Bleeding disorders, sports and exercise

Treadmill

Treadmills consist of a power or manually operated, continuous 

moving belt on which a person can walk or jog in place. Features vary

widely; models may have shock-absorbing tracks, uphill grades, and

preprogrammed workouts.

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Gymnastics

There is a risk for head trauma and intracranial bleeding with high

equipment, such as rings and uneven bars. In a well-supervised setting

that includes proper instruction and good spotting, this sport is acceptable

for people who do not have significant musculoskeletal damage. Risk for

injury increases with jumping dismounts and aerial skills, especially for

those on competitive teams.  

Hiking 

Hiking can be done almost anywhere at any time and requires only good

hiking boots or shoes. Aerobic effort, impact, and muscular workout

increase with more challenging terrain. Hiking can be a good social

experience when done in groups, and it is an excellent lifetime activity.

Hockey, Field/Ice/Street

All types of hockey are high-contact, high-collision sports that involve

potential for serious traumatic injury to the head, neck, spine, and

extremities. Hockey is 

not recommended

for people with bleeding disorders.

Horseback Riding

This activity carries significant risks because major falls with trauma to the

head and spine are not uncommon. However, in certain geographic areas it

may be necessary as a form of transportation. A hard, well-fitting,

American Society for Testing and Materials (ASTM)-certified helmet

should always be worn. Jumping should be discouraged.

Ice Skating

The greatest risk is falling on the ice and hitting the head or breaking a

bone. There is a common misconception that weak ankles make skating

difficult. Well-fitted, good quality skates with rigid ankle support eliminate

this concern.

Inline Skating

Inline skating appeals to all age groups. It can be an excellent aerobic

workout but is not without risks. A helmet and protective pads for elbows,

knees, and wrists should be worn. The risk of injury increases with aerial

skills and competitive participation.

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Physioball 

This class uses a ball to strengthen abdominal and lower back muscles,

improve balance, and add variety and challenge to exercise regimens.

Spinning

Spinning is like an indoor group ride on stationary bicycles led by an

instructor. Bikes are arranged so that each participant can see the

instructor. The workout can include sprints, slower pedaling, and

added resistance to simulate hills.

Fishing 

A relaxing activity for any age, fishing involves little risk.

Football 

Football is a high-contact, high-collision sport with potential for 

serious traumatic injury to the head, neck, spine, and extremities. It is 

not recommended

for people with bleeding disorders.

Frisbee

Whether recreational or competitive, this level of Frisbee involves 

little risk. It involves sailing a lightweight plastic disk with a flip of 

the wrist.

Frisbee Golf  

Played for recreation and also competitively, the object of the game 

is to throw the disk into the target in the fewest number of throws.

Ultimate Frisbee 

Although this game combines elements from football, soccer and

basketball, it is a non-contact team sport. It can be played 

recreationally or in competition. 

Golf

Golf is a low-impact, lifetime sport that provides a good workout for those

who walk the course rather than use a cart. Expense and access to a

course are limiting factors.

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Mountain Biking 

As with regular biking, ANSI- or Snell-certified helmets are absolutely

essential. Additional safety equipment may include elbow pads and shin

guards. Risk involves falls and collisions with obstacles, due to the rough,

uneven terrain. By acting as shock absorbers, elbows may experience

increased pressure. 

Pilates

A form of strength training that may include mat- or equipment-based

exercise. Pilates strengthens the trunk muscles. It carries little risk, if

properly performed.

Power Lifting

Power lifting is a competitive sport in which contestants demonstrate

maximum lifting ability through sudden, quick maneuvers. It is 

not

recommended

for people with bleeding disorders.

Racquetball

In this high-collision sport, there is a high risk for eye and head injury.

Rapidly swinging limbs, hard racquets, high-velocity balls, and close

quarters make for frequent injuries. 

River Rafting

Rafting should be done with reputable companies that are very familiar

with the river. There is a wide range of risk with this activity based on

classification of water current. Participating in this activity in relatively

calm water can be relaxing and enjoyable or can provide a strenuous

aerobic workout. Fast white water increases the risk for capsizing, with

potential for head trauma and drowning. An ANSI-certified helmet and U.S.

Coast Guard-approved life vest/personal flotation device are mandatory. 

Rock Climbing (Indoor or Challenge Course)

Rock climbing uses ropes and harnesses and requires good strength and

good range of motion in all joints. The primary risk of this sport is falling.

Climbing on indoor walls and challenge courses with proper instruction

and supervision may provide a safer environment for experiencing the

sport of rock climbing.

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Jet-Skiing

This activity carries significant risks for anyone who participates, because

a major accident can result in serious traumatic injuries. A U.S. Coast

Guard-approved life vest or personal flotation device is required.

Jumping Rope 

An excellent form of cardiovascular exercise, jumping rope can provide a

vigorous workout. The impact of this activity may cause stress to the

ankle joints.

Kayaking 

As in canoeing, there is a wide range of risk that varies with the

classification of the water current. Participating in this activity in relatively

calm water can be relaxing and enjoyable or can provide a strenuous

aerobic workout. Fast white water increases the risk for capsizing, with

potential for head trauma and drowning. A U.S. Coast Guard-approved life

vest/personal flotation device and ANSI-certified helmet should be used. 

Lacrosse 

Lacrosse is a high-contact, high-collision sport with potential for 

serious traumatic injury to the head, neck, spine, and extremities. It is 

not recommended

for people with bleeding disorders.

Martial Arts (Karate, Kung Fu, or Tae Kwon Do)

Studying any of these forms under the supervision of a qualified instructor

can provide good physical conditioning. Practicing the precise movements,

including strikes, punches, blocks and kicks, in a disciplined manner is

acceptable. Competitive fighting, high contact, and breaking objects are

not recommended.

Martial Arts (Tai Chi)

The emphasis on slower movements, breathing, and meditation makes this

activity appropriate for anyone.

Motorcycling/Motocross Racing

This is a high-collision activity with potential for serious traumatic injury.

Extremely dangerous for anyone, it is 

not recommended

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Scooter (Non-Motorized)

Non-motorized scooters can provide an excellent aerobic workout but

they are not without risk. Riders should wear certified helmets and

protective pads for elbows, knees, and wrists.

Scuba Diving 

This activity carries inherent risks that relate to the depth of the water and

the need for proper maintenance of equipment and oxygen supply.

Instruction is imperative, and certification is necessary in the United

States. Scuba diving provides excellent musculoskeletal strengthening and

cardiovascular conditioning, without stress to the joints.

Skateboarding

Skateboarding can be an excellent aerobic workout but is not without

risks. A certified helmet and protective pads for elbows, knees, and wrists

should be worn. The risk of injury increases with aerial skills and

competitive participation. 

Skiing (Cross-Country) 

Because of slower speed, injuries are usually less serious than those seen

in downhill skiing. There is also less chance of colliding with another

skier. This activity may also be performed on an indoor cross-country ski

machine. It is an excellent aerobic, lifetime activity.

Skiing (Downhill)

Properly fitting equipment and a helmet are essential. There is a risk of

fractures and injury to joints, ligaments, and head from falls or collisions

with trees or other skiers. Moguls, aerial skills, and jumps carry increased

risk and are not recommended.

Skiing (Telemark)

This type of skiing, which may be done cross-country or downhill, causes

repetitive stress to the knees.

Snorkeling

This low-impact recreational activity provides excellent musculoskeletal

strengthening and cardiovascular conditioning, without stress to the joints. A

U.S. Coast Guard-approved life vest or personal flotation device is mandatory.  

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Rock Climbing (Natural Setting) 

Rock climbing in natural settings increases the risk because of the

potential for falls that cause serious trauma and life-threatening injury.

Rock climbing in natural settings is 

not recommended

for people with

bleeding disorders. 

Rodeo

In this high-collision, high-contact activity, there is potential for serious

traumatic injury to the head, neck, spine, and extremities. Rodeo is 

not

recommended

for people with bleeding disorders.

Roller-Skating 

Similar to inline skating, roller-skating appeals to all age groups. It can be

an excellent aerobic workout, but is not without risks. A helmet and

protective pads for elbows, knees, and wrists are recommended.

Rowing/Crew 

Rowing provides an excellent total-body, non-impact aerobic workout,

even when done on rowing machines. Movement can be modified to

accommodate joints that lack full range of motion. Proper position and

use of the back is important to prevent injury.

Rugby

Rugby is a high-contact, high-collision sport with potential for serious

traumatic injury to the head, neck, spine, and extremities. It is 

not

recommended

for people with bleeding disorders.

Running/Jogging 

These activities cause high impact to weight-bearing joints, which may

increase the number of bleeds and contribute to severity of joint disease.

Some people with bleeding disorders are still able to jog successfully.

Scooter (Motorized)

Riding a motorized scooter is a high-collision activity with potential for

serious traumatic injury. It is a dangerous activity for anyone and 

not

recommended

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T-Ball

Recreational and competitive teams are usually well organized and

supervised. Risks of the sport include injury to the head, eye area and

chest as a result of being hit by the ball, and joint trauma caused by sliding

into base or colliding with other players. Certified helmets with ear flaps

on both sides, a chin strap and eye protection should be required. Padded

chest protection and the use of softer baseballs may reduce the severity of

injuries. Sliding and joint overuse due to pitching should be minimized or

avoided. There may be additional risks of joint injury or trauma when

playing the position of catcher.  

Tennis

There is little risk involved in tennis, but it may be stressful to the

shoulder and elbow joints. Proper grip and form are important to reduce

injury. This activity can be enjoyed at any age.

Track and Field 

Track and field includes many different events, which will be more or less

appropriate, depending on the person’s joint limitations. Specific event

choices should be discussed with the HTC team.

Trampoline

The trampoline is a dangerous piece of equipment that is 

not

recommended

. Risks include injury or death due to colliding with

another person, landing improperly while jumping or doing stunts, falling,

or jumping off. The American Academy of Pediatrics recommends that

trampolines should not be used at home, either indoors or outdoors. Their

policy also recommends that trampolines should not be part of routine

physical education classes in schools, have no place in outdoor

playgrounds, and should never be regarded as play equipment.

Volleyball 

The risk of injury increases when volleyball games become highly

competitive.

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Snowboarding 

This activity requires excellent lower-extremity and abdominal strength. A

protective helmet is essential. Risks are similar to those in downhill skiing.

Snowmobiling

Snowmobiling is a high-collision activity with potential for serious

traumatic injury. It is more dangerous in high-traffic areas. It is 

not

recommended

for people with bleeding disorders.

Soccer

Children often participate in supervised soccer games beginning at very

early ages. At older levels, games become more competitive, resulting in

higher contact and risk of injury. “Heading” the ball should be discouraged

because of the risk of bleeding in the head and face. Shin guards should be

worn. Playing goalie increases the risk of trauma.

Softball

Recreational and competitive teams are usually well organized and

supervised. Risks include injury to the head, eye area, and chest as a result

of being hit by the ball, and joint trauma caused by sliding into base or

colliding with other players. Certified helmets with ear flaps on both sides,

a chin strap, and eye protection should be required. Padded chest

protection and the use of softer baseballs may reduce the severity of

injuries. Sliding and joint overuse due to pitching should be minimized or

avoided. There may be additional risks of joint injury or trauma when

playing the position of catcher.

Surfing  

This activity carries significant risks for anyone who participates. It can be

stressful to the muscles and joints of the lower extremities. A major

accident can result in serious injury. A U.S. Coast Guard-approved life vest

or personal flotation device is recommended.

Swimming  

An important low-impact sport, swimming provides excellent

musculoskeletal strengthening and cardiovascular conditioning. Proper

technique will minimize the risk for repetitive stress injury. It is an activity

that can be continued throughout life.

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Continuing in Sports and Exercise 

After Bleeding Episodes

There are no standard guidelines about returning to sports or exercise after

a bleeding episode. Each person’s situation is unique, and the decision

may require consulting with the HTC staff. Some people’s muscles and

joints may require longer periods of recuperation and possibly a period of

rehabilitation before playing competitively again. Bleeding episodes that

resolve with a single treatment and do not interfere with normal daily

activities should cause no increased concern. However, bleeding episodes

that require multiple treatments, forced bed rest, or leave the joints or

muscles feeling stiff are signs that the HTC staff should be consulted

before resuming sports or exercise.

If bleeding continues to occur in the same joint or muscle, the normal

healing mechanisms of the body risk being interrupted leading to

permanent joint or muscle damage. A cycle of frequent bleeding can cause

you to remain inactive for periods of time, thereby limiting future

participation in sports.

Summing It Up: Prepare Yourself, 

Choose Wisely…and Have Fun!

People with bleeding disorders should be strongly encouraged to participate

in exercise and sports activities. Six points are worth emphasizing:

1.

People with bleeding disorders have a defect in their coagulation

system. Frequent bruising is a part of their lives that cannot be

avoided. For those with severe disease, bleeding into joints or

muscles can occur even with little or no trauma. 

2.

Parents must strive for a healthy attitude toward their child’s

participation in physical activities. It is important that parents

provide a safe environment in which their child can grow and

develop normally, which includes participation in athletic activities.

In general, inactive, overprotected children have more frequent,

spontaneous bleeding. A more self-confident, independent lifestyle

usually brings marked clinical improvement and fewer spontaneous

bleeding episodes.

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Walking

Whether slow and steady or brisk, walking is an excellent aerobic activity

that can be done indoors at malls, outdoors, and on varied terrain. It is also

a good social experience when done in groups and is a great lifespan activity.

Water-Skiing

This activity carries significant risks for anyone who participates. It can be

stressful to the muscles and joints of the lower extremities and to the

elbows and shoulders. A major accident can result in serious traumatic

injuries. A U.S. Coast Guard-approved life vest or personal flotation device

is required.

Weight Lifting/Resistance Training

Lifting heavy weights is not recommended for growing children because

stress to the growth plates of bones may cause early closure. Lifting lighter

weights with more repetitions is recommended and will increase strength

and endurance. This exercise frequently improves body image and self-

confidence.

Weight Lifting/Power Lifting 

Power lifting refers to the competitive sport in which the contestant

demonstrates maximum lifting ability through sudden, quick maneuvers.

It is 

not recommended

for people with bleeding disorders.

Wrestling

Wrestling is a high-contact, high-collision sport with potential for serious

injury to the head, neck, spine, and extremities. It is 

not recommended

for people with bleeding disorders.

Yoga

Yoga is a form of flexibility and strength training that varies widely and

may include mat- or equipment-based exercise. Yoga may involve

participation in a structured class or use of a home video or DVD. Proper

technique is important to minimize risk of injury.

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Full Body Stretch

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Lie on the floor with

arms overhead and 

legs straight.

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Reach as far as

possible in opposite

directions with arms

and legs.

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Hold 30 seconds, 

then relax.

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Stretch should be felt

along entire body.

Trunk Rotation

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Lie on the floor with legs

straight.

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Bend left knee up and

using right hand, pull leg

across body.

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Keep shoulders on 

the floor.

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Hold 30 seconds, 

then relax.

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Repeat with other leg.

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Stretch should be felt 

in lower back and 

side of hip.

3.

Children choose sports for excitement, friendship, and competition.

One of the biggest obstacles to their participation may be their

parents’ fear of injury. Parents should address these concerns by

talking with their children about risks and precautions, and they

should make sure that children use the appropriate safety

equipment.

4.

Honest and open communication between people with bleeding

disorders, their parents, the HTC team, school personnel and

coaches is vital. If injuries occur, people should always receive early

and appropriate treatment.

5.

It is important that people with a bleeding disorder be physically fit.

Joints that are supported by well-developed muscles are better able

to withstand the traumas of daily living. Stretching, strengthening,

cardiovascular training, and sports participation are all ways to

achieve fitness.

6.

There are many benefits to participating in sports and exercise.

Starting at an early age can build a strong routine that will be

beneficial throughout life. 

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Appendix 1