Pre-injury biomarkers linked with subsequent ACL injury | Orthopedics
Very interesting topic from Westpoint that I saw at the AOSSM meeting in Baltimore this summer.
Wednesday, August 8, 2012
Tuesday, August 7, 2012
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.
More Players Suffer Soccer Sprains When One Ankle Is Stronger
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
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.
'Double-Jointed' Soccer Players Have More Injuries
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
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.
Soccer Regimen Promising for ACL Injury Prevention
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
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.
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.
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.
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.
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.
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.
How a Soccer Player Became a Physician for US Teams
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) |
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
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: Nutrition Advice for the Athletic Patient
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
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.
Doping in Sports: Catching and Preventing It
An Expert Interview With 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.
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