School Days

“Cornelia kept her in talk till her children came from school, ‘and these,’ said she, ‘are my jewels’.”

—Robert Burton (1577–1640), quoting Seneca. In: Anatomy of Melancholy.

Part 3, Section 2, Member 2, Subsection 3.

For most children in North America, September signals the start of the school year. In my village on the outskirts of Chicago, both parents commonly accompany their 5-year-olds to the first day of kindergarten. Although the faces of the children may occasionally betray a bit of apprehension, their primary emotions are intense joy and excitement at the prospect of beginning a new phase of adventure and independence. Any tears in evidence are more likely to adorn the cheeks of their parents, who know that their little ones are indeed taking a big step toward ultimate separation. These first-day-of-school attitudes will evolve over the ensuing years—the children feeling more dread than excitement over the demise of the carefree days of summer, the parents relieved to be divested of their offspring after several months of intense proximity. As the children morph into adolescents, these feelings usually become more pronounced. This is particularly true for the parents, who may be increasingly delighted to foist their hormone-wracked teenagers onto the salaried minions of the Board of Education. The emotions of that first day of kindergarten won't return until the kids go off to college, the youth again excited at the beginning of young adulthood, the parents realizing with dismay that they really are getting rid of their aggravating yet somehow endearing progeny.

The quotation at the top of this editorial has a personal meaning for me. As a child, I had to endure the embarrassment of my father frequently repeating it in reference to his 3 sons. In fact, I thought that he had originated the metaphor until I researched it in preparation for this piece. Then I learned that it is attributed to Cornelia, the second-century bc Roman mother of 12 children including the famous brothers Tiberius and Gaius Gracchus. It has endured because it epitomizes the importance of our youth, not just to their parents but to the future of humankind. I was reminded of the quotation by 2 current publications, an article in this month's American Journal of Sports Medicine and a just-released consensus statement from the International Olympic Committee (IOC).

The first piece, The Effects of Timing of Pediatric Knee Ligament Surgery on Short-term Academic Performance in School-Aged Athletes, ¹⁵ by Trentacosta et al, reminds us of the importance of education in the lives of our younger patients. Whether youngsters look forward to it or not, school plays a central role in their preparation for adulthood. In this retrospective study, the investigators evaluated the academic repercussions of surgery among 62 children who underwent reconstruction of the anterior cruciate or medial patellofemoral ligaments.

Although the authors’ institution is located in Manhattan, their patients hailed from a mixture of suburban and urban localities and a variety of socioeconomic backgrounds. Twenty-three of the patients had surgery on a regular school day, 22 over a short holiday period during the academic term, and 17 during the long summer recess. Some of the findings would be anticipated, while others may be surprising. As expected, students who had surgery on a school day were much less likely to return to class at the first possible opportunity than those in the other 2 groups. Thirty-six percent of those who had surgery on a school day subsequently failed a test for the first time, compared with no students from the other 2 groups. More surprisingly, neither the estimated household income nor the availability of home schooling correlated with the students’ reports of adverse academic consequences.

The subjects were interviewed an average of 20.9 weeks after their surgery, so we cannot tell whether they suffered any extended educational decline. Considering that the average patient who did not return immediately after surgery missed nearly 15 days of school, the length of absence that has been identified as an insurmountable hurdle by the New York Board of Education, ¹⁴ it is not surprising that their short-term performance would have suffered. Because the timing of the surgery was primarily the choice of the patients and their parents, one might suspect an element of selection bias, with the students who valued education more highly electing to defer their procedures until the summer. However, several measurable parameters of preoperative academic performance did not differ significantly among the 3 patient groups.

Similar findings in a cohort of college students were reported over a decade ago by Freedman et al. ⁸ When they were interviewed retrospectively, only 47% of University of Pennsylvania students who had anterior cruciate ligament reconstruction during the semester were satisfied with their decision, compared with 96% of those who chose to wait for an academic recess. Students who had surgery during the semester were more likely to receive a failing or incomplete grade than those whose surgery occurred over a break.

Selecting a date for semielective knee surgery is a complex matter. As sports medicine specialists, we are used to considering the impact of surgical timing on future competition and the potential adverse consequences of postponing an operation on its ultimate outcome. The study by Trentacosta et al reminds us of a third factor that needs to be taken into account when scheduling surgery. Although we are more likely to leave scholastic considerations to the discretion of student-athletes and their families, we need to be aware of the academic implications of major knee surgery and help the patients make an informed decision.

Even youngsters who are less than excited about the start of the school year may eagerly anticipate the fall athletic season that accompanies it. This is often also the time for the preparticipation physical examination. It may not be a complete coincidence that the IOC has chosen this month to release its Consensus Statement on the Periodic Health Evaluation of Elite Athletes, the second publication I would like to highlight in this editorial (available as an appendix in the online version of this article at http://ajs.sagepub.com/content/suppl). The choice of the title “periodic health examination” rather than “preseason” or “preparticipation” examination (PPE) reflects the reality that elite athletes train almost year-round, with very little break from participation. In many parts of the world, this pattern of activity is also the rule for high-level scholastic athletes.

Whether the subject is a member of the national soccer team or a high school junior varsity squad, the principles of the health examination are the same. Nevertheless, even such an apparently mundane practice is not without its elements of controversy. The first of these involves the purpose and scope of the examination itself. Few would disagree that the primary goal of the process is to identify any life-threatening or other severe disorders that would lead to serious risk during athletic participation. Another important function of the examination is to detect remediable conditions such as lingering injuries that require treatment prior to safe participation. For this reason, many advocate performing the PPE several months before the anticipated start of competition, to allow time for treatment of any deficit that might be uncovered. More diversity of opinion arises when considering how far the PPE should go in dealing with aspects of health care not directly related to sports participation, such as risk behaviors, substance abuse, and sexuality. ¹ Some authorities stress that the PPE may be the only opportunity for many adolescents to interact with a health care provider and so should be as extensive as possible, while others worry that the environment of the screening examination is inadequate or inappropriate to deal properly with such personal issues.

Sudden death is the worst imaginable occurrence during athletics, so a major emphasis in any approach to the PPE is attempting to detect conditions that might predispose to such a tragedy. A review of the U.S. experience from 1985 to 1995 noted that 85% of sudden deaths among athletes were cardiac in origin. ¹¹ Although sudden cardiac death (SCD) is a rare event, it has been documented to occur more commonly in athletes than in nonathletes,^{3, 6} and 9 times more frequently in male athletes than in female athletes.^{3, 11} In 2006, the Lausanne group published a systematic review of SCD in 1101 athletes younger than 35 years of age. ³ Cases of SCD occurred in almost all sports, and 40% of the afflicted were younger than 18 years of age. The most common causes were congenital anomalies, hypertrophic and other cardiomyopathies, arrhythmias, atherosclerosis, and commotio cordis.

As a strategy to detect athletes at risk for SCD, the Lausanne group and the IOC recommend routine use of the 12-lead electrocardiogram (ECG) as a screening test. This differs from the recommendation of the American Heart Association ¹² and common practice in the United States. An eloquent interchange published in Circulation in 2007 explores both sides of this issue.^{4, 13} Proponents of the ECG point out that personal and family history only identify 3% to 5% of athletes with conditions that predispose to SCD,^7,9,11,13 so there is a need for supplemental screening. The primary argument in favor of the ECG as an effective screening tool is based upon the experience of a screening program for athletes begun in the Veneto region of Italy in 1982. Over the ensuing 25 years, the incidence of SCD among athletes in the region declined by 89%, while the incidence among nonathletes of the same age did not change significantly. ⁷ The program has been felt to be particularly effective at detecting hypertrophic cardiomyopathy,^{5, 7} the most common cause of SCD in the United States.^{4, 11} Arguments against the routine use of screening ECGs in U.S. athletes include possible misinterpretation of the results, the consequences of false-positive readings, differences in the causes and prevalence of SCD in athletes between the United States and Italy, inadequate numbers of personnel competent to interpret the ECGs of young athletes, and the cost of implementation.^4,10,12 The ongoing debate concerning the role of the ECG in the PPE should interest all AJSM readers who serve as team physicians or athletic trainers.

Reducing the risk of sudden death among athletes is just 1 function of the periodic health examination discussed in the IOC consensus statement. The components of the document are too numerous to review each in detail within the confines of this editorial. Also included are the evaluation of other medical conditions, such as asthma and transmissible skin disorders, the importance of the history in the assessment of concussion or musculoskeletal injury, and health concerns particular to women, such as iron depletion and the “female athlete triad.” Another valuable resource for team physicians is the PPE monograph prepared by a working group representing the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Sports Medicine, the American Medical Society for Sports Medicine, the American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. ¹ This was last updated in 2005 and is currently undergoing revision, with a projected publication date of April 2010. ²

A dedication to maintaining the health of young, competitive athletes attracted many of us to orthopaedic sports medicine. Although the unshakeable omniscience and stubborn intractability of the young can sometimes drive parents and surgeons to the brink of insanity, they also inspire us with their idealism and perseverance. The study by Trentacosta et al and the new IOC consensus statement on the periodic health examination are valuable reminders of our important role in sustaining the academic and physical well-being of these jewels of society.

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