Body Image Disturbances in NCAA Division I and III Female Athletes

### Abstract

The purpose of this study was to examine and compare eating characteristics and body image disturbances in female NCAA Division I and III athletes in the mainstream sports of basketball, softball, track/cross country, volleyball, soccer, tennis, swimming/diving, and ice hockey. Female collegiate athletes (N = 118) from Division I and III universities completed the EAT-26 and MBSRQ. Personal demographics and anthropometric data including height, weight, BMI and Body Fat estimates were also assessed. The study found that 49.2% (Division I) and 40.4% (Division III) of female athletes were in the subclinical eating disorder range. Results assessing body satisfaction, reported that 24.2% of Division I female athletes and 30.7 % of Division III female athletes were either very dissatisfied or mostly dissatisfied with their overall appearance. Results also showed that Division I female athletes were less satisfied with their appearance evaluation (body areas satisfaction, and lower torso). Division III female athletes reported higher levels of bulimic behaviors and weight preoccupation. The results indicate that athletes in refereed female sports are at risk for eating disorders, and that body image risk factors vary between NCAA competition divisions. This research provides sport professionals with a better understanding of risk factors influencing the prevalence of eating disorders between female athletes’ divisional competition levels.

**Key words:** body dissatisfaction, eating disorders, NCAA division, collegiate female athletes, eating disorder risk factors

### Introduction

Eating disorders are among the four leading causes of disease that may lead to disability or death (2). Eating disorders have the highest mortality rate of any mental health illness (41). Approximately nine million Americans suffer from an eating disorder with a lifetime prevalence rate of 0.9% – 4.5% and approximately 10% of college women suffer from a clinical or near clinical eating disorder (19,22).

Body image refers to the self-perception and attitudes an individual holds with respect to his or her body and physical appearance. Body image is a complex synthesis of psychophysical elements that are perpetual, emotional, cognitive, and kinesthetic. Cash and Fleming (10) defined body image as “one’s perceptions and attitudes in relation to one’s own physical characteristics” (p. 455). Body dissatisfaction focuses on body build and is often operationalized as the difference between ideal and current self selected figures (7).

Body dissatisfaction is a significant source of distress for many females. Gender is reported to be a convincing risk factor for disordered eating since females are 10 times more likely to develop an eating disorder compared to males (14). Research shows that the size of the “ideal” woman is far smaller than the size of the average woman (25). “The overwhelming evidence of female gender as a risk factor for the development of an eating disorder highlights the importance of determining the factors that put women at risk, particularly the sociocultural context in which these disorders develop” (31, p. 766).

Risk factors that accompany eating disorders are multi-factorial in nature. Research has revealed that sociocultural, developmental, personality, athletic, trauma, familial, and biological factors are critical identifiable areas that house potential eating disorder risk factors (31). Within these specific areas, body image dissatisfaction and low self-esteem are two situational aspects typically associated with individuals who are at risk for developing an eating disorder. In an early study on body dissatisfaction (5), 23% of the women expressed dissatisfaction with various parts of their body. The particular areas problematic for women were the abdomen, hips, thighs, and overall weight. When the study was replicated in the mid-1980s (11), the percentage of females dissatisfied with their body increased to 38%, with the same general body areas being defined by the participants. These same general body areas were also identified in a more recent study (16) in 56% of women.

Considerable scientific attention has been directed toward the potential role that sport involvement play in an athletes’ development of attitudes and behaviors about disordered eating. Female athletes experience a higher rate of eating disorders than non-athletes (4,24,43). Female athletes have an eating disorder prevalence of 15% to 62% compared to 0.5% to 3% in late adolescent and young adult female non-athletes (21). Researchers (33) assessed disordered eating in female collegiate athletes (N = 204) from three NCAA universities. The responses to the Questionnaire for Eating Disorder Diagnoses (Q-EDD) found 72.5% (n = 148) of the female athletes were asymptomatic, 25.5% (n = 52) symptomatic, and 2.0% (n = 4) eating disorder (29). Compared to recent research (8,39), this research study found a higher percentage of female athletes who were symptomatic. Athlete’s prevalence rate is an important factor, but understanding variables associated with increasing or decreasing risk factors for disordered eating is significant etiological information that should be evaluated (32).

Athletic factors promoting eating disorder development were first identified through research that began in the 1980s, which found particular sports induced higher rates of disordered eating behaviors (1,17). Even though physical activity may develop self-esteem and encourage physical and emotional well-being, there is verification that female athletes are at greater risk for developing disordered eating than their peers who are non-athletes (6). Female athletes encounter the same sociocultural pressures that of non – athletes, however the increased demand of sport – related pressures may independently or dependently increase their risk of eating disordered attitudes and behaviors (40). Coaches, sponsors, and families may all play a role in influencing an athlete’s weight and shape. Negative comments from those that surround and evaluate the athlete may trigger the onset of abnormal eating behaviors leading to an eating disorder (12,28).

The type of sport may also play a role in predisposing an individual to eating disorders based on struggles with body performance satisfaction. Specific sports where performance is judged on body leanness, shape and movement such as ballet, gymnastics, figure skating, diving, and cheerleading have a higher incidence of eating disorders (1,42,47). Shape judged sports such as gymnastics, diving, cheerleading, and dance place more importance on the individual’s body appearance, which may lead to body shape discontent among competitors (47). Researchers also report that 15% to 65% of women in “thin build” sports such as gymnastics or ballet have pathogenic eating patterns known to influence or manipulate the history and development of the eating disorder (27,44). Participation in competitive “thin build” sports in conjunction with personality traits associated with disordered eating could put these individuals at an even greater risk for developing an eating disorder (15, 44). The personality trait of many perfectionist increase disordered eating behaviors for female athletes (20). Researchers (26) compared athletes and non-athletes and reported perfectionism was the only factor that significantly distinguished the groups. In addition, Wilmore (46) reported that athletes high in perfectionism had an increased drive for thinness than athletes low in perfectionism. Refereed sports such as basketball place a stronger emphasis on training and do not rely as much on body appearance; therefore athletes participating in these sports may be less likely to be associated with disordered eating patterns (47).

Most research to date focuses on Division I female athlete’s prevalence rates, while female athletes regardless of NCAA division, experience similar sport specific pressures associated with body image disturbances. Limited research has compared prevalence between NCAA divisions, eating attitudes, and body image disturbances in female athletes. Research has reported that the prevalence of disordered eating, unhealthy dieting, and distorted body image in the athletic population ranges from 12% to 57% (30). Elite female athletes who suffer from eating disorders put themselves at greater risk for serious illnesses and/or death (38). Research has shown that more than one-third of female Division I NCAA athletes report attitudes and symptoms placing them at risk for an eating disorder (2). The National Collegiate Athletic Association study that surveyed student athletes from 11 Division I schools (N = 1,445) reported 1.1% of the female athletes met DSM-IV criteria for bulimia nervosa while 9.2% of female athletes had clinically significant symptoms of bulimia nervosa. This study also reported 0% female athletes met the DSM-IV criteria for anorexia nervosa while 2.85% of the female athletes had clinically significant symptoms of anorexia nervosa (24). Researchers believed the results suggest that Division I female athletes are at significant risk for the progression of eating disorder thoughts and behaviors. The study also stressed the need for future research to examine non-elite Division I, II and III schools since eating disorder risk factors may be higher among lower tier schools. Comparing divisional levels of competition in NCAA athletics could be an important aspect to understanding risk factors involved in the developmental process of an eating disorder.

The purpose of this study was to examine and compare eating characteristics and body image disturbances in female NCAA Division I and III athletes in mainstream sports of basketball, softball, track/cross country, volleyball, soccer, tennis, swimming/diving, and ice hockey. This study also examined female body part dissatisfaction and eating attitudes utilizing the Multidimensional Body Self-Relations Questionnaire (MBSRQ) and Eating Attitudes Test (EAT-26). These findings may assist coaches, strength and conditioning coaches, and athletic trainers in understanding disordered eating and body image disturbances across various female sports in different competition divisions.

### Methods

#### Participants

Participants (N = 118) included Division I (n = 41) and Division III (n = 87) female athletes from National Collegiate Athletic Association (NCAA) member institutes of the following sports: basketball, softball, track/cross country, volleyball, soccer, tennis, swimming/diving, and ice hockey. The convenient sample participants were voluntary, anonymous, and in accordance with university and federal guidelines for human subjects.

#### Instruments

Each athlete completed questionnaires assessing participant demographics and athletic involvement (sport, division). Eating behavior patterns were assessed utilizing the Eating Attitudes Test (EAT-26) and attitudes concerning body image were assessed with the Multidimensional Body-Self Relations Questionnaire (MBSRQ). Anthropometric measurements (height and weight) and body fat measurements were taken on each athlete. (Omron Fat Loss Monitor, Model HBF-306C). The Fat Loss Monitor (Omron Fat Loss Monitor, Model HBF-306C) displays the estimated value of body fat percentage by bioelectrical impedance method and indicates the Body Mass Index (BMI). The bioelectrical impedance, skinfold, and hydrostatic weighing methods have all been shown to be reliable measures of body composition (r = .957 – .987) (23).

##### Eating Attitudes Test (EAT-26)

Eating Attitudes Test (EAT-26) was used to differentiate participants with anorexia nervosa, bulimia nervosa, binge-eating, and those without disordered eating characteristics. It is a 26-item measurement consisting of three subscales: 1) dieting, 2) bulimia and food perception, and 3) oral control. Scoring for this instrument was a Likert scale of six possible answers (always, usually, often, sometimes, rarely, never). Scores ranged from zero to three for each question and a total score greater than 20 indicates excessive body image concern that may identify an eating disorder (Garner et al., 1982; Williamson et al., 1987). EAT-26 has been proven to be a reliable measurement (r = .88) (17). The total score of the EAT-26 and the Drive for Thinness scale of the Eating Disorder Inventory (EDI) have reports of a 90% agreement (37).

##### Multidimensional Body-Self Relations Questionnaire

The Multidimensional Body-Self Relations Questionnaire: The Multidimensional Body-Self Relations Questionnaire (MBSRQ) is a 69 item self-report inventory for the assessment of self-attitudinal aspects of the body image construct. The MBSRQ measures satisfaction and orientation with body appearance, fitness, and health. In addition to seven subscales (Appearance Evaluation and Orientation, Fitness Evaluation and Orientation, Health Evaluation and Orientation, and Illness Orientation), the MBSRQ has three special multi-item subscales: (1) The Body Areas Satisfaction Scale (BASS) approaches body image evaluation as dissatisfaction-satisfaction with body areas and attributes; 2) The Overweight Preoccupation Scale assesses fat anxiety, weight vigilance, dieting, and eating restraint; and 3) The Self-Classified Weight Scale assesses self-appraisals of weight from “very underweight” to “very overweight.” Internal consistency for MBSRQ subscales range from .74 – .91. This questionnaire has been studied and used extensively in the college population. Internal consistency for the subscales of the MBSRQ ranged from .67 to .85 for males and .71 to .86 for females (9).

### Results

#### Descriptive statistics

Participants in the study included 118 female athletes from NCAA Division I (34.7%) and Division III (73.7%) universities. Participants reported their ethnicity as 80.5% White (n =95), 16.1% Black (n =19), .02% Hispanic (n =2), .01% Asian (n =1), and .01% as other (n = 1). The female athletes had a mean age of 19.81 years + 1.29 and a mean body fat percentage of 21.17% + 5.07 (Table 1). There was no significant difference between the divisions in regards to body fat percentage F (1,117) = .727, p = .395.

#### Test for Significance

A multiple analysis of variance (MANOVA) was conducted to determine the effect of NCAA Divisional Status (I or III) on eating characteristics and body image (Table 2). Significant differences were found between Division I and III, Wilks’s Lambda = .664, F(17, 114), p<.0001.

##### Disordered Eating Behaviors

Base frequency scores indicated that 49.2% of Division I female athletes and 40.4% of Division III female athletes scored a 20 or higher on the EAT-26. A follow – up ANOVA reported no significant differences between 20 or higher EAT-26 scores and NCAA Division, F (1, 117) = 1.732, p = .190. A significant difference was found between divisions on the bulimia subscale of the EAT-26, F (1, 117) = 9.107, p = 003. No significant differences were found between division for the EAT-26 dieting subscale, F (1, 117) = .125, p = .724 and oral control subscale F (1, 117) = 2.123, p = .148.

##### Body Disturbance

The results of the MANOVA indicated a significant difference between divisions on the MBSRQ, F(17,114 ) = 3.391, p = .000. The results of the MBSRQ, which assessed body satisfaction, found that 24.2 % of Division I female athletes and 30.7 % of Division III female athletes were either very dissatisfied or mostly dissatisfied with their overall appearance. In addition, a difference was found between Division I and III athletes for appearance evaluation, F (1, 3) = 10.525, p = .001, body areas satisfaction F (1, 3) = 8.36, p = .004, lower torso F (1, 3) = 5.975, p = .016, and overweight preoccupation F (1, 3) = 17.895, p = .000. Division I female athletes were less satisfied with their appearance evaluation, body areas satisfaction, and lower torso than Division III female athletes. Division III female athletes were more weight preoccupied than Division I female athletes.

### Discussion

The main purpose of this study was to examine and compare the eating attitudes and body image satisfaction in female NCAA Division I and III athletes in mainstream sports of basketball, softball, track/cross country, volleyball, soccer, tennis, swimming/diving, and ice hockey. Limited research is available comparing eating disturbances between NCAA divisions so the information acquired may help explain the prevalence of body image disturbances and eating disorder among college female athletes at different levels of competition.

The results of this study indicated that 49.2% (Division I) and 40.4% (Division III) of the female athletes scored 20 or higher on the EAT-26, putting them in a subclinical eating disorder range (18). Comparative research studies using the EAT-26 reported percent subclinical populations of females athletes to be 15.2%, N = 425 (3); 5.8%, N = 190 (13); and 10.2%, N = 59 (36). The current research study did not find a significant difference between subclinical population scores and division, however both Division I and Division III female athletes had a considerably higher subclinical eating disorder female athletic population compared to these previous studies. This finding may be an important implication because the desire to be thin does not always result in clinically diagnosed signs and symptoms of anorexia or bulimia. If left undetected, subclinical eating disorders may result in dysfunctional social interaction, decreased physical performance reduced physical health, and an increase in the propensity for athletic injury.

Between divisions, a significant difference was found on the bulimia subscale of the EAT-26. Division III female athletes struggled more with bulimic behaviors compared to the Division I female athletes. This finding agrees with previous research suggesting that disturbed eating behavior may be higher among lower tiered athletes (35). Bulimic behaviors may be viewed as more destructive to athletic performance so the elite competitive athletes (Division I) may be deterred from participating in such behaviors. Bulimic behaviors may also require a greater level of secrecy, so elite competitive female athletes competing may avoid such behaviors due to increased time commitment, travel requirements, and contact they experience with their coaches and athletic trainers.

It has been reported that female athletes participating in judged sports such as gymnastics, cheerleading, and dance are more prone to eating disorders compared to those who participate in referred sports such as basketball, swimming, and softball (26,34,47). The assessment of body satisfaction through the MBSRQ found that 24.2 % of Division I female athletes and 30.7 % of Division III female athletes were either very dissatisfied or mostly dissatisfied with their overall appearance. We believe that our findings warrant further investigation into the relationship of female athlete’s body dissatisfaction and those participating in referred sports.

A significant difference was also reported on the MBSRQ subscales between Division I and III athletes for appearance evaluation, F (1, 3) = 10.525, p = .001, body areas satisfaction F (1, 3) = 8.36, p = .004, lower torso F (1, 3) = 5.975, p = .016, and overweight preoccupation F (1, 3) = 17.895, p = .000. Division I female athletes were less satisfied with their appearance evaluation, body areas satisfaction, and lower torso than Division III female athletes. Division III female athletes were more weight preoccupied than Division I female athletes. A performance-related drive for thinness through appearance evaluation, body areas satisfaction and lower torso may have a greater impact on female athletes that compete in higher level divisions such as Division I. Being weight preoccupied may not be as closely associated with physical performance measures as compared to general body dissatisfaction.

Even though this was a well-designed study and used a diverse sample of female athletes, it is not without limitations. The participant sample was limited in racial/ethnic minorities, therefore future research should examine female athletic samples with greater racial/ethnic diversity. This research also compared Division I female athletes to Division III female athletes. Increasing the number of institutes and divisions would greatly benefit the findings of this study. Lastly, although a diverse group of female athletic teams was represented in this study, equal number of female athletes from each team was not available due to the sports each institution offered, scholarships, and general participation. For example, ice hockey could only be evaluated at the Division III level. It is possible that the results would have varied if there were equal participant representation. Future research should examine a greater number of institutions at varied divisions to increase participant representations among each sport.

### Conclusion

Our results indicate that refereed female sports are at risk for eating disorders and body image risk factors vary between NCAA competition divisions of female sports. Body dissatisfaction factors that may lead to serious eating disorders will continue to impact the female athletic audience due to added pressures innate to sport performance. Female athletes, regardless of sport, show evidence of risk for developing an eating disorder. Understanding what motivates the developmental process to accelerate in sport may vary depending on level of competition. The educational and scholarly implications of this research project include contributing to the body of literature in the area of body image and eating attitudes of female athletes and providing professionals with a better understanding of the risk factors that influence the prevalence of eating disorders at varied levels of competition.

### Applications in Sport

These findings may assist coaches, strength and conditioning coaches, and athletic trainers in understanding disordered eating and body image disturbances across various female sports in different competition divisions. Professionals that work with female athletes understand the sensitive nature of optimizing performance without compromising overall health. Recognizing and identifying prevention indicators for body image disturbances that lead to disordered eating will assist professionals when dealing with at risk female athletes in varied levels of competition of referred sports. This information will also greatly benefit programs aimed at ceasing the progression of disordered eating

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### Corresponding Author

Kim Kato, Ed.D.
PO Box 13015, SFA Station
Nacogdoches, TX 75962-3015

Dr. Kim Kato is an Assistant Professor in Health Science in the Department of Kinesiology and Health Science at Stephen F. Austin State University in Nacogdoches, Texas.

### Authors

**Kim Kato**, EdD, NSCA-CPT
Stephen F. Austin State University

**Stephanie Jevas**, PhD, ATC, LAT
Stephen F. Austin State University

**Dean Culpepper**, PhD, CC-AASP
Lubbock Christian University

Two United States Olympic Committee Olympism Programs: Team USA Ambassador Program and Olympic Day

The United States Olympic Committee administers a number of programs with the objective of spreading Olympism and the Olympic Ideals. Outlined below are its two most robust Olympism programs: the Team USA Ambassador Program and Olympic Day.

### Team USA Ambassador Program

The USOC considers its athletes the greatest representatives of the Olympic Movement and Olympic values. By developing the Olympic values in elite athletes, and, through sharing their stories, we aim to inspire others to seek the highest levels of excellence and to have respect for all, regardless of nationality, religion, race or background.

Started prior to Beijing 2008, the goal of the Team USA Ambassador Program is to expose U.S. Olympians, Paralympians and hopefuls to the expectations, roles, and responsibilities of representing the United States at the Olympic and Paralympic Games. This extensive athlete education program guides athletes through what it means to be an ambassador for their sport and country, how to embrace and maximize their role as a role model, and to consider the legacy and impact they hope to create.

The multi-phase program includes presentations, inspirational speakers and small group activities to cover such topics as:

* What it means to be an Olympian/Paralympian
* The athlete’s role as an ambassador
* The Olympic Ideals and why they matter
* Interview and media preparedness
* Leadership
* Leaving a lasting legacy through sport and Olympism
* Challenges all Olympians and Paralympians face

The 2012 program includes mandatory half-day sessions that take place at seminars conducted around the country, based on National Federation availability. The program allows for comprehensive discussions on the program objectives, including small group activities and interactive elements. A brief wrap-up session will be conducted in conjunction with the 2012 Olympic and Paralympic Games, providing a quick overview of ambassador program learnings, while focusing on inspirational activities and final tips.

The program is primarily delivered by iconic U.S. Olympians and Paralympians who have demonstrated sportsmanship and perseverance on and off the field of play in their own careers. The Olympic facilitators have included speedskaters Bonnie Blair, Eric Heiden and Dan Jansen; football player Brandi Chastain; softball player Jessica Mendoza; skier Picabo Street; decathlete Dan O’Brien; and others.

### Positive Outcomes

* The program was first administered in 2008, followed by 2010. Both Olympic and Paralympic Games resulted in better behavior and self-awareness by members of Team USA. The overall feedback from the American public was pride in the athletes’ performances on the field of play, but also their conduct off the field as good representatives of the USA and members of the Olympic Movement.
* Athlete feedback on the program has been overwhelmingly positive. All athletes who complete the program are surveyed and rank program elements on a scale of 1-5, with 5 being the highest ranking. For the 2010 program, the average score on each question ranged from 4.0 to 4.4.
* The program has been a successful case study in bringing together cross-functional teams consisting of staff members throughout the National Olympic Committee, National Federations, alumni, coaches and athletes.

Not only have Team USA athletes represented themselves well on and off the field of play, but a nation and beyond have been inspired by their demonstration of the Olympic values. With 4 billion individuals around the world witnessing the Olympic Games, this program has the opportunity to disseminate elements of Olympism globally.

### Olympic Day

Olympic Day in the United Sates represents the pinnacle USOC-led event to educate youth on the values of Olympism by coordinating all the leaders within the U.S. Olympic Family. All constituencies within the U.S. Olympic Family work in tandem to spread the message of Olympism and plant seeds among youth about entering the athlete pipeline and pursuing their Olympic and Paralympic dreams.

U.S. Olympic Day celebrations of a national magnitude occurred for the first time in 2009 thanks to the support of Chicago 2016 and the U.S. Conference of Mayors, in conjunction with the U.S. Olympic Committee. In 2010, the U.S. Olympic Family rose to the challenge of surpassing the success of 2009 through increased participation among the National Federations, Athletes’ Advisory Council (AAC), Multi-Sport Organizations (MSO), current athletes, athlete alumni and more.

2011 proved to be the most successful U.S. Olympic Day in history From June 19-27, the U.S. saw:

* 385 events
* 311 participating cities in all 50 United States
* 230 Olympians, Paralympians, hopefuls and coaches
* 90,000 participants

At these events, athletes led discussions with youth about the Olympic Values of excellence, friendship and respect. Sports demonstrations, fun runs and festivals helped introduce young people to Olympic and Paralympic sport.

The U.S. Olympic Committee has designed a turnkey program that assists communities across the nation in celebrating Olympic Day. The organization creates a team of account managers who work directly with a portfolio of communities to provide assistance in preparing for the events. In addition, an online toolkit is available for each event, consisting of:

* Olympic Education Materials (scripts and DVD) for one of the following topics: fair play, respect, perseverance, sportsmanship
* Recommended Olympic Day agenda
* U.S. Olympic Flag
* Certificate of Participation
* Olympic Day Mayoral Proclamation Template
* News Release Templates
* Team USA Logo and Guidelines
* User-Generated website for posting photographs

The account manager also works with the more than 5,000 Olympians and Paralympians currently living in the United States, endeavoring to have an athlete present at most Olympic Day celebration to share their experiences and the role the Olympic Ideals have played in their lives.

Thanks to the support of all participating organizations, Olympic Day is on the verge of appearing in every community across America within the next several years while continuing to expand partnerships among the U.S. Olympic Family. Olympic Day is becoming a great springboard in the United States for disseminating Olympic values across and grassroots organizations and participants.

Contemporary Issues of Heat Illnesses

### Abstract
Heat illnesses are of major concern. More and more high school, college, and professional athletes are suffering from and/or dying from heat related illnesses. With all of the knowledge that medical professionals have in this day-in-age, there should be fewer instances of heat illnesses. Parents, coaches, and athletes also need to be aware of prevention and treatment procedures in case an emergency occurs. Heat stroke, the most serious heat illness, is a life threatening emergency and needs to be treated immediately. Ice water immersion is the best method for lowering the body temperature quickly and effectively.

**Key Words:** heat illness, heat stroke, heat index, prevention, treatment

### Introduction

After working on a sports medicine team for the last two years, exertional heat illnesses (EHI) were brought to my attention. I never knew how often they occurred or how life-threatening they could be. The purpose of this paper is to spread awareness to athletes, parents, and coaches, of the dangers of heat illnesses as well as how to prevent, treat, and return-to-play after an episode of heat illness. Heat illness-related deaths are on the rise, and I am curious to know why athletes are dying from heat injuries, such as heat stroke. In 2004, Coris et al. (4) stated, “the recent high-profile deaths of a collegiate athlete and a professional athlete in Florida and a professional athlete in Minnesota have the sports medicine and family medicine communities in a state of ‘high alert’ and searching for the most efficacious methods of preventing such tragedies.” In 2007, heat stroke was “the third leading cause of death in U.S. high school athletes.” (Coris, Walz, Konin, & Pescasio, 2007). Now, in 2010, “exertional heat stroke is the second leading cause of death among athletes, followed only by sudden cardiac death.” (Mazerolle, Scruggs, Casa, Burton, & McDermott, 2010). There are several different heat illnesses, ranging from mild to life threatening. Heat edema, heat rash, heat syncope, and heat cramps are the milder heat illnesses while heat exhaustion and heat stroke are more serious. Sunburns can also be considered a heat illness, ranging from mild to severe (1st degree to 3rd degree burns). Heat edema is swelling of the extremities, often found in people who are not used to activity, heat, or a combination of the two. Heat rash is a specific area of skin that has been irritated. It is often, red, inflamed, itchy, and tingly. Heat cramps are painful, involuntary muscle spasms, most often occurring in the abdomen or calf. Heat syncope is defined as an orthostatic dizziness which is a result of a sudden pooling of the blood in the extremities, commonly seen in marathon runners after they cross the finish line and abruptly stop running. Heat exhaustion occurs when an athlete has become dehydrated and has a core body temperature of approximately 102°F. This athlete will often feel dizzy, and present as pale, warm, and diaphoretic. They may also present with a rapid pulse and could be hyperventilating. Heat stroke is a life threatening emergency and care needs to be provided immediately. An athlete suffering from heat stroke will usually suddenly collapse. The athlete will have hot and dry skin, a rapid pulse, and a core body temperature above 104°F. Athletes, coaches, and medical staff will benefit the most from this paper as I provide information on how to prevent and treat heat illnesses, learn how to identify and modify risk factors, as well as considering communication and special circumstances. However, parents, family and friends of athletes can also benefit from this article in learning about ways to help if need be.

### Levels of Care

One of the best methods for preventing heat illnesses, if done correctly, is the preparticipation physical exam (PPE). The PPE is used to find any intrinsic risk factors that an athlete may have. It could be anything from low blood pressure, to heart problems, from asthma to obesity, and everything in between. “Several intrinsic risk factors that increase susceptibility to EHI have been identified, but information about their relative contributions is limited. These risk factors include (a) previous history of EHI, (b) poor cardiovascular (CV) fitness, (c) obesity, (d) inadequate heat acclimatization, (e) dehydration or electrolyte imbalance, (f) recent febrile illness, (g) sleep deprivation, (h) a ‘never give up’ or ‘warrior’ mentality (high level of motivation or zealousness), and (i) use of questionable drugs, herbs, or supplements.” (Eberman, & Cleary, 2009). Each of these risk factors needs to be considered so that appropriate actions can be taken to provide the safest situation possible for the athlete at risk. An athlete with any of the previously mentioned risk factors is at a higher risk for experiencing a heat illness.

Not only do members of the sports medicine team need to be educated, but athletes, coaches, and parents should also be informed about the risks, signs and symptoms, and treatments of heat illnesses. If an athlete is suffering from heat stroke, it is essential to provide immediate treatment, and with more people being educated properly, faster treatment may be more readily accessible. Hydration is one of the most important factors in preventing heat illness. It is important to educate athletes and coaches on proper hydration techniques. In some instances, mostly seen in football, coaches have withheld water breaks as a form of punishment or as a motivation technique. The coaches may or may not have known that withholding water could be dangerous and life threatening in long durations. It seems that football players are more susceptible to heat illnesses because they have “double days” usually during the hottest part of the year. The double days often take place in the beginning of summer after a long summer break where athletes have not been practicing and have lost any acclimatization to exercise and heat that they had before. Therefore, the athletes are more likely to suffer from some form of heat illness during the first few weeks of practice. “During prolonged work periods in the heat, the maintenance of high sweat rates leads to progressive dehydration, which may be accompanied by impairment of mental and physical performance and of heat dissipation.” (Bates, & Miller, 2008). The combination of water and sports drinks seem to offer the best hydration. The sports drinks replenish sodium and other electrolytes that water does not have. However, only drinking sports drinks can provide too much salt and therefore, drinking water becomes necessary as well. “Ingestion of non-caffeinated sports drinks containing vital nutrients such as water, electrolytes and carbohydrates during exercise may help maintain physiological homeostasis, resulting in enhanced performance and/or reduced physiological stress on an athlete’s cardiovascular, central nervous and muscular systems. Both the volume of the rehydration fluid and its composition are critical in maintaining whole body fluid homeostasis.” (Snell, Ward, Kandaswami, & Stohs, 2010).

Proper clothing, equipment, and preparation are also key factors in preventing heat illness. “Heat production during exercise is 15 to 20 times greater than at rest, and is sufficient to raise a person’s core body temperature 1°C every five minutes, if there were no inherent regulatory mechanisms.” (Miners, 2010). It is important to drink fluids, monitor oneself and others and wear proper clothing. Players should be aware of how much fluid they drink and take note if they start to cramp or feel lightheaded. Players and coaches need to be sure to wear sunscreen and to reapply it accordingly. Lightweight, breathable clothing should be worn in order to allow air to flow and dissipate heat. Light-colored clothing should be worn when possible as the light colors reflect the sun’s rays where as darker colors such as black absorb the rays and thus intensifies the heat that the body is absorbing. Shorts and short-sleeved shirts should also be worn when possible to allow for as much breeze to flow to skin contact. This is the idea behind the recommendation of the National Athletic Trainer’s Association (NATA) and American College of Sports Medicine (ACSM) to acclimatize to the heat. It is especially important for football players in the early summer months to follow this safety guideline. It can take up to 14 days to acclimatize the body to the heat. So, it is important to start off with shorter practices during the early morning or later evenings. The players should start practices in shorts and short-sleeved shirts and build up to pads, then full pads, and then finally full pads with full uniform. It is also important to slowly increase the length of time the players practice and to modify which part of the day they are practicing in. Not only do the athletes need their proper equipment to help prevent heat illness, but the coaches and sports medicine team need their proper equipment as well. Ice water immersion has been identified as the best way to cool a person’s body rapidly and so a small pool-like container is needed on the sidelines of every sporting event. Coolers of ice and others with water should be kept next to the pool with the intent to use it only for the need of an emergency. Other coolers should be provided for drinking water. In some cases where a small pool-like container is not available, ice water buckets and towels should be available to cool an athlete. The sports medicine team should also supply a few tents to allow a place for athletes to escape from the sun. Although it may be an uncomfortable situation for the athlete and/or the athletic trainer, rectal temperature is the best way to determine core body temperature. Oral, tympanic, or other methods of reading a temperature are just not sufficient enough. They do not read a true core body temperature. Ingestible pills that read the body’s temperature are a great way to find out the athlete’s temperature for a few days, however, they are costly. The pills can be used to track an athlete’s body temperature, which is especially important for those who are susceptible to heat illnesses.

_Modifiable Risks_

Some of the things listed above in prevention techniques are also found in the modifiable risks category. Acclimatization to heat, dehydration, humidity, and high heat are all risks that can be modified, and thus, prevented. With proper education and planning, a heat acclimatization process can be initiated, proper hydration methods can be provided, and practices and games can be modified accordingly whether high heat, humidity, or other environmental factors occur. As mentioned above, the ACSM has set recommendations for acclimatization to heat but they also include information on hydration, humidity, and heat. “These recommendations consist of guidelines that measure heat stress and define the severity of heat stress by a Wet Bulb Globe Temperature (WBGT) Index. Based on the WBGT at the time of the event, the ACSM also has recommendations regarding the type, durations, and frequency of exercise regimes for a particular day, the frequency of hydration and rest breaks, and whether or not the activity should be moved to a different time of day or cancelled altogether.” (Cooper, Jr, Ferrara, & Broglio, 2006). Each sports medicine team should make their own policy based on these recommendations. Each employee should receive a copy and should sign a form acknowledging receipt and cooperation. The WBGT Index has become widely recognized and used as one of the best methods to determine whether it is safe to engage in physical activity outside or not. “WBGT is not air temperature, but is measuring the relative heat and humidity. It indicates web bulb globe temperature, an index of climatic heat stress that can be on the field by the use of a psychrometer…High WBGT indicates extreme risk of heat-related problems and appears to be one of the best predictors of heat illness.” (Cleary, 2007).

_Measuring Heat_

Another way to help determine whether it is safe to participate in physical exercise outside is by using one of the many heat index charts available to the public. A new one in particular, the Kleiner Exertional Heat Illness Scale (KEHIS), eliminates the many traditional categories of heat edema, heat cramps, heat, syncope, heat exhaustion and heat stroke and combines them to set three categories: mild, moderate, and severe. This scale is similar to the Glasgow Coma Scale in that it uses a points system to help determine which category the person falls into. Since not every person will have each sign or symptom found in the traditional categories, Kleiner felt this method of a point system would help identify the seriousness of the illness the athlete is suffering from. The points range from zero to 25. “A need exists for a universal scale that can objectively quantify the severity of heat-related illness. The KEHIS has been designed to fill that void. A KEHIS score of 12 is different than a KEHIS score of 15, and a score of 15 on one patient has the same level of urgency as a score of 15 in another. There is no disagreement about the level of severity.” (Kleiner, 2002). So, the WBGT and other heat index charts are used to determine whether it is safe to begin play and the KEHIS is used to determine which level of heat illness a person is experiencing. It is important to identify which level the athlete is experiencing because a severe, or heat stroke illness, is life threatening and needs to be treated immediately. It is also important to determine if an athlete is experiencing a mild or moderate heat illness. Heat illnesses are a continuum and one level can progress to the next very quickly.

### Considerations

Communication between medical team members is crucial when dealing with an emergency. The Certified Athletic Trainer (ATC) is usually the only medical personnel on the sideline for athletic events. In some cases a physician, physical therapist, and/or Emergency Medical Services (EMS) may also be present. One of the best ways for a medical team to effectively communicate during a medical emergency is by having an Emergency Action Plan (EAP) in place. Practice of the EAP is essential so that every person knows exactly what their job is in order to help eliminate confusion and chaos during the actual emergency. The EAP should specifically list every member of the medical team, their title, and contact information. Each venue; baseball field, soccer field, gymnasium, tennis courts, pool, etc., will need their own specific EAP established. Things included should be where to locate the ATC and emergency equipment such as Automated External Defibrillator (AED), splints, crutches, spine board, and bandages, to name a few. Communication lines such as cell phone, land lines, or 2-way radio with frequency and channel information, should also be noted. Also included in the venue section are directions for EMS to reach the specific facility. Details on who will call 911 and who will meet the ambulance when it arrives should also be included. This section should also have a list of all the area hospitals and directions so that they may be given to family members of those being transported. Other things to consider are environmental concerns such as thunderstorms, lightening, hail, hurricane, tornados, etc. For each of these situations, there needs to be a specific “safe location” for people to evacuate. Instructions for athletes to drop any metal equipment (bats, rackets, clubs, etc.) and for anyone to avoid metal stadium seating or tall trees are of utmost importance. The ATC will be in direct communication with the head coaches and officials and can suspend the game for safety reasons at any point.

With specific regards to heat illness injury, communication is crucial between members of the medical team. From the time the athlete suffers an attack, the ATC must put the EAP into action. After the athlete is released from the hospital, communication needs to be present between the athlete, athletic trainer, physician, coach, and in the case of a minor, the parents or guardians. Communication is crucial in order to provide the best care possible for the athlete.


Currently, there is no one set of standards for returning-to-play (RTP) after suffering a heat illness attack. Some commonly found suggestions include: 1) athlete suffered from heat cramps can RTP after hydrating until the cramps are gone, 2) athlete who suffered heat exhaustion should not RTP for 24 hours or more, and 3) athlete who suffered from heat stroke should stay out of activity for at least one week and must be cleared by a physician. “Recovery from EHI is typically determined by normalization of serum electrolytes, CK, creatinine, liver function tests, and normal mental status. When EHI victims meet these conditions, they can resume light to moderate exercise for 15 minutes daily. Maximal efforts, such as competitive running, and competitive sports, such as football, should not be permitted until recovery is complete. . . If the victim does not exhibit heat tolerance after three months post EHI episode, recommendations can be modified to an unrestricted exercise/workload, but maximal exertion, particularly during significant heat load conditions, should avoided.” (Muldoon, Deuster, Voelkel, Capacchione, & Bunger, 2008). Even though there are no set standards of returning an athlete to play, it seems wise to assure proper hydration and clear mental status as well as being cleared by a physician before allowing the athlete to compete. The timeline of RTP widely varies depending on the type of heat illness suffered and varies from athlete-to-athlete. As far as I, a medical professional, am concerned, we need to establish a professional standard for returning athletes back to practice and competition.

_Special circumstances_

There are many special circumstances to consider when dealing with heat illnesses. Amateur athletes, older athletes, and “weekend warriors” are of major concern themselves. These athletes tend to be out of shape or far less active than the collegiate or professional athlete, and yet many expect to go out and perform just as well. They push themselves too far and often experience a myriad of injuries and illnesses as a result. “Amateur participants may not have a complete understanding of recommended strategies for handling outdoor extreme conditions like heat and humidity. Thus, heat-related illnesses like heat stress and eventually heat stroke become increasingly possible, with susceptibility increasing with age, vulnerability factors like co-morbidity (e.g., chronic diseases), and various health-related behaviors (e.g., nutrition, hydrations, and sleep or rest).” (Shendell, Alexander, Lorentzon, & McCarty, 2010).

When thinking of athletes, many think of sports that take place on land. However, athletes who compete in or on the water are also of concern. Just because the athlete is in or on the water does not mean that they should be treated any differently than the land athlete. With regards to those athletes on the water, “paddlers should be encouraged to drink to thirst and replace electrolytes during long distance races and frequently be assessed for signs and symptoms of heat illness to prevent life threatening increases in body temperature and heat stroke. Paddlers should aggressively seek sun protection and have lacerations and skin injuries properly cleaned and evaluated by medical personnel if there are signs of infection.” (Haley, & Nichols, 2009).

On the other end of the spectrum are those who may have other health issues, thus, making them even more susceptible to exertional heat illnesses. Some researchers believe that there may be a link between exertional heat illness with those who have exertional rhabdomyolysis (ER), malignant hyperthermia (MH), and/or menstrual cycles. While exertional heat illness can be described as someone who has extreme high core body temperature, impaired mental status, and possible musculoskeletal or organ damage, a person with malignant hyperthermia does as well. Both EHI and MH are also both found in otherwise healthy people. Some of the people, who suffered from what appeared to be EHI, were later found to actually have been malignant hyperthermia. In contradiction, ER can also occur in warm or cool environments. However, like EHI and MH, “ER also is a hypermetabolic state wherein the skeletal cell membrane is severely compromised and serum CK values are markedly increased.” (Muldoon, et al, 2008). The recovery process of each of these seems to be very similar in that it calls for normalization of CK, serum electrolytes, creatinine, and liver functions. As of 2008, there are no biochemical tests, genetic tests, or functional bioassay tests available to determine the differences between the three. Further research is needed in order to be able to identify the similarities, differences, and treatments for each. In addition, Muldoon mentioned that females are more susceptible to heat illnesses than males. While searching through other articles I ran across an article researching the physiological responses to the menstrual cycle. In this article it was shown that females had a longer time to exhaustion than expected but was thought that by extending their time to exhaustion they become more susceptible to injury or illness. “Given the difficulty in conducting clinical research into the development of heat illness, obtaining evidence of the theoretical increased susceptibility to heat illness during the luteal phase in females remains elusive; however, it is an area that warrants further investigation.” (Marsh, & Jenkins, 2002).

The last special circumstance to consider is that of actually warming up before an activity while wearing an ice vest. The ice vest warm up was used on runners in a long distance race. The results showed that although heart rates varied, a lower body temperature was a consistent result. “The ice vest slowed the increase in core temperature throughout cross-country warm-up and racing among the participants of this study. With the reduced thermal strain, greater blood flow may be available for transport of oxygen to muscle. Sweat rate will likely be decreased during performance when the ice vest is used during the warm-up, and with a decreased sweat rate, blood volume should be better maintained, improving oxygen delivery to muscles. The greater blood flow and blood volume should lead to a better performance.” (Hunter, Hopkins, & Casa, 2006). While it is a fairly new idea, the ice vest warm up seems to provide impressive results. If we can decrease the core body temperature before an athletic event, it will theoretically, take longer for an athlete’s core body temperature to rise to a dangerous level. I found this article of interest because I am an athletic trainer in southern California where heat illnesses seem to be on the rise.

### Conclusions

In conclusion, the hope of this paper was to provide insight to how serious heat illnesses can be and how easy it is to prevent them. Currently, it seems that not enough people are knowledgeable of heat illnesses and the danger they possess. I urge everyone to take the time to learn about the prevention, treatments, and possible outcomes of heat illnesses. Learning this information could save a life. Even after years of education and research on heat illness, more and more athletes are suffering and dying from heat stroke. It is currently the second most leading cause of death in high school athletes and I find that totally unacceptable. The research and information on heat illness is out there for the public, however, they seem unaware of it. Medical professionals need to find a way to educate the public about heat illnesses, whether it is for the athlete or just a regular person.

### Applications in Sport

The mild versions of heat illness include: heat edema, heat rash, heat syncope, and heat cramps while heat exhaustion and heat stroke are much more serious and can lead to death. Parents and athletes need to be educated about the risks of playing sports, including environmental factors such as heat and humidity. Athletes also need to be aware of proper hydration methods to keep themselves healthy. The parents, athletes, coaches, and sports medicine team need to be on the same page with regards to the athletes’ safety and well being. Things like acclimatizing to the heat over a period of at least two weeks, proper hydration techniques, wearing proper, light-colored, breathable clothing, and identifying any underlying health issues before the start of the season are all important factors in helping to prevent heat illnesses. The sports medicine team is ultimately responsible for the safety of the athletes and must provide proper equipment, like a small pool with coolers of ice and water, for use of an ice water-immersion in the event of a heat related emergency. Communication between athletes, coaches, parents, and the sports medicine team are a necessity. An emergency action plan needs to be in place and implemented should an emergency arise. The timeline of when an athlete can return to play is unclear, however, the participant should be properly hydrated, have a clear mental status and should be cleared by a physician before returning to competition. There are always athletes with special circumstances or underlying health issues and it is important to try to identify these before the sport season begins so appropriate planning can be done regarding those issues. Further research is needed in the distinction between exertional heat illness, exertional rhabdomyolysis, and malignant hyperthermia. Additional information is also sought for those with menstrual cycles and the effect of possible heat illnesses. Warming up with an ice-vest also seems like it could be beneficial to the athlete, however, I believe additional research is still needed.

### Acknowledgments


### References

1. Bates, G.P., & Miller, V.S. (2008). Sweat rate and sodium loss during work in the heat. _Journal of Occupational Medicine and Toxicology_, 3(4), Retrieved from doi: 10.1186/1745-6673-3-4
2. Cleary, M.A. (2007). Predisposing risk factors on susceptibility to exertional heat illness: clinical decision-making considerations. _Journal of Sport Rehabilitation_, 16, 204-214.
3. Cooper, Jr, E.R., Ferrara, M.S., & Broglio, S.P. (2006). Exertional heat illness and environmental conditions during a single football season in the southeast. _Journal of Athletic Training_, 41(3), 332-336.
4. Coris, E.E., Ramirez, A.M., & Van Durme, D.J. (2004). Heat illness in athletes. _Sports Medicine_, 34(1), 9-16.
5. Coris, E.E., Walz, S., Konin, J., & Pescasio, M. (2007). Return to activity considerations in a football player predisposed to exertional heat illness: a case study. _Journal of Sport Rehabilitation_, 16, 260-270.
6. Eberman, L.E., & Cleary, M.A. (2009). Preparticipation physical exam to identify at-risk athletes for exertional heat illness. _Athletic Therapy Today_, 14(4), 4-7.
7. Haley, A., & Nichols, A. (2009). A survey of injuries and medical conditions affecting competitive adult outrigger canoe paddlers on Oahu. _Hawaii Medical Journal_, 68(7), 162-165.
8. Hunter, I., Hopkins, J.T., & Casa, D.J. (2006). Warming up with an ice vest: core body temperature before and after cross-country racing. _Journal of Athletic Training_, 41(4), 371-374.
9. Kleiner, D.M. (2002). A new exertional heat illness scale. _Athletic Therapy Today_, 7(6), 65-70.
10. Marsh, S.A., & Jenkins, D.G. (2002). Physiological responses to the menstrual cycle. _Sports Medicine_, 32(10), 601-614.
11. Mazerolle, S.M., Scruggs, I.C., Casa, D.J., Burton, L.J., & McDermott, B.P. (2010). Current knowledge, attitudes, and practices of certified athletic trainers regarding recognition and treatment of exertional heat stroke. _Journal of Athletic Training_, 45(2), 170-180.
12. McDermott, B.P., Casa, D.J., Ganio, M.S., Lopez, R.M., & Yeargin, S.W. (2009). Acute whole-body cooling for exercise-induced hyperthermia: a systematic review. _Journal of Athletic Training_, 44(1), 84-93.
13. Miners, A.L. (2010). The diagnosis and emergency care of heat related illness and sunburn in athletes: a retrospective case series. _J Can Chiro Assoc_, 54(2), 107-117.
14. Muldoon, S., Deuster, P., Voelkel, M., Capacchione, J., & Bunger, R. (2008). Exertional heat illness, exertional rhabdomyolysis, and malignant hyperthermia: is there a link? _Current Sports Medicine Report_s, 7(2), 74-80.
15. Shendell, D.G., Alexander, M.S., Lorentzon, L., & McCarty, F.A. (2010). Knowledge and awareness of heat-related morbidity among adult recreational endurance athletes. +Int J Biometeorol_, 54, 441-448.
16. Snell, P.G., Ward, R., Kandaswami, C., & Stohs, S.J. (2010). Comparative effects of selected non-caffeinated rehydration sports drinks on short-term performance following moderate hydration. _Journal of the International Society of Sports Nutrition_, 7(28), Retrieved from doi: 10.1186/1550-2783-7-28
17. Spain, J.K., Liotta, C., Terrell, T., & Branoff, R. (2010). Heat-related illness in athletes: recognition and treatment. _Athletic Training & Sports Health Care_, 2(4), 152-154.
18. Spann, T. (2007). Avoiding heat illness. _Hughston Health Alert_, 19(3), 5-6.

When Pride Goes Wrong

Pride is considered to be a positive emotion and is observed in human beings throughout the world. It is fostered through positive approval received from others and is associated with success and satisfaction. Feelings of pride serve to enhance an individual’s self-concept. When pride is at stake, individuals are motivated to work longer and harder to achieve success. Pride serves individuals and groups positively, however, experienced pride may lead individuals to feel special and entitled. When they are, they experience hubristic pride. Hubristic pride is sinister and dangerous. In the name of pride, sport participants cheat, engage in violence, and selfishly take advantage of others. Hubristic pride is not to be confused with the satisfaction one receives from successful performance and positive feedback. Hubristic pride is pride that has gone wrong. It allows individuals to engage in harmful acts without feeling remorse. Coaches, athletes and parents exhibit hubristic pride that causes harm to others. In this paper, examples of hubristic behavior and the harm that it causes in sport are presented. A lack of perspective enables individuals to choose to engage in hubristically motivated behavior.

Key Words: Pride, Hubris, Coaches, Athletes, Parents, Cheating, Violence, Sexual Behavior, Abuse, Hubristic Pride

The term pride is often viewed in a favorable light. It conjures up positive images such as a toddler’s glee after successful performance of a task, a parent’s delight in the athletic accomplishment of a child, a coach’s jubilation following an important victory, and an athlete’s elation after a record-setting performance. Few would find fault with these positive images of pride.

Pride, however, can degenerate into something abhorrent. Athletes cheat and injure others in order to achieve success and bolster their pride. Coaches can become controlling and abusive of athletes as they seek success and enhancement of their pride. Parents meddle into the affairs of coaches and abuse their children in the pursuit of athletic success, their means to enhancing parental pride. Pride can be the motivation for antagonistic actions as individuals compete for the social standing, fame, and riches associated with athletic success.

“In truth, pride is double-edged: destructive and ludicrous in the wrong place and the wrong proportions, but heroic and admirable in the right ones” (19, p. 46). How does pride positively serve individuals as they navigate the waters of social relationships and as they pursue success? How does pride, which can serve as a positive social attribute, become something negative? In order to answer these questions, the nature of pride as well as its positive social functions shall be examined. Hubristic pride will be explored as the origin of many ills plaguing sport and society. When pride suggests traces hubris, it becomes a negative force in the lives of many and all that fall within reach of its acridity. By better understanding the difference between pride and hubristic pride, coaches, parents and administrators may be better able to take action to prevent hubristic pride from causing harm to themselves or others.

The Nature of Pride and Its Positive Functions

Pride is a basic emotion observed universally in human beings (35). It is exhibited through specific and recognizable non-verbal expressions spontaneously displayed when individuals experience pride. They include a low-intensity smile, expanded posture, slight head tilt, and arms to the side with hands on hips or raised above the head with hands in fists (36). Children exhibit recognizable signs of pride by the age of two and a half years and are able to recognize physical expressions of pride in others by age four.

Pride is generally considered to be a positive emotion. It can be thought of as a sense of accomplishment and satisfaction in one’s actions. Pride is often linked to success and it is achieved through the receipt of social approval and the admiration of others (33). When individuals are rewarded with positive feedback and when they see faces brimming with pride over their accomplishments, they feel pride and understand that they stand well in comparison to others (26). Success enhances self-esteem and feelings of pride. Self-esteem and a sense of pride serve as positive means to find success in society (6,21).

Pride in One’s Work and Efforts

Pride is sometimes used to describe the satisfaction achieved through the completion of a task to the best of one’s ability. Former Major League Baseball player and Hall of Fame member Don Sutton illustrated the belief that one should take pride in doing one’s job and in doing it well (22):

I grew up in rural Clio, Alabama and in rural northwest Florida where your work ethic was what you took pride in, whether you might have been a farmer or a carpenter or whatever. You showed up on time, you did your job, and you went home. (5)

Sutton believed it was his responsibility to prepare himself for games to the best of his ability each day and that by doing so; he could feel a sense of accomplishment and pride.

National Football League quarterback and Super Bowl Most Valuable Player Drew Brees explained why he believed some athletes are superior to others. The key is having pride in one’s performance efforts (5):

I think it’s pride. That encompasses so many things. But in my mind, pride is that inner discipline, that inner voice to just be the hardest-working guy on the field — as tough as you can be — to give everything you can to your team, to not be a selfish player, to fulfill your role, to fight for your teammates, to be a great leader not only on the field but off the field. And just to work at your craft. (p. 1)

The comments of Sutton and Brees reflect the belief held by most involved in sport: individuals should work to the best of their ability and take pride in their efforts. Knowing that one has supplied the best effort possible is the means by which those defeated may find solace in their loss. Providing one’s best effort also enhances one’s chances of experiencing success.

Pride and Its Effect Upon Performance

Many athletes and coaches believe that when a person’s pride is challenged, superior performances result (18). Indeed, it has been demonstrated that the level of pride individuals possess is positively associated with goal-attainment motivation and perseverance (40). Those concerned with ego-enhancement and pride possess competitive orientations geared toward maintaining self-esteem and pride (6). When the pride of individuals is at risk, they work longer and harder to succeed.

Pride, however, can be a very damaging emotion for it can serve as the motivation to engage in harmful behavior as individuals seek to bolster and protect their pride. Further, a loss of pride in the form of humiliation or the potential loss of pride through ego threats can lead people to engage in aggressive and violent behavior (39,35).

The scriptures of many world religions proscribe pride and the egoism that is reflective of pride. Scriptures from two religious texts shall serve as illustrations.

Judaism and Christianity: “Pride goes before destruction, and a haughty spirit before a fall.” Proverbs 16.18 (25).

Hinduism: “Honoured (only) by themselves, void of humility, and full of the pride and frenzy of wealth, these calumniators (of the virtuous) perform sacrifices, which are sacrifices only in name, with ostentatiousness and against prescribed rules 3; indulging (their) vanity, brute force, arrogance, lust, and anger; and hating me in their own bodies and in those of others 4. These enemies 5, ferocious, meanest of men, and unholy, I continually hurl down, to these worlds 6, only into demoniac wombs. Coming into demoniac wombs, deluded in every birth, they go down to the vilest state, O son of Kuntî! without ever coming to me.” _The Bhagavadgita_ Chapter XVI (34, p. 115)

Writers and philosophers over the ages have also observed that pride may become something negative and destructive as evidenced by the following quotes (13):

> **Samuel Johnson:** “Pride is seldom delicate; it will please itself with very mean advantages.” (p. 517)

> **Louis the Eleventh:** “When pride and presumption walk before, shame and loss follow very closely.” (p. 518)

It is evident that pride can become something problematic in the lives of human beings. Though pride may benefit us, it may also be the cause of pain, suffering, and destruction.

### Hubristic Pride

Hubris is a term taken from the Ancient Greeks. Originally hubris described those who thought themselves superior to the gods and it entailed the moral failings of not knowing one’s place in a hierarchical scheme and vaingloriously sticking to it (23). Hubris is a false pride (9). The hubristic are puffed up with pride, exaggerate their importance, act recklessly in pursuit of glory, and may believe themselves to be infallible (19). Hubristic pride is associated with arrogance, conceit, narcissism, hostility, aggression, and it results in interpersonal problems (36- 37). Hubristic pride is not to be confused with the satisfaction one receives from successful performance and positive feedback. It is pride that has morphed into prideful. Hubris is pride that has gone wrong.

When individuals engage in a harmful act or transgression against another, the perpetrator may experience either shame or pride. If the choice is to experience pride, it is an indication that the perpetrator has morally disengaged from the victimized. The personal benefit gained through the harmful action is considered to be more important than the negative impact it has upon the victim (24).

In order to illustrate the real evil that can be caused by hubristic pride, three examples taken from outside the world of sport are presented below. Rapes occur frequently in war-zones as a consequence of narcissistic pride. Rape is deemed acceptable by the rapists because they believe the victimized deserve to be shamed through the act of rape. Shame displacement and narcissistic pride preclude the rapists from feeling shame over the horrible act of rape (3).

During the “Holy Wars” known as the Crusades, Byzantine Christian and Muslim writers characterized the Latin intruders as being prideful and arrogant (27). Who could war over religious beliefs and practices? Only the proud and arrogant could. The Byzantines believed that God would ultimately punish the pride and arrogance of the invading Latins. To the Muslims, Latin pride and arrogance was considered to be the gravest of sins. Those who acted with arrogance and pride, they believed, could not be true believers in their conceptualization of God.

The colonization and expansion of European settlements in North America resulting in the death of countless Native Americans required a measure of hubris. According to Lewy (17):

> The new Americans, convinced of their cultural and racial superiority, were unwilling to grant the original inhabitants of the continent the vast preserve of land required by the Indians’ way of life. The consequence was a conflict in which there were few heroes, but which was far from a simple tale of hapless victims and merciless aggressors. (68)

If indeed hubristic pride empowers individuals to engage in behavior that harms others in the quest to achieve their goals, it seems that sport would provide a context in which those who have achieved success and those committed to athletic success might display hubristic pride. One would also expect to observe conflict, pain and suffering in the wake of the hubristic sport participant.

### Hubristic Pride and Problems in Sport

During a televised speech, professional golfer Tiger Woods apologized for extramarital affairs that gained worldwide attention, garnered negative publicity and cost him millions of dollars in commercial sponsorships. The words of Woods (42) illustrated how athletic success can lead to hubristic pride and a sense of entitlement:

> I knew my actions were wrong, but I convinced myself that normal rules did not apply. I never thought about who I was hurting… I thought I could get away with whatever I wanted to. I felt that I had worked hard my entire life and deserved to enjoy all the temptations around me. I felt I was entitled. Thanks to money and fame, I didn’t have to go far to find them. I was wrong. I was foolish. I don’t get to play by different rules. The same boundaries that apply to everyone apply to me. I brought this shame on myself. (¶ 11 – 12)

Many who find success in sport are seduced by the calling of hubris. They grow to feel that they are special; that they are more important than others, and that they are entitled to have what they want and to act as they please. Actions taken as the consequence of hubristic pride held by coaches, athletes, and parents often impact others negatively.

#### Coaches and Hubristic Pride

Hubristic coaches dish out strong humiliation to athletes in an effort to achieve success that brings to them wealth, sporting glory and enhancement of their pride (23). Strong humiliation comes in the form of abusive and degrading language meant to embarrass and degrade the athlete’s self-concept. Strong humiliation is a violation of the basic respect one human being should have for another. It often results in more than an athlete’s loss of self-esteem that may come as a result of a loss; even an embarrassing loss. Athletes experience mental anguish, embarrassment, shame and may come to hate sport as a consequence of strong humiliation. More sinister is the prospect of the athlete feeling poorly about him or herself as a human being. Hubristic coaches coldly and calculably do harm in the name of athletic success and toward the enhancement of their personal reputation, fame and pride.

Recently, a college football coach at high profile program was accused of physically attacking and verbally abusing his players. A second was accused of grabbing a player by the facemask, shaking him, choking him, and punching him in the face (38).

Losses and insubordination enraged the coaches who suffered humiliation and a loss of face. The violent actions taken by the coaches as a consequence of assaults upon their pride made it clear that pride was more important than the athletes they chose to abuse.

Hubristic, glory-seeking coaches may violate rules and regulations in an effort to increase their chances of winning. For example, the New England Patriots’ coaching staff videotaped the defensive signals used by opposing coaches during games and practices. The Patriots used the information in order to call offensive plays to best take advantage of the defense, thus increasing their chances of success. The illegal activity was found by the National Football League to have taken place during the 2007 season, however, additional allegations of illegal filming surfaced during the 2008 season. It was also reported by a former Patriots’ employee that the team had filmed opponent’s signals beginning in 2000 during head coach Bill Belichick’s first season with the team (4). It is worth noting that the Patriots won three Super Bowl Championships between 2000 and 2006.

Hubristic coaches are found in youth leagues, high schools, and colleges. They feel as though they are above having to adhere to rules and regulations. Operating rules, they believe, are for everyone else to follow. In a sense, the hubristic do not believe they are cheating. They are simply doing what the timid and uncommitted will not do to achieve success.

Hubristic pride can lead to poor coaching decisions. A coach may leave a player in the game longer than appropriate because replacing the individual may make it clear that a mistake was made by either playing the athlete or by having left him/her in too long (28). Hubristic pride can lead coaches to make decisions concerning who plays where and when entirely upon opinions rather than the objective utilization of statistics as a part of the decision-making process. When athletes question hubristic coaches for reasoning behind opinion-based coaching decisions they indignantly respond, “Because I am the coach!” Sadly, hubristic pride hampers their ability to make good decisions. It prevents them from effectively motivating and communicating with their athletes. It thwarts the coach’s desire to learn and grow.

President Bill Clinton engaged in an adulterous sexual encounter with White House intern Monica Lewinsky. When asked some years later why he had the affair, he replied that it was for the worst possible reason, “Just because I could” (20, ¶ 16). Clinton felt special and entitled to do as he pleased. His actions were motivated by hubris. Illicit sexual activity is observed in coaches and it can also be motivated by a sense of hubris. Between 1993 and 2003, 159 athletic coaches were fired or received reprimands for sexual misconduct in the state of Washington (41). Coaches form strong bonds with athletes. They may take advantage of the closeness of their relationships and the power that they have over their athletes to garner sexual favors. They engage in the behavior because they can and because they do not consider the impact that the act has upon the victims.

Hubristic pride allows coaches to believe themselves to be exempt from the moral imperative of the “Golden Rule.” For example, they expect to be respected by officials, yet berate them when calls do not go their way. How many coaches refer to officials as “blind man,” “zebra,” and worse?

Hubristic coaches may demand respect from athletes, but give none in return. They wish to have athletes attentively listen to their instructions, wants, and needs, yet they fail to consider those of their charges. Though hubristic coaches may find success, their actions result in athletes who resent and despise them. The hubristic demonstrate to the world that they alone are important and spread the message that the self is important above all. Hubristic coaches simply use athletes to achieve their personal goals.

What insidious actions will hubristic coaches take in an effort to achieve victory and bolster their pride? Before a T-Ball playoff game a coach offered to pay one of his players twenty-five dollars if he hit a teammate on purpose with a thrown ball. The intended target was Harry, a nine year old who was autistic and mildly retarded (2). The goal was to avoid having to play Harry in the three innings required by league rules. Participation by the autistic and mildly-retarded child would naturally decrease the team’s chances for success. If Harry were hurt, he would most likely go home. When hitting Harry in the groin failed to have the desired effect, the coach asked the player to hit Harry harder with a second throw. The child hit Harry in the side of his face and ear drawing blood. Traumatized, Harry did not play in the game. The coach was, however, able to bask in the glow of an epic T-Ball playoff victory.

#### Athletes and Hubristic Pride

Successful athletes often feel entitled to special treatment from others. Earlier in this paper, the words of Tiger Woods illustrated how athletes may convince themselves that hard work and success entitle them to special treatment. Athletes who feel entitled to special treatment negatively impact others and at times, harm themselves.

Few athletes in history have been the embodiment of perfection. How can athletes improve if they believe themselves above the need for improvement? How can they better contribute to the success of a team if they do not realize their potential? Hubristic athletes cannot honestly consider these questions, because they have been successful and their attitude toward instruction becomes hardened. They have an unrealistic assessment of their abilities and cannot see that their current abilities may simply make them a “big fish in a small pond.” They do not achieve their potential because they have an inflated perspective of their abilities. They lack perspective.

Hubristic athletes often feel as though they should not be required to adhere to policies and expectations set forth by the coach. For example, they are offended when they are taken out of a game in order to allow a substitute to play, when they are punished for being late, when they are asked to stop talking while the coach is trying to instruct, and when they are required to perform in tactical roles determined by the coach.

Hubristic athletes are less than a joy to have on a team in spite of how talented they may be. They cause frustration, irritation and resentment. They do so because they believe their perceived self-importance is worthy of special treatment and understanding. They believe that because they are gifted, the team cannot do well without them. They deceive themselves.

The hubristic individual is a poor teammate for it becomes clear to all that their own views and their personal success are all that is important. The hubristic athlete feels entitled to tell others what they are to do instead of making suggestions. The hubristic quickly express their displeasure in the poor performance of others and are incensed when others have the audacity to suggest that their play could be improved. Teammates come to fear and in a way despise them.

Hubristic athletes may even come to expect special treatment from officials. Some professional basketball players receive favorable calls because of their historical success and fame. They also receive favorable calls because they complain to officials to the point of embarrassment when calls do not go their way (29).

Hubristic athletes may see no problem with intentionally harming opponents in response to a loss of face experienced during competition. For example, an opponent was dominating NFL defensive tackle Albert Haynesworth during a contest. In the midst of a play the helmet of Haynesworth’s opponent had fallen off. With his opponent lying unprotected on the ground, Haynesworth intentionally stomped upon the face of his tormentor with a cleated foot. The stomping resulted in the victim being removed from the game and receiving several stitches. When asked about the motivation for the reprehensible act, Haynesworth replied, “You come to a crossroads in your life. I’m a prideful guy and I hate to lose, and I thought I was losing or at the point where it was make it or break it. I wanted to make it.” (15, ¶ 26).

#### Hubristic Pride and Parents

Modern parents often believe that the successes and failures of their children are an indication of their parental prowess. According to Coakley (10) the moral worth of parents is often tied to their children’s sporting success. In the sports setting the consequences of a child’s success and failure therefore takes on high importance concerning the pride an individual may take in being a parent.

Parents may display symptoms of hubris as they seek glory for their children. They feel entitled to impose their will, opinions, and desires upon anyone who may have an impact upon their child’s ability to shine. According to Dominowski (12):

> Some parents become obsessed with their son’s or daughter’s athletic success. Making all-conference, all-county, all-district, or all-state, for some parents caught in the web of showing themselves and their neighbors they are somehow ‘better’ because of their child’s success, is a case in point. Playing up to a coach, beseeching administrators, or running to the athletic director is a common occurrence among those with a do-or-die fixation personality. When things don’t go the way these individuals want them to go, out come the personal bashing, invective, provocative personal assaults, name-calling, and ‘get-even’ determination to end a coach’s career. (18)

Hubristic parents become a bane upon the lives of coaches. Parents evaluate all coaching decisions in light of how they may benefit or harm their child’s chances to achieve success and glory. Coaches are frequently second-guessed and criticized. Emboldened parents will often attempt to influence the decisions of coaches and become enraged if and when their attempts fail. Parents become incensed when it is perceived that their child has been “mistreated” or subjected to “humiliation” because it indirectly serves as an attack on their pride. Too frequently, their rage erupts into violence. Some salient examples are presented below.

* An angry parent attacked a coach because allegedly the coach had verbally embarrassed his son. The parent was a member of the United States House of Representatives (7).
* A parent ran onto the wrestling mat and grabbed the eleven-year-old athlete who was about to pin his child and threw him off of the mat (11).
* A parent attacked a coach after his child was forced to run a lap for being late to practice (1).
* An angry parent came after a coach with a loaded gun because his child did not get enough playing time (30).
* The organizer of a youth football league knocked his child’s coach unconscious during an argument over when the child would be placed into the game (14).
* A parent was found guilty of involuntary manslaughter over an attack leading to the death of a coach. The parent was angered over rough play that had occurred during a hockey scrimmage (8).

How many engage in violent activity because their parental pride has been wounded? How many angry parents believe that violence is justified because their pride is more important than the health, safety and even the lives of others? Those who do posses a puffed-up hubristic pride that makes them dangerous.

Parents may justify cheating as a means of assisting with their child’s success. The importance of success to the hubristic parent takes precedence over values such as fair play and sportsmanship. In an effort to achieve success, parents may falsify birth certificates or purchase performance-enhancing drugs for their children to ingest (16,32).

Hubristic parents may be despised by others because their conversational focus centers around their child’s talents, successes, future greatness, and because they often erupt into tirades concerning “unfair” treatment doled out by coaches and officials. Not to be forgotten are the stories of financial sacrifice, time invested and personal involvement in the skill development of their children. If people are not told, hubristic parents believe, how can they recognize the important impact that their actions have had upon the success of their children?

### Perspective Yields Humility

In a capitalistic society, competition is ubiquitous and the standing afforded us through our successes and failures has a tremendous impact upon our self-concept and experienced pride. Pride can indeed be a positive emotion. It serves to motivate human beings to accomplish great things both individually and collectively.

In the pursuit of success and in the afterglow of achievement we may deem ourselves special and, therefore above following the rules and standards of behavior set forth by society or the governing bodies of sport. We may come to believe ourselves to be worthy of special treatment and to take license to do as we please regardless of the harm we may do to others. When we do, we have chosen to be hubristic (27). We become a source of conflict, pain and discomfort. We may literally become a danger to others as well as to ourselves.

The perspective unknown to or unappreciated by the hubristic is that success and fame soon fade. Eventually time has its way and the mantle of greatness once bestowed upon the prideful is unceremoniously taken by vigorous youths. “In sports, more than most cultural pursuits, greatness is indeed on loan temporarily from the Gods” (23, p. 51). We cannot win forever. The applause we receive for our achievements does not echo throughout eternity.

Even those who achieve international renown should understand that to some, they are nothing more and nothing less than one of the 6.8 billion inhabitants of the earth. In an interview following Tiger Wood’s public apology for his hubristically motivated indiscretions, the Buddhist religious leader, Dalai Lama, stated that he did not know who Tiger Woods was (31). It is clear that the monumental achievements of some are unknown by and irrelevant to the many. Perspective yields humility. Perverted is the perspective held by the hubristic.

### Application in Sport

There is nothing wrong with the positive feelings of pride associated with athletic accomplishments. Athletes fittingly take pride in their abilities and performances. Coaches justifiably take pride in their work and successes. Parents rightly feel pride in the performances and accomplishments of their children. The desire to obtain a sense of accomplishment and pride drives individuals toward excellence in sport and life.

The danger to individuals and to society surfaces when pride in one’s athletic accomplishments leads them to believe that they are entitled to special treatment. At this point, pride has gone wrong. Pride has morphed into hubristic pride.

If sport is to prepare individuals to work and to live in harmony with one another, hubris must be eliminated from the competitive milieu. Athletic administrators, coaches, athletes, and parents must be vigilant for traces of hubristic behavior and sanction it quickly and effectively. In doing so, the spread of hubristic behavior through sport may be lessened.

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Corresponding Author
Dr. Steven Aicinena
Professor of Kinesiology/Athletic Director
The University of Texas of the Permian Basin
4901 East University
Odessa, TX 79762
Office: 432-552-4675

The Athletic Hurdles to Prestige: A Case Report

### Abstract

This case report presents a history, diagnosis, prognosis and treatment of a young tennis athlete on scholarship to Florida State University. He sustains an acute ankle injury while in a tournament in the last month of high school that jolts him into realizing the injury hurdles that may lie ahead in the college athletic world. He and his parents choose alternative and complementary sports medicine rather than traditional methods and procedures for the health care of the young athlete. This case report details the procedures used to manage the acute ankle injury – Chiropractic, Acupuncture, Cold Laser – and the latest athletic training methods for sports rehabilitation are given in the integrative sports injury care given this athlete.

**Key Words:** Alternative, Complementary, Integrative, Chiropractic, Acupuncture, Cold Laser

### Introduction

Leonardo da Vinci called the human foot, which contains nearly 25 percent of the human’s bones and an elegantly functional arrangement of ligaments, tendons and fascia, a marvel of bioengineering and a work of art. Centuries after that observation by da Vinci, researchers continue to discover more about how the feet work, what can go wrong with motility maneuvers, and why (1).

Since 1990, Anderson Reed, a Daphne, Alabama resident and standout student at Bayside Academy in Daphne, Alabama, had been aspiring to greater heights in his chosen athletic endeavor of tennis (2). This year he graduated at or near the top of his class to go on to the University of his choice. He had a wide choice of colleges to select from by his sophomore year in high school when he became the top ranked tennis player in the State of Alabama. Reed played in tournaments across the United States through his high school career and accomplished a top 10 national ranking in tennis.

The young athlete narrowed his field of schools down to Georgia Tech, Vanderbilt, Louisiana State University, University of Alabama and Florida State University. After visiting the schools, talking with the administration, players, coach, and coaching staff at each college he felt informed enough to make a decision. His selection turned out to be Florida State University in Tallahassee.

His academic performance had been as good as his tennis record over the last four years, and it was reflected in the colleges and universities that sought Reed for their student body. Reed had decided on his collegiate career based on the academics of the school and the tennis program of Florida State University. Florida State has competed in the National Collegiate (NCAA) Sweet Sixteen finals each year for the past five years. They have top participants in the professional ranks, so he knew the coaching was going to be some of the best and – another plus – it was fairly close to home for him.

### Athlete and Injury

Last year at a state tournament in Mobile, Alabama, Reed was returning a hard volley and came down from a jump in the air, as he had done a thousand times before for a return shot. This time, however, he went down to the court in pain. He couldn’t move without severe pain. He had to forfeit the match and the game that day. His father and mother happened to be there and brought him home. They immediately called the practitioner they had depended on to keep Reed in good playing health for the last fifteen years. They all came together at the Integrative Medicine Centre office. The young athlete was taken to an examination room. It didn’t take long to determine that he had indeed sustained a bad ankle contusion with strain and sprain. The doctor thought he should be taken to the hospital for radiographs (X-rays), imaging (MRI), or both.

At the hospital the ER physician examined and followed up with radiographs and an MRI. It was determined he had sustained a grade III strain/sprain to the ankle (3). The radiologist had pointed out a couple of stress lines that he felt in most individuals would have been fractures (4). The diagnosis was a strain/sprain of the right ankle. Reed was to be out of action for the first time in his athletic career with an ankle injury. He had suffered mild shoulder, neck, wrist, and low back strains (5) over the past ten years, but nothing that kept him out of action more than a few days. This time was going to be different.

The team of Integrative Sports Medicine Specialists had seen hundreds of these injuries and had taken care of some of the best athletes in the world. They saw this as a good opportunity to illustrate the unified professional cooperation of the group.

![Reed’s Right Ankle](
Figure 1 Lateral View – Reed’s Right Ankle

### Biomechanical Analysis

The injury stunned Reed, his family and friends. Seeing him hobble around on crutches for weeks was just not what they were used to. But there were three components to this injury they had to understand. Because of the excessive flexibility of his body, especially the foot, over-pronation could easily have caused a fracture to occur. The three components that were involved, any one of which could have resulted in the injury were: a) too-rapid pronation (a turning-in of the foot); b) too extensive a degree of pronation; and c) pronation for too long a time.

When jumping, the athlete maintains pronation from the time of ground contact all the way into what’s called the propulsion phase. (At the propulsion phase, the foot should be very rigid to propel the body forward.) With a late-phase over-pronation, the foot is hypermobile (loose) and in danger of injury (6). Simply put, the body is applying a high level of force against the ground to propel the body forward while the foot is also excessively rolling inward. This inward foot rotation is transferred up the kinetic chain, alternating joint function. The uncontrolled load results in a high impact foot strike (6). So the athlete has reacted too fast, too excessively, and too long. The most difficult part for most people to understand is that he was just doing what his mind directed his body to do with the shot he was returning (6).

While traditional treatment methods for muscle, tendon and ligament injury have always emphasized rest, ice, compression and elevation (RICE), the team felt Reed should start functional treatment right away in order to retard scar tissue development (7).

### Methods and Materials

The team discussed the treatment plan after the consultation and examination, and determined that the athlete required a minimum of eight weeks of therapy, to consist of a physical examination (orthopaedic and neurological) (8,9), applied kinesiology or manual muscle testing to determine the weakened structures (10), acupuncture for quick pain control (10,11), and chiropractic for pelvic and low back compensation correction (6,8,10,12) as well as sports therapy procedures (13,14).

One new innovation in sports therapy, the Laser Therapy, a 500 mW cold laser (15,16), was to be utilized for the innovations provided by photobiostimulation technology within the last few years of Sports Medicine application and research (16). Medical Laser Systems has been working with doctors on a number of laser investigations, and this therapy seemed to be a good integrative approach to use. The laser utilizes acupuncture points that have been used in foot and ankle injuries in martial arts for hundreds of years with safety and efficiency (17).

Rehabilitative help from athletic training procedures and expertise was invaluable (18). The role of the Athletic Trainer’s (AT) involvement with the rehabilitation began early. Having worked with athletes for years, the AT was in tune with the mind and body needs of Reed’s injury from the start. There was the obvious need for some immobilization with an injury such as this, but the vital benefit of movement to promote healing in the affected area was not to be ignored (18).

The initial rehab session involved testing the ankle for range of motion (ROM) in relation to pain. The athlete needed to work in ranges where discomfort was 1-4 on a scale of 10 (19). This assessment was done in open chain fashion as the affected ankle tested in every possible position to locate the primary hindrances to healthy ROM.

What was found was there were a few positions in ROM (i.e. dorsiflexion) that caused greater degrees of pain than others. Once located, “pain-free zones” of ROM were used to work the ankle in those zones with resistance bands in a seated position. Some pain-free ROM with light resistance in the injured ankle progressed into the areas where discomfort was evident. The stimulus was kept passive as opposed to forcing any ROM that was not compliant. It must be noted here that the non-injured ankle was trained with the same resistance and workload. Well-established research literature indicates that working a non-injured limb results in strength improvement in the injured contralateral side. This is referred to as “cross-transfer” and even in immobilization situations reports show 10-77% (of healthy side) strength increases (20).

The athlete’s progress in ROM was quite amazing. He was seen 3-4 days per week through the rehab process in combination with his acupuncture and chiropractic treatments. Stability drills were added to the program. With the ankle, a healthy joint must have both mobility and stability (20). The ankle can be quite an uncooperative joint for an athlete, since if either the stability or mobility is compromised the other attribute suffers. Being a tennis player means the demands of repeated acceleration, deceleration, and change of direction are inherent. Proficiency in these athletic skills requires high degrees of mobility in the ankle joint. However, once that mobility threshold has been violated (as was the case with this injury), stability is the number one priority. Mobility cannot be restored to the athlete’s ankle without the presence of stability. Stretching of the lower leg was done with precision and care, to locate the ROM for that day as opposed to being competitive and forcing progress.

Though “ankle stability” was the focus, the vital fact is that the human body works in kinetic chains, meaning no specific area of the body (i.e. ankle) is an island unto itself. For example, the restoration of the ankle is intimately affected by mobility and stability in other key areas such as the hip and knee (21,22). We did not want our athlete performing closed chain movements on the injured ankle that would compromise ipsilateral hip function through compensations to “protect” the ankle. Standing exercises were implemented that required a “regulated stimulus” to the injured ankle. Reed performed these drills barefoot on a cushioned surface that required him to flex his feet into the surface.

After he developed the necessary stability in the ankle, it was time to implement lunge type drills with assistance from a resistance band around the waist. The bands are used in this case to _unload_ the drill so that less of the athlete’s bodyweight is placed on the injured ankle. The progression was to go into controlled horizontal force drills where the subject would move laterally while attached to the resistance band. This gradually reintroduced the ankle to deceleration forces as well as change-of-direction demands. These drills, and others similarly performed with trunk rotation, re-educated the kinetic chain that includes the hips and other core muscles as well as the shoulders.

Figure 2 Dr. Mike Allen, Dr. John Stump, Sports Medicine Specialist, with Anderson Reed

Reed followed the treatment and rehab plan exactly as was suggested and established a routine that had him back in competitive condition within the predicted 8 weeks.

It is reported, “Reed has been a natural athlete from the beginning of his career; not taking any medications, steroids or athletic enhancements has been his prerogative.” There was no question or desire for anti-inflammatory therapy during the treatment or rehabilitation phase. The athlete understood the theory that medication may give him short-term benefit but nothing permanent (23). He followed the daily grind of the exercises and the muscle therapy explained to him each week. The manual muscle testing (AK) showed the progress being made each week. His speed, strength and agility were there as before the injury. The relationship between the force of movement and the velocity of movement was well understood (24,25).

### Conclusion

Beginning high-competitive athletics at an early age, this young man just experienced what every athlete has to face, human frailty and lack of total control, the fact that athletic injury hurdles come up suddenly, unannounced and as quickly as moguls down a ski slope.

The sports injury team had worked with athletes from elementary to professional and Olympic levels during their career. They knew there are times when this happens to the best of athletes; it’s part of the price that each athlete has to pay climbing to the top of their athletic endeavor. Some athletes take it in stride and know and understand, but the knowledge is difficult for others. They just can’t understand why the body doesn’t always respond as quickly and as efficiently as it should to a mental command and when it tries, sometimes the communication breaks down.

This athlete has a great future ahead. He crossed this injury hurdle just as he had all other hurdles put in front of him, with hard work and patience. He took on his treatment and rehabilitation as if it was part of the challenge of the game, and it is a very important part. Our athletic staff would not be surprised at all to see him at Wimbledon in the near future if he continues to follow the work ethic he has set up for himself in the early stages of his athletic career. We want to thank the Physicians and staff of Thomas Hospital for their contribution and help with the imaging of the ankle.

Please address any questions, comments or suggestions to the authors at the following email address: or visit

### Applications in Sport

This article was written for the coaches, trainers and other sports health related personnel not familiar with the benefits of working in an Integrative Sports Healthcare facility. In this type of facility there are chiropractic, acupuncture, laser, nutrition and many non-traditional clinical applications that can speed an athlete’s injury toward recovery, in addition to the traditional approach in Sport Medicine.

### Acknowledgements

The authors wish to thank the radiology staff at Thomas Hospital, Fairhope, Alabama, especially the physicians who consulted with us in this case.

### References

1. Keele, KD with a commentary by Carlo Pedretti, Corpus of the anatomical works in the collection of her Majesty the Queen, New York: Johnson, 1979-1981. 3 vol. See also his fundamental study, Leonardo da Vinci’s elements of the science of man, New York: Academic Press, 1983.
2. American Academy of Orthopaedic Surgeons The Young Athlete New York, NY, July 2009.
3. Hole JW, Human Anatomy & Physiology, Wm C Brown Brothers, Oxford 1995 pages 172-200.
4. Fore, David and Radiology Staff, Thomas Hospital, Fairhope, AL. May 2009.
5. Gibble, M and Ashton, J. Young Athletes Fight Sports Injury www.CBS.Com June 2009.
6. Schafer RC. Clinical Biomechanics Musculoskeletal Actions and Reactions. Williams & Wilkins, Baltimore, 1998, pages 579-582.
7. Hammer, W. New Trends in Treating Muscle Injury. Dynamic Chiropractic, March, 2009.
8. Jenkins, DB Functional Anatomy of the Limbs and Back W.B. Saunders Company, Philadelphia, 1991.
9. Cyriax, J Orthopaedic Medicine Vol I & II Bailliere Tindall, London, 1984.
10. Micozzi M Fundamentals of Complimentary and Alternative Medicine Saunders Elsevier, 2006 pp 223-225.
11. Ibid pp255-73
12. Mayor DF Electroacupuncture Churchill Livingstone, London 2007 pp 191-195.
13. Oschman JL Energy Medicine: The Scientific Basis Churchill Livingstone London 2000 pp 165-193.
14. Stump JL Neuroma Pain of the Foot Successfully Managed with Laser Therapy Practical Pain Management, May 2009 pp 47-51.
15. Medical Laser Systems, Brandford, CT
16. White J and Kaesberg-White K Laser Therapy and Pain Relief. Dynamic Chiropractic. October 1994. 12(21).
17. Deadman P, AL- Khafaji M, and Baker K. A Manual of Acupuncture Journal of Chinese Publications. East Sussex, England. 2001.pp 10-20.
18. Konin JG Clinical Athletic Training SLACK Inc., Publishers, Thorofare, NJ 1996.
19. Irvin RL Classification of Chronic Pain. Pain. Supplement 3. 395-396.
20. Muscolino JE. The Muscular System Manual. Elsevier Mosby, St Louis, 2005.
21. Liebenson, C. Building Speed and Agility. Dynamic Chiropractic, June 2009.
22. Miller, John P. and Croce, Ronald V. (2007). “Analysis of Isokinetic and Closed Chain Movements for Hamstring Reciprocal Coactivation”. Journal of Sport Rehabilitation (16): 319–325.
23. Mishra DK, Friden J, Schmitz MC, et al. Anti-inflammatory medication after muscle injury. A treatment resulting in short-term improvement but subsequent loss of muscle function. J Bone Joint Surg Am, 1995; 77(10): 1510-9.
24. Munn, J., Herbert, R., & Grandevia, S. (2004). Contralateral effects of unilateral resistance training: a meta-analysis. Journal of Applied Physiology, 96, 1861-1866.
25. Lee, M., & Carrol, T. (2007). Cross Education: Possible mechanisms for the contralateral effects of unilateral resistance training. Sports Medicine, 37, 1-14.

### Authors

John Stump did his undergraduate work in biology at the University of Maryland and a Master’s and Doctorate in Sports Medicine at the United States Sports Academy. In addition he accomplished a doctorate in Chiropractic from Palmer College in Davenport, Iowa. He went on to do postdoctoral work in Oriental Medicine and Acupuncture in Japan, China and Korea. In addition he holds black belts in Judo, Karate, and Kempo.

Dr. Stump is armed with a unique perspective on health care from an eastern and western scientific view. Because of this Dr. Stump was asked to be a team doctor for the South Korean government in 1986 for the Asian Games and 1988 Seoul Olympics. He is the author of numerous scientific articles, and has coauthored 4 textbooks. The latest textbook publication Stump contributed to being Electroacupuncture, edited by David Mayor, published by Elsevier 2007. Later that year he released a non-fiction account of the tragic stroke he survived (“A Stroke of Midnight” Alternative Concepts Publishing, 2007.) John is now writing a unique east-west anatomy text for McGraw-Hill to be released in 2011. He is a National Faculty member of the United States Sports Academy.

Mike Allen did his undergraduate work at the University of Tennessee at Knoxville and graduated in 1999. He did post-graduate studies in Sports Medicine at the United States Sports Academy and Athletic Training at the University of Mobile in Alabama. He is presently assistant Clinic Director at Southwest College of Acupuncture, and attends patients at a clinic in Denver, Colorado. In addition he is Consultant in Acupuncture to the Integrative Medicine Centre, Fairhope, Alabama since 2005.

Bob Saxon did his undergraduate work biology at Loch Haven University in Pennsylvania. He graduated from New York Chiropractic College with his DC degree in 2000. He has worked at the Integrative Medicine Centre for the past three years as Assistant Clinic Director, Chiropractic Department. He is also certified in Acupuncture by the International College of Acupuncture. In addition he teaches Anatomy and Kinesiology for Blue Cliff College in Mobile, Alabama.

Vince McConnell is a certified fitness trainer and athletic preparation specialist. Coach McConnell has been working with private clients, as well as high school, collegiate and professional athletes. He has written numerous articles for various fitness magazines and is often a guest on TV and Radio programs. He owns and operates McConnell’s Athletics in Fairhope, Alabama.

### Corresponding Author

John L. Stump, DC, PhD, EdD
Integrative Medicine Centre
315 Magnolia Avenue
Fairhope, AL 36532

John Stump did his undergraduate work in biology at the University of Maryland and took his Master’s and Doctorate in Sports Medicine at the United States Sports Academy. In addition he accomplished a doctorate in Chiropractic from Palmer College in Davenport, Iowa. He went on to do postdoctoral work in Oriental Medicine and Acupuncture in Japan, China and Korea. He also holds black belts in Judo, Karate, and Kempo.

Dr. Stump is armed with a unique perspective of health care from an eastern and western scientific view. Because of this Dr. Stump was asked to be a team doctor for the South Korean government in 1986 for the Asian Games and 1988 Seoul Olympics. He is the author of numerous scientific articles, and has coauthored 4 textbooks. The latest textbook publication Stump contributed to was Electroacupuncture, edited by David Mayor, published by Elsevier in 2007. Later that year he released “A Stroke of Midnight” (Alternative Concepts Publishing, 2007), a non-fiction account of the tragic stroke he survived. John is now writing a unique east-west anatomy text for McGraw-Hill to be released in 2011. He is a National Faculty member of the United States Sports Academy.