Administrative Issues
2013-14 NCAA
Sports Medicine
2013-14 NCAA Sports Medicine Handbook
P.O. Box 6222
Indianapolis, Indiana 46206-6222
Twenty-fourth Edition
August 2013
Compiled By: David Klossner, Director of NCAA Sport
Science Institute.
Distributed to head athletic trainers.
Available online at
Note: Revisions to the guidelines contained in the NCAA
Sports Medicine Handbook may be made on a yearly
basis. Between printings of the handbook, revisions will
be published on It is important that people
using this handbook be aware of any such revisions.
The NCAA Committee on Competitive Safeguards and
Medical Aspects of Sports suggests that such revisions
be recorded in the handbook, thereby keeping this publication current. New guidelines and major revisions
have been highlighted with teal shading.
ATHLETIC ASSOCIATION are registered marks of the
Association and use in any manner is prohibited unless
prior approval is obtained from the Association.
Member institutions and conferences may reproduce
information in this publication for their own use, provided the NCAA copyright is included on the material.
Also found on the NCAA website at the following
Copyright, 2013, by the National Collegiate
Athletic Association.
Printed in the United States of America.
2013-14 NCAA Sports Medicine Handbook
The health and safety principle of the National
Collegiate Athletic Association’s constitution provides
that it is the responsibility of each member institution
to protect the health of, and provide a safe environment for, each of its participating student-athletes. To
provide guidance in accomplishing this objective and
to assist member schools in developing a safe intercollegiate athletics program, the NCAA Committee on
Competitive Safeguards and Medical Aspects of Sports
creates a Sports Medicine Handbook. The committee
has agreed to formulate guidelines for sports medicine
care and protection of student-athletes’ health and
safety for topics relevant to intercollegiate athletics,
applicable to a large population of student-athletes,
and not accessible in another easily obtainable source.
This handbook consists of guidelines for each institution to consider in developing sports medicine policies
appropriate for its intercollegiate athletics program. In
some instances, accompanying best practices, and
references to sports medicine or legal resource materials are provided for further guidance. These recommendations are not intended to establish a legal standard of care that must be strictly adhered to by
member institutions. In other words, these guidelines
are not mandates that an institution is required to
follow to avoid legal liability or disciplinary sanctions
by the NCAA. However, an institution has a legal duty
to use reasonable care in conducting its intercollegiate
athletics program, and guidelines may constitute some
evidence of the legal standard of care.
These general guidelines are not intended to supersede the exercise of medical judgment in specific situations by a member institution’s sports medicine staff.
In all instances, determination of the appropriate care
and treatment of student-athletes must be based on
the clinical judgment of the institution’s team physician
or athletic health care team that is consistent with
sound principles of sports medicine care. These recommendations provide guidance for an institution’s
athletics administrators and sports medicine staff in
protecting student-athletes’ health and safety, but do
not establish any rigid requirements that must be followed in all cases.
This handbook is produced annually, sent to head
athletic trainers, and made available online to directors of athletics, senior woman administrators, faculty
athletics representatives, athletic trainers, team physicians, life skills coordinators and student-athlete advisory committees at each member institution, as well
as to conference commissioners. Please view the
NCAA Sports Medicine Handbook as a tool to help
your institution develop its sports medicine administrative policies. Such policies should reflect a commitment to protecting your student-athletes’ health and
well-being as well as an awareness of the guidelines
set forth in this handbook.
Table of Contents
Sports Medicine Guidelines
Table of contents
Administrative Issues................................................................................................................................5
Sports Medicine Administration..........................................................................................................................6
Interdisciplinary Health Care Teams....................................................................................................................8
Medical Evaluations, Immunizations and Records............................................................................................11
Emergency Care and Coverage........................................................................................................................14
Lightning Safety................................................................................................................................................16
Catastrophic Incident in Athletics.....................................................................................................................18
Dispensing Prescription Medication..................................................................................................................20
Nontherapeutic Drugs.......................................................................................................................................22
Alcohol, Tobacco and Other Drug Education Guidelines..................................................................................23
Preseason Preparation......................................................................................................................................24
Strength and Conditioning Principles: Foundations for Athlete Development..................................................27
2. Medical Issues............................................................................................................................................33
A. Medical Disqualification ...................................................................................................................................34
B. Cold Stress and Cold Exposure........................................................................................................................35
C. Prevention of Heat Illness.................................................................................................................................39
D. Weight Loss­-Dehydration..................................................................................................................................43
E. Assessment of Body Composition....................................................................................................................44
F. Nutrition and Athletic Performance...................................................................................................................48
G. Dietary Supplements.........................................................................................................................................51
H. ‘Burners’ (Brachial Plexus Injuries)....................................................................................................................54
I. Sports-Related Concussion..............................................................................................................................56
J. Skin Infections..................................................................................................................................................67
K. Menstrual-Cycle Dysfunction............................................................................................................................74
L. Blood-Borne Pathogens....................................................................................................................................76
M. The Use of Local Anesthetics...........................................................................................................................81
N. Injectable Corticosteroids in Sports Injuries.....................................................................................................82
O. Mental Health: Interventions.............................................................................................................................84
P. Participation by the Student-Athlete With Impairment......................................................................................90
Q.Pregnancy ........................................................................................................................................................91
R. The Student-Athlete With Sickle Cell Trait........................................................................................................93
S. Sun Protection..................................................................................................................................................96
T. Exertional Rhabdomyolysis ..............................................................................................................................99
3. Equipment.....................................................................................................................................................105
A. Protective Equipment......................................................................................................................................106
B. Eye Safety in Sports........................................................................................................................................111
D. Use of the Head as a Weapon in Football and Other Contact Sports............................................................115
E. Helmet Fitting and Removal ...........................................................................................................................116
F. Use of Trampoline and Minitramp...................................................................................................................119
A. 2013-14 NCAA Banned Drugs........................................................................................................................122
B. NCAA Legislation Involving Health and Safety Issues....................................................................................123
C. NCAA Injury Surveillance Program Summary..................................................................................................129
New or significantly revised guidelines are highlighted on this page.
Limited revisions are highlighted within the specific guideline.
2013-14 NCAA Sports Medicine Handbook
Shared Responsibility for Intercollegiate Sports Safety
Participation in intercollegiate athletics involves
unavoidable exposure to an inherent risk of injury.
However, student-athletes rightfully assume that those
who sponsor intercollegiate athletics have taken reasonable precautions to minimize the risks of injury from athletics participation. In an effort to do so, the NCAA collects injury data in intercollegiate sports. When appropriate, the NCAA Committee on Competitive Safeguards
and Medical Aspects of Sports makes recommendations to modify safety guidelines, equipment standards
or a sport’s rules of play.
It is important to recognize that rule books, safety
guidelines and equipment standards, while helpful
means of promoting safe athletics participation, are
themselves insufficient to accomplish this goal. To
effectively minimize the risks of injury from athletics
participation, everyone involved in intercollegiate athletics must understand and respect the intent and objectives of applicable rules, guidelines and standards.
The institution, through its athletics director, is responsible
for establishing a safe environment for its student-athletes
to participate in its intercollegiate athletics program.
Coaches should appropriately warn student-athletes
about the sport’s inherent risks of injury and instruct
them how to minimize such risks while participating in
games, practices and training.
The team physician and athletic health care team
should assume responsibility for developing an appropriate injury prevention program and providing quality
sports medicine care to injured student-athletes.
Student-athletes should fully understand and comply
with the rules and standard of play that govern their
sports and follow established procedures to minimize
their risk of injury.
In summary, all people participating in, or associated
with, an institution’s intercollegiate athletics program
share responsibility for taking steps to reduce effectively the risk of injury during intercollegiate athletic
Administrative Issues
2013-14 NCAA Sports Medicine Handbook
Sports Medicine
October 1977 • Revised July 2013
incidents of endangerment. Staff and students
reporting such behaviors and incidents should be
protected from any negative repercussion. These
policies should govern student-to-student, coachathlete and staff-athlete interaction.
The following components of a safe athletics program are
an important part of injury prevention. They should serve
both as a checklist and as a guideline for use by athletics
administrators in the development of safe programs.
1. Preparticipation Medical Exam. Before studentathletes accept the rigors of any organized sport,
their health must be evaluated by qualified medical
personnel. Such an examination should determine
whether the student-athlete is medically cleared to
engage in a particular sport.
Divisions I, II and III require student-athletes new
to their campus to complete a sickle cell solubility
test, to show results of a prior test or to sign a
written release declining the test.
2. Health Insurance. Each student-athlete should be
covered by individual, parental or institutional
medical insurance to defray the costs of significant
injury or illness.
NCAA institutions must certify insurance coverage for
medical expenses resulting from athletically related
injuries in a covered event (see NCAA bylaws).
3. Preseason Preparation. The student-athlete
should be protected from premature exposure to
the full rigors of sports. Preseason conditioning
should provide the student-athlete with optimal
readiness by the first practice (see Guideline 1I,
Preseason Preparation).
4. Acceptance of Risk. Any informed consent or
waiver by student-athletes (or, if minors, by their
parents) should be based on an awareness of the
risks of participating in intercollegiate sports.
5.Planning/Supervision. Safety in intercollegiate
athletics can be attained only by appropriate planning for and supervision of practice, competition
and travel.
6. Safe Environments. Member institutions should
support a positive student-athlete development
model through respect and sportsmanship. Each
student-athlete should be afforded a reasonably
safe environment protected from personal endangerment such as abuse (physical, sexual, emotional), assault, hazing or harmful punishment. Policies
and procedures should be in place to immediately
identify, report and protect individuals reporting
A member of the institution’s sports medicine staff
should be empowered to have the unchallengeable
authority to cancel or modify a workout for health
and safety reasons, as he or she deems appropriate. A member of the institution’s sports medicine
staff should be empowered and protected when
reporting events thought to endanger a studentathlete or conflict with the institution’s medical
care and safe environments policies.
7. Minimizing Potential Legal Liability. Liability
must be a concern of responsible athletics administrators and coaches. Those who sponsor and
govern athletics programs should accept the
responsibility of minimizing the risk of injury.
8. Equitable Medical Care. Member institutions
should neither practice nor condone illegal discrimination on the basis of race, creed, national
origin, sex, age, disability, social status, financial
status, sexual orientation or religious affiliation
within their sports medicine programs.
Availability and accessibility to medical resources
should be based on established medical criteria
(e.g., injury rates, rehabilitation) rather than the
sport itself.
Member institutions should not place their sports
medicine staffs in compromising situations by
having them provide inequitable treatment in violation of their medical codes of ethics.
Institutions should be encouraged to incorporate
questions regarding adequacy of medical care,
with special emphasis on equitable treatment, in
exit interviews with student-athletes.
9.Equipment. Purchasers of equipment should be
aware of and use safety standards. In addition, attention should be directed to maintaining proper repair
and fitting of equipment at all times in all sports.
Student-athletes should:
a. Be informed what equipment is mandatory and
what constitutes illegal equipment;
Administrative Issues
b. Be provided the mandated equipment;
c. Be instructed to wear and how to wear mandatory equipment during participation; and
d. Be instructed to notify the coaching staff when
equipment becomes unsafe or illegal.
10.Facilities. The adequacy and conditions of the
facilities used for particular intercollegiate athletics
events should not be overlooked, and periodic
examination of the facilities should be conducted.
Inspection of the facilities should include not only
the competitive area, but also warm-up and adjacent areas. Athletic training facilities should adhere
to local, state and federal regulations pertaining to
health care facilities. A new Board of Certification
Facilities best practices has been published.
11. Blood-Borne Pathogens. In 1992, the Occupational
Safety and Health Administration (OSHA) developed a
standard directed to minimizing or eliminating occupational exposure to blood-borne pathogens. Each
member institution should determine the applicability
of the OSHA standard to its personnel and facilities.
14. Catastrophic Incident Plan. NCAA member institutions should develop a catastrophic incident guideline to provide a response plan and support that is
necessary during and after a catastrophe such as
death or permanent disability during an intercollegiate athletics sponsored activity (see Guideline 1F).
15. Concussion Management Plan. NCAA member
institutions must have a concussion management
plan for their student-athletes on file with specific
components as described in NCAA bylaws (see
Guideline 2I).
16. Drug Testing. NCAA member institutions are
responsible for ensuring compliance with NCAA
drug testing program requirements (see NCAA Drug
Testing Program book, NCAA bylaws, and
Appendixes A and B).
17.Legislation. NCAA member institutions are
responsible for ensuring compliance with the
NCAA bylaws relevant to health and safety as outlined in the division manuals (see Appendix B for a
quick reference guide).
12. Security and Safety Plan. NCAA member institutions should develop a critical response plan to
provide facility, staff and fan safety for potential
incidents such as bombings, riots, fire, natural
disasters, terrorism threats, etc.
13. Emergency Care. NCAA member institutions
should have on file and annually update an emergency action plan for each athletics venue (see
Guideline 1C).
2013-14 NCAA Sports Medicine Handbook
Health care Teams
July 2013
NCAA values are promoted when athletics and institutional leadership create an administrative system
where athletics health care professionals – team physicians and athletic trainers – are able to make medical
decisions with only the best interests of student-athletes at the forefront. An athletics health care program
should be developed by each institution for all student-athletes. An interdisciplinary health care team is
fundamental to accomplishing this vision.
The first obligation of athletics health care providers is
the safety and well-being of student-athletes that are
under their care. Institutions should designate an individual with a health care background who has a current
contractual or employee agreement with the institution to
serve as an athletics health care coordinator. An individual so designated should coordinate, monitor, and evaluate the delivery of health care and event coverage services for student-athletes as determined by the member
institution. A coach should not have a primary hiring or
firing role in determining employment of health care staff.
Health Care Services
An athletics program should have a designated licensed
physician (e.g., team physician) overseeing athletics
health care policy and services. The team physician(s)
should be a medical doctor (MD) or osteopathic physician (DO) with a current license in good standing to
practice medicine in the same state as the institution.
The team physician(s) and athletics health care team
are responsible for injury reduction and management
and should provide equitable access to quality health
care for all student-athletes. Institutions should have
clearly written organizational charts that outline their
athletics health care services reporting and supervision
plans. All members of the athletics health care team
should have clear written job descriptions, yearly goals,
benchmarks and outlined day-to-day job duties.
Just as a school designates other positions of importance (e.g., provost, dean, director of athletics) the
team physician should have an official school appointment. Since the clinical practice appointment for a
team physician may reside in athletics, on campus or
off campus, an institution should provide a contract,
employment, or agreement that is consistent with its
policy for services provided by other key designated
positions. He/she should serve a leadership role in the
management, organization, oversight and provision of
medical care for student-athletes, as well as the evaluation of staff.
An athletics program should have health care providers
who oversee the development and implementation of a
policies-and-procedures document including, but not
limited to, health care providers’ job descriptions, an
appropriate health care sport coverage plan, emergency
action plans, a concussion management plan, studentathlete medical examinations and clearance to participate, student-athlete medical care, continuing eligibility
cases (e.g. medical hardship waiver, medical non-counters), and return-to-play decision-making processes.
Event Coverage Services
Institutions should have on file an appropriate athletics
health care coverage (event) plan that includes equitable access to athletics health care providers for each
NCAA sport and student-athlete.
The athletics health care coverage plan should take into
consideration the emergency action plans for sport
venues, the qualification of coaches to respond to an
emergency, and a systemic approach to determine additional athletics health care needs for the venue and sport.
The team physician integrates medical expertise with
athletic trainers, medical consultants, and other health
care professionals. Even if the team physician is not on
site at all times, he/she should make regular on-site
visits and check in frequently with the athletic training
staff. The team physician is ultimately responsible for
the clearance to participate and the return-to-play
decisions for the institution’s student-athletes.
Athletics health care providers (e.g. athletic trainers,
team physicians) must be empowered to have the
unchallengeable authority to stop any activity that they
deem unsafe, and they should determine management
and return-to-play of any ill or injured student-athletes
without risk of employment status change.
Institutions and athletics health care providers should
adhere to federal, state and local regulations; NCAA
bylaws and sport playing rules; and the NCAA Sports
Medicine Handbook. Athletics health care providers for
the student-athlete should be appointed by and should
report to institution administrators who are independent from coaches (e.g., health center, campus hospital/medical center, student affairs).
Campus health care facilities are being used more for
medical provider oversight while creating a direct link
to additional student services. These partnerships are
Administrative Issues
desirable as they help eliminate gaps in medical record
information and open care access for general medical
conditions and mental health counseling.
An athletics program should feature an adequate
number of athletic trainers who are able to provide for
the safety and well-being of student-athletes across all
sports. These athletic trainers provide the clinical
health care services and sideline care for student-athletes in intercollegiate athletics as part of a physician
supervised medical model. Forty-eight states regulate
the practice of athletic trainers, and 36 states require
that an athletic trainer work under the supervision or
direction of a physician. All athletic trainers certified by
the Board of Certification must provide health care services under the direction of a physician.
The core athletics health care team at many institutions also includes sports psychologist/mental health
professionals, strength and conditioning specialists,
and sports dietitians. In addition, some institutions
include chiropractors, dentists, exercise scientists,
facilities personnel, insurance coordinators, massage
therapists, nurse practitioners, optometrists, physical
therapists and physician assistants as part of their athletics health care team. These individuals must also
meet current state and national credentialing requirements for their profession (e.g., licensure, certification,
registration). A coach should not have a primary hiring
or firing role in determining employment of these additional athletics health care team members.
An institution should evaluate its health care services on
a routine basis. Performance appraisals for health care
providers in the athletics setting are an important assessment component for establishing an effective quality
improvement program for the sports medicine team.
Performance appraisals should include two main areas:
(1) individual staff performance and (2) athletics health
care services. Athletics health care team members
should be evaluated by a person who understands and
can evaluate the delivery of quality health care.
An athletics program should use a systematic
approach to determine the appropriate level of health
care and staffing for student-athlete medical care and
sport coverage at an institution. The Appropriate
Medical Coverage for Intercollegiate Athletics assessment tool is a rating system using injury rates, the
potential for catastrophic injury, and treatment/rehabilitation demands for both time-loss and non-time-loss
injuries per sport. Consideration should also include a
year-round assessment of squad sizes, travel, traditional and nontraditional season practices and competitions, out-of-season skill instruction sessions, yearround strength and conditioning, and individual health
characteristics of team members.
Some examples of day-to-day duties at NCAA institutions include:
Medical Services
• Injury evaluation and treatment
• Injury rehabilitation and reconditioning
• After-hours/on-call consultation and injury/illness
• Outside medical provider services
• Team physician services
• Concussion pre-injury baseline testing
• Concussion management
• Diagnostic testing
• Exclusive medical provider contracts
• Championships/tournament event coverage
• Injury prevention programs
• Visiting team services
• Ancillary medical services
Injury prevention and care policies
Environmental monitoring
Emergency action plans
Functional movement assessments/assessment
of pre-existing conditions
Mental health counseling referrals
Nutrition suggestions and referral
Safe facilities (e.g., BOC Facility Principles)
Create/maintain appropriate medical referral system
Review epidemiologic and current evidencebased research for clinical outcomes assessment
Design and application of preventive and postinjury taping, bracing and padding
Protective equipment selection, fitting and use
Recommendations for sport rule changes
Make appropriate play/no-play decisions
First aid/CPR training
Infection control
Coordinate pre-participation medical examinations
Practice/event coverage
Knowledge of and recommendations for institutional and governing body drug testing
Budget management to provide adequate
resources to purchase risk-reduction supplies
Use communication and interpersonal skills to
2013-14 NCAA Sports Medicine Handbook
create trust between student-athletes, coaches,
administrators and the athletic training staff
Organization and Administration
• Budgeting
• Electronic medical record management
• Meetings (recruits, parents, coaches and
• Credential maintenance
• Pre-participation examination (PPE)/medical history
• Sports Medicine Team relations, staff scheduling,
performance evaluations
• Emergency action plans (EAPs)
• Hosting physician clinics
• Insurance claims management
• Quality control for facilities and care
• Student-athlete transport to medical appointments
• Drug use prevention
• Inventory management
• Risk management
• Athlete, coach, peer education
Fiscal Management
• Insurance premiums
• Staffing and workload management
• Medical services
• Budget management
• Fundraising
• Academic success
• Contracts
• Academic teaching/Athletic Training Education
Program preceptor
• Life skills presentations
• Psychological issues and referrals
• Counseling referrals/medication documentation
(e.g., for attention deficit hyperactivity disorder)
• Student retention through active return-to-play
Of upmost importance is the daily documentation of
these services through an adequate medical recordkeeping system for any person (including current, prospective and visiting team student-athletes) with whom
the athletics health care team is in contact.
1. Team Physician Consensus Statement: 2013 Update. Medicine &
Science in Sports & Exercise. July 2013.
2. Inter-Association Consensus Statement on Best Practices for Sports
Medicine Management for Secondary Schools and Colleges. Courson,
R, Goldenberg, M, Adams, K, Anderson, S, Colgate, B, Cooper, L,
Dewald, L, Floyd, RT, Gregory, D, Indelicato, PA, Klossner, K, O’Leary,
R, Ray, T, Selgo, T, Thompson, C, Turbak, G. 2013.
Wilkerson G. Patient-centered care and conflict interests in sports
medicine-athletic training. International Journal of Athletic Therapy and
Training 2012;17(4):1-3.
Board of Certification, Inc. BOC Standards of Professional Practice.
Available at:
National Athletic Trainers’ Association. NATA Code of Ethics. Available
National Athletic Trainers’ Association. Recommendations and
Guidelines for Appropriate Medical Coverage of Intercollegiate
Athletics. Available at:
AMCIARecsandGuides.pdf. June 2007.
National Athletic Trainers’ Association. College-University Value Model.
Available at:
Medical Evaluations,
Immunizations and Records
Administrative Issues
July 1977 • Revised June 2011
Preparticipation medical evaluation. A preparticipation medical evaluation is required upon a student-athlete’s entrance into the institution’s intercollegiate athletics program. The evaluation should be conducted by
a medical doctor (MD) or doctor of osteopathic medicine (DO) licensed and in good standing in his or her
state. Within this evaluation process, Division I, Division
II and Division III require student-athletes new to their
campus to confirm their sickle cell solubility status by
showing results of a diagnostic test or to sign a written
release declining the test. This initial medical evaluation
should include a comprehensive health history, immunization history as defined by current Centers for
Disease Control and Prevention (CDC) guidelines and a
relevant physical exam, with strong emphasis on the
cardiovascular, neurologic and musculoskeletal evaluation. After the initial medical evaluation, an updated
history should be performed annually. Further preparticipation physical examinations are not believed to be
necessary unless warranted by the updated history or
the student-athlete’s medical condition.
Official and unofficial visit medical evaluations.
Institutions should follow regulations pertaining to conducting medical examinations on prospective studentathletes as outlined by their respective division bylaws.
Cardiac. Sudden cardiac death (SCD) is the leading
medical cause of death in NCAA athletes and represents
75 percent of all sudden death cases that occur during
training, exercise or competition. In a five-year review of
sudden deaths involving NCAA student-athletes, the
incidence of SCD was approximately one in every
40,000 student-athletes per year. The American Heart
Association has modified its 1996 recommendation for a
cardiovascular screening every two years for collegiate
athletes. The revision recommends cardiovascular
screening as a part of the physical exam required upon
a student-athlete’s entrance into the intercollegiate athletics program. In subsequent years, an interim history
and blood pressure measurement should be made.
Important changes in medical status or abnormalities
may require more formal cardiovascular evaluation.
Preparticipation Physical Evaluation (PPE)
Monograph. This document guides a practitioner
through the PPE process for young athletes from middle school through college. Included are recommendations on PPE timing, setting and structure; medical
history questions; and how to determine participation
clearance. The manual lists return-to-play guidelines;
addresses medicolegal and ethical concerns; and
Medical Documentation
Standards Guidelines
(From the NCAA)
Contemporaneous Diagnosis of Injury
• Contemporaneous medical documentation
that validates timing of injury or illness
• Contemporaneous medical documentation
that verifies initial severity of injury or illness
(demonstrates incapacitation likely results for
remainder of season) (Recommended)
• Operation report(s) or surgery report(s) or
emergency room document(s)
Acknowledgment That the Injury Is
• Contemporaneous letter or diagnosis from
treating physician identifying injury or illness
as “incapacitating” OR
• Noncontemporaneous letter or diagnosis from
treating physician identifying injury or illness
as “incapacitating” AND
• Treatment logs or athletic trainer’s notes (indicating continuing rehabilitation efforts)
Length of Incapacitation (verifying opportunity
for injured student-athlete to resume playing
within championship season in question is
medically precluded)
• Estimated length of incapacitation or recovery
time range contained within original contemporaneous medical documentation AND
• Contemporaneous documentation of followup doctor visits (within the estimated time
range) in which student-athlete is not cleared
to resume playing OR
• Treatment logs or athletic trainer’s notes (indicating continuing rehabilitation efforts)
explores future research and use of electronic formats.
The prepared forms are often used as a template or
minimum guideline for institutions.
Medical records. Student-athletes have a responsibility to truthfully and fully disclose their medical history
and to report any changes in their health to the team’s
health care provider. Medical records should be main-
2013-14 NCAA Sports Medicine Handbook
tained during the student-athlete’s collegiate career
and should include:
1. A record of injuries, illnesses, new medications or
allergies, pregnancies and operations, whether
sustained during the competitive season or the
3. Subsequent care and clearances;
Note: Records maintained in the athletic training facility are medical records, and therefore subject to state
and federal laws with regard to confidentiality and
content. Each institution should obtain from appropriate legal counsel an opinion regarding the confidentiality and content of such records in its state.
4. A comprehensive entry-year health-status questionnaire and an updated health-status questionnaire each year thereafter. Components of the
questionnaire should consider recommendations
from the American Heart Association (see reference
Nos. 3 and 4) and the 4th Edition Preparticipation
Physical Evaluation (see reference No. 6).
Medical records and the information they contain
should be created, maintained and released in accordance with clear written guidelines based on this
opinion. All personnel who have access to a studentathlete’s medical records should be familiar with such
guidelines and informed of their role in maintaining the
student-athlete’s right to privacy.
5. Immunizations. It is recommended that student-athletes be immunized and up to date for the following:
a. Measles, mumps, rubella (MMR);
b. Hepatitis B;
c. Diphtheria, tetanus (and boosters when appropriate);
d. Meningitis; ande. Seasonal influenza (flu).
Institutions should consider state statutes for medical
records retention (e.g., seven years, 10 years); institutional policy (e.g., insurance long-term retention
policy); and professional liability statute of limitations.
2. Referrals for and feedback from consultation,
treatment or rehabilitation;
6. Written permission, signed annually by the student-athlete, which authorizes the release of medi-
cal information to others. Such permission should
specify all people to whom the student-athlete
authorizes the information to be released. The
consent form also should specify which information may be released and to whom.
Follow-up examinations. Those who have sustained a
significant injury or illness during the sport season
should be given a follow-up examination to re-establish
medical clearance before resuming participation in a
particular sport. This policy also should apply to preg-
Administrative Issues
nant student-athletes after delivery or pregnancy termination. These examinations are especially relevant if the
event occurred before the student-athlete left the institution for summer break. Clearance for individuals to
return to activity is solely the responsibility of the team
physician or that physician’s designated representative.
Medical Hardship Waivers. Documentation standards
should assist conferences and institutions in designing
a medical treatment protocol that satisfies all questions of incapacitation and reflects such in the records.
To clarify:
• Hardship waiver: A hardship waiver deals with a
student-athlete’s seasons of competition and
may only be granted if a student-athlete has
competed and used one of the four seasons of
• Extension waiver: An extension waiver deals with
time on a student-athlete’s eligibility clock and
may be granted if, within a student-athlete’s
period of eligibility (five years or 10 semesters),
he or she has been denied more than one participation opportunity for reasons beyond the student-athlete’s and the institution’s control.
Screening for Cardiovascular Abnormalities in Competitive Athletics:
2007 Update: Circulation. Mar 2007; 115:1643-1655.
4. Gardner P, Schaffner W: Immunizations of Adults. The New England
Journal of Medicine 328(17):1252-1258, 1993.
5. Hepatitis B Virus: a comprehensive strategy for eliminating
transmission in the United States through universal childhood
vaccination: recommendations of the Immunization Practices Advisory
Committee. Morbidity and Mortality Weekly Report 40 (RR-13), 1991.
6. Preparticipation Physical Evaluation. 4th Ed. American Academy of
Family Physicians, American Academy of Pediatrics, American
Medical Society of Sports Medicine, American Orthopaedic Society of
Sports Medicine. Published by the American Academy of Pediatrics,
2010. Available at
7. Eligibility Recommendations for Competitive Athletes with
Cardiovascular Abnormalities. 36th Bethesda Conference. Journal of
American College of Cardiology, 45(8), 2005.
8. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of Sudden
Cardiac Death in NCAA Athletes. Circulation. Apr 2011.
9. Persons for Whom Annual Vaccination Is Recommended: Influenza
Prevention and Control Recommendations. CDC. 2012. Available at:
In order to demonstrate that an injury or illness prevented competition and resulted in incapacitation for
the remainder of the playing season, an institution
needs to provide objective documentation to substantiate the incapacitation. Three key components need to
be included in this documentation:
1. Contemporaneous diagnosis of injury/illness;
2. Acknowledgment that the injury/illness is incapacitating; and
3. Length of incapacitation.
For more information about medical hardship waivers,
read the complete article at or contact the
NCAA’s student-athlete reinstatement staff.
1. Cook LG, Collins M, Williams WW, et. al.: Prematriculation
Immunization Requirements of American Colleges and Universities.
Journal of American College Health 42:91-98, 1993.
2. ACHA Guidelines Recommendations for Institutional Prematriculation
Immunizations. 2012. Available at:
3. Recommendations and Considerations Related to Pre-Participation
2013-14 NCAA Sports Medicine Handbook
Emergency Care
and Coverage
October 1977 • Revised July 2012
Reasonable attention to all possible preventive measures will not eliminate sports injuries. Each scheduled
practice or contest of an institution-sponsored intercollegiate athletics event, and all out-of-season practices and skills sessions, should include an emergency
plan. Like student-athlete well-being in general, a plan
is a shared responsibility of the athletics department;
administrators, coaches and medical personnel should
all play a role in the establishment of the plan, procurement of resources and understanding of appropriate
emergency response procedures by all parties.
Components of such a plan should include:
1. The presence of a person qualified and delegated
to render emergency care to a stricken participant;
2. The presence or planned access to a physician for
prompt medical evaluation of the situation, when
3. Planned access to early defibrillation;
4. Planned access to a medical facility, including a
plan for communication and transportation
between the athletics site and the medical facility
for prompt medical services, when warranted.
Access to a working telephone or other telecommunications device, whether fixed or mobile,
should be assured;
5. All necessary emergency equipment should be at
the site or quickly accessible. Equipment should
be in good operating condition, and personnel
must be trained in advance to use it properly.
Additionally, emergency information about the student-athlete should be available both at campus
and while traveling for use by medical personnel;
6. An inclement weather policy that includes provisions for decision-making and evacuation plans
(See Guideline 1e);
ciated with practices, competitions, skills instruction, and strength and conditioning. New staff
engaged in these activities should comply with
these rules within six months of employment.
Refer to Appendix B for NCAA coach sport safety
legislative requirements.
7. A thorough understanding by all parties, including
the leadership of visiting teams, of the personnel
and procedures associated with the emergencycare plan; and
9. A member of the institution’s sports medicine staff
should be empowered to have the unchallengeable
authority to cancel or modify a workout for health
and safety reasons (i.e., environmental changes),
as he or she deems appropriate.
8. Certification in cardiopulmonary resuscitation techniques (CPR), first aid and prevention of disease
transmission (as outlined by OSHA guidelines)
should be required for all athletics personnel asso-
10. Institutions should ensure that the emergency
action plan (EAP) incorporates roles and responsibilities of coaching staff, medical staff, spectators
and others during injury evaluation/response on
Administrative Issues
Guidelines to Use During
a Serious On-Field Player Injury
These guidelines have been recommended for
National Football League (NFL) officials and have
been shared with NCAA championships staff.
1. Players and coaches should go to and
remain in the bench area once medical
assistance arrives. Adequate lines of vision
between the medical staffs and all available
emergency personnel should be established
and maintained.
2. Players, parents and nonauthorized personnel should be kept a significant distance
away from the seriously injured player or
3. Players or nonmedical personnel should not
touch, move or roll an injured player.
4. Players should not try to assist a teammate
who is lying on the field (i.e., removing the
helmet or chin strap, or attempting to assist
breathing by elevating the waist).
5. Players should not pull an injured teammate
or opponent from a pileup.
6. Once medical staff members begin to work
on an injured player, they should be allowed
to perform services without interruption or
7. Players and coaches should avoid dictating
medical services to the athletic trainers or
team physicians or taking up their time to
perform such services.
1. Halpern BC: Injuries and emergencies on the field. In Mellion MB,
Shelton GL, Walsh WM (eds): The Team Physician’s Handbook. St.
Louis, MO: Mosby-Yearbook, 1990, pp. 128-142.
2. Harris AJ: Disaster plan—A part of the game plan. Athletic Training
23(1):59, 1988.
3. Recommendations and Guidelines for Appropriate Medical Coverage
of Intercollegiate Athletics. National Athletic Trainers’ Association,
(2952 Stemmons Freeway, Dallas, Texas) 2003.
4. Van Camp SP, et al: Nontraumatic sports death in high school and
college athletics. Medicine and Science in Sports and Exercise
27(5):641-647, 1995.
5. Mass Participation Event Management for the Team Physician: A
Consensus Statement. Medicine and Science in Sports and Exercise
36(11):2004-2008, 2004.
6. Sideline Preparedness for the Team Physician: A Consensus
Statement. Medicine and Science in Sports and Exercise 33(5):846849, 2001.
7. Laws on Cardiac Arrest and Defibrillators, 2007 update. Available at:
8. Inter-Association Task Force Recommendations on Emergency
Preparedness and Management of Sudden Cardiac Arrest in High
School and College Athletic Programs: A Consensus Statement.
Journal of Athletic Training. 42:143-158. 2007.
9. National Athletic Trainers’ Association Position Statement: Acute
Management of the Cervical Spine-Injured Athlete. Journal of Athletic
Training. 44:306-331. 2009.
the field, to ensure appropriate first response and
medical evaluation. The EAP should provide that
appropriate medical staff have access to the
injured athlete without interference.
11. Institutions should have on file and annually
update an emergency action plan for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not
limited to, concussions, heat illness, spine injury,
cardiac arrest, respiratory distress (e.g., asthma)
and sickle cell trait (SCT) collapses. All athletics
health care providers and coaches, including
strength and conditioning coaches, sport coaches
and all athletics personnel conducting activities
with student-athletes, should review and practice
the plan at least annually.
2013-14 NCAA Sports Medicine Handbook
Lightning Safety
July 1997 • Revised June 2013
Lightning is the most consistent and significant
weather hazard that may affect intercollegiate athletics.
Within the United States, the National Oceanic and
Atmospheric Administration (NOAA) estimates that 40
fatalities and about 10 times as many injuries occur
from lightning strikes every year. NOAA attributes 48
percent of the fatalities to lightning strikes during organized sport activities at all levels across the country.
While the probability of being struck by lightning is low,
the odds are significantly greater when a storm is in the
area and proper safety precautions are not followed.
Education and prevention are the keys to lightning
safety. The references associated with this guideline are
an excellent educational resource. Prevention should
begin long before any intercollegiate athletics event or
practice by being proactive and having a lightning safety
plan in place. The following steps are recommended by
the NCAA and NOAA to mitigate the lightning hazard:
Outside locations increase the risk of being struck by
lightning when thunderstorms are in the area. Small
covered shelters are not safe from lightning. Dugouts,
refreshment stands, open press boxes, rain shelters,
golf shelters and picnic shelters, even if they are properly grounded for structural safety, are usually not
properly grounded from the effects of lightning and
side flashes to people. They are usually very unsafe
and may actually increase the risk of lightning injury.
Other dangerous locations include bodies of water
(pools, ponds, lakes) and areas connected to, or near,
light poles, towers and fences that can carry a nearby
strike to people. Also dangerous is any location that
makes the person the highest point in the area.
3. Monitor local weather reports each day before any
practice or event. Be diligently aware of potential
thunderstorms that may form during scheduled intercollegiate athletics events or practices. Weather
information can be found through various means via
local television news coverage, the Internet, cable
and satellite weather programming, a lightning
detection and notification service, or the National
Weather Service (NWS) website at
5. Know where the closest “safer structure or location” is to the field or playing area, how long it
takes to evacuate to that location for all personnel
at the event, and have access to it. A safer structure or location is defined as:
a. Any building normally occupied or frequently
used by people, i.e., a building with plumbing
and/or electrical wiring that acts to electrically
ground the structure. Avoid the shower, plumbing
facilities, contact with electrical appliances and
open windows/doorways during a thunderstorm.
b. In the absence of a sturdy, frequently inhabited
building, any vehicle with a hard metal roof
(neither a convertible, nor a golf cart) with the
windows shut provides a measure of safety. The
hard metal frame and roof, not the rubber tires,
are what protects occupants by dissipating
lightning current around the vehicle and not
through the occupants. It is important not to
touch the metal framework of the vehicle. Some
athletics events rent school buses as safer locations to place around open courses or fields.
4. Be informed of National Weather Service (NWS) issued
thunderstorm “watches” or “warnings,” and the warning
signs of developing thunderstorms in the area, such as
high winds or darkening skies. A “watch” means conditions are favorable for severe weather to develop in an
area; a “warning” means that severe weather has been
reported in an area and for everyone to take the proper
precautions. It should be noted that neither watches nor
warnings are issued for lightning. A NOAA weather radio
is particularly helpful in providing this information.
6. Lightning awareness should be heightened at the
first flash of lightning, clap of thunder, and/or other
signs of an impending storm such as increasing
winds or darkening skies, no matter how far away.
These types of activities should be treated as a
warning or “wake-up call” to intercollegiate athletics personnel. Lightning safety experts suggest
that if you hear thunder, begin preparation for
evacuation; if you see lightning, consider suspending activities and heading for your designated safer
1. Develop a lightning safety plan for each outdoor venue.
2. Designate a person to monitor threatening weather
and to notify the chain of command who can make
the decision to remove a team, game personnel,
television crews and spectators from an athletics
site or event. A lightning safety plan should include
planned instructions/announcements for participants and spectators, designation of warning and
all-clear signals, proper signage and designation of
safer places from the lightning hazard.
Dangerous Locations
Administrative Issues
locations. For large-scale events, continuous monitoring of the weather should occur from the time
pre-event activities occur throughout the event.
The following specific lightning safety guidelines have
been developed with the assistance of lightning safety
experts. Design your lightning safety plan to consider local
safety needs, weather patterns and thunderstorm types.
• As a minimum, lightning safety experts strongly
recommend that by the time the monitor observes
30 seconds between seeing the lightning flash
and hearing its associated thunder or by the time
the leading edge of the storm is within six miles of
the venue, all individuals should have left the athletics site and be wholly within a safer structure or
location. Individuals just entering the outdoor
venue should be directed to the safer location.
• Please note that thunder may be hard to hear if
there is an athletics event going on, particularly in
stadiums with large crowds. Implement your
lightning safety plan accordingly.
• Ensure a safe and orderly evacuation from the
venue with announcements, signage, safety information in programs, and entrances that can also
serve as mass exits. Planning should account for
the time it takes to move a team and crowd to
their designated safer locations.
• Lightning can strike from blue sky and in the absence
of rain. At least 10 percent of lightning occurs when
there is no rainfall and when blue sky is often visible
somewhere in the sky, especially with summer thunderstorms. Lightning can, and does, strike as far as
10 (or more) miles away from the rain shaft. Be aware
of local weather patterns and review local weather
forecasts before an outdoor practice/event.
• Avoid using landline telephones, except in emergency situations. People have been killed while
using a landline telephone during a thunderstorm.
Cellular or cordless phones are safe alternatives
to a landline phone, particularly if the person and
the antenna are located within a safer structure or
location, and if all other precautions are followed.
• To resume athletics activities, lightning safety
experts recommend waiting 30 minutes after both
the last sound of thunder and last flash of lightning
is at least six miles away and moving away from
the venue. If lightning is seen without hearing
thunder, lightning may be out of range and therefore less likely to be a significant threat. At night, be
aware that lightning can be visible at a much
greater distance than during the day as clouds are
being lit from the inside by lightning. This greater
distance may mean that the lightning is no longer a
significant threat. At night, use both the sound of
thunder and seeing the lightning channel itself to
decide on re-setting the 30-minute “return-to-play”
clock before resuming outdoor athletics activities.
• People who have been struck by lightning do not
carry an electrical charge. Therefore, cardiopulmonary resuscitation (CPR) is safe for the responder.
If possible, an injured person should be moved to
a safer location before starting CPR. Lightningstrike victims who show signs of cardiac or respiratory arrest need prompt emergency help. If you
are in a 911 community, call for help. Prompt,
aggressive CPR has been highly effective for the
survival of victims of lightning strikes.
Automatic external defibrillators (AEDs) are a safe and
effective means of reviving people in cardiac arrest.
Planned access to early defibrillation should be part of
your emergency plan. However, CPR should never be
delayed while searching for an AED.
Note: Weather watchers, real-time weather forecasts and
commercial weather-warning devices or services are all
tools that can be used to aid in the monitoring and notification of threatening weather situations, decision-making
regarding stoppage of play, evacuation and return to play.
1. Cooper MA, Andrews CJ, Holle RL, Lopez RE. Lightning Injuries. In:
Auerbach, ed. Management of Wilderness and Environmental
Emergencies. 5th ed. C.V. Mosby, 2007:67-108.
2. Bennett BL. A Model Lightning Safety Policy for Athletics. Journal of
Athletic Training. 32(3):251-253. 1997.
3. Price TG, Cooper MA: Electrical and Lightning Injuries. In: Marx et al.
Rosen’s Emergency Medicine, Concepts and Clinical Practice, Mosby,
6th ed. 2006; 22: 67-78.
4. National Lightning Safety Institute website:
5. Uman MA. All About Lightning. New York: Dover Publications. 1986.
6. NOAA lightning safety website:
7. Walsh KM, Hanley MJ, Graner SJ, Beam D, Bazluki J. A Survey of
Lightning Safety Policy in Selected Division I Colleges. Journal of
Athletic Training. 32(3):206-210. 1997.
9. Holle RL. 2005: Lightning-caused recreation deaths and injuries.
Preprints, 14th Symposium on Education, January 9-13, San Diego,
California, American Meteorological Society, 6 pp.
10.The Weather Channel on satellite or cable, and on the Internet at
11. Walsh KM, Cooper MA, Holle R, Rakov V, Roeder WP, Ryan M. National
Athletic Trainers’ Association Position Statement. Lightning Safety for
Athletics and Recreation. Journal of Athletic Training. 48(2);258-270. 2013
2013-14 NCAA Sports Medicine Handbook
Incident in Athletics
July 2004 • Revised July 2008
The NCAA Committee on Competitive Safeguards and
Medical Aspects of Sports acknowledges the significant input of Timothy Neal, ATC, Syracuse University,
who originally authored this guideline.
Catastrophes such as death or permanent disability
occurring in intercollegiate athletics are rare. However,
the aftermath of a catastrophic incident to a studentathlete, coach or staff member can be a time of uncertainty and confusion for an institution. It is recommended that NCAA member institutions develop their own
catastrophic incident guideline to provide information
and the support necessary to family members, teammates, coaches and staff after a catastrophe.
Centralizing and disseminating the information is best
served by developing a catastrophic incident guideline.
This guideline should be distributed to administrative,
sports medicine and coaching staffs within the athletics
department. The guideline should be updated and
reviewed annually with the entire staff to ensure information is accurate and that new staff members are
aware of the guideline.
Components of a catastrophic incident guideline
should include:
1. Definition of a Catastrophic Incident. The
sudden death of a student-athlete, coach or staff
member from any cause, or disabling and/or
quality-of-life-altering injuries.
2. A Management Team. A select group of administrators who receive all facts pertaining to the
catastrophe. This team works collaboratively to
officially communicate information to family
members, teammates, coaches, staff, the institution and media. This team may consist of one or
more of the following: director of athletics, head
athletic trainer, university spokesperson, director of
athletic communications and university risk
manager. This team may select others to help
facilitate fact finding specific to the incident.
3.Immediate Action Plan. At the moment of the
catastrophe, a checklist of whom to call and
immediate steps to secure facts and offer support
are items to be included.
4. Chain of Command/Role Delineation. This area
outlines each individual’s responsibility during the
aftermath of the catastrophe. Athletics administrators, university administrators and support servic-
Catastrophic injury research
The National Center for Catastrophic Sports
Injury Research continues to research catastrophic injuries in sports through funding by the
NCAA. The football fatality research and data
collection has been done since 1931. The football catastrophic research started in 1977 at the
University of North Carolina, Chapel Hill, and the
research on fatalities and catastrophic injuries in
all other sports was added beginning in 1982.
Reports can be found on the NCCSI website at
Catastrophic injuries include the following:
2. Permanent disability injuries.
3. Serious injuries (fractured neck or serious
head injury) even though the athlete has a
full recovery.
4. Temporary or transient paralysis (athlete has
no movement for a short time but has a
complete recovery).
Please report an incident at www.SportInjury or via email at
es personnel should be involved in this area.
5. Criminal Circumstances. Outline the collaboration of the athletics department with university,
local and state law enforcement officials in the
event of accidental death, homicide or suicide.
6. Away-Contest Responsibilities. Catastrophes
may occur at away contests. Indicate who should
stay behind with the individual to coordinate communication and act as a university representative
until relieved by the institution.
7. Phone List and Flow Chart. Phone numbers of all
key individuals (office, home, cell) involved in the
management of the catastrophe should be listed
and kept current. Include university legal counsel
numbers and the NCAA catastrophic injury service
line number (800/245-2744). A flow chart of who is
to be called in the event of a catastrophe is also
useful in coordinating communication.
8.Incident Record. A written chronology by the
management team of the catastrophic incident is
Administrative Issues
recommended to critique the process and provide
a basis for review and enhancement of procedures.
9. Notification Process. After the catastrophic incident, the director of athletics, assistant director of
athletics for sports medicine (head athletic trainer),
head coach (recruiting coach if available) and university risk manager/legal counsel, as available, will
contact the parents/legal guardians/spouse of the
victim. The director of athletics, head coach and
others deemed necessary will inform the team,
preferably in person, as soon as possible and offer
counseling services and support.
4. Catastrophic injuries in pole vaulters: a prospective 9-year follow-up
study. Boden BP, Boden MG, Peter RG, Mueller FO, Johnson JE.
Am J Sports Med. 2012 40(7):1488-94.
5. Fatalities in high school and college football players. Boden BP, Breit
I, Beachler JA, Williams A, Mueller FO. Am J Sports Med. 2013
6. Catastrophic Sport Injury Research 28th Annual Report 2011.
Available at:
7. Incidence of sudden cardiac death in National Collegiate Athletic
Association athletes.Harmon KG, Asif IM, Klossner D, Drezner JA.
Circulation. 2011 123(15):1594-600.
10. Assistance to Visiting Team’s Catastrophic
Incident as Host Institution. In the event that a
visiting team experiences a catastrophic incident,
the host institution may offer assistance by alerting
the director of athletics or another member of the
catastrophic incident management team in order
to make as many resources available as possible
to the visiting team. The host institution may assist
in contacting the victim’s institution and athletics
administration, as well as activating, as appropriate, the host institution’s catastrophic incident
guideline to offer support to the visiting team’s
student-athletes, coaches and staff.
Catastrophic Injury Insurance Program
The NCAA sponsors a catastrophic injury insurance
program that covers a student-athlete who is catastrophically injured while participating in a covered intercollegiate athletic activity. The policy has a $90,000 deductible
and provides benefits in excess of any other valid and
collectible insurance. The policy will pay $25,000 if an
insured person dies as a result of a covered accident or
sustains injury due to a covered accident that, independent of all other causes, results directly in the death of
the insured person within twelve (12) months after the
date of such injury. Both catastrophic injuries and sudden
deaths should be reported to the NCAA national office
insurance staff. For more information, visit
1. Neal, TL: Catastrophic Incident Guideline Plan. NATA News: 12, May 2003.
2. Neal, TL: Syracuse University Athletic Department Catastrophic
Incident Guideline, 2012.
3. Catastrophic Cervical Spine Injuries in the Collision Sport Athlete, Part
1: Epidemiology, Functional Anatomy, and Diagnosis. Banerjee, R,
Palumbo, MA, and Fadale, PD. American Journal of Sports Medicine,
32: 4. 1077-1087.
2013-14 NCAA Sports Medicine Handbook
Prescription Medication
May 1986 • Revised June 2008
Research sponsored by the NCAA has shown that prescription medications have been provided to studentathletes by individuals other than people legally authorized to dispense such medications. This is an important concern because the improper dispensing of both
prescription and nonprescription drugs can lead to
serious medical and legal consequences.
Research also has shown that state and federal regulations regarding packaging, labeling, record keeping
and storage of medications have been overlooked or
disregarded in the dispensing of medications from the
athletic training facility. Moreover, many states have
strict regulations regarding packaging, labeling, record
keeping and storage of prescription and nonprescription medications. Athletics departments must be concerned about the risk of harm to the student-athletes
when these regulations are not followed.
Administering drugs and dispensing drugs are two
separate functions. Administration generally refers to
the direct application of a single dose of drug.
Dispensing is defined as preparing, packaging and
labeling a prescription drug or device for subsequent
use by a patient. Physicians cannot delegate to athletic trainers the authority for dispensing prescription
medications under current medication-dispensing
laws, since athletic trainers are not authorized by law
to dispense these drugs under any circumstances. The
improper delegation of authority by the physician or
the dispensing of prescription medications by the athletic trainer (even with permission of the physician)
places both parties at risk for legal liability.
If athletics departments choose to provide prescription
and/or nonprescription medications, they must comply
with the applicable state and federal laws for doing so.
It is strongly encouraged that athletics departments
and their team physicians work with their on-site or
area pharmacists to develop specific policies.
The following items form a minimal framework for an
appropriate drug-distribution program in a college-athletics environment. Since there is extreme variability in
state laws, it is imperative for each institution to consult
with legal counsel in order to be in full compliance.
Administrative Issues
1. Drug-dispensing practices are subject to and
should be in compliance with all state, federal and
Drug Enforcement Agency (DEA) regulations.
Relevant items include appropriate packaging,
labeling, counseling and education, record keeping, and accountability for all drugs dispensed.
2. Certified athletic trainers should not be assigned
duties that may be performed only by physicians or
pharmacists. A team physician cannot delegate diagnosis, prescription-drug control or prescription-dispensing duties to athletic trainers.
3. Drug-distribution records should be created and
maintained where dispensing occurs in accordance
with appropriate legal guidelines. The record should
be current and easily accessible by appropriate
medical personnel.
3. Herbert DL: Dispensing prescription medications to athletes. In
Herbert, DL (ed): The Legal Aspects of Sports Medicine Canton, OH:
Professional Sports Publications, 1991, pp. 215-224.
4. Huff PS: Drug Distribution in the Training Room. In Clinics in Sports
Medicine. Philadelphia, WB Saunders Co: 211-228, 1998.
5. Huff PS, Prentice WE: Using Pharmacological Agents in a
Rehabilitation Program. In Rehabilitation Techniques in Sports
Medicine (3rd Ed.) Dubuque, IA, WCB/McGraw-Hill 244-265, 1998.
6. Laster-Bradley M, Berger BA: Evaluation of Drug Distribution Systems
in University Athletics Programs: Development of a Model or Optimal
Drug Distribution System for Athletics Programs. Unpublished report,
1991. (128 Miller Hall, Department of Pharmacy Care Systems,
Auburn University, Auburn, AL 36849-5506)
7. Price KD, Huff PS, Isetts BJ, University-based sports pharmacy
program. American Journal Health-Systems Pharmacy. 52:302-309, 1995.
8. National Athletic Trainers’ Association Consensus Statement:
Managing Prescriptions and Non-Prescription Medication in the
Athletic Training Facility. NATA News. January 2009.
4. All prescription and over-the-counter (OTC) medications should be stored in designated areas that
ensure proper environmental (dry with temperatures
between 59 and 86 degrees Fahrenheit) and security
5. All drug stocks should be examined at regular intervals for removal of any outdated, deteriorated or
recalled medications.
6. All emergency and travel kits containing prescription
and OTC drugs should be routinely inspected for
drug quality and security.
7. Individuals receiving medication should be properly
informed about what they are taking and how they
should take it. Drug allergies, chronic medical conditions and concurrent medication use should be documented in the student-athlete’s medical record and
readily retrievable.
8. Follow-up should be performed to be sure student-athletes are complying with the drug regimen
and to ensure that drug therapy is effective.
1. Adherence to Drug-Dispensation and Drug-Administration Laws and
Guidelines in Collegiate Athletic Training Rooms. Journal of Athletic
Training. 38(3): 252-258, 2003.
2. Anderson WA, Albrecht RR, McKeag DB, et al.: A national survey of
alcohol and drug use by college athletes. The Physician and
Sportsmedicine.19:91-104, 1991.
2013-14 NCAA Sports Medicine Handbook
Nontherapeutic Drugs
July 1981 • Revised June 2013
The NCAA and professional societies such as the
American Medical Association (AMA) and the American
College of Sports Medicine (ACSM) denounce the
employment of nontherapeutic drugs by student-athletes. These include drugs that are taken in an effort to
enhance athletic performance, and those drugs that
are used recreationally by student-athletes. Examples
include, but are not limited to, alcohol, amphetamines,
ephedrine, ma huang, opiates, anabolic-androgenic
steroids, barbiturates, caffeine, cocaine, heroin, LSD,
PCP, marijuana and all forms of tobacco. The use of
such drugs is contrary to the rules and ethical principles of athletics competition.
The patterns of drug use and the specific drugs
change frequently, and it is incumbent upon NCAA
member institutions to keep abreast of current trends.
The NCAA conducts drug-use surveys of student-athletes in all sports and across all divisions every four
years. The 2009 NCAA Study of Substance Use
Habits of College Student-Athletes, which surveyed
20,474 student-athletes at 1,076 NCAA institutions,
showed a continued decline in use of some drugs
and an overwhelming majority of athletes who have
never used banned substances. The study found that
less than 4 percent of respondents had ever used
anabolic steroids (0.6 percent), ephedrine (0.9
percent) or amphetamines (3.7 percent) and 94
percent reported having never taken any ergogenic
aids while in college. Those responses indicate a 0.5
percent decrease in amphetamine use and 0.7
percent drop in use of anabolic steroids from the previous survey conducted in 2005. An overwhelming
majority of respondents also reported never using
cocaine (98.2 percent) or other narcotics (96.7
percent). But use of social drugs and alcohol showed
increases since 2005.
The NCAA maintains a banned drug classes list (see
Appendix A) and conducts drug testing at championship events and year-round random testing in sports.
Some NCAA member institutions have developed
drug-testing programs to combat the use of nontherapeutic substances. Such programs should follow best
practice guidelines established by the NCAA
Committee on Competitive Safeguards and Medical
Aspects of Sports. While not all member institutions
have enacted their own drug-testing programs, it is
essential to have some type of drug-education
program as outlined in Guideline 1I. Drug testing
should not be viewed as a replacement for a solid
drug-education program.
student-athlete drug use
Patterns of Ergogenic Drug Use by Sex
Overall Percentage of Use Within the Past 12 Months
Female Male
Amphetamines3.7 4.5
Anabolic Steroids 0.3
3.3 4.0
Patterns of Social Drug Use by Sex
Overall Percentage of Use Within the Past 12 Months
Spit Tobacco
Female Male FemaleMale
77.3 77.683.1 83.1
16.3 13.413.5 16.8
1.3 2.51 2.3
17.9 23.518.4 25.3
— — 3.13.5
25.2 2.4
All medical staff should be familiar with the regulations regarding dispensing medications as listed in
Guideline 1G.
All member institutions, their athletics staff and their
student-athletes should be aware of current trends in
drug use and abuse, and the current NCAA list of
banned drug classes. It is incumbent upon NCAA
member institutions to act as a positive influence in
order to combat the use of drugs in sport and society.
1. American College of Sports Medicine, Position Stand: The Use of
Anabolic-Androgenic Steroids in Sports, 1984. (P.O. Box 1440,
Indianapolis, IN 46206-1440)
2. American Medical Association Compendium, Policy Statement:
Medical and Non-Medical Use of Anabolic-Androgenic Steroids
(105.001), 1990. (P.O. Box 10946, Chicago, IL 60610)
3. American Medical Association Compendium, Policy Statement: NonTherapeutic Use of Pharmacological Agents by Athletes (105.016),
1990. (P.O. Box 10946, Chicago, IL 60610)
4. NCAA Study of Substance Use Habits of College Student-Athletes.
NCAA, P.O. Box 6222, Indianapolis, IN 46206-6222, June 2009.
Available at
Alcohol, Tobacco and Other
Drug Education Guidelines
Administrative Issues
August 2000 • Revised June 2003, June 2009, June 2010
NCAA bylaws require that the director of athletics or
his or her designee disseminate the list of banned drug
classes to all student-athletes and educate them about
products that might contain banned drugs. The following provides a framework for member schools to
assure they are conducting adequate drug education
for all student-athletes. Athletics administrators,
coaches and sports medicine personnel should also
participate in drug-education sessions. Campus colleagues may provide additional support for your efforts.
In preparation for institution drug-education
programs, annually:
• Develop a written policy on alcohol, tobacco,
marijuana (THC), opiate, and other drugs. This
policy should include a statement on recruitment
activities, drug testing, disclosure of all medications and supplements, discipline, and counseling
or treatment options.
• Review the NCAA, conference and institutional
drug-testing program policies and update handbook materials accordingly.
• Include the NCAA list of banned drug classes and
NCAA written policies in the student-athlete
• Identify NCAA, conference and institutional rules
regarding the use of street drugs, performanceenhancing substances, and nutritional supplements, and consequences for breaking the rules.
• Display posters and other NCAA educational
materials in high-traffic areas.
• Include the following printed warning in the student-athlete handbook:
Before consuming any nutritional/dietary supplement product, review the product and its label with
your athletics department staff. Dietary supplements
are not well regulated and may cause a positive
drug test result. Any product containing a dietary
supplement ingredient is taken at your own risk.*
Tasks and Timelines for
educating student-athletes
• Provide student-athletes with a copy of the
written drug policies as outlined prior.
• Show “NCAA Drug-Education and Testing” video.
• Verbally explain all relevant drug policies with
student-athletes and staff:
- NCAA banned drug classes (note that all
related compounds under each class are
banned, regardless of if they are listed as an
- NCAA drug-testing policies and consequences for testing positive, including failure to
show or tampering with a urine sample.
- Risks of using nutritional/dietary supplements
– read the dietary-supplement warning.
- NCAA tobacco use ban during practice or
- Conference and institutional drug-testing
program policies, if appropriate.
- Street drug use policies and institutional sanctions for violations, if appropriate.
Team Meetings:
• Repeat the information from the orientation at
team meetings throughout the year.
Start of Each New Academic Term:
• Repeat the information from the orientation at the
start of new academic terms to reinforce messages and to ensure transfer student-athletes are
exposed to this information.
Throughout the Year:
• Provide additional drug-education opportunities
using NCAA resources found at
*For authoritative information on NCAA banned substances, medications and nutritional supplements,
contact the Resource Exchange Center (REC) at
877/202-0769 or (password
ncaa1, ncaa2 or ncaa3).
By July 1:
• Send out the NCAA list of banned drug classes,
the dietary supplement warning and Resource
Exchange Center (REC)* information to all returning student-athletes and known incoming student-athletes.
Orientation at Start of Academic Year:
• Ensure that student-athletes sign NCAA compliance forms.
2013-14 NCAA Sports Medicine Handbook
Preseason Preparation
July 2013
Athletic performance training is often divided into separate segments: preparation segment, competitive
segment and offseason segment. Guideline 1A of this
handbook notes that the student-athlete should be
protected from premature exposure to the full rigors
of sports. Optimal readiness for the first practice and
competition is often individualized to the student-athlete rather than a team as a whole. However, there is
a lack of scientific evidence to set a specific number
of days of sport practice that is needed for the first
sport competition.
It is commonly accepted that student-athletes should
participate in at least six to eight weeks of preseason
conditioning. Gradual progression of type, frequency,
intensity, recovery and duration of training should be
the focus of the preparation segment. In addition to
these areas warranted for progression, 10 to 14 days
are needed for heat acclimatization when applicable
(see Guideline 2C). The fall sport preseason period is
often challenging as August presents added heat risks
for sports and there is a lack of time limits for practice
activities (with the exception of football).
Changes to practice opportunities or the preseason
period should be accompanied by an educational
campaign for both coaches and student-athletes as to
the expectations for the sport season. Specifically, student-athletes should know that the designated preseason practice period might be considered part of the
competitive season and therefore a time when they
may practice at contest-level intensities.
A shortened preseason period based only on time
spent on campus or coach expectations for contestlevel intensities during the preparation period often
increases the time spent practicing sport-specific
skills without ample opportunity for preparatory conditioning exercises and can lead to injury and overtraining. If this is the expectation for the preparatory oncampus experience, athletes should be encouraged to
improve fitness through a progressive training and
conditioning program at least four weeks before starting the preseason segment.
The preparatory and preseason phases provide ample
time to improve fitness and skill; however, performing
novel exercise or actively doing too much too soon can
result in a disparity between workload and load tolerance, thus increasing risk for injury. In addition, a student-athlete’s psychological well-being can be directly
dependent on the level of fatigue driven by volume
Practice injury rates for fall sports
Field Hockey
Injury rate (per 1,000 athlete-exposures)
(2004-05 to 2008-09 NCAA Injury Surveillance)
(quantity) and intensity of training. Similarly, the incidence
in stress-related injuries (e.g., stress fractures, tendinitis)
can be proportional to the work-rest ratio of the athlete.
A member of the institution’s sports medicine staff
should be empowered to have the unchallengeable
authority to cancel or modify a workout for health and
safety reasons (i.e., environmental changes), as he or
she deems appropriate.
Preparatory Phase. The following are general concepts
to consider during the preparatory phase of training:
• Training should be periodized so that variation in
the volume and intensity occurs in a scheduled
• Progressively increase workloads and intensity
following transitional periods. Conditioning
periods should be phased in gradually and progressively to encourage proper exercise acclimatization and to minimize the risk of adverse effects
on health. The first seven to 10 days of any new
conditioning cycle (including, but not limited to
return in January, return after spring break, return
in summer, return for fall preseason or return after
an injury) are referred to as transitional periods.
• Plan recovery to allow for growth and development
while avoiding acute and overtraining injuries.
Administrative Issues
• A proper heat acclimatization plan is essential to
minimize the risk of exertional heat illness during
the fall preseason practice period. Minimizing
exertional heat illness risk requires gradually
increasing athletes’ exposure to the duration and
intensity of physical activity and to the environment over a period of 10 to 14 days.
• Prolonged, near-maximal exertion should be
avoided before acquired physical fitness and heat
acclimatization are sufficient to support high-intensity, long duration exercise training or competition.
Fall Preseason Period. Institutions are encouraged to
regularly review their preseason policies for fall sports
and consider the following points of emphasis for protecting the health of and providing a safe environment
for all student-athletes participating in preseason
workout sessions.
• Before participation in any preseason-practice
activities, all student-athletes should have completed the medical examination process administered by medical personnel (see Bylaw 17.1.5).
• Institutions should implement an appropriate
rest and recovery plan that includes a hydration
• Preseason practice should begin with an acclimatization period for first-time participants, as well
as continuing student-athletes.
• During the acclimatization period, an institution
should conduct only one practice per calendar day.
• Practice sessions should have maximum time
limits based on sport and individual needs, as
well as environmental factors.
• An institution should ensure student-athletes
have continuous recovery time (e.g., three hours)
between multiple practice sessions on the same
calendar day.
• Subsequent to the initial acclimatization period,
an institution should consider a practice model
that promotes recovery if practice sessions are to
occur on consecutive days (e.g., two-one-twoone format).
• Student-athletes should be provided at least one
recovery day per week on which no athleticsrelated activities are scheduled, similar to the
regular playing season.
• Coaches are encouraged to consult with health
care staff (e.g., athletic trainer) in the development of the conditioning sessions. All personnel
should be aware of the impact of exercise intensity and duration, heat acclimatization, hydration,
medications and drugs, existing medical conditions, nutritional supplements, and equipment on
student-athletes’ health while participating in
strenuous workouts.
• Appropriate on-field personnel should review,
practice and follow their venue emergency plan,
as well as be trained in administering first aid,
cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use.
1. Joy, EA, Prentice, W, and Nelson-Steen, S. Coaching and Training.
SSE Roundtable #44: Conditioning and nutrition for football. GSSI:
Sports Science Library. Available Online:
2013-14 NCAA Sports Medicine Handbook
NCAA Football Preseason Model (see Bylaw 17)
The following concepts outline the legislation involving the NCAA football preseason period. Institutions
should refer to division-specific legislation for exact requirements.
Five-Day Acclimatization Period.
In football, preseason practice begins with a fiveday acclimatization period for both first-time participants (e.g., freshmen and transfers) and continuing
student-athletes. All student-athletes, including
walk-ons who arrive to preseason practice after the
first day of practice, are required to undergo a fiveday acclimatization period. The five-day acclimatization period should be conducted as follows:
(a) Before participation in any preseason practice
activities, all prospects and student-athletes initially
entering the intercollegiate athletics program shall
be required to undergo a medical examination
administered by a physician (see Guideline 1C).
(b) During the five-day period, participants shall
not engage in more than one on-field practice
per day, not to exceed three hours in length.
(c) During the first two days of the acclimatization
period, a helmet shall be the only piece of protective equipment a student-athlete may wear.
During the third and fourth days of the acclimatization period, helmets and shoulder pads shall
be the only pieces of protective equipment student-athletes may wear. During the final day of
the five-day period and on any days thereafter,
student-athletes may practice in full pads.
2. Bompa, Tudor O. (2004). Primer on Periodization. Olympic Coach,
16(2): 4-7.
3. Kraemer, W. J., & Ratamess, N. A. (2004). Fundamentals of
Resistance Training: Progression and Exercise Prescription. Medicine
& Science in Sports & Exercise, 36(4), 674-688. Available Online:
4. Pearson et al. (2000). The national strength and conditioning
association’s basic guidelines for the resistance training of athletes.
Strength and Conditioning Journal, 22(4): 14-27.
5. Herring et al. The team physician and conditioning of athletes for
sports: A consensus statement.
6. United Educators. (2006). Putting safety before the game: College
and high school athletic practices. Risk Research Bulletin, Student
Affairs, June/July. Available online:
7. National Athletic Trainers' Association. (2009). Pre-Season heat
acclimatization practice guidelines for secondary school athletics.
Journal of Athletic Training, 44(3), 332–333.
8. Hartmann, U and Mester, J. (2000). Training and overtraining markers
The remaining preseason practice period is
conducted as follows:
(a) After the five-day period, institutions may
practice in full pads. However, an institution
may not conduct multiple on-field practice
sessions (e.g., two-a-days or three-a-days) on
consecutive days;
(b) Student-athletes shall not engage in more
than three hours of on-field practice activities
on those days during which one practice is
(c) Student-athletes shall not engage in more
than five hours of on-field practice activities
on those days during which more than one
practice is permitted; and
(d) On days that institutions conduct multiple
practice sessions, student-athletes must be
provided with at least three continuous hours
of recovery time between the end of the first
practice and the start of the last practice that
day. During this time, student-athletes may
not attend any meetings or engage in other
athletically related activities (e.g., weightlifting); however, time spent receiving medical
treatment and eating meals may be included
as part of the recovery time.
in selected sports events. Medicine & Science in Sports & Exercise,
32(1): 209–215.
9. Haff, G et al. (2004). Roundtable discussion: Periodization of training
[part 1-2]. Strength & Conditioning Journal, 26(1): 50-69
10. Plisk, S and Stone, MH. (2003). Periodization strategies. Strength &
Conditioning Journal, 25(6): 19-37.
11. Armstrong et al. (2007). ACSM Position Stand: Exertional heat illness
during training and competition. Medicine & Science in Sports &
Exercise. Available Online:
12. (2012). The Inter-Association Task Force for Preventing Sudden Death
in Collegiate Conditioning Sessions: Best Practices
Recommendations. Journal of Athletic Training, 47(4), 477-480.
Strength and Conditioning
Principles: Foundations
for Athlete Development
Administrative Issues
Guideline 1K
July 2013
The integration of strength and conditioning sessions
has become fundamental to student-athlete development across sports. Appropriately structured sessions
can provide student-athletes with optimal readiness for
the first practice and the full rigors of their sport. The
combination of strength, speed, power, cardiorespiratory fitness and other physiologic components of
athletic capacity can complement skill and enhance
performance for all athletes.
Applied Sport
Sport Performance Team. A multidisciplinary applied sport science approach to
athlete performance development proSkill
vides the best foundation for success as
strength and conditioning specialists, athletic trainers, physicians, dietitians, sport
coaches, sport psychologists, and exercise
physiologists are interconnected and work in
concert. This approach creates a sound and
effective sport training program based on
scientific principles intended to produce outLearning
comes that are sensitive and specific to the
sport while accounting for any potential
medical limitation and builds a foundation for
long-term athlete development. The basics of
Recovery and
strength and conditioning are grounded in seven
principles of training: individuality, specificity, overload, progression, variation, diminishing returns and
reversibility. These principles are the basic tenants
of exercise science and are valid in designing any
exercise program.
Overload Principle. In order for an individual to
Individuality Principle. Every student-athlete is unique achieve a certain training adaptation, the body must
and will respond differently to the same training stimu- be stressed by working against a stimulus or load that
is greater than that to which it is accustomed.
lus. Many factors affect how student-athletes respond
Overload ensures improvement by challenging
to training including their fitness status; current health
status and past injuries; genetic predisposition; gender changes in resistance, terrain, movement complexity
and many others. When more is demanded, within
and race; diet and sleep; environmental factors such
reason, the body adapts to the increased demand.
as heat, cold and humidity; and motivation.
Overload can be applied in duration, intensity or both.
Specificity Principle. All training adaptations are specific to the stimulus applied. The specific physiological Progression Principle. To achieve the desired training
adaptations for a certain activity or skill consistently, the
adaptations to condition are determined by various
training stimulus must gradually and constantly increase.
factors, including muscle actions involved, speed of
This implies that there is an optimal level and time frame
movement, range of motion, muscle groups trained,
for the overload to occur. Injury may result if overload
energy systems involved and intensity and volume of
increases too quickly or an athlete uses poor technique
training. In an attempt to perfect a specific skill or
or improper muscle firing patterns. If overload progresses
activity, the athlete must perform that skill or activity
too slowly, improvements will be minimal or nonexistent.
with proper body mechanics and correct technique.
2013-14 NCAA Sports Medicine Handbook
Rest and recovery must also be included in the progression, as consistent training volumes and/or loads can
result in fatigue, a decrease in performance and/or injury.
Variation. Variation, or periodization, is the systematic
process of altering one or more program variable(s) over
time to allow for the training stimulus to remain challenging yet effective. The concept of periodization is to optimize performance and recovery. Because the human body
adapts quickly, at least some changes are needed in order
for continual progression to occur. It has been shown that
systematic variation of volume and intensity over several
training cycles is most effective for long-term progression.
Variation may take place in many forms and manifests by
manipulation of any one or a combination of the acute
program variables. However, the two most commonly
studied variables have been volume and intensity.
Principle of Diminishing Returns. Performance gains
are related to the level of training experience of the individual. Student-athletes new to a conditioning program
will experience large initial performance gains. In contrast, student-athletes that have strength trained over
several years will make small strength gains over a long
period of time. As athletes near their genetic potential,
the gains in performance will be much harder to obtain.
The principle of diminishing returns highlights the
importance of being able to interpret performance
results and understanding the individual student-athlete.
Reversibility/Regression. When the training stimulus
is removed or reduced, the ability of the student-athlete to maintain performance at a particular level is
also reduced, and eventually the gains that were made
from the training program will revert back to their original level. Also known as detraining, the decrease in
performance is directly related to the inactivity of the
muscles that have been atrophied from nonuse.
When designing strength and conditioning programs, it
is important to have a clear understanding of the basic
training principles. Understanding these principles will
help the student-athlete, sport coach and strength and
conditioning coach set realistic goals and develop
training programs that will provide the greatest opportunity to achieve performance gains. Student-athletes
often have time constraints and are under pressure to
be at their peak level of performance. It is the responsibility of the strength and conditioning coach to thoroughly evaluate the level of conditioning of all new and
returning athletes and to properly prescribe the appropriate training volume, load and intensity to protect the
health and safety of each student-athlete.
Common Terms
Bioenergetics: the flow of energy in a biological
system; the source of energy for muscular contractions.
Energy: the capacity to perform work.
Frequency: the number of training sessions
expressed per day, per week, per month.
Intensity: the difficulty of the work. Intensity is
the amount of weight or resistance used in a
particular exercise.
Muscular Strength: the ability of the muscles to
generate force.
Periodization: the systematic process of altering
one or more program variable(s) over time to
allow for the training stimulus to remain challenging and effective.
Progression: the selection of exercises, loads or
resistances, order of exercises, and readiness of
the athlete that are conducive to the athlete’s
training status and the demands of the activity.
Progression in resistance training may be defined
as the act of moving forward or advancing
toward a specific goal over time until the target
goal has been achieved.
Progressive Overload: the gradual increase of
stress placed upon the body during exercise training.
Training: the process of preparing an athlete
physically, technically, tactically, psychologically
for the highest levels of performance.
Volume: the total amount of work performed.
Sets and repetitions of an exercise combine to
make volume. Training volume is a summation of
the total number of repetitions performed during
a training session multiplied by the resistance
used (kg) and is reflective of the duration of
which muscles are being stressed.
Volume-Load: the combination of volume and
intensity. Volume-load is calculated as sets x
repetitions x weight, or resistance used.
Administrative Issues
The safest approach after a break is to provide flexibility within the strength and conditioning program.
Extended periods of time away from training reduce
aerobic and anaerobic thresholds. Not only are incoming athletes at risk of injury, but returning, “de-trained”
athletes can be at risk of injury and exertional collapse.
Flexibility within the strength and conditioning program
allows for adaptations to be made based on the
returning athletes' present physiological status.
training adaptations in athletes. One of the primary
advantages of this training approach is to avoid overtraining. Thus, built within the annual plan is time
needed for physical and mental recovery. Many overtraining syndromes are a function of the rate of progression – attempting to do too much too soon,
before the body’s physiological adaptations can cope
with the stress. This typically results in extreme soreness, injury and in rare cases death.
Sports-Specific Performance Enhancement. As
defined in the principle of specificity, training needs to be
relevant to the individual needs of the activity or sport.
Although there is some carryover of training effects to
other general fitness and performance attributes, the
most effective strength and conditioning programs are
those that are designed to target-specific training goals.
Like all athletic activities, injury is a possibility and
preparation for conditioning sessions should be
designed to reduce the likelihood of injury. The goal of
physical conditioning is to optimize the performance
of the athlete and minimize the risk of injury and
illness. A well-designed strength and conditioning
program along with appropriate, sport-specific skill
development are the best approaches to preventing
injury. Strength training protects the joints from trauma
while sport-specific skill training can help prevent
injury by improving the athlete’s proprioception. By
increasing the strength of the muscles that surround
the hips, knees, ankles, shoulders and elbows before
the season starts, athletes will be less likely to suffer
muscle strains and joint sprains. Athletes returning to
athletic activity from a detrained state are at the greatest risk of injury.
Trainable characteristics include muscular strength,
power, hypertrophy and local muscular endurance.
Performance attributes such as speed and agility,
balance, coordination, jumping ability, flexibility, core
strength and other measures of motor performance are
enhanced by resistance training.
Injury Prevention. After the student-athlete completes the preparticipation examination, strength and
conditioning coaches should be made aware of
health-related issues that could affect training (e.g.
sickle cell trait status, asthma and cardiac conditions,
acute illness, lack of sleep, suboptimal nutrition, as
well as any relevant medications being taken).
The use of the periodization concept and creating an
annual plan have proven vital to the optimization of
The first step to safe performance is thorough and
competent training of strength and conditioning
coaches. Strength and conditioning professionals
apply scientific knowledge to train athletes for the
primary goal of improving athletic performance. They
conduct sport-specific testing sessions, design and
implement safe and effective strength training and
2013-14 NCAA Sports Medicine Handbook
conditioning programs, monitor facilities for safety, and
convey principles of nutrition and injury prevention as
a member of the performance team. Recognizing that
their area of expertise is separate and distinct, strength
and conditioning coaches can consult with and refer
student-athletes to other athletics health care professionals when appropriate. Strength and conditioning
coaches should be certified by a nationally accredited
organization. The required components for certification
of strength and conditioning personnel vary across
national certifying agencies, and individual states lack
professional practice regulation similar to medical professionals. Therefore, institutions should identify a particular agency or agencies that meet their institution’s
expectations for developing and conducting appropriate workouts for intercollegiate student-athletes. When
considering components for appropriate strength and
conditioning certifications, institutions should note
whether the certifying agency:
1. Is accredited by an oversight organization (e.g.,
National Commission for Certifying Agenciesaccredited);
2. Requires an undergraduate college degree;
3. Requires a continuing education component; and
4. Requires current first aid, CPR and AED use certification.
Preventing Sudden Death. Recent evidence has
identified several important complications to studentathlete health of which everyone in athletics should
be aware. These include sudden cardiac death,
asthma, concussion, exertional rhabdomyolysis, heat
illness and an increased risk of exertional collapse in
athletes with sickle cell trait. The Inter-Association
Task Force for Preventing Sudden Death in Collegiate
Conditioning Sessions published the following 10 recommendations for preventing sudden death in collegiate conditioning sessions:
1. Acclimatize progressively for utmost safety.
2. Introduce new conditioning activities gradually.
3. Do not use exercise and conditioning activities as
4. Ensure proper education, experience and credentialing of strength training and conditioning coaches.
Summer conditioning period
points of emphasis
1. Institutions should review the guidelines in
the NCAA Sports Medicine Handbook (e.g.
hydration, emergency care and coverage,
medical evaluations, etc.) in developing and
updating their policies.
2. Institutions should implement an appropriate
rest and recovery plan that includes a hydration strategy.
3. Coaches are encouraged to consult with
medical staff in the development of the conditioning sessions. All personnel should be
aware of the potential impact acclimatization, hydration, medications and drugs,
existing medical conditions, nutritional supplements, and clothing/equipment have on
student-athletes’ health while participating in
strenuous workouts.
4. All on-field personnel should review, practice
and follow their venue emergency plan and
be trained in administering first aid and cardiopulmonary resuscitation (CPR).
5. Before summer participation, student-athletes should be oriented to the logistics of
the summer period and any health and safety concerns that may be associated with
participating in strenuous workouts.
6. Incoming freshman/transfers should ideally
work out separate from the varsity; or, at
the very least be provided a closely monitored, lower-intensity conditioning program
to allow gradual physiological adaptation
to occur.
7. Student-athletes should be encouraged to
report illnesses, injuries and the use of medications and nutritional supplements.
8. Discourage athletes from using caffeine and/
or other stimulants that mask fatigue.
9. Monitor athletes closely for the emergence
of overtraining signs and symptoms such as
unusual fatigue and/or muscle soreness,
musculoskeletal injuries and rhabdomyolysis;
and promptly refer for immediate medical
evaluation with obvious indications of muscle breakdown, such as dark brown urine or
severe muscle pain.
Administrative Issues
5. Provide appropriate medical coverage.
6. Develop and practice, at least annually, the institution's emergency action plan.
7. Be cognizant of medical conditions.
8. Properly design and administer strength and conditioning programs.
9. Partner with recognized professional organizations.
10. Provide adequate continuing education for the
entire coaching and medical teams.
1. Baechle, T.R., and Roger, W.E. (2008). Essentials of strength and
conditioning, 3rd edition. Champaign, IL: Human Kinetics.
2. Bergeron, M., Nindl, B., F., Deuster, P., Baumgartner, N., et. Al.
(2011). Consortium for Health and Military Performance and American
College of Sports Medicine Consensus Paper on Extreme
Conditioning Programs in Military Personnel. Current Sports Medicine
Reports, 383-389.
3. Brown, L. (Ed). (2007). Strength training / National Strength and
Conditioning Association. Champaign, IL: Human Kinetics.
4. Casa, D.J., Anderson, S.A., Baker, L., Bennett, S., Bergeron, M.F.,
Connolly, D., et al. (2012).The inter-association task force for
preventing sudden death in collegiate conditioning sessions: Best
practices recommendations. Journal of Athletic Training, 47(4):477-480
5. Hoffman, J. (2002). Physiological aspects of sport training and
performance. Champaign, IL: Human Kinetics.
6. Martens, R. (2012). Successful Coaching. Champaign, IL: Human
7. Ratamess, N., Alvar, B. A., Evetoch, T.K., Housh, T.J., Kibler, W.B.,
Kraemer, W.J. et al. (2009). Progression models in resistance training
for healthy adults. Medicine & Science in Sports & Exercise, 687-708.
8. Sands, W.A., Wurth, J.J., Hewitt, J.K. (2012). The National Strength and
Conditioning Association’s Basics of Strength and Conditioning Manual.
Colorado Springs, CO: National Strength and Conditioning Association.
2013-14 NCAA Sports Medicine Handbook
Medical Issues
2013-14 NCAA Sports Medicine Handbook
January 1979 • Revised June 2004
Withholding a student-athlete from activity. The
team physician has the final responsibility to determine
when a student-athlete is removed or withheld from
participation due to an injury, an illness or pregnancy.
In addition, clearance for that individual to return to
activity is solely the responsibility of the team physician or that physician’s designated representative.
Procedure to medically disqualify a student-athlete
during an NCAA championship. As the event sponsor, the NCAA seeks to ensure that all student-athletes
are physically fit to participate in its championships
and have valid medical clearance to participate in the
1. The NCAA tournament physician, as designated by
the host school, has the unchallengeable authority
to determine whether a student-athlete with an
injury, illness or other medical condition (e.g., skin
infection, communicable disease) may expose others to a significantly enhanced risk of harm and, if
so, to disqualify the student-athlete from continued participation.
2. For all other incidents, the student-athlete’s on-site
team physician can determine whether a studentathlete with an injury or illness should continue to
participate or is disqualified. In the absence of a
team physician, the NCAA tournament physician
will examine the student-athlete and has valid medical authority to disqualify him or her if the studentathlete’s injury, illness or medical condition poses a
potentially life-threatening risk to himself or herself.
3. The chair of the governing sports committee (or a
designated representative) shall be responsible for
administrative enforcement of the medical judgment, if it involves disqualification.
1. Team Physician Consensus Statement. Project-based alliance for the
advancement of clinical sports medicine composed of the American
Academy of Family Physicians, the American Academy of Orthopaedic
Surgeons, the American College of Sports Medicine (ACSM), the American
Medical Society for Sports Medicine, and the American Osteopathic
Academy of Sports Medicine, 2000. Contact ACSM at 317/637-9200.
Cold Stress
and Cold Exposure
Medical Issues
June 1994 • Revised June 2002, June 2009
Any individual can lose body heat when exposed to
cold air, but when the physically active cannot maintain heat, cold exposure can be uncomfortable, can
impair performance and may be life threatening. A
person may exhibit cold stress due to environmental
or nonenvironmental factors. The NATA position statement (2008) states that injuries from cold exposure are
due to a combination of low air or water temperatures
and the influence of wind on the body’s ability to
maintain a normothermic core temperature, due to
localized exposure of extremities to cold air or surface.
The variance in the degree, signs and symptoms of
cold stress may also be the result of nonenvironmental
factors. These factors are, but not limited to, previous
cold weather injury (CWI), race, geological origin,
ambient temperature, use of medications, clothing
attire, fatigue, hydration, age, activity, body size/composition, aerobic fitness level, clothing, acclimatization
and low caloric intake. Nicotine, alcohol and other
drugs may also contribute to how the person adapts to
the stresses of cold.
Early recognition of cold stress is important. Shivering,
a means for the body to generate heat, serves as an
early warning sign. Excessive shivering contributes to
fatigue and makes performance of motor skills more
difficult. Other signs include numbness and pain in
fingers and toes or a burning sensation of the ears,
nose or exposed flesh. As cold exposure continues,
the core temperature drops. When the cold reaches the
brain, a victim may exhibit sluggishness and poor judgment and may appear disoriented. Speech becomes
slow and slurred, and movements become clumsy. If
the participant wants to lie down and rest, the situation
is a medical emergency, and the emergency action
plan should be activated.
Cold injuries can be classified into three categories:
freezing of extremities, nonfreezing of extremities and
Definitions of Common
Cold Injuries in Sports
Frostbite. Frostbite is usually a localized response to
a cold, dry environment, but in some incidents, moisture may exacerbate the condition. Frostbite can
appear in three distinct phases: frostnip, mild frostbite
and deep frostbite.
Frostnip, also known as prefreeze, is a precursor to
frostbite and many times occurs when skin is in contact
with cold surfaces (e.g., sporting implements or liquid).
The most characteristic symptom is a loss of sensation.
Frostbite is the actual freezing of skin or body tissues,
usually of the face, ears, fingers and toes, and can
occur within minutes. Signs and symptoms include
edema, redness or mottled gray skin, and transient tingling and burning. Permanent numbness, chronic pain,
cold sensitivity, sensory loss and a variety of other
symptoms may last for years.
Hypothermia. Hypothermia is a significant drop in
body temperature [below 95 degrees Fahrenheit (35
degrees Celsius)] as the body’s heat loss exceeds its
production. The body is unable to maintain a normal
core temperature. An individual may exhibit changes in
motor function (e.g., clumsiness, loss of finger dexterity, slurred speech), cognition (e.g., confusion, memory
loss) and loss of consciousness (e.g., drop in heart
rate, stress on the renal system, hyperventilation, sensation of shivering). The signs and symptoms of hypothermia will vary with each individual, depending upon
previous cold weather injury (CWI), race, geological
origin, ambient temperature, use of medications, clothing attire, fatigue, hydration, age, activity and others.
Hypothermia can occur at temperatures above freezing. A wet and windy 30- to 50-degree exposure may
be as serious as a subzero exposure. As the WindChill Equivalent Index (WCEI) indicates, wind speed
interacts with ambient temperature to significantly
increase body cooling. When the body and clothing
are wet, whether from sweat, rain, snow or immersion,
the cooling is even more pronounced due to evaporation of the water held close to the skin by wet clothing.
Chilblain and Immersion (Trench) Foot. Chilblain is a
nonfreezing cold injury associated with extended cold
and wet exposure and results in an exaggerated or
inflammatory response. Chilblain may be observed in
exposure to cold, wet conditions extending beyond
one hour in endurance and alpine events, and team
sports, in which clothing remains wet. The feet and
hands are usually affected.
Prevention of Cold Exposure
and Cold Stress
Educating all participants in proper prevention is the
key to decreasing the possibility of cold exposure
injury or illness. Individuals unaccustomed to cold
conditions who are participating at venues that may
place them at risk for cold stress may need to take
2013-14 NCAA Sports Medicine Handbook
extra precautionary measures (e.g., proper clothing,
warm-up routines, nutrition, hydration, sleep).
caffeine, nicotine and other drugs that cause water
loss, vasodilatation or vasoconstriction of skin vessels.
The sports medicine staff and coaches should identify
participants or conditions that may place members of
their teams at a greater risk (e.g., predisposing medical
conditions, physiological factors, mechanical factors,
environmental conditions).
Fatigue/Exhaustion. Fatigue and exhaustion deplete
energy reserves. Exertional fatigue and exhaustion
increase the susceptibility to hypothermia, as does
sleep loss.
Clothing. Individuals should be advised to dress in
layers and try to stay dry. Moisture, whether from perspiration or precipitation, significantly increases body
heat loss. Layers can be added or removed depending on temperature, activity and wind chill. Begin with
a wicking fabric next to the skin; wicking will not only
keep the body warm and dry, but also eliminates the
moisture retention of cotton. For example, polypropylene and wool can wick moisture away from the skin
and retain insulating properties when wet. Add lightweight pile or wool layers for warmth and use a windblocking garment to avoid wind chill. Because heat
loss from the head and neck may account for as
much as 40 percent of total heat loss, the head and
ears should be covered during cold conditions. Hand
coverings should be worn as needed, and in extreme
conditions, a scarf or face mask should be worn.
Mittens are warmer than gloves. Feet can be kept dry
by wearing moisture-wicking or wool socks that
breathe and should be dried between wears.
Energy/Hydration. Maintain energy levels via the use
of meals, energy snacks and carbohydrate/electrolyte
sports drinks. Negative energy balance increases the
susceptibility to hypothermia. Stay hydrated, since
dehydration affects the body’s ability to regulate temperature and increases the risk of frostbite. Fluids are
as important in the cold as in the heat. Avoid alcohol,
Warm-Up. Warm up thoroughly and keep warm
throughout the practice or competition to prevent a
drop in muscle or body temperature. Time the
warm-up to lead almost immediately to competition.
After competition, add clothing to avoid rapid cooling.
Warm extremely cold air with a mask or scarf to
prevent bronchospasm.
Partner. Participants should never train alone. An
injury or delay in recognizing early cold exposure
symptoms could become life-threatening if it occurs
during a cold-weather workout on an isolated trail.
Practice and Competition Sessions
The following guidelines, as outlined in the 2008 NATA
position statement, can be used in planning activity
depending on the wind-chill temperature. Conditions
should be constantly re-evaluated for change in risk,
including the presence of precipitation:
• 30 degrees Fahrenheit and below: Be aware of
the potential for cold injury and notify appropriate
personnel of the potential.
• 25 degrees Fahrenheit and below: Provide additional protective clothing; cover as much exposed
skin as practical; provide opportunities and facilities for re-warming.
• 15 degrees Fahrenheit and below: Consider
modifying activity to limit exposure or to allow
more frequent chances to re-warm.
Medical Issues
0 degrees Fahrenheit and below: Consider terminating or rescheduling activity.
Environmental Conditions
To identify cold stress conditions, regular measurements of environmental conditions are recommended
during cold conditions by referring to the Wind-Chill
Equivalent Index (WCEI) (revised November 1, 2001).
The WCEI is a useful tool to monitor the air temperature index that measures the heat loss from exposed
human skin surfaces. Wind chill is the temperature it
“feels like” outside, based on the rate of heat loss from
exposed skin caused by the effects of the wind and
cold. Wind removes heat from the body in addition to
the low ambient temperature.
When traveling to areas of adverse weather conditions, the following terms will be consistently referred
to in weather forecasting.
Wind Chill. Increased wind speeds accelerate heat
loss from exposed skin, and the wind chill is a measure
of this effect. No specific rules exist for determining
when wind chill becomes dangerous. As a general
guideline, the threshold for potentially dangerous wind
chill conditions is about minus-18 degrees Fahrenheit.
Cooling is accelerated with wet clothing. Frostbite can
occur within 30 minutes or faster if clothing is wet, it is
windy, or wind is produced during sport movement.
Wind Chill Advisory. The National Weather Service
issues this product when the wind chill could be life
threatening if action is not taken. The criteria for this
warning vary from state to state.
Wind Chill Factor. Increased wind speeds accelerate
heat loss from exposed skin. No specific rules exist
for determining when wind chill becomes dangerous.
As a general rule, the threshold for potentially dan-
Wind Chill Chart
Available at:
2013-14 NCAA Sports Medicine Handbook
gerous wind chill conditions is about minus-18
degrees Fahrenheit.
Wind Chill Warning . The National Weather Service
issues this product when the wind chill is life threatening. The criteria for this warning vary from state to state.
Blizzard Warning. The National Weather Service
issues this product for winter storms with sustained or
frequent winds of 35 miles per hour or higher with considerable falling and/or blowing snow that frequently
reduces visibility to one-quarter of a mile or less.
1 Cappaert, T., Stone, J.A., Castellani, J.W., Krause, B.A., Smith, D.,
and Stephens, B.A. National Athletic Trainers’ Association Position
Statement: Environmental Cold Injuries. Journal of Athletic Training.
43(6):640-658. 2008.
2. Prevention of Cold Injuries During Exercise. ACSM Position Stand.
Medicine & Science in Sports & Exercise. 2006: 2012-2029.
3. Armstrong, LE: Performing in Extreme Environments. Champaign, IL:
Human Kinetics Publishers. 1999.
4. Askew EW: Nutrition for a cold environment. The Physician and
Sportsmedicine 17(12):77-89, 1989.
5. Frey C: Frostbitten feet: Steps to treatment and prevention. The
Physician and Sportsmedicine 21(1):67-76, 1992.
6. Young, A.J., Castellani, J.W., O’Brian, C. et al., Exertional fatigue,
sleep loss, and negative-energy balance increases susceptibility to
hypothermia. Journal of Applied Physiology. 85:1210-1217, 1998.
7. Robinson WA: Competing with the cold. The Physician and
Sportsmedicine 20(1):61-65, 1992.
8. Thornton JS: Hypothermia shouldn’t freeze out cold-weather athletes.
The Physician and Sportsmedicine 18(1): 109-114, 1990.
9. NOAA National Weather Service,
10.Street, Scott, Runkle, Debra. Athletic Protective Equipment: Care,
Selection, and Fitting. McGraw-Hill, 2001.
Medical Issues
of Heat Illness
June 1975 • Revised June 2002, June 2010
Practice or competition in hot and/or humid environmental conditions poses special problems for studentathletes. Heat stress and resulting heat illness is a
primary concern in these conditions. Although deaths
from heat illness are rare, exertional heatstroke (EHS)
is the third-leading cause of on-the-field sudden death
in athletes. There have been more deaths from heatstroke in the recent five-year block from 2005 to 2009
than any other five-year block in the previous 30 years.
Constant surveillance and education are necessary to
prevent heat-related problems. The following practices
should be observed:
1. An initial complete medical history and physical
evaluation, followed by the completion of a yearly
health-status questionnaire before practice begins,
is required, per Bylaw 17.1.5. A history of previous
heat illnesses, sickle cell trait and the type and
duration of training activities for the previous
month should also be considered.
2. Prevention of heat illness begins with gradual acclimatization to environmental conditions. Student-
athletes should gradually increase exposure to hot
and/or humid environmental conditions during a
minimum period of 10 to 14 days. Each exposure
should involve a gradual increase in the intensity
and duration of exercise and equipment worn until
the exercise is comparable to that likely to occur in
competition. When environmental conditions are
extreme, training or competition should be held during a cooler time of day. Hydration should be maintained during training and acclimatization sessions.
3. Clothing and protective equipment, such as helmets, shoulder pads and shinguards, increase
heat stress by interfering with the evaporation of
sweat and inhibiting other pathways needed for
heat loss. Dark-colored clothing increases the
body’s absorption of solar radiation, while moisture-wicking-type clothing helps with the body’s
ability to dissipate heat. Frequent rest periods
should be scheduled so that the gear and clothing
can be removed and/or loosened to allow heat
dissipation. During the acclimatization process, it
may be advisable to use a minimum of protective
Protect Yourself and Your Teammates
Intense exercise, hot and humid weather and dehydration
can seriously compromise athlete performance and increase
the risk of exertional heat injury. Report problems to
medical staff immediately.
Know the Signs
• Muscle cramping.
• Decreased performance.
• Unsteadiness.
• Confusion.
• Vomiting.
• Irritability.
• Pale or flushed skin.
• Rapid weak pulse.
Report Your Symptoms
• High body temperature.
• Nausea.
• Headache.
• Dizziness.
• Unusual fatigue.
• Sweating has stopped.
• Disturbances of vision.
• Fainting.
2013-14 NCAA Sports Medicine Handbook
gear and clothing and to practice in moisturewicking T-shirts, shorts, socks and shoes.
Rubberized suits should not be worn.
4. To identify heat stress conditions, regular measurements of environmental conditions are recommended. The wet-bulb globe temperature (WBGT),
which includes the measurement of wet-bulb temperature (humidity), dry-bulb temperature (ambient
temperature) and globe temperature (radiant heat),
assesses the potential impact of environmental
heat stress. A WBGT higher than 82 degrees
Fahrenheit (28 degrees Celsius) suggests that
careful control of all activity should be undertaken.
Additional precautions should be taken when
wearing protective equipment (see reference No.
6). The American College of Sports Medicine publishes guidelines for conducting athletic activities
in the heat (see reference No. 1).
5. EHS has the greatest potential of occurrence at
the start of preseason practices and with the introduction of protective equipment during practice
sessions. The inclusion of multiple practice sessions during the same day may also increase the
risk of EHS. Ninety-six percent of all heat illnesses
in football occur in August.
6. Hydration status also may influence the occurrence
of EHS; therefore, fluid replacement should be
readily available. Student-athletes should be
encouraged to drink frequently throughout a practice session. They should drink two cups or more
of water and/or sports drink in the hour before
practice or competition, and continue drinking during activity (every 15 to 20 minutes). For activities
up to two hours in duration, most weight loss represents water loss, and that fluid loss should be
replaced as soon as possible. After activity, the
student-athlete should rehydrate with a volume
that exceeds the amount lost during the activity. In
general, 20 ounces of fluid should be replaced for
every pound lost. Urine volume and color can be
used to assess general hydration. If output is plentiful and the color is “pale yellow or straw-colored,”
the student-athlete is not dehydrated. As the urine
color gets darker, this could represent dehydration
of the student-athlete. Water and sport drinks are
appropriate for hydration and rehydration during
exercise in the heat. Sport drinks should contain
no more than 6-8 percent carbohydrates and electrolytes to enhance fluid consumption. In addition,
the carbohydrates provide energy and help maintain immune and cognitive function.
7. During the preseason period or periods of high
environmental stress, the student-athletes’ weight
should be recorded before and after every workout, practice and competition. This procedure can
detect progressive dehydration and loss of body
fluids. Those who lose 5 percent of their body
weight or more should be evaluated medically and
their activity restricted until rehydration has
occurred. For prevention, the routine measurement
of pre- and post-exercise body weights is useful
for determining sweat rates and customizing fluid
replacement programs.
8. Some student-athletes may be more susceptible
to heat illness. Susceptible individuals include
those with sickle cell trait, inadequate acclimatization or aerobic fitness, excess body fat, a history
of heat illness, a febrile condition, inadequate
rehydration and those who regularly push themselves to capacity. Also, substances with a diuretic
effect or that act as stimulants may increase risk
of heat illness. These substances may be found in
some prescription and over-the-counter drugs,
nutritional supplements and foods.
9. Student-athletes should be educated on the signs
and symptoms of EHS, such as elevated core temperature, weakness, cramping, rapid and weak
pulse, pale or flushed skin, excessive fatigue, nausea, unsteadiness, disturbance of vision, mental
confusion and incoherency. If heatstroke is suspected, prompt emergency treatment is recommended. When training in hot and/or humid conditions, student-athletes should train with a partner or
be under observation by a coach or athletic trainer.
Medical Issues
As identified throughout Guideline 2C, the following are potential risk factors associated with heat illness:
1.Intensity of exercise. This is the leading factor
that can increase core body temperature higher
and faster than any other.
2. Environmental conditions. Heat and humidity
combine for a high wet-bulb globe temperature
that can quickly raise the heat stress on the body.
3. Duration and frequency of exercise. Minimize
multiple practice sessions during the same day
and allow at least three hours of recovery
between sessions.
4.Dehydration. Fluids should be readily available
and consumed to aid in the body’s ability to regulate itself and reduce the impact of heat stress.
5. Nutritional supplements. Nutritional supplements may contain stimulants, such as ephedrine, ma huang or high levels of caffeine.* These
substances can have a negative impact on
hydration levels and/or increase metabolism
and heat production. They are of particular
concern in people with underlying medical conditions such as sickle cell trait, hypertension,
asthma and thyroid dysfunction.
6.Medication/drugs. Certain medications and drugs
have effects similar to those of some nutritional
supplements. These substances may be ingested
through over-the-counter or prescription medica-
First aid for heat illness
Heat exhaustion. Heat exhaustion is a moderate illness characterized by the inability to sustain adequate
cardiac output, resulting from strenuous physical exercise and environmental heat stress. Symptoms usually
include profound weakness and exhaustion, and often
dizziness, syncope, muscle cramps, nausea and a core
temperature below 104 degrees Fahrenheit with excessive sweating and flushed appearance. First aid should
include removal from activity, taking off all equipment
and placing the student-athlete in a cool, shaded environment. Fluids should be given orally. Core temperature and vital signs should be serially assessed. The
student-athlete should be cooled by ice immersion and
ice towels, and use of IV fluid replacement should be
determined by a physician. Although rapid recovery is
typical, student-athletes should not be allowed to
practice or compete for the remainder of that day.
tions, recreational drugs, or food. Examples
include antihistamines, decongestants, certain
asthma medications, Ritalin, diuretics and alcohol.
7. Medical conditions. Examples include illness
with fever, gastrointestinal illness, previous heat
illness, obesity or sickle cell trait.
8. Acclimatization/fitness level. Lack of acclimatization to the heat or poor conditioning.
9.Clothing. Dark clothing absorbs heat. Moisture
wicking-type material helps dissipate heat.
10. Protective equipment. Helmets, shoulder pads,
chest protectors, and thigh and leg pads interfere with sweat evaporation and increase heat
11.Limited knowledge of heat illness. Signs and
symptoms can include elevated core temperature, pale or flushed skin, profound weakness,
muscle cramping, rapid weak pulse, nausea, dizziness, excessive fatigue, fainting, confusion,
visual disturbances and others.
*NOTE: Stimulant drugs such as amphetamines, ecstasy,
ephedrine and caffeine are on the NCAA banned substance list and may be known by other names. A complete
list of banned drug classes can be found on the NCAA
website at
Exertional Heatstroke. Heatstroke is a medical emergency. Medical care should be obtained at once; a
delay in treatment can be fatal. This condition is characterized by a very high body temperature (104
degrees Fahrenheit or greater) and the student-athlete
likely will still be sweating profusely at the time of collapse, but may have hot, dry skin, which indicates failure of the primary temperature-regulating mechanism
(sweating), and CNS dysfunction (e.g., altered consciousness, seizure, coma). First aid includes activation
of the emergency action plan, assessment of core temperature/vital signs and immediate cooling of the body
with cold water immersion. Another method for cooling
includes using cold, wet ice towels on a rotating basis.
Student-athletes who incur heatstroke should be hospitalized and monitored carefully. The NATA’s InterAssociation Task Force recommends “cool first, transport second” in these situations (see reference No. 7).
2013-14 NCAA Sports Medicine Handbook
1. American College of Sports Medicine Position Stand: Exertional Heat
Illness During Training and Competition. Med: Sci Sport Exerc.
2. Armstrong LE, Maresh CM: The induction and decay of heat acclimatization in trained athletes. Sports Medicine 12(5):302-312, 1991.
3. Armstrong, LE: Performing in Extreme Environments. Champaign, IL:
Human Kinetics Publishers, p. 64, 2000.
4. Haynes EM, Wells CL: Heat stress and performance. In: Environment
and Human Performance. Champaign, IL: Human Kinetics Publishers,
pp. 13-41, 1986.
5. Hubbard RW and Armstrong LE: The heat illness: Biochemical,
ultrastructural and fluid-electrolyte considerations. In Pandolf KB,
Sawka MN and Gonzalez RR (eds): Human Performance Physiology
and Environmental Medicine at Terrestrial Extremes. Indianapolis, IN:
Benchmark Press, Inc., 1988.
6. Kulka TJ and Kenney WL: Heat balance limits in football uniforms. The
Physician and Sportsmedicine. 30(7): 29-39, 2002.
7. Inter-Association Task Force on Exertional Heat Illnesses Consensus
Statement. National Athletic Trainers’ Association, June 2003.
8. Casa DJ, Armstrong LE, Ganio MS, Yeargin SW. Exertional Heat
Stroke in Competitive Athletes. Current Sports Medicine Reports
2005, 4:309–317.
9. Casa DJ, McDermott BP, Lee EC, Yeargin SW, Armstrong LE, Maresh
CM. Cold Water Immersion: The Gold Standard for Exertional
Heatstroke Treatment. Exercise and Sport Sciences Reviews. 2007.
10.Casa DJ, Becker SM, Ganio MS, et al. Validity of Devices That Assess
Body Temperature During Outdoor Exercise in the Heat. Journal of
Athletic Training 2007; 42(3):333–342.
11.National Athletic Trainers’ Association Position Statement: Exertional
Heat Illnesses. Journal of Athletic Training 2002; 37(3):329–343.
12.American College of Sports Medicine Position Stand: Exercise and
Fluid Replacement. Med: Sci Sport Exerc. 2007; 384-86.
13.Ganio MS, Brown CM, Casa DJ, Becker SM, Yeargin SW, McDermott
BP, Boots LM, Boyd PW, Armstrong LE, Maresh CM. Validity and
reliability of devices that assess body temperature during indoor
exercise in the heat. J Athl Train. 2009;44(2):124–135.
14.Sunderland C, Morris JG, Nevill ME. A heat acclimation protocol for
team sports. Br J Sports Med. 2008; 42:327–333.
15.Yeargin SW, Casa DJ, Armstrong LE, Watson G, Judelson DA,
Psathas E, Sparrow, SL. Heat acclimatization and hydration status of
American football players during initial summer workouts. J Strength
Cond Res. 2006; 20:463–470.
16.Lopez RM, Casa DJ. The influence of nutritional ergogenic aids on
exercise heat tolerance and hydration status. Curr Sports Med Rep.
2009; 8:192–199.
Tips for student-athletes
and coaches
Conduct warm-ups in the shade.
Schedule frequent breaks.
Break in the shade.
Use fans for cooling.
Take extra time – at least three hours –
between two-a-day practices.
• Wear light-colored, moisture-wicking,
loose-fitting clothing.
• Increase recovery interval times between
exercise bouts and intervals.
Stay hydrated
• Drink before you are thirsty (20 ounces two
to three hours before exercise).
• Drink early (8 ounces every 15 minutes
during exercise).
• Replace fluids (20 ounces for every
pound lost).
• Lighter urine color is better.
• Incorporate sports drinks when possible.
• Avoid workouts during unusually hot temperatures by picking the right time of day.
• Progress your exercise time and intensity
slowly during a two-week period before
• Reduce multiple workout sessions; if multiple sessions are performed, take at least
three hours of recovery between them.
Coaches be prepared
• Use appropriate medical coverage.
• Have a cell phone on hand.
• Know your local emergency numbers and
program them in your phone.
• Report problems to medical staff
• Schedule breaks for hydration and cooling
(e.g., drinks, sponges, towels, tubs, fans).
• Provide ample recovery time in practice
and between practices.
• Monitor weight loss.
• Encourage adequate nutrition.
Weight Loss­-Dehydration
July 1985 • Revised June 2002
There are two general types of weight loss common to
student-athletes who participate in intercollegiate
sports: loss of body water or loss of body weight (fat
and lean tissue). Dehydration, the loss of body water,
leads to a state of negative water balance called dehydration. It is brought about by withholding fluids and
carbohydrates, the promotion of extensive sweating
and the use of emetics, diuretics or laxatives. The
problem is most evident in those who must be certified
to participate in a given weight class, but it also is
present in other athletics groups.
There is no valid reason for subjecting the student-athlete’s body to intentional dehydration, which can lead
to a variety of adverse physiological effects, including
significant pathology and even death. Dehydration in
excess of 3 to 5 percent leads to reduced strength and
muscular endurance, reduced plasma and blood
volume, compromised cardiac output (elevated heart
rate, smaller stroke volume), impaired thermoregulation, decreased kidney blood flow and filtration,
reduced liver glycogen stores and loss of electrolytes.
Pathological responses include life-threatening heat
illness, rhabdomyolysis (severe muscle breakdown),
kidney failure and cardiac arrest.
Medical Issues
appropriate competitive weight. Spot checks (body
composition or dehydration) should be used to ensure
compliance with the weight standard during the season.
Student-athletes and coaches should be informed of
the health consequences of dehydration, educated in
proper weight-loss procedures, and subject to disciplinary action when approved rules are violated.
1. American College of Sports Medicine, Position Stand: Weight Loss in
Wrestlers, 1995. (P.O. Box 1440, Indianapolis, IN 46206-1440).
2. Armstrong, LE. Performing in Extreme Environments. Champaign, IL:
Human Kinetics Publishers, pp. 15-70, 2000.
3. Horswill CA: Does Rapid Weight Loss by Dehydration Adversely
Affect High-Power Performance? 3(30), 1991. (Gatorade Sports
Science Institute, P.O. Box 9005, Chicago, IL 60604-9005).
4. Hyperthermia and Dehydration-Related Deaths Associated With
Intentional Rapid Weight Loss in Three Collegiate Wrestlers. Morbidity
and Mortality Weekly 47(6):105-108, 1998.
5. Sawka, MN (chair): Symposium—Current concepts concerning thirst,
dehydration, and fluid replacement. Medicine and Science in Sports
and Exercise 24(6):643-687, 1992.
With extensive dehydration, attempts at acute rehydration usually are insufficient for body fluid and electrolyte homeostasis to be restored before competition.
For example, in wrestling this is especially true
between the official weigh-in and actual competition.
All respected sports medicine authorities and organizations have condemned the practice of fluid deprivation.
To promote sound practices, student-athletes and
coaches should be educated about the physiological
and pathological consequences of dehydration. The use
of laxatives, emetics and diuretics should be prohibited.
Similarly, the use of excessive food and fluid restriction,
self-induced vomiting, vapor-impermeable suits (e.g.,
rubber or rubberized nylon), hot rooms, hot boxes and
steam rooms should be prohibited. Excessive food
restriction or self-induced vomiting may be symptoms
of serious eating disorders (see Guideline 2F).
Dehydration is a potential health hazard that acts with
poor nutrition and intense exercise to compromise
health and athletic performance. The sensible alternative to dehydration weight loss involves preseason
determination of an acceptable (minimum) competitive
weight, gradual weight loss to achieve the desired
weight, and maintenance of the weight during the
course of the competitive season. Standard body composition procedures should be used to determine the
2013-14 NCAA Sports Medicine Handbook
Assessment of
Body Composition
June 1991 • Revised June 2002
The NCAA Committee on Competitive Safeguards and
Medical Aspects of Sports acknowledges the significant input of Dr. Dan Benardot, Georgia State
University, who authored a revision of this guideline.
Athletic performance is, to a great degree, dependent
on the ability of the student-athlete to overcome resistance and to sustain aerobic and/or anaerobic power.
Both of these elements of performance have important
training and nutritional components and are, to a large
degree, influenced by the student-athlete’s body composition. Coupled with the common perception of
many student-athletes who compete in sports in which
appearance is a concern (swimming, diving, gymnastics, skating, etc.), attainment of an “ideal” body composition often becomes a central theme of training.
Successful student-athletes achieve a body composition that is within a range associated with performance
achievement in their specific sport. Each sport has different norms for the muscle and fat levels associated
with a given height, and the student-athlete’s natural
genetic predisposition for a certain body composition
may encourage him or her to participate in a particular
sport or take a specific position within a sport. For
instance, linemen on football teams have different
responsibilities than receivers, and this difference is
manifested in physiques that are also different.
Besides the aesthetic and performance reasons for
wanting to achieve an optimal body composition, there
may also be safety reasons. A student-athlete who is carrying excess weight may be more prone to injury when
performing difficult skills than the student-athlete with a
more optimal body composition. However, the means
student-athletes often use in an attempt to achieve an
optimal body composition may be counterproductive.
Diets and excessive training often result in such a severe
energy deficit that, while total weight may be reduced,
the constituents of weight also change, commonly with a
lower muscle mass and a relatively higher fat mass. The
resulting higher body fat percentage and lower muscle
mass inevitably result in a performance reduction that
motivates the student-athlete to follow regimens that
produce even greater energy deficits. This downward
energy intake spiral may be the precursor to eating disorders that place the student-athlete at serious health risk.
Therefore, while achieving an optimal body composition
is useful for high-level athletic performance, the processes student-athletes often use to attain an optimal body
composition may reduce athletic performance, may place
them at a higher injury risk and may increase health risks.
Purpose of Body Composition Assessment
The purpose of body composition assessment is to
determine the student-athlete’s distribution of lean
(muscle) mass and fat mass. A high lean mass to fat
mass ratio is often synonymous with a high strength to
weight ratio, which is typically associated with athletic
success. However, there is no single ideal body composition for all student-athletes in all sports. Each sport
has a range of lean mass and fat mass associated with
it, and each student-athlete in a sport has an individual
range that is ideal for him or her. Student-athletes who
try to achieve an arbitrary body composition that is not
right for them are likely to place themselves at health
risk and will not achieve the performance benefits they
seek. Therefore, a key to body composition assessment is the establishment of an acceptable range of
lean and fat mass for the individual student-athlete,
and the monitoring of lean and fat mass over regular
time intervals to assure a stability or growth of the lean
mass and a proportional maintenance or reduction of
the fat mass. Importantly, there should be just as much
attention given to changes in lean mass (both in weight
of lean mass and proportion of lean mass) as the attention traditionally given to body fat percent.
In the absence of published standards for a sport, one
strategy for determining if a student-athlete is within
the body composition standards for the sport is to
obtain a body fat percent value for each student-athlete on a team (using the same method of assessment), and obtaining an average and standard deviation for body fat percent for the team. Student-athletes
who are within 1 standard deviation (i.e., a Z-score of
± 1) of the team mean should be considered within the
range for the sport. Those greater than or less than ±
1 standard deviation should be evaluated to determine
the appropriateness of their training schedule and
nutrient intake. In addition, it is important for coaches
and student-athletes to use functional performance
measures in determining the appropriateness of a student-athlete’s body composition. Student-athletes
outside the normal range of body fat percent for the
sport may have achieved an optimal body composition
for their genetic makeup, and may have objective performance measures (e.g., jump height) that are well
within the range of others on the team.
Body composition can be measured indirectly by
several methods, including hydrostatic weighing, skinfold and girth measurements (applied to a nomogram
or prediction equation), bioelectrical impedance analysis (BIA), dual-energy X-ray absorptiometry (DEXA),
Medical Issues
ultrasound, computerized tomography, magnetic-resonance imagery, isotope dilution, neutron-activation
analysis, potassium-40 counting and infrared interactance. The most common of the methods now used to
assess body composition in student-athletes are skinfold measurements, DEXA, hydrostatic weighing and
BIA. While hydrostatic weighing and DEXA are considered by many to be the “gold standards” of the indirect measurement techniques, there are still questions
regarding the validity of these techniques when
applied to humans. Since skinfold-based prediction
equations typically use hydrostatic weighing or DEXA
as the criterion methods, results from skinfolds typically carry the prediction errors of the criterion
methods plus the added measurement errors associated with obtaining skinfold values. BIA has become
popular because of its noninvasiveness and speed of
measurement, but results from this technique are influenced by hydration state. Since student-athletes have
hydration states that are in constant flux, BIA results
may be misleading unless strict hydration protocols
are followed. In general, all of the commonly used
techniques should be viewed as providing only estimates of body composition, and since these techniques use different theoretical assumptions in their
prediction of body composition, values obtained from
one technique should not be compared with values
obtained from another technique.
Concerns With Body
Composition Assessment
1.Using Weight as a Marker of Body Composition.
While the collection of weight data is a necessary
adjunct to body composition assessment, by itself
weight may be a misleading value. For instance,
young student-athletes have the expectation of
growth and increasing weight, so gradual increases
in weight should not be interpreted as a body composition problem. A student-athlete who has
increased resistance training to improve strength
may also have a higher weight, but since this
increased weight is likely to result from more
muscle, this should be viewed as a positive
change. The important consideration for weight is
that it can be (and often is) misused as a measure
of body composition, and this misuse can detract
from the purpose of body composition assessment.
2. Comparing Body Composition Values With
Other Athletes. Student-athletes often compare
body composition values with other student-athletes, but this comparison is not meaningful and
may drive a student-athlete to change body composition in a way that negatively impacts both performance and health. Health professionals
involved in obtaining body composition data
should be sensitive to the confidentiality of this
information, and explain to each student-athlete
that differences in height, age and gender are
likely to result in differences in body composition,
without necessarily any differences in performance. Strategies for achieving this include:
• Obtaining body composition values with only
one student-athlete at a time, to limit the
chance that the data will be shared.
• Giving student-athletes information on body
composition using phrases such as “within the
desirable range” rather than a raw value, such
as saying “your body fat level is 18 percent.”
• Providing athletes with information on how
they have changed between assessments,
rather than offering the current value.
• Increasing the focus on muscle mass, and
decreasing the focus on body fat.
• Using body composition values as a means of
helping to explain changes in objectively measured performance outcomes.
3. Seeking an Arbitrarily Low Level of Body Fat.
Most student-athletes would like their body fat
level to be as low as possible. However, studentathletes often try to seek a body fat level that is
2013-14 NCAA Sports Medicine Handbook
arbitrarily low, and this can increase the frequency
of illness, increase the risk of injury, lengthen the
time the student-athlete can return to training after
an injury, reduce performance and increase the
risk of an eating disorder. Body composition
values should be thought of as numbers on a continuum that are usual for a sport. If a student-athlete falls anywhere on that continuum, it is likely
that factors other than body composition (training,
skills acquisition, etc.) will be the major predictors
of performance success.
4. Frequency of Body Composition Assessment.
Student-athletes who have frequent weight and/or
skinfolds taken are fearful of the outcome, since
the results are often (inappropriately) used punitively. Real changes in body composition occur
slowly, so there is little need to assess student-athletes weekly, biweekly or even monthly. If body
composition measurements are sufficient and
agreed upon by all parties, measurement frequency
of twice a year should be sufficient. In some isolated circumstances in which a student-athlete has
been injured or is suffering from a disease state, it
is reasonable for a physician to recommend a more
frequent assessment rate to control for changes in
lean mass. Student-athletes and/or coaches who
desire more frequent body composition or weight
measurement should shift their focus to assessments of objective performance-related measures.
The assessment of body composition can be a useful
tool in helping the student-athlete and coach understand the changes that are occurring as a result of
training and nutritional factors. However, the body
composition measurement process and the values
obtained can be a sensitive issue for the student-athlete. A legitimate purpose for body composition
assessment should dictate the use of these measurement techniques. Health professionals involved in
obtaining body composition data should focus on
using the same technique with the same prediction
equations to derive valid comparative data over time.
Institutions should have a protocol in place outlining
the rationale for body composition measurements, who
is allowed to measure the student-athlete, who is permitted to discuss the results with the student-athlete
and what frequency of body composition measurement
is appropriate. The student-athlete should not feel
forced or obligated to undergo body composition or
weight measurement.
Optimal Body Composition
For each student-athlete, there may be a unique
optimal body composition for performance, for
health and for self-esteem. However, in most
cases, these three values are NOT identical.
Mental and physical health should not be sacrificed for performance. An erratic or lost menstrual cycle, sluggishness or an obsession with
achieving a number on a scale may be a signs
that health is being challenged.
Everyone involved directly or indirectly with body composition measurement should understand that inappropriate measurement and use of body composition data
might contribute to the student-athlete experiencing
unhealthy emotional stress. This stress can lead to the
development or enhancement of eating disorders in the
student-athlete (see Guideline 2F). All coaches (sport or
strength/conditioning) should be aware of the sizable
influence they may have on the behaviors and actions of
their student-athletes. Many student-athletes are sensitive about body fat, so care should be taken to apply
body composition measurement, when appropriate, in a
way that enhances the student-athlete’s well-being.
1. Benardot D: Working with young athletes: Views of a nutritionist on
the sports medicine team. Int. J. Sport Nutr. 6(2):110-120, 1996.
2. Boileau RA and Lohman TG. The measurement of human physique
and its effect on physical performance. Orthopedic Clin. N. Am.
3. Clarkson PM. Nutritional supplements for weight gain. Sports
Science Exchange SSE#68(11): 1-18, 1998.
4. Clasey JL, Kanaley JA, Wideman L, Heymsfield SB, Teates CD,
Gutgesell ME, Thorner MO, Hartman ML, and Weltman A. Validity of
Medical Issues
methods of body composition assessment in young and older men
and women. J. Appl. Physiol. 86(5):1728-38, 1999.
5. Fleck SJ. Body composition of elite American athletes. Am. J. Sports
Med. 11:398-403, 1983.
6. Heymsfield SB and Want Z. Measurement of total-body fat by
underwater weighing: new insights and uses for old method. Nutrition
9:472-473, 1993.
7. Houtkooper LB and Going SB. Body composition: How should it be
measured? Does it affect sport performance? Sports Science
Exchange SSE#52(7):1-15, 1994.
8. Houtkooper LB, Going SB, Lohman TG, Roche AF, and Van Loan M.
Bioelectrical impedance estimation of fat-free body mass in children and
youth: a cross-validation study. J. Appl. Physiol. 72:366-373, 1992.
9. Jackson AS and Pollock ML. Generalized equations for predicting
body density in men. Br. J. Nutr. 40:497-504, 1978.
10.Jackson AS, Pollock ML, and Ward A. Generalized equations for
predicting body density of women. Med. Sci. Sports Exerc. 12:175182, 1980.
11.Lukaski HC. Methods for the assessment of human body
composition—traditional and new. Am. J. Clin. Nutr. 46:537-56, 1987.
12.Malina RM and Bouchard C. Characteristics of young athletes. In:
Growth, Maturation and Physical Activity. Champaign, IL: Human
Kinetics Books, pp. 443-463, 1991.
13.Manore M, Benardot D, and Love P. Body measurements. In:
Benardot D (Ed). Sports Nutrition: A Guide for Professionals Working
With Active People. Chicago, IL: American Dietetic Association, pp.
70-93, 1993.
14.Melby CL and Hill JO. Exercise, macronutrient balance, and body
weight regulation. Sports Science Exchange SSE#72(12): 1-16, 1999.
15.Thomas BJ, Cornish BH, Ward LC, and Jacobs A. Bioimpedance: is it a
predictor of true water volume? Ann. N.Y. Acad. Sci. 873:89-93, 1999.
2013-14 NCAA Sports Medicine Handbook
Nutrition and
Athletic Performance
January 1986 • Revised June 2002, May 2009, 2013
Athletic performance and recovery from training are
enhanced by attention to nutrient intake. Optimal nutrition for health and performance includes the identification of both the quantity and quality of food and fluids
needed to support regular training and peak performance. As training demands shift during the year, athletes need to adjust their caloric intake and macronutrient distribution while maintaining a high nutrientdense diet that supports their training and competition
nutrient needs. The following key points summarize the
impacts of training on energy, nutrient and fluid recommendations for competitive student-athletes as recommended by the American College of Sports Medicine
(ACSM) and the Academy of Nutrition and Dietetics.
It is helpful to think of collegiate
athletes’ training year as including
three phases: base, competition
and transition. During base training when training volume is high
(practices are longer and/or more
frequent), athletes’ energy needs
are at their highest. A high-quality
nutritional plan is key during this
phase. Base training is also the
best phase to experiment with and
define event fueling and hydration
strategies that can be continued
throughout the year.
glycogen stores and to prevent low blood sugar
(hypoglycemia) during training. Carbohydrate intake
has been well documented to have a positive impact
on adaptation to training, performance and improved
immune function.
During base training, a daily intake of 6 to 10 grams of
carbohydrate per kilogram of body weight per day is
advised. As training intensity and/or volume increase,
carbohydrate need may easily exceed 10 grams of
carbohydrates per kilogram of body weight. Athletes
should begin to think about fueling for their next athletics activity immediately after the one they just completed. Recovery carbohydrates, to replace glycogen
stores, can be calculated based on
1 to 1.5 grams of carbohydrates
per kilogram of body weight and
should be consumed immediately
after training sessions. Within two
hours after training, additional carbohydrates will help continue glycogen repletion.
The U.S. Dietary Guidelines and
experts in performance nutrition
recommend that athletes focus their
food choices on less-refined types
of carbohydrates, as these contain
essential micronutrients vital to
health and performance. Whole
grain breads and pasta, whole fruits and vegetables
The competition phase usually reflects a decrease in
are excellent sources of high-quality carbohydrates.
training volume, and perhaps high-intensity training
sessions with extended periods of tapering leading up
Protein requirements are slightly higher in both
to competition and travel. During the competition
phase, athletes should adjust calorie and macronutrient endurance (1.2 to 1.4 grams per kilogram body weight)
and strength-training student-athletes (1.6 to 1.7 grams
intake to prevent unwanted weight gain. They should
per kilogram body weight), above the typical recomlearn how to eat before competition, how to eat while
mended daily intake (0.8 grams per kilogram body
traveling and how to adjust fluid needs based on enviweight). Recommendations include ingesting a snack
ronmental impacts. Athletes who consume a balanced
rich in carbohydrates with 10-20 grams of protein within
diet will likely exhibit the best performance and experi30 minutes after a training session for effectiveness.
ence less illness during the competition phase.
Fortunately, the higher intakes recommended for
athletes are easily achieved in a well-balanced diet
The transition (recovery) phase, during which athletes’
training volume and intensity are at their lowest, requires without the use of additional supplements.
some attention to the prevention of unwanted changes
Fat intake is an important source of essential fatty
in body weight (increased body fat or decreased muscle
acids and carrier for fat-soluble vitamins necessary for
mass). During this phase, athletes may need to
optimal physiological immune function. During prodecrease total calorie intake and resist overindulging
longed, lower-intensity training, fats are a major energy
while still maintaining a nutrient-dense diet.
contributor and are stored in muscle as triglyceride for
Carbohydrates, the primary fuel for higher intensity use during activity. Dietary fat intake is suggested to
be from 20 to 35 percent of total daily caloric intake.
activity, are required to replenish liver and muscle
Diets low in fat can negatively impact training, nutrient
density of the diet and the ability to consistently
improve performance.
In general, vitamin and mineral supplements are not
required if a student-athlete is consuming adequate
energy from a variety of foods to maintain body
weight. However, the risk of micronutrient deficiencies is
greatest in student-athletes who are restricting calories,
engaging in rapid weight-loss practices or eliminating
specific foods or food groups from their diet. A multivitamin providing not more than 100 percent of the daily recommended intake can be considered for these studentathletes. Female student-athletes are especially prone to
deficiencies in calcium and iron due to the impacts of
regular menstrual cycles. The diets and iron status of
endurance athletes and vegetarians (especially females)
should be evaluated. However, megadoses of specific
vitamins or minerals (10 to 100 times the Recommended
Dietary Allowances) are not recommended.
Hydration status affects health and performance.
Athletes should consume fluids throughout their day
(water, low-fat milk, 100 percent fruit juices) and
before, during and after training.
Fluids containing electrolytes and carbohydrates are a
good source of fuel and rehydration for exercise lasting
longer than 60 minutes. Fluids (e.g., energy drinks) containing questionable supplement ingredients and high
levels of caffeine or other stimulants (e.g. 500 milligrams)
may be detrimental to the health of the competitive
athlete and are not effective forms of fuel or hydration.
Adequate overall energy intake throughout the day is
important for all student-athletes. Insufficient energy
intakes (due to skipped meals or dieting) will have a
Medical Issues
Fact sheets from the Sport Science
Institute available online at
rapid negative impact on training and performance,
and over time, on bone, immune function and injury
risk. Inadequate energy intake increases fatigue,
depletes muscle glycogen stores, increases the risk of
dehydration, decreases immune function, increases
the risk of injury and can result in unwanted loss of
muscle mass. A low caloric intake in female studentathletes can lead to menstrual dysfunction and
decreased bone mineral density.
The maintenance or attainment of an ideal body weight
is sport-specific and represents an important part of a
nutritional program. However, student-athletes in certain
sports face a difficult paradox in their training/nutrition
regimen, particularly those competing in “weight class”
sports (e.g., wrestling, rowing), sports that favor those
with lower body weight (e.g., distance running, gymnastics), sports requiring student-athletes to wear body
contour-revealing clothing (track, diving, swimming, volleyball) and sports with subjective judging related to
“aesthetics” (gymnastics, diving). These student-athletes are encouraged to eat to provide the necessary
fuel for performance, yet they often face self- or teamimposed weight restrictions. Emphasis on low body
weight or low body fat may benefit performance only if
the guidelines are realistic, the calorie intake is reasonable and the diet is nutritionally balanced.
The use of extreme weight-control measures can jeopardize the health of the student-athlete and possibly
trigger behaviors associated with disordered eating.
NCAA studies have shown that at least 40 percent of
member institutions reported at least one case of
anorexia nervosa or bulimia nervosa in their athletics
programs. Once identified, these individuals should be
referred for interdisciplinary medical care (medical,
psychological, sports dietetics).
2013-14 NCAA Sports Medicine Handbook
A more prevalent issue is the large number of subclinical or chronically dieting athletes. Departmentwide efforts to educate staff and student-athletes
should include addressing the negative impacts of
under-fueling and weight/food preoccupation on the
athletes’ performance and overall well-being. Although
disordered eating is much more prevalent in women
(approximately 90 percent of the reports in NCAA
studies were in women’s sports), disordered eating
also occurs in men. Female athletes who miss three or
more menstrual cycles in a year, are preoccupied with
weight, experience rapid changes in body weight,
avoid eating with others, or are over-focused on
shape and food are exhibiting warning signs worth
addressing for health reasons. The medical examination and updated health history (Bylaw 17.1.5) is an
opportunity to assess athletes for these risk factors
and refer them to appropriate professionals for further
evaluation and diagnosis.
Disordered eating is often an expression of underlying
emotional distress that may have developed long
before the individual was involved in athletics.
Disordered eating can be triggered in psychologically
vulnerable individuals by a single event or comments
(such as offhand remarks about appearance, or constant badgering about a student-athlete’s body
weight, body composition or body type) from a
person important to the individual. Coaches, athletic
trainers, sport dietitians and supervising physicians
must be watchful for student-athletes at higher risk
for eating disorders. Disordered eating can lead to
dehydration, resulting in loss of muscular strength
and endurance, decreased aerobic and anaerobic
power, loss of coordination, impaired judgment, and
other complications that decrease performance and
impair health. These symptoms may be readily apparent or may not be evident for an extended period of
time. Many student-athletes have performed successfully while experiencing an eating disorder. Therefore,
diagnosis of this problem should
not be based entirely on a
decrease in athletic performance.
Body composition and body weight
can affect exercise performance but
should not be used as the main criteria for participation in sports.
Decisions regarding weight loss
should be based on the following
recommendations to reduce the risk
of disordered eating:
1. Frequent weigh-ins (either as a team or individually) are discouraged unless part of strategies to
determine sweat loss as outlined in Guideline 2C.
2. Weight loss (fat loss) should be addressed during
base or transition phases.
3. Weight-loss goals should be determined by the
student-athlete, sports dietitian and medical staff
with consultation from the coach.
4.Weight-loss plans should be individualized, realistic and preferably designed by a board certified
specialist in sports dietetics (CSSD).
For each student-athlete, there may be a unique optimal
body composition for performance, for health and for
self-esteem. However, in most cases, these three values
are NOT identical. Mental and physical health should
not be sacrificed for performance. An erratic or lost
menstrual cycle, sluggishness or an obsession with
achieving a number on a scale may be signs that a student-athlete’s health is being challenged.
1. Nutrition and Athletic Performance. American College of Sports
Medicine, American Dietetic Association, and Dietitians of Canada,
Joint Position Stand, Medicine and Science in Sports and Exercise.
109:3:509-527, March 2009
2. The Female Athlete Triad. American College of Sports Medicine
(ACSM) Position Stand, Medicine and Science in Sports and
Exercise, 39:10: 1-10 2007.
3. Exercise and Fluid Requirements. American College of Sports
Medicine (ACSM) Position Stand. 2007
4. Brownell KD, Rodin J, Wilmore JH: Eating, Body Weight, and
Performance in Athletes: Disorders of Modern Society Malvern, PA:
Lea and Febiger, 1992.
5. Dale, KS, Landers DM. Weight control in wrestling: eating disorders or
disordered eating? Medicine and Science in Sports and Exercise
31:1382-1389, 1999.
6. Dick RW: Eating disorders in NCAA athletics
programs. Athletic Training 26:136-140, 1991.
7. Sandborn CF, Horea M, Siemers BJ, Dieringer KI.
Disordered eating and the female athlete triad. Clinics
in Sports Medicine:19:199-213, 2000.
Available online at
Dietary Supplements
January 1990 • Revised June 2004, June 2009
Nutritional and dietary supplements are marketed to
student-athletes to improve performance, recovery time
and muscle-building capability. Many student-athletes
use nutritional supplements despite the lack of proof of
effectiveness. In addition, such substances are expensive and may potentially be harmful to health or performance. Of greater concern is the lack of regulation and
safety in the manufacture of dietary supplements. Most
compounds obtained from specialty “nutrition” stores
and mail-order businesses are not subject to the strict
regulations set by the U.S. Food and Drug
Administration. Therefore, the contents of many of
these compounds are not represented accurately on
the list of ingredients and may contain impurities or
banned substances, which may cause a student-athlete
to test positive. Positive drug-test appeals based on
the claim that the student-athletes did not know the
substances they were taking contained banned drugs
have not been successful. Student-athletes should be
instructed to consult with the institution’s sports medicine staff before taking ANY nutritional supplement.
Reference NCAA Banned Drug Classes in Appendix A.
Member institutions are restricted in the providing of
nutritional supplements – see NCAA bylaws for divisional regulations.
It is well known that a high-carbohydrate diet is associated with improved performance and enhanced ability to
train. Carbohydrates in the form of glycogen are the
body’s main fuel for high-intensity activity. A large
number of student-athletes only consume 40 to 50
percent of their total calories from carbohydrates, versus
the recommended 55 to 65 percent for most people
(about 5 to 10 grams per kilogram of body weight). The
lower end of the range should be ingested during
regular training; the high end during intense training.
High-carbohydrate foods and beverages can provide
the necessary amount of carbohydrates for the high
caloric demand of most sports to optimize performance. Low-carbohydrate diets are not advantageous
for athletes during intense training and could result in
a significantly reduced ability to perform or train by the
end of an intense week of training. When the levels of
carbohydrates are reduced, exercise intensity and
length of activity decreases, and fatigue rapidly
increases. A high-carbohydrate diet consisting of
complex carbohydrates, fruits, vegetables, low-fat
dairy products and whole grains (along with adequate
protein) is the optimal diet for peak performance. (See
Guideline 2F, Nutrition and Athletic Performance.)
Medical Issues
Resource Exchange Center
The NCAA subscribes to the Resource Exchange
Center (REC). The REC (
rec) provides accurate information on performance-enhancing drugs, dietary supplements,
medications, new ingredients and validity of
product claims, and whether a substance is
banned by the NCAA. This service is provided 24
hours a day via a password-protected website
for all NCAA member schools and their studentathletes and athletics personnel. To access the
REC, go to The
password is ncaa1, ncaa2 or ncaa3, depending
on your divisional classification.
Protein and amino acid supplements are popular with
bodybuilders and strength-training student-athletes.
Although protein is needed to repair and build muscles
after strenuous training, most studies have shown that
student-athletes ingest a sufficient amount without
supplements. The recommended amount of protein in
the diet should be 12 to 15 percent of total energy
intake (about 1.4 to 1.6 grams per kilogram of body
weight) for all types of student-athletes. Athlete should
consider eating a post-workout carbohydrate snack
that contains protein within one hour of concluding
that vigorous exercise session. Although selected
amino acid supplements are purported to increase the
production of anabolic hormones, studies using manufacturer-recommended amounts have not found
increases in growth hormone or muscle mass.
Ingesting high amounts of single amino acids is contraindicated because they can affect the absorption of
other essential amino acids, produce nausea, and/or
impair kidney function and hydration status.
Other commonly advertised supplements are vitamins
and minerals. Most scientific evidence shows that
selected vitamins and minerals will not enhance performance provided no deficiency exists. Some vitamins
and minerals are marketed to student-athletes for other
benefits. For example, the antioxidants, vitamins E and
C, and beta carotene, are used by many student-athletes because they believe that these antioxidants will
protect them from the damaging effects of aerobic exercise. Although such exercise can cause muscle damage,
studies have found that training will increase the body’s
natural antioxidant defense system so that megadoses
of antioxidants may not be needed. Supplementation in
2013-14 NCAA Sports Medicine Handbook
high dosages of antioxidants, such as vitamins E and C,
and beta carotene, could disrupt the normal balance of
these compounds and the balance of free radicals in the
body and cause more harm than good. (American
Council on Science and Health)
The mineral chromium has been suggested to increase
muscle mass and decrease fat; these claims have little,
if any, credible support. In fact, the Federal Trade
Commission has declared such claims to be unsubstantiated and deceptive. Similarly, magnesium is purported, but not proven, to prevent cramps. To obtain
necessary vitamins and minerals, student-athletes
should eat a wide variety of foods because not all vitamins and minerals are found in every food.
Other substances naturally occurring in foods, such as
carnitine, herbal extracts and special enzyme formulations, do not provide any benefit to performance. The
main source of energy for the muscle during exercise
will come from carbohydrate rich foods. The high-protein diet has received recent attention, but data
showing that this diet will enhance performance are
weak. High-protein diets are discouraged by most
nutrition experts due to increased stress placed on the
kidneys. Mild to severe stomach cramping and diar-
rhea, dehydration and gout have been associated with
use of certain amino acid supplements.
Creatine has been found in some laboratory studies to
enhance short-term, high-intensity exercise capability,
delay fatigue on repeated bouts of such exercise and
increase strength. Several studies have contradicted
these claims, and, moreover, the safety of creatine
supplements has not been verified. Weight gains of 1
to 3 kilograms per week have been found in creatine
users, but the cause is unclear.
Many other “high-tech” nutritional or dietary supplements may seem to be effective at first, but this is
likely a placebo effect — if student-athletes believe
these substances will enhance performance, they
may train harder or work more efficiently. Ultimately,
most nutritional supplements are ineffective, costly
and unnecessary.
Student-athletes should be aware that nutritional supplements are not limited to pills and powders; “energy”
drinks that contain stimulants are popular. Many of
these contain large amounts of either caffeine (e.g. 500
milligrams) or other stimulants, both of which can
result in a positive drug test. Student-athletes should
be wary of drinks that promise an “energy boost,”
because they may contain banned stimulants. In addition, the use of stimulants while exercising can
increase the risk of heat illness.
Student-athletes should be provided accurate and
sound information on nutritional supplements. It is not
worth risking eligibility for products that have not been
scientifically proven to improve performance and may
contain banned substances. Member institutions
should review NCAA Bylaw 16.5.2, educational
The danger of supplements
Nutritional/dietary supplements may contain NCAA
banned substances. The U.S. Food and Drug
Administration does not strictly regulate the supplement industry; therefore, purity and safety of nutritional/dietary supplements cannot be guaranteed.
Impure supplements may lead to a positive NCAA
drug test. The use of supplements is at the studentathlete’s own risk. Student-athletes should contact
their institution’s team physician or athletic trainer
for further information.
Medical Issues
columns and interpretations for guidance on restrictions on providing supplements to student-athletes.
Institutions should designate an individual (or individuals) as the athletics department resource for questions
related to NCAA banned drugs and the use of nutritional supplements. In addition, institutions should
educate athletics department staff members who have
regular interaction with student-athletes that the NCAA
maintains a list of banned drug classes and provides
examples of banned substances in each drug class on
the NCAA website; any nutritional supplement use may
present risks to a student-athlete’s health and eligibility; and questions regarding NCAA banned drugs and
the use of nutritional supplements should be referred
to the institution’s designated department resource
individual (or individuals). See Appendix B for Division I
legislative requirements.
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Sciences 13:S83-90, 1995.
2. Clarkson PM, Haymes EM: Trace Mineral Requirements for Athletes.
International Journal of Sport Nutrition 4:104-19, 1994.
3. Clarkson PM: Micronutrients and exercise: Antioxidants and
minerals. Journal of Sports Sciences 12:S11-24, 1995.
4. American College of Sports Medicine. The physiological and health
effects of oral creatine supplementation. Medicine and Science in
Sports and Exercise. 32 (3): 706-717, 2000.
5. Lemon PWR: Do athletes need more dietary protein and amino
acids? International Journal of Sport Nutrition 5:S39-61, 1995.
6. Volek JS, Kraemer WJ: Creatine supplementation: Its effect on
human muscular performance and body composition. Journal of
National Strength and Conditioning Research 10:200-10, 1996.
7. Williams C: Macronutrients and performance. Journal of Sports
Sciences 13:S1-10, 1995.
8. The National Center for Drug Free Sport, Inc., 810 Baltimore, Suite
200, Kansas City, Missouri. 64105; 816/474-8655.
9. ACSM JOINT POSITION STATEMENT, Nutrition and Athletic
Performance, 2000. Available at
10. Nutritional Supplements, The NCAA News, April 15, 2005.
11. IOC study, 2001.
12. HFL study, 2007.
2013-14 NCAA Sports Medicine Handbook
(Brachial Plexus Injuries)
June 1994 • Revised June 2003
“Burners” or “stingers” are so named because the injuries can cause a sudden pain and numbness along the
forearm and hand. The more formal medical terminology is transient brachial plexopathy or an injury to the
brachial plexus. A brachial plexus injury may also
involve injury to a cervical root. An injury to the spinal
cord itself is more serious and frequently does not fall
under this category of injury, although it shares certain
symptoms; therefore, spinal cord injuries should be
ruled out when diagnosing stingers.
The majority of stingers occur in football. Such injuries
have been reported in 52 percent of college football
players during a single season. As many as 70 percent
of college football players have experienced stingers.
Stingers also can occur in a variety of other sports,
including basketball, ice hockey, wrestling and some
field events in track.
The most common mechanism for stingers is head
movement in an opposite direction from the shoulder
either from a hit to the head or downward traction of
the shoulder, although foramen encroachment may
also be a cause of symptoms. This can stretch the
nerve roots on the side receiving the blow (traction), or
compress or pinch those on the opposite side. Contact
to the side of the neck may cause a direct contusion
to the brachial plexus. In football, improper blocking
and tackling techniques may result in a brachial plexus
injury. Coaches, parents and student-athletes should
be cautioned regarding the consequences of improper
techniques, which may result in cervical spine injuries
or trauma to the brachial plexus.
Symptoms and Severity
Student-athletes who suffer burners may be unable to
move the affected arm from their side and will complain of burning pain, and potentially, numbness traveling from the injured side of the neck through the shoulder down the arm and forehand, and sometimes into
the hand. Weakness may be present in the muscles of
the shoulder, elbow and hand.
Brachial plexus injuries can be classified into three
categories. The mildest form (Grade 1) are neuropraxic
injuries that involve demyelination of the axon sheath
without intrinsic axonal disruption. Complete recovery
typically occurs in a few seconds to days. Grade 1
injuries are the most common in athletics. Grade 2
injuries involve axonotmesis, or disruption of the axon
and myelin sheath, with preservation of the epineuri-
um, perineurium and endoneurium, which can serve as
the conduit for the regenerating axon as it re-grows at
1 to 7 millimeters per day. Weakness can last for
weeks, but full recovery typically occurs. Grade 3 injuries, neurotmesis, or complete nerve transections, are
rare in athletes. Surgical repair of the nerve is required
in these cases, and complete recovery may not occur.
These classifications have more meaning with regard
to anticipated recovery of function than a grading on
the severity of symptoms at the time of initial injury.
Treatment and Return to Play
Burners and stingers typically result in symptoms that
are sensory in nature, frequently involving the C5 and
C6 dermatomes. All athletes sustaining burners
should be removed from competition and examined
thoroughly for injury to the cervical spine and shoulder. All cervical roots should be assessed for motor
and sensory function. If symptoms clear within
seconds to several minutes and are not associated
with any neck pain, limitation of neck movement or
signs of shoulder subluxation or dislocation, the
athlete can safely return to competition. It is important
to re-examine the athlete after the game and for a few
successive days to detect any reoccurrence of weakness or alteration in sensory exam.
If sensory complaints or weakness persists for more
than a few minutes, a full medical evaluation with radiographs and consideration for an MRI should be done to
rule out cervical disk or other compressive pathology. If
symptoms persist for more than two to three weeks, an
EMG may be helpful in assessing the extent of injury.
However, an EMG should not be used for return-to-play
criteria, as EMG will not show positive findings until at
least two weeks after the nerve injury and those nerve
changes may persist for several years after the symptoms have resolved. Shoulder injuries (acromioclavicular separation, shoulder subluxation or dislocation, and
clavicular fractures) should be considered in the differential diagnosis of the athlete with transient or prolonged neurologic symptoms of the upper extremity.
Any injured athlete who presents with specific cervicalpoint tenderness, neck stiffness, bony deformity, fear of
moving his/her head and/or complains of a heavy head
should be immobilized on a spine board (as one would
for a cervical spine fracture) and transported to a
medical facility for a more thorough evaluation.
Bilateral symptoms indicate that the cord itself has
been traumatized and may suggested transient
Medical Issues
quadriplegia. These athletes should also be immobilized and transported to a medical facility for a more
thorough evaluation.
All athletes sustaining burners or stingers should
undergo a physical rehabilitation program that includes
neck and trunk strengthening exercises. The fit of
shoulder pads should be re-checked, and consideration of other athletic protective equipment, such as
neck rolls and/or collars, should be given. The athlete’s
tackling techniques should be reviewed.
Stinger assessment should be part of the student-athletes’ preseason physical and mental history (see
Guideline 1C) so that these “at-risk” athletes can be
instructed in a preventative exercise program and be
provided with proper protective equipment.
Recurrent Burners
Recurrent burners may be common; 87 percent of
athletes in one study had experienced more than one.
Medical personnel should pay special attention to this
condition. Although rare, risk of permanent nerve
injury exists for those with recurrent burners.
Therefore, participants should report every occurrence
to their certified athletic trainers or team physician.
Any player with persistent pain, burning, numbness
and/or weakness (lasting longer than two minutes)
should be held out of competition and referred to a
physician for further evaluation.
A Word of Caution
Management of the student-athlete with recurrent
burners can be difficult. There are no clear guidelines
concerning return to play. However, at-risk studentathletes are those who have: 1) narrow cervical
foramen or 2) poor neck and should muscular stabilization. Although some risk of permanent nerve injury
exists, a review of the literature shows this risk to be
small for those with recurrent episodes. The most
important concern for student-athletes with recurrent
burners is to stress the importance of reporting all
symptoms to the attending medical personnel so that
a thorough physical examination, with particular attention to strength and sensory changes, can be
obtained. Any worsening of symptoms should provoke
a more thorough evaluation.
1. Meyer S, Schulte K, et al: Cervical Spinal Stenosis and Stingers in
Collegiate Football Players. American Journal of Sports Medicine
22(2):158-166, 1994.
2. Torg J, et al: Cervical Cord Neuropraxia: Classification
Pathomechanics, Morbidity and Management Guidelines. Journal of
Neurosurgery 87:843-850, 1997.
3. Feinberg J, et al: Peripheral Nerve Injuries in the Athlete. Sports
Medicine 12(6):385-408, 1997.
4. Meyer S, et al: Cervical Spinal Stenosis and Stingers in Collegiate
Football Players. American Journal of Sports Medicine 22(2), 1994.
5. Cantu R: Stingers, Transient Quadriplegia, and Cervical Spinal
Stenosis: Return-to-Play Criteria. Medicine and Science of Sports and
Exercise 7(Suppl):S233-235, 1997.
6. Levitz C, et al: The Pathomechanics of Chronic Recurrent Cervical
Nerve Root Neuropraxia, the Chronic Burner Syndrome. American
Journal of Sports Medicine 25(1), 1997.
7. Castro F, et al: Stingers, the Torg Ratio, and the Cervical Spine.
American Journal of Sports Medicine 25(5), 1997.
8. Weinstein S: Assessment and Rehabilitation of the Athlete With a
Stinger. A Model for the Management of Non-catastrophic Athletic
Cervical Spine Injury. Clinic and Sports Medicine 17(1), 1998.
9. Shannon B, Klimkiewicz J, Cervical Burners in the Athlete. Clinic and
Sports Medicine 21(1):29-35 January 2002.
10.Koffler K, Kelly J, Neurovascular Trauma in Athletes. Orthop Clin N
Am 33: 523-534(2002).
11.Feinberg J, Burners and Stingers, Phys Med Rehab N Am 11(4): 771783 Nov 2000.
2013-14 NCAA Sports Medicine Handbook
June 1994 • Revised July 2004, 2009, July 2010, July 2011, July 2013
In April 2013, the NCAA Sport Science Institute hosted
a Concussion Task Force composed of concussion
experts (scientists, physicians, clinicians) whose charge
was to study concussion in college sports and to
develop a consensus, when possible, on concussion
definition, epidemiology, pathophysiology, management
and long-term ramifications. When a consensus was
not possible, the NCAA Concussion Task Force
members made recommendations for further study that
could provide a pathway for consensus. The
Concussion Task Force members reviewed in particular
three peer-reviewed journal articles that had been
recently published: (1) “Consensus statement on concussion in sport: the 4th International Conference on
Concussion in Sport held in Zurich, November 2012”;
(2) “American Medical Society for Sports Medicine
position statement: concussion in sport”; (3) “Summary
of evidence-based guideline update: Evaluation and
management of concussion in sports.” The first two
articles are consensus driven, and the third article is
evidence-based. Despite differing methodologies and
authors, there was a common thread of agreement
regarding sports-related concussion diagnosis and
management. Notably, for the first time, there was universal agreement in the peer-reviewed literature that
athletes should not return to play on the same day in
which they suffer a concussion.
The Concussion Task Force members did not recommend any changes to the NCAA Concussion
Management Plan, which is outlined on pages 64-65
under “NCAA Concussion Policy and Legislation” and
“Best Practices for a Concussion Management Plan.”
Concussion Definition
The consensus definition from the 4th International
Conference on Concussion in Sport (Zurich 2012) is
that concussion is a brain injury and is defined as a
complex pathophysiological process affecting the
brain, induced by biomechanical forces. These guidelines further describe common features that incorporate clinical, pathologic and biomechanical injury constructs that may be used in defining the nature of a
concussive head injury, including:
• Direct blow to the head, face or neck or an
impulsive force transmitted to the head.
• Rapid onset of short-lived impairment of neurological function that resolves spontaneously. In
some cases, symptoms and signs may evolve
over a number of minutes to hours.
• Functional disturbance rather than a structural
injury and, as such, no abnormality is seen on
standard structural neuroimaging studies.
• Grades set of clinical symptoms that may or may
not involve loss of consciousness.
As noted in the definitions box below, there is not one
uniform definition of concussion.
It is also noteworthy that concussion is sometimes
used interchangeably with mild traumatic brain injury
and at other times is considered one of several possible manifestations of traumatic brain injury.
Importantly, the absolute guide for mild traumatic brain
injury is a Glasgow Coma Scale of 13-15.
Sports Participation Definitions and
Concussion Epidemiology
Concussion incidence varies among sports. The
American Academy of Pediatrics published a classification of sports by contact in 2001. Then in 2013, the
American Academy of Neurology’s statement
described contact and collision sports as those in
which athletes purposely hit other athletes or inani-
Concussion Definitions
American Academy
of Neurology
Pathophysiologic disturbance in
neurologic function characterized
by clinical symptoms induced by
biomechanical forces, occurring
with or without loss of consciousness. Standard structural neuroimaging is normal, and symptoms
typically resolve over time.
American Medical Society
for Sports Medicine
A traumatically induced transient
disturbance of brain function
involving a complex pathopysiological process. Concussion is a
subset of mild traumatic brain
injury (MTBI), which is generally
self-limited and at the less-severe
end of the brain injury spectrum.
A brain injury. Concussion is
defined as a complex pathophysiological process affecting the brain,
induced by biomechanical forces.
A complex pathophysiological
process affecting the brain, induced
by traumatic biomechanical forces.
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mate objects. The purposeful collisions put athletes
participating in this class of sports at greater risk for
concussions. Limited contact sports were described
as those in which the force and the frequency of collisions, whether with other athletes or inanimate
objects, are decreased. Noncontact sports were
described as those in which players do not come in
contact with athletes or inanimate objects by force.
The rate of concussion in NCAA sports can be
assessed in various ways. Figure 1 demonstrates the
rate of competition concussion per 1,000 student-athlete exposures. It is noteworthy that the higher rates
occur in contact/collision sports. All meaningfully measurable rates occur in either contact/collision or limited
contact/impact sports. It is also noteworthy that
women have a higher rate of concussion than men for
soccer and basketball. Another way to look at concussion is through annual estimates of the actual number
of concussions within the sport, combining both practice and competition sessions. Figure 2 depicts the
percentage of concussions from each sport given the
total number of concussion in 14 NCAA sports.
Because of the large size of football teams and the
higher rate of concussion relative to other sports, concussion incidence is highest in football. In assessing
Figure 1: Rate of competition concussion injury in 14 NCAA sports
Men’s Lacrosse
Women’s Ice Hockey
Men’s Ice Hockey
Women’s Soccer
Men’s Soccer
Women’s Lacrosse
Women’s Field Hockey
Women’s Basketball
Men’s Basketball
Women’s Volleyball
Number of injuries per 1,000 athlete-exposures
Data from 2004-2009. Overall practice and game injury rates for each sport can be found in Appendix C.
Women’s Lacrosse
Women’s Field Hockey
Women’s Basketball
2013-14 NCAA Sports Medicine Handbook
Men’s Basketball
Women’s Volleyball
Number of injuries per 1,000 athlete-exposures
Data from 2004-2009. Overall practice and game injury rates for each sport can be found in Appendix C.
the available data, anticipating concussion risk can be
made based on the sport; anticipating concussion risk
can also be guided by impact expectation. For each
sport, it is important to follow the institution’s concussion management plan.
The NCAA reviewed various concussion
guidelines in addition to the injury
data across sports to classify sports
by an expectation for impacts and
collisions. Unlike the previous
two classifications, this classification (Figure 3) lists lower-tier
sports as limited contact
because athletes are still at
risk of a concussion both in
sports and daily life. Figure 2: National annual estimate
of concussions for practice and
competition in 14 NCAA sports
Women’s Field Hockey 2%
Women’s Ice Hockey 2%
Women’s Volleyball 3%
Women’s Lacrosse 3%
Men’s Ice Hockey 3%
Football 37%
Baseball 3%
Wrestling 3%
Men’s Lacrosse 4%
Concussion is not a static
event, but is rather a pathoSoccer
physiological process that may
evolve over minutes, hours and
days. Following a biomechanical
linear or rotational impact to the brain,
either directly or indirectly, the nerve cell
and/or nerve axon become perturbed. The
threshold of this impact is not known with certainty,
and can vary between individuals, and even within the
same individual.
Data from 2004-2009.
Figure 3: Impact expectation by sport
Contact and
Men’s Basketball 8%
In most cases, the brain energy crisis is restored
within seven to 10 days. This seven- to 10-day period
is known as the “metabolic recovery phase.” Upon
completion of the seven- to 10-day metabolic recovery
phase, brain blood flow, brain energy availability, and
Men’s Soccer 7%
Once an individual receives a traumatic impact that
exceeds the nerve cell’s ability to adapt, the pathophysiological process begins. This process includes an
interruption of the normal balance of chemicals such
as potassium and calcium inside and outside the nerve
cell. Restoring this balance requires extra energy, but
part of the pathophysiologic process is also a
decrease in blood flow to the brain. Thus, there is a
mismatch between brain energy need and brain energy
availability, sometimes referred to as an “energy
crisis.” If the chemical balance is not restored, then
there may be ongoing brain dysfunction that can
include inflammation, changes in physical structure of
the cell, and even nerve cell death.
Softball 4%
Field hockey
Ice hockey
Pole vault
Water polo
Cross country Swimming
Track and field
brain chemical balance have returned to normal. If
someone receives a concussion during the metabolic
recovery phase of a prior concussion, the temporal
resolution of the subsequent concussion will be further
delayed. Whereas potassium and glutamate dysfunc-
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Signs and Symptoms of Concussion
• Headache
• Nausea
• Vomiting
• Balance problems
• Fatigue
• Sensitivity to light
• Numbness/tingling
• Dazed
• Stunned
American Medical Society for Sports Medicine 2013 Position Stand
• Feeling mentally “foggy”
• Feeling slowed down
• Difficulty concentrating
• Difficulty remembering
• Forgetful of recent
information and
• Confused about
recent events
• Answers questions slowly
tion resolves within minutes, it may take six to 10 days
for calcium perturbation and cerebral blood flow to
normalize. This correlates with clinical symptomatology, which is discussed next.
Clinical Manifestations of Concussion
Because the definition of concussion is not uniform
and because there are no clearly defined genetic predispositions, serum/brain biomarkers, or definitive
neuroimaging classifications of concussion, it is critical to be well versed in clinical manifestations of concussion. Unlike many other medical conditions (e.g.
breast cancer, myocardial infarction) in which there are
numerous identified predispositions, biomarkers and
imaging criteria, concussion remains largely defined by
its clinical presentation, which can be varied, subtle
and easily overlooked. Concussion results from a brain
pathophysiological process, but the brain location (or
locations), and the extent of brain injury can vary considerably from concussion to concussion. Thus, concussion manifestations can range from mild visual
obscurations (e.g., “seeing stars”) to profound
amnesia, incoordination and even loss of consciousness. There are no clear prognostic factors for the
many varied concussion manifestations. The above
table lists signs and symptoms of concussion, as
included in the American Medical Society of Sports
Medicine Position Stand (AMSSM, 2013).
As noted in the signs and symptoms table, concussion
symptoms and signs are varied. Also, many symptoms
are nonspecific (e.g., headache, difficulty concentrating), and need to be placed in the proper context. For
example, a student-athlete may have difficulty concentrating and complain of headache while coping with a
tension-type headache (physical and mental stress) or
• Irritable
• Sad
• More emotional
• Nervous
• Drowsiness
• Sleeping more than usual
• Sleeping less than usual
• Difficulty falling asleep
migraine, or after a night of alcohol drinking and sleep
deprivation, but that does not mean he or she is suffering with a concussion. However, if the student-athlete develops such symptoms following a traumatic
head impact, either directly or indirectly, then concussion is highly probable.
Any athlete who is suspected of suffering with concussion must be evaluated immediately on the field, on
the sideline or in a quiet locker room. Many tools exist
to aid in the diagnosis of concussion, and it is best to
include a combination of symptoms checklist, cognitive testing and balance testing, all within a clinical
context. The SCAT2 and SCAT3 combine these variables into one test. There is universal consensus, and
NCAA policy, that any athlete who is diagnosed with a
concussion must not return to play or practice that day
and must be cleared by a health care professional
(team physician or his or her designee) before returning to play or practice.
The diagnosis of concussion is influenced by:
1. Medical Team Awareness. When there exists a
comprehensive program in which all medical team
members and athletes are well versed in concussion management, there is a high internal consistency and reliability in diagnosing concussion.
Conversely, when the medical team and athletes
have not rehearsed concussion management, the
internal consistency and reliability for concussion
diagnosis diminish considerably.
2. Athlete Self-Report. Unfortunately, even welleducated athletes have a high rate of not reporting concussion symptoms. Indeed, studies reveal
that 40 to 50 percent of athletes will not report
concussion symptoms, especially if they have had
2013-14 NCAA Sports Medicine Handbook
a prior concussion. Reasons vary, and range from
a sense of invincibility to fear of losing one’s
playing position.
3. Over-Reliance on Computerized Testing.
Concussion diagnosis must be clinical, and cannot
be made by computerized testing. Such tests may
help make a clinical decision, but are not valid
indicators of a diagnosis as a stand-alone tool.
Concussion Diagnosis and Management
The sideline evaluation of an athlete with a suspected
concussion should include an assessment of airway,
breathing and circulation (ABCs), followed by an
assessment of the cervical spine and skull for associated injury. The sideline evaluation should also
include a neurological and mental status examination
and some form of brief neurocognitive testing to
assess memory function and attention. This can be in
the form of questions regarding the particular practice
or competition, previous game results, and remote
and recent memory, and questions to test the athlete’s recall of words, months of the year backwards
and calculations. Special note should be made
regarding the presence and duration of retrograde or
anterograde amnesia, and the presence and duration
of confusion. A timeline of injury and the presence of
symptoms should be noted. These sideline tests
should be performed and repeated as necessary, but
do not take the place of other comprehensive neuropsychological tests.
Once an injury occurs and an initial assessment has
been made, it is important to determine an immediate
plan of action, which may include deciding on whether
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Graduated Return-to-Play Protocol*
Rehabilitation stage
Functional exercise at each stage of rehabilitation
Objective of each stage
1. No activity.
Symptom-limited physical and cognitive rest.
2. Light aerobic exercise.
Walking, swimming or stationary cycling keeping intensity less than 70 percent maximum permitted
heart rate. No resistance training.
Increase heart rate.
3. Sport-specific exercise. Skating drills in ice hockey, running drills in soccer. Add movement.
No head-impact activities.
4. Noncontact training drills. Progression to more complex training drills, e.g. passing drills in football and ice hockey. May start progressive resistance training.
Exercise, coordination
and cognitive load.
5. Full-contact practice.
Following medical clearance, participate in normal
training activities. Restore confidence
and assess functional
skills by coaching staff.
6. Return to play.
Normal game play.
* 2013 International Conference on Concussion in Sport. Zurich, Switzerland.
additional referral to a physician and/or emergency
department should take place, and determining the follow-up care. The medical staff should also determine
whether additional observation or hospital admission
should be considered.
Follow-up care and instructions should be given to the
athlete, including ensuring that the athlete not be left
alone for an initial period of time. Athletes who have
suffered concussion should avoid alcohol or other substances that will impair their cognitive function, and
also avoid aspirin and other medications that can
increase their risk of bleeding.
Conventional imaging studies such as MRI and CT
scans are usually normal in concussions, and they
contribute little to concussion evaluation but should be
employed whenever suspicion of an intracerebral or
structural lesion (e.g., skull fracture) exists. If an athlete
experiences prolonged loss of consciousness, confusion, seizure activity, focal neurologic deficits or persistent clinical or cognitive symptoms, then additional
emergency evaluation is indicated.
The diagnosis of concussion is clinical. In other
words, there are no laboratory tests, biomarkers, or
computerized cognitive tests that make a diagnosis.
Concussion diagnosis is based on the clinical presentation of symptoms and signs that have been dis-
cussed in this guideline. Concussion is best diagnosed by a clinician with experience in managing athletes with concussion. Several recent publications
have endorsed the use of neurocognitive or neuropsychological (NP) testing as an important cornerstone of
concussion evaluation. It is likely that NP testing of
memory performance, reaction time, and speed of
cognitive processing, regardless of whether administered by paper-and-pencil or computerized method, is
useful in helping to identify the presence of concussion. These tests provide a reliable assessment and
quantification of brain function by examining brainbehavior relationships. NP tests are designed to
measure a broad range of cognitive function, including speed of information processing, memory recall,
attention and concentration, reaction time, scanning
and visual tracking ability, and problem-solving ability.
Several computerized versions of these tests also
have been designed to improve the availability of
these tests, and make them easier to distribute and
use. Ideally, these tests are performed before the
season as a “baseline” with which post-injury tests
can be compared. Despite the utility of NP test batteries in the assessment and treatment of concussion in
athletes, several questions remain unanswered.
Computerized NP testing should be interpreted by
health care professionals trained and familiar with the
type of test and the individual test limitations, including a knowledgeable assessment of the reliable
2013-14 NCAA Sports Medicine Handbook
change index, baseline variability and false-positive
and false-negative rates. NP testing should be used
only as part of a comprehensive concussion management strategy and should not be used in isolation.
Further research is needed to understand the complete role of neuropsychological testing.
The clinical diagnosis of concussion is aided by comparing baseline cognitive and balance tests, such as
the NP tests noted above, with post-incident tests.
These baseline tests are in flux, including SCAT III,
which has not been validated clinically. In addition,
investigators are evaluating eye movement, vestibular
reaction, and voice recognition tests, among others,
that may serve as an adjunct in the clinical diagnosis
of concussion. NCAA Best Practices for a Concussion
Management Plan states that at a minimum, baseline
assessments of athletes should consist of the use of a
symptoms checklist and standardized cognitive and
balance assessments such as SAC, SCAT, SCAT II,
and Balance Error Scoring System (BESS). The clinical
diagnosis of concussion is ultimately made when a
discerning clinician notes an inciting event (e.g., blow
to the head), which is followed by symptoms and signs
that are consistent with concussion and that are not
indicative of other brain injury.
Once concussion is diagnosed, the cornerstone of
concussion management is physical and cognitive
rest until the acute symptoms resolve, followed by a
supervised graded program of exertion before
medical clearance and return to play. Once an athlete
is completely asymptomatic, the return-to-play progression should occur in a step-wise fashion with
gradual increments in physical exertion and risk of
contact. After a period of remaining asymptomatic,
the first step is an “exertional challenge” in which the
athlete exercises for 15 to 20 minutes in an activity
such as biking or running; this leads to an increase in
heart rate with some sweating. If he/she does not
experience any symptoms in conjunction with this
first exercise challenge, this can be followed by a
steady increase in exertion, followed by a return to
sport-specific activities that do not put the athlete at
risk for contact. Examples include dribbling a ball or
shooting, stickwork or passing, or other agilities. This
allows the athlete to return to the practice setting,
albeit in a limited role. Then, the athlete can be progressed to practice activities with limited contact and
finally full contact. There are not universally accepted
guidelines for how quickly to move from one exercise
stage to the next; in general, it is recommended that
each rehabilitation stage take 24 hours before progressing to the next stage, and such progression
should be individualized. Final clearance for a return
to play should be provided by a physician or a physician’s designee.
There are no standardized guidelines for returning the
athlete to school. If the athlete develops increased
symptoms with cognitive stress, student athletes may
require academic accommodations such as a reduced
workload, extended test-taking time, days off or a
shortened school day. Returning the student to
school, even if the day is shortened, can be considered when the student can tolerate cognitive activity or
stimulation for approximately 30 to 45 minutes. This
arbitrary cutoff is based on the observation that a good
amount of learning takes place in 30- to 45-minute
increments. Given that most concussions resolve
within three weeks of the injury, adjustments may often
be made in the individual classroom setting without
formal written plans such as a 504 plan or individualized education program (IEP).
Preinjury mood disorders, learning disorders, attention
deficit disorders (ADD/ADHD) and migraine headaches
complicate diagnosis and management of a concussion. Students may require cognitive rest and may
require academic accommodations such as reduced
workload and extended time for tests while recovering
from a concussion.
Post-Concussion Ramifications
There is considerable controversy with regard to longterm implications of concussion. On one end of the
spectrum, some claim that repeated concussions
cause a neurodegenerative brain disease called
chronic traumatic encephalopathy or CTE. On the
other end of the spectrum, some claim that there are
no significant long-term sequelae of concussion. The
murky evidence lies somewhere in between.
Post-Concussion Syndrome. Post-concussion syndrome refers to prolonged concussion symptoms following concussion. It is not truly a “syndrome”
because there is no core of consistent symptoms and
there is no clear correlation with type or severity of
concussion, biomarkers, or genetic/personality predisposition. Symptoms may be neurologic (e.g., dizziness, light sensitivity), cognitive (memory, attention
deficits) and emotional (depression, anxiety). Postconcussion syndrome is best considered a neuropsychiatric disorder, and it is important to recognize that it
Medical Issues
has no bearing on the extent of, or expected recovery
from, concussion. Post-concussion syndrome is best
managed in a multidisciplinary manner that includes
gradual increase in physical and cognitive activity.
Management is distinctly different from acute concussion management, and individuals should not simply
be relegated to prolonged rest, which may perpetuate
the symptomatology.
Chronic Neurobehavioral Impairment. Cognitive
and executive dysfunction has been described following multiple concussions. However, only two
Class I studies exist, and these are for jockeys and
rugby players. There are seven Class II studies that
include boxers, NFL players and soccer players,
which demonstrate long-term cognitive impairment.
Two studies show an association with apoE4 genotype, suggesting a genetic predisposition, and one
study shows an association with a prior history of
learning disability. There is one Class III study of
NFL players. There is some correlation with magnitude of exposure and chronic neurobehavioral
impairment in professional athletes, but the relationship between exposure and chronic neurobehavioral
impairment in amateur athletes is uncertain. This
may be from a combination of underpowered studies
and possible brain adaptations that are different in
younger individuals.
2013-14 NCAA Sports Medicine Handbook
NCAA concussion policy and legislation
The NCAA Executive Committee adopted
(April 2010) the following policy for institutions
in all three divisions:
“Institutions shall have a concussion management
plan on file such that a student-athlete who exhibits signs, symptoms or behaviors consistent with a
concussion shall be removed from practice or
competition and evaluated by an athletics health
care provider with experience in the evaluation and
management of concussions. Student-athletes
diagnosed with a concussion shall not return to
activity for the remainder of that day. Medical
clearance shall be determined by the team physician or his or her designee according to the concussion management plan.
“In addition, student-athletes must sign a statement in which they accept the responsibility for
reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms
of concussions. During the review and signing
process, student-athletes should be presented
with educational material on concussions.”
NCAA adopted concussion management
plan legislation
An active member institution shall have a concussion management plan for its student-athletes.
The plan shall include, but is not limited to, the
(a) An annual process that ensures student-athDepression. Depression also has been reported as a
possible long-term manifestation of repeated concussion. Two Class II studies of retired NFL players note
an increased rate of depression in a dose-response
manner, and one Class III study of retired NFL players
notes a higher depression rate than the general population. There are also studies that show no clear relationship between depression and prior concussion. Of
note: about 21 percent of college student-athletes
report depression at baseline.
Chronic Traumatic Encephalopathy (CTE). CTE is a
progressive neurodegenerative disease whose pathologic hallmark is abnormal tau deposition, with clinical
manifestations of mood disorder, neuromuscular incoordination, dementia and death. There are not agreed-
letes are educated about the signs and symptoms of concussions. Student-athletes must
acknowledge that they have received information about the signs and symptoms of concussions and that they have a responsibility to
report concussion-related injuries and illnesses
to a medical staff member;
(b) A process that ensures a student-athlete who
exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from
athletics activities (e.g., competition, practice,
conditioning sessions) and evaluated by a
medical staff member (e.g., sports medicine
staff, team physician) with experience in the
evaluation and management of concussions;
(c) A policy that precludes a student-athlete diagnosed with a concussion from returning to athletic activity (e.g., competition, practice, conditioning sessions) for at least the remainder of
that calendar day; and
(d) A policy that requires medical clearance for a
student-athlete diagnosed with a concussion to
return to athletics activity (for example, competition, practice, conditioning sessions) as determined by a physician (e.g., team physician) or
the physician’s designee.
Effect of violation. A violation of Constitution shall be considered an institutional violation
per Constitution 2.8.1; however, the violation shall
not affect the student-athlete’s eligibility.
upon pathological and clinical criteria for CTE,
although it seems clear that CTE is a distinct clinical
entity from Alzheimer’s disease. In a 2012 publication
of CTE case series (Brain), CTE is described as a “progressive tauopathy that occurs as a consequence of
repetitive mild traumatic brain injury.” In the Zurich
2012 consensus paper, it is noted that “it is not possible to determine the causality or risk factors [of CTE]
with any certainty. As such, the speculation that
repeated concussion or subconcussive impacts cause
CTE remains unproven.” The universal consensus in
the NCAA Concussion Task Force was that we need to
better understand CTE with regard to genetic predispositions and biomarkers. No task force member
noted a clear cause-and-effect relationship between
concussion and CTE.
Medical Issues
Best practices for a concussion management plan
In addition to the Executive Committee policy
requirements, additional best practices for a concussion management plan include, but are not limited to:
1. Although sports currently have rules in place,
athletics staff, student-athletes and officials
should continue to emphasize that purposeful
or flagrant head or neck contact in any sport
should not be permitted and current rules of
play should be strictly enforced.
2. Institutions should have on file and annually
update an emergency action plan for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not
limited to, concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g., asthma) and sickle cell trait collapses. All athletics
health care providers and coaches (including
strength and conditioning staff) should review
and practice the plan at least annually.
3. Institutions should have on file an appropriate
health care plan that includes equitable access to
athletics health care providers for each NCAA sport.
4. Athletics health care providers should be
empowered to have the unchallengeable authority to determine management and return to play
of any ill or injured student-athlete, as the provider deems appropriate. For example, a countable coach should not serve as the primary
supervisor for an athletics health care provider,
nor should the coach have sole hiring or firing
authority over a provider.
5. The concussion management plan should outline
the roles of athletics health care staff (e.g., physician, certified athletic trainer, nurse practitioner,
physician assistant, neurologist, neuropsychologist).
In addition, the following components have been
specifically identified for the collegiate environment:
a. Institutions should ensure that coaches
have acknowledged that they understand
the concussion management plan and their
role within the plan and that they received
education about concussions.
b. Athletics health care providers should practice
within the standards as established for their
professional practice (e.g., physician, certified
athletic trainer, nurse practitioner, physician
assistant, neurologist, neuropsychologist).
c. Institutions should record a baseline assess-
ment for each student-athlete before the first
practice in the sports of baseball, basketball,
diving, equestrian, field hockey, football,
gymnastics, ice hockey, lacrosse, pole vaulting, rugby, skiing, soccer, softball, water polo
and wrestling, at a minimum. The same baseline assessment tools should be used postinjury at appropriate time intervals. The baseline assessment should consist of one or
more of the following areas of assessment.
1) At a minimum, the baseline assessment
should consist of the use of a symptoms checklist and standardized cognitive and balance assessments [e.g.,
SAC; SCAT; SCAT II; Balance Error
Scoring System (BESS)].
2) Additionally, neuropsychological testing
(e.g., computerized, standard paper and
pencil) has been shown to be effective in
the evaluation and management of concussions. The development and implementation of a neuropsychological
testing program should be performed in
consultation with a neuropsychologist
who is in the best position to interpret NP
tests by virtue of background and training. However, there may be situations in
which neuropsychologists are not available and a physician experienced in the
use and interpretation of such testing in
an athletic population may perform or
interpret NP screening tests.
d. The student-athlete should receive serial monitoring for deterioration. Athletes should be
provided with written instructions upon discharge, preferably with a roommate, guardian
or someone who can follow the instructions.
e. The student-athlete should be evaluated by a
team physician as outlined within the concussion management plan. Once asymptomatic
and post-exertion assessments are within
normal baseline limits, return-to-play should
follow a medically supervised stepwise process.
6. Institutions should document the incident, evaluation, continued management and clearance
of the student-athlete with a concussion.
For references, visit
2013-14 NCAA Sports Medicine Handbook
1. Broglio, Ferrara, Macciocchi, Baumgartner, & Elliott. Test-retest
reliability of computerized concussion assessment programs. Journal of
Athletic Training. 2007;42:509-514.
2. Cantu RC: Concussion severity should not be determined until all
postconcussion symptoms have abated. Lancet 3:437-8, 2004.
3. Cantu RC: Recurrent athletic head injury: risks and when to retire. Clin
Sports Med. 22:593-603, 2003.
4. Cantu RC: Post traumatic (retrograde/anterograde) amnesia:
pathophysiology and implications in grading and safe return to play.
Journal of Athletic Training. 36(3): 244-8, 2001.
5. Committee on Sports Medicine: Recommendations for Participation in
Competitive Sports. Pediatrics. 1988;81:737-739.
6. Giza, CC and Hovda, DA: The Neurometabolic Cascade of
Concussion. Journal of Athletic Training. 2001. 36(3): 228-235
7. Giza, Kutcher, Ashwal, Barth, Getchius, Gioia, et al. Evidence-based
Guideline Update: Evaluation and Management of Concussion in
Sports. American Academy of Neurology. 2013.
8. Guskiewicz KM, Bruce SL, Cantu R, Ferrara MS, Kelly JP, McCrea M,
Putukian M, McLeod-Valovich TC; National Athletic Trainers’
Association Position Statement: Management of Sport-related
Concussion: Journal of Athletic Training. 39(3): 280-297, 2004.
9. Guskiewicz, McCrea, Marshall, Cantu, Randolph, Barr, Onate, & Kelly.
Cumulative Effects Associated with Recurrent Concussion in Collegiate
Football Players: The NCAA Concussion Study. Journal of the American
Medical Association. 2003.
10.Harmon, Drezner, Gammons, Guskiewicz, Halstead, Herring, Kutcher,
et. al. American Medical Society for Sports Medicine position
statement: concussion in sport. British Journal of Sports Medicine.
11. Hovda DA, Lee SM, Smith ML et al: The Neurochemical and metabolic
cascade following brain injury: Moving from animal models to man. J
Neurotrauma 12(5):143-146, 1995.
12.Kutcher & Eckner. At-Risk Populations in Sports-Related Concussion.
Current Sports Medicine Reports. 2010;16-20.
13.McCory, Meeuwisse, Aubry, Cantu, Dvorak, Echemendia, Engebretsen,
Johnston, Jutcher, et. al. Consensus statement on concussion in sport:
the 4th International Conference on Concussion in Sport held in Zurich,
November 2012. British Journal of Sports Medicine. 2013;47:250–258.
14.McCrea, Guskiewicz, Barr, Marshall, Randolph, Cantu, Onate, & Kelly.
Acute Effects and Recovery Time Following Concussion in Collegiate
Football Players: The NCAA Concussion Study. Journal of the American
Medical Association. 2003.
15. McCrea M, Hammeke T, Olsen G, Leo , Guskiewicz K: Unreported concussion in high school football players. Clin J Sport Med 2004;14:13-17.
16.Mihalik, Bell, Marshall, & Guskiewicz. Measurement of Head Impacts In
Collegiate Football Players: An Investigation of Positional And EventType Differences. Neurosurgery. 2007;61:1229-1235.
• NCAA Concussion Fact Sheets and Video
for Coaches and Student-Athletes
Available at
• Heads Up: Concussion Tool Kit
CDC. Available at
• Heads Up Video
NATA. Streaming online at
Skin Infections
July 1981 • Revised June 2008
Skin infections may be transmitted by both direct
(person to person) and indirect (person to inanimate
surface to person) contact. Infection control measures,
or measures that seek to prevent the spread of disease,
should be used to reduce the risks of disease transmission. Efforts should be made to improve student-athlete
hygiene practices, to use recommended procedures for
cleaning and disinfection of surfaces, and to handle
blood and other bodily fluids appropriately. Institutions
should promote hand- and personal-hygiene practices;
educate athletes and athletics staff; ensure procedures
for cleaning and disinfection of hard surfaces are followed; and verify the cleanup of blood and other potentially infectious materials is done according to the
Occupational Health and Safety Administration (OSHA)
Blood-borne Pathogens standard.
Categories of skin conditions and examples include:
1. Bacterial skin infections
d. Staphylococcal disease, MRSA;
e. Folliculitis (generalized);
f. Hidradenitis suppurativa;
2. Parasitic skin infections
Medical Issues
3. Viral skin infections
a. Herpes simplex;
b. Herpes zoster;
c. Molluscum contagiosum; and
4. Fungal skin infections
a. Tinea corporis (ringworm).
b. Tinea pedis (athlete’s foot).
Note: Current knowledge indicates that many fungal
infections are easily transmitted by skin-to-skin
contact. In most cases, these skin conditions can be
covered with a securely attached bandage or nonpermeable dressing to allow participation.
Open wounds and infectious skin conditions that
cannot be adequately protected should be considered
cause for medical disqualification from practice or competition (see Guideline 2A). The term “adequately protected” means that the wound or skin condition has
been deemed as noninfectious and adequately treated
as deemed appropriate by a health care provider and is
able to be properly covered. The term “properly
covered” means that the skin infection is covered by a
securely attached bandage or dressing that will contain
all drainage and will remain intact throughout the sport
activity. A health care provider might exclude a studentathlete if the activity poses a risk to the health of the
infected athlete (such as injury to the infected area),
even though the infection can be properly covered. If
wounds can be properly covered, good hygiene measures such as performing hand hygiene before and
after changing bandages and throwing used bandages
in the trash should be stressed to the athlete.
Antibiotic Resistant Staph Infections
There is much concern about the presence and spread
of antibiotic-resistant Staphylococcus aureus in intercollegiate athletics across sports. Athletes are at risk due to
the presence of open wounds, poor hygiene practices,
close physical contact, and the sharing of towels and
equipment. Institutions and conferences should continue
efforts and support for the education of staff and student-athletes on the importance of proper hygiene and
wound care to prevent skin infections from developing
and infectious diseases from being transmitted.
Staphylococcus aureus, often referred to as “staph,”
are bacteria commonly carried on the skin or in the
nose of healthy people. Occasionally, staph can cause
an infection. Staph bacteria are one of most common
causes of skin infections in the U.S. Most infections
2013-14 NCAA Sports Medicine Handbook
preventing skin infections
1. Keep hands clean by washing thoroughly
with soap and warm water or using an alcohol-based sanitizer routinely
2. Encourage good hygiene
• Immediate showering after activity
• Ensure availability of adequate soap and water
• Pump soap dispensers are preferred over
bar soap
3. Avoid whirlpools or common tubs
• Individuals with active infections, open
wounds, scrapes or scratches could infect
others or become infected in this environment
4. Avoid sharing towels, razors and daily athletic gear
• Avoid contact with other people’s wounds
or material contaminated from wounds
5. Maintain clean facilities and equipment
• Wash athletic gear and towels after each use
• Establish routine cleaning schedules for
shared equipment
6. Inform or refer to appropriate health care
personnel for all active skin lesions and
lesions that do not respond to initial therapy
• Train student-athletes and coaches to
recognize potentially infected wounds
and seek first aid
• Encourage coaches and sports medicine
staff to assess regularly for skin lesions
• Encourage health care personnel to seek
bacterial cultures to establish a diagnosis
7. Care and cover skin lesions appropriately
before participation
• Keep properly covered with a proper
dressing until healed
• “Properly covered” means that the skin
infection is covered by a securely
attached bandage or dressing that will
contain all drainage and will remain intact
throughout the sport activity
• If wounds can be properly covered, good
hygiene measures should be stressed to the
student-athlete such as performing hand
hygiene before and after changing bandages and throwing used bandages in the trash
• If wound cannot be properly covered,
consider excluding players with potentially infectious skin lesions from practice
and/or competition until lesions are
healed or can be covered adequately
are minor, typically presenting as skin and soft tissue
infections (SSTI) such as pimples, pustules and boils.
They may be red, swollen, warm, painful or purulent.
Sometimes, athletes confuse these lesions with insect
bites in the early stages of infection. A purulent lesion
could present as draining pus; yellow or white center;
central point or “head”; or a palpable fluid-filled cavity.
In the past, most serious staph bacterial infections
were treated with antibiotics related to penicillin. In
recent years, antibiotic treatment of these infections
has changed because staph bacteria have become
resistant to various antibiotics, including the commonly used penicillin-related antibiotics. These resistant
bacteria are called methicillin-resistant
Staphylococcus aureus, or MRSA. Fortunately, the
first-line treatment for most purulent staph, including
MRSA, skin and soft tissue infections is incision and
drainage with or without antibiotics. However, if antibiotics are prescribed, patients should complete the full
course and consult physicians if the infection does not
get better. The Centers for Disease Control and
Prevention (CDC), American Medical Association
(AMA) and Infectious Diseases Society of America
(IDSA) have developed a treatment algorithm that
should be reviewed; it is accessible at
Staph bacteria including MRSA can spread among
people having close contact with infected people.
MRSA is almost always spread by direct physical
contact, and not through the air. Spread may also
occur through indirect contact by touching objects
contaminated by the infected skin of a person with
MRSA or staph bacteria (e.g. towels, sheets, wound
dressings, clothes, workout areas, sports equipment).
If a lesion cannot be properly covered for the rigors of
the sport, consider excluding players with potentially
infectious skin lesions from practice and competition
until lesions are healed.
Staph bacteria including MRSA can be found on the
skin and in the nose of some people without causing
illness. The role of decolonization is still under investigation. Regimens intended to eliminate MRSA colonization should not be used in patients with active infections. Decolonization regimens may have a role in preventing recurrent infections, but more data are needed
to establish their efficacy and to identify optimal regimens for use in community settings. After treating
active infections and reinforcing hygiene and appropri-
Medical Issues
ate wound care, consider consultation with an infectious disease specialist regarding use of decolonization
when there are recurrent infections in an individual
patient or members of a defined group.
tion techniques and appropriate precautions if suspicious wounds appear. Each institution should develop
prevention strategies and infection control policies
and procedures.
MRSA infections in the community are typically SSTI,
but can also cause severe illness such as pneumonia.
Most transmissions appear to be from people with
active MRSA skin infections. Staph and MRSA infections are not routinely reported to public health
authorities, so a precise number is not known. It is
estimated that as many as 300,000 hospitalizations
are related to MRSA infections each year. Only a small
proportion of these have disease onset occurring in
the community. It has also been estimated that there
are more than 12 million outpatient (i.e., physician
offices, emergency and outpatient departments) visits
for suspected staph and MRSA SSTIs in the U.S.
each year. Approximately 25 to 30 percent (80 million
people) of the population is colonized in the nose with
staph bacteria at a given time and approximately 1.5
percent (4.1 million people) is colonized with MRSA.
Skin Infections in Wrestling
In an effort to educate the public about the potential
risks of MRSA, organizations such as the CDC, NCAA
and the National Athletic Trainers’ Association (NATA)
have issued official statements recommending all
health care personnel and physically active adults and
children take appropriate precautions if suspicious
skin infections appear, and immediately contact their
health care provider.
Individual cases of MRSA usually are not required to
be reported to most local/state health departments;
however, most states have laws that require reporting
of certain communicable diseases, including outbreaks
regardless of pathogens. So in most states if an outbreak of skin infections is detected, the local and/or
state health department should be contacted.
Recognition of MRSA is critical to clinical management. Education is the key, involving all individuals
associated with athletics, from student-athletes to
coaches to medical personnel to custodial staff.
Education should encompass proper hygiene, preven-
Data from the NCAA Injury Surveillance Program indicate that skin infections are associated with at least 17
percent of the practice time-loss injuries in wrestling.
It is recommended that qualified personnel, including a
knowledgeable, experienced physician, examine the
skin of all wrestlers before any participation (practice
and competition). Male student-athletes shall wear
shorts and female student-athletes should wear shorts
and a sports bra during medical examinations.
Open wounds and infectious skin conditions that
cannot be adequately protected should be considered
cause for medical disqualification from practice or
competition (see Guideline 2A). The term “adequately
protected” means that the wound or skin condition
has been deemed as noninfectious and adequately
treated as deemed appropriate by a health care provider and is able to be properly covered. The term
“properly covered” means that the skin infection is
covered by a securely attached bandage or dressing
that will contain all drainage and will remain intact
throughout the sport activity. An example would be a
noncontagious/noninfectious skin condition covered
by a gas impermeable dressing, pre-wrap and stretch
tape that is appropriately anchored and cannot be dislodged. A health care provider might exclude a student-athlete if the activity poses a risk to the health of
the infected athlete (such as injury to the infected
area), even though the infection can be properly
covered. If wounds can be properly covered, good
hygiene measures such as performing hand hygiene
before and after changing bandages and discarding
used bandages in the biohazard waste should be
stressed to the athlete. (See Wrestling Rule 6.1.4.)
Medical Examinations
Medical examinations must be conducted by knowledgeable physicians and/or certified athletic trainers.
2013-14 NCAA Sports Medicine Handbook
The presence of an experienced dermatologist is recommended. The examination should be conducted in
a systematic fashion so that more than one examiner
can evaluate problem cases. Provisions should be
made for appropriate lighting and the necessary facilities to confirm and diagnose skin infections.
Wrestlers who are undergoing treatment for a communicable skin disease at the time of the meet or tournament shall provide written documentation to that effect
from a physician. The status of these individuals
should be decided before the screening of the entire
group. The decision made by a host event physician
and/or certified athletic trainer “on site” should be
considered FINAL.
Guidelines for Disposition
of Skin Infections
Unless a new diagnosis occurs at the time of the
medical examination conducted at the meet or tournament, the wrestler presenting with a skin lesion shall
provide a completed Skin Evaluation and Participation
Status Form from the team physician documenting
clinical diagnosis, lab and/or culture results, if relevant,
and an outline of treatment to date (i.e., surgical intervention, duration, frequency, dosages of medication).
Adequately covered is defined as “the noninfectious/
noncontagious lesion is covered by a gas impermeable
dressing, pre-wrap and stretch tape that is appropriately anchored and cannot be dislodged throughout
the sport activity.”
Bacterial infections
(Furuncles, Carbuncles, Folliculitis, Impetigo, Cellulitis
or Erysipelas, Staphylococcal disease, MRSA)
1. Wrestler must have been without any new skin lesion
for 48 hours before the meet or tournament.
2. Wrestler must have completed 72 hours of antibiotic therapy and have no moist, exudative or draining lesions at meet or tournament time.
3. Gram stain of exudate from questionable lesions (if
4. Active purulent lesions shall not be covered to
allow participation. See above criteria when making decisions for participation status.
Hidradenitis suppurativa
1. Wrestler will be disqualified if extensive or purulent
draining lesions are present.
2. Extensive or purulent draining lesions shall not be
covered to allow participation.
Percentage of infections in practices
al )
ng orm
Skin infections in practices, men’s wrestling, 1993-1994 through
2003-2004 (n = 1151).
Wrestler must be treated with appropriate pediculicide
and re-examined for completeness of response before
Wrestler must have negative scabies prep at meet or
tournament time.
Herpes simplex
Primary Infection
1. Wrestler must be free of systemic symptoms of
viral infection (fever, malaise, etc.).
2. Wrestler must have developed no new blisters for
72 hours before the examination.
3. Wrestler must have no moist lesions; all lesions
must be dried and surmounted by a FIRM
4. Wrestler must have been on appropriate dosage of
systemic antiviral therapy for at least 120 hours
before and at the time of the meet or tournament.
5. Active herpetic infections shall not be covered to
allow participation.
See form on page 73 when making decisions for participation status.
Medical Issues
Cleaning and Disinfecting Athletic Facilities for MRSA
Shared equipment that comes into direct skin
contact should be cleaned after each use and
allowed to dry. Equipment, such as helmets and
protective gear, should be cleaned according to the
equipment manufacturers’ instructions to make sure
the cleaner will not harm the item.
1. Athletic facilities such as locker rooms should
always be kept clean whether or not MRSA
infections have occurred among the athletes.
2. Review cleaning procedures and schedules with
the janitorial/environmental service staff.
• Cleaning procedures should focus on commonly touched surfaces and surfaces that
come into direct contact with people’s bare
skin each day.
• Cleaning with detergent-based cleaners or
Environmental Protection Agency (EPA)registered detergents/disinfectants will
remove MRSA from surfaces.
• Cleaners and disinfectants, including household chlorine bleach, can be irritating, and
exposure to these chemicals has been associated with health problems such as asthma
and skin and eye irritation.
• Take appropriate precautions described on
the product’s label instructions to reduce
exposure. Wearing personal protective
equipment such as gloves and eye protection may be indicated.
3. Follow the instruction labels on all cleaners and
disinfectants, including household chlorine bleach,
to make sure they are used safely and correctly.
• Some key questions that should be
answered by reading the label include:
- How should the cleaner or disinfectant
be applied?
- Do you need to clean the surface first
before using the disinfectant (e.g., pre-
cleaned surfaces)?
- Is it safe for the surface? Some cleaners
and disinfectants, including household
chlorine bleach, might damage some
surfaces (e.g., metals, some plastics).
- How long do you need to leave it on the
surface to be effective (i.e., contact time)?
- Do you need to rinse the surface with water
after using the cleaner or disinfectant?
• If you are using household chlorine bleach,
check the label to see if the product has specific instructions for disinfection. If no disinfection instructions exist, then use 1/4 cup of
regular household bleach in 1 gallon of water
(a 1:100 dilution equivalent to 500-615 parts
per million [ppm] of available chlorine) for
disinfection of pre-cleaned surfaces.
• Environmental cleaners and disinfectants
should not be put onto skin or wounds and
should never be used to treat infections.
• The EPA provides a list of registered products that work against MRSA (Available
online at
4. There is a lack of evidence that large-scale use
(e.g., spraying or fogging rooms or surfaces) of
disinfectants will prevent MRSA infections more
effectively than a more targeted approach of
cleaning frequently touched surfaces.
5. Repair or dispose of equipment and furniture
with damaged surfaces that do not allow surfaces to be adequately cleaned.
6. Covering infections will greatly reduce the risks
of surfaces becoming contaminated with MRSA.
Recurrent Infection
1. Blisters must be completely dry and covered by a
FIRM ADHERENT CRUST at time of competition,
or wrestler shall not participate.
2. Wrestler must have been on appropriate dosage of
systemic antiviral therapy for at least 120 hours
before and at the time of the meet or tournament.
3. Active herpetic infections shall not be covered to
allow participation.
See form on page 73 when making decisions for participation status.
Centers for Disease Control and Prevention
Available online at
Questionable Cases
1. Tzanck prep and/or HSV antigen assay (if available).
2. Wrestler’s status deferred until Tzanck prep and/or
HSV assay results complete.
Wrestlers with a history of recurrent herpes labialis or
2013-14 NCAA Sports Medicine Handbook
herpes gladiatorum could be considered for seasonlong prophylaxis. This decision should be made after
consultation with the team physician.
Herpes zoster
Skin lesions must be surmounted by a FIRM
ADHERENT CRUST at meet or tournament time and
have no evidence of secondary bacterial infection.
Molluscum contagiosum
1. Lesions must be curetted or removed before the
meet or tournament.
2. The only way that coverage ensures prevention of
transmission is if the molluscum is on the trunk or
most uppermost thighs, which are assured of
remaining covered with clothing; Band-Aids are
not sufficient.
3. Solitary or localized, clustered lesions can be covered with a gas impermeable dressing, pre-wrap
and stretch tape that is appropriately anchored
and cannot be dislodged.
Verrucae (wart)
1. Wrestlers with multiple digitate verrucae of their
face will be disqualified if the infected areas cannot
be covered with a mask. Solitary or scattered
lesions can be curetted away before the meet or
tournament but cannot be seeping.
2. Wrestlers with multiple verrucae plana or verrucae vulgaris must have the lesions “adequately
Tinea infections (ringworm)
1. A minimum of 72 hours of topical therapy is considered appropriate therapeutic regimen to allow
effective drug intervention for most tinea infections. The NCAA Skin Evaluation and Participation
Status form shall be used to confirm time-undertreatment.
2. Status of lesions (activity) can be judged by KOH
preparation or a review of documented therapeutic
3. On-site medical personnel will disqualify wrestlers with extensive, multiple lesions following
4. A minimum of two weeks of systemic (oral) antifungal therapy is required for scalp (diagnosed
tinea capitus) lesions.
5. Active lesions may be covered to allow participation if lesions are in a body location that can be
“adequately covered.”
6. The final disposition of student-athletes with tinea
infections will be decided on an individual basis
by the on-site examining physician or certified
athletic trainer.
1. Descriptive Epidemiology of Collegiate Men’s Wrestling Injuries: National
Collegiate Athletic Association Injury Surveillance System, 1988–1989
Through 2003–2004. Journal of Athletic Training 2007;42(2):303–310.
2. Adams, BB.: Transmission of cutaneous infection in athletics. British
Journal of Sports Medicine 34(6):413-4, 2000 Dec.
3. Anderson BJ.: The Effectiveness of Valacyclovir in Preventing
Reactivation of Herpes Gladiatorum in Wrestlers. Clin J Sports Med
9(2):86-90, 1999 Apr.
4. Association for Professionals in Infection Control and Epidemiology
(APIC). 1996. APIC infection control and applied epidemiology
principles and practice. St. Louis: Mosby.
5. Beck, CK.: Infectious diseases in sports: Medicine and Science in
Sports and Exercise 32(7 Suppl):S431-8, 2000 Jul.
6. Belongia EA, Goodman JL, Holland EJ, et. al.: An outbreak of herpes
gladiatorum at a high school wrestling camp. The New England
Journal of Medicine. 325(13):906-910, 1991.
7. Cordoro, KM and Ganz, JE. Training room management of medical condition:
Sports Dermatology. Clinics in Sports Medicine. 24: 565-598, 2005.
8. Cozad, A. and Jones, R. D. Disinfection and the prevention of
disease. American Journal of Infection Control, 31(4): 243-254, 2003.
9. Centers for Disease Control and Prevention (CDC) Division of
Healthcare Quality Promotion. (2002). Campaign to prevent
antimicrobial resistance in health care settings. Available at www.cdc.
10.Dorman, JM.: Contagious diseases in competitive sport: what are the
risks? Journal of American College Health 49(3):105-9, 2000 Nov.
11. Mast, E. and Goodman, R.: Prevention of Infectious Disease
Transmission in Sports. SportsMedicine 24(1):1-7,1997.
12. Kohl TD, Martin DC, Nemeth R, Hill T, Evans D.: Fluconazole for the
prevention and treatment of tinea gladiatorum. Pediatric Infectious
Disease Journal 19(8):717-22, 2000 Aug.
13. Lindenmayer JM, Schoenfeld S, O’Grady R, Carney JK.: Methicillin-resistant
Staphylococcus aureus in a high school wrestling team and the surrounding
community. Archives of Internal Medicine 158(8):895-9, 1998 Apr.
14. Vasily DB, Foley JJ.: More on Tinea Corporis Gladiatorum. J Am Acad
Dermatol 2002, Mar.
15.Vasily DB, Foley JJ, First Episode Herpes Gladiatorum: Treatment with
Valacyclovir (manuscript submitted for publication). Weiner, R.
Methicillin-Resistant Staphylcoccus aureus on Campus: A new challenge
to college health. Journal of American College Health. 56(4):347-350.
16.Zinder SM, Basler RS, Foley J, Scarlata C, Vasily DB. National Athletic
Trainers’ Association Position Statement; Skin Diseases. Journal of
Athletic Training. 2010; 95 (H);411-428.
17.Selected EPA-registered Disinfectants. U.S. Environmental Protection
Agency. October 22, 2012, Available online at
Medical Issues
National Collegiate Athletic Association
(Physician Release for Student-Athlete to Participate with Skin Lesion)
Student-Athlete: ______________________________________________
Date of Exam: ____ / ____ / ____
Institution: __________________________________________________
Please Mark Location of Lesion(s):
Dual(s)/Tournament: __________________________________________
Number of Lesion(s): __________________________________________
Yes _______________________________________
Diagnosis: ___________________________________________________
Medication(s) used to treat lesion(s): ________________________________
Date Treatment Started: ____ / ____ / ____
Time: ________________
Earliest Date student-athlete may return to participation: ____ / ____ / ____
Physician Name (Printed): ________________________________________
Physician Signature:_____________________________________________ Specialty: _______________________________________
(M.D. or D.O.)
Office Address: _______________________________________________ Contact #: ______________________________________
Institution Certified Athletic Trainer Notified:
Yes Signature: _____________________________________________________
Physician: Non-contagious lesions do not require treatment prior to return to participation (e.g. eczema, psoriasis, etc.). Please familiarize yourself with
NCAA Wrestling Rules which state: (refer to the NCAA Wrestling Rules and Interpretations publication for complete information)
“9.6.4 … The presence of a communicable skin disease … shall be full and sufficient reason for disqualification.”
“9.6.5 … If a student-athlete has been diagnosed as having such a condition, and is currently being treated by a physician (ideally a dermatologist) who has
determined that it is safe for that individual to compete without jeopardizing the health of the opponent, the student-athlete may compete. However, the studentathlete or his/her coach or athletic trainer shall provide current written documentation from the treating physician to the medical professional at the medical
examination, … ”
“9.6.6 … Final determination of the participant’s ability to compete shall be made by the host site’s physician or certified athletic trainer who conducts the medical
examination after review of any such documentation and the completion of the exam.”
Below are some treatment guidelines that suggest MINIMUM TREATMENT before return to wrestling: (please refer to the NCAA Sports Medicine Handbook
for complete information)
Bacterial Infections (Furuncles, Carbuncles, Folliculitis, Impetigo, Cellulitis or Erysipelas, Staphylococcal disease, CA-MRSA): Wrestler must have been without any new
skin lesion for 48 hours before the meet or tournament; completed 72 hours of antibiotic therapy and have no moist, exudative or draining lesions at meet or tournament time.
Gram stain of exudate from questionable lesions (if available). Active bacterial infections shall not be covered to allow participation.
Herpetic Lesions (Simplex, fever blisters/cold sores, Zoster, Gladiatorum): Skin lesions must be surmounted by a FIRM ADHERENT CRUST at competition time, and
have no evidence of secondary bacterial infection. For primary (first episode of Herpes Gladiatorum) infection, the wrestler must have developed no new blisters for 72 hours
before the examination; be free of signs and symptoms like fever, malaise, and swollen lymph nodes; and have been on appropriate dosage of systemic antiviral therapy for at
least 120 hours before and at the time of the competition. Recurrent outbreaks require a minimum of 120 hours of oral anti-viral treatment, again so long as no new lesions
have developed and all lesions are scabbed over. Active herpetic infections shall not be covered to allow participation.
Tinea Lesions (ringworm): Oral or topical treatment for 72 hours on skin and 14 days on scalp. Wrestlers with solitary, or closely clustered, localized lesions will be
disqualified if lesions are in a body location that cannot be adequately covered.
Molluscum Contagiosum: Lesions must be curetted or removed before the meet or tournament and covered.
Verrucae: Wrestlers with multiple digitate verrucae of their face will be disqualified if the infected areas cannot be covered with a mask. Solitary or scattered lesions can be
curetted away before the meet or tournament. Wrestlers with multiple verrucae plana or verrucae vulgaris must have the lesions adequately covered.
Hidradenitis Suppurativa: Wrestler will be disqualified if extensive or purulent draining lesions are present; covering is not permissible.
Pediculosis: Wrestler must be treated with appropriate pediculicide and re-examined for completeness of response before wrestling.
Scabies: Wrestler must have negative scabies prep at meet or tournament time.
DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made herein, or exam performed in
connection therewith, by the above named physician/provider, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information
provided herein.
2013-14 NCAA Sports Medicine Handbook
January 1986 • Revised June 2002
The NCAA Committee on Competitive Safeguards and
Medical Aspects of Sports acknowledges the significant input of Dr. Anne Loucks, Ohio University, in the
revision of this guideline.
In 80 percent of college-age women, the length of the
menstrual cycle ranges from 23 to 35 days.
Oligomenorrhea refers to a menstrual cycle that occurs
inconsistently, irregularly and at longer intervals.
Amenorrhea is the cessation of the menstrual cycle
with ovulation occurring infrequently or not at all. A
serious medical problem of amenorrhea is the lower
level of circulating estrogen (hypoestrogenism) and its
potential health consequences.
The prevalence of menstrual-cycle irregularities found in
surveys depends on the definition of menstrual function
used, but has been reported to be as high as 44 percent
in athletic women. Research suggests that failure to
increase dietary energy intake in compensation for the
expenditure of energy during exercise can disrupt the
hypothalamic-pituitary-ovarian (HPO) axis. Exercise training appears to have no suppressive effect on the HPO
axis beyond the impact of its strain on energy availability.
There are several important reasons to discuss the
treatment of menstrual-cycle irregularities. One reason
is infertility; fortunately, the long-term effects of menstrual cycle dysfunction appear to be reversible.
Another medical consequence is skeletal demineralization, which occurs in hypoestrogenic women. Skeletal
demineralization was first observed in amenorrheic athletes in 1984. Initially, the lumbar spine appeared to be
the primary site where skeletal demineralization occurs,
but new techniques for measuring bone mineral density
show that demineralization occurs throughout the skeleton. Some women with menstrual disturbances
involved in high-impact activities, such as gymnastics
and figure skating, display less demineralization than
women runners. Despite resumption of normal menses,
the loss of bone mass during prolonged hypoestrogenemia is not completely reversible. Therefore, young
women with low levels of circulating estrogen, due to
menstrual irregularities, are at risk for low peak bone
mass, which may increase the potential for osteoporotic fractures later in life. An increased incidence of
stress fractures also has been observed in the long
bones and feet of women with menstrual irregularities.
The treatment goal for women with menstrual irregularities is the re-establishment of an appropriate hormonal environment for the maintenance of bone health.
This can be achieved by the re-establishment of a
regular menstrual cycle or by hormone replacement
therapy, although neither change has been shown to
result in complete recovery of the lost bone mass.
Additional research is necessary to develop a specific
prognosis for exercise-induced menstrual dysfunction.
All student-athletes with menstrual irregularities should
be seen by a physician. General guidelines include:
1. Full medical evaluation, including an endocrine
work-up and bone mineral density test;
2. Nutritional counseling with specific emphasis on:
a. Total caloric intake versus energy expenditure;
b. Calcium intake of 1,200 to 1,500 milligrams a
day; and
3. Routine monitoring of the diet, menstrual function,
weight-training schedule and exercise habits.
If this treatment scheme does not result in regular
menstrual cycles, estrogen-progesterone supplementation should be considered. This should be coupled
with appropriate counseling on hormone replacement
and review of family history. Hormone-replacement
therapy is thought to be important for amenorrheic
women and oligomenorrheic women whose hormonal
profile reveals an estrogen deficiency.
The relationship between amenorrhea, osteoporosis
and disordered eating is termed the “female athlete
triad.” In 1997, the American College of Sports
Medicine issued a position stand calling for all individuals working with physically active girls and women to
be educated about the female athlete triad and
develop plans for prevention, recognition, treatment
and risk reduction. Recommendations are that any student-athlete who presents with any one component of
the triad be screened for the other two components
and referred for medical evaluation.
Other recommendations include:
• All sports medicine professionals, including
coaches and athletic trainers, should learn to recognize the symptoms and risks associated with
the female athlete triad.
• Coaches and others should avoid pressuring
female athletes to diet and lose weight and
should be educated about the warning signs of
eating disorders.
• Sports medicine professionals, athletics administrators and officials of sport governing bodies
Medical Issues
share a responsibility to prevent, recognize and
treat this disorder.
• Sports medicine professionals, athletics administrators and officials of sport governing bodies
should work toward offering opportunities for
educating and monitoring coaches to ensure safe
training practices.
• Young, physically active females should be educated about proper nutrition, safe training practices, and the risks and warning signs of the
female athlete triad.
1. Ackerman KE, Misra M. Bone health and the female athlete triad in
adolescent athletes. Phys Sportsmed. 2011 Feb;39(1):131-41.
2. American Academy of Pediatrics Committee on Sports Medicine:
Amenorrhea in adolescent athletes. Pediatrics 84(2):394-395, 1989.
3. Doyle-Lucas AF, Akers JD, Davy BM. Energetic efficiency, menstrual
irregularity, and bone mineral density in elite professional female ballet
dancers. J Dance Med Sci. 2010;14(4):146-54.
4. Ducher G, Turner AI, Kukuljan S, Pantano KJ, Carlson JL, Williams NI,
De Souza MJ. Obstacles in the optimization of bone health outcomes
in the female athlete triad. Sports Med. 2011 Jul 1;41(7):587-607.
5. Gibbs JC, Williams NI, Scheid JL, Toombs RJ, and MJ De Souza. The
Association of a High Drive for Thinness With Energy Deficiency and
Severe Menstrual Disturbances: Confirmation in a Large Population of
Exercising Women. Int J Sport Nutr Exerc Metab. 2011 Aug
6. Joy EA. ACSM Clinician Profile. Curr Sports Med Rep. 2011 MayJun;10(3):121.
7. Keen AD, Drinkwater BL: Irreversible bone loss in former amenorrheic
athletes. Osteoporosis International 7(4):311-315, 1997.
8. Loucks AB, Verdun M, Heath EM: Low energy availability, not stress
of exercise, alters LH pulsatility in exercising women. Journal of
Applied Physiology 84(1):37-46, 1998.
9. Otis CT, Drinkwater B, Johnson M, Loucks A, Wilmore J: American
College of Sports Medicine Position Stand on the Female Athlete
Triad. Medicine and Science in Sports and Exercise 29(5):i-ix, 1997.
10.Shangold M, Rebar RW, Wentz AC, Schiff I: Evaluation and
management of menstrual dysfunction in athletes. Journal of the
American Medical Association 262(12):1665-1669, 1990.
2013-14 NCAA Sports Medicine Handbook
April 1988 • Revised August 2013
Blood-borne pathogens are disease-causing microorganisms that can be potentially transmitted through
blood contact. The blood-borne pathogens of concern
include (but are not limited to) the hepatitis virus (HBV,
HCV) and the human immunodeficiency virus (HIV).
Infections with these (HBV, HCV, HIV) viruses have
increased throughout the last decade among all portions of the general population. These diseases have
potential for catastrophic health consequences.
Knowledge and awareness of appropriate preventive
strategies are essential for all members of society,
including student-athletes.
The particular blood-borne pathogens HBV and HIV
are transmitted through sexual contact (heterosexual
and homosexual), direct contact with infected blood or
blood components, and perinatally from mother to
baby. In addition, behaviors such as body piercing and
tattoos may place student-athletes at some increased
risk for contracting HBV, HIV or hepatitis C.
The emphasis for the student-athlete and the athletics
health care team should be placed predominately on
education and concern about these traditional routes
of transmission from behaviors off the athletics field.
Experts have concurred that the risk of transmission
on the athletics field is minimal.
Hepatitis B Virus (HBV)
HBV is a blood-borne pathogen that can cause infection of the liver. Many of those infected will have no
symptoms or a mild flu-like illness. One-third will have
severe hepatitis, which will cause the death of
1 percent of that group. Approximately 300,000 cases
of acute HBV infection occur in the United States
every year, mostly in adults.
Five to 10 percent of acutely infected adults become
chronically infected with the virus (HBV carriers).
Currently in the United States there are approximately
1 million chronic carriers. Chronic complications of HBV
infection include cirrhosis of the liver and liver cancer.
Individuals at the greatest risk for becoming infected
include those practicing risky behaviors of having
unprotected sexual intercourse or sharing intravenous
(IV) needles in any form. There is also evidence that
household contacts with chronic HBV carriers can lead
to infection without having had sexual intercourse or
sharing of IV needles. These rare instances probably
occur when the virus is transmitted through unrecognized-wound or mucous-membrane exposure.
The incidence of HBV in student-athletes is presumably low, but those participating in risky behavior off
the athletics field have an increased likelihood of infection (just as in the case of HIV). An effective vaccine to
prevent HBV is available and recommended for all
college students by the American College Health
Association. Numerous other groups have recognized
the potential benefits of universal vaccination of the
entire adolescent and young-adult population.
HIV (AIDS Virus)
The acquired immunodeficiency syndrome (AIDS) is
caused by the human immunodeficiency virus (HIV),
which infects cells of the immune system and other
tissues, such as the brain. Some of those infected with
HIV will remain asymptomatic for many years. Others will
more rapidly develop manifestations of HIV disease (i.e.,
AIDS). In the United States, adolescents are at special
risk for HIV infection. This age group is one of the fastest
growing groups of new HIV infections. Approximately 14
percent of all new HIV infections occur in people from 12
to 24 years old. The risk of infection is increased by
having unprotected sexual intercourse, and the sharing
of IV needles in any form. Like HBV, there is evidence
that suggests that HIV has been transmitted in household-contact settings without sexual contact or IV
needle sharing among those household contacts. Similar
to HBV, these rare instances probably occurred through
unrecognized-wound or mucous-membrane exposure.
Comparison of HBV/HIV
Hepatitis B is a much more “sturdy/durable” virus than
HIV and is much more concentrated in blood. HBV has
a much more likely transmission with exposure to infected blood; particularly parenteral (needle-stick) exposure,
but also exposure to open wounds and mucous membranes. There has been one well-documented case of
transmission of HBV in the athletics setting, among
sumo wrestlers in Japan. There are no validated cases
of HIV transmission in the athletics setting. The risk of
transmission for either HBV or HIV on the field is considered minimal; however, most experts agree that the specific epidemiologic and biologic characteristics of the
HBV virus make it a realistic concern for transmission in
sports with sustained, close physical contact, such as
wrestling. HBV is considered to have a potentially higher
risk of transmission than HIV.
Testing of Student-Athletes
Routine mandatory testing of student-athletes for
either HBV or HIV for participation purposes is not recommended. Individuals who desire voluntary testing
Medical Issues
based on personal reasons and risk factors, however,
should be assisted in obtaining such services by
appropriate campus or public-health officials.
Student-athletes who engage in high-risk behavior are
encouraged to seek counseling and testing. Knowledge
of one’s HBV and HIV infection is helpful for a variety of
reasons, including the availability of potentially effective
therapy for asymptomatic patients, and modification of
behavior, which can prevent transmission of the virus to
others. Appropriate counseling regarding exercise and
sports participation also can be accomplished.
Participation by the Student-Athlete
With Hepatitis B (HBV) Infection
Individual’s Health. In general, acute HBV should be
viewed just as other viral infections. Decisions regarding ability to play are made according to clinical signs
and symptoms, such as fatigue or fever. There is no
evidence that intense, highly competitive training is a
problem for the asymptomatic HBV carrier (acute or
chronic) without evidence of organ impairment.
Therefore, the simple presence of HBV infection does
not mandate removal from play.
Disease Transmission. The student-athlete with either
acute or chronic HBV infection presents very limited
risk of disease transmission in most sports. However,
the HBV carrier presents a more distinct transmission
risk than the HIV carrier (see previous discussion of
comparison of HBV to HIV) in sports with higher
potential for blood exposure and sustained, close body
contact. Within the NCAA, wrestling is the sport that
best fits this description.
The specific epidemiologic and biologic characteristics
of hepatitis B virus form the basis for the following rec-
ommendation: If a student-athlete develops acute HBV
illness, it is prudent to consider removal of the individual from combative, sustained close-contact sports
(e.g., wrestling) until loss of infectivity is known. (The
best marker for infectivity is the HBV antigen, which
may persist up to 20 weeks in the acute stage).
Student-athletes in such sports who develop chronic
HBV infections (especially those who are e-antigen
positive) should probably be removed from competition indefinitely, due to the small but realistic risk of
transmitting HBV to other student-athletes.
Participation of the
Student-Athlete With HIV
Individual’s Health. In general, the decision to allow an
HIV-positive student-athlete to participate in intercollegiate athletics should be made on the basis of the individual’s health status. If the student-athlete is asymptomatic and without evidence of deficiencies in immunologic function, then the presence of HIV infection in
and of itself does not mandate removal from play.
The team physician must be knowledgeable in the
issues surrounding the management of HIV-infected
student-athletes. HIV must be recognized as a potentially chronic disease, frequently affording the affected
individual many years of excellent health and productive life during its natural history. During this period of
preserved health, the team physician may be involved
in a series of complex issues surrounding the advisability of continued exercise and athletics competition.
The decision to advise continued athletics competition
should involve the student-athlete, the student-athlete’s personal physician and the team physician.
Variables to be considered in reaching the decision
include the student-athlete’s current state of health
2013-14 NCAA Sports Medicine Handbook
and the status of his/her HIV infection, the nature and
intensity of his/her training, and potential contribution
of stress from athletics competition to deterioration of
his/her health status.
care, have additions or modifications relevant to athletics. They are divided into two sections — the care of
the student-athlete, and cleaning and disinfection of
environmental surfaces.
There is no evidence that exercise and training of moderate intensity is harmful to the health of HIV-infected
individuals. What little data that exists on the effects of
intense training on the HIV-infected individual demonstrates no evidence of health risk. However, there is no
data looking at the effects of long-term intense training
and competition at an elite, highly competitive level on
the health of the HIV-infected student-athlete.
Care of the Athlete
Disease Transmission. Concerns of transmission in
athletics revolve around exposure to contaminated
blood through open wounds or mucous membranes.
Precise risk of such transmission is impossible to calculate, but epidemiologic and biologic evidence suggests that it is extremely low (see section on comparison of HBV/HIV). There have been no validated reports
of transmission of HIV in the athletics setting.
Therefore, there is no recommended restriction of student-athletes merely because they are infected with
HIV, although one court has upheld the exclusion of an
HIV-positive athlete from the contact sport of karate.
Administrative Issues
The identity of individuals infected with a blood-borne
pathogen must remain confidential. Only those people
in whom the infected student-athlete chooses to
confide have a right to know about this aspect of the
student-athlete’s medical history. This confidentiality
must be respected in every case and at all times by all
college officials, including coaches, unless the student-athlete chooses to make the fact public.
Athletics Health Care Responsibilities
The following recommendations are designed to
further minimize risk of transmission of blood-borne
pathogens and other potentially infectious organisms
in the context of athletics events and to provide treatment guidelines for caregivers. In the past, these
guidelines were referred to as “Universal (blood and
body fluid) Precautions.” Over time, the recognition of
“Body Substance Isolation,” or that infectious diseases
may also be transmitted from moist body substances,
has led to a blending of terms now referred to as
“Standard Precautions.” Standard precautions apply to
blood, body fluids, secretions and excretions, except
sweat, regardless of whether they contain visible
blood. These guidelines, originally developed for health
1. All personnel involved in sports who care for injured
or bleeding student-athletes should be properly
trained in first aid and standard precautions.
2. Assemble and maintain equipment and/or supplies
for treating injured/bleeding athletes. Items may
include personal protective equipment (PPE) (minimal protection includes gloves, goggles, mask,
fluid-resistant gown if chance of splash or splatter); antiseptics; antimicrobial wipes; bandages or
dressings; medical equipment needed for treatment; appropriately labeled “sharps” container for
disposal of needles, syringes and scalpels; and
waste receptacles appropriate for soiled equipment, uniforms, towels and other waste.
3. Pre-event preparation includes proper care for
wounds, abrasions or cuts that may serve as a
source of bleeding or as a port of entry for bloodborne pathogens or other potentially infectious
organisms. These wounds should be covered with
an occlusive dressing that will withstand the
demands of competition. Likewise, care providers
with healing wounds or dermatitis should have
these areas adequately covered to prevent transmission to or from a participant. Student-athletes
may be advised to wear more protective equipment
on high-risk areas, such as elbows and hands.
4. The necessary equipment and/or supplies important for compliance with standard precautions
should be available to caregivers. These supplies
include appropriate gloves, disinfectant bleach,
antiseptics, designated receptacles for soiled
equipment and uniforms, bandages and/or dressings, and a container for appropriate disposal of
needles, syringes or scalpels.
5. When a student-athlete is bleeding, the bleeding
must be stopped and the open wound covered with
a dressing sturdy enough to withstand the demands
of activity before the student-athlete may continue
participation in practice or competition. Current
NCAA policy mandates the immediate, aggressive
treatment of open wounds or skin lesions that are
Medical Issues
deemed potential risks for transmission of disease.
Participants with active bleeding should be
removed from the event as soon as is practical.
Return to play is determined by appropriate medical staff personnel and/or sport officials. Any participant whose uniform is saturated with blood must
change the uniform before return to participation.
6. During an event, early recognition of uncontrolled
bleeding is the responsibility of officials, studentathletes, coaches and medical personnel. In particular, student-athletes should be aware of their
responsibility to report a bleeding wound to the
proper medical personnel.
7. Personnel managing an acute blood exposure must
follow the guidelines for standard precaution and
presume all blood is infectious. Gloves and other
PPE, if necessary, should be worn for direct contact with blood or other body fluids. Gloves should
be changed after treating each individual participant. After removing gloves, hands should be washed.
8. If blood or body fluids are transferred from an injured
or bleeding student-athlete to the intact skin of another athlete, the event must be stopped, the skin
cleaned with antimicrobial wipes to remove gross
contaminate, and the athlete instructed to wash with
soap and water as soon as possible. NOTE: Chemical
germicides intended for use on environmental surfaces should never be used on student-athletes.
9. Any needles, syringes or scalpels should be carefully
disposed of in an appropriately labeled “sharps” container. Medical equipment, bandages, dressings and
other waste should be disposed of according to facility
protocol. During events, uniforms or other contaminated linens should be disposed of in a designated container to prevent contamination of other items or personnel. At the end of competition, the linen should be
laundered and dried according to facility protocol; hot
water at temperatures of 71 degrees Celsius (160
degrees Fahrenheit) for 25-minute cycles may be used.
10. Post-exposure evaluation and follow-up. Following
the report of any incident in which an athlete has
nonintact skin, eye, mouth, mucous membrane or
parenteral (under the skin) contact with blood or
other potentially infectious materials, the athlete
should seek a confidential medical evaluation and
follow-up. This evaluation must be conducted by a
licensed health care professional.
Disinfecting of Environmental Surfaces
1. All individuals responsible for cleaning and disinfection of blood spills or other potentially infectious
materials (OPIM) should be properly trained on
procedures and the use of standard precautions.
2. Assemble and maintain supplies for cleaning and
disinfection of hard surfaces contaminated by
blood or OPIM. Items include personal protective
equipment (PPE) (gloves, goggles, mask, fluidresistant gown if chance of splash or splatter);
supply of absorbent paper towels or disposable
cloths; red plastic bag with the biohazard symbol
on it or other waste receptacle according to facility
protocol; and properly diluted tuberculocidal disinfectant or freshly prepared bleach solution diluted
(1:100 bleach/water ratio).
3. Put on disposable gloves.
4. Remove visible organic material by covering with
paper towels or disposable cloths. Place soiled
towels or cloths in red bag or other waste receptacle according to facility protocol. (Use additional
towels or cloths to remove as much organic material as possible from the surface and place in the
waste receptacle.)
5. Spray the surface with a properly diluted chemical
germicide used according to manufacturer’s label
recommendations for disinfection, and wipe clean.
Place soiled towels in waste receptacle.
6. Spray the surface with either a properly diluted
tuberculocidal chemical germicide or a freshly prepared bleach solution diluted 1:100, and follow
manufacturer’s label directions for disinfection;
wipe clean. Place towels in waste receptacle.
7. Remove gloves and wash hands.
8. Dispose of waste according to facility protocol, the
Occupational Safety and Health Administration
(OSHA) and the Centers for Disease Control and
Prevention (CDC).
Final Notes:
1. All personnel responsible for caring for bleeding
individuals should be encouraged to obtain a hepatitis B (HBV) vaccination.
2013-14 NCAA Sports Medicine Handbook
2. Latex allergies should be considered. Non-latex
gloves may be used for treating student-athletes
and the cleaning and disinfection of environmental
3. Occupational Safety and Health Administration
(OSHA) standards for Bloodborne Pathogens
(Standard #29 CFR 1910.1030) and Hazard
Communication (Standard #29 CFR 1910.1200)
should be reviewed for further information.
Member institutions should ensure that policies exist
for orientation and education of all health care workers
on the prevention and transmission of blood-borne
pathogens. Additionally, in 1992, the Occupational
Safety and Health Administration (OSHA) developed a
standard directed to eliminating or minimizing occupational exposure to blood-borne pathogens. Many of
the recommendations included in this guideline are
part of the standard. Each member institution should
determine the applicability of the OSHA standard to its
personnel and facilities.
1. AIDS education on the college campus: A theme issue. Journal of
American College Health 40(2):51-100, 1991.
2. American Academy of Pediatrics: Human immunodeficiency virus
(AIDS virus) in the athletic setting. Pediatrics 88(3):640-641, 1991.
3. Calabrese L, et al.: HIV infections: exercise and athletes. Sports
Medicine 15(1):1-7, 1993.
4. Canadian Academy of Sports Medicine position statement: HIV as it
relates to sport. Clinical Journal of Sports Medicine 3:63-68, 1993.
5. Fitzgibbon J, et al.: Transmissions from one child to another of human
immunodeficiency virus type I with azidovudine-resistance mutation.
New England Journal of Medicine 329 (25):1835-1841, 1993.
6. HIV transmission between two adolescent brothers with hemophilia.
Morbidity and Mortality Weekly Report 42(49):948-951, 1993.
7. Kashiwagi S, et al.: Outbreak of hepatitis B in members of a highschool sumo wrestling club. Journal of American Medical Association
248 (2):213-214, 1982.
8. Klein RS, Freidland GH: Transmission of human immunodeficiency
virus type 1 (HIV-1) by exposure to blood: defining the risk. Annals of
Internal Medicine 113(10):729-730, 1990.
9. Public health services guidelines for counseling and antibody testing
to prevent HIV infection and AIDS. Morbidity and Mortality Weekly
Report 36(31):509-515, 1987.
10.Recommendations for prevention of HIV transmission in health care
settings. Morbidity and Mortality Weekly Report 36(25):3S-18S, 1987.
11.United States Olympic Committee Sports Medicine and Science
Committee: Transmission of infectious agents during athletic competition,
1991. (1750 East Boulder Street, Colorado Springs, CO 80909)
12.Update: Universal precautions for prevention of transmission by
human immunodeficiency virus, hepatitis B virus, and other blood
borne pathogens in health care settings. Morbidity and Mortality
Weekly Report 37:377-388, 1988.
13.When sports and HIV share the bill, smart money goes on common sense.
Journal of American Medical Association 267(10):1311-1314, 1992.
14.World Health Organization consensus statement: Consultation on
AIDS and sports. Journal of American Medical Association
267(10):1312, 1992.
15.Human immunodeficiency virus (HIV) and other blood-borne
pathogens in sports. Joint position statement by the American
Medical Society for Sports Medicine (AMSSM) and the American
Academy of Sports Medicine (AASM). The American Journal of Sports
Medicine 23(4):510-514, 1995.
16.Most E, et al.: Transmissions of blood-borne pathogens during sport: risk
and prevention. Annals of Internal Medicine 122(4):283-285, 1995.
17.Brown LS, et al.: Bleeding injuries in professional football: estimating
the risk for HIV transmission. Annals of Internal Medicine 122(4):271274, 1995.
18.Arnold BL: A review of selected blood-borne pathogen statements and
federal regulations. Journal of Athletic Training 30(2):171-176, 1995.
19.Montalov v. Radcliffe, 167 F. 3d 873 (4th Cir. 1999), cert. denied, 120
S Ct. 48 1999.
20. Bitting, LA, Trowbridge, CA, Costello, LE. A Model for a Policy on
HIV/AIDS and Athletics. J Athl Train. 1996 Oct-Dec; 31(4): 356–357
21. McGrew CA, Dick RW, Schniedwind K, Gikas P. Survey of NCAA
institutions concerning HIV/AIDS policies and universal precautions.
Med Sci Sports Exerc. 1993 Aug;25(8):917-21.
22. Brown LS Jr, Phillips RY, Brown CL Jr, Knowlan D, Castle L, Moyer J.
HIV/AIDS policies and sports: the National Football League. Med Sci
Sports Exerc. 1994 Apr;26(4):403-7.
23. Kordi, R. and Wallace, WA. Blood-borne infections in sport: risks of
transmission, methods of prevention, and recommendations for
hepatitis B vaccination. Br J Sports Med 2004;38:678-684
The Use of
Local Anesthetics
Medical Issues
June 1992 • Revised June 2004
The use of local injectable anesthetics to treat sportsrelated injuries in college athletics is primarily left to
the discretion of the physician treating the individual,
since there is little scientific research on the subject.
This guideline provides basic recommendations for the
use of these substances, which commonly include
lidocaine (Xylocaine), 1 or 2 percent; bupivacaine
(Marcaine), 0.25 to 0.50 percent; and mepivacaine
(Carbocaine), 3 percent. The following recommendations do not include the use of corticosteroids.
It is recommended that:
1. These agents should be administered only by a
qualified clinician who is licensed to perform this
procedure and who is familiar with these agents’
actions, reactions, interactions and complications.
The treating clinician should be well aware of the
quantity of these agents that can be safely injected.
2. These agents should only be administered in facilities equipped to handle any allergic reaction,
including a cardiopulmonary emergency, which
may follow their use.
3. These agents should only be administered when
medically justified, when the risk of administration
is fully explained to the patient, when the use is
not harmful to continued athletics activity and
when there is no enhancement of a risk of injury.
The following procedures are not recommended:
1. The use of local anesthetic injections if they jeopardize
the ability of the student-athlete to protect himself or
herself from injury.
2. The administration of these drugs by anyone other
than a qualified clinician licensed to perform this
3. The use of these drugs in combination with epinephrine or other vasoconstrictor agents in fingers,
toes, earlobes and other areas where a decrease
in circulation, even if only temporary, could result
in significant harm.
2013-14 NCAA Sports Medicine Handbook
Injectable Corticosteroids
in Sports Injuries
June 1992 • Revised June 2004
Corticosteroids, alone or in combination with local
anesthetics, have been used for many years to treat
certain sports-related injuries. This guideline is an
attempt to identify specific circumstances in which
corticosteroids may be appropriate and also to remind
both physicians and student-athletes of the inherent
dangers associated with their use.
The most common reason for the use of corticosteroids in
athletics is the treatment of chronic overuse syndromes
such as bursitis, tenosynovitis and muscle origin pain (for
example, lateral epicondylitis). They have also been used
to try to prevent redevelopment of a ganglion and to
reduce keloid scar formation. Rarely is it appropriate to
treat acute syndromes such as acromioclavicular (AC)
joint separations or hip pointers with a corticosteroid.
There is still much to be learned about the effects of
intra-articular, intraligamentous or intratendinous injection of corticosteroids. Researchers have noted
reduced synthesis of articular cartilage after corticosteroid administration in both animals and human models.
However, a causal relationship between the intra-articular corticosteroid and degeneration of articular cartilage
has not been established. Research also has shown
that a single intraligamentous or multiple intra-articular
injections have the potential to cause significant and
long-lasting deterioration in the mechanical properties
of ligaments and collagenous tissues in animal models.
Finally, studies have shown significant degenerative
changes in active animal tendons treated with a corticosteroid as early as 48 hours after injection.
This research provides the basis for the following recommendations regarding the administration of corticosteroids in college-athletics.
It is recommended that:
1. Injectable corticosteroids should be administered
only after more conservative treatments, including
nonsteroidal anti-inflammatory agents, rest, ice,
ultrasound and various treatment modalities, have
been exhausted.
2. Only those physicians who are knowledgeable
about the chemical makeup, dosage, onset of
action, duration and potential toxicity of these
agents should administer corticosteroids.
3. These agents should be administered only in facilities that are equipped to deal with allergic reactions, including cardiopulmonary emergencies.
4. Repeated corticosteroid injections at a specific
site should be done only after the consequences
and benefits of the injections have been thoroughly evaluated.
5. Corticosteroid injections only should be done if a
therapeutic effect is medically warranted and the
student-athlete is not subject to either short- or
long-term significant risk.
6. These agents should only be administered when
medically justified, when the risk of administration is fully explained to the student-athlete,
when the use is not harmful to continued athletics activity and when there is no enhancement of
a risk of injury.
The following procedures are not recommended:
1. Intra-articular injections, particularly in major
weight-bearing joints. Intra-articular injections have
a potential softening effect on articular cartilage.
2. Intratendinous injections, since such injections
have been associated with an increased risk of
3. Administration of injected corticosteroids immediately before a competition.
4. Administration of corticosteroids in acute trauma.
5. Administration of corticosteroids in infection.
1. Corticosteroid injections: balancing the benefits. The Physician and
Sports Medicine 22(4):76, 1994.
2. Corticosteroid Injections: Their Use and Abuse. Journal of the
American Academy of Orthopaedic Surgeons 2:133-140, 1994.
3. Kennedy JC, Willis RD: The effects of local steroid injections on
tendons: A biomechanical and microscopic correlative study.
American Journal of Sports Medicine 4:11-21, 1970.
4. Leadbetter WB: Corticosteroid injection therapy in sports injuries. In:
Sports Induced Inflammation Park Ridge, IL: American Academy of
Orthopaedic Surgeons, pp. 527-545, 1990.
5. Mankin HJ, Conger KA: The acute effects of intra-articular
hydrocortisone on articular cartilage in rabbits. Journal of Bone and
Joint Surgery 48A:1383-1388, 1966.
6. Noyes FR, Keller CS, Grood ES, et al.: Advances in the understanding
of knee ligament injuries, repair and rehabilitation. Medicine and
Science in Sports and Exercise 16:427-443, 1984.
7. Noyes FR, Nussbaum NS, Torvik PT, et al.: Biomechanical and
Medical Issues
ultrastructural changes in ligaments and tendons after local corticosteroid
injections. Abstract, Journal of Bone and Joint Surgery 57A:876, 1975.
8. Pfenninger JL: Injections of joints and soft tissues: Part I. General
guidelines. American Family Physician 44(4):1196-1202, 1991.
9. Pfenninger JL: Injections of joints and soft tissues: Part II. Guidelines
for specific joints. American Family Physician 44(5):1690-1701, 1991.
2013-14 NCAA Sports Medicine Handbook
Mental Health:
June 2006 • Revised 2012
Considerations in Identifying and
Referring Student-Athletes With
Potential Mental Health Issues
The full range of mental health issues found in the
general student population can also be found in the
life of a student-athlete. The mental health of a
college student is challenged by any number of
factors of student life, and participation in athletics
does not provide the student-athlete with immunity
from mental health issues. Rather, participation in
intercollegiate athletics imposes additional stressors
on the student-athlete that can increase the risk for
mental health issues. The unique stressors of intercollegiate athletic participation include the physical
demands of training and competition, the time commitment to their sport, sustaining a time-loss, chronic
or season-/career-ending injury, having difficulty interacting with teammates and coaches, and struggling
with poor sports performance. This chapter offers
suggestions in developing an institution’s StudentAthlete Mental Health Considerations Plan. Each plan
may vary from institution to institution; however,
having a plan assists the athletics department in navigating the student-athlete’s health and well-being.
Coaches, athletic trainers, team physicians, strength
and conditioning staff, academic support staff, equipment managers and administrators are in position to
observe and interact with student-athletes on a daily
basis. In most cases, athletics department personnel
have the trust of the student-athlete and are someone
that the student-athlete turns to in difficult times or
personal crisis. In some cases, the student-athlete will
confide in a teammate and/or roommate. Also, there
are some student-athletes who will not be aware of
and/or inform anyone of their developing mental or
emotional health issue, but will act out in nonverbal
ways to let on that something is bothering them. In
addition, some student-athletes will demonstrate
behaviors that have at their root mental health issues.
For example, someone who gets in fights when drinking and shows up late all the time may actually be
struggling with depression.
Behaviors to Monitor
The behaviors in the following list are not all-inclusive,
may be singular or multiple in nature, and may be
subtle in appearance. Concern is warranted when the
following behaviors for a student-athlete change from
his/her normal lifestyle:
• Changes in eating and sleeping habits.
• Unexplained weight loss.
Drug and/or alcohol abuse.
Gambling issues.
Withdrawing from social contact.
Decreased interest in activities that have been
enjoyable, or taking up risky behavior.
Talking about death, dying or “going away.”
Loss of emotion, or sudden changes of emotion
within a short period of time.
Problems concentrating, focusing or remembering.
Frequent complaints of fatigue, illness or being
injured that prevent participation.
Unexplained wounds or deliberate self-harm.
Becoming more irritable or problems managing
Sport Psychology
Commonly, the term “sport psychologist” can mean
one of two things – someone who is licensed to practice psychology and can diagnose and treat mental
health problems with a special emphasis on athletes,
or someone trained to apply mental preparation techniques to athletes with an understanding of how physiological processes relate to performance.
While performance enhancement is a major part of
sport psychology and often provides a psychologist
entrée to discuss more serious clinical issues, some
NCAA member institutions are hiring licensed, clinical
psychologists to work with student-athletes on issues
ranging from mental preparation for competition and
relaxation to clinical depression and eating disorders.
Licensed mental health professionals can enhance the
medical care for student-athletes by:
• Providing mental health screening and prevention
• Conducting pre-participation evaluation screenings.
• Providing continuing care for concussion management.
• Managing eating disorders.
• Providing counseling on challenges and stresses
related to being a student-athlete.
• Resolving conflict between athlete and coach,
athlete and athlete, coach and administrator,
athlete and parent, etc.
• Serving as a key member of the athletics department catastrophic-incident team.
Establishing a Relationship
With Mental Health Services
Unless the athletics department staff member is a credentialed and practicing mental health care profession-
Medical Issues
Trigger events
There are events that may serve to trigger or
exacerbate a mental or emotional health concern
with a student-athlete. Some examples:
• Poor performance, or perceived “poor” performance by the student-athlete.
• Conflicts with coaches or teammates.
• A debilitating injury or illness, resulting in a
loss of playing time or surgery.
• Concussions.
• Class issues — schedule, grades, amount
of work.
• Lack of playing time.
• Family and relationship issues.
• Changes in importance of sport, expectations by self/parents, role of sport in life.
• Violence — being assaulted, a victim of
domestic violence, automobile accidents, or
merely witnessing a personal injury or assault
on a family member, friend or teammate.
• Adapting to college life.
• Death of a loved one or close friend.
• Alcohol or drug abuse.
• Significant dieting or weight loss.
• History of physical or sexual abuse.
• Gambling issues.
• Post-traumatic stress disorder (PTSD) for
combat veterans who are now enrolled in
college and participating in intercollegiate
al, the athletics department staff member should
refrain from attempts to “counsel” a student-athlete
who may be experiencing a mental health issue.
Encouraging student-athletes, or “giving them permission,” to seek help from mental health providers that
will help them gain insight into their situation, and
encouraging athletes that seeking counseling is a sign
of strength, not weakness, can be very useful.
Athletics departments should identify and foster relationships with mental health resources on campus or
within the local community that will enable the development of a diverse and effective referral plan
addressing the mental well-being of their student-athletes and staff. Because student-athletes are less
likely to use counseling than nonathlete students,
increasing interaction among mental health staff
members, coaches and student-athletes will improve
compliance with referrals. The sports medicine staff is
often a reasonable first resource for student-athletes
who are not at imminent risk, yet who do not feel
comfortable going directly to a mental health provider.
If the student-athlete requests a mental health care
evaluation, or is compelled to be evaluated because of
behavior that violates an institutional code of conduct,
then referring the student-athlete to the mental health
care system at your institution is recommended. There
are many avenues for the student-athlete to be
referred. Athletics departments can seek psychological services and mental health professionals from the
following resources:
• Athletics department sports medicine services.
• Athletics department academic services.
• University student health and counseling services.
• University medical school.
• University graduate programs (health sciences,
education, medical, allied health).
• Local community.
Understand that per institutional policy, unless a code
of conduct violation has occurred, the student-athlete
makes the final decision to go for a mental health
evaluation and care. The athletics department staff
member can encourage the student-athlete to go for
an evaluation and care, but unless there is a violation,
or a threat of self-harm or harm to others, then, per
institutional policy, the student-athlete can’t be compelled to go for an evaluation or care.
Available online at
2013-14 NCAA Sports Medicine Handbook
It is recommended that a relationship be developed
with the campus counseling services and any community mental health care professionals in order to facilitate referrals.
Confidentiality. The student-athlete’s privacy must be
respected unless he/she is at risk for self-harm or harm
to others. The student-athlete may be encouraged to
inform others about his/her care as appropriate. If the
student-athlete is under age, then refer to your institutional general counsel and student affairs office for
guidance in informing the parents or guardians.
Create a Supportive Environment. Coaches and
sports medicine staff members should follow the following guidelines in order to help enhance studentathlete compliance with mental health referrals:
• Express confidence in the mental health professional (e.g., “I know that other student-athletes
have felt better after talking to Dr. Kelly.”).
• Be concrete about what counseling is and how it
could help (e.g., “Amy can help you focus more
on your strengths.”).
• Focus on similarities between the student-athlete
and the mental health professional (e.g., “Bob
has a sense of humor that you would appreciate.”
“Dr. Jones is a former college student-athlete and
understands the pressures student-athletes
• Offer to accompany the student-athlete to the
initial appointment.
• Offer to make the appointment (or have the student-athlete make the appointment) while in your
• Emphasize the confidentiality of medical care and
the referral process.
The following self-help strategies may improve mild
depression symptoms:
• Reduce or eliminate the use of alcohol and drugs.
• Break large tasks into smaller ones; set realistic
• Engage in regular, mild exercise.
• Eat regular and nutritious meals.
• Participate in activities that typically make you
feel better.
• Let family, friends and coaches help you.
• Increase positive or optimistic thinking.
• Engage in regular and adequate sleep habits.
Emergency Considerations. If the student-athlete
reports suicidal feelings or comments, or he/she
reports feeling like harming others, follow the institution’s mental health issue emergency protocol. Be sure
the procedure is included in the athletics department
plan. Include phone numbers, protocol in staying with
the student-athlete, where to take the student-athlete
on campus or in the community, and counseling services contact numbers. It is recommended to work
with the student affairs office in developing this component of the plan, and be sure to contact appropriate
institutional departments in the event of an emergency,
per the institution’s plan.
Institutional Review of Plan. Have the Student-Athlete
Mental Health Considerations Plan reviewed and
approved by the institution’s general counsel, risk management, student affairs office and any other department recommended by the institution’s general counsel.
Mental Health Conditions and
Intercollegiate Athletics
As with physical injuries, mental health problems may,
by their severity, affect athletic performance and limit or
even preclude training and competition until successfully managed and treated. Some examples include:
Mood Disorders
• Depression
• Suicidal Ideation
Anxiety Disorders
• Panic Attacks
• Stress
• General Anxiety
• Obsessive Compulsive Disorder
• Eating Disorders and Disordered Eating
• Substance Abuse Disorders
Depression is more than the blues, letdowns from a
game loss, or the normal daily ups and downs. It is
feeling “down,” “low” and “hopeless” for weeks at a
time. Depression is a serious medical condition.
Little research has been conducted on depression
among student-athletes; however, preliminary data
indicate that student-athletes experience depressive
symptoms and illness at similar or increased rates than
nonathlete students. Approximately 9.5 percent of the
population — or one out of 10 people — suffers from a
depressive illness during any given one-year period.
Women are twice as likely to experience depression as
men; however, men are less likely to admit to depression. Moreover, even though the majority of people’s
Medical Issues
depressive disorders can be improved, most people
with depression do not seek help.
Depression is important to assess among student-athletes because it impacts overall personal well-being,
athletic performance, academic performance and injury
healing. No two people experience depressed feelings
in exactly the same way. However, with the proper treatment 80 percent of those who seek help and 50 percent
of those who are clinically depressed get better, and
many people begin to feel better in just a few weeks.
Student-athletes may experience depression because
of genetic predisposition, developmental challenges of
college transitions, academic stress, financial pressures,
interpersonal difficulties and grief over loss/failure.
Participation in athletics does not provide student-athletes any immunity to these stresses, and it has the
potential to pose additional demands. Studentathletes must balance all of the demands of being a
college student along with athletics demands. This
includes the physical demands of their sport, and the
time commitment of participation, strength and conditioning, and skill instruction.
Most student-athletes participate almost year-round,
often missing holidays, school and summer breaks,
classes and even graduation. In addition, if they struggle in their performance, have difficulty interacting with
the coach or teammates, or they lose their passion for
their sport, it can be very difficult to handle. Many athletes also define themselves by their role as an athlete,
and an injury can be devastating.
Some attributes of athletics and competition can make
it extremely difficult for student-athletes to obtain help.
They are taught to “play through the pain,” struggle
through adversity, handle problems on their own and
“never let anyone see you cry.” Seeking help is seen
as a sign of weakness, when it should be recognized
as a sign of strength.
Team dynamics also may be a factor. Problems often are
kept “in the family,” and it is common for teams to try to
solve problems by themselves, often ignoring signs or
symptoms of more serious issues. Depression affects
approximately 19 million Americans, and for many, the
symptoms first appear before or during college.
Early identification and intervention (referral/treatment)
for depression or other mental illness is extremely
important, yet may be inhibited within the athletics
culture for the following reasons:
• Physical illness or injury is more readily measured
and treated within sports medicine, and often
there is less comfort in addressing mental illness.
• Mental wellness is not always perceived as necessary for athletic performance.
• The high profile of student-athletes may magnify
the attention paid on campus and in the surrounding community when an athlete seeks help.
• History and tradition drive athletics and can
stand as barriers to change.
• The athletics department may have difficulty associating mental illness with athletic participation.
Enhancing Knowledge and Awareness of
Depressive Disorders. Sports medicine staff, coaches
and student-athletes should be knowledgeable about
the types of depression and related symptoms. Men
may be more willing to report fatigue, irritability, loss of
interest in work or hobbies and sleep disturbances,
rather than feelings of sadness, worthlessness and
excessive guilt, which are commonly associated with
depression in women. Men often mask depression with
the use of alcohol or drugs, or by the socially acceptable habit of working excessively long hours.
Types of Depressive Illness
Depressive illnesses come in different forms. The following are general descriptions of the three most prevalent, though for an individual the number, severity and
duration of symptoms will vary.
Major Depression, or “clinical depression,” is
manifested by a combination of symptoms that
interfere with a person’s once pleasurable activities
(school, sport, sleep, eating, work). Student-athletes
experiencing five or more symptoms for two weeks
or longer, or noticeable changes in usual functioning,
are factors that should prompt referral to the team
physician or mental health professional. Fifteen percent
of people with major depression die by suicide. The
rate of suicide in men is four times that of women,
though more women attempt it during their lives.
Dysthymia is a less severe form of depression that
tends to involve long-term, chronic depressive symptoms. Although these symptoms are not disabling,
they do affect the individual’s overall functioning.
Bipolar Disorder, or “manic-depressive illness,”
involves cycling mood swings from major depressive
2013-14 NCAA Sports Medicine Handbook
episodes to mania. Depressive episodes may last as
little as two weeks, while manic episodes may last as
little as four days.
In addition to the three types of depressive disorders,
student-athletes may suffer from an adjustment disorder. Adjustment disorders occur when an individual
experiences depressive (or anxious) symptoms in
response to a specific event or stressor (e.g., poor
performance, poor relationship with a coach). An
adjustment disorder can also progress into major
depressive disorder.
Screening for Depression
and Related Risk for Suicide
One way to ensure an athletics department is in tune
with student-athletes’ mental well-being is to systematically include mental health checkups, especially
around high-risk times such as the loss of a coach or
teammate, significant injury, being cut from the team
and catastrophic events. Members of the sports
medicine team and/or licensed mental health professionals should also screen athletes for depression at
pre-established points in time (e.g., pre-participation,
exit interviews). Research indicates that sports medicine professionals are better equipped to assess
depression with the use of appropriate mental health
instruments; simply asking about depression is not
A thorough assessment on the part of a mental health
professional is also imperative to differentiate major
depression from dysthymia and bipolar disorder, and
other conditions, such as medication use, viral illness,
anxiety disorders, overtraining and illicit substance
use. Depressive disorders may co-exist with substance-abuse disorders, panic disorder, obsessivecompulsive disorder, anorexia nervosa, bulimia nervosa
and borderline personality disorder.
For depression screening, it is recommended that
sports medicine teams use the Center for
Epidemiological Studies Depression (CES-D) Scale
published by the National Institute for Mental Health
(NIMH). The CES-D is free to use and available at Other resources include such programs as QPR (Question, Persuade, Refer) Gatekeeper
training; the Jed Foundation ULifeline; and the
Screening for Mental Health depression and anxiety
screenings. Information about these programs, and
ways to incorporate them into student-athlete checkups, can be found at
What to look for
Depressive signs and symptoms
Individuals might present:
• Decreased performance in school or sport.
• Noticeable restlessness.
• Significant weight loss or weight gain.
• Decrease or increase in appetite nearly
every day (fluctuating?).
Individuals might express:
• Indecisiveness.
• Feeling sad or unusual crying.
• Difficulty concentrating.
• Lack of or loss of interest or pleasure in
activities that were once enjoyable (hanging
out with friends, practice, school, sex).
• Depressed, sad or “empty” mood for most
of the day and nearly every day.
• Recurrent thoughts of death or thoughts
about suicide.
• Frequent feelings of worthlessness, low
self-esteem, hopelessness, helplessness or
inappropriate guilt.
Manic signs and symptoms
Individuals might present:
• Abnormal or excessive elation.
• Unusual irritability.
• Markedly increased energy.
• Poor judgment.
• Inappropriate social behavior.
• Increased talking.
Individuals might express:
• Racing thoughts.
• Increased sexual desire.
• Decreased need for sleep.
• Grandiose notions.
Seeking Help
Most individuals who suffer from depression will fully
recover to lead productive lives. A combination of
counseling and medication appears to be the most
effective treatment for moderately and severely
depressed individuals. Although some improvement in
mood may occur in the first few weeks, it typically
takes three to four weeks of treatment to obtain the full
therapeutic effect. Medication should only be taken
and/or stopped under the direct care of a physician,
Medical Issues
Approaching the
Student-Athlete with a
Potential Mental Health Issue
Approaching anyone with a concern over mental
well-being can be an uncomfortable experience.
However, the health and wellness of the studentathlete is paramount. It is important to have
facts correctly, with context, before arranging a
private meeting with the student-athlete. The
conversation should focus on the student-athlete
as a person, not as an athlete. Empathetic listening and encouraging the student-athlete to
talk about what is happening is essential.
Consider questions that are open ended and
encouraging for the student-athlete to talk about
his or her issue:
• “How are things going for you?”
• “Tell me what is going on.”
• “Your behavior (mention the incident or incidents) has me concerned for you. Can you
tell me what is going on, or is there something I need to understand or know why
this incident happened?”
• “Tell me more (about the incident).”
• “How do you feel about this (the incident or
the facts presented?”
• “Tell me how those cuts (or other wounds)
got there.”
• “Perhaps you would like to talk to someone
about this issue?”
• “I want to help you, but this type of issue is
beyond my scope as (coach, athletic
trainer, administrator, support staff
member), but I know how to refer you to
someone who can help.”
• Alcohol and drug abuse as an attempt at selftreatment.
• Overtraining or burnout, since depression has
many of the same symptoms.
• Manic-type symptoms.
1. Backmand J, et. al. Influence of physical activity on depression and
anxiety of former elite athletes. International Journal of Sports
Medicine. 2003. 24(8):609-919.
2. Hosick, M. Psychology of sport more than performance enhancement.
The NCAA News. March 14, 2005. Available online.
3. Klossner, DA. Essay: Individuals Providing Consultation on the
Psychology of Sport within NCAA Division I Institutions. Journal of
Intercollegiate Sport. 2012;4(2): 243 – 246.
3. Maniar SD, Chamberlain R, Moore N. Suicide risk is real for studentathletes. The NCAA News. November 7, 2005. Available online.
4. Maniar SD, Curry LA, Sommers-Flanagan J, Walsh JA. Studentathlete preferences in seeking help when confronted with sport
performance problems. The Sport Psychologist. 2001;15(2):205-23.
5. National Institute of Mental Health. Depression. Bethesda (MD):
National Institute of Mental Health, National Institutes of Health, U.S.
Department of Health and Human Services; 2000. (NIH Publication
No 02-3561). 25 pages. Available at
6. Neal, TL. Syracuse University. Considerations in Identifying and
Referring Student-Athletes with Potential Mental Health Issues. 2010.
7. Pinkerton RS, Hinz LD, Barrow JC. The college student-athlete:
Psychological considerations and interventions. Journal of American
College Health. 1989;37(5):218-26.
8. Putukian, M, Wilfert, M. Student-athletes also face dangers from
depression. The NCAA News. April 12, 2004. Available online.
9. Schwenk, TL. The stigmatization and denial of mental illness in
athletes. British Journal of Sports Medicine. 2000. 34:4-5.
and the team physicians should consult with psychiatrists regarding complex mental health issues.
A referral should be made to a licensed mental health
professional when coaches or sports medicine staff
members witness any of the following with their student-athletes:
• Reported suicidal thoughts.
• Multiple depressive symptoms.
• A few depressive symptoms that persist for
several weeks.
• Depressive symptoms that lead to more severe
symptoms or destructive behaviors.
2013-14 NCAA Sports Medicine Handbook
Participation by the StudentAthlete With Impairment
January 1976 • Revised August 2004
In accordance with the recommendations of major
medical organizations and pursuant to the requirements of federal law (in particular, the Rehabilitation
Act of 1976 and the Americans With Disabilities Act),
the NCAA encourages participation by student-athletes
with physical or mental impairments in intercollegiate
athletics and physical activities to the full extent of
their interests and abilities. It is imperative that the university’s sports medicine personnel assess a studentathlete’s medical needs and specific limitations on an
individualized basis so that needless restrictions will be
avoided and medical precautions will be taken to minimize any enhanced risk of harm to the student-athlete
or others from participation in the subject sport.
A student-athlete with impairment should be given an
opportunity to participate in an intercollegiate sport if
he or she has the requisite abilities and skills in spite
of his or her impairment, with or without a reasonable
accommodation. Medical exclusion of a student-athlete from an athletics program should occur only when
a mental or physical impairment presents a significant
risk of substantial harm to the health or safety of the
student-athlete and/or other participants that cannot
be eliminated or reduced by reasonable accommodations. Recent judicial decisions have upheld a university’s legal right to exclude a student-athlete from
competition if the team physician has a reasonable
medical basis for determining that athletic competition
creates a significant risk of harm to the student-athlete or others. When student-athletes with impairments not otherwise qualified to participate in existing
athletics programs are identified, every means should
be explored by member institutions to provide suitable sport and recreational programs in the most
appropriate, integrated settings possible to meet their
interests and abilities.
Participation Considerations
Before allowing any student-athlete with an impairment
to participate in an athletics program, it is recommended that an institution require joint approval from the
physician most familiar with the student-athlete’s condition, the team physician and an appropriate official of
the institution, as well as his or her parent(s) or guardian. The following factors should be considered on an
individualized basis in determining whether he or she
should participate in a particular sport:
1. Available published information regarding the medical risks of participation in the sport with the athlete’s mental or physical impairment;
2. The current health status of the student-athlete;
3. The physical demands of the sport and position(s)
that the student-athlete will play;
4. Availability of acceptable protective equipment or
measures to reduce effectively the risk of harm to
the student-athlete or others; and
5. The ability of the student-athlete [and, in the case
of a minor, the parent(s) or guardian] to fully understand the material risks of athletic participation.
Organ Absence or Nonfunction
When the absence or nonfunction of a paired organ
constitutes the impairment, the following specific
issues need to be addressed with the student-athlete
and his/her parents or guardian (in the case of a
minor). The following factors should be considered:
• The quality and function of the remaining organ;
• The probability of injury to the remaining organ; and
• The availability of current protective equipment
and the likely effectiveness of such equipment to
prevent injury to the remaining organ.
Medical Release
When a student-athlete with impairment is allowed to
compete in the intercollegiate athletics program, it is recommended that a properly executed document of understanding and a waiver release the institution for any legal
liability for injury or death arising from the student-athlete’s participation with his or her mental or physical
impairment/medical condition. The following parties
should sign this document: the student-athlete, his or her
parents/guardians, the team physician and any consulting physician, a representative of the institution’s athletics department, and the institution’s legal counsel. This
document evidences the student-athlete’s understanding
of his or her medical condition and the potential risks of
athletic participation, but it may not immunize the institution from legal liability for injury to the student-athlete.
1. American Academy of Pediatrics, Committee on Sports Medicine and
Fitness. Medical Conditions Affecting Sports Participation Pediatrics.
94(5): 757-60, 1994.
2. Mitten, MJ. Enhanced risk of harm to one’s self as a justification for
exclusion from athletics. Marquette Sports Law Journal. 8:189-223, 1998.
3. CASE SUMMARY: Knapp v. Northwestern University: No. 95 C6454,
1996 WL 495559 (N.D.ILL. AUG. 18, 1996) Journal of Art and
Entertainment Law
Medical Issues
January 1986 • Revised June 2009
The NCAA Committee on Competitive Safeguards
and Medical Aspects of Sports acknowledges the
significant input of Dr. James Clapp, FACSM, in the
revision of this guideline.
Pregnancy Policies
Pregnancy places unique challenges on the student-athlete. Each member institution should have a
policy clearly outlined to address the rights and
responsibilities of the pregnant student-athlete. The
policy should address:
• Where the student-athlete can receive confidential counseling;
• Where the student-athlete can access timely
medical and obstetrical care;
• How the pregnancy may affect the student-athlete’s team standing and institutional grants-in-aid;
• That pregnancy should be treated as any other
temporary health condition regarding receipt of
institutional grants-in-aid; and
• That NCAA rules permit a one-year extension of
the five-year period of eligibility for a female student-athlete for reasons of pregnancy.
Student-athletes should not be forced to terminate a
pregnancy because of financial or psychological pressure or fear of losing their institutional grants-in-aid.
See Bylaw, which specifies that institutional
financial aid based in any degree on athletics ability
may not be reduced or canceled during the period of
its award because of an injury, illness or physical or
mental medical condition.
The team’s certified athletic trainer or team physician is
often approached in confidence by the student-athlete.
The sports medicine staff should be well-versed in the
athletics department’s policies and be able to access
the identified resources. The sports medicine staff
should respect the student-athlete’s requests for confidentiality until such time when there is medical reason
to withhold the student-athlete from competition.
Exercise in Pregnancy
Assessing the risk of intense, strenuous physical activity in pregnancy is difficult. There is some evidence
that women who exercise during pregnancy have
improved cardiovascular function, limited weight gain
and fat retention, improved attitude and mental state,
easier and less complicated labor and enhanced postpartum recovery. There is no evidence that increased
activity increases the risk of spontaneous abortion in
uncomplicated pregnancies. There are, however, theo-
Warning Signs to Terminate
Exercise While Pregnant
Vaginal bleeding
Shortness of breath before exercise
Chest pain
Calf pain or awelling
Preterm labor
Decreased fetal movement
Amniotic fluid leakage
Muscle weakness
retical risks to the fetus associated with increased core
body temperatures that may occur with exercise,
especially in the heat.
The fetus may benefit from exercise during pregnancy in
several ways, including an increased tolerance for the
physiologic stresses of late pregnancy, labor and delivery.
The safety of participation in individual sports by a
pregnant woman should be dictated by the movements and physical demands required to compete in
that sport and the previous activity level of the individual. The American College of Sports Medicine discourages heavy weight lifting or similar activities that
require straining or valsalva.
Exercise in the supine position after the first trimester
may cause venous obstruction, and conditioning or
training exercises in this position should be avoided.
Sports with increased incidences of bodily contact
(basketball, ice hockey, field hockey, lacrosse, soccer,
rugby) or falling (gymnastics, equestrian, downhill
skiing) are generally considered higher risk after the
first trimester because of the potential risk of abdominal trauma. The student-athlete’s ability to compete
also may be compromised due to changes in physiologic capacity, and musculoskeletal issues unique to
pregnancy. There is also concern that in the setting of
intense competition a pregnant athlete will be less
2013-14 NCAA Sports Medicine Handbook
likely to respond to internal cues to moderate exercise
and may feel pressure not to let down the team.
The American College of Obstetrics and Gynecology
states that competitive athletes can remain active
during pregnancy but need to modify their activity as
medically indicated and require close supervision.
If a student-athlete chooses to compete while pregnant, she should:
• Be made aware of the potential risks of her particular sport and exercise in general while pregnant;
• Be encouraged to discontinue exercise when
feeling overexerted or when any warning signs
(see page 91) are present;
• Follow the recommendations of her obstetrical provider in coordination with the team physician; and
• Take care to remain well-hydrated and to avoid
After delivery or pregnancy termination, medical clearance is recommended to ensure the student-athlete’s
safe return to athletics. (See Follow-up Examinations
section of Guideline 1C.) The physiologic changes of
pregnancy persist four to six weeks postpartum;
however, there have been no known maternal complications from resumption of training. Care should be taken
to individualize return to practice and competition.
1. Pregnant & Parenting Student-athletes: Resources and Model
Policies. 2009.
2. American College of Obstetrics and Gynecology Committee on
Obstetric Practice: Exercise During Pregnancy and the Postpartum
Period. Obstetrics and Gynecology 99(1) 171-173, 2002.
3. American College of Sports Medicine: Exercise During Pregnancy. In:
Current Comment from the American College of Sports Medicine,
Indianapolis, IN, August 2000.
4. Clapp JF: Exercise During Pregnancy, A Clinical Update. Clinics in
Sports Medicine 19(2) 273-286, 2000.
The Student-Athlete
With Sickle Cell Trait
Medical Issues
October 1975 • Revised June 2013
Sickle cell trait is not a disease and is not a barrier to
exercise or participation in sport. It is the inheritance
of one gene for normal hemoglobin (A) and one gene
for sickle hemoglobin (S), giving the genotype AS.
Sickle cell trait (AS) is not sickle cell anemia (SS), in
which two abnormal genes are inherited. Sickle cell
anemia causes major anemia and many clinical problems, whereas sickle cell trait causes no anemia and
few clinical problems. Sickle cell trait will not turn into
the disease. However, it is possible to have symptoms
of the disease under extreme conditions of physical
stress or low oxygen levels. In some cases, athletes
with the trait have expressed significant distress, collapsed and even died during rigorous exercise.
People at high risk for having sickle cell trait are those
whose ancestors come from Africa, South or Central
America, the Caribbean, Mediterranean countries,
India and Saudi Arabia. Sickle cell trait occurs in about
8 percent of the U.S. African-American population and
rarely (between one in 2,000 and one in 10,000) in the
Caucasian population. It is present in athletes at all
levels, including high school, collegiate, Olympic and
professional. Sickle cell trait is no barrier to outstanding athletic performance.
Sickle cell trait is generally benign and consistent with
a long, healthy life. As they get older, some people
with the trait become unable to concentrate urine nor-
mally, but this is not a key problem for college athletes. Most athletes complete their careers without any
complications. However, there are three constant concerns that exist for athletes with sickle cell trait: gross
hematuria, splenic infarction, and exertional rhabdomyolysis, which can be fatal.
Gross hematuria, visible blood in the urine, usually
from the left kidney, is an occasional complication of
sickle cell trait. Athletes should consult a physician for
return-to-play clearance.
Splenic infarction can occur in people with sickle cell
trait, typically at altitude. The risk may begin at 5,000 feet
and increases with rising altitude. Vigorous exercise (e.g.,
skiing, basketball, football, hiking, anaerobic conditioning) may increase the risk. Splenic infarction causes left
upper quadrant or lower chest pain, often with nausea
and vomiting. It can mimic pleurisy, pneumothorax, side
stitch or renal colic. Splenic infarction at altitude has
occurred in athletes with sickle cell trait. Athletes should
consult a physician for return-to-play clearance.
Exertional rhabdomyolysis can be life threatening.
During intense exertion and hypoxemia, sickled red
cells can accumulate in the blood. Dehydration
worsens exertional sickling. Sickled red cells can
“logjam” blood vessels in working muscles and
provoke ischemic rhabdomyolysis. Exertional rhabdo-
NCAA fact sheets and video for coaches and student-athletes are available at
2013-14 NCAA Sports Medicine Handbook
Best practices
The NCAA has published best practices for fall
sports preseason periods throughout guidelines
in this handbook on emergency care, preseason
preparation and heat illness prevention.
myolysis is not exclusive to athletes with sickle cell
trait. Planned emergency response and prompt access
to medical care are critical components to ensure adequate response to a collapse or athlete in distress.
The U.S. armed forces linked sickle cell trait to sudden
unexplained death during basic training. Recruits with
sickle cell trait were about 30 times more likely to die
than other recruits. The deaths were initially classified as
either acute cardiac arrest of undefined mechanism or
deaths related to heatstroke, heat stress or rhabdomyolysis. Further analysis showed that the major risk was
severe exertional rhabdomyolysis, a risk that was about
200 times greater for recruits with sickle cell trait. Deaths
among college athletes with sickle cell trait, almost
exclusively in football dating back to 1974, have been
from exertional rhabdomyolysis, including early cardiac
death from hyperkalemia and lactic acidosis and later
metabolic death from acute myoglobinuric renal failure.
In other cases, athletes have survived collapses while
running a distance race, sprinting on a basketball court
or football field, and running timed laps on a track. The
harder and faster athletes go, the earlier and greater the
sickling. Sickling can begin in only two to three minutes
of sprinting, or in any other all-out exertion of sustained
effort, thus quickly increasing the risk of collapse.
Athletes with sickle cell trait cannot be “conditioned” out
of the trait, and coaches pushing these athletes beyond
their normal physiological response to stop and recover
place these athletes at an increased risk for collapse.
An exertional collapse in a student-athlete with sickle
cell trait can be a medical emergency. Even the fittest
athletes can experience a collapse. Themes from the
literature describe athletes with sickle cell trait experiencing ischemic pain and muscle weakness rather than
muscular cramping or “locking up.” Unlike cardiac collapse (with ventricular fibrillation), the athlete who
slumps to the ground from sickling can still talk. This
athlete is typically experiencing major lactic acidosis,
impending shock and imminent hyperkalemia from
sudden rhabdomyolysis that can lead to life-threaten-
ing complications or even sudden death. The emergent
management of a collapsed athlete is covered in the
references. In general, athletes with sickle cell trait may
have more problems recovering during exercise or following a collapse and should be monitored closely.
Screening for sickle cell trait as part of the medical
examination process is required in Division I, Division II
and Division III institutions unless documented results
of a prior test are provided to the institution or the student-athlete or prospective student-athlete declines the
test and signs a written release. The references allude
to growing support for the practical benefits of screening, and campuses that screen are increasing in frequency. Although sickle cell trait screening is normally
performed on all U.S. babies at birth, many student-athletes may not know whether they have the trait.
Screening can be accomplished with a simple blood
test that is relatively inexpensive. However, screening
positives must be confirmed with additional diagnostic
testing such as hemoglobin electrophoresis or high performance liquid chromatography (HPLC) to detect the
specific hemoglobinopathies. If a test is positive, the
student-athlete should be offered counseling on the
implications of sickle cell trait, including health, athletics
and family planning. Screening can be used as a
gateway to targeted precautions.
Precautions can enable student-athletes with sickle
cell trait to thrive in their sport. These precautions are
outlined in the references and in a 2007 NATA
Consensus Statement on Sickle Cell Trait and the
Athlete. Knowledge of a student-athlete’s sickle cell
status should facilitate prompt and appropriate
medical care during a medical emergency.
Student-athletes with sickle cell trait should be knowledgeable of these precautions, and institutions should
provide an environment in which these precautions
may be activated. In general, these precautions
suggest student-athletes with sickle cell trait should:
• Set their own pace.
• Engage in a slow and gradual preseason conditioning regimen to be prepared for sports-specific
performance testing and the rigors of competitive
intercollegiate athletics.
• Build up slowly while training (e.g., paced
• Use adequate rest and recovery between repetitions, especially during “gassers” and intense
station or “mat” drills.
Medical Issues
• Not be urged to perform all-out exertion of any kind
beyond two to three minutes without a breather.
• Be excused from performance tests such as
serial sprints or timed mile runs, especially if
these are not normal sport activities.
• Stop activity immediately upon struggling or experiencing symptoms such as muscle pain, abnormal weakness, undue fatigue or breathlessness.
• Stay well hydrated at all times, especially in hot
and humid conditions.
• Maintain proper asthma management.
• Refrain from extreme exercise during acute
illness, if feeling ill, or while experiencing a fever.
• Access supplemental oxygen at altitude as
• Seek prompt medical care when experiencing
unusual distress.
1. NATA Consensus Statement: Sickle cell trait and the athlete, June 2007.
2. Clarke CE, Paul S, Stilson M, Senf J: Sickle cell trait preparticipation
screening practices of collegiate physicians. Clin J Sport Med
3. Eichner ER: Sickle cell trait. J Sport Rehab 2007;16:197-203.
4. Eichner ER: Sickle cell trait and athletes: three clinical concerns.
Curr Sports Med Rep 2007;6:134-135.
5. Kark JA, Posey DM, Schumacher HR, Ruehle CJ: Sickle-cell trait as a
risk factor for sudden death in physical training. N Engl J Med
6. Gardner JW, Kark JA: Fatal rhabdomyolysis presenting as mild heat
illness in military training. Milit Med 1994;159:160-163.
7. Bergeron MF, Gannon JG, Hall EL, Kutlar A: Erythrocyte sickling during
exercise and thermal stress. Clin J Sport Med 2004;14:354-356.
8. Eichner ER: Sickle cell trait and the athlete. Gatorade Sports Science
Institute Sports Science Exchange 2006; 19(4):1-4.
9. Browne RJ, Gillespie CA: Sickle cell trait: A risk factor for lifethreatening rhabdomyolysis? Phys Sportsmed 1993;21(6):80-88.
10.Dincer HE, Raza T: Compartment syndrome and fatal rhabdomyolysis
in sickle cell trait. Wisc Med J 2005;104:67-71.
11.Makaryus JN, Catanzaro JN, Katona KC: Exertional rhabdomyolysis
and renal failure in patients with sickle cell trait: Is it time to change
our approach? Hematology 2007;12:349-352.
12.Mitchell BL: Sickle cell trait and sudden death – bringing it home. J
Nat Med Assn 2007;99:300-305.
2013-14 NCAA Sports Medicine Handbook
Sun Protection
June 2012
Exposure to sunlight or ultraviolet (UV) light has a profound effect on the skin causing damage, premature
skin aging, eye damage, immune system suppression
and skin cancer. Repeated unprotected exposure to
the sun’s UVA and UVB rays can lead to sunburns,
cataracts (clouding of the eye lens), photoaging and
skin wrinkling and can contribute to skin cancer.
Skin cancer is the most common type of cancer and
is thought to account for half of all cancers. About
3.5 million cases of nonmelanoma skin cancer (basal
cell or squamous cell cancers, the two most common
types of skin cancer) are diagnosed each year.
Melanoma, the third most common type of skin cancer,
accounts for fewer than 5 percent of skin cancer cases
but causes a majority of skin cancer deaths.
Risk Factors
Skin cancer is largely preventable by limiting exposure
to the primary source of ultraviolet (UV) radiation, sunlight. Reducing exposure to the sun’s UV rays can
decrease the risk of sunburn, skin cancer and photoaging. People with high levels of exposure to UV radiation
are at an increased risk for all three major forms of skin
cancer. The U.S. Environmental Protection Agency (EPA)
estimates that the sun causes 90 percent of nonmelanoma skin cancers. Approximately 65 to 90 percent of
melanomas can be attributed to exposure to UV radiation, and because a substantial percentage of lifetime
sun exposure occurs before age 20, UV light exposure
during childhood and adolescence plays an important
role in the development of skin cancer. Other risk
factors include lighter natural skin color and skin that
burns, freckles, reddens easily, or becomes painful in
the sun; appearance of moles (particularly an increased
number of moles or an atypical mole or changing mole);
family history of skin cancer; increasing age; and use of
artificial UV radiation (e.g. tanning beds).
Environmental factors that increase the
amount of UV radiation exposure are also of
importance to note, including latitude (closer
distance to the equator), higher altitude, light
cloud coverage (UV rays can penetrate clouds,
windshields, windows and light clothing) and the
presence of materials that reflect the sun (e.g.
snow, pavement, water and sand).
Unprotected skin can be damaged by the sun’s
UV rays in as little as 15 minutes. Reducing exposure to the sun’s UV rays can decrease the risk of
skin damage and developing skin cancer. Wearing
Risk factors
Primary Risk Factors
Exposure to UV radiation is the most important
risk factor for developing skin cancer. Other risk
factors include:
• Those who have had at least one severe,
blistering sunburn.
• A lighter natural skin color and skin that
burns, freckles, reddens easily or becomes
painful in the sun.
• Appearance of moles (particularly, an
increased number of moles or an atypical
or changing mole).
• Total amount of sun exposure over a lifetime.
• Use of artificial UV radiation (e.g. tanning
• Family history of skin cancer.
• Increasing age.
Environmental Risk Factors
The hours between 10 a.m. and 4 p.m. daylight
saving time (9 a.m. to 3 p.m. standard time) are
the most hazardous for UV exposure outdoors.
Environmental factors that increase the amount
of UV radiation exposure include:
• Latitude (closer distance to the equator).
• Higher altitude.
• Light cloud coverage (UV rays can get
through clouds, windshields, windows and
light clothing).
• The presence of materials that reflect the
sun (e.g. snow, pavement, water and sand).
Medical Issues
broad spectrum (UVA and UVB) sunscreens and/or
clothing to protect as much skin as possible when
exposed to the sun are key components of a comprehensive skin protection program. Sunscreens help to
prevent UV radiation from reaching the skin; however,
no sunscreen provides complete and total protection.
Avoiding the sun during the midday hours provides
additional defense against skin damage. However, if
the sun cannot be avoided, implementation of alternative sun protection measures (e.g. seeking shade,
wearing a hat, protective clothing, sunglasses and
using sunscreen) is paramount. With the right precautions student-athletes and athletics staff can participate safely in outdoor athletics activities.
Protective measures
Primary protective measures that help reduce the
risk for skin cancer:
• Avoiding the sun between 10 a.m. and 4 p.m.
• Wearing sun-protective clothing when
exposed to the sun.
• Using a broad spectrum sunscreen with a
sun-protection factor (SPF) greater than or
equal to 30.
• Avoiding tanning beds and other artificial
sources of UV light.
Research suggests a need for improved primary prevention of UV damage among NCAA student-athletes.
According to research, fewer than 10 percent of collegiate student-athletes reported using sunscreen regularly, defined as at least three of the previous seven days.
Fifty-three percent of U.S. adults were “very likely” to
protect themselves from the sun by practicing at least
one sun protection measure. Another study of 290 student-athletes from two NCAA universities found that 96
percent of respondents believed sunscreen would help
protect them from skin cancer. Yet, 43 percent of the
student-athletes surveyed reported never using sunscreen, 31 percent reported only using sunscreen one
to three days per week, 18 percent reported using sunscreen four to six days per week, and 8 percent reported using sunscreen every day of the week.
wearing a hat and protective clothing; and using sunscreen), which can be implemented without compromising athletics participation while gradually making
feasible scheduling changes.
More than 250,000 NCAA student-athletes participate
in outdoor sports. Sun protection measures should not
reduce student-athlete participation. Institutions may
find it difficult to avoid scheduling activities around the
midday hours or when UV radiation is most damaging.
Institutions should focus their efforts on promoting
other protection measures (e.g. seeking shade;
Personal Sun Protection Recommendations
Research suggests improved availability of sunscreen
increases use among collegiate athletes. A study of
collegiate women golfers reported the application of
sunscreen increased significantly when athletes had
easy access to sunscreen during practice and competition, highlighting an opportunity to improve sun-protective behaviors. A study, which included 13 NCAA
outdoor sports, found that the percentage of athletes
who wore sunscreen increased significantly with the
frequency of coaches or athletic administrators speaking with them about sun protection.
• Liberally and evenly apply a golf ball-sized amount
(palm full) of a broad-spectrum sunscreen evenly
over all exposed areas. For those with thin or thinning hair, apply sunscreen to the scalp, as well.
• Apply a broad spectrum sunscreen with an SPF
greater than 30 before going outdoors.
2013-14 NCAA Sports Medicine Handbook
• Reapply sunscreen every two hours and after
swimming, perspiring and toweling off.
• Always wear protective clothing before going
- Long-sleeve shirts or sun sleeves.
- A wide-brimmed hat to shade the face, head,
ears, and neck (at least a 2- to 3-inch brim all
around is ideal).
- Sunglasses that wrap around and block as close
to 100 percent of both UVA and UVB rays as
• Do not use tanning beds or other artificial
sources of UV light.
• Maintain proper hydration.
Recommendations for Athletics Health Care
Providers and Athletics Administrators
• Serve as a sun safety role model.
• Promote a culture of sun safety and awareness.
• Educate student-athletes and athletics staff about
UV protection and skin cancer prevention.
• Use the preparticipation examination as an
opportunity to educate student-athletes and
parents about skin damage and skin cancer
• Assess athletics staff and each team’s sun exposure patterns and reinforce sun-safe behaviors.
• Provide sun protection resources to student-athletes, coaches, athletics staff, administrators and
institutional staff.
• Advocate for sun protection policies and practices with appropriate athletics and institutional
• Improve access to sunscreen for student-athlete
use at every outdoor practice and competition.
• Encourage sunscreen and protective clothing
(e.g. long-sleeve shirts, hats and sunglasses) as
indispensable during outdoor practice as sports
• Consider ultraviolet protection factor (UPF)
clothing for outdoor practice and competition
• Stay in the shade whenever possible and assist
athletics staff in choosing locations with shade
for outdoor activities. Seek alternative methods
of shade such as tents, umbrellas and shade
from buildings.
• Make sun protection behaviors routine so that
wearing protective gear and taking time out to
reapply sunscreen become as much a part of athletics practices and competitions as water breaks.
1. Centers for Disease Control and Prevention (CDC) Division of Cancer
Prevention and Control, National Center for Chronic Disease
Prevention and Health Promotion (NCCDPHP). (2012). Skin cancer.
Available at
2. Chavez, Daniel. Young athletes and skin cancer risk. Medical News
Today. MediLexicon, Intl., 16 Aug. 2005. Available online at www.
3. Cohen PH, Tsai H, Puffer JC.: Sun-protective behavior among highschool and collegiate athletes in Los Angeles, CA. Clin J Sport Med,
16(3):253-60, 2006 May.
4. Dubas, LE, Adams, BB., Department of Dermatology, University of
Cincinnati, Cincinnati, Ohio.: Sunscreen use and availability among
female collegiate athletes. J Am Acad Dermatol, 2012 Feb.
5. Hamant, ES, Adams BB.: Sunscreen use among collegiate athletes. J
Am Acad Dermatol, 53(2):237-41, 2005 Aug.
6. Miller, NS. NCAA athletes not using sunscreen. Skin & Allergy News
Digital Network 10 Nov. 2011. Available online at www.
7. The Nemours Foundation. (2012). Sun safety. Available at http://
8. Rogers HW, et al.: Incidence estimate of nonmelanoma skin cancer in
the United States, 2006. Arch Dermatol,. 46(3):283-287, 2010.
9. United States Environmental Protection Agency. The SunWise
Program. (2012). Available at
Medical Issues
July 2013
The NCAA Committee on Competitive Safeguards and
Medical Aspects of Sports acknowledges the significant
input of Dr. Randy Eichner in the revision of this guideline.
Rhabdomyolysis is breakdown of skeletal muscle. In
common use, however, rhabdomyolysis connotes an
acute clinical syndrome of major muscle breakdown
and leakage into the bloodstream of muscle contents
(electrolytes, myoglobin, other proteins) as reflected
by a sharp rise in serum creatine kinase (CK). The
many causes of rhabdomyolysis can be categorized
as: 1) trauma; 2) muscle hypoxia; 3) genetic defects;
4) infections; 5) body temperature changes; 6) metabolic or electrolyte disturbances; 7) drugs or toxins;
and 8) exercise. This guideline focuses on rhabdomyolysis from exercise, or exertional rhabdomyolysis
(ER). The first case series of ER was in 1960 in
Marines doing squat jumps. ER also occurs in police
and firefighter trainees, in overeager weightlifters and
novice extreme exercise participants, in prisoners who
overexert, in fraternity men who endure exercise
hazing, in school kids pushed too hard in physical
education class, and in recreational athletes who
overdo it in training or competition. This guideline will
focus on the NCAA student-athlete.
Exertional rhabdomyolysis occurs in the setting of
strenuous exercise and can range from mild to severe.
Clinical signs are often nonspecific: muscle pain, soreness, stiffness, and, in severe cases, weakness, loss of
mobility, and swollen, tender muscles. Severe ER is far
more problematic than the milder form known as
delayed onset muscle soreness (DOMS), in which
muscles become sore and stiff in the first few days
after a bout of unaccustomed, moderately strenuous
exercise. DOMS is rarely a clinical problem and tends
to be self-limited with only relative rest or a cutback in
level of training. An even milder form of ER is the physiologic breakdown of muscle that commonly occurs
while athletes train. This physiological muscle adaption
to exercise overload has few or no symptoms, or only
mild muscle symptoms that are generally ignored by
the athlete, and so is manifest only by an elevation in
serum creatine kinase (CK) – a condition sometimes
called hyperCKemia.
Unlike hyperCKemia or DOMS, severe ER is a major
health concern for any athlete. A challenge to the early
recognition of ER for the athlete and clinician is that
signs and symptoms of it during the triggering bout of
intense exercise can be few and subtle. But there are
clues that coaches and athletic trainers can watch for
outlined by case examples involving team outbreaks.
Importantly, signs and symptoms of severe ER can
begin in the first few hours after the triggering exercise
bout and tend to peak over the subsequent two days.
Severe Exertional Rhabdomyolysis
The clinical diagnosis of severe exertional rhabdomyolysis soon after an overly intense exercise bout is a
physician’s judgment call that hinges in part on the fol-
Serial Postures of Exertional Collapse
Athletes in active recovery to early fatigue: continue rehydration, rest intervals, cooling and controlled breathing.
Athletes who are showing signs of physical distress should be allowed to set their own pace while conditioning.
Instruct athletes to rest while experiencing symptoms as they may soon feel better and be ready to continue. If
symptoms reoccur or progress, the athlete should stop exercise and be assessed by a health care provider.
Athletes unable to stand on their own from a kneeling position or having trouble walking normally during
recovery should raise suspicion of distress, and additional medical intervention should be considered.
2013-14 NCAA Sports Medicine Handbook
lowing features that help separate severe ER from the
overlapping but milder DOMS:
• Muscle pain more severe and sustained than
• Swelling of muscles and adjacent soft tissues.
• Weak muscles, especially in hip or shoulder
• Limited active and passive range of motion.
• Brown (“Coca-Cola”) urine from myoglobin.
First, men tend to have CK levels about twice as high
as women, and African-American men tend to have CK
levels about twice as high as white men. These gender
and ethnic differences in baseline CK level may in part
reflect differences in muscle mass, muscle-fiber type
and habits of physical activity.
Thirteen football players were hospitalized for ER
following the first team workout after their threeweek winter break. The workout was characterized as some upper body work and sled pushing
with 100 timed back squats at 50 percent top
weight for one repetition. The institution’s investigative committee concluded that the back squats
were the likely cause of the ER and said that
coaches told the players that the workout would
be a tough challenge that “would demonstrate
who wanted to be on the team.” Within the first
two days, players reported with dark urine and
severe leg pain, with complaints of difficulty
putting on shoes or climbing stairs. These symptoms continued for days until ER was diagnosed
in the players. All athletes went home over the
next few days as symptoms subsided, and all but
one returned to play within the next few weeks.
Second, athletes tend to have CK levels higher than
nonathletes, and CK can vary by sport and stage of
training. For example, in a study of 12 Division I football players during two-a-days, mean CK was normal
at the start (about 200 U/L), but by Day 4 had risen
25-fold (to about 5,000 U/L). Despite this sharp rise in
CK level, all 12 players practiced football throughout
the 10-day study without complications.
Another football team outbreak of ER occurred in
January out-of-season training at a Division I
institution. It was similar in some ways to the
previously mentioned outbreak, occurring soon
after a winter break transition period and including an intense back-squat drill. Up to five players
developed ER, and one player had bilateral fasciotomy for thigh compartment syndrome.
The clinical diagnosis of ER is commonly confirmed by
documenting an elevated serum creatine kinase level.
This raises the question of how to interpret CK levels.
Several variables must be considered.
Third, there can be a wide range of serum CK elevation
among exercising athletes. This was seen in the above
football study, and is even more striking in laboratory
studies that control the type and duration of exercise.
For example, when college men perform the same bout
of elbow-flexor exercise, the peak CK response can
vary 100-fold, from about 250 U/L to about 25,000 U/L.
Fourth, the rate of rise in CK levels can vary in developing exertional rhabdomyolysis cases. This rate can be
slow, over three to four days to a peak CK, as in the
elbow-flexor exercise studies; or it can be rapid, as in
exertional collapse in athletes or soldiers with sickle cell
trait (SCT), where serum CK can reach 100,000 U/L in a
few hours and exceed 1 million U/L by the next day.
Given these variables, what level of CK confirms ER that
requires action? The U.S. military advises the following
action for severe muscle pain if the CK is five times the
upper limit of normal (ULN): oral hydration, relative rest
and re-evaluation the next day. If the CK is greater than
Case 1: Football
5,000 U/L, the military advises referral to a medical treatment facility for full clinical and laboratory evaluation,
intravenous hydration and possible hospital admission.
These low CK values for clinical action cast a wide
safety net but seem to conflict with research on ER in
basic military training (BMT). In a recent study of 499
recruits during two weeks of BMT in hot and cool climates, none developed “clinically significant” ER
(defined by muscle weakness, elevated CK, and myoglobin in serum or urine), although muscle pain and soreness were common, and nearly 90 percent of recruits
had elevations in CK. At Day 7 of BMT, the range in CK
levels was wide, from about 55 U/L to about 35,000 U/L;
just more than 25 percent of the recruits had a CK
greater than five times the ULN, and just more than 10
percent had a CK greater than 10 times the ULN.
The military researchers concluded that any ER in
recruits in BMT is not “clinically significant” if there is no
muscle weakness or swelling, no myoglobin in the urine,
Medical Issues
no laboratory evidence of acute kidney injury (AKI) or
electrolyte imbalance, and if the CK is less than 50 times
the ULN. If this can be translated to sports medicine,
given that the ULN for CK tends to be about 200-250
U/L, then any ER in an athlete is not necessarily “clinically significant” if the serum CK is less than 10,000-12,500
U/L. This may be true, but it casts too narrow a safety
net, because in fulminant ER from exertional collapse in
the athlete with sickle cell trait, for example, the initial CK
in the emergency room can be less than 1,000 U/L, but
the CK can increase exponentially in a few hours to
50,000-100,000 U/L. The bottom line is that wise and
timely clinical decisions in athletes with ER are not easy
and require informed physician judgment. Some lessons
can be learned from recent NCAA team outbreaks of ER.
Lessons From Team Outbreaks:
10 Factors That Can Increase the Risk
of Exertional Rhabdomyolysis
1. Athletes who try the hardest — give it their all to
meet the demands of the coach (externally driven) or
are considered the hardest workers (internally driven).
2. Workouts not part of a periodized, progressive
performance enhancement program (e.g., workouts not part of the annual plan).
3. Novel workouts or exercises immediately following
a transitional period (winter/spring break).
4. Irrationally intense workouts intended to punish or
intimidate a team for perceived underperformance,
or to foster discipline and “toughness.”
5. Performing exercise to muscle failure during the
eccentric phase of exercise such as repetitive
squats (e.g. the downward motion of squats) and
then pushed beyond to continue.
6. Focusing a novel intense drill/exercise on one
muscle with overload and fast repetitions to failure.
7. Increasing the number of exercise sets and reducing the time needed to finish (e.g., 100 squats,
timed runs, station drills).
8. Increasing the amount of weight lifted as a percentage of body weight.
9. Trying to “condition” athletes into shape in a day
or even over several days, especially with novel
exercises or loads.
10. Conducting an unduly intense workout ad hoc after
a game loss and/or perceived poor practice effort.
Risk Factors for ER
Exertional rhabdomyolysis in an NCAA team athlete is
commonly linked to three conditions:
• Novel overexertion.
• Exertional heatstroke.
• Exertional collapse with complications in athletes
with sickle cell trait.
Novel overexertion is the single most common cause of
exertional rhabdomyolysis and is characterized as too
much, too soon, and too fast. Team outbreaks of ER in
NCAA athletes (refer to case examples) have similarities
of irrationally intense workouts designed and conducted
by coaches and/or strength and conditioning personnel.
Consistent factors in military service ER cases include
low baseline fitness and repetitive eccentric exercises.
2013-14 NCAA Sports Medicine Handbook
Eccentric exercise is when a muscle contracts as an
external force tries to lengthen it. Examples include
downhill running, squats, push-ups, sit-ups, pull-ups,
chair dips, plyometrics and lowering weights. Even
though almost every athletic workout has an eccentric
component, ER often occurs when exertion is pushed
beyond the point at which fatigue would normally
compel an individual to stop, such as what can occur
during group exercise under demanding supervision
or peer pressure.
Exertional heatstroke (EHS) and ER share common risk
factors such as history of prior heat illness, elevated
environmental heat and humidity, dehydration, or the
abuse of stimulants. ER can accompany EHS but is
rarely if ever the vital problem. Deaths in EHS are from
heat damage to vital organs; the victim dies with some
ER, but not directly from ER. In contrast, sickle cell
trait is a critical risk factor for ER as deaths have been
attributed directly to a seemingly unrecoverable metabolic cascade of ER. How to approach both EHS and
sickle cell trait are covered in separate guidelines elsewhere in this handbook.
Other risk factors for ER are either rare or would preclude top athleticism in the first place. These include a
severe viral invasion of the muscles, gravely low blood
potassium, or an inborn metabolic myopathy. Among
the drugs considered risk factors for ER, special consideration should be given to stimulants and pre-workout supplements.
Novel overexertion is by far the most common cause
of ER; with early diagnosis and proper therapy, this
condition is benign. For example, a recent brief review
reported nearly 400 cases of ER (absent EHS or SCT)
from novel overexertion in soldiers, athletes or other
young people. All were benign. In sharp contrast, both
EHS and exertional sickling can be fatal. However, ER
from novel overexertion can lead to mild AKI, and/or
muscle compartment syndrome, which if not treated
promptly can lead to long-term disability.
It is vital that all coaches, strength and conditioning
personnel, and athletic trainers prevent ER from novel
overexertion, recognize it early and activate their emergency action plan while notifying the team physician
for full clinical and laboratory assessment, rehydration
to ensure good urine output, pain relief, and monitoring for acute compartment syndrome. After treatment
for ER, the physician must assess the athlete for risk
of recurrence, consider further testing, and decide on
Case 2: Football summer camp
A team outbreak of ER occurred in a small high
school. A new football coach introduced an
intense, novel, triceps-focused drill, alternating
chair dips and push-ups on the first day of a
summer camp. This reported workout involved
five consecutive bouts, with fast repetitions,
competitive motivation and no rest periods.
Over the next few days, half of the team
members went to the hospital for ER, 12 were
admitted, and three had surgery (fasciotomy) to
release triceps muscle compartments under
high pressure from the ER (compartment syndrome). The risk of ER was higher in the harder
working players.
Case 3: Swimming
On a Day 1 practice after a summer break, the
41 members of a Division I swim team met a new
coach and a new, grueling drill before their usual
two hours of swimming. The drill was as many
push-ups as possible in a minute, followed by as
many body squats as possible in a minute, with
the sequence repeated for 10 minutes. Other
upper body workouts continued on Days 2-3,
along with swim practice. Beginning on Day 2
and continuing on subsequent days, several
swimmers, men and women, presented with
severe pain, swelling, and limited motion of the
triceps and pectoral muscles, and dark urine. All
were hospitalized. All went home in three to six
days as their symptoms subsided, and all
returned to college swimming.
when, if and under what conditions the athlete can
safely return to play. A three-phase return-to-play
guideline is recommended for athletes deemed as low
risk for recurrence (refer to O’Conner et al reference).
Athletes with recurrent rhabdomyolysis or cramping should seek additional testing by a specialist.
Tips for Prevention and Early Recognition
of ER from Novel Overexertion
• Moderation. Avoid too much, too soon, too fast.
Educate everyone in the athletics department
conducting exercise sessions – especially the
Medical Issues
Case 4: Lacrosse
On Day 1, after a three-month hiatus, a women’s
NCAA lacrosse team did three sets of 20 biceps
curls with weights. The next day, several of them
had painful, stiff, swollen biceps muscles. They
gradually improved and by three weeks were
back to full participation. They all completed the
competitive season.
Case 5: Lacrosse
An outbreak in NCAA women’s lacrosse occurred
after a team lost its first game of the season. The
student-athletes’ next workout was reported to
design focus on the upper body and was new to
them, with limited recovery on subsequent days.
Example exercises included many pull-ups, chinups and dips. Subsequent complaints included
arms feeling “prickly, tingly” and being shaky and
stiff; difficulty raising arms overhead to catch
balls; and difficulty driving because of sore and
stiff arms. Athletes experienced dark urine and
were hospitalized for ER three days after the
initial workout. All went home over the next three
to five days, and all but one soon returned to
lacrosse. The athlete who did the most pull-ups
had the worst and longest course of ER.
coaches/strength and conditioning personnel –
on all aspects of exertional rhabdomyolysis from
novel overexertion and the additive effect of all
physical exertion on the athlete.
• Strength and conditioning workouts are the
highest risk rather than sport skills, drills or competitions. Group workouts in general can be risky
if they drive all athletes at the same pace and
intensity. Sometimes the athlete who tries the
hardest to meet the demands of his/her coach
suffers the worst ER.
• Avoid high-intensity conditioning workouts after
vacations or seasonal breaks or on returning from
injury. Athletes cannot be “conditioned into shape”
in a day.
• The design of a workout should reflect a collaborative effort between a strength and conditioning coach and medical staff. However, athlete
safety assumes the individual conducting the
exercise sessions takes reasonable actions to
allow recovery and prevent exertional collapse.
All training programs should start slowly, build
gradually, include adequate rest, and allow for individual differences. Avoid reckless intensity in an
effort to make everyone bigger, stronger and faster.
Workouts are meant to improve fitness, skills and
athletic performance. They should be rational,
physiologic and sport-specific. Avoid the use of
additive physical activity as punishment or for
building toughness.
Athlete’s physical readiness changes day to day.
Encourage athletes to set their own pace or at
least communicate with them frequently to learn
if undue symptoms are developing. As the
workout ends, watch them closely and ask them
how they feel. Athletes who are showing signs of
physical distress should be allowed to set their
own pace while conditioning.
Fluids should be regularly available, and frequent
breaks should be scheduled.
Set the right tone. Workouts are to enhance performance, not to punish or intimidate. Never use
exercise as a form of punishment in an athlete
experiencing physical distress. Athletes should
feel free to report any symptom at any time and
obtain immediate help. Athletic trainers should
be authorized to step in to provide care for an
athlete in distress at any time without retribution.
Encourage athletes to read their body, cut back
or stop if they start to struggle, and report immediately any concerning symptom, especially any
peculiar, atypical or undue muscle discomfort,
pain, swelling, stiffness or weakness.
Post a urine-color chart in the locker room, athletic
training room, and near urinals and restroom stalls.
Athletes should report dark urine immediately.
If one athlete on a team develops early signs or
symptoms of possible ER, evaluate all members
of the team who participated in the exercise
session for ER.
Design, file and practice an emergency action
plan (EAP) for exertional heatstroke (EHS) and for
exertional sickling in sickle cell trait (SCT).
Coaches should be ready to intervene when athletes show signs of distress. Minutes count in
these life-threatening emergencies. See the guidelines in this handbook on EAP, EHS and SCT.
If you suspect that an athlete is developing ER
from novel overexertion (absent EHS or SCT), the
EAP should be activated, and the team physician
should be promptly notified.
2013-14 NCAA Sports Medicine Handbook
1. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury.
NEJM 2009;361:62-72.
2. Ehlers GG, Ball TE, Liston L. Creatine kinase levels are elevated
during 2-a-day practices in collegiate football players. J Athl Train
3. Eichner ER. An outbreak of muscle breakdown: A morality play in
four acts. Curr Sports Med Rep 2010;9:325-26.
4. Eichner ER. Rhabdo redux: “Don’t know much about history.” Curr
Sports Med Rep 2011;10:174-75.
5. Galvez G, Stacy J, Howley A. Exertional rhabdomyolysis in seven
Division-1 swimming athletes. Clin J Sport Med 2008;18:366-68.
6. Hill OT, Wahi MM, Carter R, et al. Rhabdomyolysis in the US active
duty Army, 2004-2006. Med Sci Sports Exerc 2012;44:442-49.
7. Kenney K, Landau ME, Gonzalez RS, et al. Serum creatine kinase
after exercise: Drawing the line between physiologic response and
exertional rhabdomyolysis. Muscle Nerve 2012;45:356-62.
8. Landau ME, Kenney K, Deuster P, Campbell R. Exertional
rhabdomyolysis: A clinical review with a focus on genetic influences.
J Clin Neuromusc Dis 2012;13:122-36.
9. Mougios V. Reference intervals for serum creatine kinase in athletes.
Br J Sports Med 2007;41:674-78.
10.Oh JY, Laidler M, Fials SC, Hedberg K. Acute exertional
rhabdomyolysis and triceps compartment syndrome during a high
school football camp. Sports Health 2012;4:57-62.
11.O’Conner FG, Brennan FH, Campbell, W, Heled Y, Deuster, P. Return
to physical activity after exertional rhabdomyolysis. Current Sports
Medicine Reports 2008;7:328-331.
12.Smoot MK, Amendola A, Cramer E, et al. A cluster of exertional
rhabdomyolysis affecting a Division 1 football team. Clin J Sport Med
2013;0:1-8 (Epublished ahead of print).
2013-14 NCAA Sports Medicine Handbook
Protective Equipment
June 1983 • Revised June 2007
Rules governing mandatory equipment and equipment
use vary by sport. Athletics personnel should be familiar with what equipment is mandatory by rule and
what constitutes illegal equipment; how to wear mandatory equipment during the contest; and when to
notify the coaching staff that the equipment has
become illegal during competition. Athletics personnel
involved in sports with established equipment standards should adhere to those standards.
American Society for Testing and Materials (ASTM)
International is one organization that creates specifications, test methods and practices for sports
equipment, surfaces and facilities to reduce inherent
risk of injuries. The National Operating Committee
on Standards for Athletic Equipment (NOCSAE) mark
on a helmet or Hockey Equipment Certification
Council (HECC) seal on an ice hockey face mask
indicates that the equipment has been tested by the
manufacturer in accordance with NOCSAE or HECC
test standards. By keeping a proper fit, by not modifying its design, and by reporting to the coach or
equipment manager any need for its maintenance,
the student-athlete also is complying with the
purpose of the standard.
The following list of mandatory equipment and rules
regarding protective equipment use is based on NCAA
sports rules. The most updated information should be
obtained from relevant NCAA rules committees.
Sport Mandatory Protective Equipment
Rules Governing Special Protective Equipment
1. Baseball
1. A double ear-flap protective helmet while
batting, on deck and running bases.
Helmets must carry the NOCSAE mark.
2. All catchers must have a built-in or
attachable throat guard on their masks.
3. All catchers are required to wear a protective helmet when fielding their position.
2. Basketball
Elbow, hand, finger, wrist or forearm
guards, casts or braces made of fiberglass,
plaster, metal or any other nonpliable substance shall be prohibited. Pliable (flexible
or easily bent) material covered on all exterior sides and edges with no less than
½-inch thickness of a slow-rebounding
foam shall be used to immobilize and/or
protect an injury. The prohibition of the use
of hard-substance material does not apply
to the upper arm, shoulder, thigh or lower
leg if the material is padded so as not to
create a hazard for other players.
Equipment that could cut or cause an injury
to another player is prohibited, without
respect to whether the equipment is hard.
Equipment that, in the referee’s judgment, is
dangerous to other players, may not be worn.
3. Fencing
1. Masks with meshes (space between the
wires) of a maximum of 2.1 millimeters and
from wires with a minimum gauge of 1 millimeters diameter.
2. Gloves, of which the gauntlet must fully
cover approximately half the forearm of the
competitor’s sword arm.
3. Jacket or vest and metallic lames.
4. Ladies’ chest protectors made of metal
or some other rigid material.
5. Underarm protector.
4. Field
1. The following equipment is permitted for
use only by goalkeepers: body and wraparound throat protectors, pads, kickers,
gauntlet gloves, helmet incorporating fixed
full-face protection and cover for the head,
and elbow pads.
2. Mouthguards for all players including
3. Wrap-around throat protector and helmet
for player designated as a “kicking back.”
In the event of a defensive penalty corner,
the “kicking back” must also wear a chest
protector and distinguishing jersey.
Mandatory Equipment and Special Equipment Rules
Players shall not wear anything that may be
dangerous to other players. Players have
the option of wearing soft headgear subject
to game official approval.
2013-14 NCAA Sports Medicine Handbook
Mandatory Equipment and Special Equipment Rules
Sport Mandatory Protective Equipment
Rules Governing Special Protective Equipment
5. Football
1. Soft knee pads at least ½-inch
thick that are covered by pants. It is strongly recommended that they cover the knees.
No pads or protective equipment may be
worn outside the pants.
2. Face masks and helmets with a secured
four- or six-point chin strap. All players
shall wear helmets that carry a warning
label regarding the risk of injury and a
manufacturer’s or reconditioner’s certification indicating satisfaction of NOCSAE test
3. Shoulder pads, hip pads with tailbone
protectors and thigh guards.
4. An intra-oral mouthpiece of any readily
visible color (not white or transparent) with
FDA-approved base materials (FDCS) that
covers all upper teeth. It is recommended
that the mouthpiece be properly fitted.
Illegal equipment includes the following:
1. Equipment worn by a player, including
artificial limbs, that would endanger other
2. Hard, abrasive or unyielding substances
on the hand, wrist, forearm or elbow of any
player, unless covered on all exterior sides
and edges with closed-cell, slow-recovery
foam padding no less than ½-inch thick, or
an alternate material of the same minimum
thickness and similar physical properties.
Hard or unyielding substances are permitted, if covered, only to protect an injury.
Hand and arm protectors (covered casts or
splints) are permitted only to protect a fracture or dislocation.
3. Thigh guards of any hard substances,
unless all surfaces are covered with material
such as closed-cell vinyl foam that is at
least ¼-inch thick on the outside surface
and at least 3/8-inch thick on the inside surface and the overlaps of the edges; shinguards not covered on both sides and all
edges with closed-cell, slow-recovery foam
padding at least ½-inch thick, or an alternate material of the same minimum thickness having similar physical properties; and
therapeutic or preventive knee braces,
unless worn under the pants and entirely
covered from direct external exposure.
4. Projection of metal or other hard substance from a player’s person or clothing.
6. Gymnastics
7. Ice Hockey
1. Helmet with chin straps securely fastened. It is recommended that the helmet
meet HECC standards.
2. An intra-oral mouthpiece that covers all
the upper teeth.
3. Face masks that have met the standards
established by the HECC-ASTM F 513-89
Eye and Face Protective Equipment for
Hockey Players Standard.
1. The use of pads or protectors made of
metal or any other material likely to cause
injury to a player is prohibited.
2. The use of any protective equipment that
is not injurious to the player wearing it or
other players is recommended.
3. Jewelry is not allowed, except for religious or medical medals, which must be
taped to the body.
8. Women’s
1. The goalkeeper must wear a helmet with
face mask, separate throat protector, a
mouthpiece and a chest protector.
2. All field players shall wear properly an intraoral mouthpiece that covers all upper teeth.
3. All field players shall wear protective
eyewear that meets current ASTM lacrosse
standards (effective January 1, 2005).
Protective devices necessitated on genuine
medical grounds must be approved by the
umpires. Close-fitting gloves, nose guards,
eye guards and soft headgear may be worn
by all players. These devices must create
no danger to other players.
Sport Mandatory Protective Equipment
Rules Governing Special Protective Equipment
9. Men’s
1. Protective helmet that carries the
NOCSAE mark, equipped with face mask
and chin pad, with a cupped four-point chin
strap (high-point hookup).
2. Intra-oral mouthpiece that covers all the
upper teeth and is yellow or any other highly visible color.
3. Protective gloves, shoulder pads,
shoes and jerseys. Shoulder pads shall
not be altered.
4. Throat protector and chest protector are
required for the goalie.
1. A player shall not wear any equipment
that, in the opinion of the official, endangers the individual or others.
2. The special equipment worn by the
goalkeeper shall not exceed standard
equipment for a field player, plus standard
goalkeeper equipment, which includes
shinguards, chest protectors and throat
10. Rifle
Shooters and range personnel in
the immediate vicinity of the range
required to wear hearing protection
during smallbore. Shooters are urged
to wear shatterproof eye protection.
11. Soccer
Players shall wear shinguards under the
stockings in the manner intended, without
exception. The shinguards shall be professionally manufactured, age and size
appropriate and not altered to decrease
protection. The shinguards must meet
NOCSAE standards.
1. A player shall not wear anything that is
dangerous to another player.
2. Knee braces are permissible provided no
metal is exposed.
3. Casts are permitted if covered and not
considered dangerous.
4. A player shall not wear any jewelry of
any type whatsoever. Exception: Medical
alert bracelets or necklaces may be worn
but must be taped to the body.
12. Skiing
Helmets manufactured for ski racing are
required in all Alpine events and event training.
13. Softball
1. Catchers must wear foot-to-knee shinguards; NOCSAE-approved protective helmet with face mask and built-in or attachable throat guard; and chest protector.
2. An NOCSAE-approved double-ear flap
protective helmet must be worn by players
while batting, running the bases or warming
up in the on-deck circle.
Casts, braces, splints and protheses must
be well-padded to protect both the player
and opponent and must be neutral in color.
If worn by a pitcher, they cannot be distracting on the nonpitching arm. If worn on
the pitching arm, they may not cause safety
risk or unfair competitive advantage.
14. Swimming
and Diving
15. Track and
Pole vault box collar pad that meets ASTM
standard beginning December 1, 2013.
1. No taping of any part of the hand,
thumb or fingers will be permitted in the
discus and javelin throws, and the shot
put, except to cover or protect an open
wound. In the hammer throw, taping of
individual fingers is permissible. Any taping must be shown to the head event
judge before the event starts.
2. In the pole vault, the use of a forearm
cover to prevent injuries is permissible.
Mandatory Equipment and Special Equipment Rules
2013-14 NCAA Sports Medicine Handbook
Mandatory Equipment and Special Equipment Rules
Sport Mandatory Protective Equipment
Rules Governing Special Protective Equipment
16. Volleyball
1. It is forbidden to wear any object that may
cause an injury or give an artificial advantage
to the player, including but not limited to
headgear, jewelry and unsafe casts or braces. Religious medallions or medical identifications must be removed from chains and
taped or sewn under the uniform.
2. All jewelry must be removed. Earrings
must be removed. Taping of earrings or
other jewelry is not permitted.
3. Hard splints or other potentially dangerous protective devices worn on the arms or
hands are prohibited, unless padded on all
sides with at least ½-inch thick slow
rebounding foam.
17. Water Polo
Cap with protective ear guards.
18. Wrestling
Protective ear guard.
1. Anything that does not allow normal
movement of the joints and prevents one’s
opponent from applying normal holds shall
be barred.
2. Any legal device that is hard and abrasive must be covered and padded. Loose
pads are prohibited. It is recommended that
all wrestlers wear a protective mouthguard.
3. Jewelry is not allowed.
Eye Safety in Sports
January 1975 • Revised August 2013
Eye injuries in sports are relatively frequent, sometimes
catastrophic, and almost completely preventable with
the use of appropriate protective devices. A sports eye
protector may be a spectacle, a goggle, a face-supported protector, or a protector attached to a helmet. It
comes with or without lenses, is capable of being held
securely in place and may protect the face as well as
the eyes. Some forms can be worn over regular
glasses. Sports eye protectors are specially designed,
fracture-resistant units that comply with the American
Society for Testing and Materials (ASTM), or the
National Operating Committee on Standards for Athletic
Equipment (NOCSAE) standards for specific sports.
ed for all sports with the potential for impact. Other
impact-resistant lens materials may be available in the
near future. Contact lenses are not capable of protecting the eye from direct blows. Student-athletes who
wear contact lenses for corrective vision should wear
appropriate sports safety eyewear for ocular protection.
Approximately one-third of all people participating in
sports require corrective lenses to achieve the visual
acuity necessary for proper and safe execution of their
particular sports activity. Athletes who need corrective
eyewear for participation should use lenses and frames
that meet the appropriate safety standards. At this
time, polycarbonate plastic is the only clear lens material that has been tested for sports and is recommend-
1. Protection: Athletes’ eyes need certified sports protective eyewear that will protect against injury with
lenses that protect from impact and ultra-violet light.
Sports with a moderate to high risk of eye injury
include basketball, baseball, softball, lacrosse, field
hockey, ice hockey, fencing, rifle, tennis, soccer, volleyball, water polo, football, golf and wrestling.
The most common sports vision concerns include:
2. Correction: Spectacle wearers require sports protective eyewear that also will correct their vision,
while contact-lens wearers may need a different
lens than their everyday one.
2013-14 NCAA Sports Medicine Handbook
3. Vision enhancement: Athletes may desire help
enhancing their binocularity or depth perception.
The American Academy of Ophthalmology recommends
that head, face and eye protection should be certified
by either the Hockey Equipment Certification Council
(HECC —, the National Operating
Committee on Standards for Athletic Equipment
(NOCSAE), or the Canadian Standards Association
(CSA — The cited websites
will have more specific information on these standards.
Certification ensures that the protective device has
been properly tested to current standards.
Protective eyewear should be considered for all sports
that have a projectile object (ball/stick) whose size and/or
speed could potentially cause ocular damage. Eye protection is especially important for functionally one-eyed
sports participants (whose best corrected vision in their
weaker eye is 20/40 or worse). Eye protection devices
are designed to significantly reduce the risk of injury but
can never provide a guarantee against such injuries.
1. Appropriate for eye protection in sports:
a. Safety sports eyewear that conforms to the
requirements of the American Society for
Testing and Materials (ASTM) Standard F803
for selected sports (racket sports, basketball,
women’s lacrosse and field hockey).
b. Sports eyewear that is attached to a helmet or is
designed for sports for which ASTM F803
eyewear alone provides insufficient protection.
Those for which there are standard specifications
include skiing (ASTM 659) and ice hockey (ASTM
F513). Other protectors with NOCSAE standards
are available for football and men’s lacrosse.
2. Not appropriate for eye protection in sports:
a. Streetwear (fashion) spectacles that conform
to the requirements of American National
Standards Institute (ANSI) Standard Z80.3.
b. Safety eyewear that conforms to the requirements of ANSI Z87.1, mandated by OSHA for
industrial and educational safety eyewear.
1. Prevent Blindness America: 1998 Sports and Recreational Eye
Injuries. Schaumburg, IL: Prevent Blindness America; 1999.
2. Napier SM, Baker RS, Sanford DG, et al.: Eye Injuries in Athletics and
Recreation. Survey of Ophthalmology. 41:229-244, 1996.
3. Vinger PF: The Eye and Sports Medicine. In Duane TD, Jaeger EA
(eds): Clinical Ophthalmology, vol. 5, chapter 45, J.B. Lippincott,
Philadelphia, PA 1994.
4. Vinger PF, Parver L, Alfaro DV, Woods T, Abrams BS. Shatter
resistance of spectacle lenses. JAMA 1997; 277:142-144.
5. Vinger PF. A practical guide for sports eye protection. Physician and
Sportsmedicine, 2000;28;49-69.
6. Play hard—play safe. San Francisco, CA: American Academy of
Ophthalmology, 2001.
January 1986 • Revised August 2007
The NCAA has mandatory equipment rules, including the
use of mouthguards for selective sports. Various studies of
“properly fitted mouthguards” indicate that they may reduce
dental injuries when blows to the jaws or head are received.
The American Dental Association has urged the mandatory use of mouthguards for those engaged in athletics activities that involve body contact and endorsed
their use “in sporting activities in which a significant
risk of oral injury may occur.” It is important when considering the optimum protection for an athlete that a
thorough medical history be taken and the demands of
his or her position and sporting activity be considered.
Specific objectives for the use of “properly fitted mouthguards” as protective devices in sports are as follows:
1. “Properly fitted mouthguards” could reduce the
potential chipping of tooth enamel surfaces and
reduce fractures of teeth, roots or bones.
2. “Properly fitted mouthguards” could protect the lip
and cheek tissues from being impacted and lacerated against tooth edges.
3. “Properly fitted mouthguards” could reduce the
incidence of a fractured jaw caused by a blow
delivered to the chin or head.
4. “Properly fitted mouthguards” could provide protection to toothless spaces, so support is given to
the missing dentition of the student-athlete.
Stock, mouth-formed and custom-fitted are three
types of mouthguards recognized by the American
Dental Association. All need to be properly fitted for
maximum protection. Student-athletes should be
advised as to which “properly fitted mouthguard” is
best for them and how it is best maintained to ensure
the maximum fit and protection for daily practices and
game-day wear. Medical staff personnel should regularly oversee and observe the student-athletes and the
“properly fitted mouthguards.”
In order to realize fully the benefits of wearing a
mouthguard, the coach, student-athlete and medical
staff need to be educated about the protective functions of a mouthguard, and the game rules regarding
mouthguard use must be enforced.
2013-14 NCAA Sports Medicine Handbook
Mandatory Equipment and Special Equipment Rules
Covers All
Sport Position Mouthguard
ColorUpper Teeth
(NCAA Mod. 8.1.b);
strongly recommended for
Not specified
Not specified
Regular season
competition and
NCAA championships
(NCAA 1.4.4.e)
Readily visible
color (not white or
Regular season
postseason competition and NCAA
Ice Hockey
(NCAA 9.5)
Covers all
the remaining
teeth of one
Regular season
competition and
NCAA championships
(NCAA 2.8)
Not specified
Regular season
competition and
NCAA championships
(NCAA 1.20)
Yellow or any other
visible color
Regular season
competition and
NCAA championships
1. Using mouthguards to reduce the incidence and severity of sportsrelated oral injuries. American Dental Association. 2006.
2. Kumamoto, D and Maeda, Y. A literature review of sports-related
orofacial trauma. General Dentistry. 2004:270-281.
3. Bourdin M, Brunet-Patru I, Hager P, Allard Y, Hager J, Lacour J,
Moyen B. Influence of maxillary mouthguards on physiological
parameters. MSSE. (38)8: 1500-1504. 2006.
4. Academy for Sports Dentistry. “Position Statement: ‘A Properly
Fitted Mouthguard’ Athletic Mouthguard Mandates.” Available at
5. Stenger, J.M. “Mouthguards: Protection Against Shock to Head,
Neck and Teeth.” Journal of the American Dental Association. Vol.
69 (3). 273-281. 1964.
6. “Sports Dentistry.” (1991, October. Revised 2000, April). Dental
Clinics of North America.
7. American Dental Association. “Your Smile With a Mouthguard.” (211
East Chicago Avenue, Chicago, IL, 60611). 1999.
8. Winters, J.E. “The Profession’s Role in Athletics.” Journal of the
American Dental Association. Vol. 127. 810-811. 1996.
9. Using mouthguards to reduce the incidence and severity of sports-
related oral injuries. ADA Council on Access, Prevention and
Interprofessional Relations; ADA Council on Scientific Affairs. J Am
Dent Assoc. Dec;137(12):1712-20. 2006.
10.Knapik JJ, Marshall SW, Lee RB, Darakjy SS, Jones SB, Mitchener
TA, delaCruz GG, Jones BH. Mouthguards in sport activities: history,
physical properties and injury prevention effectiveness. Sports Med.
Use of the Head as
a Weapon in Football
and Other Contact Sports
January 1976 • Revised June 2002
Head and neck injuries causing death, brain damage
or paralysis occur each year in football and other
sports. While the number of these injuries each year
is relatively small, they are devastating occurrences
that have a great impact on student-athlete health
and well-being. Most of these catastrophic injuries
result from initiating contact with the head. The injuries may not be prevented due to the forces encountered during collisions, but they can be minimized by
helmet manufacturers, coaches, players and officials
complying with accepted safety standards and
playing rules.
The American Football Coaches Association, emphasizing that the helmet is for the protection of the
wearer and should not be used as a weapon, addresses this point as follows:
1. The helmet shall not be used as the brunt of contact in the teaching of blocking or tackling;
2. Self-propelled mechanical apparatuses shall not be
used in the teaching of blocking and tackling; and
3. Greater emphasis by players, coaches and officials
should be placed on eliminating spearing.
Proper training in tackling and blocking techniques,
including a “see what you hit approach,” constitutes
an important means of minimizing the possibility of
catastrophic injury. Using the helmet as an injuryinflicting instrument is illegal and should be strongly
discouraged and penalized by coaches and game officials. This concern is not only in football, but also in
other contact sports in which helmets are used (e.g.,
ice hockey and men’s lacrosse).
Football and all contact sports should be concerned
with the prevention of catastrophic head injuries. The
rules against butting, ramming and spearing with the
helmet are for the protection of the helmeted player
and the opponent. A player who does not comply with
these rules in any sport is at risk for a catastrophic
injury or causing a catastrophic injury.
1. Banerjee R, Palumbo MA, Fadale FD. Catastrophic Cervical Spine
Injuries in the Collision Sport Athlete, Part 1: Epidemiology, Functional
Anatomy, and Diagnosis. Am J Sports Med. (32)4: 1077- 87. 2004.
2. Boden BP, Breit I, Beachler JA, Williams A, Mueller FO. Fatalities in
high school and college football players. Am J Sports Med.
41(5):1108-16. 2013
3. Boden BP, Tacchetti RL, Cantu, RC. Catastrophic Cervical Spine
Injuries in High School and College Football Players. Am J Sports
Med. (34)8:1223-32. 2006.
4. Kleiner, D.M., Almquist, J.L., Bailes, J., Burruss, P., Feurer, H., Griffin, L.Y.,
Herring, S., McAdam, C., Miller, D., Thorson, D., Watkins, R.G., Weinstein,
S. Prehospital Care of the Spine-Injured Athlete: A Document From the
Inter-Association Task Force for Appropriate Care of the Spine-Injured
Athlete. Dallas, National Athletic Trainers’ Association, March, 2001.
5. LaParade RF, Schnetzler KA, Broxterman RJ, Wentorf F, Wendland E,
Gilbert TJ: Cervical Spine Alignment in the Immobilized Ice Hockey
Player: A Computer Tomographic Analysis of the Effects of Helmet
Removal: Am J Sports Med 27: 177-180, 1999.
6. The Spine Injury Management Video Human Kinetics, Champaign,
7. Thomas BE, McCullen GM, Yuan HA: Cervical Spine Injuries in Football
Players: J Am Acad Orthop Surg Sept-Oct; 7 (5), 338-47, 1999.
8. Wojtys EM, Hovda D, Landry G, Boland A, Lovell M, McCrea M, Minkoff
J: Concussion in Sports: Am J Sports Med 27: 676-687, 1999.
NCAA Concussion Fact Sheets and Video
Available at
Heads Up: Concussion Tool Kit
CDC. Available at
3. Heads Up Video
NATA. Streaming online at
2013-14 NCAA Sports Medicine Handbook
Helmet Fitting
and Removal
June 1990 • Revised June 2013
Several sports, including football, men’s lacrosse and
ice hockey, require wearing tight-fitting, similarly constructed helmets. The following guidelines, while
focused on football, are applicable to periodic evaluation, fitting and removal of protective helmets worn in
any sport. These guidelines represent minimal standards of care that are designed to assist physicians,
coaches, athletic trainers, paramedics, EMTs and hospital personnel who care for student-athletes.
Medical coverage of interscholastic and intercollegiate
teams entails many routine preventive and acute health
care duties for dedicated practicing professionals;
however, an occasional, serious, on-the-field, lifethreatening head and/or neck injury poses a difficult
challenge. It is incumbent upon those individuals
assigned to provide medical coverage to be prepared
to handle each situation efficiently and expertly.
Proper on-the-field management of head and neck
injuries is essential to minimize sequelae, expedite
emergency measures and to prepare for transportation. The action of those in attendance must not compound the problem. For this reason, clear communication between the medical staff and emergency-transportation personnel should be maintained. It is important that those involved in the medical management of
teams engaged in collision and contact sports, and the
student-athlete be knowledgeable about the helmet.
The student-athlete should be instructed in the fitting,
care and use of the helmet. Helmet manufacturer
guidelines should be reviewed and followed for proper
fitting and care techniques.
The resilient plastic shell is shaped spherically to deflect
impacts. Interior suspension pads are designed to
match the skull contour to ensure a snug crown fit.
Various rigid and removable jaw and brow pads, along
with the chin strap, help to hold the sides of the helmet
firmly against the mandible and the forehead. When in
place, the front edge of the helmet should be positioned
about a finger’s breadth above the eyebrows. Pressure
on the helmet crown should be dissipated through the
interior suspension padding over the top of the head.
The helmet should fit snugly without dependence on the
chin strap. The helmet should not twist or slide when an
examiner grasps the face mask and attempts to rock or
turn the helmet with the wearer resisting the movement.
With a properly fitted helmet, the top of the head is
separated from the helmet shell by a uniform, function-
al, shock-absorbing support lining. Daily evaluation of
this support mechanism, including cheek and brow
pads, for placement and resiliency should be taught to
the student-athlete. Helmets that require air inflation
should be inflated and inspected daily by the studentathlete. Helmet shells should be examined weekly for
cracking and be inspected closely again if the face
mask has been bent out of shape. All helmets need to
be reconditioned and the attachments of the mask
replaced on a yearly basis.
Although the helmet is designed for a stable fit for protection during play, removal of the helmet by others is
relatively difficult. In the case of a head or neck injury,
jostling and pulling during removal presents high
potential for further trauma.
Unless there are special circumstances such as
respiratory distress coupled with an inability to
access the airway, the helmet should never be
removed during the pre-hospital care of the studentathlete with a potential head/neck injury unless:
1. The helmet does not hold the head securely, such
that immobilization of the helmet does not immobilize the head;
2. The design of the sport helmet is such that even
after removal of the face mask, the airway cannot
be controlled or ventilation provided;
3. After a reasonable period of time, the face mask
cannot be removed; or
4. The helmet prevents immobilization for transportation in an appropriate position.
When such helmet removal is necessary in any setting,
it should be performed only by personnel trained in
this procedure.
Ordinarily, it is not necessary to remove the helmet on
the field to evaluate the scalp. Also, the helmet can be
left in place when evaluating an unconscious studentathlete, an individual who demonstrates transient or
persistent neurological findings in his/her extremities,
or the student-athlete who complains of continuous or
transient neck pain.
Before the injured student-athlete is moved, airway,
breathing and circulation (ABCs) should be evaluated
by looking, listening and palpation. To monitor breathing, care for facial injury, or before transport regardless
of current respiratory status, the face mask should be
removed by cutting or unscrewing the loops that
attach the mask to the helmet. These loops may be
difficult to cut, necessitating the use of PVC pipe
cutters, garden shears or a screwdriver. Those involved
in the pre-hospital care of the injured student-athlete
should have readily available proper tools for easy face
mask removal and should frequently practice removal
techniques for face masks and helmets. It should be
noted that cold weather and old loops may make
cutting difficult. The chin strap can be left in place
unless resuscitative efforts are necessary. For resuscitation, the mouthpiece needs to be manually removed.
Once the ABCs are stabilized, transportation to an
emergency facility should be conducted with the head
secure in the helmet and the neck immobilized by
strapping, taping and/or using lightweight bolsters on
a spine board. When moving an athlete to the spine
board, the head and trunk should be moved as a unit,
using the lift/slide maneuver or a log-roll technique.
At the emergency facility, satisfactory initial skull and
cervical X-rays usually can be obtained with the helmet
in place. Should removal of the helmet be needed to
initiate treatment or to obtain special X-rays, the following protocol should be considered:
• With the head, neck and helmet manually stabilized, the chin strap can be cut.
• While maintaining stability, the cheek pads can
be removed by slipping the flat blade of a screwdriver or bandage scissor under the pad snaps
and above the inner surface of the shell.
• If an air cell-padding system is present, it can be
deflated by releasing the air at the external port
with an inflation needle or large-gauge hypodermic needle.
• By rotating the helmet slightly forward, it should
now slide off the occiput. If the helmet does not
move with this action, slight traction can be
applied to the helmet as it is carefully rocked
anteriorly and posteriorly, with great care being
taken not to move the head/neck unit.
• The helmet should not be spread apart by the
earholes, as this maneuver only serves to tighten
the helmet on the forehead and on the occipital
• All individuals participating in this important
maneuver must proceed with caution and coordinate every move.
If the injured student-athlete, after being rehabilitated
fully, is allowed to participate in the sport again, refitting his/her helmet is mandatory. Re-education about
helmet use as protection should be conducted. Using
the helmet as an offensive, injury-inflicting instrument should be discouraged and places the athlete
and opponents at risk for a catastrophic injury.
Soft Headgear Use in Nonhelmeted Sports
When considering the use of this optional equipment
during practice or permitted competition, athletes and
coaches should take the time to read the qualifying
statements provided with such a product addressing
its limitations, particularly to prevent serious head
injuries. If protective soft headgear or headbands are
2013-14 NCAA Sports Medicine Handbook
to be used in a sport then they should be manufactured under the guidelines of an accepted standard
for that sport.
the equipment is used for mitigating the risk of injuries
for which they are designed.
The NCAA does not view the use of soft headgear
products as equipment for the prevention of concussion in nonhelmeted sports. As explained below, soft
headgear products may be worn in nonhelmeted
sports whose rules allow for such optional equipment,
but the purpose of that equipment should be for
reasons other than concussion prevention. It should
be noted that there is no helmet that can prevent a
concussion. There continues to be a need for valid
scientific evidence that the use of such products
decreases the incidence of concussion.
In nonhelmeted sports requiring a medical waiver for
the use of such optional equipment, use of soft headgear as a condition to be medically cleared to play
sports is ineffective. Therefore, the NCAA will not
provide medical waivers for the use of soft headgear
for the prevention of concussion in order to be medically cleared to play sports.
Current design and recommended use of these
devices fail to address the proposed primary mechanism of concussive injury, that being rotational acceleration and deceleration forces acting on the brain.
Institutions should refer to equipment standards from
NOCSAE, ASTM, HECC and CPSC when considering
protective equipment for student-athletes and ensure
1. Anderson C: Neck Injuries—Backboard, bench or return to play? The
Physician and Sports Medicine 21(8): 23-34, 1993.
2. Guidelines for Helmet Fitting and Removal in Athletics. Illinois State Medical
Society, 1990. (20 North Michigan Avenue, Chicago, Illinois 60602)
3. Inter-Association Task Force for the Cervical Spine. National Athletic
Trainers’ Association, 2000. (2952 Stemmons Freeway, Dallas, Texas
4. AOSSM Helmet Removal Guidelines. The American Orthopaedic
Society for Sports Medicine. (6300 N. River Road, Suite 200,
Rosemont, Illinois 60018
5. The Hockey Equipment Certification Council Inc.
6. US Lacrosse. Lacrosse Helmet Facemask/
Chinguard Removal Hints for Certified Athletic Trainers. US Lacrosse,
2008. Available at
7. National Operating Committee on Standards for Athletic Equipment
Use of Trampoline
and Minitramp
June 1978 • Revised June 2002
The NCAA recognizes that the coaches and studentathletes in selected sports use the trampoline and
minitramp for developing skills. The apparent safety
record accompanying such use has been good, but
the use of the trampoline can be dangerous. Therefore,
these guidelines should be followed in those training
activities in which student-athletes use the trampoline:
1. Trampolines should be supervised by people with
competence in the use of the trampoline for developing athletics skills. This implies that:
a. Fellow coaches, student-athletes, managers,
etc., are trained in the principles and techniques of spotting with the overhead harness,
“bungee system” and/or hand spotting on the
b. New skills involving somersaults should be
learned while wearing an overhead safety
harness. (Exception: Use of the overhead
system is not recommended for low-level salto
activities such as saltos from the knees or
back.) Those people controlling the safety
harness should have the necessary strength,
weight and training for that responsibility;
c. Skills being encouraged should be commensurate with the readiness of the student-athlete,
and direct observation should confirm that the
student-athlete is not exceeding his or her
readiness; and
d. Spotters are aware of the particular skill or
routine being practiced and are in an appropriate position to spot potential errors. Accurate
communication is important to the successful
use of these techniques.
2. Potential users of the trampoline should be taught
proper procedures for folding, unfolding, transporting, storing and locking the trampoline.
3. The trampoline should be erected in accordance
with manufacturer’s instructions. It should be
inspected regularly and maintained according to
established standards. All inspection reports,
including the date of inspection and name of
inspector, should be kept on file.
trained for that purpose (spotting somersaults on the
minitramp differs from the trampoline because of the
running action preceding the somersault), emphasis on
the danger of somersaults and dive rolls, security
against unsupervised use, proper erection and maintenance of the apparatus, a planned procedure for emergency care should an accident occur, and documentation of participation and any accidents that occur. In
addition, no single or multiple somersault should be
attempted unless:
1. The student-athlete has demonstrated adequate
progression of skill before attempting any somersault (i.e., on the trampoline with a safety harness,
off a diving board into a swimming pool or tumbling with appropriate spotting);
2. One or more competent spotters who know the
skill being attempted are in position and are physically capable of spotting an improper execution;
3. The minitramp is secured reasonably or braced to
prevent slipping at the time of execution in accordance with recommendations in the USA
Gymnastics Safety Handbook; and
4. A mat is used that is sufficiently wide and long to
prevent the performer from landing on the mat’s
edge and to provide proper footing for the
1. American Alliance for Health, Physical Education, Recreation and
Dance: The use of the trampoline for the development of competitive
skills in sports. Journal of Physical Education, Recreation and Dance
49(8):14, 1978.
2. Hennessy JT: Trampoline safety and diving programs. U.S. Diving
Safety Manual. Indianapolis, IN: U.S. Diving Publications, 1990.
3. Larson BJ, Davis JW. Trampoline-related injuries. J Bone Joint Surg
Am. 1995; 77:1174-1178.
4. Trampolines at Home, School and Recreational Centers Policy
Statement of the America. Available at http://pediatrics.
5. USA Gymnastics: USA Gymnastics Safety Handbook, 1994. (201 S.
Capitol St., Ste. 300, Indianapolis, IN 46225)
The minitramp, while different in nature and purpose
from the trampoline, shares its association with risk of
spinal cord injury from poorly executed and/or spotted
tricks. Like the trampoline, the minitramp requires
competent instruction and supervision, spotters
2013-14 NCAA Sports Medicine Handbook
2013-14 NCAA Sports Medicine Handbook
Appendix A
2013-14 NCAA
Banned Drugs
July 2013
The NCAA bans the following
classes of drugs:
a. Stimulants;
b. Anabolic agents;
c. Alcohol and beta blockers (banned for rifle only);
d. Diuretics and other masking agents;
e. Street drugs;
f. Peptide hormones and analogues;
g. Anti-estrogens; and
h. Beta-2 agonists.
Note: Any substance chemically related to these
classes is also banned. The institution and the studentathlete shall be held accountable for all drugs within the
banned-drug class regardless of whether they have been
specifically identified. Examples of substances under
each class can be found at
]Drugs and Procedures
Subject to Restrictions:
Blood Doping.
Local anesthetics (under some conditions).
Manipulation of urine samples.
Beta-2 agonists permitted only by prescription
and inhalation.
• Caffeine – if concentrations in urine exceed 15
NCAA Nutritional/Dietary
Supplements Warning:
• Before consuming any nutritional/dietary supplement product, review the product and its label
with your athletics department staff!
• Dietary supplements are not well regulated and
may cause a positive drug test result.
• Student-athletes have tested positive and lost
their eligibility using dietary supplements.
• Many dietary supplements are contaminated with
banned drugs not listed on the label.
• Any product containing a dietary supplement
ingredient is taken at your own risk.
Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting the Resource Exchange Center (REC) at
877/202-0769 or (password ncaa1, ncaa2 or ncaa3).
NCAA Legislation Involving
Health and Safety Issues
Appendix B
July 2013
This chart should be used as a quick reference for NCAA
legislation involving health and safety issues that
appears in the 2013-14 NCAA Divisions I, II and III
Manuals. The comment section does not capture the full
scope of the legislation; users are encouraged to review
the full bylaw in the appropriate divisional manual.
Because of the dynamic nature of the NCAA legislative
process, the most current information on these and any
new legislation should be obtained through the institution’s athletics department compliance staff.
Regulations Involving Health and Safety Issues
Topic Issue
Banned Drugs
NCAA Bylaw Cite
List of Banned
Drug Classes
Lists all drug classes currently banned by the NCAA.
Drugs and Procedures
Subject to Restrictions
List of drugs and procedures that are restricted.
Effect on Eligibility
A positive test for use of a banned (performance enhancing or “street”) substance results in loss of eligibility.
Effect on
A positive test for a banned (performance
enhancing or “street”) substance results in loss
of eligibility, including eligibility for participation in
postseason competition.
Transfer While
Ineligible Due to
Positive Drug Test (Div. I), (Div. II), (Div. III)
Institution at which student-athlete tested positive for
use of a banned substance must report the test result to
the institution to which the student-athlete is transferring.
Knowledge of Use
of Banned Drugs
Athletics department staff members or others
employed by intercollegiate athletics department
with knowledge of a student-athlete’s use of a
banned substance must follow institutional policies.
Athletics Department
Resource for Banned
Drugs and Nutritional
Supplements (Div. I)
Institutions must designate an individual (or
individuals) as an athletics department resource
for questions related to NCAA banned drugs and
nutritional supplements.
All student-athletes shall be provided the list of banned
drug classes; receive education about products
that might contain banned drugs; and be notified of
changes and updates during the academic year. (Div. I)
Institutions must educate athletics department staff
members who have regular interaction with studentathletes that: (1) the NCAA maintains a list of banned
drug classes and provides examples of banned
substances in each drug class on the NCAA website; (2) any nutritional supplement use may present
risks to a student-athlete’s health and eligibility; and
(3) questions regarding NCAA banned drugs and the
use of nutritional supplements should be referred
to the institution’s designated athletics department
resource individual (or individuals).
2013-14 NCAA Sports Medicine Handbook
Regulations Involving Health and Safety Issues
Topic Issue
NCAA Bylaw Cite
Banned Drugs
and Drug-Testing
Methods (Div. II)
NCAA Executive Committee is charged with
developing a list of banned substances and
approving all drug-testing procedures.
Consent Form:
Content and Purpose
Consent must be signed before competition or
practice or before the Monday of the fourth week
of classes. Failure to sign consent results in loss of
Consent Form:
(Div. I);, (Div. II);,
(Div. III)
Institution must administer consent form to all
student-athletes each academic year at the time
the intercollegiate squads report for practice.
At this time, institutions must also distribute to
student-athletes the list of banned drug classes.
Consent Form:
Exception, 14-Day
Grace Period (Div. I), (Div. II)
Student-athletes who are trying out must sign the
form within 14 days of the first athletics-related activity
or before they compete, whichever occurs first.
Effect of NonNCAA Athletics
Positive Drug Test
A student-athlete under a drug-test suspension
from a national or international sports governing
body shall not compete in NCAA intercollegiate
Failure To
Properly Administer
Consent Form
(Div. I and Div. III only) (Div. I), (Div. III)
Failure to properly administer drug-testing consent
form is considered an institutional violation.
Drug Rehabilitation
Program Expenses
Permissible for institution to cover the costs of a
student-athlete’s drug rehabilitation program.
Travel To and From
Drug Rehabilitation
Permissible to file a waiver under Bylaw 16.12.1 to
cover costs associated with a drug rehabilitation
16.5.2-(g) (Div.
I), 16.5.1-(h)
(Div. II)
Institution may provide only permissible nutritional
supplements that do not contain any NCAA
banned substances. See bylaw for details.
Tobacco Use
Advertising and
Activities (Div. I), (Div. II), (Div. III)
No tobacco advertisements in, or sponsorship of,
NCAA championships or regular-season events.
Tobacco Use at
Member Institution
17.1.8 (Div. I);
17.1.9 (Div. II); (Div. III)
Use of tobacco products is prohibited by all game
personnel and all student-athletes in all sports
during practice and competition.
Permissible Medical
Permissible medical expenses are outlined.
Eating Disorders
(Div. I and Div. II only)
Institution may cover expenses of counseling
related to the treatment of eating disorders.
Transportation for
Medical Treatment
(Div. I and Div. II only)
Institution may cover or provide transportation to
and from medical appointments.
Drug Testing
Topic Issue
Records and
Consent Forms
NCAA Bylaw Cite
Conditioning Basketball
An institution may finance medical expenses
for a prospect who sustains an injury while
participating in an on-campus evaluation; a
voluntary summer workout conducted by an
institution’s strength and conditioning coach; or
required summer athletic activities.
Conditioning Football
Institution may finance medical expenses for a
prospect who sustains an injury while participating
in nonmandatory summer conditioning activities
that are conducted by an institution’s strength and
conditioning coach.
Conditioning Sports Other Than
Basketball and
Football (Div. I only)
Institution may finance medical expenses for a
prospect who sustains an injury while participating
in nonmandatory summer conditioning activities
that are conducted by an institution’s strength and
conditioning coach.
Certification of
Insurance Coverage (Div. I
and Div. III)
Institutions must certify insurance coverage for
medical expenses resulting from athletically
related injuries sustained while participating in a
covered event.
Hardship Waiver
14.2.4 (Div. I),
14.2.5 (Div. II
and Div. III)
Under certain circumstances, a student-athlete may
be awarded an additional season of competition to
compensate for a season that was not completed
due to incapacitating injury or illness.
Rule Waiver (Div. I), (Div. II), (Div. III)
Under certain circumstances, a studentathlete may be awarded an additional year of
eligibility if he or she was unable to participate
in intercollegiate athletics due to incapacitating
physical or mental circumstances.
Consent Forms, 14.1.5
(Div. I);,
14.1.5 (Div. II);, 14.1.6
(Div. III)
The authorization/consent form shall be
administered individually to each studentathlete by the athletics director or the athletics
director’s designee before the student-athlete’s
participation in intercollegiate athletics each
academic year. Signing the authorization/
consent shall be voluntary and is not required
by the student-athlete’s institution for medical
treatment, payment for treatment, enrollment in
a health plan or for any benefits (if applicable)
and is not required for the student-athlete to be
eligible to participate. Any signed authorization/
consent forms shall be kept on file by the
director of athletics.
Examinations During
Campus Visit (Div. I)
During a prospective student-athlete’s visit
to campus, a member institution, through its
regular team or other designated physician, may
conduct a medical examination to determine
the prospective student-athlete’s medical
qualifications to participate in intercollegiate
athletics, provided no athletics department staff
member other than the athletic trainer is present.
Regulations Involving Health and Safety Issues
2013-14 NCAA Sports Medicine Handbook
Regulations Involving Health and Safety Issues
Topic Issue
Welfare and
NCAA Bylaw Cite
Time Restrictions
on Athletics-Related
(Div. I and Div. II only)
All NCAA sports are subject to the time limitations
in Bylaw 17.
Daily/Weekly Hour
Limitation – Inside
Playing Season
(Div. I and Div. II only)
During the playing season, a student-athlete cannot
engage in more than 20 hours of athletics-related
activity (see Bylaw 17.02.1) per week, with not more
than four hours of such activity in any one day.
Weekly Hour
Limitations – Outside
Playing Season
(Div. I and Div. II only)
Outside the playing season, student-athletes
cannot engage in more than eight hours of
conditioning activities per week.
Skill Instruction
Exception (Div. I and
Div. II only) See Bylaws and (Div. I) for
additional exceptions.,
(Div. I);, (Div. II)
Outside the playing season, two of the studentathlete’s eight hours of conditioning activity may
be skill-related instruction with coaching staff.
Required Day Off –
Playing Season
(Div. I and Div. II), (Div. III)
During the playing season, each student-athlete
must be provided with one day per week on which
no athletics-related activities are scheduled.
Required Days Off
– Outside Playing
Season (Div. I and
Div. II only)
Outside the playing season, each student-athlete
must be provided with two days per week on
which no athletics-related activities are scheduled.
Voluntary Summer
(Div. I only)
Prospective student-athletes, who signed an NLI or
enrolled in the institution’s summer term before initial,
full-time enrollment, may engage in voluntary summer
workouts conducted by an institution’s strength and
conditioning coach with department-wide duties.
Voluntary Summer
(Div. I only)
Prospective student-athletes, who signed an NLI
or enrolled in the institution’s summer term before
initial, full-time enrollment, may engage in voluntary
summer workouts conducted by an institution’s
strength and conditioning coach with departmentwide duties (FBS) or a countable coach who is a
certified strength and conditioning coach (FCS).
Voluntary Summer
(Div. I only)
(Sports Other
Than Football
and Basketball)
In sports other than football and basketball, a
prospective student-athlete may engage in voluntary
summer workouts conducted by an institution’s
strength and conditioning coach with department-wide
duties and may receive workout apparel (on an issuance
and retrieval basis), provided he or she is enrolled in
the institution’s summer term before the student’s initial
full-time enrollment at the certifying institution. Such
a prospective student-athlete may engage in such
workouts only during the period of the institution’s
summer term or terms (opening day of classes through
last day of final exams) in which he or she is enrolled.
Topic Issue
Welfare and
NCAA Bylaw Cite
Voluntary WeightTraining or
(Div. I only)
A strength and conditioning coach who conducts
voluntary weight-training or conditioning activities
is required to maintain certification in first aid and
cardiopulmonary resuscitation. If a member of the
institution’s sports medicine staff (e.g., athletic trainer,
physician) is present during voluntary conditioning
activities conducted by a strength and conditioning
coach, the sports medicine staff member must be
empowered with the unchallengeable authority to
cancel or modify the workout for health and safety
reasons, as he or she deems appropriate.
11.1.6 (Div. II)
Each head coach and all other coaches who are
employed full time at an institution shall maintain
current certification in first aid, cardiopulmonary
resuscitation (CPR) and automatic external
defibrillator (AED) use.
11.1.6 (Div. III)
Each head coach shall maintain current
certification in first aid, cardiopulmonary
resuscitation (CPR) and automatic external
defibrillator (AED) use.
Discretionary Time
(Div. I only)
Student-athletes may only participate in athletics
activities at their initiative during discretionary time.
Mandatory Medical
17.1.5 (Div. I
and Div. II), (Div. III)
All student-athletes beginning their initial season
of eligibility and students who are trying out for a
team must undergo a medical exam before they
are permitted to engage in any physical activity.
The exam must take place within six months
before the physical activity. Each subsequent year,
an updated medical history must be administered
by an institutional medical staff member.
Mandatory Medical
Examinations (Div. I), II)
The examination or evaluation of student-athletes
who are beginning their initial season of eligibility and
students who are trying out for a team shall include
a sickle cell solubility test, unless documented
results of a prior test are provided to the institution
or the prospective student-athlete or student-athlete
declines the test and signs a written release.
Confirmation of
Sickle Cell Trait
(Div. III)
An institution shall confirm the sickle cell trait
status of student-athletes, before participation
in intercollegiate athletics in one of the following
manners: (a) Documentation; (b) Pending
Documentation; or (c) Waiver.
Mandatory Sickle
Cell Trait Status
(Div. III)
Each student-athlete shall be provided education
regarding sickle cell trait status. Student-athletes
who have been tested, but do not have confirmed
results documented, or have signed a waiver per
Bylaw, shall be provided additional
education regarding the risks, impact and
precautions associated with sickle cell trait.
Regulations Involving Health and Safety Issues
2013-14 NCAA Sports Medicine Handbook
Regulations Involving Health and Safety Issues
Topic Issue
Welfare and
NCAA Bylaw Cite
Period – Football (Div. I), (Div. II
and Div. III)
Five-day acclimatization for conducting
administrative and initial practices is required for
first-time participants (freshmen and transfers) and
continuing student-athletes.
Preseason Practice
Activities – Football
(Div. I),
(Div. II and Div. III)
Preseason practice time limitations and general
Football Activities
17.9.6 (Div. I
and Div. III),
17.9.8 (Div. II)
Permissible summer conditioning activities.
Safety Exceptions
(Equestrian; Fencing;
Gymnastics; Rifle;
Women’s Rowing;
Skiing; Swimming;
Track and Field;
Water Polo; and
Wrestling) (Div. I and
Div. II only) (Div. I);
17.6.7; 17.7.7;
17.11.7; 17.14.7;
17.15.7 (Div. I);
17.15.9 (Div. II);
17.18.7; 17.23.7
(Div. I); 17.23.8
(Div. II); 17.25.8
(Div. I and Div. II);
A coach may be present during voluntary
individual workouts in the institution’s regular
practice facility (without the workouts being
considered as countable athletics-related
activities) when the student-athlete uses sportspecific equipment. The coach may provide
safety or skill instruction but cannot conduct the
individual’s workouts.
Playing Rules
Oversight Panel
The panel shall be responsible for resolving issues
involving player safety, financial impact or image
of the game.
Management Plan (Div. I
and Div. II); (Div. III)
Institutions must have a concussion management
plan for student-athletes. See Guideline 2I.
Evaluations – Men’s
Basketball (Div. I)
Under certain circumstances, an institution
may conduct an evaluation of a prospect on its
campus or at a site it normally uses for practice
and competition.
Summer Access –
Men’s Basketball (Div. I);
(Div. I)
Under certain circumstances, prospects and
student-athletes may engage in required weighttraining, conditioning and skill instruction for up to
eight weeks in the summer.
NCAA Injury Surveillance
Program Summary
Appendix C
July 2013
The NCAA Injury Surveillance Program was developed
in 1982 to provide current and reliable data on injury
trends in intercollegiate athletics. It collects injury and
activity information in order to identify and highlight
potential areas of concern and interest related to student-athlete health and safety.
Injury data are collected yearly by the Datalys Center
from a sample of NCAA member institutions, and the
resulting data summaries are reviewed by the NCAA
Committee on Competitive Safeguards and Medical
Aspects of Sports. The committee’s goal continues to
be to reduce injury rates through suggested changes in
rules, protective equipment or coaching techniques,
based on the data.
In some instances, the evaluation of the injury surveillance information has led the NCAA to commission
research studies to better understand the underlying
factors that have contributed to the observed surveillance findings. To support the objective and nature of
the NCAA Injury Surveillance Program – monitoring to
identify areas of concern for potential further investigation – the Datalys Center does not collect identifiable
information or treatment information.
Program Benefits
Participation in the NCAA Injury Surveillance Program
supports rule and policy changes that improve student-athlete health and safety. In addition, program
participation provides a number of benefits to athletic
trainers and their institutions:
Safer participation in collegiate sports. In some
cases, surveillance information has led to a mitigation
of injuries and treatments (e.g., heat illness episodes).
Resource Justification and Allocation.
Surveillance information has been used in the NATA’s
Recommendations and Guidelines for Appropriate
Medical Coverage of Intercollegiate Athletics
(AMCIA) document.
Supports Clinical Best Practices. Regional and
national injury rate comparisons allow a university to
explore relevant clinical best practices with appropriate
peer groups.
Supports Risk Management Best Practice. The electronic documentation of injuries (e.g., through an Export
Engine Certified vendor or the Injury Surveillance Tool)
is a recognized risk management best practice.
NCAA Injury Surveillance
Data Requests
Research Requests allows researchers and academicians to request data from the NCAA Injury
Surveillance Program for research purposes.
The NCAA uses the Datalys Injury Statistics
Clearinghouse (DISC) to process all requests to
sports injury data. Researchers and others can
request access to de-identified, line item exposure and injury data from the 2004-09 NCAA
Injury Surveillance Program through a two-step
process. Completion of appropriate material with
initial approval by Datalys Center’s Independent
Review Committee is the first step. The NCAA
will also internally review your application.
Applications must have a focused and sound
scientific rationale.
Visit Datalys Injury Statistics Clearinghouse
(DISC) website at to
view available data and variables and to access
the data request form.
Facilitates Paper Record Keeping Processes. For
institutions managing their health records via a paperprocess, the Injury Surveillance Tool facilitates the
work flow and supports an enhanced level of documentation and record keeping.
Two easy ways to participate:
The Injury Surveillance Tool (IST). The Injury
Surveillance Tool facilitates the work flow in the athletic training room and supports an enhanced level of
documentation and record keeping. The IST is
designed as a free injury incident report, and allows
documentation of injuries. In doing so, the IST provides important injury information to the Datalys
Center and helps to initiate a paper record keeping
process for the athletic trainer.
The Export Engine Program (EE). The Export Engine
Program is a public data transmission standard that
commercial vendors can voluntarily adopt. Through the
Export Engine Program, athletic trainers can directly
and easily submit data from their vendor systems to
the Injury Surveillance Program. If you are considering
a new system, be sure to look for the Datalys Certified
logo. Its certified vendors currently include ATS, Nextt
Solutions and SIMS.
2013-14 NCAA Sports Medicine Handbook
Data Availability and Access
All Sports Figures
The following figures outline selected information from
the sports currently reported by the NCAA Injury
Surveillance Program from 2004 to 2009. Complete
summary reports for each sport are available online at
Since its inception, the surveillance program has
depended on a volunteer “convenience sample” of
reporting schools. Participation is available to the population of institutions sponsoring a given sport. Schools
qualifying for inclusion in the final sample are selected
from the total participating schools for each NCAA sport,
with the goal of representation of all three NCAA divisions. A school is selected as qualifying for the sample if
it meets the minimum standards for data collection.
Any questions regarding the NCAA Injury Surveillance
Program or its data reports should be directed to:
Megan Barr, Director of Operations, Datalys Center for
Sports Injury Research and Prevention, Indianapolis,
Indiana (317/275-3665).
Injury surveillance data collected through the NCAA
Injury Surveillance Program is available to the public
through an application process administered by the
Datalys Center Independent Review Committee
located at
It is important to recognize that this system does not
identify every injury that occurs at NCAA institutions in
a particular sport. Rather, the emphasis is collecting all
injuries and exposures from schools that voluntarily
participate in the Injury Surveillance Program. The
Injury Surveillance Program attempts to balance the
dual needs of maintaining a reasonably representative
cross-section of NCAA institutions while accommodating the needs of the voluntary participants.
A reportable injury in the Injury Surveillance Program is
defined as one that:
1. Occurs as a result of participation in an organized
intercollegiate practice or competition; and
2. Requires medical attention by a team athletic
trainer or physician regardless of time loss.
Exposures (Activity)
An athlete exposure is defined as one athlete participating in one practice or competition in which he or
she is exposed to the possibility of athletics injury.
Injury Rate
An injury rate is simply a ratio of the number of injuries
in a particular category to the number of athlete exposures in that category. This value is expressed as injuries per 1,000 athlete exposures.
Historical Data
The NCAA published 16 years of injury data in 15
sports in the Journal of Athletic Training National
Collegiate Athletic Association Injury Surveillance,
1988-1989 Through 2003-2004. J Athl Train. 2007;42(2).
David Klossner, Director, NCAA Sport Science Institute,
P.O. Box 6222, Indianapolis, Indiana 46206-6222
Practice Injury Rate
Competition Injury Rate
Men’s Football
Men’s Wrestling
Men’s Soccer
Men’s Lacrosse
Men’s Ice Hockey
Chart 1: Competition and practice injury rates
Women’s Gymnastics
Women’s Soccer
Men’s Basketball
Women’s Field Hockey
Men’s Indoor Track*
Women’s Basketball
Women’s Ice Hockey
Women’s Cross Country*
Men’s Outdoor Track*
Women’s Lacrosse
Men’s Baseball
Women’s Outdoor Track*
Men’s Cross Country*
Women’s Tennis*
Women’s Softball
Women’s Volleyball
Women’s Indoor Track*
Men’s Tennis*
Women’s Swimming and Diving**
Men’s Swimming and Diving**
Injury Rate (per 1,000 athlete-exposures)
Figure illustrates the average injury rates for 25 sports from 2004-05 to 2008-09 unless otherwise noted below.
* Available data from 2005-06 to 2008-09
**Available data from 2006-07 to 2008-09
If a sport is not included, it is because there was not enough data collected to report that sport.
2013-14 NCAA Sports Medicine Handbook
Chart 2: Percentage of all injuries occurring in practices and competition
Competition Injuries
Practice Injuries
Men’s Ice Hockey
Men’s Baseball
Women’s Ice Hockey
Women’s Soccer
Women’s Softball
Men’s Soccer
Women’s Tennis*
Men’s Lacrosse
Women’s Field Hockey
Men’s Football
Women’s Lacrosse
Women’s Basketball
Men’s Basketball
Men’s Wrestling
Women’s Volleyball
Women’s Outdoor Track*
Men’s Tennis*
Men’s Indoor Track*
Men’s Outdoor Track*
Women’s Gymnastics
Women’s Cross Country*
Men’s Swimming and Diving**
Men’s Cross Country*
Women’s Swimming and Diving** 13.5
Women’s Indoor Track*
Percentage of all injuries
Figure represents the national estimates of injury percentages for 25 sports from 2004 to 2009 unless
otherwise noted below.
* Sports with data from 2005-06 to 2008-09 (4 years only).
**Sports with data from 2006-07 to 2008-09 (3 years only).
If a sport is not included in the figure, it is because there was not enough data collected to report that sport.
Appendix D
From 1974 to 2013, the following individuals have served on the NCAA Committee on Competitive Safeguards
and Medical Aspects of Sports and contributed to the information in the NCAA Sports Medicine Handbook:
John R. Adams
Nicholas J. Cassissi, M.D.
Michelle Gober
Western Athletic Conference
University of Florida
Kutztown University of Pennsylvania
Ken Akizuki
Rita Castagna
Gordon L. Graham
University of San Francisco
Assumption College
Minnesota State University, Mankato
Jeffrey Anderson
Charles Cavagnaro
Gary A. Green, M.D.
University of Connecticut
University of Memphis
University of California, Los Angeles
James R. Andrews, M.D.
Kathy D. Clark
Letha Griffin, M.D.
Troy University
University of Idaho
Georgia State University
Elizabeth Arendt, M.D.
Kenneth S. Clarke
Eric Hall
University of Minnesota, Twin Cities
Pennsylvania State University
Elon University
William F. Arnet
Priscilla M. Clarkson
Eric Hamilton
University of Missouri, Columbia
University of Massachusetts, Amherst
The College of New Jersey
James A. Arnold
Bob Colgate
Kim Harmon
University of Arkansas, Fayetteville
University of Washington
Janet Kay Bailey
National Federation of State
High School Associations
Glenville State College
Donald Cooper, M.D.
Trinity College (Connecticut)
Dewayne Barnes
Oklahoma State University
Larry Holstad
Whittier College
Kip Corrington
Winona State University
Amy Barr
Texas A&M University, College Station
Maria J. Hutsick
Eastern Illinois University
Lauren Costello, M.D.
Boston University
Fred L. Behling
Princeton University
Nell C. Jackson
Stanford University
Ron Courson
Binghamton University
Daphne Benas
University of Georgia
John K. Johnston
Yale University
Carmen Cozza
Princeton University
Brant Berkstresser
Yale University
Don Kaverman
Harvard University
Scot Dapp
Southeast Missouri State University
John S. Biddiscombe
Moravian College
Janet R. Kittell
Wesleyan University (Connecticut)
Bernie DePalma
California State University, Chico
Carl S. Blyth
Cornell University
Fran Koenig
University of North Carolina, Chapel Hill
Jerry L. Diehl
Central Michigan University
Cindy D. Brauck
National Federation of State
High School Associations
Olav B. Kollevoll
Missouri Western State University
Donald Bunce, M.D.
Randy Eichner
Jerry Koloskie
Stanford University
University of Oklahoma
University of Nevada, Las Vegas
Elsworth R. Buskirk
Brenna Ellis
Roy F. Kramer
Pennsylvania State University
University of Texas at San Antonio
Vanderbilt University
Peter D. Carlon
Larry Fitzgerald
Michael Krauss, M.D.
University of Texas, Arlington
Southern Connecticut State University
Purdue University
Gene A. Carpenter
Gregory Frazer
Carl F. Krein
Millersville University of Pennsylvania
Duquesne University
Central Connecticut State University
Frank Carr
Paul W. Gikas, M.D.
Russell M. Lane, M.D.
Earlham College
University of Michigan
Amherst College
Marino H. Casem
Pamela Gill-Fisher
Melinda Larson
Southern University, Baton Rouge
University of California, Davis
Whitworth University
Richard J. Hazelton
Lafayette College
2013-14 NCAA Sports Medicine Handbook
Kelsey Logan
Jeffrey O’Connell
Lori Runksmeier
The Ohio State University
University of Virginia
New England College
John Lombardo, M.D.
Roderick Paige
Felix Savoie
The Ohio State University
Texas Southern University
Tulane University
Scott Lynch
Joseph V. Paterno
Richard D. Schindler
Pennsylvania State University
Pennsylvania State University
William B. Manlove Jr.
Marc Paul
National Federation of State
High School Associations
Delaware Valley College
University of Nevada, Reno
Kathy Schniedwind
Jeff Martinez
Daniel Pepicelli
Illinois State University
University of Redlands
St. John Fisher College
Brian J. Sharkey
Lois Mattice
Frank Pettrone, M.D.
University of Montana
California State University, Sacramento
George Mason University
Willie G. Shaw
Arnold Mazur, M.D.
Marcus L. Plant
North Carolina Central University
Boston College
University of Michigan
Jen Palancia Shipp
Chris McGrew, M.D.
Sourav Poddar
University of New Mexico
University of Colorado, Boulder
University of North Carolina
at Greensboro
William D. McHenry
Nicole Porter
Washington and Lee University
Shippensburg University
of Pennsylvania
Malcolm C. McInnis Jr.
Gary Skrinar
Boston University
Andrew Smith
University of Tennessee, Knoxville
Will Prewitt
Canisius College
Douglas B. McKeag, M.D.
Great American Conference
Bryan W. Smith, M.D.
Michigan State University
James C. Puffer, M.D.
University of North Carolina, Chapel Hill
Kathleen M. McNally
University of California, Los Angeles
Lynn Snyder-Mackler
La Salle University
Margot Putukian
Lyndon State College
Robin Meiggs
Princeton University
Michael Storey
Humboldt State University
Ann Quinn-Zobeck
Bridgewater State University
Dale P. Mildenberger
University of Northern Colorado
Grant Teaff
Utah State University
Tracy Ray
Baylor University
Melinda L. Millard-Stafford
Samford University
Carol C. Teitz, M.D.
Georgia Institute of Technology
Butch Raymond
University of Washington
Fred L. Miller
Northern Sun Intercollegiate Conference
Patricia Thomas
Arizona State University
Joy L. Reighn
Matthew Mitten
Rowan University
Marquette University
Frank J. Remington
James Morgan
University of Wisconsin, Madison
Laurie Turner
California State University, Chico
Rochel Rittgers
University of California, San Diego
Frederick O. Mueller
Augustana College (Illinois)
Christopher Ummer
University of North Carolina,
Chapel Hill
Darryl D. Rogers
Lyndon State College
Southern Connecticut State University
Jerry Weber
David M. Nelson
Yvette Rooks
University of Nebraska, Lincoln
University of Delaware
University of Maryland, College Park
Christine Wells
William E. Newell
Debra Runkle
Arizona State University
Purdue University
University of Dubuque
Kevin M. White
Georgetown UniversitySusan S. True
National Federation of State
High School Associations
Tulane University
Robert C. White
Wayne State University (Michigan)
Sue Williams
University of California, Davis
Charlie Wilson
Olivet College
G. Dennis Wilson
Auburn University
Mary Wisniewski
University of Chicago
Glenn Wong
University of Massachusetts, Amherst
Joseph P. Zabilski
Northeastern University
Connee Zotos
Drew University
2013-14 NCAA Sports Medicine Handbook
2013-14 NCAA Sports Medicine Handbook
The NCAA salutes the more than
450,000 student-athletes
participating in 23 sports at more
than 1,200 member institutions
NCAA 89593-8/13
MD 14
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