1. Sport Psychology in
Sports Medicine
Continuing Education Workshop AASP 2009
Sharon A. Chirban, Ph.D.
Sport Psychologist
Division of Sports Medicine
Children’s Hospital Boston
Harvard Medical School

2. Sports Medicine

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5.  Youth Sports
– Less Free Play
– Greater Intensity
– Higher Competitive Levels
– Single Sport Focus
– Parents, Coaches, Scouts
– $
– Goals: Kids vs Adults

6.  Benefits of Youth Exercise
– Medical
• Obesity
• Diabetes
• Cardiovascular risk
• Bone Health
– Psychosocial
• Self-esteem
• Teen Pregnancy
• Recreational Drug Use

7.  Pediatric Athlete
– “Child is not a little adult.”
– “Child athlete is not a little
adult athlete.”

8.  First & Foremost Pediatric
Sports Medicine Clinic
– 20,000 patient visits per year
– 2,500 surgeries per year
 Staff
– Orthopaedic Surgeons
– Primary Care Physicians
– Sports Podiatrists
• Athletic Trainers
• Sports Pyschology
• Nutritionists
• Exercise Physiology
Introduction
Division of Sports Medicine

9.  Research
– Clinical Research
• ACL Injuries
• Osteochondritis Dissecans
• Stress Fractures
• Spondylolysis
• Rugby Injuries
– Basic Science
• ACL primary healing
Introduction
Division of Sports Medicine

10.  Community Outreach
– School Coverage
• 6 Colleges
• 18 High Schools
– Boston Public Schools Sports
Medicine Initiative
– Boston Ballet
– Performing Arts
– Track & Field
– Baystate Games
– Sports Camps
– US Figure Skating
Introduction
Division of Sports Medicine

11. Overview of Workshop
 The role of a sports psychologist in treating sports
medicine patients
 Discuss issues around professional development and
integration
 Discuss working in a medical milieu and working on a
treatment team
 An overview of sports medicine clinical topics
 Case presentations will be used as a teaching tool for
participants.

12. Role of a sports psychologist in
treating sports medicine patients
 SP is licensed within Sports Medicine
Department
 SP works in coordination with primary care
sports med physicians, orthopedic surgeons,
physical therapists, athletic trainers,
nutritionists, fellows and interns in training
 Associated University affiliation coverage
 Event Coverage

13. Clinical Issues in Sports Medicine
Acute Injuries
vs
Overuse Injuries

15. Acute Injury
 Fracture
 Contusion
 Sprain
 Strain
 Concussion

17. Overuse Injury
 Stress Fracture
 Tendinopathy
 Chondromalacia
 Bursitis
 Fascitis

18. Risk Factors
•Host
•Environmental

19. Risk Factors: Sport Injuries
HOST
 Anatomic Alignment
 Muscle Tendon Imbalance
 Fitness Level
 Growth and Maturation
 Nutrition
 Gender

20. Risk Factors: Sport Injuries
ENVIRONMENTAL
 Training
 Conditioning
 Surface
 Footwear
 Equipment
 Coaching

21. Training: Environmental Factor
 Sports Training
– The young athlete
– How much is too much?
– How much is enough?

22. Overtraining
 Performance
 Fatigue
 Growth
 Endocrine
 Injury

23. Overuse Syndrome
 Types of Training
 Amount of Training
 Rate of Training

24. Case Report
 15 year-old “Clara”
 Boston Ballet
 Chronic back pain
 RSD/Perfectionistic Personality
 Two years of counseling
 Back to ballet

25. Female Athlete Triad
 Amennorhea
 Osteopenia
 Disordered Eating
Overuse Injury: Stress Fracture

26. Cases
 Eating Disordered Athletes
– Karyn
 Athletes with Eating Disorders
– Boston College Runner

27. Preadmission Information
Summer 2003
17 year old Cross country
scholarship athlete was preparing
to matriculate September 2003
Coaches intercepted series of photos
on the internet

28. Female Athlete Triad
Pierre d’Hemecourt, MD

29. Preadmission Information
Summer 2003
17 year old Cross country
scholarship athlete was preparing
to matriculate September 2003
Coaches intercepted Series of photos
on the internet

30. September 2002
(Senior High School Year)

31. November 2002
(Senior High School Year)

32. January 2003
(Senior High School Year)

33. June 2003
(Senior High School Year)

34. Preparticipation Evaluation
PMD office notes 2/03 wt =
110
PMD office notes 7/14 wt =
90
Initial evaluation 8/25/03
No hx of eating disorder or
depression
HX of elevated cholesterol
Hx lactose intolerance
Menarche at age 15 but no
menses since August 2002
Denies purge

35. Initial Lab
EKG normal with QT
interval 0.4
HCT/ Hgb =
39.1/14.1
BUN/Cr =15/.8
Chol=249, Tg = 149
LFT’s normal
Estradiol<32
LH<.7
TSH = 3.5
Free thyroxin =.7
Prolactin: 6.06
ng/mL
PTH = 37
25- OHD=28
Ca 9.9
MG 2.2

36. Decision
Home vs. intense care
on campus
Contract signed that
stipulated:
Weekly Health
Service visits
Weekly gain of 1-2 lb
(wts in shorts and
tank top)
Weekly Counseling
Counseling
Nutrition
Medical
Monitoring
ATC

37. Freshman Year 1st
SemesterDate Weight Urine SG Comments
9/5 86 1.003
9/12 87 1.005
9/16 90.5 1.004 Roommate
trouble
9/30 95.25 1.008 Roommate
trouble
10/7 96.25 1.006 Start Wt
training
Light run
10/17 98 1.004
10/25 98 1.001 Run 5 mi

38. Freshman 2nd
Semester
Date Weight Urine SG Comments
1/16 103.5
BMI= 19.6
1.020 Cleared for
Track
Limit 40
mi/wk
2/16 106.5 1.023
3/05 104 1.019
3/16 102 1.020 Warned
3/23 103 1.017 Mild T-L
pain→PT
4/20 104 1.117 Pain Cleared
5/5/04 104 1.023 Thoracic and

39. Bone Scan
Sacral Stress
fracture
Mild compressions
at T7 and T8

40. Summer 04
(Freshman-Sophomore)
No running for 2 months
July started running 10 mi/ wk
Saw orthopedist for recurrent pain in
early August and MRI showed new
right sacral stress fracture
Started her on Actonel 35 mg per week
Instructed to not run for 3 months:

41. Sophomore Year 1st
SemesterDate Weight Urine SG Comments
9/08/04 104.5
10/07 104 1.017 Noted to cry
a lot
11/9 99.75 1.019 Run 15 min
QOD
11/16 100 1.022 ETOH/?
Purge
11/23 100 BMI=
18.9
1.025
12/17 101 Run 35 min
3x/wk

42. Sophomore Year 2nd
SemesterDate Weight Urine SG Comments
1/21/05 110 1.015 Great Affect
Mild sacral
pain
MRI (-)
2/2 108 No Pain
2/18 108 Runs 37 mi/
wk
Mild intermittent non impact pain through the semester but
tolerated increased running to 40 mi wk.
Some alcohol abuse was reported.
That summer developed a tibial plateaux non displaced stress
fracture

43. Summer Sophomore- Junior Year
That summer developed a tibial
plateau non displaced stress
fracture
fracture and cross trained all summer

44. Junior Year 1st
Semester
No pain on return, normal exam
including jump test
Uneventful semester maintaining wt at
110 with minimal pain
Ran modified with team, about 4 times
per week to a max of 25 miles per wk

45. Junior Year 2nd
Semester
DEXA repeated and showed increased
density
Hip ↑ 4.4% to Z score of -1.2
Lumbar ↑ 2.2% (not clinically
significant) to Z -2.1
Stable weight about 115
Some hip and tibia pain with a normal bone
scan in February
Progressed to 50 miles per wk.

46. Senior Year 2006-2007
Maintained her wt
well
Running about 40
mi/wk
November
developed a left
tibial stress
fracture
Now with right

47. Female Athlete Triad
Studies have found
that 15 to 62% of
female college
athletes have
disordered eating.
3.4 to 66% of female
athletes are
amenorrheic.
At least 90% of peak
bone mass is

48. Female Athlete Triad
OLD THEORY
Disordered eating and/or excessive exercise →
Low body weight and low body fat →
Amenorrhea →
Low estrogen →
Decreased calcium absorption and utilization →
Low bone density

49. Negative Energy Balance →
Disruption of HPO axis
Leptin
polypeptide secreted by adipocytes,
with receptors on hypothalamus and bone!1
Helps regulate food intake, energy expenditure, growth,
sexual maturation, and likely GnRH/LH pulsitility.2
Evidence of absence of diurnal leptin levels in amenorrheic,
high level athletes.3
Possible negative central effects and positive peripheral
effects.4
1 Bradley SJ, Taylor MJ, Rovet JF, et al. Assessment of brain function in adolescent anorexia nervosa before and after weight gain.
J Clin Exper Neuropsych 19(1): 20-33, 1997.
2 Cheung CC, Thornton JE, Kuijper JL, et al. Leptin is a metabolic gate for the onset of puberty in the female rat. Endocrinology 138(2):855-8, 1997.
3 Laughlin GA, Yen SCC. Hypoleptinemia in women athletes: absence of diurnal rhythm with amenorrhea.
J Clin Endocrinol Metab 82(1):318-21, 1997.
4 Burguera B, Hofbauer LC, Thomas T, et al. Leptin reduces ovariectomy-induced bone loss in rats. Endocrinology 142(8):3546-53, 2001.

50. IMPROVING DETECTION OF
Awareness in PPEs:
Menstrual History
History of Stress Fractures
Calcium Intake and Vitamin D intake
Frequent Follow-up:
Labs and radiologic testing
More extensive H & P: Mood, Stressors, Diet, Cardiac exam,
Tanner stage, Hair growth

51. IMPROVING TREATMENT OF
Medical/Nutritional/Psychiatric Teamwork
Coach/Trainer/Athletic Department/Family
support and awareness

52. IMPROVING TREATMENT OF
Hormonal Therapy- Currently NO
pharmacologic tx approved by FDA for
premenopausal women that improve bone
formation.
Future Options?:
Bisphosphonates (ex: Fosamax, Actonel, Boniva)
Selective Estrogen Receptor Modulators (SERMs- ex. Raloxifene and
Tamoxifene)
Parathyroid analogs (ex: Forteo)
Black Cohosh- animal studies and human osteoblasts (osteoprotegrin)
Leptin

53. Thank You

54. Fitness:
Environmental Risk Factor
 Cardiovascular/Metabolic
 Musculoskeletal
– Strength
– Flexibility
– Endurance
 Body Composition
 Psychological

55. Head Injuries
Post Concussive Syndrome
Delayed response
Distracted
Disoriented
Coordination issues
Emotional lability
Memory deficit
Amnesia

56. Second Impact Syndrome
SIS
Occurs mostly in the adolescent 14-16
A second head injury(often minor) is sustained while
still symptomatic from the first injury
Altered cerebral autoregulation ⇒malignant brain
edema
Stable for 15 seconds to minutes ⇒precipitous
collapse, comatose, respiratory failure
Rapid intubation and osmotic diuresis(mannitol)

57. Cantu 1986American Academy of Neurology
Grade I -No LOC,
amnesia < 30
minutes
Grade II - LOC <
5min or amnesia >
30 min but < 24
hrs
Grade III -LOC > 5
min or amnesia > 24
hrs
Grade I- No LOC,
transient confusion
less than 15 minutes
Grade II- No LOC,
transient confusion
more than 15 min
Grade III- LOC

58. AAN Return to Play Guidelines
Grade I: May return to play if symptoms clear within
15 minutes
Grade II: Terminate contest. May return to play if no
symptoms on exertion for one week
Grade III: Terminate contest. May return to play after
one week without symptoms if LOC < 1 min or 2
weeks if LOC > 1min (consider hospital evaluation)

59. Return to Play with a
Second Concussion
Grade I: Terminate contest and return after
one week without symptoms at rest and
exertion
Grade II: Terminate contest and return after 2
weeks without symptoms at rest and
exertion
Grade III: Return after one month without
symptoms at rest and exertion

60. Return To Play
Recommend injury grading in
retrospect
Symptom scores
Question the significance of
loss of consciousness
Significance of amnesia
Pediatric considerations

61. Symptom Scores
Headache
Neck pain
Balance or dizziness
Nausea
Visual difficulty
Hearing abnormally
Dazed
Confused
Feeling confused
Feeling in a fog
Drowsiness
Fatigue
Emotional lability
Difficulty concentration
Difficulty remembering
Trouble sleeping

62. Concussion Cases
Nick soccer player
Hannah hockey Player
Gigi cheerleader

63. Upper Extremity Overuse
Shoulder Syndromes
Labal tears: popping
Instability:
subluxation or dead
arm feeling
Impingement: painful
arch
Biceps tendonitis:
anterior pain
AC joint:
impingement

64. Upper Extremity Overuse
Swimmers Shoulder
Constellation of instability
and impingement
Training may require 10 to
15 thousand yards per
day.
75% of this may be
freestyle
McMaster and Troup found
shoulder pain in:
10% of age 13- 14
13% of age 15- 16
26% of elite college
swimmers

65. Upper Extremity Overuse
Swimmers Shoulder
Inflammation in the
supraspinatus and/or
biceps tendons
usually caused by
glenohumeral
instability
Supraspinatus ischemia
at the end of the pull
phase

66. Upper Extremity Overuse
Swimmers Shoulder
Diagnosis
History of pain at
which part of the
stroke
Signs of impingement
and instability
Signs of rotator cuff
weakness and
inflexibility

67. Upper Extremity Overuse
Swimmers Shoulder
Treatment
Relative rest but
not deconditioned
Some pool work
Address rotator
cuff stabilization

68. Upper Extremity Overuse
Swimmers Shoulder
Treatment
Technique:
1)Finish of the
stroke so that the
arm exits the water
at the iliac crest
2)Roll 70-
90 degrees
3) Entry just
outside the line of
the shoulder

69. Upper Extremity Overuse
Swimmers Shoulder
Prevention
10% rule for increase
in volume of time
and intensity
Weight train with
attention to the
rotator cuff
Cross training

70. Make it or Break it