Athlete safety is predicated on communication with sports medicine personnel, athlete monitoring/observation, and knowledge of how to adjust programming by strength and conditioning coaches (SCC). The risks to athletes, as relevant to SCC, can be classified as acute injuries (e.g. concussions), exertional (e.g. rhabdomyolysis) and pre-existing (e.g. sickle cell trait) which require awareness of signs and symptoms, at-risk training, and what steps are necessary to improve safety. The review of the physical conditions that may be exacerbated or place the athlete at risk of hospitalization or death must be assessed by the sports medicine team and physician.

The SCC must be made aware of the specific condition an athlete may have, causations of symptoms, ability to recognize symptoms and develop emergency plans should an athlete succumb to the conditions. This manuscript is meant to highlight the main domains of physical conditions that places athletes at a higher risk of injury/death during strength and conditioning sessions.

Specific Conditions


Concussions are the result of a traumatic impact of the brain against the inside of the skull that results in the loss of training and competition time, hospitalization and potentially impact other health conditions. Athletes that sustain a concussion can experience headaches, dizziness, impaired movement, susceptibility to fatigue, dysfunction in the autonomic nervous system, and reduced cognitive ability (Alsco et al., 2012; Costello et al., 2018; National Collegiate Athletic Association 2016). Once an athlete has entered collegiate athletics they should be part of a management plan as outline by the National Collegiate Athletic Association (2016) that includes education, pre-participation assessment, recognition and diagnosis of concussion, and post-concussion management. All coaches and athletes should be observant if any athletes or teammates are demonstrating signs of dizziness, loss of consciousness, complaints of fatigue, headache, demonstrating diminished motor function by stumbling or loss of balance, confusion, and possibly neck pain (Alsco et al., 2012; Costello et al., 2018). Athletes that have a sport incident which may have caused a concussion should be evaluated by the appropriate sports medicine personnel (e.g. team doctor). Furthermore, Hutchinson et al., (2016) observed that 85% of the concussions reported by the National Hockey League were the result of player to player collisions. Strength and conditioning coaches should be aware of not only what are the common incidents for concussions in a particular sport but also if there are any programming methods that can be used to reduce the severity of the concussion. Athletes that are returning to practices and competitions should be observed for abnormal behavior because proprioception, stability, and possibly other impairments (National Collegiate Athletic Association, 2016). Athletes cleared by sports medicine staff may be reintroduced to low intensity (<75% VO2max) aerobic exercises and be monitored for a reoccurrence of concussion symptoms (National Collegiate Athletic Association, 2014). Athletes that have previous concussions may be susceptible to other risks as stated by Alsoco et al, (2012), “Athletes with a history of concussion reported a greater number of symptoms associated with exertional heat illness than those without such a history.”

Exertional Rhabdomyolysis

Athletes that are detrained or unaccustomed to training may be more susceptible to exertional rhabdomyolysis (ER) when the programming has high training volume, an over emphasis on eccentric exercises, inadequate rest between exercise bouts, or training in an extreme heat environment (Asplund et al, 2016; Ebereman et al, 2011). Strength and conditioning coaches should be observant if athletes are demonstrating a greater than usual signs of muscular stiffness, fatigue and pain, have the inability to urinate or has coffee colored urine and possibly loss of mobility as these can be indicators of ER (Asplund et al, 2016; Ebereman et al, 2011; National Collegiate Athletic Association, 2014). Exertional rhabdomyolysis is trauma and breakdown of skeletal muscles that release muscular biochemical (e.g. creatine kinase, myoglobin) into the blood stream which stresses the kidneys (Asplund et al, 2016; Ebereman et al, 2011; National Collegiate Athletic Association, 2014). If these physical symptoms are not treated then kidney damage is possible or even death. Strength and conditioning coaches should be aware that athletes with sickle cell trait have a greater chance of suffering from ER with improper programming (Asplund et al, 2016). As programs are developed and implemented, they should be reviewed for appropriate work to rest ratios that allow for adequate muscular recovery and allow for progression to higher training intensities such as more repetitions (Asplund et al., 2015; Casa et al., 2012). Athletes with previous incident of ER should be determined by sports medicine staff if they are classified as high risk so the SCC can be more attentive to these athletes (Asplund et al., 2015; Casa et al., 2012). High-risk, returning from ER, or following a transition period (e.g. summer break), SCC should avoid introducing non-planned exercises, over emphasis of eccentric muscular actions and sessions that may be used assess “toughness” of an athlete (Casa et al., 2012; National Collegiate Athletic Association, 2014). Programs should be progressed based on athletes’ improvements from the training over a period of several weeks while expectations of conditioning in several days avoided (National Collegiate Athletic Association, 2014). Furthermore, any use of activity as a method of punishment or discipline can increase the chance of ER, especially when those activities are performed at a greater volume or intensity than normal training (Casa et al., 2012). The practice of “pushing” an athlete after fatigue has diminished performance can increase the chance of ER and should be avoided by SCC (National Collegiate Athletic Association, 2014). Athletes returning after prolonged inactivity or transitional periods should have an appropriate level of training volume and intensity, while SCC should be aware of the increased risk of ER if an athlete experiences an exertional heat illness (EHI).

Exertional Heat Illnesses

Training in environments of high air temperatures, humidity, inadequate rest during session, and training loads greater (>25% added) than previously used may predispose an athlete to muscle cramping, heat exhaustion, exertional heatstroke, or heat related death (Armstrong et al., 2007). Strength and conditioning coaches should adjust their programming for the first 10 to 14 days of training in a new environment so athletes can acclimate (National Collegiate Athletic Association, 2014). During training sessions the SCC should be observant of early signs of exertional heat illnesses (EHI) as muscle cramping, confusion, dizziness, nausea, vomiting, and decrease in normal performance may quickly precede the onset of exertional heat stroke (Armstrong et al., 2007; Asplund et al, 2016; National Collegiate Athletic Association, 2014). Athletes that progress to exertional heat stroke will display low blood pressure, cessation of sweating, hyperventilation, vomiting, diarrhea, seizures, or loss of consciousness, which is a life-threatening situation that the SCC should have protocols for in their emergency action plan. Return to practice and competitions for athletes that have sustained an EHI should be cleared by sports medicine staff to resume activity and may need to pass a heat tolerance test (Asplund et al, 2016). To reduce the chance of an EHI during training, SCC should program work-to-rest ratios that are adjusted based on athletes’ acclimation level (e.g. transitional), environment, past injury history (e.g. concussion), and volume plus intensity of activity that incorporates adequate cooling modalities (e.g. misting fans) and hydration breaks (Alosco et al., 2012; Armstrong et al., 2007; Casa et al., 2012;). Outdoor conditioning should be ceased and/or closely monitored when wet-bulb globe temperature (WBGT) goes above 82 degrees Fahrenheit as the risk of an EHI increases (National Collegiate Athletic Association, 2014). The time frame for athletes return to activity should be at least a week of no exercise following release from medical and have a 2-week acclimation period starting with a controlled environment (e.g. air conditioning) (Armstrong et al., 2007). If the SCC observes no signs and symptoms of an EHI after 2 to 4 weeks of training in higher WBGT readings that should be able to resume full practices and competitions (Asplund et al, 2016). The reduction of EHI risk begins with appropriate programming and acclimatization that is partnered with good hydration habits, and the monitoring signs and symptoms (Armstrong et al., 2007; National Collegiate Athletic Association, 2014).

Respiratory Diseases and Conditions

Strength and conditioning coaches should be aware of athletes that have respiratory disorders, what is the exact diagnosis, signs and symptoms, specific training precautions, and if unique additions need to be added to the emergency action plan. Athletes may have exercise-induced bronchoconstriction (EIB), asthma (AST), cystic fibrosis, and other diagnoses such as chronic obstructive pulmonary disorder, which all can have intermittent inflammation and constriction of the bronchial airways that may occur during activity (Burnett et al., 2016; Bussotti et al., 2014; Stang et al., 2018). Athletes in sports such as cross-country running, marathons, Nordic cross-country skiing and others that require high endurance training loads (e.g. large volumes of inspired air) have an increased risk of developing EIB (Bussotti et al., 2014). During training, the SCC should be observant if athletes are showing signs of chest tightness (e.g. grasping of chest or verbal recognition), wheezing, shallow rapid breathing, coughing, and shortness of breath that is not typically seen. Conditioning drills and sports that are performed at high intensity (e.g. high intensity interval training, > 80% HRmax) or classified as endurance intensity (e.g. 75% VO2max) have been associated with increased risk of EIB or respiratory complications (Bussotti et al., 2014; Stang et al., 2018). This association is important for the SCC to be aware that athletes with a diagnosed respiratory condition may need to have greater time to acclimate or adapt to the training stimulus, and training adjusted if in an extreme environment (e.g. elevated pollution level, cold air). The SCC should be in contact with the sports medicine staff on which athletes may need an inhaler or “epi-pen” on site in the chance respiratory distress occurs. Furthermore, acute respiratory illnesses can increase the risk to athletes and requiring adjustment to strength and conditioning programs (Spence et al., 2007). Swimming and other aquatic sports have a higher prevalence of acute respiratory illnesses developing in athletes requiring monitoring for signs and symptoms when conditioning programs take place in this environment (Bussotti et al., 2014). Conditioning drills in colder air temperatures with increased particulate matter from ice maintenance such as ice rinks increases the athlete’s risk to exercise induced bronchoconstriction and upper tract infections. One method to reduce the risk of a respiratory illnesses is having an athlete breath through the nose, while using masks during cold environment training can assist in warming air prior to entering the air passages (Bussotti et al., 2014). Strength and conditioning coaches can reduce the occurrence of respiratory illnesses by adjusting training programs that are based an athlete’s condition, at-risk environments, pre-existing physical conditions.

Cardiovascular Diseases

All athletes should be given an cardiovascular screening prior to the start of the academic and athletic seasons screening for Marfan Syndrome, hypertrophic cardiomyopathy and other cardiac dysfunctions that can be life threatening during strength and conditioning sessions, practices and competitions (Braverman et al., 2015; Hainline et al., 2016). Athletes that have a cardiovascular event during strength and conditioning sessions need immediate activation of the emergency medical services system, CPR, and access to an AED if the athlete collapses, becomes unresponsive or experiences a seizure (Casa et al., 2012). Emergency situations can be reduced in athletes with cardiovascular diseases by pre-participation screening, communication with sports medicine staff on conditions, and the appropriate programming adjustments based on the specific disease (Hainline et al., 2016). Athletes that have demonstrated severe cardiovascular conditions such as Marfan syndrome and abnormal aortic diameter size may require restrictions in their programming or exclusion from sports (e.g. exclusion from collision sports) (Braverman et al., 2015). Strength and conditioning coaches will need to monitor heart rate, rate of perceived exertion, and for physical signs that the training load is greater than the athlete can tolerate. Lastly, improving the cardiovascular health of athletes suggests a lowering risk of an EHI (McClelland et al., 2018).

Sickle Cell Trait

The health screening of athletes prior to the start of their collegiate athletic career or when transferring into a program should involve medical determination if an athlete has sickle cell trait (SCT) as step to reduce the occurrence of an exertional collapse associated with SCT (Anderson 2017; Casa et al., 2012; O’Connor et al., 2012). Exercise related deaths have been shown to be 40 times greater in individuals with SCT than those without, that requires adjustments to programming based on WBGT, reductions in training load, increased rest periods, and adequate hydration (Asplund et al, 2016; National Athletic Trainers Association, 2018; Ferster & Eichner, 2012). Athletes with SCT should be watched during any training program for signs of muscle weakness that exceeds muscle pain, unexpected collapse or kneeling during a session, and rapid breathing are visual indications that an athlete is on the verge of exertional collapse (Asplund et al, 2016; O’Connor et al, 2012). Furthermore, SCC should be cognizant if athletes with SCT are complaining of increasing pain and weakness in the leg, buttocks, and low back muscles as these areas tend be more susceptible to injury (Asplund et al, 2016). The SCC can help reduce the chance of an exertional collapse associated with SCT during the initial 2-weeks of conditioning for athletes by gradually increasing repeated high-intensity (e.g. > 90% VO2max) exercises and gradual reducing in rest times between exercise collapse (O’Connor et al, 2012). Athletes with SCT should be encouraged to participate in a year-round conditioning program along with emphasizing the early season training to establish aerobic base, acclimatization to heat/humidity, and arrive to the start of the pre-season camp conditioned and acclimated (Asplund et al, 2016). The physical exertions that are imposed on athletes at the beginning of a season that require maximal efforts over 2 minutes can be triggers for sickle cell collapse (National Athletic Trainers Association, 2018; Ferster & Eichner, 2012). Athlete physical preparation, appropriate progression and recognizing the signs of exertional collapse related to SCT can reduce athlete risk and improve survival ability (Asplund et al, 2016). Athlete safety and performance can be maximized with proper acclimatization, programming, and appropriate emergency training.


The development of an emergency action plan (EAP) should be established, discussed and practiced by the strength and conditioning staff at least annually or more often as new staff are hired. The location of the automated external defibrillator (AED) and other resuscitation items should be known by all coaches and athletes. Appendix A provides an outline of the different conditions, their physiology, programming, rest, symptoms, and the health related factors. The roles of each SCC should be understood prior to the start of training year and what adjustments are necessary if the training location is altered because of inclement weather, sport practice alterations, and university functions. Athletes’ prescreening by the sports medicine staff should be completed before the start of practices and information on at-risk athletes shared with strength and conditioning staff about any restrictions or precautions that may need to be applied to programming. Departmental meetings prior to the start of pre-season training should include reviews of exertional illnesses and diseases that may risk athlete safety along with educational discussion on how strength and conditioning programs will need to be adjusted.


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Appendix A. (Armstrong et al., 2007; Asplund and O’Connor, 2015; Braverman et al., 2015; Burnett et al., 2016; Bussotti et al., 2014; Casa et al., 2012; Casa & Armstrong, 2003; Collins et al., 2014; Costello et al., 2018; Hainline et al., 2016; NATA Consensus Statement Sickle Cell Trait; NCAA, 2014; NCAA Interassociation Consensus, 2016)

At-Risk Condition Physiology of Conditions Programming Rest and recovery Signs and symptoms Treatment and Health
Concussions and chronic traumatic encephalopathy (CTE) Concussion: mild traumatic brain injury; Swelling of fluid in cranial space; CTE: neurodegenerative disease Increase neck strength in off-season; Aerobic exercise initially post; Light resistance training if asymptomatic; Strength training to reduce head displacement Symptoms persistent for 3 months is post-concussion syndrome; Gradually reduce rest if asymptomatic; Hot/humid environments need > rest as EHI risk increases Cognitive tests differ from baseline; Emotional distress, anxiety and academic stress or difficulty; CTE: symptoms similar of dementia; Mood swings, altered personality Pre-season > occurrence of concussion; Coach and athlete targeted approach; Annual training for coaching staff; Balance error scoring system for assessment
Cardiovascular Hypertrophic cardiomyopathy death > in 35 years; Loeys-Dietz syndrome; Marfan syndrome; Genetic aortic diseases; High blood pressure Monitor heart rate during strenuous exercise; Isometric exercises should be limited with condition; > Susceptibility to EHI; Gradual increase of interval training with heart rate spikes & drops Greater rest periods with heart condition; Hot/humid environments need > rest; Recovery that allows gradual decrease in exercise heart rate; Greater rests with detrained athletes. Irregular ECG; Seizures; Sudden athlete collapse or unresponsive; Severe tightness and pain in chest, between scapulae, and radiating down left arm; Difficulty breathing; Syncope Men’s basketball > chance of sudden cardiac death; 3 min to access AED; Athletes should have ECG or MRI prior to start of season and annually with preexisting condition
Exertional Rhabdomyolysis (ER) Excessive, prolonged, or repetitive exercise; Training not part of a periodized/progressive program; Unfamiliar/novel training; Prolonged layoff (e.g. 3 months) of inactivity Gradual progression of training load, addition of eccentric exercises and longer rest; 48 hours between “two a day” practices; Low training intensity returning from injury; No “extra” training Programs need to be progressed over weeks not days (< 7 days); Fluid intake during breaks; Increase rest with diminished performance Elevated serum creatine kinase, tissue edema, possible cardiac arrhythmias, muscular pain and dark “cola” colored urine; Rapid onset of muscle pain, weakness, or swelling Athletes with previous ER need monitoring; Record reports of unusual muscle pain, weakness or stiffness; Prolonged inactivity increases risk of ER; Excessive stimulant use increases risk
Exertional Heat Illness (EHI) Chance of heat stroke with Wet bulb globe temperature (WBGT) > 82°F; Exhaustion is inability to continue exercise; Exertional heat cramps from prolonged strenuous exercise in heat Heat acclimatization ? 2 weeks; Gradual progression and longer rest; 48 hours between “two a day” practices; No exercise 7 days following medical release; Train during cooler hours of the day or in climate controlled High heat 40 min maximum before 10 min rest; Full return following heat stroke 2-4 weeks; Daily body weight measurements; fluid intake every 15 min break in WBGT 75.0—78.6°F; Heat exhaustion: low blood pressure, elevated pulse, respiratory rates sweaty, and pale/ashen; Heat stroke: body’s heat dissipation ability is exceeded, cessation of sweating, and red/dry skin Immediate cooling of body, hydration if conscious, move into shade, increase cool air circulation; Ice tubs or towels soaking in ice buckets; increased susceptibility to reoccurrence of EHI
Respiratory Asthma; Exercise-induced bronchoconstriction Cystic fibrosis; Chronic obstructive pulmonary disorder; Upper respiratory tract infection Use mask if training in cold environment (< 35° F); Sprint intervals and like training may induce asthmatic attacks; Breathing through the nose to reduce respiratory irritation; Develop aerobic base prior to preseason Allow time for fast-acting bronchodilator to take effect; Gradually reduce rest times during intervals; Rest periods should be in ventilated and warm air environment; Fluid intake during rests Shortness of breath, coughing and wheezing; Chest tightness; Inflammation and constriction bronchial airways; Chronic air obstruction/scarring Fast-acting bronchodilator; Prescreening for bronchoconstriction; Respiratory care for positive diagnosed athletes;
Sickle Cell Trait (SCT) Red blood cells are ¼ moon shaped, increased blood viscosity; Sickle cells block blood vessels creating ischemic situation; SCT increases chance of ER Gradually increase anaerobic training; closely monitor SCT athletes during interval training; Develop aerobic fitness base; Program longer rest after extended inactivity/illness/injury Increased rest between anaerobic sets; Adequate sleep prior to exercise; Increase rest and decrease total volume in hot/humid environment Blood vessel blockage, muscular weakness, kneeling or slumping, severe muscle pain or cramping; ER symptoms; Collapse Maximal effort training of 2-3 minutes may induce exertional sickling; Avoid timed runs; Include ≥ 48 hrs. between training and testing