardiomyopathy. The ultimate goal is not treatment, but early detection. Therefore, it is the position of the Rhode Island Interscholastic League that every Rhode Island community have in place a comprehensive pre-participation screening program with appropriate procedures for identification of these potentially lethal cardiovascular abnormalities. The objective of these exams is the disqualification of selected athletes from competition thereby reducing their risk for sudden death during sports activities. Although sudden cardiac death is a rare event, it is the responsibility of our communities to provide a safe environment for our student athletes. The RIIL has produced a comprehensive sports-oriented history and physical examination form to aid Rhode Island physicians in identifying these and other problems. The history is the most sensitive method for detection. The majority of cardiac problems will be identified by the history rather than by the physical exam. The physical exam must be performed by a clinician familiar and comfortable with the physical signs of the causes of sudden cardiac death. It is the goal of the Rhode Island Interscholastic League that all communities utilize this screening form in order to standardize the approach of all Rhode Island physicians, thereby optimizing our chances of detecting these potentially lethal conditions in our student-athletes. Section 2. CONCUSSIONS
Please refer to the NFHS – Sports Medicine Handbook (3rd Edition 2008, Pages 77-82) that was distributed to every member high school.
Section 3. BURNERS AND STINGERS
The Rhode Island Interscholastic League has taken the following position on return to play criteria after sustaining a burner.
Burners or stingers are terms used to describe an injury to one side of the upper extremity, which typically includes burning pain and muscle weakness most commonly involving the biceps, deltoids, and rotator cuff muscles (supraspinatos and infraspinatos). A burner usually occurs from downward movement of the shoulder associated with the lateral flexion of the neck toward the opposite shoulder.
A detailed assessment should be performed consisting of neck palpation for pain and range of motion. If all motor and sensory symptoms resolve within seconds to minutes and there is no associated neck pain or limitation of neck motion, the athlete may return to competition. If symptoms persist for more than a few minutes, an MRI of the cervical spine should be considered to look for a herniated disc or any other cervical compressive pathology. Electromyography (EMG) is recommended when symptoms remain for more than two weeks. Any athlete who suffers two repetitive stingers should use high shoulder pads and a soft cervical roll or cowboy collar. One should also undergo cervical radiographs and an MRI to evaluate a possible underlying cervical spinal stenosis. Burners can be minimized with appropriate equipment and education on tackling technique. An on-field evaluation is crucial to differentiate burners from a far more serious spinal cord injury. An individual who sustains recurrent burners and demonstrates evidence of cervical spinal stenosis should be disqualified from any contact athletic events. Section 4. LISCENSED/CERTIFIED ATHLETIC TRAINERS AT RIIL CHAMPIONSHIP EVENTS
The Rhode Island Interscholastic League provides certified athletic trainers to all high school championship events. The purpose of these certified athletic trainers is to provide emergency medical coverage to all participants of these games. As more and more schools have begun to see the necessity of proper athletic medical coverage, high schools have begun using certified athletic trainers, physicians and other medical professionals to assist with the schools' medical needs. Many of these medical personnel have developed a strong working relationship with the teams. A. To provide the best possible coverage for all students-athletes at these games, the following protocol
will be observed by all athletic trainers at all contests. We hope that this outline will promote better quality care at all championship events.
1. Upon arrival at the game/meet, the athletic trainers will situate themselves in such a location to
be available to both teams, without interfering with the area of competition.
2. Prior to the start of the game, the athletic trainer will introduce themselves to a member of the
coaching staff from each team. The athletic trainer will state their purpose for being at the game, their location and availability. The athletic trainer will then ask if there is any medical personnel traveling with the team. The athletic trainer will also inquire if there are any medical problems or conditions that any member of their team may have that they should be aware of during the contest.
3. The athletic trainer will also introduce themselves to the officiating staff and alert them of their
4. If there is NO medical coverage traveling with a team, the athletic trainer will inform the coach
that they will go out onto the floor/field if it is warranted to provide medical care to a downed athlete. All medical decisions regarding the treatment of the athlete will be made by the athletic trainer.
5. If there IS medical personnel (ATC, PT/ATC, EMT) with a team, the athletic trainers will
introduce themselves and offer assistance. In the event that medical treatment for one of their athletes is needed, the athletic trainer will accompany their medical personnel on the floor/field. However, the athletic trainer will remain at a discrete distance to observe the incident and to assist if needed. All medical decisions made in regard to the athlete will be done by the team's medical personnel.
6. If the medical personnel is a physician, all decisions made by the doctor will be considered final. 7. If there is "medical personnel" with a team that is not a certified athletic trainer, physician, EMT or if
the "medical personnel" is a non-accredited individual, (i.e., a student athletic trainer or a certified first-aider) then all medical decisions regarding the care and treatment of the athlete will be made by the athletic trainer.
Section 5. COMMUNICABLE DISEASE PROCEDURES
While the risk of one student-athlete infecting another with HIV/AIDS during competition is close to non- existent, there is a remote risk that other blood-borne infectious diseases can be transmitted. For example: Hepatitis B can be present in blood as well as other body fluids. Procedures for reducing the potential for transmission of these infectious agents should include, but not be limited to, the following: 1.
The bleeding must be stopped and the open wound covered. If there is an excessive
amount of blood on the uniform; it must be changed before the athlete may participate.
Routine use of gloves or other precautions to prevent skin and mucous membrane exposure
when contact with blood or other body fluids is anticipated.
Immediately wash hands and other skin surfaces if contaminated (in contact) with blood or other body fluids. Wash hands immediately after removing gloves.
Clean all contaminated surfaces and equipment with an appropriate disinfectant before competition resumes.
Practice proper disposal procedures to prevent injuries caused by needles, scalpels, and other sharp instruments or devices.
Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be available for use.
Athletic trainers/coaches with bleeding or oozing skin conditions should refrain from all direct athletic care until the condition resolves.
Contaminated towels should be properly disposed of and/or disinfected.
Follow acceptable guidelines in the immediate control of bleeding and when handling bloody dressings, mouth-guards, and articles containing body fluids.
Section 6. USE OF LEGAL CAST IN ATHLETIC CONTESTS
If the student/athlete's doctor gives clearance to participate with the use of a protective cast that is approved by the Rule of the game (NFHS), the student athlete will be required and must have an authorization letter from the doctor which shall be considered valid for a period of six (6) weeks form the date of letter. (It shall not be necessary for the student-athlete to present a note each week). At the end of the six (6) week period the student- athlete may provide another doctors note which shall remain valid for another six (6 weeks from the date of the letter). The school is required to have the doctor’s authorization letter for review by the officials prior to any RIIL contest. Section 7. STUDENT CHEMICAL HEALTH/ALCOHOL/TOBACCO
The RI Interscholastic League and its member schools have a vital interest in the health and safety of its student-athletes.
The RIIL recognizes the use of mind-altering/performance enhancing chemicals as a significant health problem for many adolescents, resulting in negative effects on behavior, learning and the total development of each individual. The use of mind-altering/performance enhancing chemicals for some adolescents affects co-curricular participation and development of related skills. The lives of other adolescents are affected when family members, team members and other significant persons use these chemicals. The RIIL member schools assume a partnership role, along with families and their community by providing an educational environment where students learn about the harmful effects of such substances and where such use is strictly prohibited.
It is the position of the RIIL and its member schools that: a. Scholastic athletes and other students should abstain from the use of alcohol and controlled
substances as well as refrain from using tobacco and smokeless tobacco.
b. Coaches and other adult school personnel should demonstrate responsible use of alcohol and
tobacco in an appropriate setting and abstain from the use of controlled substances.
c. No coach should use alcohol, tobacco, or other drugs before, during or immediately after any
interscholastic contest until his/her supervisory duties are completed for that contest.
d. Adults should abstain from the use of 1) alcohol before and during, and 2) tobacco during
meetings when business related to athletics is conducted.
e. Chemical dependency is an illness and it may be treated.
C. Guidelines for Developing a Code of Conduct for Schools
To this end the RIIL will support its member schools who provide professional leadership and programs to achieve the following purposes:
a. emphasize the schools’ concerns for health of students in areas of safety while participating in
activities and the long-term physical and emotional effects of chemical use on their health
b. promote equity and a sense of order and discipline among students c. confirm and support existing state laws and local regulations which restrict the use of such mind-
altering/performance enhancing chemicals
d. establish standards of conduct for those students who are leaders and standard-bearers among
e. assist students who desire to resist peer pressure which directs them toward the use of mind-
altering/performance enhancing chemicals
assist students who should be referred for assistance or evaluation regarding their use of mind-altering/performance enhancing chemicals
Section 8. POSITION STATEMENT ON PRE-PARTICIPATION PHYSICAL EXAMINATIONS
The RI Interscholastic League endorses the use of a sports-specific Pre-Participation Physical Examination to screen all RI student athletes prior to their inclusion in sports programs. The position of the RIIL is that all school districts in RI utilize the same standard history and physical form to exam and screen athletes prior to their participation in sports. We feel this standardization may improve overall effectiveness. The Sports Medicine Advisory Committee of the RIIL has produced a comprehensive history and physical form for this purpose. The Committee is composed of sports medicine specialists in the field of family medicine, orthopedics, athletic training, sports psychology, sports podiatry and dentistry. In addition, other members included high school athletic directors and sports administrators. The Committee performed an extensive review of the current sports medicine literature and reviewed numerous history and physical forms from other states. It is the opinion of this committee that, at the time of this writing, many districts are performing inadequate and cursory examinations. The goal of these exams is to identify potential medical and orthopedic problems that could lead to further injury or death. They required a detailed history, specific to sports, which can be completed by the parent. The committee asserts that the medical history is a least as important as the physical exam in its ability to identify past medical problems and family medical history. The Committee further asserts that a pre-participation physical examination is distinctly different from a routine annual physical exam. The exam must be specific to participation in athletics thorough and with particular attention to the cardiovascular and musculoskeletal systems. Attached is a copy of the pre- participation exam form produced by the RIIL Sports Medicine Advisory Committee. We strongly urge all RI school districts to adopt this form as their own and utilize it with all potential student-athletes. Section 9. POSITION STATEMENT INVASIVE MEDICAL PROCEDURES ON THE DAY OF COMPETITION
The NFHS SMAC was formed in 1996 to assist the NFHS in ensuring the safety of high school athletes across the nation. The SMAC investigates numerous issues, rules, and situations and considers their potential risks to athletes. Recently, the SMAC (Sports Medicine Advisory Committee) has reviewed the issue of invasive medical procedures such as intravenous (IV) rehydration and the use of injectable anesthetic/analgesic drugs during or before athletic contests and events. While we believe these practices are not widespread at the high school level, a handful of such incidents have been reported to the SMAC over the past year. It is reported that these procedures are carried out at the college and professional levels. The SMAC is very concerned that occurrence of, or the desire for, such medical procedures will continue to “trickle done” to high school athletics. The SMAC encourages a philosophy that high school athletics serve the purpose of providing young men and women the opportunity for personal growth in a controlled environment. The pursuit of victory is not, by itself, justification for medical intervention. We believe that invasive procedures such as the administration of IV fluids and the use of injectable anesthetic/analgesic drugs performed on the day of competition with the sole purpose of enabling a student athlete to participate are inconsistent with the philosophy of high school sports. This position applies to any athlete requiring a local (example: lidocaine) or systemic (example: Toradol) pain-killing medication to enable him or her to play. This practice increases the risk of further injury to the affected body part. The use of prescription medication this is administered by injection for chronic medical conditions (such as insulin for diabetes or Imitrex for migraine headaches) is appropriate, and will not be affected. Second, the performing medical procedures in a locker room, training room, or other facility is fraught with the potential for infection and other complications. The placement of an intravenous catheter or the administration of an intramuscular or subcutaneous injection is a medical procedure and should be treated as such. Thus, a medical facility is the proper venue for any such invasive procedures to be carried out. Finally, while our primary concern is with protecting the health of the young athlete, we believe this is also a matter of participation equity. Due to a variety of factors, few high school sports programs have team physicians attending the competitions and in many instances these volunteers do not have special training in sports medicine. Thus, teams and individuals who have a physician or other medical provider willing and able to provide such services will have a significant competitive advantage over their opponents who may not have such a specialist available. After a review of the potential risks, consequences, and limited medical benefits of these invasive procedures, the NFHS Sports Medicine Advisory Committee takes the position that there is no proper role for these procedures in high school athletics. We strongly recommend to coaches, school administrators, athletic trainers, and team physicians that athletes should not be allowed to participate in athletic contests or events if they have received IV hydration or been injected with an anesthetic or analgesic medication on that same day. Section 10. NFHS STATEMENT OF MEDICAL APPLIANCES
Although still relatively rare, the use of insulin pumps by athletes with diabetes has become more commonplace over the past few years. With the wider use of insulin pumps, as well as other medical devices such as heart monitoring equipment, concerns have been raised regarding the safety of the athlete wearing the device, teammates, opponents, and the device itself. The NFHS SMAC has discussed these issues and come to the following conclusion: When it is necessary for an athlete to wear a medical appliance (such an insulin pump) during athletic competitions, the device shall be padded and securely attached to the player’s body underneath the uniform. Devices attached to the head (such as hearing aids and cochlear implants) do not need to be padded, but
shall be firmly secured to the body. No medical appliance should pose a risk of injury to others. It is recommended that the athlete notify the official of the presence of the medical appliance prior to a contest. Section 11. SUPPLEMENTS POSITION STATEMENT
The NFHS Sports Medicine Advisory Committee (SMAC) strongly opposes the use of dietary supplements for the purpose of athletic advantage. Research data shows widespread use of dietary supplements by adolescent and high school athletes, despite considerable safety concerns. Dietary supplements are marketed as an easy way to enhance athletic performance, increase energy levels, lose weight and feel better. It is proven that adolescents are more susceptible to advertising messages and peer pressure, increasing the risk of dietary supplement usage. This can create a culture more concerned about short term performance rather than overall long term health. The Dietary Supplement Health and Education Act of 1994 removed dietary supplements from pre-market regulation by the Food and Drug Administration (FDA). Thus, many of the substances that can be obtained from nutrition stores and the internet are not subject to the same strict tests and regulation as “over the counter” and prescription medications. The companies that produce dietary supplements do not need to test their safety or effectiveness before they are available to consumers. In fact, dietary supplements cannot be removed from the marketplace unless they present a significant or unreasonable risk of illness or injury. • MYTHS regarding dietary supplements:
If a substance is natural, it must be safe and beneficial.
Athletes that consume a well balance diet still have nutritional deficiencies
Since dietary supplements may be purchased at a store or over the internet, they must be safe and legal
The NFHS SMAC discourages the use of supplements by athletes due to the lack of published, reproducible scientific research addressing the benefits and documenting long term adverse health effects of the supplements, particularly in the adolescent age group. Dietary supplements should be used only upon the advice of one’s health care provider. School personnel and coaches should never recommend, endorse or encourage the use of any dietary supplement, drug, or medication for performance enhancement. We recommend that coaches, athletic directors, and school personnel develop strategies that address the growing concerns of using dietary supplements. Such strategies may include conversations with athletes and their parents about the potential dangers of dietary supplement use. Athletes should be encouraged to pursue their goals through hard work and good nutrition, not dietary shortcuts. • Dietary supplements receive no FDA regulation:
There is no guarantee the true amount or concentration of ingredients is listed on the label
There is no guarantee the substance is pure, as studies have found lead and arsenic in supplements.
There may be other compounds not listed on the label in the dietary supplement which may be illegal or banned substances.
• There is minimal evidence that dietary supplements enhance performance for most high school sports.
There is even less evidence supporting their use in adolescents.
• In order to help prevent dietary supplement use:
School personnel, coaches and parents should allow for open discussion about supplement use, but strongly encourage optimal nutrition and a well balanced diet.
Remind athletes that no supplement is harmless and free from consequences.
Remind athletes that there is no short cut to improved performance, it takes hard work.
Because they are not regulated, dietary supplements may contain impurities and illegal substances not listed on the label.
Adolescents that use dietary supplements are more likely to use steroids, continue usage into adulthood, and to engage in other high risk behaviors like smoking, drinking and using drugs.
Section 12. POSITION STATEMENT ON ANABOLIC STEROIDS
A. EXISTING POLICIES/STAND
The NFHS strongly opposes the use of anabolic steroids and other performance-enhancing substances by high school student-athletes. Such use violates legal, ethical and competitive equity standards, and imposes unreasonable long-term health risks. The NFHS supports prohibitions by educational institutions, amateur and professional organizations and governmental regulators on the use of anabolic steroids and other controlled substances, except as specifically prescribed by physicians for therapeutic purposes.
Anabolic, androgenic steroids (AAS) are synthetic derivatives of the male hormone testosterone. Natural testosterone regulates, promotes and maintains physical and sexual development, primarily in the male, but with effects in the female as well. Like testosterone, AAS have both an anabolic effect (increase in muscle tissue) and an androgenic effect (masculinizing effects that boys experience during puberty). No AAS is purely anabolic. As a result, the use of AAS won’t lead to muscle growth without also leading to the other unintended, undesirable side effects. According to national surveys, the use of AAS among high school students has been decreasing since about 2001. There are no national studies that measure the extent of AAS use by high school student-athletes, although some states publish statewide prevalence data. Nearly one-third of high school age steroid users do not participate in organized athletics and are taking AAS primarily to modify their physical appearance. Athletes who use AAS do so for two main reasons: 1) to gain strength and (2) to recover more quickly from injury. AAS are controlled substances and are illegal to use or possess without a prescription from a physician for a legitimate medical diagnosis. Some AAS are used by veterinarians to treat pigs, horses and cows. In humans, medical uses of AAS include weight gain in wasting diseases such as HIV-infection or muscular dystrophy, absent gonadal function in males, and metastatic breast cancer in women. AAS should not be confused with corticosteroids, which are steroids that doctors prescribe for medical conditions such as asthma and inflammation. AAS are prohibited by all sports governing organizations.
C. FACTS ABOUT ANABOLIC STEROIDS
• Anabolic steroids are controlled substances and are illegal to possess or sell without a prescription
for a legitimate medical condition by the prescribing physician.
• Androstenedione, norandrostenedione and other similar prohormones, at one time available over
the counter as dietary supplements, are now defined as controlled anabolic steroids.
• Athletes who have injected anabolic steroids in high school have tested positive in collegiate drug
tests – months after they stopped injecting.
• Athletes who have injected anabolic steroids are at greater risk for infections, HIV and hepatitis.
D. POTENTIAL NEGATIVE SIDE EFFECTS FROM THE USE OF ANABOLIC STEROIDS
• Decreased eventual height if consumed before growth plates have fused in pre-pubertal youngsters
• Secondary sex characteristic changes
• Mood swings, loss of sleep, paranoia
• Organ damage and death from heavy use
E. PREVENTING ATHLETES FROM TAKING ANABOLIC STEROIDS
• School personnel, coaches and parents can reduce steroid abuse by speaking out against such use
• Talk with your athletes about frustrations they may have about how they look or how they are
performing in their sport. Help them establish healthy expectations of their bodies.
• Talk to athletes about realistic performance standards
• Focus on proper nutrition and hydration. Work with a registered dietician to develop a plan for
appropriate weight gain and/or weight loss
• Don’t trust Internet marketing messages about quick fixes
• Restrict athletes’ access to environments where steroid use might occur and to people who are
• Don’t subscribe to publications such as muscle magazines that depict unrealistic pictures of men
• Help athletes understand that using anabolic steroids not only is illegal, but also cheating
• Consider imitating a formal performance-enhancing, drug-education program to educate athletes
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