Unlike typical sports injuries, medical conditions are not always immediately apparent. This post identifies 10 common medical conditions in athletes.
The information is taken from our new textbook Medical Conditions in the Athlete 3rd Edition and covers medical conditions by body system, their mechanism of acquisition, signs, symptoms, differential diagnosis, referral, treatment and return to participation criteria.
Common medical conditions in athletes
Airway disease is the most frequently encountered chronic respiratory condition in athletes (Hull et al. 2012). Several terms are often used to describe airway disease, especially if a definitive diagnosis has not yet been determined. Asthma, exercise-induced asthma (EIA) and exercise-induced bronchoconstriction (EIB) are the most common of the airway diseases (Krafczyk and Asplund 2011; Simpson, Romer and Kippelen 2015). Many sources use these terms interchangeably because they clinically present with many of the same signs and symptoms. Specifically, however, EIB is used to describe an exercise-induced, transient, and reversible narrowing of the airways and it may occur in persons with or without underlying asthma.
Exercise triggers bronchoconstriction but does not induce the clinical syndrome of asthma (Krafczyk and Asplund 2011). Asthma is a pulmonary disorder characterised by reversible airway obstruction that results from hyperreactivity; it is also referred to as “twitchy” airways (Boulet 2012). Allergens, stress or anxiety, smoke or other environmental pollutants, cold ambient temperatures and even exercise commonly trigger this hyperreactivity (Carey, Aase and Pliego 2010).
The rule of thumb is that asthma occurs outside of exercise or strenuous activity and generally has two components that lead to the obstruction: inflammation and spasm. Inflammation, characterised by mucosal edema and increased secretions, along with bronchospasm of smooth muscle, results in an increase in airway resistance and impeded airflow.
Asthma often begins in childhood and has various degrees of severity and progression. Some people need daily oral or inhaled medicines, whereas others need only sporadic or intermittent treatment. Many patients do not have asthmatic symptoms except during strenuous exercise. Despite the various presentations of asthma, it can be life-threatening if not treated promptly and adequately.
Many professional athletes have suffered from Asthma. These include Manchester United’s Champions League winning midfielders Paul Scholes and David Beckham. Five times NBA winner Dennis Rodman. Marathon runner Paula Radcliffe, Olympic medalist Rebbecca Adlington and cricket legend Sir Ian Botham.
Signs and Symptoms
Patients with airway disease (asthma, EIA and EIB) experience episodic, paroxysmal attacks of shortness of breath and wheezing as well as other symptoms, such as chest tightness and a dry cough. These episodes can be transient, lasting a few minutes to hours, or prolonged over several days. Severe attacks can be associated with much respiratory distress and tachypnea. Wheezing may be audible to the unaided ear in some cases. Mild cases may present as only a chronic cough (cough variant asthma).
On examination, both the respiratory rate and heart rate may be elevated, depending on the severity of the condition. In particular, the use of accessory muscles of respiration may be seen during respiratory distress. On auscultation, wheezes are usually present, particularly during expiration. There is also prolongation of the expiratory phase as airway resistance is increased. Breath sounds can be diminished.
Referral and Diagnostic Tests
If the patient history and examination suggest asthma, response to empirical treatment with \gb\-agonist medications such as albuterol is often diagnostic. A decrease in the predicted forced expiratory volume within the first second (FEV1) measured by spirometry, particularly in response to cholinergics such as methacholine (i.e. methacholine challenge test), is considered the “gold standard” for diagnosis (Millward et al. 2009; Morris 2010; Ostrom et al. 2011). A peak flow meter provides a quick record of pulmonary function and can be used to help assess the severity of the asthma or the effectiveness of the medication. Here is how a patient should use a peak flow meter:
- Stand or sit up straight.
- Place the mouthpiece onto the peak flow meter.
- Slide the indicator to the base of the meter.
- Exhale completely.
- Take a deep breath.
- Place the mouthpiece in mouth and seal lips tightly around the mouthpiece.
- Blow out as hard and fast as you can one time.
- Reset the indicator.
- Repeat steps 4 through 7.
- Record the higher of the two numbers.
- Assess forced expiratory volume.
Treatment and Return to Participation
Inhaled \gb\-agonist medications, both long- and short-acting, are the mainstays in the treatment of asthma (Hull et al. 2012; Boulet, Hancox, and Fitch 2010; Boulet 2012). Other medications used to treat asthma include oral and inhaled steroids, mast cell stabilisers such as cromolyn, leukotriene modifiers and theophylline (Morris 2010; Barros, Prinzivalli, and Christi 2016). Treatment recommendations generally follow a stepwise approach in the use of both “rescue” and maintenance medications as the severity of the disease dictates (Stack and Hakemi 2011).
Although strenuous exercise can provoke airway disease, several studies have shown that regular exercise and improvement in physical fitness (specifically pulmonary function) may reduce the symptoms and irritability of the airways (Stack and Hakemi 2011; Parsons et al. 2012).
In general, athletes with mild asthma may participate in most sports. However, because cold ambient temperatures are known to exacerbate the symptoms of asthma, many athletes with asthma prefer sports that involve competition in warm, temperate climates, such as track and field. Individuals with moderate to severe asthma are unlikely to be involved in vigorous athletic activities because the disease often will limit performance. Athletes with acute exacerbations of the disease should refrain from activity until the acute attack resolves and they no longer need rescue medications, such as albuterol, on a regular basis.
2. Thermoregulation Concerns (hot and cold conditions)
Athletes have to perform in a variety of weather conditions. Thermoregulation concerns must be considered, especially for athletes that participate in outdoor sports in the heat or cold wet temperatures.
Evaporative cooling is the most effective heat loss mechanism for the body, providing more than 80% of heat loss in the able-bodied athlete. Those with spinal cord injury (SCI) cannot depend on the autonomic nervous system to lower their core temperature by regulating blood flow. In addition, sweating is often impaired below the level of the spinal cord lesion, requiring the athlete’s body to rely on less surface area for evaporative cooling (Griggs, Price, and Goosey-Tolfrey 2015). Therefore, athletes with SCI are at greater risk of heat illness than their able-bodied counterparts. Athletes with tetraplegia and those with lesions above T6 are especially vulnerable to heat illness because they cannot increase heart rate to sustain cardiac output when blood must flow to both the muscle and the skin (Griggs, Price, and Goosey-Tolfrey 2015).
Likewise, in cold conditions, these athletes may lack normal warming mechanisms, such as piloerection, shivering and circulatory shunting. A lack of working muscle mass below the level of lesion contributes to temperature regulation problems. Even temperatures around 10 °C (50 °F) may pose problems for an athlete with a cervical or high thoracic lesion. Impaired or absent sensation intensifies the risk of hypothermia because these athletes may be unaware of the loss of body heat. Athletes with spinal cord injury are particularly susceptible to cold. The athlete, athletic trainer (physio), coaches and other team members need to be sensitive to not only the environmental conditions but also inadequate clothing, prolonged levels of inactivity during competition, improper warm-up and dehydration.
Signs and Symptoms
Recognising the early warning signs and symptoms of dehydration is crucial in preventing severe complications from heat stress. Signs and symptoms include thirst, irritability, fatigue, headache, weakness, dizziness, decreased performance, erratic wheelchair propulsion, flushed skin, head or neck heat sensations, vomiting or nausea and general discomfort. In able-bodied athletes chills and muscle cramps are common.
Dehydration can also occur in hyperthermal situations during cold weather or when hypothermia also exists. Dehydration causes reduced blood volume, resulting in less fluid available to cool or warm tissues. Low temperatures accentuated by wind and dampness can pose a major threat to any athlete but especially to the athlete with a spinal cord injury, who may lack the normative mechanisms for warming.
Hyperthermia occurs when an athlete’s body temperature rises and remains above the normal 37 °C (98.6 °F) due to the body’s failure to thermoregulate. The most severe form of hyperthermia is heatstroke, a life-threatening emergency characterised in the able-bodied population by a core temperature over 40.5 °C (105 °F) (Casa et al. 2015); a rapid increase in pulse is present as well (160–180 beats/min). The chief symptom of heatstroke is central nervous system dysfunction. Other symptoms are similar to those associated with concussions, namely confusion, agitation, inappropriate behaviour or language, apathy, vacillating emotions, stupor and coma or death if untreated.
These factors contribute to heat-related illness:
- Hot, humid conditions
- Recent illness
- Inability to sweat
- Lack of acclimation to temperature
- High-intensity workout
- Dark-colored clothing
- Use of medications or dietary supplements
- Lack of fitness
- Excessive motivation
- Behaviour risks (e.g., lack of sleep, alcohol intake)
- Amount and type of clothing or equipment causing impaired evaporation
Referral and Diagnostic Tests
Thermoregulatory problems are often incorrectly attributed to fatigue, illness, hypoglycemic reactions, concussion, or head injury (Prentice 2014). When the thermoregulatory system is impaired, typical signs such as shivering might not be observable. It is critical that the health care provider be able to review a thorough medication and nutritional supplement history for the athlete that includes prescriptions and over-the-counter products. Sympathomimetics and anticholinergics affect thermoregulation, as do diuretics and excessive caffeine (Patel and Greydanus 2010). Emergency referral is warranted if the athlete is not responding to treatment or if heatstroke is suspected.
Treatment and Return to Participation
For hyperthermia, the athlete is moved to a shaded or cooled area, clothing is loosened, equipment removed, oral fluids are administered and cooling is accomplished with cold water. Intravenous fluids are administered if the athlete is not coherent. If heatstroke is suspected, emergency measures to reduce the athlete’s temperature (e.g., sponge application of cool water, fanning body with a towel) are performed first; then the athlete must be transported to an advanced emergency care facility (Casa et al. 2015). Although immersion in an ice bath has been recommended for able-bodied athletes, this treatment should be used with caution for an athlete with a spinal cord injury, especially one with a complete, high level of lesion because the thermoregulatory system is impaired. Cooling may occur too rapidly. If you’d like to read more about ice baths take a look at our recent post Could you benefit from cold-water immersion?
Treating hypothermia involves administering warm fluids, transporting the athlete to a warm environment, removing wet clothing immediately and replacing them with warm, dry clothing. The use of heating pads or hot water bottles on paralysed areas should be avoided because using heat on areas without sensation is contraindicated.
Heat-related illnesses are entirely preventable. The availability of proper hydration and rehydration techniques, appropriate adaptation to environmental conditions, wearing appropriate clothing and screening for a prior history of heat-related illnesses can prevent hyperthermia. We took a look at how the heat affected the performance of footballers in the 2014 FIFA World Cup in Brazil, take a look at Weather and jet lag implications for footballers.
Preventing hypothermia includes encouraging the athlete to drink plenty of fluids, warm up properly, wear adequate layers of clothing, change wet clothing immediately after exercise and wear a hat.
Special Concerns in the Adolescent and Mature Athlete
Children tend to absorb more heat from their surroundings, have a lower sweating capacity and produce more metabolic heat per mass unit than adults. Therefore, exercise time and intensity are reduced when environmental conditions are extreme. In addition, sports coaches should make sure that children have 10 to 14 days acclimatisation.
Older adults may have decreased fitness levels, decreased lean body mass and potentially chronic diseases. They may use prescription medications, which may affect the athlete’s reaction to the environment. Trainer’s should check for fitness, acclimatisation and frequent intake of fluids, as well as should consult with the athlete’s physician about medications.
3. Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy (HCM) is the leading cause of sudden cardiac death in athletes in the United States under the age of 35. The genetic disorder is characterised by an abnormally hypertrophied but nondilated left ventricle in the absence of physiological conditions such as physical training or pathological conditions like aortic stenosis or hypertension that would result in left ventricular hypertrophy (Maron, Ackerman, et al. 2005). More than 400 specific mutations within genes have been identified.
The prevalence of HCM is estimated at 1 in 500 in the general population and is more prevalent in males of African-American descent.
The walls of the left ventricle thicken in a variable pattern in HCM. As often as 28% of the time, physical obstruction of blood flow occurs during systole. Up to 80% of individuals with HCM have abnormally small coronary arteries that may cause myocardial ischemia (Maron, Ackerman, et al. 2005). Cellular abnormalities include myofibrillar disorganisation and death with resultant fibrotic scarring.
Although outflow obstruction can occur, the presence of left ventricular diastolic dysfunction is more common. Either outflow obstruction or diastolic dysfunction can impair exercise performance even in the least symptomatic person (Maron, Ackerman, et al. 2005). Both decreased wall distensibility and incomplete myocardial relaxation contribute to altered left ventricular filling (Maron et al. 1987), which leads to left atrial dilation and potential development of emboli.
Regional myocardial ischemia likely occurs because of the abnormally small coronary arteries and inadequate capillary density (Maron et al. 1987). Adding random fibrosis of the cardiac musculature produces a combination of ischemia, fibrosis and impaired vasodilator reserve that can lead to arrhythmia and sudden death.
Signs and Symptoms
Symptoms of HCM are fatigue, dyspnea, exertional angina and syncope or near syncope. These symptoms may not correlate with the degree of ventricular hypertrophy or be predictive for sudden death (Maron, Shirani, and Poliac 1996). Physical examination can provide valuable information, but the findings are not consistent. On palpation, an increased left ventricular impulse may be felt. Pulses may be bifid in character and exhibit a brisk upstroke. On cardiac auscultation, a classic, harsh precordial ejection murmur may be heard at the left lower sternal border toward the apex. The murmur increases with standing or Valsalva manoeuvre and diminishes with squatting; however, a murmur is not always present.
It is important to consider differential diagnoses before determining clinical HCM. The clinical symptoms alone of exertional angina, syncope, and near syncope point to many conditions that could cause sudden death. They also can be related to benign conditions, such as dehydration or vasovagal syncope, or noncardiac conditions, such as asthma or gastroesophageal reflux disease. The potential for a serious, life-threatening condition, however, warrants an immediate referral.
Referral and Diagnostic Tests
Athletes with symptoms of exertional angina, syncope, or near syncope should be referred immediately to a physician who specialises in cardiology for evaluation. Fatigue and dyspnea uncharacteristic for a particular athlete warrant concern and certainly physician referral when accompanied by a heart murmur.
Standard laboratory tests, such as a resting 12-lead ECG or chest radiograph, have limited utility in screening for HCM. The most useful diagnostic test is echocardiography, or magnetic resonance imaging (MRI) with gadolinium contrast (Maron, Douglas, et al. 2005; Maron 2015b). Increased left ventricular wall thickness (>15 mm) is the most helpful diagnostic parameter. The majority of male athletes and all female athletes have a ventricular wall thickness of 12 mm or less (Pelliccia et al. 1991). Therefore, the range from 13 to 15 mm may pose a diagnostic dilemma because it is possible to have physiological hypertrophy in this wall thickness range; however, this hypertrophy has been reported only in male cyclists and rowers (Pelliccia et al. 1991).
Another sign of HCM that can be seen on an echocardiogram is a ventricular septum or free wall thickness ratio greater than 1:3. Asymmetric wall thickening and decreased left ventricular diastolic cavity dimension (<45 mm) may also be present. In addition, the echo may reveal abnormal diastolic filling with decreased early filling and increased late filling and abnormal ultrasonic myocardial reflex activity in the athlete with HCM (Maron et al. 1993).
Discontinuing athletic activities for a few weeks to 1 mo for the athlete with these symptoms may help clinicians to determine whether the problem is HCM or simply athlete’s heart (Maron et al. 1993). Hypertrophy of the ventricular wall will not resolve with detraining in a person with HCM.
As a diagnostic tool for HCM, echocardiography is the gold standard. People with HMC are limited to low-intensity sports, but there is a suggestion that those with a family history of sudden death at a young age due to HCM are strong candidates for an implantable cardioverter defibrillator to allow for a more normal life (Maron 2015a).
Treatment and Return to Participation
On the basis of the 36th Bethesda Conference recommendations, athletes with hypertrophic cardiomyopathy should be restricted from participation in all competitive sports with the possible exception of low-intensity (class IA) sports such as golf, bowling and billiards (Mitchell et al. 2005). Furthermore, the placement of an implantable cardioverter defibrillator (ICD) in a patient with HCM does not change the competitive sports recommendations for this disease.
Although the clinical significance and natural history of genotype positive–phenotype negative individuals remain unresolved, no compelling data are available at present with which to preclude these patients from competitive sports, particularly in the absence of cardiac symptoms or a family history of sudden death.
Detection of HCM can be difficult, but the patient’s medical history is invaluable. A comprehensive medical history can reveal an autosomal dominant transmission pattern, a family history of cardiac disease, or a record of other premature sudden death in family members. Unfortunately, medical histories have not been as useful as expected because of the variability of expression of the trait.
Anxiety is one of the most common human experiences despite some cross-cultural differences (Asnaan et al. 2010). For example, most people have experienced a momentary sensation of “butterflies” in the stomach. In fact, the ability to respond with anxiety is considered normal and even desirable and anxiety is what helps us “get our game face on.” However, given the right set of factors—physiology, central nervous system sensitivity, perceptual filters, belief system, coping and support system—people may respond to one or more acute or chronic stressors by developing anxiety serious enough to be considered a disorder. This is a case of too much of a good or necessary thing. The individual is wracked with very serious and debilitating apprehension, excessive and ongoing worry, overwhelming fears, panic attacks, or compulsive behaviours.
Red flags for problems with anxiety include outbursts of irritability or anger, substance abuse, changes in athletic performance, or other behaviours that are uncharacteristic for the athlete. The presence of some or all of these symptoms may signal an anxiety problem or even an anxiety disorder:
- Difficulty getting to sleep
- Shortness of breath
- Dizziness, lightheadedness
- Feeling of choking
- Impairment of performance
- Feelings of unreality
- Worry, nervousness
- Appetite disturbance
- Chills or hot flashes
- Gastritis, nausea
- Psychomotor agitation
- Fear of losing control
- Feelings of going crazy or dying
People can be screened for anxiety disorders using a variety of standardised measures, such as the Generalized Anxiety Disorder-7 (GAD-7) (Spitzer et al. 2006).
Women are twice as likely as men to report generalised anxiety (Anxiety Disorders Association of America 2016). Adolescents and young adults into their 20’s are prone to develop anxiety as well (Merikangas, He, and Burstein 2010). Consistent with the BPSS model described previously, the causes of GAD and other anxiety problems are varied. Fortunately, a number of effective treatment approaches and self-help measures are available (Antony and Hood 2012; Gorman 2002).
Among the 6 million people who experience panic attacks, some say that these episodes seem to come out of nowhere when, in fact, they are probably in response to an accumulation of stressors. At other times, the attacks may be stimulated by an identifiable, acutely stressful event (Antony and Hood 2012).
Symptoms that seem to be cardiovascular, such as chest pain or shortness of breath, are especially striking during these episodes. The attacks can be so overwhelming and can produce such fear and intense anxiety that the affected person may begin avoiding stressful situations and other stimuli perceived as triggers (Antony and Hood 2012). As a result, the panic attacks may become panic disorder accompanied by agoraphobia, avoiding open spaces or public places. Panic disorder can be so severe and distressing that some victims might consider suicide as the only way out; in fact, up to 20% of those affected consider this step.
Posttraumatic Stress Reactions
Similar to the intense responses involved in panic attacks are varying degrees of posttraumatic stress reactions (e.g., acute stress disorder [ASD], posttraumatic stress disorder [PTSD]) These reactions are in response to exposure to life-threatening events or other situations outside the normal range of human experience (e.g., war, serious physical or sexual assault, motor vehicle accident).
Fairly often, people will re-play or re-experience the traumatic event in the form of recurrent or intrusive and distressing recollections, images, thoughts, perceptions, dreams, illusions, or hallucinations. They often have strong physiological reactions to these experiences and therefore they try to avoid stimuli and to numb their responses. This leads them to avoid thoughts, feelings, conversations, activities, places and people they associate with the traumatic event. At times, this process of compartmentalization can be so severe that it leads to an inability to recall important aspects of the event, marked anhedonia, detachment or estrangement, restricted range of affect, and a sense of a foreshortened future.
Treatment of Anxiety Disorders
Treatment plans for anxiety disorders are often recommended by the practitioner on the basis of assessment and experience and then negotiated with the individual or family members according to personal preferences. The treatment plan for anxiety can include one or all of a group of evidence-based interventions (Anxiety and Depression Association of America 2015).
When there is a strong family history of anxiety problems, there is probably a biological or physiological predisposition that can be managed with medications. One class of psychotropic medications often used includes those that act on the serotonin system. These include selective serotonin reuptake inhibitors such as fluoxetine (Prozac), paroxetine (Paxil) and escitalopram (Lexapro). When anxiety coexists with depression, medications that affect dopamine or norepinephrine, as well as serotonin, can be useful. These include venlafaxine (Effexor) and mirtazapine (Remeron). Benzodiazepines have been used for many years to treat anxiety and are fairly well known. These medications include clonazepam (Klonopin), diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax).
The anti-anxiety drugs are prescribed according to their rate of onset, effects, and adverse effect profiles. Medication can be used from the outset or added after treatment begins. It is usually recommended that the person stays on the medication for 9 to 12 mo or until symptoms are fully resolved.
Other important steps to take to reduce anxiety on a physical level are to get regular exercise and regulate sleep. Exercise, especially aerobic exercise, has been shown to significantly reduce levels of anxiety. This may be a moot point for those who are already physically active, but, at times, people will stop exercising if they are distressed enough. For the injured athlete, maintaining aerobic conditioning during rehabilitation is important for mental as well as physical well-being. Most people should be encouraged to slowly re-establish healthy patterns of physical activity. Similarly, good sleep hygiene addresses the basic human need for restful sleep, which in turn supports well-being and stable functioning:
- Establish regular times for going to bed and awakening.
- Minimise distractions and noises.
- Avoid stimulating activity or substances before bedtime (e.g., exercise, caffeine).
5. Sports Hematuria
A Sports hematuria is the benign, self-limiting presence of three or more red blood cells per high-power field in a centrifuged urine specimen and is directly associated with exercise or activity. Sports hematuria is asymptomatic and has been documented to occur in both contact and non-contact sports. The degree of hematuria is believed to be related to the intensity and duration of the exercise. In most circumstances, the hematuria will resolve within 72 hours of onset in athletes without any coexisting urinary tract pathology (Varma, Sengupta, and Nair 2014). Active people under age 30 had higher incidences of post-exertional hematuria than did older participants (Varma, Sengupta, and Nair 2014; Bernard 2009).
The incidence of sports hematuria is estimated to be as high as 80% in swimming, lacrosse and track and field; 55% in rowing; and 20% in marathon runners. These incidence levels have led to the development of several possible causes of sports hematuria (e.g. increased permeability of the glomerulus, direct or indirect trauma to the kidneys, renal ischemia, dehydration, release of a hemolyzing factor), all of which appear to be related to exercise duration and exercise intensity (Varma, Sengupta, and Nair 2014; Shephard 2015).
Signs and Symptoms
By definition, sports hematuria is asymptomatic. The finding of hematuria may occur during a routine urinalysis, such as those that may be performed during a physical examination or pre-participation examination. On occasion, athletes will present with gross hematuria (i.e. visible presence of blood in the urine) after a prolonged and strenuous workout. However, microscopic hematuria is not visibly apparent but is noted during a dipstick or urine analysis. Regardless of how hematuria is determined, the general rule is that sports hematuria will resolve within 72 hours without any further intervention than rest. One study with 500 runners noted that post-exertional hematuria continued up to 7 days in some (12%) and beyond 7 days in 7% of participants. It was determined that the three who had persistent (beyond 14 d) hematuria had other kidney pathologies (Varma, Sengupta, and Nair 2014).
The differential diagnosis includes distinguishing true hematuria from false-positive urine blood dipsticks. True hematuria may result from a urinary tract infection, urethritis, interstitial nephritis, renal papillary necrosis, nephrolithiasis (kidney stone), polycystic kidney disease, kidney laceration, a neoplasm arising from any structure in the urinary tract, urinary bladder cancer and prostatitis in males (Ferri 2016). Causes of a false-positive urine dipstick examination for blood include those related to drug intake (i.e., phenazopyridine, rifampin, nitrofurantoin, phenytoin), food dyes, menses, and myoglobin in the urine.
Referral and Diagnostic Tests
The finding of asymptomatic hematuria in an athlete during some form of routine testing needs to be reviewed by the team physician. As a general rule, these athletes are retested at 24 to 72 h to document resolution. Any athlete with symptomatic hematuria or systemic symptoms is referred to a physician for immediate evaluation.
Although sports hematuria is a benign condition, not all hematuria is benign and therefore the evaluation must include some basic tests. A urinalysis or dipstick test will demonstrate the presence of blood in the urine. If symptoms of dysuria (painful urination) are present, a urine culture may be performed. If hypertension, renal disease, repeated urinary tract infections, or pyelonephritis is found in the athlete’s history, an initial serum creatinine may be performed. As a general rule, if hematuria persists beyond 72 hours, further evaluation is warranted. Additional tests include a renal ultrasound and possible cystoscopy.
Treatment and Return to Participation
The treatment of sports hematuria is simply to rest for 24 to 72 hours. Resolution is the rule and it should be documented with a repeat urinalysis after rest. The prognosis is excellent because sports hematuria is a benign and self-limiting condition (Varma, Sengupta, and Nair 2014; Shephard 2015).
6. Deep Vein Thrombosis
Deep vein thrombosis (DVT) is a condition in which a blood clot becomes lodged in a large vein. This results in venous blockage with stasis distal to the clot. Most of these clots occur in the lower legs. However, a DVT can occur in any limb. For instance, subclavian vein thrombosis, although rare, has been reported in baseball pitchers (Hurley et al. 2006).
Many factors contribute to the formation of a DVT. In an active population, a DVT is usually caused by trauma to the extremity from injury or surgery. Other causes include prolonged sitting on a plane, bus, or car. Hypercoagulability disorders such as factor V Leiden anticoagulant gene mutation can also cause DVT. Women who use oral contraceptives, particularly women who smoke, also have an increased risk of blood clots (National Institutes of Health 2011).
It is possible to confuse a DVT with a more superficial thrombophlebitis, postphlebitic syndrome, ruptured Baker’s cyst, or even cellulitis, as they all have similar presentations with a swollen extremity. Even the common problem of calf muscle strain may be confused with a DVT. Usually, the mechanism of injury can help differentiate a strain from a DVT. If the patient has had recent surgery, travelled long distances while sitting down, or been subject to a known trauma, a DVT is highly possible.
Signs and Symptoms
The symptoms of DVT are often nonspecific; some DVTs are actually asymptomatic (no symptoms). The key symptoms are limb pain and swelling. In the leg, these symptoms are worsened by standing and walking. On examination, there is usually distal edema of the affected extremity. This can be confirmed by comparison with the contralateral extremity. In the lower leg, the examiner squeezes a passively dorsiflexed calf, as a test for Homans’ sign, realising the test is not specific for a DVT nor is it commonly present with DVT (Delis et al. 2001).
Measuring the patient’s temperature can be important because a fever may be the clue to a DVT proximal to the knee, which is closely associated with the often-fatal pulmonary embolus (PE). The Wells’ Clinical Prediction Rule for DVTs (Wells et al. 1997), which provides a score for predisposing factors, signs, and symptoms of a DVT, has been validated as being useful for patients at low risk of a blood clot (Tamariz et al. 2014). Pitting edema, calf swelling greater than 3 cm and tenderness along the distribution of the affected veins and collateral superficial veins are all score-worthy signs of a DVT (Wells et al. 1997). The thrombus is generally confirmed through Doppler ultrasound testing but may require invasive contrast venography.
Red Flags for Deep Vein Thrombosis and Pulmonary Embolism
Suspicion of DVT or PE rests with athletes who have recently had surgery, been bedridden, or had sustained sitting (such as in a long bus commute or air travel). Athletes with unexplained pain, limb swelling (either upper or lower), edema, or shortness of breath should be evaluated for possible DVT or PE. Shortness of breath, chest pain and hemoptysis are more indicative of a PE.
Treatment and Return to Participation
Treatment requires anticoagulation (blood thinners), which can be started on an outpatient basis but may require hospitalisation. After adequate anticoagulation is reached with heparin, the patient usually must keep taking other anticoagulants such as warfarin for 3 months or more (Schreiber 2015). Anticoagulation medications must be monitored and adjusted following blood tests every week or so until the medication level is stabilised. Another, more expensive, injectable drug, enoxaparin (Lovenox), is also available and requires less monitoring than other anticoagulants. Note that mixing alcoholic beverages with anticoagulant medications is dangerous; alcohol can increase the blood-thinning properties of the drugs. Patients also need to be aware that anti-inflammatory medications alter the blood-clotting process and may exacerbate bleeding time.
Athletes undergoing continued anticoagulation therapy should not participate in collision or contact sports. Once anticoagulation is completed and if a hypercoagulable evaluation is negative, a gradual return to play may be granted with careful monitoring for recurrence. The patient’s diet needs to include adequate but not excessive vitamin K.
Simple prevention is difficult, with the exception that everyone should avoid prolonged sitting when travelling by plane or automobile. Also, as women age, they may need to consider an alternative form of contraception to birth control pills. To read more on flight saftety and tips on how to avoid jet leg particullary check out 7 Hacks That Help Athletes Overcome Jet Lag.
7. Food Poisoning or Bacterial Diarrhoea
The term food poisoning is often overused. People who experience the sudden onset of gastrointestinal symptoms often will attribute it to something they ate or drank. Food poisoning generally should be suspected when multiple people who ate the same food become ill at about the same time. Sampling and culturing the person’s stool can confirm the diagnosis. Food poisoning typically occurs when food is improperly handled, cooked, stored or refrigerated. In some cases, the problem is the bacterium itself and in other cases, it may be from the toxin or toxins produced by the bacterium. The most common causes are Campylobacter, Salmonella and Staphylococcus species, but several other bacteria can also cause problems, including Shigella species, Bacillus cereus, Yersinia and Escherichia coli (Ferri 2016). Athletes from developed countries travelling to countries where food hygiene isn’t always a high priority must take extra precaution.
Signs and Symptoms
Bacterial diarrhoea is typically more severe and lasts longer than viral gastroenteritis. It may cause higher fevers or severe abdominal cramps and is more likely to result in weight loss and dehydration. Depending on the bacterium, the onset may occur 4 to 6 hours after eating the contaminated food (e.g., Staphylococcus) or 3 to 10 days later (e.g., Salmonella). This variable duration obviously makes it difficult to pinpoint a specific food.
Treatment and Return to Participation
Initial management of diarrhoea can include over-the-counter medicines as for viral gastroenteritis. If the athlete is significantly ill or there is blood in the stool, then a referral is needed for thorough evaluation and treatment. This may include stool specimens and antibiotics. If several athletes become ill at the same time, then it may be important to trace back to a shared meal as the source. If the problem was simply poor refrigeration of a single food, then the problem may resolve on its own. However, the problem may be an infected food worker who may continue to spread the infection until treated. The athlete may return to participation when symptoms have been completely resolved and strength and hydration are back to normal.
Parasitic infections of the gastrointestinal tract are less common than bacterial or viral infections but may still cause significant problems. The most common parasites are single-celled organisms called protozoa. Giardia is a common waterborne protozoan that is found worldwide, especially in people who drink from more remote streams when hiking or camping. Entamoeba species are parasitic protozoa that are also found worldwide but are much more common in tropical regions (Domino et al. 2016). In addition, tapeworms, roundworms and flukes can be parasitic in humans. These infestations are uncommon, and discussion is beyond the scope of this text.
Giardia-induced diarrhoea is characterised by the significant gas that typically results. Diarrhoea may be acute or chronic and intermittent. The diarrhoea is often explosive in nature, with patients complaining of dull abdominal cramping and bloating with gas and flatulence. Entamoeba may cause a variety of symptoms from chronic intermittent diarrhoea, abdominal pain, and weight loss to profound bloody diarrhoea and fever (Ferri 2016).
Parasitic infections must be recognised by the coaching staff as different from self-limited viral and bacterial diarrhoea and promptly referred for the appropriate antibiotic treatments. The treating physician is the one to make decisions about return to participation.
8. Insect Bites
As sport is becoming more global athletes travel the world a lot so insect bites are common, especially for athletes who perform outdoors.
Dermatological reaction to insect bites is extremely common. In the United States, 1 to 2 million people are severely allergic to insect venom. These bites also can lead to anaphylaxis, which causes 90 to 100 deaths in the United States each year (U.S. National Library of Medicine 2016). These data may be underrepresented, as many deaths are attributed to heart attacks or heat stroke. Exposure to insects becomes a possibility for physically active people during outdoor practice and events.
In addition to mosquitoes, chiggers, ticks, wasps, bees, ants and spiders can produce particularly bothersome reactions. Bites and stings can cause direct irritation from the insect’s body parts or secretions, immediate or delayed-hypersensitivity responses, or specific effects from venoms, or they can serve as vectors for secondary invaders (U.S. Food and Drug Administration 2015). Common reactions may be localised or spread across a larger part of the body and may include redness, pain, and swelling that may last as long as 10 days. Individuals with a prior history of allergic reaction to specific insect bites or stings can be extremely vulnerable and often carry an EpiPen (an epinephrine injection) when participating in outdoor activities.
Signs and Symptoms
Insect bites can range from a nuisance to an emergency. Chigger bites can cause extreme discomfort for days and possibly lead to secondary lesions with a bacterial infection as a result of scratching. Wasp and bee stings can be extremely dangerous when the person stung has an allergic reaction, which may quickly progress to anaphylaxis in sensitive individuals; therefore, first aid kits should be equipped with EpiPens for emergencies. Symptoms resulting from tick bites, which can result in Rocky Mountain spotted fever or Lyme disease, do not develop immediately, often making diagnosis a challenge.
Red Flags for Insect Bites
- Take the bites of any venomous insect seriously because the secretions, venom, and insect body parts can provoke dramatic or life-threatening reactions in sensitive individuals.
- Be aware of the insect varieties common to the geographical location.
- Recognise and refer athletes with signs and symptoms of anaphylaxis: agitation, chills, facial edema, swollen tongue, wheezing, difficulty breathing, flushing, generalized urticaria, hoarseness or difficulty talking, palpitations, near-syncopal or syncopal episodes, profuse sweating, palpitations, cardiovascular collapse.
- Have epinephrine on hand for emergency use in the event of a severe reaction.
Referral and Diagnostic Tests
A patient who presents with a history of a bite with associated local severe reaction, fever, or systemic manifestations is referred to a physician immediately.
Treatment and Return to Participation
Insect bites usually are treated conservatively with ice and elevation of the affected extremity. Strenuous exercise, heat, and surgery are avoided. Topical antibiotic ointment may be applied under a sterile dressing to retard infection. Antibiotics for S. aureus or S. pyogenes may be initiated and a tetanus booster should be administered by a physician if the term of the vaccine has lapsed. Serious bites become evident in the first 24 to 48 hours; in this event, the athlete is referred for medical treatment immediately.
Prevention of most insect bites involves avoiding the insects’ habitat, including shrubs and wooded and bushy areas. Not always possible if your event or training camp is located near them. Use chemical repellents properly by applying them to clothing. Use structural barriers, such as window screens, netting and protective clothing, to prevent contact with insects. When putting on shoes, socks, and other apparel that have been left unattended outdoors, athletes must thoroughly shake them out. Exercise caution during storms and floods that may drive insects from their normal habitats.
- Proper Application of Insect Repellant
- Only use insect repellant approved by the Environmental Protection Agency (EPA).
- Do not use insect repellant on babies or pets.
- Repellent used on older children should have less than 10% DEET.
- Do not apply insect repellent to children’s hands or faces.
- Spray repellent on clothing or skin but not on the face.
- Read the label to determine effectiveness time as well as the specific insect(s) the product deters.
- Completely wash hands with soap and water after application.
Normal pregnancy consists of a series of remarkable changes that occur within the female body. Multiple organ systems are affected in order to support a growing fetus while maintaining the health of the mother.
Before becoming pregnant, a woman should maintain proper nutrition, start the use of prenatal vitamins and discontinue using or avoid potentially harmful substances such as tobacco, alcohol, and illicit drugs. Folic acid is present in most prenatal vitamins and is important in helping to prevent neural tube defects in the fetus. It should be taken by all pregnant women.
Signs and symptoms
The initial signs and symptoms of pregnancy include a missed menstrual period and breast swelling or tenderness. Nausea and vomiting, known as morning sickness, may also be present early in the pregnancy. If severe, this may compromise hydration, nutrition and weight gain. Severe cases of nausea and vomiting termed hyperemesis gravidarum, can lead to hospitalisation for fluid replacement, electrolyte correction and control of emesis.
In general, however, symptoms are not this severe and they typically subside. In fact, the pregnant woman’s fluid status increases during pregnancy. Blood volume increases, as does intracellular and extracellular fluid. Fluid tends to accumulate more during the day and swelling to distal extremities is very common (Perales et al. 2015).
Plasma volume and cardiac output increase as a result of increases in stroke volume and heart rate. In addition, blood pressure decreases in the normal pregnancy because of an overall decrease in systemic vascular resistance. Respiratory changes include an increased tidal volume, increased minute ventilation and decreased overall airway resistance. Despite these changes, the woman’s FEV1 and respiratory rate usually remain unchanged at rest (May et al. 2015; Perales et al. 2015).
Gastroesophageal reflux is another common symptom occurring among pregnant women and is due to both anatomical and physiological changes. An athlete may note that certain foods aggravate reflux, and avoidance of these foods is prudent. If avoidance of the offending foods does not help, pharmacological therapy may be necessary. This therapy can consist of calcium-containing antacids, histamine (H2) antagonists, or proton pump inhibitors as prescribed.
Low back pain is a common complaint as well and is largely due to the woman’s altered centre of gravity secondary to the enlarging fetus, uterus and breast tissue. Low back pain is generally more of a problem during the latter stages of pregnancy. Interestingly, although the woman’s bones may adjust to the various stresses placed on them, they appear to suffer no ill effects from the high calcium demands of the fetus.
Throughout the course of pregnancy, a woman’s breasts enlarge and may become tender. It is also possible for a pregnant woman to notice that she is expressing fluid from her breasts before the birth of her child. The fluid expressed is known as colostrum and is a normal change associated with pregnancy.
Training while pregnant
Exercise and physical activity for healthy women should be encouraged in pregnancy. Women who exercise regularly during pregnancy have the benefits of improved cardiac function, limited weight gain, improved mental health and decreased time in labour (Perales et al. 2015; May et al. 2014).
Few scientific data address the participation in vigorous and competitive sport by the pregnant athlete, but some recommendations are noteworthy. Pregnant athletes should avoid exercise in the supine position as much as possible, particularly after the first trimester. Scuba diving, downhill skiing, contact sports and the use of hot tubs, steam baths and saunas place the fetus at potential risk and are discouraged during pregnancy (American Congress of Obstetricians and Gynecologists 2011). In addition, pregnant athletes are generally discouraged from participation in contact or collision sports after the 14th week of pregnancy, although this is based on indirect evidence. Further, a pregnant athlete who participates in competitive endurance sports should consider participation at the non-competitive level for the duration of the pregnancy.
Whereas exercise during pregnancy is safe in most cases, in some situations, exercise needs to be discontinued pending a complete evaluation by a physician. The American College of Obstetrics and Gynaecologists lists contraindications to exercise in pregnancy, including vaginal bleeding, pregnancy-induced hypertension, an incompetent cervix, preterm labour, premature rupture of membranes and intrauterine growth restriction. Warning signs that suggest the immediate cessation of exercise include back, pubic, or abdominal pain; dizziness; nausea; uterine contractions; excessive fatigue and decreased fetal movements (American Congress of Obstetricians and Gynecologists 2011). When in doubt, the athlete should discuss these issues with her physician. According to the NCAA recommendations (Parsons 2014), the pregnant athlete should do the following:
- Avoid supine exercise after the first trimester.
- Be discouraged from heavy weightlifting.
- Be discouraged from activities that require the Valsalva manoeuvre.
- Avoid activities associated with a high risk of falling (gymnastics, horseback riding, or downhill skiing).
- Consider non-competitive activity for those athletes involved in endurance sports.
- Avoid contact sports after the 14th week of pregnancy, even though there are no data regarding contact sports and pregnancy.
- Avoid any physical activity pending evaluation by an obstetrician when the mother has a previously diagnosed medical condition that may affect normal pregnancy, such as uncontrolled diabetes, hypertension, or cervical defects.
- Remain well hydrated.
- Avoid overheating.
- Yoga can be great during pregnancy as discussed in 24 Pregnancy Yoga Poses For A Strong, Healthy & Safe Pregnancy
- For more information you can watch our webinar with Dr Hayley Mills. The webinar discussed the current recommendations and evidence for physical activity during pregnancy Dr Mills is one of the leading Dr’s in the UK on physical activity during pregnancy.
Red Flags for Terminating Exercise While Pregnant
Signs to terminate exercise while pregnant and follow-up with your obstetrician:
- Vaginal bleeding
- Shortness of breath before exercise
- Chest pain
- Calf pain or swelling
- Preterm labor
- Decreased fetal movement
- Amniotic fluid leakage
- Muscle weakness
Ectopic pregnancy is also covered in Medical Conditions in the Athlete 3rd Edition which can be lethal for fetus and mother.
The liver is the largest organ in the body and it functions primarily as the central organ of glucose homoeostasis. It lies protected chiefly by the lower right ribs in the upper right abdominal cavity. This four-lobe organ secrets bile to facilitate the digestion of fats and it has metabolic functions as well. The liver also assists in amino acid and carbohydrate metabolism, fat-soluble vitamin storage (A, D, E, K), phagocytosis and detoxification of potentially harmful substances. Damage to the liver has profound repercussions for many body functions.
Hepatitis, literally translated, means inflammation of the liver and it is characterised by diffuse necrosis affecting the smallest secretory units of the liver (Porter and Kaplan 2011). The many varieties of the disease are differentiated by letters, mechanisms of acquisition and lasting sequelae. The diseases are typically abbreviated to HAV (hepatitis A virus), HBV, HCV, and so on. The emphasis in this chapter is on hepatitis A, B, C, and D; hepatitis E and hepatitis G typically do not affect the healthy population, occurring more often in endemic countries or immunocompromised patients.
In general, hepatitis can be caused by certain bacteria or viruses in addition to some drugs, toxins and excessive alcohol abuse. Hepatitis A and hepatitis E are infectious and highly contagious forms of the disease associated with poor sanitation and oral–fecal transmission. Hepatitis B, hepatitis C, and hepatitis D are varieties of serum hepatitis and are transmitted via parenteral (blood) or sexual contact; these forms can lead to chronic conditions.
Signs and Symptoms
Viral hepatitis has an incubation period of 2 weeks to 6 months and has several phases, each marked by specific signs and symptoms, except phase 1, in which patients are asymptomatic.
In the prodromal stage (phase 2), the patient could experience malaise, fatigue, upper respiratory infection (URI), anorexia, nausea and vomiting, mild abdominal pain, myalgia, or arthralgia (Buggs 2014). Some patients have accompanying headaches, fever, and a rash. When jaundice occurs, it typically manifests 5 to 10 days after the prodromal symptoms present.
Phase 3—the icteric phase—is typically marked by patients presenting with pale stools and dark urine. Icteric means “pertaining to jaundice,” and this phase is when jaundice appears. The chief complaints besides jaundice are gastrointestinal symptoms, malaise and hepatomegaly (Buggs 2014).
The final phase (4) is a 2 to 4-week recovery and convalescent phase marked by a state of well-being, return of appetite and disappearance of fatigue and pain. General recovery is based on the specific virus, but the acute illness typically subsides within 2 to 3 weeks. Some patients have few of these signs but instead experience a lingering, unexplainable fatigue. Taking a good and thorough history is critical because each type is distinguished by its method of transmission.
Differential diagnoses may include EBV, herpes simplex, URI, cholecystitis (gallstones), pancreatitis, influenza, and infectious mononucleosis (Ferri 2016).
Referral and Diagnostic Tests
Patients with unexplainable fatigue are referred to a physician for further evaluation. Physical findings include an enlarged liver and jaundice, but if these occur, it is later in the progression of the disease. Blood and urine tests will reveal a normal to low white blood cell (WBC) count, mild proteinuria, and bilirubinuria in patients with jaundice (Porter and Kaplan 2011). Each type of hepatitis has its own antigen that will be assessed to ascertain the specific type of virus, and therefore the treatment plan.
Treatment and Return to Participation
Hepatitis typically resolves spontaneously within 4 to 8 weeks but can have lasting sequelae. Until the patient has completely recovered, alcohol and sex is avoided. To prevent the possible spread of the disease, household members receive immune globulin and initiation of vaccine as appropriate. Physician follow-up for hepatitis requires thorough management to ensure complete resolution of the disease.
Athletes who participate in collision sports may need additional laboratory tests to determine any residual effects of the disease before resuming full activity (Harris 2011).
Prevention and Public Health Implications
HAV and HBV can be prevented by vaccine and good personal sanitation measures, such as hand washing after bowel movements and after contact with contaminated linens, clothing, patients, or utensils. Sports coaches and physios must routinely adhere to universal precautions when working with athletes with open wounds or when cleaning up body fluid spills (Harris 2011). Hepatitis B and C can be transmitted via contact during competition, so return-to-play decisions must be made individually by athlete and type of sport (Anish 2004; Buxton et al. 1994). Sexually transmitted hepatitis can be prevented by using prophylactic barriers, such as a condom. All cases of acute hepatitis need to be reported to local or state health agencies after diagnosis.
Hepatitis A virus (HAV) is caused almost exclusively by poor sanitation because it is transmitted via oral–fecal contact. Outbreaks occur most often in crowded areas and through contaminated food or water. Transmission of HAV through food is typical via milk, sliced meat, shellfish, and salads (Gilroy 2016). In HAV, patients present with mild flu-like symptoms. In the icteric phase, they acquire dark urine, pale stools, and jaundice. Jaundice is present in 70% to 85% of adults with acute-onset HAV (Gilroy 2016). Forty percent also have abdominal pain and pruritus (itching). Although the acute phase of the disease lasts up to 3 weeks, the convalescence is prolonged and relapsing HAV is common. Treatment consists of supportive care for the side effects. HAV is a self-limiting disease that rarely causes death. There has been a vaccine available for HAV since 1995, and it is nearly 100% effective after two doses (Gilroy 2016).
HBV is a worldwide health care problem (although more common in developing countries). Nearly one-third of the earth’s population has been infected with HBV, and about 400 million will have a lifelong infection from it (Pyrsopoulos 2015). HBV reportedly causes 5,000 deaths a year in the United States. The prevalence rate is believed to be between 0.1% and 0.5% of the UK population. HBV infections are usually acquired in adulthood (although an infected mother can pass it to her unborn child).
Transmission of HBV is primarily by sexual activity and high-risk activities include multiple sex partners, intravenous drug (needle) use, men who have sex with men, and piercing or tattooing. HBV is commonly contracted through exposure to blood, saliva, semen, vaginal secretions, urine, and faeces (Pyrsopoulos 2015). This is a hardy virus that can live for an extended time outside the human host, including on inanimate objects such as toothbrushes, utensils and medical supplies (Ferri 2016). HBV is approximately 100 times easier to contract than HIV (Buxton et al. 1994). HBV has been shown to be transmitted among American football players and sumo wrestlers (Tobe et al. 2000; Kashiwagi et al. 1982; Ferri 2016).
Most athletes in non-contact sports who contract acute HBV are allowed to participate in athletics depending on clinical signs and symptoms. In the absence of fever or fatigue, there is no evidence that intense training is contraindicated. In close-contact sports, such as wrestling or boxing, however, athletes with acute HBV need to refrain from participation until they are not infectious (Howe 2003).
Although HCV is less prevalent than HBV, approximately 50% to 84% of the patients remain chronic carriers of the virus (Buggs 2014). HCV is a dangerous variety of the virus and is the cause of liver disorders. Close to 20% of chronic HCV carriers will develop cirrhosis over 20 to 30 years; of these cases, up to 2.5% will also develop hepatocellular carcinoma (Dhawan 2015).
Common transmission routes for HCV involve intravenous or intranasal drug use (60%) or multiple sex partners (20%); the remaining transmission comes from needle sticks, maternal–fetus transmission, and unknown etiology (Buggs 2014; Ferri 2016). At present, there is no known prevention method for HCV other than avoiding risky behaviours. Hepatitis C is a nationally reportable disease.
HCV is the most likely hepatitis virus to fluctuate for several months or years, and HBV is likely to have a higher mortality rate than HAV or HCV. Chronic hepatitis occurs most often with HBV; 5% to 10% of patients have persistent inflammation and cirrhosis and are sub-clinical chronic carriers (Porter and Kaplan 2011).
HDV, or delta virus, is linked to HBV but is structurally dissimilar to HAV, HBV and HCV. It is far less common than other hepatitis viruses (Roy 2015). Transmission is via sexual contact and injected drug use. Those at particular risk are the recipients of multiple blood products, but the transmission is less efficient for HDV than for HBV (Buggs 2014). As a separate disease, HDV presents with symptoms similar to those of other hepatitis viruses, but it has a shorter incubation period, 21 to 45 days (Roy 2015). There is no vaccine for HDV, but HBV immunisation also prevents HDV disease.
So there you have it, 10 common medical conditions in athletes and how to spot, prevent and treat them. Medical Conditions in the Athlete 3rd Edition covers 100’s of medical conditions. These range from pharmacology interventions such as drug misuse to medical conditions by system. These include: respiratory system, cardiovascular system, gastrointestinal system, genitourinary and
- Respiratory system
- Cardiovascular system
- Gastrointestinal system
- Genitourinary and gynecological systems
- Neurological system
- The eye
- Ear, nose and mouth
- Systemic disorders
- Infectious diseases
- Dermatological conditions
- Psychological and substance use disorders
- Working with special populations