Do 'pathologic' cardiac murmurs in adolescents identify structural heart disease? An evaluation of 15 141 active adolescents for conditions that put them at risk of sudden cardiac death.

OBJECTIVES: We assessed whether the presence and character of a cardiac murmur in adolescents were associated with structural heart disease that confers risk of sudden cardiac death (SCD). METHODS: We performed a retrospective analysis of 15 141 adolescents age 12-19 who underwent a heart screen with history, physical examination and ECG. Participants with any screening abnormality underwent an echocardiogram for the assessment of structural heart disease. Murmurs were classified as physiological or pathological according to standard clinical criteria, and participants with murmurs were compared with a comparison group without murmurs. The primary outcome was echocardiogram-detected structural heart disease associated with SCD. RESULTS: 905 participants with a cardiac murmur (mean age 15.8; 58% male) and 4333 participants without a murmur (comparison group; mean age 15.8; 55% male) had an echocardiogram to detect structural heart disease. 743 (82%) murmurs were described as physiological and 162 (18%) as pathological. Twenty-five (2.8%) participants with murmurs and 61 (1.4%) participants without murmurs had structural heart disease. Three (0.3%) participants in the murmur group were diagnosed with hypertrophic cardiomyopathy (HCM) which was the only identified condition associated with SCD. Two participants with HCM had physiological murmurs, one had a pathological murmur, and all three had an abnormal ECG. The most common minor structural heart disease was bicuspid aortic valve in both the murmur (7; 0.8%) and comparison (20; 0.5%) groups. The positive predictive value of physiological versus pathological murmurs for identifying any structural heart disease was 2.4% versus 4.3% (p=0.21), respectively. The positive predictive value of having any murmur versus no murmur for identifying structural heart disease was 2.8% versus 1.4% (p=0.003), respectively. CONCLUSIONS: In adolescents, the traditional classification of cardiac murmurs as 'physiologic' or 'pathologic' does not differentiate for structural heart disease that puts individuals at risk for SCD. We recommend ECG evaluation in all patients with a cardiac murmur found during preparticipation screening to increase detection of HCM.

American Medical Society for Sports Medicine Sports Ultrasound Curriculum for Sports Medicine Fellowships.

ABSTRACT: Sports ultrasound is commonly used by sports medicine physicians to enhance diagnostic and procedural accuracy. This expert consensus statement serves as an update to the 2015 American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Although written in the context of the American sports medicine fellowship training model, we present a stepwise progression in both diagnostic and interventional sports ultrasound that may be applicable to the broader sports medicine community. The curriculum is divided into 12 units with each unit including didactic instructional sessions, practical hands-on instruction, independent scanning practice sessions, and mentored clinical experience. To assist with prioritization of learning, we have organized relevant pathology and procedures as essential, desirable, and optional. The expanded content can serve as an outline for continuing education postfellowship or for any physician to further advance their sports ultrasound knowledge and skill. We also provide updated scanning protocols, sample milestones, and a sample objective structured clinical examination (OSCE) to aid fellowships with implementation of the curriculum and ongoing assessment of fellow progress.

Suggested Curricular Guidelines for Musculoskeletal and Sports Medicine in Family Medicine Residency Training.

Patients often seek care from a family physician when they have a musculoskeletal injury or sport-related ailment. Family physicians must be adequately trained to provide this care. While general guidance is provided by the Accreditation Counsel for Graduate Medical Education (ACGME) it is left up to the individual programs to develop, implement, and execute their orthopedic and sports medicine curriculums. The American Academy of Family Physicians' (AAFP) Recommended Curriculum Guideline for Family Medicine Residents - Musculoskeletal and Sports Medicine provides a basic outline format for curriculum content and reference resources. The aim of this article is to elaborate on those training requirements and help programs to develop a curriculum implementation plan that will deliver a baseline level of competence for family medicine trainees.

Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review.

BACKGROUND: The incidence and cause of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy often reported as the most common cause. METHODS AND RESULTS: A database of all National Collegiate Athletic Association deaths (2003-2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4 242 519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16 508 AY) followed by medical causes (147, 29%, 1:28 861 AY). The most common medical cause of death was SCD (79, 15%, 1:53 703 AY). Males were at higher risk than females 1:37 790 AY versus 1:121 593 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9-5.5; P<0.00001), and black athletes were at higher risk than white athletes 1:21491 AY versus 1:68 354 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9-5.2; P<0.00001). The incidence of SCD in Division 1 male basketball athletes was 1:5200 AY. The most common findings at autopsy were autopsy-negative sudden unexplained death in 16 (25%), and definitive evidence for hypertrophic cardiomyopathy was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%), whereas the percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs. CONCLUSIONS: The rate of SCD in National Collegiate Athletic Association athletes is high, with males, black athletes, and basketball players at substantially higher risk. The most common finding at autopsy is autopsy-negative sudden unexplained death. Media reports are more likely to capture high-profile deaths, and insurance claims are not a reliable method for case identification.

The impact of diagnosis: measuring the psychological response to being diagnosed with serious or potentially lethal cardiac disease in young competitive athletes.

AIM: To determine the psychological impact of athletes diagnosed with cardiac disease. METHODS AND DESIGN: Athletes diagnosed with cardiovascular disorders were recruited to complete the Impact of Event Scale (IES), a validated tool measuring responses to a traumatic event. IES scoring =0-88 (<12= normal, 12-32=recommend monitoring, >33=significant stress reaction). Subscales include: intrusion, avoidance and hyperarousal. RESULTS: 30 athletes (53% male, 83% Caucasian, median age 18.0, median age at diagnosis 15.7) participated. Diagnoses included: 6 hypertrophic cardiomyopathy, 9 Wolff Parkinson White, 4 Long QT syndrome, 3 atrial septal defect, 2 supraventricular tachycardia and 6 other. For the group, the mean IES-Revised (IES-R) score=16.6 (SD=12.1), subscales: intrusion 6.6 (SD=4.3), avoidance=7.4 (SD=6.5), hyperarousal=2.7 (SD=3.5). Higher risk individuals included: permanently disqualified athletes (p<0.01), athletes requiring daily medication (p<0.01), those with genetically inheritable conditions (p<0.01), and athletes undergoing medical management instead of definitive therapy (p<0.01). No differences were reported by gender (male=16.6, female=16.6). Higher IES-R scores were reported in more competitive athletes (college=17.8, high school=13.3; p=0.369) and African-American individuals (African-American=25.8, Caucasian=14.8 p=0.061), although not statistically significant. Athletes with cardiomyopathy (IES-R=24) and channelopathy (IES-R=28) reported the highest IES results. Athletes with high IES-R scores were most likely to psychologically respond through avoidance of feelings/situations/ideas. CONCLUSIONS: Athletes diagnosed with potentially lethal cardiac disorders are at risk for significant psychological distress. These athletes tend to avoid thoughts, feelings and conversations associated with their diagnosis and should be offered consistent emotional support to mitigate psychological morbidity. SIGNIFICANCE: Currently, there are no recommendations to guide physicians on how to support an athlete that is newly diagnosed with a potentially career altering heart condition. Proper planning and use of appropriate support mechanisms can be useful for emotionally vulnerable athletes.

Death by homicide in National Collegiate Athletic Association athletes between 2003 and 2013.

BACKGROUND: The incidence of homicide-related death among individuals of college age in the United States population is estimated at 15.5/100,000. The incidence of homicide among National Collegiate Athletic Association (NCAA) athletes is unknown. AIM: To investigate the rate of homicide-related death in NCAA athletes and to identify associated risk factors. METHODS: The NCAA Resolutions list, NCAA catastrophic insurance claims, media reports, and published NCAA demographic data were used to identify student athlete deaths and total participant seasons from 2003-04 through 2012-13. Homicide-related deaths were analysed by sex, race, division, sport, method, location, and circumstance. Internet searches were used to gather case details. RESULTS: Forty-two cases of homicide-related death were identified from 4,242,519 individual participant seasons during the ten-year study period. The incidence of homicide-related death in NCAA athletes was 1.0/100,000. The incidence in males was 1.45/100,000 and in females was 0.4/100,000 (relative risk (RR) 2.9, p=0.01). The incidence in black athletes was 4.2/100,000 and in white athletes was 0.4/100,000 (RR 7.0, p<0.001). The highest sport-specific homicide-related death rate was in American football (3.7/100,000), with a RR of 4.4 (p=0.002) compared to all other sports. 88% of cases occurred off-campus. 38% of cases occurred at a social gathering, and 38% of cases occurred in a place of residence. 74% involved a fatal shooting. CONCLUSIONS: Homicide-related deaths in NCAA athletes occur most commonly in males, black athletes, and American football players. Understanding the incidence, risk factors, and circumstances of homicide-related deaths in college athletes may assist NCAA institutions in developing preventative measures. TRIAL REGISTRATION NUMBER: University of Washington Human Subjects Application, HSD No. 42077.

Stages of psychological impact after diagnosis with serious or potentially lethal cardiac disease in young competitive athletes: a new model.

IMPORTANCE: Sudden cardiac death (SCD) in sports is a tragic event. Pre-participation cardiovascular screening is required before participation in high school and college athletic programs and is universally endorsed by major medical societies. The medical impact of a diagnosis may be life-saving; however, the detection of disease should not be the sole endpoint of care. Physicians have an obligation to attend to both the medical and psychological well-being of their patients. OBJECTIVE: To determine the psychological impact of being diagnosed with cardiac disease in young competitive athletes. DESIGN: Athletes diagnosed with cardiac conditions were recruited to participate in a semi-structured interview, which was analyzed by sport psychology experts using qualitative research. Individuals shared reactions and experiences regarding diagnosis, lifestyle implications, coping strategies, major concerns, and overall impact on psychosocial functioning. SETTING: Young competitive athletes from across the United States. PARTICIPANTS: 25 athletes (52% male, 80% Caucasian, median age 17.7) participated. Diagnoses included: 5 hypertrophic cardiomyopathy, 8 Wolff Parkinson White, 4 long QT syndrome, 3 atrial septal defect, 2 supraventricular tachycardia, and 3 other. MAIN OUTCOME MEASURES: Interviews were analyzed using consensual qualitative research (CQR) to identify domains, categories, and core ideas. RESULTS: Athletes progressed through 4 stages of psychological impact including: 1) immediate reactions and challenge to athlete identity, 2) grief/coping, 3) adaptation, and 4) acceptance. Risk factors for increased psychological morbidity included: higher level of competition, permanent disqualification from sports, persistent reminders (e.g. daily medication, monitoring heart rate during activity), and unanticipated outcomes (e.g. failed procedures). Those undergoing simple corrective procedures came to terms with their diagnosis quickly with little impact on daily life. Few athletes described emotional support mechanisms provided by medical programs. Diagnosis often led to new goals such as mentoring or coaching. All athletes diagnosed through advanced cardiovascular screening stated they would repeat the process. CONCLUSIONS AND RELEVANCE: Athletes diagnosed with cardiac disease represent an emotionally vulnerable population and experience 4 stages of psychological adjustment not previously described. This proposed model of psychological impact should be used to develop improved support mechanisms, awareness, and education to assist athletes diagnosed with serious or potentially lethal cardiac disease.

The Psychological Impact of Cardiovascular Screening in Young Athletes: Perspectives Across Age, Race, and Gender.

OBJECTIVE: To determine the psychological impact of electrocardiogram (ECG) screening in young competitive athletes based on age, race, and gender. DESIGN: Prospective multisite cross-sectional investigation. SETTING: Young competitive athletes. PATIENTS: One thousand five hundred six high school athletes (59.3% male with a mean age of 15.5 years, 56.2% white, 24.5% African American). INDEPENDENT VARIABLES: Athletes underwent screening with a standardized American Heart Association-based history, physical examination, and ECG. MAIN OUTCOME MEASURES: Prescreen and postscreen validated assessments for health attitudes, anxiety, and impact of screening on sport. RESULTS: Of the athletes participated, 76.3% had normal screens, 22.7% false-positive (FP) results (12.9% history, 4.2% examination, 3.1% ECG), and 0.9% were diagnosed with serious cardiac disorders. There were no differences in anxiety levels among athletes screening normal versus FP (P = 0.69). There was no difference in anxiety based on the reason for a FP result (history, physical examination, or ECG) both during (P = 0.95) and after (P = 0.40) screening. Analysis by age, race, and gender demonstrated that before screening, females were more likely to prefer knowing about underlying cardiac conditions compared with males (P < 0.001), and males were less concerned about having cardiac disease (P < 0.001) compared with females. African Americans were less concerned about underlying disease (P < 0.001) and less interested (P < 0.001) in cardiac screening compared with whites. Athletes diagnosed with a cardiac disease described anxiety after screening, but still believe that all athletes should receive an ECG before competition. CONCLUSIONS: Electrocardiogram screening does not cause excessive anxiety in US high school athletes across spectrums of age, race, and gender. Recognition of age, race, and gender-specific perspectives could improve physician-patient dialogue and support mechanisms for those diagnosed with potentially lethal cardiac disorders. CLINICAL RELEVANCE: This article provides evidence that undue anxiety should not be used as an argument against the implementation of ECG screening during the preparticipation examinaton for young athletes. Although males and African Americans seem to be at highest risk for sudden cardiac death during exercise, they actually report being the least concerned and least worried about potentially harboring an underlying condition that might predispose them to such an event. Emotional support should readily be available for athletes who are diagnosed with cardiovascular conditions as these individuals report emotional distress after their diagnosis.

The psychological impact of cardiovascular screening: the athlete's perspective.

BACKGROUND: Published guidelines suggest that ECG screening in US athletes may cause excessive anxiety, especially in those with false-positive findings. However, this has never been formally evaluated. METHODS AND STUDY DESIGN: Prospective, non-randomised controlled trial. High school athletes received a standardised history and physical examination (control) or a history and physical examination with an ECG (experimental). Prescreen and postscreen assessments for health attitudes, anxiety and impact of screening on sport were conducted. RESULTS: 952 athletes (49.7% girls, mean age 15.5 years) participated (control=150; experimental=802). 4.4% worried about having an underlying cardiac condition, and 73% wanted to learn if they had a cardiac abnormality prior to competition. In the experimental group, 576 had normal screens, 220 had an abnormal screen (by history 15.8%, physical examination 6.2% or ECG 1.7%) but normal work up (false-positive) and 6 were identified with a serious cardiac condition (true-positive, 0.75%). Compared with the control group, those who received an ECG were more likely to: (1) be significantly more satisfied with their screening (p<0.001), (2) feel safer during competition (p<0.01), (3) support that all athletes should receive cardiac screening (p<0.001) and (4) state the ECG positively impacted their training (p<0.001). False-positive athletes did not report anxiety during or after screening. Distress levels did not differ based on reason for needing further evaluation (history, physical examination or ECG, p=0.311). Compared with control participants, individuals with false-positive results: (1) reported no difference in postscreen anxiety (p=0.775), (2) felt safer during competition (p<0.001), (3) would recommend ECG screening to others (p<0.001) and (4) expressed a positive impact on training (p<0.001). CONCLUSIONS: Excessive anxiety should not be used as a reason to forego ECG screening in athletes.

Cardiovascular screening in adolescents and young adults: a prospective study comparing the Pre-participation Physical Evaluation Monograph 4th Edition and ECG.

BACKGROUND: This study compares the accuracy of cardiovascular screening in active adolescents and young adults using a standardised history, physical examination and resting 12-lead ECG. METHODS: Participants were prospectively screened using a standardised questionnaire based on the Pre-participation Physical Evaluation Monograph 4th Edition (PPE-4), physical examination and ECG interpreted using modern standards. Participants with abnormal findings had focused echocardiography and further evaluation. Primary outcomes included disorders associated with sudden cardiac arrest (SCA). RESULTS: From September 2010 to July 2011, 1339 participants underwent screening: age 13-24 (mean 16) years, 49% male, 68% Caucasian, 17% African-American and 1071 (80%) participating in organised sports. Abnormal history responses were reported on 916 (68%) questionnaires. After physician review, 495/916 (54%) participants with positive questionnaires were thought to have non-cardiac symptoms and/or a benign family history and did not warrant additional evaluation. Physical examination was abnormal in 124 (9.3%) participants, and 72 (5.4%) had ECG abnormalities. Echocardiograms were performed in 586 (44%) participants for abnormal history (31%), physical examination (8%) or ECG (5%). Five participants (0.4%) were identified with a disorder associated with SCA, all with ECG-detected Wolff-Parkinson-White. The false-positive rates for history, physical examination and ECG were 31.3%, 9.3% and 5%, respectively. CONCLUSIONS: A standardised history and physical examination using the PPE-4 yields a high false-positive rate in a young active population with limited sensitivity to identify those at risk for SCA. ECG screening has a low false-positive rate using modern interpretation standards and improves detection of primary electrical disease at risk of SCA.

Sudden cardiac death in young athletes: what is the role of screening?

PURPOSE OF REVIEW: To review the recent literature and recommendations for cardiovascular screening in young athletes. RECENT FINDINGS: The primary purpose of the preparticipation examination is to detect the cardiovascular disorders known to cause sudden cardiac arrest in the athlete. Studies demonstrate that the traditional history and physical-based examination has a limited sensitivity, does not detect the majority of athletes with at-risk conditions, and may provide false reassurance for athletes with disorders that remain undetected. Electrocardiogram (ECG) screening increases the sensitivity of the examination to detect disease, and cost modeling suggests protocols inclusive of ECG are the only screening strategies to be cost-effective. Proper ECG interpretation that distinguishes physiologic cardiac adaptations in athletes from findings suggestive of underlying cardiac pathology is essential to avoid high false-positive rates. SUMMARY: The goal of cardiovascular screening is to maximize athlete safety. This includes the detection of underlying cardiac disease associated with sudden cardiac death and reduction of risk through both medical management and activity modification. Greater physician education and research are needed to improve the preparticipation examination in athletes.

Outcomes from sudden cardiac arrest in US high schools: a 2-year prospective study from the National Registry for AED Use in Sports.

BACKGROUND: Sudden cardiac arrest (SCA) is the leading cause of death in athletes during exercise. The effectiveness of school-based automated external defibrillator (AED) programmes has not been established through a prospective study. METHODS: A total of 2149 high schools participated in a prospective observational study beginning 1 August 2009, through 31 July 2011. Schools were contacted quarterly and reported all cases of SCA. Of these 95% of schools confirmed their participation for the entire 2-year study period. Cases of SCA were reviewed to confirm the details of the resuscitation. The primary outcome was survival to hospital discharge. RESULTS: School-based AED programmes were present in 87% of participating schools and in all but one of the schools reporting a case of SCA. Fifty nine cases of SCA were confirmed during the study period including 26 (44%) cases in students and 33 (56%) in adults; 39 (66%) cases occurred at an athletic facility during training or competition; 55 (93%) cases were witnessed and 54 (92%) received prompt cardiopulmonary resuscitation. A defibrillator was applied in 50 (85%) cases and a shock delivered onsite in 39 (66%). Overall, 42 of 59 (71%) SCA victims survived to hospital discharge, including 22 of 26 (85%) students and 20 of 33 (61%) adults. Of 18 student-athletes 16 (89%) and 8 of 9 (89%) adults who arrested during physical activity survived to hospital discharge. CONCLUSIONS: High school AED programmes demonstrate a high survival rate for students and adults who suffer SCA on school campus. School-based AED programmes are strongly encouraged.

Head Injuries and Emergencies in Sports.

Head injuries are a common occurrence in sports and can involve injuries to the brain, skull, and superficial soft tissues. The most commonly discussed diagnosis is a concussion. Head and cervical spine injuries must be considered together at times, due to the overlapping nature of symptoms present during on-field evaluation. This article presents a range of head injuries, along with critical steps in evaluation and management.

Accuracy of ECG interpretation in competitive athletes: the impact of using standised ECG criteria.

BACKGROUND: Interpretation of ECGs in athletes is complicated by physiological changes related to training. The purpose of this study was to determine the accuracy of ECG interpretation in athletes among different physician specialties, with and without use of a standised ECG criteria tool. METHODS: Physicians were asked to interpret 40 ECGs (28 normal ECGs from college athletes randomised with 12 abnormal ECGs from individuals with known ciovascular pathology) and classify each ECG as (1) 'normal or variant--no further evaluation and testing needed' or (2) 'abnormal--further evaluation and testing needed.' After reading the ECGs, participants received a two-page ECG criteria tool to guide interpretation of the ECGs again. RESULTS: A total of 60 physicians participated: 22 primary care (PC) residents, 16 PC attending physicians, 12 sports medicine (SM) physicians and 10 ciologists. At baseline, the total number of ECGs correctly interpreted was PC residents 73%, PC attendings 73%, SM physicians 78% and ciologists 85%. With use of the ECG criteria tool, all physician groups significantly improved their accuracy (p<0.0001): PC residents 92%, PC attendings 90%, SM physicians 91% and ciologists 96%. With use of the ECG criteria tool, specificity improved from 70% to 91%, sensitivity improved from 89% to 94% and there was no difference comparing ciologists versus all other physicians (p=0.053). CONCLUSIONS: Providing standised criteria to assist ECG interpretation in athletes significantly improves the ability to accurately distinguish normal from abnormal findings across physician specialties, even in physicians with little or no experience.

Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators.

BACKGROUND: US high schools are increasingly adopting automated external defibrillators (AEDs) for use in campus settings. We analyzed the effectiveness of emergency response planning for sudden cardiac arrest (SCA) in a large cohort of US high schools that had onsite AED programs. METHODS AND RESULTS: A cohort of US high schools with at least 1 onsite AED was identified from the National Registry for AED Use in Sports. A school representative completed a comprehensive survey on emergency planning and provided details of any SCA incident occurring within 6 months of survey completion. Surveys were completed between December 2006 and July 2007. In total, 1710 high schools with an onsite AED program were studied. Although 83% (1428 of 1710) of schools have an established emergency response plan for SCA, only 40% practice and review the plan at least annually with potential school responders. A case of SCA was reported by 36 of 1710 schools (2.1%). The 36 SCA victims included 14 high school student athletes (mean age, 16 years; range, 14 to 17 years) and 22 older nonstudents (mean age, 57 years; range, 42 to 71 years) such as employees and spectators. No cases were reported in student nonathletes. Of the 36 SCA cases, 35 (97%) were witnessed, 34 (94%) received bystander cardiopulmonary resuscitation, and 30 (83%) received an AED shock. Twenty-three SCA victims (64%) survived to hospital discharge, including 9 of the 14 student athletes and 14 of the 22 older nonstudents. CONCLUSIONS: School-based AED programs provide a high survival rate for both student athletes and older nonstudents who suffer SCA on school grounds. High schools are strongly encouraged to implement onsite AED programs as part of a comprehensive emergency response plan to SCA.

Expert opinion and controversies in musculoskeletal and sports medicine: preventing sudden cardiac death in young athletes.

Sudden cardiac death in young athletes has become a highly visible public health concern. Over the past 2 decades, unexplained or premature deaths of numerous athletes at the youth, collegiate, and professional levels have garnered extensive media coverage and stimulated a discussion centered on prevention of such tragic events. A number of issues related to the prevention and management of sudden cardiac arrest on the playing field are currently debated in the medical literature, including the true incidence of sudden death in the young athletic population, the adequacy of the preparticipation physical evaluation, and the emergency response and effectiveness of secondary prevention strategies such as use of automated external defibrillators in the athletic setting. Clinicians who care for competitive athletes and/or cover youth sporting events must be aware of the benefits and limitations of different preparticipation screening programs to identify at-risk athletes, and they must be prepared to respond to life-threatening emergencies during athletic participation.

The Use and Abuse of Human Growth Hormone in Sports.

CONTEXT: Recombinant human growth hormone (rHGH) has become a target of abuse in the sporting world. Conversely, sports medicine clinicians may encounter athletes using rHGH to achieve normalcy in the context of growth hormone (GH) deficiency. EVIDENCE ACQUISITION: Medline and PubMed databases were queried using the following keywords: GH, GH physiology, GH deficiency, acromegaly, GH athlete, GH sports, GH athletic performance, and GH deficiency concussion. Articles focusing on GH physiology, deficiency, excess, and its effects in both deficient and healthy patients were included. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: GH is a naturally occurring hormone with important roles in human physiology. Patients with GH deficiency (GHD) present variably, and GHD has numerous etiologies. rHGH treatment has substantial therapeutic benefits for patients with GHD. The benefits of rHGH treatment in otherwise-healthy adults are uncertain. GH excess may cause health problems such as acromegaly. Professional, collegiate, and international sports leagues and associations have banned rHGH use to maintain athlete health, safety, and fair play. Athletes misusing GH may face prolonged suspensions from competition. Implementing GH abuse testing is challenging, but new methods, such as the biomarker testing procedure, are being finalized. CONCLUSION: rHGH is not only an important therapeutic agent for GH-deficient patients but also a target of abuse in competitive athletics. Its benefits in a healthy, adult population are uncertain. A safe exercise and competition plan, developed with a physician knowledgeable of GH use, physiology, and abuse potential, should be of benefit to a longitudinal clinician-patient relationship.