Monday, August 27, 2012

Stem Cell Research & Therapy | Abstract | Adipose stem cells can secrete angiogenic factors that inhibit hyaline cartilage regeneration

Stem Cell Research & Therapy | Abstract | Adipose stem cells can secrete angiogenic factors that inhibit hyaline cartilage regeneration

Adipose stem cells can secrete angiogenic factors that inhibit hyaline cartilage regeneration

Christopher SD Lee, Olivia A Burnsed, Vineeth Raghuram, Jonathan Kalisvaart, Barbara D Boyan and Zvi Schwartz

Stem Cell Research & Therapy 2012, 3:35 doi:10.1186/scrt126
Published: 24 August 2012

Abstract (provisional)

Introduction

Adipose stem cells (ASCs) secrete many trophic factors that can stimulate tissue repair, including angiogenic factors, but little is known about how ASCs and their secreted factors influence cartilage regeneration. Therefore, the aim of this study was to determine the effects ASC-secreted factors have in repairing chondral defects.

Methods

ASCs isolated from male Sprague Dawley rats were cultured in monolayer or alginate microbeads supplemented with growth (GM) or chondrogenic medium (CM). Subsequent co-culture, conditioned media, and in vivo cartilage defect studies were performed.

Results

ASC monolayers and microbeads cultured in CM had decreased FGF-2 gene expression and VEGF-A secretion compared to ASCs cultured in GM. Chondrocytes co-cultured with GM-cultured ASCs for 7 days had decreased mRNAs for col2, comp, and runx2. Chondrocytes treated for 12 or 24 hours with conditioned medium from GM-cultured ASCs had reduced sox9, acan, and col2 mRNAs; reduced proliferation and proteoglycan synthesis; and increased apoptosis. ASC-conditioned medium also increased endothelial cell tube lengthening whereas conditioned medium from CM-cultured ASCs had no effect. Treating ASCs with CM reduced or abolished these deleterious effects while adding a neutralizing antibody for VEGF-A eliminated ASC-conditioned medium induced chondrocyte apoptosis and restored proteoglycan synthesis. FGF-2 also mitigated the deleterious effects VEGF-A had on chondrocyte apoptosis and phenotype. When GM-grown ASC pellets were implanted in 1 mm non-critical hyaline cartilage defects in vivo, cartilage regeneration was inhibited as evaluated by radiographic and equilibrium partitioning of an ionic contrast agent via microCT imaging. Histology revealed that defects with GM-cultured ASCs had no tissue ingrowth from the edges of the defect whereas empty defects and defects with CM-grown ASCs had similar amounts of neocartilage formation.

Conclusions

ASCs must be treated to reduce the secretion of VEGF-A and other factors that inhibit cartilage regeneration, which can significantly influence how ASCs are used for repairing hyaline cartilage.

Friday, August 10, 2012

Urine Test Can Indicate A Woman's Risk Of Bone Fracture, Pitt Study Finds

Urine Test Can Indicate A Woman's Risk Of Bone Fracture, Pitt Study Finds

A simple urine test can indicate a premenopausal woman's risk of suffering bone fractures as she ages, according to new research led by University of Pittsburgh Graduate School of Public Health (GSPH) epidemiologists.

Women in their 40s and early 50s had a 59 percent greater risk of bone fracture as they aged when they had above-normal levels of N-telopeptide (NTX) - the byproduct of bones breaking down - in their urine, compared with women who had low NTX levels. When women with high NTX levels also had a low spinal bone density measurement, their risk of fracture increased nearly three-fold.

The study is the first to look for signs of bone breakdown in younger, premenopausal women in an effort to determine if such signs can predict the risk that these women will suffer fractures as they age.

The results were published today in the online edition of Menopause, the journal of The North American Menopause Society. The report will be published in the journal's November print issue.

"Bone fractures - particularly in the hip, wrist and back - have serious consequences, including disability and death," said Jane Cauley, Dr.P.H., professor of epidemiology, GSPH, and lead author of the study. "Knowing a woman's risk of fracture can help doctors determine the best course of action to protect her bones as she enters menopause, a time when estrogen deficiency negatively affects skeletal health."

By the time a woman turns 50, her risk of a fracture at some point in the remainder of her life is estimated to be at least 40 percent. Fractures are more common for these women than heart attacks, strokes and breast cancer combined.

During menopause, bone remodeling increases, leading to an imbalance between bone formation and bone resorption, or the process by which bones are broken down and their minerals are returned to the blood. This remodeling persists for several years and is associated with an increased rate of bone loss, making it easier for bones to fracture.

Cauley and her colleagues used data from 2,305 premenopausal or perimenopausal women aged 42 to 52 collected over an average of 7.6 years as part of the Study of Women's Health Across the Nation (SWAN). Participants were from Boston, Detroit, Los Angeles, Pittsburgh and Oakland, Calif.

SWAN examines the physical, biological, psychological and social health of women during their middle years. The goal is to help scientists, health care providers and women learn how mid-life experiences affect health and quality of life during aging.

Collaborators on this study include Michelle E. Danielson, Ph.D., Yue-Fang Chang, Ph.D., Kristine Ruppert, Dr.P.H., Leslie Meyn, M.S., and Beth A. Prairie, M.D., M.S., all of the University of Pittsburgh; Gail A. Greendale, M.D., and Carolyn J. Crandall, M.D., M.S., both of the University of California Los Angeles; Joel S. Finkelstein, M.D., and Robert M. Neer, M.D., both of Massachusetts General Hospital; Joan C. Lo, M.D., of Kaiser Permanente Northern California; and MaryFran R. Sowers, Ph.D., of the University of Michigan.

This research was supported by the National Institutes of Health (NIH), Department of Health and Human Services, through the National Institute on Aging, the National Institute of Nursing Research and the NIH Office of Research on Women's Health (grants NR004061, AG012495, AG012505, AG012531, AG012553 through AG012535, AG012539 and AG012546). This work also was supported by Department of Defense grant DAMD17-96-6118; NIH grants K24-DK02759 and RR-1066; the Iris Cantor-University of California, Los Angeles Women's Health Center; and University of California, Los Angeles Center of Excellence in Women's Health grant RFP 282-97-0025.  

Wednesday, August 8, 2012

Award-winning study details simple method to make anatomic ACL femoral tunnels | Orthopedics

Award-winning study details simple method to make anatomic ACL femoral tunnels | Orthopedics

Award-winning study details simple method to make anatomic ACL femoral tunnels

  • July 20, 2012
BALTIMORE — Research presented at the American Orthopaedic Society for Sports Medicine Annual Meeting 2012 yielded helpful guidelines for anatomic femoral tunnel placement in ACL reconstruction. 

“We know that it is important to produce an anatomic femoral tunnel and an anatomic ACL, but there are two questions,” Alexander D. Davis, MD, said in his presentation of the work, for which he and his colleagues received the Aircast Award for Basic Science. “How do we find the anatomic femoral insertion and how do we create a tunnel at this location?”
Davis and colleagues removed the medial condyles from 12 fresh, frozen distal femurs. They dissected all the soft tissue except the ACL attachment and marked the centers of the ACL and its two bundles. The researchers than observed the femur in 90° flexion and marked the lowest point on the lateral wall of the notch. This point was then used as the starting point for a vertical line, against which Davis and colleagues measured the height of the ACL center and its composite bundles. They then measured the distance from those center points to the front and back of the notch.
The team placed metal beads at these three centers and took lateral radiographs using the quadrant method, according to Davis. They then seated a 7-mm femoral offset aimer at the vertical height of the ACL center, he said, and placed a pin through the aimer to mark a point on the lateral wall of the notch.
Results of the study illustrated that the femoral attachment of the ACL and its bundles can be identified through a method based on the height of these structures on the lateral wall of the notch, Davis said. Intra-operatively, a 7-mm femoral offset aimer seated at the height of the central ACL directs a pin about halfway between the ACL central and anteromedial bundle attachments. Then the shallow and deep ACL positions and their bundles can be referenced to a vertical line that starts at the low point of the notch’s lateral wall or cartilage borders, he explained.
“Whether you are using rigid reamers in a hyperflexed position or flexible reamers, once you have established your starting point you can then produce an anatomic femoral tunnel that is based upon a reproducible reference point that can be seen intra-operatively based upon the lowest point of articular cartilage,” Davis said.
Reference:
Davis AD, Brown C, Steiner ME. Simple guidelines for anatomic femoral tunnel placement in ACL reconstruction. Paper #17. Presented at the American Orthopaedic Society for Sports Medicine Annual Meeting  2012. July 12-15. Baltimore.

Biomarkers could be used to prevent atrophy in ACL-deficient patients, study finds | Orthopedics

Biomarkers could be used to prevent atrophy in ACL-deficient patients, study finds | Orthopedics

Biomarkers could be used to prevent atrophy in ACL-deficient patients, study finds

Interesting paper and possible utility.

Pre-injury biomarkers linked with subsequent ACL injury | Orthopedics

Pre-injury biomarkers linked with subsequent ACL injury | Orthopedics

Pre-injury biomarkers linked with subsequent ACL injury

Very interesting topic from Westpoint that I saw at the AOSSM meeting in Baltimore this summer.

Tuesday, August 7, 2012

More Players Suffer Soccer Sprains When One Ankle Is Stronger

More Players Suffer Soccer Sprains When One Ankle Is Stronger

More Players Suffer Soccer Sprains When One Ankle Is Stronger

By Frederik Joelving

NEW YORK (Reuters Health) Jun 22 - Pro soccer players are much more likely to suffer ankle sprains when one foot is stronger than the other, Greek researchers have found.
There has been a slew of studies into the reasons athletes suffer sprains, but few have focused on soccer players, according to Dr. George Vagenas, of the University of Athens, and colleagues.
The researchers did preseason tests of ankle strength and stability in 100 players from four professional soccer teams in Greece. Then they followed the players over the next 10 months to see who would get hurt on the field.
Seventeen players suffered one or more non-contact sprains during the season. Those with considerable functional strength differences between their left and right ankles were nine times as likely to suffer sprains as those whose ankles were about the same strength.
When a player cuts or lands from a jump, Dr. Vagenas told Reuters Health by email, it's important to have symmetrical activation of the two sets of ankle muscles to help the joints absorb the impact and prevent damage.
He suggested that "all soccer players, professionals or not, must be evaluated during the preseasonal period by sports specialists for verification of potential functional asymmetry of the ankle joint."
But that might not be realistic, said Dr. Timothy A. McGuine, a sports medicine specialist at the University of Wisconsin-Madison.
"Most lay people won't have the time and money to do this kind of screening," he told Reuters Health.
But there is still an important message from the new study, even for amateur athletes, according to Dr. Erik Wikstrom, an expert in ankle sprains at The University of North Carolina at Charlotte.
"This study does suggest that if soccer players want to lower their risk of suffering ankle sprains, then they should strengthen their ankle musculature evenly, so that they have a good balance between both legs," Dr. Wikstrom told Reuters Health by email.
"This take-home message can apply to just about all athletes and non-athletes," he added. "Proper balance between the lower extremities is very important."
Earlier studies have shown that both lace-up ankle braces and balance training on a wobble board can help stave off injuries to the joint.
"I tell people to go ahead and balance on one leg, then the other for two to three minutes," said Dr. McGuine, who led those studies, adding that two to three times a week is a good start.
The Greek researchers, who published their study June 4 in the American Journal of Sports Medicine, also found that heavy players were more prone to sprains, which makes sense given the extra force their ankles have to absorb when they land or cut.
Apart from keeping a healthy weight, Dr. McGuine told Reuters Health that it's important for athletes to learn how to land properly, too.
"Don't land stiff legged," he said. "We want a soft foot strike."
SOURCE: http://bit.ly/MoUQb5
Am J Sports Med, 2012.

'Double-Jointed' Soccer Players Have More Injuries

'Double-Jointed' Soccer Players Have More Injuries

'Double-Jointed' Soccer Players Have More Injuries

By Amy Norton
NEW YORK (Reuters Health) Jan 03 - Soccer players with hypermobile joints may have a higher injury risk than their less flexible teammates, a study of one professional team suggests.
Benign joint hypermobility syndrome is diagnosed when a person is found to have at least four abnormally flexible joints -- based on tests of whether knees or elbows can bend backwards, the thumb can be flexed to touch the forearm, the pinkie finger can bend backward beyond 90 degrees and they can place their palms on the floor without bending the knees.
Hypermobile joints are not as stable as less-flexible joints, so in theory they could be more vulnerable to injuries like sprains. But researchers have come to conflicting conclusions on whether hypermobile athletes do sustain more injuries.
For the new study, UK researchers followed 54 men on an English Premier League soccer team over one season.
Of the players, 18 (one third of the group) were deemed hypermobile. And over the season, those 18 men suffered 72 injuries -- for a rate of 22 injuries for every 1,000 hours of practice and competition.
By comparison, the 36 players with less-flexible joints sustained 61 injuries: a rate of just over six injuries per 1,000 hours.
The mean difference in injury rates, 15.65 injuries/1000 h, was significant at p=0.001.
Matt D. Konopinski and colleagues at Leeds Metropolitan University reported the findings online December 16 in the American Journal of Sports Medicine.
The study adds to evidence that general hypermobility contributes to sports injuries, according to Verity Pacey, a physical therapist at the Children's Hospital in Westmead, Australia, who has studied the question.
In a recent study, Pacey and her colleagues found that across contact sports, players with joint hypermobility were nearly five times more likely to suffer a knee injury than their less-flexible counterparts.
That was based on a meta-analysis that combined the results of 18 previous studies.
It's not known yet whether weekend athletes with extra-flexible joints face the same risks as professional athletes seem to, Pacey told Reuters Health in an email.
Amateur athletes do not go through the amount of intense training and competition that pros do, pointed out Gareth J. Jones, one of the researchers on the current study.
On one hand, that might protect the hypermobile weekend athlete, Jones told Reuters Health in an email.
"However," he added, "they are also generally less well conditioned, which may increase the risk."
In this study, soccer players' injuries were often relatively mild -- like muscle strains, cramps or tears in the legs.
But some injuries were severe, meaning they kept players out of the game for at least 28 days. And hypermobile players were much more likely to have a severe injury.
Twelve of the 18 athletes suffered at least one severe injury during the season -- often a ligament or cartilage tear in the knee. That compared with only two of the 36 non-hypermobile athletes.
The knee is especially vulnerable to injury in soccer, Jones said. And for people with hypermobile joints, ligaments and other structures in the knee may be "less able to cope" with the stress placed on them.
Exercises to boost strength, muscle control and balance can help hypermobile people who already have joint pain or injuries.
And it's possible that such training could curb their risk of future sports injuries, Jones said.
But whether that is the case is not clear.
"Unfortunately," Pacey said, "at present we don't have any strong research evidence to support ways we can reduce the risk of injury in hypermobile sporting participants."
In general, researchers still aren't sure exactly how harmful hypermobile joints might be. Some extra-flexible people have chronic joint pain, but many don't. And there's no evidence yet that people with hypermobile joints face an increased arthritis risk.
One issue is that studies have varied widely in estimating how common hypermobility is in the general public, or among athletes.
A recent study, though, found that among teenagers, hypermobility is common -- a sign, the researchers said, that such flexibility is often perfectly normal.
Of 6,000 teenagers the researchers assessed, 27% of girls and 11% of boys met the criteria for benign joint hypermobility syndrome.
The current findings suggest that hypermobility could be very common in soccer, according to Konopinski's team. But it's not clear, they add, whether it's any more common in soccer than in other sports, or compared with the public at large.
Pacey said there is research underway to better understand hypermobility, its effects and, when needed, how to manage it.
One unknown, Pacey noted, is why some people who are hypermobile in their youth become less flexible as they age. "We've yet to understand why this occurs in only some individuals."
SOURCE: http://bit.ly/uICyg8
Am J Sports Med 2011.

Soccer Regimen Promising for ACL Injury Prevention

Soccer Regimen Promising for ACL Injury Prevention

Soccer Regimen Promising for ACL Injury Prevention

Laird Harrison

June 7, 2012 (San Francisco, California) — Girls can learn movements that might reduce damage to their anterior cruciate ligaments (ACL), researchers reported here at the American College of Sports Medicine 59th Annual Meeting.
After learning a set of techniques for jumping and changing direction, none of the girls on a high-school soccer team sustained ACL injuries the following season, said first author Amelia Goodfellow, a researcher at the University of California, Davis.
The team was highly competitive; in previous seasons, there were typically 1 or 2 knee injuries, according to coach reports.
ACL injuries are common among female athletes, particularly soccer and basketball players, Goodfellow told Medscape Medical News. "It's a humungous problem, especially with young athletes; they have not developed the skills and coaches are not focusing on them."
To see if they could reduce the risk for this injury, Goodfellow and her researchers taught 23 girls (age, 16 ± 1 years) on varsity and junior varsity high-school soccer teams movements based on the Prevent Injury and Enhance Performance protocol.
Girls learned to keep their knees flexed and aligned with their hips while staying low and balanced, Goodfellow explained. The girls also learned to land on the balls of their feet, following through to their heels.
Keeping these goals in mind, the girls practiced running and cutting to the side and other typical soccer movements. "A lot of ACL injuries happen during transitions — cutting side to side or jumping for a header," said Goodfellow.
The girls also practiced movements like jumping for a head ball and kicking a volley shot on a balance disc. "We strove to incorporate natural movements into conditioning," Goodfellow said.
The players did exercises to build core strength and stretched their quadriceps and hamstrings.
The girls completed 8 sessions of this 20- to 30-minute warm-up protocol.
To see whether the program worked, the researchers measured the girls' force of landing from a 28 cm drop jump. They also measured the girls' knee flexion angle and the extent of their valgus/varus collapse.
They took measurements before and after training using a Kistler Quattro Jump force plate and Dartfish video analysis.
None of the girls got injured during the practice or games during the season.
The distance between the girls' knees increased from 27.4 ± 6.0 cm to 29.9 ± 8.2 cm (a decreased valgus), which was statistically significant (P < .01).
Knee flexion angle improved from 119.7 ± 11.9 degrees to 110.5 ± 13.4 degrees.
The force of landing decreased, but the difference was not statistically significant.
After the training, 65% of the girls showed improvement in knee width, 78% in knee flexion, and 91% in ground reaction.
Andrea Fradkin, PhD, associate professor of exercise science at Bloomsburg University in Pennsylvania, told Medscape Medical News she is impressed by the study.
"This is definitely showing some performance improvement at the same time as reducing injury," said Dr. Fradkin, who was not involved with this study. "That's what a warm-up program is meant to do."
The study makes an important contribution to the literature, she noted. "There is not much out there," she added. "It's difficult to study injuries."
Ms. Goodfellow and Dr. Fradkin have disclosed no relevant financial relationships.
American College of Sports Medicine (ACSM) 59th Annual Meeting: Abstract 1218. Presented June 2, 2012.

How a Soccer Player Became a Physician for US Teams

How a Soccer Player Became a Physician for US Teams

How a Soccer Player Became a Physician for US Teams

John C. Hayes; Raymond R. (Rocco) Monto, MD

Editor's Note:
Among the teams competing for soccer gold in London will be the US Men's National Team. Although Rocco Monto, MD, won't be there, he will be rooting for the players, many of whom he knows personally. Dr. Monto is an orthopedic surgeon at Nantucket Cottage Hospital in Nantucket, Massachusetts, and a member of a group that has provided orthopedic care to youth and adult US soccer programs since 1993. He is also a former professional soccer player. Dr. Monto discussed with Medscape the orthopedic issues in team soccer and the perspective that athlete-orthopedists bring to sports medicine.
Medscape: Could you describe your relationship to the US Olympic soccer team?
Dr. Monto: I'm a member of US Soccer Team Physicians, and we are a group of doctors that cover all of the US soccer programs, one of which is the Olympic team -- but we have many teams in that corral. I am not the US Olympic team doctor for the soccer team this year, but I have represented the United States as the team physician, or one of the team physicians, since 1993.
In addition, I've been a consultant to the Real Madrid CF soccer team, the US Ski Team, and the Boston Ballet, among others.
Rocco Monto, MD
(Photo by John Dorton, ISI)
Medscape: What brought you to this position?
Dr. Monto: I was a soccer player myself. I was a college All-American soccer player and played some professional ball before I went to medical school, so I've always had an interest in the game.
As a patient with many injuries during my career, going into orthopedics was natural. A lot of guys in my field are former athletes. It's what draws us to the field of orthopedics and sports medicine in particular.
Medscape: I was struck by how many names cropped up when I searched orthopedics, orthopedic physicians, and the Olympics.
Dr. Monto: You see a lot of them who are now productive orthopedic surgeons working in sports medicine. It's a natural fit for us as athletes. We know how to relate to athletic patients, and we know their sense of vulnerability. It really makes for a good match between doctor and patient.

Types of Injuries

Medscape: Could you describe the types of orthopedic injuries that are most common among soccer players?
Dr. Monto: Probably the most common injuries are the ankle sprain and the hamstring strain. There are very few players who can make it through a career without those injuries. After that would come fractures and typical lower extremity injuries. These are less common but can be more severe.
In soccer, we also have a lot of heading, and so concussive injuries and concussions have become a much more identified injury. It's probably no more common than it's always been, but we're identifying it with more prevalence now, and that's just because we're all tuned into the injury and the injury pattern more than we were before.
As for other injuries, surprisingly we see a lot of upper extremity injuries in soccer, usually from falls, whether it's shoulder dislocations or wrist injuries. After that are the ligament injuries, the anterior cruciate ligament (ACL) being the most common, particularly in female soccer players.
Medscape: Have you seen injuries that you would consider highly unusual in soccer?
Dr. Monto: I'm always surprised that we don't see more dental injuries than we do. I had my teeth knocked out as a college player. You would expect to see more than we actually do, with all the flying elbows and kicking that goes on. When we do see them, they can be quite severe. Most players don't wear mouth protection.

Avoiding Injuries

Medscape: When you're trying to teach people how to protect against these injuries, what kind of training is provided, or what do they have to do to make sure they're in condition to avoid an injury? I would imagine it's a matter of playing style but also certain types of strengthening.
Dr. Monto: The real revolution in soccer training in the past 15 years has been the addition of strength training. I think it's interesting that in our sport, there are many different philosophies, when you look at different countries, teams, and leagues and how they approach training. Despite those wide variations, however, the injury patterns remain fairly constant. Some of the things we can't change.
Things we have had success improving have been the incidence of ACL tears, particularly among women. Bert Mandelbaum, MD, of Santa Monica Orthopaedic and Sports Medicine Group, has done some fantastic work in helping women learn the risk factors that lead to ACL tears and the imbalance of the hamstring and quadricep muscles and how they land after they jump. Along with FIFA (Fédération Internationale de Football Association), our worldwide soccer group has developed training techniques to try to help the athletes avoid those injuries.
Medscape: Are there other Olympic competitions that have risks similar to soccer's?
Dr. Monto: It would be similar to men's team handball. I worked with the US handball team several years ago, and many of the injuries I see in soccer are similar to those in team handball. You see some of these in other sports as well, such as basketball.
A lot of the injuries that happen in soccer are noncontact. They happen away from the run of play, particularly ACL injuries. These injuries happen when you land after a jump or while trapping the ball, and there is a quick twist of the knee. The land-and-pivot problem is common to many sports.

Getting Back to the Field Sooner

Medscape: Are new therapies or techniques allowing soccer players to return to play earlier after an injury?
Dr. Monto: We've been much more open to the use of orthobiologic treatments, whether that's platelet-rich plasma treatments or more novel physical therapy approaches. We've gotten much better in getting our athletes back quicker, but as Freddie Fu, MD, in Pittsburgh, Pennsylvania, says, you can only heal so fast. We've pushed it without using any type of real medications or other potentially problematic techniques -- just using aggressive physical therapy and treatment and letting the body use its ability to heal. We're much better at doing that.
I'd say the biggest advance has been in using platelet-rich plasma and other types of treatments where we use growth factors to try to help people heal their muscle strains more quickly. In the past 2 years, that's been approved by the Olympic Committee and is now okay for use in Olympic athletes. It's not really a performance enhancer.
Platelet-rich plasma and bone marrow aspirate concentrate for more severe injuries are really the future in nonsurgical treatment of muscle strains, medial collateral ligament tears, and ankle sprains.

Bonding With the Athletes

Medscape: What about your experience as an athlete has enhanced your knowledge of orthopedics?
Dr. Monto: As an athlete who's become an orthopedic surgeon, I think the one thing that I took with me is the importance of the bond between the physician and the athlete and the importance of the personal relationship. A lot of trust is required, and gaining an athlete's trust is the most difficult part of being an orthopedic surgeon.
You really must have walked the walk to understand what athletes go through and the importance of decisions that might not be important to someone else. Whereas a doctor might feel that making next week's game isn't important, to an athlete it can mean the difference between completing a career successfully or not. You may be getting a player at the end of his career, and you need to understand how critical a little bit more time for him can be. You learn this eventually as a surgeon, but I think you learn it much earlier as an athlete.
Medscape: That presents an interesting dilemma.
Dr. Monto: Yes. This is where a surgeon has to have a very strong ethical and moral compass, because an athlete may be willing to take much higher risk than the surgeon will. This is where the bond and the trust come under a test, and you really have to put yourself in the athlete's shoes a little bit and understand where they're coming from, and also you have to communicate with them where you are too.
Obviously, no one wants to send an athlete to one last game that ends with them unable to walk right the rest of their lives. Nobody wants to put anyone in those kinds of precarious positions -- but again, it's all about relative value. Just as it's important to get a carpenter back to work as quickly as possible, it's also important to get the athlete back.
Then we have the pressures from fans, the media, owners, players, and other various interests -- sponsors and things like that, especially with the professionalism now that's pervasive in all the Olympic sports and test sports (women's boxing this year, and golf and rugby sevens to be added in 2016). These are all competing interests that you have to take into account to come up with the best compromise for the athlete.
Medscape: What do you most enjoy about being part of the US Soccer Team Physicians?
Dr. Monto: My favorites have always been the under-17 men's teams, because they are the stars of tomorrow. They still have an innocence and joy about the way they play and the way in which they approach the game and life, and it's always fantastic. It's just a real charge to work with those guys.
I remember being the doctor when Landon Donovan was a 16-year-old just making his way and suddenly we're playing in the Junior World Cup. [Landon Donovan is on the Los Angeles Galaxy team and is one of the world's most highly paid soccer players.] Those are fantastic experiences. They're very important to those players at that age, because they carry them for the rest of their career.
People don't quite understand how integrated the team physician is into the team and into the character and the fabric of the team. We're on the sidelines. We're with them in the games. We're with them in training. When you're taking care of the young athletes like they're children, they're part of your family, and that bond really helps them through crises when they get hurt. Those are things that people don't see. There's another whole layer of care for the athletes.

Olympics 2012: Nutrition Advice for the Athletic Patient

Olympics 2012: Nutrition Advice for the Athletic Patient

Olympics 2012: Nutrition Advice for the Athletic Patient

Marrecca Fiore; Nancy Clark, MS, RD, CSSD

Editor's Note:
With the 2012 Olympic games in full swing, it's a good time to review how best to advise the athletic patient on proper nutrition. Medscape interviewed Nancy Clark, a registered dietician and author of Nancy Clark's Sports Nutrition Guidebook, who offered advice on how to set up nutrition plans for athletes. A board-certified specialist in sports dietetics, Clark's clients have included players from the Boston Red Sox and Boston Celtics, as well as elite and Olympic athletes from a variety of sports.
Medscape: What are the first steps a clinician or healthcare provider should take in setting up a nutritional plan for an athletic patient?
Ms. Clark: The first thing I do is figure out their protein needs because protein needs are based on body weight. Athletes need about 1.2-1.7 g of protein per kilogram or 0.5-0.8 g protein per pound of body weight. From there, I figure out what the rest of their caloric needs are and fill in the plan with fruits, vegetables, and grains to make a balanced diet.
I advise even fueling throughout the day. Generally when I work with clients, I give them 4 food buckets. Every 4 hours they have a food bucket, so they are always fueling up or refueling. The food buckets are their breakfast, lunch one, lunch two, and dinner. If they train in the morning then they have part of their breakfast bucket before they work out and then the rest of it afterwards. If they are training in the afternoon, they might divide up the lunch one or lunch two buckets so that they are fueling and refueling around that training session. Regardless of when they work out, the plan evens out throughout the day so there is always a constant infusion of protein to build and repair muscles and carbs to fuel the muscles.
Medscape: Are the nutritional needs different according to the age and sex of the patient you're working with?
Ms. Clark: For certain, a 200-lb athlete has different needs from a 100-lb gymnast. But even though their food plates might look a lot different, they still have similar protein needs based on their body weight. Their calorie needs would vary. Their fluid needs would vary according to their body size. They just need different quantities of food.
Medscape: How should a provider determine how many calories a person needs? Is it just based on body weight? Or is it a combination of body weight and the type of athletic activity the patient is involved in?
Ms. Clark: I look at how many calories they need to breathe, which is their resting metabolic rate. Then I look at what they do when they're not training. Many athletes are very sedentary, so there is something called sedentary athlete syndrome. If they are doing double workouts, which a lot of them do, they train in the morning and then they lounge around and rest and recover. Then they train in the afternoon and then they lounge around and rest and recover. So even though they are training hard, when they're not training they're doing nothing and that can certainly affect their energy needs. That's the sedentary athlete as opposed to the athlete who trains and is not sedentary. That person trains and then is taking care of a family and doing the gardening, the laundry, the food shopping, and bringing the groceries in.
Medscape: How should providers figure out how much protein an athlete needs as opposed to their carbohydrate or healthy fat needs?
Ms. Clark: They need about 1.2-1.7 g of protein per kilogram or 0.5-0.8 g of protein per pound of body weight. Most people are already getting that, so it's a matter of distributing it evenly throughout the day, because generally a breakfast might be a bowl of oatmeal and dinner would be 3 chicken breasts. But I want them to more evenly divide their protein throughout the daytime so that they have protein with their oatmeal, or maybe instead of oatmeal they have some Greek yogurt with some nuts and toast with peanut butter, or they have a couple of poached eggs or some cottage cheese and fruit; this helps them even out how much protein they are eating. That is important for athletes who are weight conscious, because protein is very satiating, but also for athletes who want to optimize their muscle development and repair.
Medscape: Intense exercise tends to make people really hungry, so what kind of advice should physicians and healthcare providers give athletes so that they don't put on unwanted weight while training?
Ms. Clark: That is a common problem, particularly in women, because women tend to get hungrier than men do. This is where they really need to make sure they have protein at each meal and that they eat evenly throughout the day to prevent hunger. A lot of weight-conscious athletes will diet at breakfast and diet at lunch and then train on empty. Later, they end up starving and they blow it in the afternoon or evening because they have become too hungry; so, again we have to look at meal timing. Have them fuel by day and then lose weight at nighttime when they are sleeping. But they don't want to try to lose weight when they're training.
Medscape: And what advice should be given when the opposite happens and an athlete experiences unwanted weight loss while training?
Ms. Clark: I look at what they are drinking for fluids. Most of them are drinking a lot of water, and I just have them trade that water in for some kind of a healthy juice. Maybe they have more orange juice or grape juice or some low-fat chocolate milk. Juices and milk are 90%-95% water, but there is also some energy in it, and that energy adds value to fuel their muscles and be an additional source of calories to their sports diet.
Medscape: Why is eating so important to an athlete? How can it make or break somebody's performance?
Ms. Clark: Well, how important is gas to a car? You have a car; you put gas in it and it goes. You have a body; you put food in it and it goes a lot better. Certainly, it enhances stamina and endurance. Food is the sparkplugs that are needed for health, with the vitamins and minerals and the chemicals that fight inflammation.
Medscape: Olympic swimmer Ryan Lochte said in a recent interview that he ate poorly during the Beijing Olympics, adding that he ate at McDonald's almost every day. He mentioned this because he's since removed junk food from his diet with the hope of enhancing his performance. What type of effect does eating poorly have on an athlete's performance? Some of these Olympic athletes seem to be able to eat junk food but maintain a healthy body weight. Are these foods still damaging their bodies on the inside, even if you don't see any damage on the outside?
Ms. Clark: Definitely. If an athlete is filling up on Big Macs and French fries and fatty, greasy foods, the fat will fill the stomach but the muscles will remain unfueled. Only carbohydrates get stored in the muscles as glycogen; depleted muscle glycogen is associated with fatigue. You can go to McDonald's and you can get oatmeal, English muffins, juice, and fruit parfaits, so you can get a healthy carbohydrate-based diet if you look for it. But you can also go and choose the totally wrong things, and if your muscles aren't well fueled day after day after day, then you just get increasingly tired. When you are trying to perform at your best, you really want a foundation of healthy carbs at each meal.
But just as food can be powerfully bad for you, it can be powerfully good for you. If you put quality, premium nutrition in your tank, it makes a big difference -- not just in terms of energy level, but also in terms of health and vitality.
Medscape: How should clinicians advise patients who aren't currently athletic but are inspired by the Olympics or some other event to begin working out? How should they approach their nutritional needs?
Ms. Clark: I start at breakfast. As I mentioned, if you have a car, you put gas in it and it goes, so you want to have a quality breakfast so you can go. Research suggests that people who have a high-protein breakfast end up eating fewer calories at the end of the day. If you have a dinner-size portion of protein at breakfast, it feeds you throughout the day and it keeps you fed so that it is easier to bypass the doughnuts, the Danish pastry, and the so-called junk food that manages to creep into people's lives when they haven't had much of a good breakfast. If you start out with a substantial breakfast, you'll have good energy, and it keeps you satiated so you feel like going to the gym. Even at the end of the workday you'll still have some energy to go to the gym.
With the workout, the place to start is to do some strengthening exercises to strengthen your muscles. If your muscles are stronger, it's easier to walk farther, run farther, bike farther. But first you get stronger and then you add the more aerobic exercise. Unfortunately most people start out with, "Oh, I'm going to run a mile," but it's much more important to get strong first.
The Olympics is a great time for people to take a look at how sedentary they are, how they could get in shape even if they just got up and marched in place during TV commercials, or if they kept little weights by their chair and got up to lift some weights a couple of times each day. There is a lot that can be done if people get creative and just figure out how they can move their bodies more. And certainly sitting around, even sitting all day at work, is an occupational health hazard. We know that smoking and being around smoke is a health hazard, but if people look at sitting as being hazardous to their health as well, then they can take small steps to move a little more.

Olympics 2012: Treating Female Athletes

Olympics 2012: Treating Female Athletes

Doping in Sports: Catching and Preventing It

An Expert Interview With Gary I. Wadler, MD

Carol Peckham; Gary I. Wadler, MD

Editor's Note:
As part of our coverage of the 2012 Olympics, Medscape interviewed Gary I. Wadler, MD. Dr. Wadler is an internist with special expertise in the field of drug use in sports. He is Clinical Associate Professor of Medicine at Hofstra North Shore-LIJ School of Medicine. He is also the lead author of the internationally acclaimed textbook Drugs and the Athlete, and an editor of the textbook The Healthy Dancer.
Dr. Wadler served as the Chairman of the World Anti-Doping Agency's (WADA) Prohibited List and Methods Sub-Committee and as an ex-officio member of WADA's Health, Medicine, and Research Committee. In addition, he was a Medical Advisor to the White House Office of National Drug Control Policy and has been a Trustee of the Board of the American College of Sports Medicine and of the Women's Sports Foundation. Among his other sports medicine activities, Dr. Wadler has served as Tournament Physician of the US Open Tennis Championships and Chairman of Nassau County Sports Commission.
Medscape: Would you give a brief description of WADA and how it determines which drugs are banned?
Dr. Wadler: The International Olympic Committee Medical Commission first published a list of banned drugs for the 1968 Winter Olympic Games. WADA assumed oversight of it in 2004 after implementation of the World Anti-Doping Code. This List of Prohibited Substances and Methods (referred to as "The List") is now the international standard for drugs prohibited in national competition and is updated annually.
Each year, the WADA Prohibited List Committee -- a diverse group of experts, including physicians, pharmacologists, pharmacists, laboratory experts, and researchers -- begin their deliberations by reviewing the most recent list of proposed banned drugs, which became effective on the first day of the current year. Before any drug is considered for The List, it has to meet 2 out of 3 criteria: The drug must enhance performance, pose a threat to an athlete's health, and violate the spirit of the sport. Even meeting all 3 criteria doesn't necessarily mean that the drug is added to The List.
There are 4 days of intense discussions, and a lot of heavy-duty science that goes into this process. It's not like the old days. The WADA Committee then creates a draft of all the drugs it recommends for The List and sends it to more than 1700 stakeholders, which include public authorities, national and regional antidoping agencies, international para-Olympic committees, such organizations as the Olympic Games, and antidoping laboratories. The stakeholders send back there assessments, and the WADA Scientific Committees and their experts consider their feedback in their own analysis.
The List Committee then integrates this information into a revised list, which is then presented to WADA's Health Medical Research Committee. They review it and, in turn, give their recommendations to the executive committee of WADA -- the ultimate policy-making body.
Medscape: Could you describe the Olympic standard testing procedures for performance-enhancing drugs?
Dr. Wadler: The Olympic testing procedures currently are predicated on the policies incorporated into the World Anti-Doping Code. The procedures for developing these standards are complicated, but you can find all the information on these plus banned drugs on the WADA Website.
Medscape: How easy is it to cheat on these tests for the Olympics?
Dr. Wadler: It's not easy to cheat at all. We're very good at our science. A cheating athlete can test positive on a blood or urine test, depending on the particular substance.
We also have what we call nonanalytical positives. An athlete can be sanctioned if he or she is caught in possession of a prohibited substance or manipulating these substances in any way, independent of any tests. For example, this could include criminal activities, such as trafficking in prohibited substances. We've had individuals without a positive drug test who were caught violating the policies of the World Anti-Doping Code and wind up getting sanctioned.
Medscape: Everyone is aware of the problems with anabolic steroids, but could you just discuss them a bit?
Dr. Wadler: It's important to stress that the substances that are abused in athletics are often therapeutically used by physicians like me to care for patients. These drugs were not developed to help athletes cheat.
Anabolic steroids are the synthetic derivatives of the hormone testosterone. They are available in a variety of forms, and now in new delivery systems. In the old days, anabolic steroids had to be injected frequently -- like insulin in diabetes -- in patients who needed them because of deficiencies. To make life easier, there are now delivery systems using patches and creams, which unfortunately have been abused by some athletes. So it's not only the substance itself, it's the delivery system.
Medscape: I would think blood doping is very difficult to detect.
Dr. Wadler: Erythropoietin (EPO) abuse involves using very low doses, called "microdosing." Athletes get a boost in their EPO levels, which increases oxygen, but levels stay below detection.
The use of autologous blood transfusions is particularly challenging. The athlete has some of his own blood removed weeks before an event and then refrigerates it. The body senses a loss of blood, but of course it doesn't know why -- it could have been a hemorrhage, could have been surgery, any variety of reasons. The kidney then produces EPO in response, and the bone marrow begins to make red blood cells. Right before the competitive event, the athlete who cheats reinfuses the refrigerated blood. Now there are 2 ways that blood levels have increased naturally: by increased activity in the bone marrow, plus the blood put back into their bodies.
For years, athletes used other people's blood; it wasn't autologous. But now, because it's his or her own blood, how do you detect that? We have better methods now, but this is an example of a challenge that we deal with.
Medscape: I noticed that beta-2 agonists, beta-blockers, and diuretics are on the list of banned agents. Of course, those are used for a lot of medical conditions; EPO is too. How do you differentiate between medical use and performance enhancement?
Dr. Wadler: Let me talk about therapeutic use exemptions. This is a very important area, because we want to make sure that we do not penalize people who have legitimate medical issues and need specific drugs that would eliminate them from competing. People who have a variety of medical conditions typically might take an otherwise banned substance, but are allowed to do so provided that this in compliance with the Therapeutic Use Exemption principles and protocols.
I'll give you an extreme example. There was a sailor years ago who had his testicles removed because of cancer and had very low testosterone levels. He wanted to participate in an elite sport. He couldn't just take testosterone. He had to get a Therapeutic Use Exemption.
The sailor would have to make his case before an independent panel and say, "I have a legitimate medical need" -- in this case, "I have no testicles, therefore I have very low testosterone level, and I'd like to compete." The panel would then say, "Yes, looking at the medical record, you have a legitimate deficiency. Therefore, we would allow you to take testosterone or anabolic steroids, but we will monitor the dose and the frequency, to make sure you're taking it as prescribed for medical purposes but not to enhance your performance. You're not taking megadoses, you're taking therapeutic doses."
Here, you have a situation where we are not in any way interfering with this athlete's ability to perform, but we're saying, "Here are the conditions." They need to present documents before an independent panel that proves they have a medical condition, and they have to show the acceptable doses, and then they are monitored.
Medscape: What about human growth hormone (hGH)? I know that's one of the banned drugs, but isn't there some question about whether it actually enhances performance?
Dr. Wadler: I've not been overwhelmingly convinced that hGH by itself is particularly performance-enhancing. It does have anabolic properties. What we suspect is going on is the combined use of anabolic steroids and growth hormone. Some people believe that if you take them together, you can take lower doses of anabolic steroids, which makes them harder to detect, and yet the athlete has the same level of enhancement as if he or she were taking higher doses of steroids.
This is an example of one of the issues in US professional sports, where some did not want to test for hGH. However, even if hGH by itself is not necessarily performance-enhancing, if we're not testing for it, we may miss people taking the lower doses of anabolic steroids because they are taking HGH.
Medscape: Are there any particular drugs that are abused more often in specific sports?
Dr. Wadler: Let me just go through the list with you. We have many anabolic agents. There are also peptide hormones; growth factors; and related substances, which include EPO, human chorionic gonadotropin, insulin, cortisone, and hGH. Then there are the beta-2 agonists, which we talked about briefly. Diuretics and other masking agents are also prohibited.
There are also hormones, such as estrogen, and metabolic modulators, such as aromatase inhibitors. Let me explain these. If a male athlete takes anabolic steroids, he'll become feminized, because anabolic steroids convert into the female hormone estrogen. Therefore, these male athletes wind up with breasts, a high-pitched voice, testicular atrophy, and other feminizing attributes. One way to get around that is to take aromatase inhibitors and other estrogen receptor modulators, which help prevent feminization.
Medscape: Do women abuse drugs in a similar way? I would assume they would have a different effect.
Dr. Wadler: They wind up getting masculinized. They'll get deep voices, acne, and a male hair pattern, and they'll have menstrual irregularities. So they experience different side effects related to sex hormones.
There are also prohibited procedures, which include enhancement of oxygen transfer -- including blood doping -- and intravenous infusion and or injections of saline with the intent to overhydrate and mask the use of drugs.
Medscape: What about gene doping? Is that anywhere near a problem yet?
Dr. Wadler: Gene doping, as opposed to doping with drugs, is probably going to be upon us in not too many years. We're working on controlling it and are making significant progress in that field.
Medscape: Are the substances you mentioned banned at all times, or just during competition?
Substances banned at all times include anabolic agents, peptic hormones, growth factors and related substances, beta-2 agonists, hormones as metabolic modulators, and diuretics and other masking agents. There are also methods that are banned at all times, which include those that enhance oxygen transfer and chemical and physical manipulation and gene doping. Some substances and methods are prohibited only in competition; these include stimulants, narcotics, cannabinoids, and glucocorticosteroids.
Stimulants are very important and fall under 2 categories: nonspecified and specified. Nonspecified are the more powerful stimulants; if an athlete tests positive or is caught using one of these, then the sanctions against sports participation are equivalent to those imposed for anabolic steroid use, which can be up to 4 years. In contrast, sanctions for specified stimulants, the less potent agents, are less severe, although sanctions against playing can still last for up to 2 years.
So you have to know which drugs are banned in competition, which ones are banned out of competition, and so on.
Medscape: How can athletes and their coaches get all this information?
Dr. Wadler: Details are spelled out on the WADA Website or the Websites of the athletes' respective sports federations. Governing bodies of particular sports -- football or track and field, for example -- have highly organized ways of disseminating this information.
Medscape: Are the rules consistent across these governing bodies?
Dr. Wadler: The WADA governance consists of 50% of sporting bodies and 50% of the public authorities worldwide.
Medscape: I've been reading that some individuals want to legalize all performance-enhancing drugs. I'm assuming you're not in favor in this.
Dr. Wadler: I'm 150% opposed.It's a matter of cheating. It's also a matter of health.
You're abusing drugs. These drugs are developed by researchers, pharmacologists, and pharmaceutical companies to help patients deal with their diseases. They're not developed to help people cheat. Peter Mere Latham in the early 1800s wrote, "Poisons and medicines are oftentimes the same substance given with different intents."
And here's another point, and it may be unique to athletic doping. When you really think about it, with anabolic steroid abuse both the seller and the user make money. The seller makes money when he sells the product, and the user can wind up getting a bigger sports contract because he performed better. It raises the complexity of controlling something where money is dangling at both ends: the provider and the user.
What I tried to say today is this is not a simple process. It is complex, involving multiple levels of expertise, and many people don't understand the broader context.

Olympics 2012: Treating Female Athletes

Olympics 2012: Treating Female Athletes

Olympics 2012: Treating Female Athletes

Stephanie Cajigal; Abigail K. Allen, MD

Editor's Note:
The 2012 Olympics represents a watershed for female athletes. Not only do women outnumber men on the US National Team, but for the first time, all participating countries will have sent female athletes to the competition. According to Abigail K. Allen, MD, a pediatric orthopedic surgeon at the Mount Sinai College of Medicine in New York City who manages many young athletes and Olympic hopefuls, the 2012 games are mirroring what has already been happening for years in the United States: An increasing number of women are becoming involved in sports. Medscape interviewed Dr. Allen about the challenges involved in treating female athletes.
Medscape: Studies show that female athletes are more prone to injury than male athletes. Can you elaborate on the specific types of injuries that women are more susceptible to?
Dr. Allen: Historically in sports, and even just several decades ago, sports were thought of as male activities; females didn't really play sports as much. But now, more and more females are playing sports. And more and more females are getting injured more commonly than males -- so they are not really created equal.
The most classic example of injury that female athletes are more prone to is the anterior cruciate ligament (ACL) tear. As females participate in sports more and more, they are getting the same injuries as males but at a higher rate. I think the incidence of ACL tears in female college soccer players is about 5%, which is pretty high; it's actually about 3 times higher than for male soccer players.
Medscape: What are some of the reasons why women are injured more often than men? How much of it relates to intrinsic biologic differences vs the way they're trained?
Dr. Allen: The reasons behind this are probably multifactorial, but it is thought to be potentially hormone related or anatomy related, because the notch in the knee is shaped a little differently in the female.
Differences in landing mechanics have been proposed as well. Females don't land the same way as males. They are thought to land a little more knock-kneed and not squatting down as much as how a male would land. Nowadays, a lot of the training programs focus on landing to try to decrease the incidence of ACL tears.
Medscape: Do you think training in landing mechanics is something that physicians should recommend, or is more research needed in this area?
Dr. Allen: This research is from a few years ago, so people are recommending it now.
Medscape: What research related to female athletes are you most enthusiastic about?
Dr. Allen: I've always been intrigued by the huge studies on improving landing mechanics and proprioception of the female athlete -- essentially, to get them to jump and land like a male so that they don't get ACL injuries as much. There are some studies that show that these training programs work.
Medscape: What research is lacking in this area?
Dr. Allen: You could think of this as a new frontier because females are just now becoming athletes and elite athletes. It is more common for females to play sports nowadays, even from childhood. Doing research, even if it is reproducing in a female population the same research that has been done in males in the past, would be beneficial. Research is lacking in the female population in general, because we haven't been playing sports as much as the male population until recent years.
Medscape: What should the medical community be doing to better cater to female athletes?
Dr. Allen: It goes back to the concept of being a team. It's partly about the physician gaining knowledge and trying to do things preventatively, but it's not just the role of the physician. It's also the athlete, the athlete's family, the coach, the athletic trainer, etc. It's about just being aware that females are athletes nowadays and that they can get the same injuries as men.
Also, the injury may not be the musculoskeletal injury that one always thinks of, such as a fracture or a sprain or an ACL tear. Especially in the female population, one should be aware of the Female Athlete Triad: disordered eating, amenorrhea, and resultant osteoporosis. The physicians (whether they be orthopedic or primary care physicians), the coaches, and the family should not just ask how Sally's ankle is doing but also make sure that they address her eating habits and ensure that she is menstruating relatively regularly.

Scientists Skeptical as Athletes Get All Taped up

Scientists Skeptical as Athletes Get All Taped up

 

Scientists Skeptical as Athletes Get All Taped up



By Kate Kelland
LONDON (Reuters) Aug 01 - German beach volleyball player Ilka Semmler wears it on her buttocks - in pink. Swedish handball player Johanna Wiberg prefers it in blue from her knee to her groin. British sprinter Dwain Chambers has even worn it with a Union Jack design.
Athletic tape made in every color under the sun seems to be the latest must-have sports injury treatment at London 2012, where athletes may have been influenced by other big name tape fans such as Serena Williams and David Beckham.
Called Kinesio tape and developed by a Japanese doctor more than 30 years ago, the adhesive strapping is designed to provide muscle and joint support without restricting movement.
According to Kinesio's product website, it is also designed to be used with a particular taping technique - a skill practitioners need to learn on a special training course.
More than 4,000 people in Britain are now trained in the art of Kinesio taping, it says, and many of them look after some of the country's top sportsmen and women.
But does it really work?
Compared with the abundance of its use, rigorous scientific research on Kinesio tape is scant. But a handful of research papers suggest its ability to relieve pain or improve muscle strength is limited.
"Kinesio tape may be of some assistance to clinicians in improving pain-free active range of movement immediately after tape application for patients with shoulder pain," wrote scientists in one study published in the Journal of Orthopaedic and Sports Physical Therapy.
But the researchers added their findings did not support the use of Kinesio tape for decreasing pain intensity or disability in patients with shoulder problems.
In a review of all the scientific research so far, published in the Sports Medicine journal in February, researchers found "little quality evidence to support the use of Kinesio tape over other types of elastic taping in the management or prevention of sports injuries."
Kevin Anderson, managing director of Kinesio UK, which supplies the tape in Britain and trains people in how to apply it, says the scientific research has yet to catch up with what athletes and physiotherapists say about the tape's benefits.
"There's a lot more needed on the research side to confirm the positive results we're seeing so far," he told Reuters.
"There's nothing magical in the tape, it certainly can't improve your performance or make you into Superman, but the way people use the tape is to lift the skin, reduce the pressure and that helps relieve pain and swelling."
Whatever the science, German beach volleyball player Sara Goller sported two long pink strips of the tape on her left leg during matches on Tuesday, while her partner Laura Ludwig had two vertical blue strips on her stomach.
"I don't really mind the color, it's more about what it does. It can release or put tension on a muscle, it depends on what you want. Our physio is really good at doing it," Goller told Reuters.
John Brewer, a professor of sports science at Britain's University of Bedfordshire, remains doubtful.
"As a scientist, I'm still not convinced about the underlying mechanisms," he told Reuters, voicing skepticism about the supposed "lifting" effect and the ability of tape applied to the skin to enhance the performance of muscles deep inside the body.
Steve Harridge, a professor of human and applied physiology at King's College London, said many athletes appeared to be wearing tape even when they had no injury, possible hoping for some preventative or enhancing effect.
"It may be a fashion accessory, and it may be just one of those fads that come along from time to time, but to my knowledge there's no firm scientific evidence to suggest it will enhance muscle performance," he told Reuters.
Both scientists agreed, however, that there may be a benefit, in the form of the placebo effect.
"The fact that athletes think it's going to do them some good can help in a psychological way," said Harridge.
An effective placebo, Brewer said, "could make all the difference between success and failure."
SOURCE: http://bit.ly/NUMF5I
Sports Med 2012.

On-the-Spot Treatment of Sports Injuries

On-the-Spot Treatment of Sports Injuries

On-the-Spot Treatment of Sports Injuries

An Expert Interview With Margot Putukian, MD

Carol Peckham; Margot Putukian, MD


 
Editor's Note:
As part of Medscape's coverage of the 2012 Summer Olympics, we interviewed Margot Putukian, MD, Director of Athletic Medicine and Head Team Physician for Princeton University. Dr. Putukian is a former President of the American Medical Society for Sports Medicine (AMSSM) (2004-2005) and is currently President of the AMSSM Foundation. She also serves on the Ad Hoc Sports Science Safety Committee Task Force on Clinical Medicine for the American College of Sports Medicine. Dr. Putukian has been a leader in research on concussion, with involvement in the Team Physician Consensus Statements, the National Athletic Trainers' Association Position Statement, as well as the Zurich International Consensus Conference on Concussion. She has served on the US Lacrosse Sports Science & Safety Committee since 2004 and in 2009 was named Chair. She is also involved with the National Football League Head, Neck & Spine Committee, serving as Chair of the Return-to-Play Subcommittee. In this interview, Medscape asked Dr. Putukian about on-the-spot treatments for injuries during competitive events.
Medscape: What are common on-the-spot treatments for injuries to the lower extremities? And what are the criteria for allowing an athlete to return to competition after such injuries?
Dr. Putukian: Obviously it depends on what the exact injury is, but most acute lower extremity injuries are treated on the spot with ice, splinting, or immobilization, and, as long as there is no contraindication, nonsteroidal anti-inflammatory medications for pain. Additional diagnostic testing, such as an x-ray or other studies, may be helpful in determining the extent of injury, and the splinting or immobilization necessary, again, depends on the injury. For an acute ankle sprain, where the ligaments on the outer aspect of the ankle are torn, for example, it may be useful to provide some support (splinting and protection of the ankle as necessary), apply ice and compression, and elevate the ankle or leg. X-rays may be indicated to exclude fracture, and if there is no fracture, then the rehabilitation is to slowly restore range of motion, strength, and proprioception. It is often necessary to modify activities, such as having the athlete swim instead of run, or use other modes of exercise that do not interfere with the rehabilitative process. The criteria for return to play (RTP) after such injuries is restoration of full range of motion, full strength, and then assessment to make sure that functional activities (eg, running, jumping, cutting side to side) are back to an acceptable level where the athlete can participate without significant risk for additional injury. The RTP is typically gradual and slowly increases both the demands and the level of competition of the specific athlete.
Medscape: What about upper extremity injuries?
Dr. Putukian: This is the same as with lower extremity injuries. The only difference is that it's typically easier to immobilize and/or modify activities because weight bearing is not an issue.
Medscape: What protections are in place to prevent, diagnose, and treat cardiac arrest in intensive athletes?
Dr. Putukian: This depends on the age we are discussing. For youth athletes, we have the preparticipation physical examination, which should include and endorse the American Heart Association (AHA) 12-Element recommendations for preparticipation cardiovascular screening of competitive athletes. These recommendations address personal history, family history, and physical exam findings.[1] The PreParticipation Physical Evaluation (PPE) monograph,[2] currently endorsed by all major sports medicine organizations, also includes these 12 questions, so our college and youth participants have reasonable screening. Athletes who give even 1 positive response to these questions should have appropriate evaluations to exclude cardiac disease. Older athletes should have a physical examination that assesses cardiac risk factors and, in my opinion, should include the AHA 12 questions as well. An ECG and cholesterol screening might also be indicated.
Treating cardiac arrest should ideally include having available personnel certified in cardiopulmonary resuscitation and knowledgeable about the use of an automated external defibrillator (AED). Ideally, early access to defibrillation is defined as having the AED and personnel within 3-5 minutes.
Medscape: What is being used now to immediately stabilize patients who experience concussion?
Dr. Putukian: There is a spectrum of concussion, so this is difficult to answer. On the one extreme are athletes who present with symptoms that cannot exclude more serious brain injury or cervical spine injury; they should be spine-boarded and transported to an emergency center with facilities and personnel to handle cervical spine and brain injuries. On the other extreme are athletes with short-lived symptoms of concussion, with no evidence or concern for complications or more serious brain injury. These athletes improve within minutes, and the immediate concern is to make sure they do not return to activity until they are evaluated by a healthcare provider experienced in evaluating and managing concussion. Athletes should also be told to remain out of physical activity and minimize cognitive activity (eg, avoid texting, video games, computer use) until they are evaluated. Athletes should be given information on what to watch for (symptoms or signs of deterioration) and what to avoid, such as aspirin and alcohol, as well as when they should be seen for follow-up.
Medscape: What about patients who experience hyperthermia? Can they be treated immediately and in time to return to competition?
Dr. Putukian: Hyperthermia is a general term that includes a spectrum of heat-related illness that includes heat cramps, heat syncope, heat exhaustion, and exertional heat stroke, the most extreme and sometimes fatal form of heat-related illness. It is important to define the extent of thermal injury that is occurring because treatment can be different. A lot can be done to prevent heat-related illness, including hydrating, avoiding exercising in the heat and humidity (avoid the hottest part of the day), acclimatizing to the heat, and having an emergency action plan that incorporates guidelines for avoiding heat injury. When heat injuries do occur, it is important that they are assessed by reliable measures (rectal temperature), that the athlete is moved to a cool/shaded area, and that immediate cooling occurs, ideally with whole-body ice water immersion. If possible, the athlete should be provided with oral rehydration. RTP after heat-related illness depends on the extent of the thermal injury. For heat exhaustion, the recommendation is to wait at least 24-48 hours before returning and at least a week for exertional heat stroke. Each situation must be considered individually, as several factors should be considered in the RTP decision. The Korey Stringer Institute has a lot of good information related to avoiding hyperthermia, treating it, and RTP.
Medscape: How are electrolyte and dehydration deficiencies recognized and dealt with during events? Specifically, what happens to athletes who experience muscle cramping? Can they return to competition?
Dr. Putukian: Electrolyte imbalances and dehydration are recognized by healthcare providers during events in various fashions. Dehydration can be assessed by measuring blood pressure and pulse after an athlete is lying down for 2-3 minutes, then standing up for 2-3 minutes ("orthostatics"). Changes in blood pressure and pulse are then evaluated with this change in position. If there is a drop in blood pressure or an increase in heart rate when going from the lying to standing position, the athlete may be dehydrated.
Electrolyte abnormalities can be evaluated using various methods and are measured with a portable unit that takes a small amount of blood and provides a result. Electrolytes are most often measured during endurance road-running events. They are not typically measured in organized sports such as soccer, football, or other events that are not endurance-type activities.
Muscle cramping can occur if an athlete has electrolyte deficiencies or is dehydrated. Typically in organized sports, such as soccer and football, these can be treated by stretching, icing, replacing fluid and salt balance, and decreasing activity; often these athletes can return to activity. It may be more difficult for athletes participating in endurance sport events to return to activity immediately. It is important to make sure that they are not suffering from sickle cell crisis, where cramping occurs that typically is not associated with muscle contractions. Exertional sickling can be associated with rhabdomyolysis (muscle breakdown) and death and should be treated as an emergency. Screening for the presence of sickle cell trait can be useful, and knowing which athletes are at risk for heat-related illness is also important.

What Have the Olympics Taught Us About Sports Medicine?

What Have the Olympics Taught Us About Sports Medicine?

Medscape: You were a NCAA Division I swimmer. What insights does an athlete at that level bring to the practice of orthopedics?
Dr. Frey: It helps in understanding not only the type of injuries they have, but also their motivation and desire to get back to the team after an injury. They're like injured warriors. At Walter Reed National Military Medical Center, one of the first things you will hear from even the most injured troops is their desire to get back to their unit.
It is similar with an athlete. It is such a part of their identity and how they define themselves that their first motivation is to get back to the team or get back to the sport, as the case may be. They don't want to hear, "Maybe you shouldn't swim again," or "Maybe you shouldn't do this again," or "Why don't you take 6 months off?" To an athlete, that is code that that person who is speaking has never played sports or is not an athlete.
Carol Frey, MD
You need to understand the motivation -- the core personality of an athlete. People don't become athletes as adults. As a swimmer, for example, I became very competitive when I was about 9 years old, and today, it begins at 7 years. People specialize much earlier, and when they do, it becomes much more than physical.
Outsiders ("civilians") look at athletics as something that is just physical. They think, "They're naturals, they work out, they're strong, that's all it is." It's more than that. A lot of people are strong and a lot of people work out, but only a few will make it to the Olympics. The difference is heart; discipline; dedication; and, of course, genetics. Athletes drop out of competitive sports for many reasons. They may lack the heart or the discipline, or they get injured.
Medscape: I talked to an orthopedist who works with soccer teams, and he mentioned the same thing: the underpinning of the motivation of the athletes and that, when injured, they want to get back to the game or to the team. One question that it raises is, do you have a responsibility to the athlete that extends beyond the team? How do you manage being pulled in different directions?
Dr. Frey: You don't do anything that is dangerous or bad for the athlete. As a physician, I will tell you the most difficult thing to do is not the diagnosis or the surgery; it's the rehabilitation and the return to the sport. It helps being a former athlete. I'm not saying that nonathlete physicians can't do it, but it takes more work and you need to invest more time to get to know your patient -- that is the first thing.
The second thing is that there are ways to do rehabilitation without the athlete losing strength or no longer being part of the team, and ways to do it without further injuring the athlete. In my opinion, many physicians do not know how to properly rehabilitate an athlete.
For example, let's say the athlete has a stress fracture. The easy way to treat it is to put the athlete in a cast and tell him or her not to do the sport for 6 months. It will work. The patient will get better, but there is another way. Immobilize the athlete for a couple of weeks, and then kick-start the process by getting the athlete in a pool doing really good pool exercises, with high kicks, side steps, a noodle workout, and core work. Get the athlete doing Pilates, using the core ball, and working on core strength and upper body strength. Use physical therapy to your advantage, and even do deep soft-tissue work to get the muscles loosened up.
It takes a lot of time to get to know the patient and explain and prescribe these exercises. Not every doctor has the time or the motivation. I'm not saying that the physician is lazy. Some of them just don't know. Some know but don't quite trust the method because they haven't done it enough. Why take a chance? The athlete might injure himself while he is in the pool.
It takes a level of knowledge and specialty to know how to rehabilitate a patient. It is the more difficult part of orthopedics. It certainly takes the longest. You really have to listen to the patient. You really have to get to know the patient and the patient's motivation.

Resisting the Pushes

You also have to be immune to the pushes. The coaches and the parents get involved, so you have to handle them as well. When you have an athlete at that high a level, especially Olympic level, division I level, or even club level or high school varsity, the parents and coaches can be more difficult than the athletes.
Furthermore, other athletes may treat the injured player differently. He or she is not ostracized, but is not quite a member of the team. The injured athlete is sitting on the bench or in the stands, not playing and not functioning as part of the team.
You have to be confident, too, because some of those coaches are pushy and they have their own ideas. They also have the ear of the athlete more than you do. The physician comes in as a satellite member of the team. You only see the athlete when the athlete is injured. The athlete sees the coach every day. You have to convince the coach to be on your side, as part of the rehabilitation program. You have to get the coaches on board.
Medscape: I can see how it would be a very difficult challenge, particularly the professional one.
Dr. Frey: Yes, and the parents have so much invested. By the time a kid becomes an Olympic athlete -- swimmer, tennis player, volleyball player -- think of the tremendous amount of time and money they have invested: the 5-AM wake-ups, the meets, the $300 swimsuits, and the private coaching. It is a very expensive enterprise to produce an Olympic athlete.
When a child gets injured, the parent doesn't just say, "My poor son. He isn't going to be able to realize his potential," but also, "Oh my God, I wasted all that money." All these thoughts are going through their heads. "You can't quit now. This is getting you into Stanford."

Injury Patterns in Swimmers

Medscape: Could you discuss injury patterns in swimmers?
Dr. Frey: It has been said that at some point in a swimmer's career, if the swimmer is at a competitive level, more than 80% will have a shoulder issue. It won't necessarily mean that the swimmer will have to stop swimming, but it is very common to have a shoulder issue. So much of the stroke is built into the stability and position of the shoulder.
The shoulder is a unique joint and has more range of motion than any other joint in the body, so it is not hard to imagine how it can get injured. It is very mobile, and in swimmers, it tends to get almost hypermobile because of the mechanics of swimming. Swimmer's shoulder is an inflammation around the shoulder unit, and the person who is most at risk for this type of injury is a swimmer with a more relaxed or more hypermobile shoulder because his shoulder can assume more complex and varied positions.
It is not unusual for a competitive swimmer who swims up to 20,000 meters a day, 6 days a week and then does dry-land exercises, too, to do about 4000 strokes per shoulder per day. The rotator cuff and biceps tendon are commonly inflamed. The cause of swimmer's shoulder is a combination of this hypermobile shoulder and problems with swimming technique.
The technique that leads to swimmer's shoulder is often related to the way the swimmer's hand enters the water. Swimmers enter the water at midline or off to the side a little bit. We call it "crossover." He enters the water, and then his hand crosses over his body a little bit. People with swimmer's shoulder have a little more of that crossover and may enter the water completely thumbs down. That puts a little too much torque on the shoulder.
These are some of the things you can look for that might cause some repetitive trauma, malpositioning, or mechanical problems to the shoulder. It requires an analysis of the swimming technique.
Medscape: When you come across a situation like that -- let's say you find it in an athlete who is in a competitive situation -- what can you do?
Dr. Frey: The main thing to do is change the swimmer's technique. Technique is one of the reasons that speed has increased so much. We also have kids who are just getting bigger, and that helps in swimming -- big feet and big hands. Having swimming coaches who really work on the mechanics of the stroke has improved swimming tremendously in the past 20 years.
You can look at the swimmer's mechanics and change the position of the swimmer's hand as it enters the water, with less torque on the shoulder. The swimmer can enter just short of midline.
That is just one example, but you need to look at the mechanics first of all and change the mechanics because you can do that, much like a weightlifter can change the position of his hands on the weight bar. You want the muscles of the shoulder to work through a stable arc. You don't want an unstable shoulder, with too much motion.
The key remedies for swimmer's shoulder are physical therapy, working on mechanics, and working on core strength. Why core strength? Core strength allows the swimmer to streamline well, and in swimming, streamlining is making sure you don't wobble side to side.
Think of the midline or the lane line. You want the body to stay on that lane line. It's like an airplane landing. Side-to-side movement, also called "body roll," can be reduced by core strengthening. Core strengthening will also put the shoulder in a better position. The exercise ball is really good for that.
There are so many good exercises for swimmers, such as the supine back extension stretch, that can be done with a core ball. Another exercise is called "Superman." Most swimmers know what a Superman is. You lay on the core ball face down, your opposite leg goes up from your arm, and you go back and forth doing a back extension.
Push-ups and trunk rolls can be done on the core ball. The upper and lower abdominal muscles must be kept very strong. This will stabilize the pelvis, stop the lateral trunk movement in the water and stabilize the shoulders and trunk. This will make the swimmer more powerful and less apt to get injured. Physical therapy and looking at mechanics will solve 90% of the problems with swimmer's shoulder.

Injuries in Practice

Medscape: What if you are in a situation where somebody is injured during competition? Do Olympic swimmers develop swimmer's shoulder during competition?
Dr. Frey: Most injuries happen during practice, when athletes are swimming 20,000 meters. They don't swim 20,000 meters during a competition; they swim 200 meters. I can't think of an example where an injury has happened during competition. That is how rare it is. The injuries at competition are accidents, not overuse.
Medscape: You were a Division I swimmer. Did that lead to your medical career, or were you already embarked on it?
Dr. Frey: I probably always wanted to be a doctor. I may have been brainwashed a little bit by my grandmother, who was a medical missionary. She used to say, "You would be a great doctor," so I always had it in the back of my mind.
What solidified orthopedics, and this is probably true of a lot of orthopedic surgeons, was that I had an injury in college. I was a swimmer but I also played volleyball, having grown up at the beach, and during a pick-up volleyball game right after coming out of the pool, I tore my anterior cruciate ligament.
My injury didn't hurt my swimming. I actually rehabilitated in the pool really well. Just going through that -- and I was at Stanford University at the time -- I got to know orthopedics and orthopedists, and I thought it was a brilliant career. The patients you see are wounded, not really sick, and they get better. If you do the right thing, they get better in 6 or 12 weeks. Very few specialties in medicine are like that. There is instant feedback that makes orthopedics a very positive career.
Medscape: You follow the Olympics swimming very closely. Do you follow the rest of the Olympics, and do you have any general observations about orthopedics in the Olympics?
Dr. Frey: My husband is one of the Olympic doctors. He is an orthopedic surgeon, as well. To be an Olympic doctor, you have to train for 2 weeks. You have to leave your practice, go to Colorado Springs, move into a dormitory, and train with the Olympic people and personnel to learn how to treat the athletes. You get to know their specific trainers. These are not random doctors. They are selected by the Olympic committee.
There are other international games that take place before the Olympics. For example, the US volleyball team was in Bulgaria 2 weeks ago, and my husband was with the US volleyball and weightlifting teams. Each sport has at least 1 physician, and often more, who travel with those teams when they go to the international qualifying games leading up to the Olympics.

Developments in Training

Medscape: Are there new things in swimming that orthopedic physicians would like to hear about? Are there new developments coming down the line?
Dr. Frey: The developments have to do with training. Everybody wants to know what makes Michael Phelps or Ryan Lochte so good. Why are they so spectacular? There is a lot of talk about how big Phelps' hands and feet are. You can't do anything about that. That is a genetic lottery.
One of the things that has come out of the Olympics happened when the East Germans came on the scene. It was in Munich. Everybody disapproved of their methods. They looked for markers -- physical traits -- and funneled kids into sports really early, like at 5 years old, on the basis of these traits. This information came out when the Berlin Wall came down and the Cold War ended.
They were the ones who started the weightlifting and emphasized dry-land exercises for swimmers. When I was swimming, which was in the 1970s, we weren't doing much dry-land work, and when we saw how big and powerful the East Germans were, that was a turning point for swimming. Maybe there was a lot more going on behind the scenes, but we started weightlifting and realizing it was important to have strong upper-body muscles, a strong trunk, and core strength.
The practice of doing genetic testing and picking kids on the basis of genetic traits sounds awful to the sensibilities of the Western world, and some of the books also show that the East German athletes were using steroids and strength-enhancing drugs. It wasn't all dry-land work, as it turns out.
I have a true story about swimming against the East Germans. The first time we saw them, upon walking into the women's dressing room with the showers in our peripheral vision, and just seeing them from behind -- their backs, their shoulders -- and hearing their voices, I walked out and said, "Are we in the boys' locker room?" I was not small. I was 5' 11" and 165 lb. I was considered big in those days, and those girls were bigger than me.
Medscape: As I think back on that, the East Germans were notorious.
Dr. Frey: They were, but we can learn from them. We learned that we needed dry-land exercises, that we couldn't just swim in the pool 20,000 meters. Even today, we are learning new training techniques. When you pick up a magazine, such as Triathlon or Outside, which profiles a lot of athletes, their nutrition gets as much publicity as anything.
Ryan Lochte is famous for saying that he eats French fries and hamburgers all the time, but in a recent edition of Outside magazine, he said that he has changed his diet. One US decathlon player spent half an article giving recipes for highly nutritious meals. Nutritional status, flexibility, and body work have become much more important in our training. It is not just how many miles you log or how many laps you swim anymore.

The Personality of an Athlete

Medscape: Any final words?
Dr. Frey: What we need to understand about athletes is that so much of their personality is being an athlete. All of their spare time has been devoted to their sport. These people essentially gave up their youth to train and watch their diets, to go to meets, and to try to prevent injuries. To help them as physicians, we have to let them know that we are part of their team and will work to keep them in the game. I know that's a cliché. We don't want them to play so that they injure themselves, but 99% of the time, there is a way to keep them in the game.
When athletes get injured, they need to know they are on the injury list. Most people at an elite level have had an injury at some point in time and have lost a week or more of playing time or practice. It is part of getting to that level. I can't think of one player who hasn't had an injury at some point that required an orthopedic surgeon, a physical therapist, or time off from play.
If you can manage it, keep them in the game even when they are injured, by seeing a physical therapist and getting them in the pool doing pool exercises, side steps, and Pilates exercises, which were actually designed for injured warriors.
Remember that mentally, this is their identity. They have given up so much, and you have to keep them positive.