By Greg Scholand

Greg Scholand is an Associate Editor at Athletic Management. He can be reached at: gs@MomentumMedia.com.

They're not pleasant topics to think about: Infectious disease. Deaths caused by sports participation. Season-ending knee injuries. Eating disorders. But they are becoming a bigger part of athletic administration.

With scheduling, game management, and many other details to worry about, it's easy to leave issues of health and safety to sports medicine professionals. However, as the leader of an athletic department, these topics need to be on your radar screen, too.

This past fall, a spike in high school football deaths alarmed observers nationwide. MRSA outbreaks continued to make headlines in many communities. And one high school in Illinois had to cancel athletic contests due to a meningococcemia scare.

The good news, though, is that being on top of sports medicine issues can prevent problems from striking your athletic programs. Exciting new ideas on how to prevent ACL tears can help you cut the rate of debilitating knee injuries. And recent research on eating disorders provides direction on how to curtail this pervasive problem.

THE MRSA MENACE
By now, you've likely heard about methicillin-resistant Staphylococcus aureus (MRSA), the virulent staph infection that's immune to standard antibiotics and has struck countless athletic teams throughout the country. Despite all the attention and heightened awareness, MRSA continues to wreak havoc in the sports world.

The nation's tallest college basketball player, 7-foot-9 Kenny George of the University of North Carolina-Asheville, was among those victimized by MRSA this past fall. The infection usually spreads when athletes are in close-contact situations, and it's believed George contracted it at a summer basketball camp in Las Vegas through a skin wound on his right foot. After several surgeries were unsuccessful at clearing the infection site, part of his foot had to be amputated.

A former Big South Conference Defensive Player of the Year, George spent three months in the hospital recovering from the infection and surgery. When he was released in November, UNC-Asheville Head Men's Basketball Coach Eddie Biedenbach said the infection was finally gone. "I think he is starting to adjust to the reality of his situation," Biedenbach told USA Today. "And he's really looking forward to returning to school."

While MRSA ended George's basketball career, others have paid an even higher price. In September, Alonzo Smith, an 18-year-old football player at Liberty High School in Kissimmee, Fla., died from a MRSA infection that spread to his bloodstream. It's impossible to know exactly when or how Smith was exposed to the bacteria, but as with most MRSA cases, it likely entered through a break in his skin.

Osceola County health department officials visited the school shortly after Smith's death, and said they found no problems with its level of cleanliness. Still, school administrators had their facilities thoroughly scrubbed with an antibacterial solution. "Parents should know our school is extremely safe," Osceola County Schools spokesperson Dana Shafer told local TV stations during the cleaning. "We are wiping it down and disinfecting."

Cleaning is always a positive step, but MRSA can spread anytime someone with the bacteria on their skin touches a surface or another person, so even ultra-clean facilities don't eliminate the risk of transmission. In fact, soon after the school's scrub-down, a second member of Liberty's football team was diagnosed with MRSA. That athlete's infection was confined to skin on his elbow, and he was successfully treated with a special MRSA-killing antibiotic.

The above are just a few of many recent examples of MRSA affecting athletes. According to the Centers for Disease Control and Prevention (CDC), MRSA is linked to 126,000 hospitalizations nationwide every year, and nearly 20,000 deaths.

How can you keep your program as safe as possible? Experts agree that the two main prongs of MRSA prevention are raising awareness and promoting cleanliness.

Athletes should be educated on getting every skin wound checked by an athletic trainer or physician, even if it seems like a minor cut, scrape, bug bite, or ingrown hair. Skin breaks like these are a typical entryway for MRSA bacteria, so they should be kept covered at all times and closely monitored. At any sign of abnormal healing, such as discoloration, the sensation of heat, pus production, or redness around the wound, the athlete should seek immediate medical attention.

If there is an infection and it's MRSA (which can be determined by a lab test), special antibiotics can kill it fairly quickly. But if the problem is ignored, or if a physician prescribes a standard antibiotic, the infection can spread and literally threaten life and limb.

Preventing infection in the first place is where cleanliness comes in. Experts recommend that athletes shower immediately after workouts, practices, and games--especially in contact sports. This helps wash away bacteria that may have been picked up through contact with others, equipment, or their surroundings. Frequent hand washing by everyone in the athletic department will also help prevent the distribution of bacteria.

MRSA, staph, and other germs can spread through athletic padding, uniforms, and other porous surfaces, so athletes should wash these items frequently and allow them to dry after each use. Teammates should also be actively discouraged from sharing towels, razors, bars of soap, and anything else they use in the locker room, as these can harbor bacteria.

The good news is that scientists continue to find better ways to identify and fight MRSA. Standard lab tests to determine whether a wound is infected with MRSA bacteria can take two to three days, but a new test can reportedly make the same determination in just five hours. The testing method is currently being studied at several research universities, and if approved, it may be available by next year.

Other labs are working to discover new drugs that kill MRSA. The main challenge is a microscopic game of cat-and-mouse: Once a certain antibiotic is found effective against MRSA, it becomes widely prescribed to treat infections, and eventually the bacteria develop resistance to it. New formulations must be tested extensively and evaluated by the Food and Drug Administration, so it can take years for new MRSA-fighting drugs to reach the market.

FACING DEATH
On Aug. 12, Chapel Hill (N.C.) High School football player Atlas Fraley called 911 from his home, shortly after that afternoon's practice. "My body is hurting all over," the 17-year-old told a dispatcher. "I think I'm just dehydrated and I need an IV." He was visited by an EMS crew, but according to local news station WRAL, was not taken to the hospital. By the time his parents came home that evening, he was dead.

Two weeks later, 15-year-old Matt Gfeller of Reynolds High School in Winston-Salem, N.C., died after a head injury he'd suffered during a football game led to cranial bleeding. And less than a month after that, Jaquan Waller, a 17-year-old running back at J.H. Rose High School in Greenville, N.C., collapsed on the sideline shortly after being tackled. Local news station WNCT reported that he was taken to the hospital, where he was placed on life support. He died Sept. 20.

Three deaths in one state in under two months: It was an unprecedented tragedy, but North Carolina wasn't alone. The Charlotte News & Observer reported in October that at least five other states experienced a high school football-related death this past season. Based on figures from the National Center for Catastrophic Sports Injury Research, that means 2008 was the deadliest year for high school football in recent memory--there were just three deaths nationwide directly related to prep football in 2007, one in 2006, and two in 2005.

Has high school football become more dangerous? "We're still figuring out what these numbers mean," says Bob Colgate, Assistant Director of the NFHS and liaison to the Football Rules Committee. "We're obviously concerned--one death is too many. But it's too early to tell whether this is an actual increase, or if something else is going on, like the reporting channels for catastrophic injury have improved.

"Our sports medicine advisory committee will take a close look at the situation this off-season," he continues. "We'll figure out if there's anything we should do differently to minimize risk."

After North Carolina's third death, the North Carolina High School Athletic Association (NCHSAA) called an emergency meeting of its own sports medicine advisory committee and put several policies in place. First, each school was ordered to develop an emergency action plan (if it didn't already have one) with procedures for a catastrophic injury, heart attack, heat-related illness, or other serious medical situation.

Second, the NCHSAA instituted a policy to help prevent second-impact syndrome (SIS), which occurs when someone suffers a second concussion before their brain has fully recovered from an earlier one. According to the News & Observer, the medical examiner in Waller's case determined that SIS caused his death--he had sustained a concussion during football practice just two days before the game in which he collapsed.

"Anytime there is a suspected head injury in football, that player must be removed from activity and cannot return until he's released by a licensed medical doctor," explains Que Tucker, Deputy Executive Director of the NCHSAA. "We believe that was standard practice at most schools anyway, but we put it in writing to emphasize its importance."

Third, each school now has to report to the association the current status of its athletic medical coverage--whether it has a full-time athletic trainer, what medical personnel cover sporting events, and any other arrangements for on-site injury treatment and prevention. The News & Observer reported that there was no athletic trainer at the practice to treat Waller after his first concussion, though he was evaluated by an "injury management specialist" with first responder training.

Beyond those immediate steps, a new task force was created to find ways to reduce catastrophic injuries. Its primary recommendation is a statewide mandate that each school have a certified athletic trainer. "That idea makes a lot of sense, but there's an obvious budget concern involved," says Tucker. "So first we need to see where funding might come from. An unfunded mandate would be a major hardship for some schools."

In the meantime, the NCHSAA is considering other task force recommendations, such as revamping the state's required pre-participation exam and adding required baseline neurocognitive testing to help guide return-to-play decisions after concussions. These tests, which are typically computer-based, assess an athlete's reaction time, processing speed, and other basic mental performance factors. After a concussion, the athlete takes the same tests again, and the scores are compared to determine if brain function has returned to normal.

"We have been devastated by the loss of three young people," Tucker says. "In their memory and for their families, we've pledged to do everything we can to make high school athletics as safe as possible."

PROTECTING THE ACL
For female athletes at all levels, a tear of the anterior cruciate ligament (ACL) in the knee is among the most feared injuries--it is painful, debilitating, and requires a lengthy rehab. Roughly two percent of high school female athletes injure their ACLs each year, while one study of NCAA Division I female athletes found the rate to be near 10 percent. Overall, females are four to eight times more likely than males to suffer a torn ACL, with reasons ranging from growth patterns to hormones to strength imbalances.

A new program, however, is proving it can drastically reduce those numbers--with little expense or expertise required. The Prevent Injury and Enhance Performance (PEP) program, a specialized warmup routine developed by the Santa Monica (Calif.) Orthopaedic and Sports Medicine Research Foundation, was tested on 1,435 female soccer players from 61 NCAA Division I teams. Some teams used the PEP program three times per week while others served as a control group, not using the program at all. The results were published in the July issue of The American Journal of Sports Medicine.

The authors reported no ACL injuries on teams using the PEP program, compared to six injuries on the control teams. Even athletes with a history of ACL injury who used the PEP warmup avoided re-injury. The program is also proving successful in curtailing other lower-extremity injuries and improving athletic performance.

The PEP protocol focuses on building flexibility, strength, and balance. It requires no specialized equipment, and can be performed in 20 to 25 minutes as a prelude to team practice. Athletes complete a series of 19 short activities, ranging from jogging to various stretching and jumping movements.

Initially intended for soccer players, PEP has been used successfully in other sports as well, and the creators have developed a basketball-specific version. "The programs are very similar--we just used movement patterns that are more applicable to basketball," says Holly Silvers, ACL Prevention Project Coordinator for the Santa Monica Foundation. "For example, in women's basketball there is more jump landing and deceleration. When players land there is usually caving of the knee, so that's what we concentrated on addressing."

Silvers says the results of an initial study of the basketball PEP program were outstanding. "There were zero ACL injuries and there was a 62-percent reduction overall in lower extremity injuries," she says.

The program is already spreading to teams and clinics around the country. The University of South Florida Sports Medicine and Athletic Related Trauma Institute (SMART), a state-sponsored sports safety outreach program, implemented PEP at 10 high schools last year in three girls' sports: soccer, basketball, and volleyball. "We chose the PEP program because it is so simple," says Barbara Morris, Assistant Director of SMART. "It's easy to understand and doesn't take up much time. Coaches are quite willing to give up 20 minutes of practice two or three days a week for it. And the girls who use the program love it. It's more exciting than traditional warmup programs."

It's also an easy sell, since it boosts athleticism in several ways. "We saw improvements in sprint and agility times for program participants," says Silvers. "We also have a paper coming out soon that looks at how the PEP program increases vertical leap."

EARLY SCREENING
It shouldn't surprise athletic directors that a recently published research review found eating disorders to be an ongoing problem for adolescents. The October issue of the journal Preventing Chronic Disease reported that among high school students nationwide, almost 15 percent of girls and four percent of boys may have an eating disorder based on self-reported eating habits. The review also found that 25 percent of girls and 11 percent of boys showed signs of disordered eating or weight control symptoms (such as induced vomiting or laxative use) serious enough to warrant clinical evaluation.

What may be surprising, however, is a recommendation from the article that high schools consider screening their students for eating disorders. By identifying those most at risk, intervention can begin as soon as possible, the authors explain. "A shorter period between symptom onset and start of treatment may improve prognosis for recovery," they wrote. "Early detection through school-based screening can ... help adolescents begin treatment at younger ages. Support staff in schools may be ideally situated to help identify at-risk youth."

The National Athletic Trainers' Association (NATA) agrees wholeheartedly with that idea for student-athletes, issuing a new position statement on disordered eating last year. Tina Bonci, Co-Director of Athletic Training/Sports Medicine for Intercollegiate Athletics at the University of Texas, chaired the group that wrote it.

"We wanted to emphasize that adolescence is a period of time when young people--athletes especially--face enormous pressure with regard to their eating habits," Bonci explains. "Everyone from direct caregivers to athletic administrators needs to understand the risks, and help create an environment where healthy behaviors are encouraged and student-athletes who have problems can be identified and treated as soon as possible.

"Without a doubt, screening is a vital part of that," Bonci continues. "Every school's pre-participation exam [PPE] should include questions about eating behaviors and body image."

What exactly should schools ask athletes? "There should be specific questionnaire items about dietary restraint, body weight fluctuations, and weight control behaviors," Bonci says. "Another important question for adolescents involves body weight and shape satisfaction. Even if someone doesn't report disordered eating, if they're unhappy about their body, that's a risk factor."

Equally important is having someone to evaluate the responses and determine if any athletes need follow-up, which can be with a physician, a registered dietitian, an athletic trainer, or someone else with appropriate training. When an athlete's responses raise red flags, this person can take the lead in deciding what intervention is required.

Along with screening, Bonci advises athletic directors to make sure school staff members are educated on the warning signs of disordered eating. "School nurses, coaches, guidance counselors, and athletic trainers should be vigilant," Bonci says. "That might mean noticing an unexplained change in weight, or an athlete's comments or attitudes that suggest an unhealthy preoccupation with food."

Coaches in particular must understand the triggers and signs. "Recent research tells us that coaches often play a role in bringing on eating disorders among athletes, " Bonci explains. "A coach might say something about an athlete needing to lose weight, but not provide any resources to help them do it safely. An athlete can easily interpret that as, 'I'm fat and I need to stop eating.'

"Coaches might also set target weights or have weekly weigh-ins that put a lot of unhealthy pressure on athletes to restrict their diets," she continues. "Those things all create the wrong environment. On the other hand, if coaches are educated about eating disorders, they can be an athletic program's greatest asset, because athletes will often turn to them first with questions or confide in them about personal issues."

Bonci adds that several great educational resources are now available, aimed at athletes and those who work with them. Athletes Targeting Healthy Exercise & Nutrition Alternatives (ATHENA), for example, uses a coach and an athlete as "squad leaders" to teach teams about everything from healthy eating habits to avoiding drugs and alcohol.

"The best part of raising awareness about eating disorders throughout an athletic program is that it sets student-athletes up for a lifetime of better habits," Bonci says. "If they're surrounded by people who support them in making healthy choices and steering clear of dangerous behaviors, they'll carry those lessons with them forever."

Sidebar: DOCTOR'S ORDERS
Sometimes, knowing what to do during a medical crisis is easy: You take your cues from the experts. That worked this past October for Chris Olson, Athletic Director at Joliet (Ill.) Central High School, after a student at his school was diagnosed with meningococcemia, a severe bloodstream infection. Spread by the exchange of respiratory or throat secretions, such as during coughing or sneezing, it is brought on by the same bacterium that causes meningitis and is fairly rare, but can be deadly if not recognized and treated quickly with antibiotics.

"As soon as our school nurse notified county health department officials of the situation, they recommended that we shut down all contact sports, so that's exactly what we did," says Olson. "That was on a Friday, and it lasted through the weekend."

The directive applied to football and soccer, and the football team was forced to forfeit its last game of the season. The soccer team co-ops with Joliet West High School, and only West players participated in a soccer playoff game that Friday evening. Missing six starters, the Steelmen lost 3-1.

"We asked the Illinois High School Association to move the game to Monday, but the playoff schedule was already set and we couldn't even say for sure when our Central athletes would be cleared to return, so that didn't work," explains Olson. "I definitely felt bad for our kids, but safety was our first concern. We never hesitated to follow the health department's advice."

Sidebar: RESOURCES

www.Training-Conditioning.com
For more information on the Prevent Injury and Enhance Performance (PEP) program, visit the Web site of our sister publication, Training & Conditioning. Click on "Video Library" to view exercise clips from the PEP instructional DVD and access an order form to purchase your own copy.

www.cdc.gov/MRSA
For the latest recommendations and comprehensive advice on preventing MRSA infections, visit the Centers for Disease Control and Prevention's MRSA Web site.

nata.org/statements/position/DisorderedEating.pdf
This site contains the National Athletic Trainers' Association's position statement on disordered eating, which offers specific advice on screening methods.

www.ohsu.edu/hpsm/athena.cfm
More information on the ATHENA program can be found here.