--- title: Risk Factors and When to Refer description: If your grandfather first risk factor walks into his primary care physician for his annual physical and presents with elevated insulin levels second --- [![BSMPG Logo](https://www.bsmpg.com/hs-fs/hubfs/BSMPG_June2016-theme_Images/logo.png?width=570&name=logo.png "BSMPG Logo")](https://www.bsmpg.com/) # Boston Sports Medicine and Performance Group, LLC Blog ## [Risk Factors and When to Refer](https://www.bsmpg.com/Blog/bid/47518/Risk-Factors-and-When-to-Refer) Posted by Boston Sports Medicine and Performance Group on Wed, Jul 14, 2010 @ 20:07 PM - [Tweet](https://twitter.com/share) If your grandfather (first risk factor) walks into his primary care physician for his annual physical and presents with elevated insulin levels (second risk factor), low HDL cholesterol (third risk factor), and abdominal obesity (fourth risk factor), chances are that he’ll be suffering from insulin resistance pretty soon. Just having *one* of these risk factors alone doesn’t necessarily predict future disaster. But *put them all *together and mix them up?  Well, you have a nice recipe for some serious problems.  Assessing multiple risk factors and contributing their sum towards an end pathology or disease is common in all fields of medicine.  Another example would be the patient with elevated LDL cholesterol, high blood pressure, and insulin resistance.  Mix these all up and I’m pretty sure you’ll be tipping the scales with obesity soon.  And yet another set of risk factors predicts hypertension and so forth. In Sports Medicine and orthopedic screening, this concept has been lost.  Let me elaborate. So, a tight achilles with a loss of dorsiflexion compared bilaterally without pain by itself surely never deserves a referral to an orthopedic doctor? Neither does a weak right glut medius muscle, a single leg hop discrepancy left to right, right knee valgus collapse during an overhead squat, and of course a tight right psoas muscle from sitting all day surely doesn’t deserve orthopedic referrals when observed by themselves.  I mean, your athlete can run and jump just fine, right? Again, all of these by themselves do not deserve a referral, but all of these combined certainly spell future knee pain or other pending disaster, agreed?  Yet, we usually don’t do anything until the knee hurts, or worse, when the athlete hobbles in on crutches after tearing up their knee. Why are we waiting until an athlete’s season is over to address contributing risk factors? For example, we measure blood pressure and refer immediately after obtaining an abnormally high reading, but did the heart initially hurt? What gives?   *Suggested Reading and Inspiration provided by: Why Zebra’s don’t get Ulcers by Robert M. Sapolsky   **Art Horne** is the Coordinator of Care and Strength & Conditioning Coach for the Men’s Basketball Team at Northeastern University, Boston MA.  He can be reached at [a.horne@neu.edu](mailto:a.horne@neu.edu). Topics: [athletic training](https://www.bsmpg.com/blog/topic/athletic-training), [orthopedic risk factors](https://www.bsmpg.com/blog/topic/orthopedic-risk-factors), [orthopedic assessment](https://www.bsmpg.com/blog/topic/orthopedic-assessment), [pre-participation screening](https://www.bsmpg.com/blog/topic/pre-participation-screening), [pre-participation assessment](https://www.bsmpg.com/blog/topic/pre-participation-assessment) ### Barefoot in Boston now available on Amazon.com “The residents who live here, according to the parable, began noticing increasing numbers of drowning people caught in the river’s swift current and so went to work inventing ever more elaborate technologies to resuscitate them. 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