Working Diagnosis:
Lateral ankle sprain with associated contusion on dorsal foot complicated by previous unknown Hemophilia A diagnosis with no evidence of hemarthrosis.

Treatment:
No additional Advate infusion was necessary and he was continued on his regular infusion schedule. He was held from practice and monitored closely until signs of bruising and swelling resolved. Ice and range of motion exercises were used to help with bruising. Tylenol was used for pain control with strict instructions to avoid aspirin. On repeat exam 12 days after initial presentation his swelling had completely resolved. He was permitted to practice with padding. He was instructed to report any signs of bruising or trauma immediately.

Outcome:
He was held from practice for a total of 7 days. He continued to ice his foot after games and practice. There were no signs of hemarthrosis. He did not require any additional Advate infusions. He played the rest of the soccer season without injuries.

Author's Comments:
Once hemophilia is diagnosed, it is recommended to have Factor VIII replacement therapy for athletes competing in contact sports. Advate is an albumin free recombinant factor VIII replacement. When an injury with bleeding occurs, additional dosing may be indicated at the guidance of hematology. No running should be done when joint swelling is present to prevent hemarthrosis. Use of protective equipment where appropriate for patients with hemophilia.

Editor's Comments:
The World Federation of Hemophilia recommends the practice of non contact sports (especially swimming) as it has shown to improve quality of life and reduce musculoskeletal tissue injuries as well as hemophilic atrophy. While participation in high risk sports is possible, it requires careful considerations and coordination/good communication between the members of the treatment team including an hematologist. Below is a link from the National Hemophilia Foundation providing information on "Playing it Safe". It includes a safety rating by activities:
https://www1.wfh.org/publication/files/pdf-1472.pdf

References:
Gomis M, Querol F, Gallach JE, Gonzalez LM, Aznar JA. Exercise and Sport in the Treatment of Haemophilic Patients: a Systematic Review. Haemophilia. 2009 Jan;15(1):43-54.

Gonzalez-Porras JR, Lopez-Cadenas F, Alberca I, Bastida JM. Top-Level Sports in Athletes with Severe Hemophilia A. Haemophilia. 2017 Jul;23(4):e391-e393.

Maffet M, Roton J. Hemophilia in Sports: A Case Report and Prophylactic Protocol. Journal of Athletic Training. 2017;52(1):65-70. doi:10.4085/1062-6050-51.11.14.

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